Sinus Surgery in Sydney
Functional Endoscopic Sinus Surgery (FESS) is the standard surgical approach for chronic rhinosinusitis, nasal polyps, and recurrent acute sinusitis that has failed to respond to appropriate medical management. Performed entirely through the nostrils using small rigid telescopes and fine instruments — without external incisions and without facial scarring — it has transformed the surgical treatment of sinus disease since its widespread adoption in the 1980s and 1990s. Modern FESS uses high-definition cameras, angled telescopes, powered instrumentation, and image guidance systems that have made it substantially safer and more precise than earlier techniques.
Dr Roth completed an accredited fellowship in advanced rhinology and sinus surgery at Rush University Medical Center in Chicago. He performs more than 300 nasal and sinus procedures per year.
The Paranasal Sinuses and Why They Become Diseased
The four pairs of paranasal sinuses — maxillary, ethmoid, frontal, and sphenoid — are air-filled cavities within the skull bones around the nose and eyes. They drain into the nasal cavity through small openings that converge at the ostiomeatal complex (OMC) — a critical zone in the lateral nasal wall where blockage produces downstream obstruction of multiple sinuses simultaneously.
Normal sinus function requires two things: patent drainage pathways and functional mucociliary transport. Mucociliary clearance — the rhythmic beating of millions of cilia on the sinus lining, continuously moving the mucus blanket toward the ostia — keeps the sinuses clear of debris, inhaled particles, and pathogens. When either drainage or mucociliary function is impaired — by viral infection, allergy, polyps, or structural abnormalities — mucus accumulates, infection establishes, and chronic inflammation cycles.
FESS restores sinus function by addressing the anatomical and structural components of this failure: opening the natural drainage pathways, removing obstructing polyps or diseased mucosa, and creating widely patent cavities that improve both mucus clearance and the penetration of topical post-operative treatments to the sinus lining.
Indications for FESS
Sinus surgery is not a first-line treatment. International guidelines (EPOS — European Position Paper on Rhinosinusitis) recommend surgery only after an adequate and well-conducted trial of medical management has failed. The standard indications include:
The FESS Procedure in Detail
Anaesthetic Technique
FESS is performed under general anaesthesia using total intravenous anaesthesia (TIVA) — anaesthetic agents given intravenously rather than by inhalation. TIVA is the preferred technique for sinus surgery because it significantly reduces mucosal bleeding compared with inhaled anaesthetic agents, improving surgical visualisation and reducing operating time. A hypotensive technique — maintaining mean arterial pressure at approximately 60–70 mmHg — further minimises bleeding. Local anaesthetic with adrenaline is infiltrated into the nasal mucosa at the start of the procedure.
Endoscopes and Instruments
Rigid endoscopes (0°, 30°, 45°, and 70° angled telescopes) transmit a high-definition image to a monitor, allowing the entire procedure to be performed under magnified direct vision. The 0° scope provides a straight-ahead view; angled scopes allow visualisation of the frontal sinus, the maxillary sinus floor, and other difficult-to-reach areas that would otherwise require traditional open approaches. Fine powered instruments — a microdebrider with disposable blades — allows precise removal of polyps and diseased mucosa with minimal bleeding and minimal disruption of normal tissue.
Image-Guided Surgery
For complex or revision cases — where anatomy is distorted by previous surgery, extensive disease, or anatomical variants near the skull base or orbit — electromagnetic image guidance (StealthStation, Medtronic or equivalent) is used. The patient’s pre-operative CT scan is loaded into the navigation system, and a tracked instrument allows the surgeon to confirm its position within the three-dimensional CT anatomy in real time. Image guidance does not replace anatomical knowledge or surgical skill but provides an additional safety margin when operating near the skull base, carotid artery, or orbit.
Extent of Surgery
The extent of sinus surgery is tailored to the individual patient’s CT anatomy and disease distribution. Options range from limited procedures (uncinectomy — removal of the uncinate process — and anterior ethmoidectomy alone for anterior disease) through to full bilateral extended procedures (complete anterior and posterior ethmoidectomy, wide antrostomy, Draf IIa frontal sinusotomy, and sphenoidotomy) for pan-sinusitis with large polyp burden. The modified Lothrop (Draf III) procedure — drilling the combined frontal sinuses into a single large cavity in the skull base — is reserved for complex frontal sinus disease, particularly recurrent disease after standard frontal sinusotomy.
Septoplasty and Turbinate Surgery
Septoplasty (correction of a deviated nasal septum) and turbinoplasty (reduction of enlarged inferior turbinates) are commonly performed at the same time as FESS. A deviated septum may obstruct the middle meatus and impair endoscopic access to the sinuses, and enlarged turbinates contribute to nasal obstruction. Combining these procedures avoids a second anaesthetic and provides comprehensive improvement in nasal airflow.
Before Surgery — Preparation
- CT sinuses: Must be performed at a stable baseline (not during an acute sinusitis episode) and brought to the hospital on the day of surgery. The CT serves as the surgical “road map” and is essential for image-guided navigation.
- Pre-operative corticosteroids: Patients with significant nasal polyps or severe mucosal oedema may be prescribed a course of oral prednisolone for 5–7 days pre-operatively to reduce polyp bulk and mucosal swelling, improving surgical conditions.
- Medications: Blood-thinning medications (aspirin, clopidogrel, NSAIDs, anticoagulants) must be ceased before surgery — specific instructions are provided at the pre-operative appointment. Warfarin and DOAC management should be discussed in detail with the rooms.
- Allergy management: Patients with uncontrolled allergic rhinitis should have this addressed pre-operatively — operating through actively inflamed, swollen nasal mucosa increases bleeding, reduces visualisation, and worsens outcomes.
Recovery in Detail
Risks and Complications
FESS is a well-established and generally safe procedure, but it is performed in close proximity to critical structures — the orbit, the skull base, and the internal carotid artery — and complications, while uncommon, are important to understand.
- Bleeding: Intraoperative or post-operative. Most bleeding settles conservatively. Significant post-operative haemorrhage requiring intervention occurs in less than 1% of cases. Patients on anticoagulants or with bleeding disorders are at higher risk.
- Orbital injury: The medial orbital wall (lamina papyracea) is the thin bony partition between the ethmoid sinuses and the orbit. Accidental entry into the orbit can cause periorbital emphysema (air under the eyelid skin), orbital haematoma, or, in the most serious cases, visual impairment or loss from optic nerve damage or direct injury to the orbital contents. Orbital complications occur in approximately 0.5–1.5% of cases, with serious orbital injury in well under 0.1%.
- CSF leak: A breach of the thin cribriform plate separating the ethmoid sinuses from the anterior cranial fossa allows cerebrospinal fluid to leak into the nasal cavity. Incidence approximately 0.1–0.5% in primary FESS; higher in revision surgery and extended skull base procedures. A CSF leak may be repaired endoscopically with a fat or fascial graft at the time it occurs, or subsequently if identified post-operatively.
- Anosmia: Temporary worsening of smell is common and expected post-operatively as the nasal mucosa heals. Permanent olfactory loss is uncommon but possible, particularly with extensive dissection near the olfactory cleft.
- Adhesion formation: Scar bands (synechiae) can form between opposing mucosal surfaces in the healing surgical cavity, narrowing or occluding the sinus openings. This is significantly reduced by thorough post-operative debridement and irrigation.
- Incomplete disease control or recurrence: FESS does not cure CRS in most patients but establishes a surgical anatomy that allows medical treatment to work more effectively. Polyp recurrence and return of symptoms occurs in a proportion of patients, particularly those with severe eosinophilic disease, AERD, or inadequate post-operative medical management.
- Anaesthetic risks: Discussed with the anaesthetist pre-operatively.
- Heavy nasal bleeding that does not settle with sustained nasal pressure
- Swelling around an eye, double vision, or reduced vision
- Clear watery fluid dripping from the nose (may represent CSF leak)
- Severe headache, neck stiffness, or fever
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Dr Roth’s Clinical Perspective
The outcome of sinus surgery is determined about as much by what happens in the first six weeks after the procedure as by the surgery itself. That is not an exaggeration — it is the consistent finding of the post-operative management literature, and it matches what I see in practice. A patient who irrigates twice daily, attends every debridement appointment, and follows the topical treatment protocol will almost always do better than a patient who had equally good surgery but did not. The surgery creates the anatomy. The post-operative care determines whether that anatomy stays open.
For patients with nasal polyps specifically, I make a point of explaining at consultation that surgery is not a cure — it is a reset. The eosinophilic inflammation that drives polyp formation does not go away because the polyps have been removed. Without ongoing treatment after surgery — nasal steroid sprays, budesonide rinse, and in appropriate patients dupilumab — recurrence is predictable. The long-term management plan is part of the surgical plan, not an afterthought.
On the question of whether to operate at all: I follow a simple principle — surgery is appropriate when medical management has been properly tried and has not worked. Not when it has been partially tried. Not when the patient has tried one antibiotic course and a nasal spray. A genuine, well-conducted trial of medical therapy first. If that fails, surgery is indicated and generally produces a very good result. If it has not been tried properly, I will ask that it be tried first.
— Dr Jason Roth, MBBS, FRACS (ORL-HNS)
Frequently Asked Questions
Common questions about sinus surgery (FESS) answered by Dr Jason Roth, fellowship-trained rhinologist and Specialist Otolaryngologist, Sydney.
Functional endoscopic sinus surgery (FESS) is performed entirely through the nostrils using a fine endoscope and specialised instruments — there are no external incisions and no external scars. The endoscope provides a magnified view of the internal nasal passages on a monitor, allowing Dr Roth to open the natural drainage pathways of the sinuses, remove diseased mucosa and polyps, and restore ventilation under direct vision.
FESS is performed under general anaesthesia using total intravenous anaesthesia (TIVA) to minimise bleeding in the surgical field. It is most commonly day surgery.
Antibiotics treat acute bacterial sinus infections but do not address the underlying structural or inflammatory reasons why the infection occurred. Sinus surgery is indicated when chronic rhinosinusitis has not responded adequately to a full course of appropriate medical therapy — including antibiotics, nasal steroid sprays, and saline irrigation — typically over a period of three or more months.
The decision to proceed with surgery follows a thorough assessment including nasal endoscopy and in most cases a CT scan of the sinuses. Surgery is not the first line of treatment; it is appropriate when medical management has been exhausted.
FESS is performed under general anaesthesia and is not painful during the procedure. Post-operatively, the predominant complaint is nasal congestion and pressure from post-operative swelling rather than sharp pain. Most patients manage comfortably with regular paracetamol. The first post-operative debridement appointment — where Dr Roth cleans the nasal passages with microsuction — is the most uncomfortable part of the post-operative period for most patients, though it is brief.
Post-operative debridement is a clinic procedure performed at approximately one and two weeks after FESS, in which Dr Roth uses microsuction to remove crusting, debris, and clots from the surgical cavities under endoscopic vision. It also allows assessment of healing and identification of any early adhesion formation.
Debridement is not optional — it is as important to the outcome of sinus surgery as the surgery itself. Patients who miss debridement appointments have significantly higher rates of adhesion formation and incomplete surgical success. These visits are included in the surgical fee.
Most patients take one week off work following FESS. The nasal passages feel very blocked in the first week due to post-operative swelling and crusting. A recovery timeline:
- Days 1–7: Nasal congestion prominent. Twice-daily saline irrigation essential from day one.
- Week 1–2: Debridement appointments. Breathing beginning to improve.
- Weeks 2–6: Progressive improvement. Continue irrigation. Resume nasal steroid spray as directed.
- Months 2–6: Sinuses fully re-mucosalise. Full benefit of surgery apparent.
Twice-daily saline nasal irrigation is not optional after FESS — it is one of the most important determinants of a good surgical outcome. Irrigation clears blood, mucus, and crusting from the healing sinus cavities, reduces the risk of infection, and accelerates the restoration of normal mucociliary function. Large-volume delivery (NeilMed Sinus Rinse or similar) should be purchased before surgery and used from the morning after the procedure, every day, for at least six weeks.
Nasal polyps are a manifestation of chronic eosinophilic inflammation of the sinus mucosa — they are not cured by surgery. FESS removes the polyps and opens the sinuses, which dramatically improves symptoms and quality of life, but the underlying inflammatory tendency remains. Without ongoing medical management after surgery, polyps will recur in the majority of patients over time.
Post-operative management with nasal steroid sprays, continued irrigation, and in suitable patients biological therapy (dupilumab, which is PBS-listed for severe CRS with nasal polyps) significantly reduces the recurrence rate. A long-term management plan is established at the time of surgery.
Dupilumab (Dupixent) is a biological therapy — an injectable monoclonal antibody that blocks the IL-4 and IL-13 inflammatory pathways involved in eosinophilic airway disease, including severe nasal polyps and associated asthma. It significantly reduces polyp burden and improves nasal symptoms in patients with severe chronic rhinosinusitis with nasal polyps (CRSwNP).
Dupilumab is PBS-listed in Australia for CRSwNP meeting specific criteria, making it available at the standard PBS patient contribution. Eligibility assessment and prescription can be arranged through Dr Roth’s practice.
About Dr Jason Roth
Dr Roth completed an accredited fellowship in rhinology and advanced endoscopic sinus surgery at Rush University Medical Center in Chicago — an American Rhinologic Society-accredited centre with a subspecialty focus on advanced rhinology and endoscopic skull base surgery — under Professor Bruce Tan. He performs more than 300 nasal and sinus procedures per year from his practice on Sydney’s Northern Beaches.
Specialist Otolaryngologist & Head and Neck Surgeon
Specialist registration — Otorhinolaryngology, Head & Neck Surgery
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