Allergy, Nose & Sinus

Headaches in the forehead region after sinus surgery – What could be the cause? (WARNING – GRAPHIC SURGICAL IMAGES & VIDEOS)

February 10, 2020
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I recently saw a patient, Madam A, who had sinus surgery done by another surgeon for frequent sinus infections (recurrent sinusitis). She used to suffer from 4-5 episodes of sinus infections a year over the last few years. About a month after her sinus surgery, she started getting headaches in her left forehead region, just above her left eyebrow. She never had this pain prior to her sinus surgery. A review of the CT scan of her sinuses (special X-rays of her sinuses) before she underwent surgery showed that her sinus drainage pathways in both her cheek regions (maxillary sinuses) may be congested, predisposing her to frequent sinus infection. However, her forehead sinus (frontal sinus) was not affected.

 

 

A front view of the CT scan of Madam A’s sinuses showing a clear (black part indicating the sinus is filled with air) frontal sinus before her first sinus surgery

 

 

On examination, a nasoendoscopy (scope through the nose) showed that her cheek sinuses (maxillary sinuses) were open and clean. However, there was some scarring close to the drainage pathway of her left frontal sinus region. A repeat CT scan of her sinuses showed a complete blockage of her left frontal sinus, causing her to have constant left frontal headaches. A course of oral antibiotics, nasal wash and nasal steroid sprays did not alleviate her symptoms.

 

 

A repeat CT scan of Madam A’s sinuses showing a blocked left frontal sinus (grey part) after her sinus surgery

 

 

A CT scan showing the side view of Madam A’s sinuses. The left frontal sinus is completely filled with mucous (grey part)

 

 

Madam A underwent revision functional endoscopic sinus surgery (re-do sinus surgery) to unblock her left frontal sinus. The surgery was performed with Image Guidance System (IGS). IGS allows the surgeon to determine the exact position of the surgical instrument during sinus surgery.  The position of the surgical instrument is indicated by a green cross and superimposed on the CT scan images (refer to images below). This is especially useful in revision sinus surgery where by scarring or loss of surgical landmarks caused by previous surgery may make it difficult for the operating surgeon. Another good use of IGS is in patients with complex sinus anatomy (especially in the frontal recess). During Madan A’s sinus surgery, there was thick mucous encountered in the left frontal sinus. The frontal sinus pathway was widened and flushed with normal saline.  Post surgery, Madam A is glad that the headaches in the forehead region has resolved.

 

 

 

 

IGS images showing the position of the surgical instrument (suction tube) in the frontal recess where the mucous is suctioned out

 

 

IGS images showing the tip of the surgical instrument in the left frontal sinus

 

 

The extent of sinus surgery is often determined by a combination of patient’s symptoms and the severity of the sinus disease on a CT scan. One of the potential complication of sinus surgery is scarring, which can block off previously unaffected sinuses. Although uncommon, it is a potentially serious and debilitating complication like in Madam A’s case. Hence, it is important for the sinus surgeon to be meticulous during sinus surgery to avoid such a complication.

 

 

Best wishes,

 

Dr Gan Eng Cern
ENT Specialist Singapore

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