For accurate understanding of sinus infection, a little bit of knowledge on the nose structure is needed. As seen in the picture below, there are two empty spaces inside the skull (referred as paranasal cavity in medical language) in both sides. In structural views we divide each empty side into 4 parts, since these spaces are connected to the nostrils and osculum, ventilation and excretion of secretions are available. This so-called sinus infection is a condition of suppurative nasal discharge filled in the paranasal cavity because of the inflammation. Likewise the epityphlitis are commonly known as appendicitis, the exact disease name is sinusitis. And it is sorted into two phases acute and chronic, depending on the duration of the disease.

Symptoms in acute sinusitis are : malaise, headache, mild fever with nasal congestion, nasal discharge, pain on the paranasal cavity. Patients with chronic sinusitis experience nasal congestion, persistent yellow nasal discharge, post nasal drip, frequent nose bleed. If this progresses, it may lead to hyposmia, headache and lack of concentration and even otitis media or bronchitis.

The main cause of acute sinusitis are acute rhinitis which means frequent occurrence of a cold and structural abnormalities such as pharyngitis, dental infection, septal deviation. Besides the causes stated above, it can also be caused by infection, allergy, obstruction because of intranasal tumor, swimming, trauma, maxillofacial deformity. Other factors that could easily cause sinusitis are changes in temperature and humidity, air pollution, unsanitary living environment, sub-nutrition in vitamins A and D, genetic predisposition.

Chronic sinusitis occurs when acute inflammation wasn’t properly treated before and when acute inflammation repeatedly recurs. If a structural or physiological condition interferes in the excretion of sinus secretion and cause paranasal cavity’s infection, this becomes a great source of nutrition to the bacterias. As this makes the mucous membrane to swell, incurs a vicious cycle of atresia in the sinus lining. Through this progress, the lesion becomes chronic. In order to prevent sinusitis, it is important not to catch a cold and avoid causing other problems like getting otitis media by blowing your nose too hard.

We first suspect sinusitis by the patient’s symptoms and medical history. Then we observe the inside of the nose for otolaryngology examination purposes, sometimes using the endoscope. And lastly diagnose the disease by radiographic examination (X-ray examination). It is usually diagnosed with plain photography but when the patient is needed of a surgery or suspected a peculiar sinusitis or a tumor, for accurate observation a CT on the paranasal cavity region is needed.

The treatment principle of sinus infection is to maintain ventilation and excretion of the paranasal cavity.

As for children patients with acute sinusitis, drug treatment with antibiotics takes priority. When this treatment shows positive reaction, the conditions of nasal discharge improves by showing lighter color and thinner viscosity. Then the amount gradually decrease and make great improvement on the nasal ventilation. Usually after 1-2 months of drug treatment, many patients obtain satisfactory results. Nasal lavage using the physioligical saline can also be helpful. If necessary, tapping inside the nose by cleansing through the paranasal cavity may proceed. In case of self-treatment methods such as cleansing the nose with bamboo salt, when done incorrectly it may damage the nasal mucosa and cause diseases like disseminated polyposis that could not be cured even within surgery. So a specialist’s advice is essential. Sinusitis patient that doesn’t react to drug treatment, should consider going through surgical treatment. The surgical treatment opens the inflamed paranasal cavity and helps ventilation, excretion, and corrects the structural abnormalities in the nose that might be causing sinusitis. In the past, we usually used surgical methods that approach the paranasal cavity by cut opening the inside of the upper lips. However recently thanks to the development, improvement of endoscopic surgery, except for particular cases, most of the sinusitis patients go through endoscopic surgery. Especially the development of surgical excisers with suction, the surgery for polyps is now proceeded safely which had many difficulties in the past.

In addition for children sinusitis patients with prepubertal age, surgery performed inside the nose was banned because it may lead to interference of the patient’s facial bone growth. But recent introduction of pediatric endoscopes and surgical excisers with suction, children sinusitis patients that show no reaction to drug treatment has options of surgical treatment too.

At first we examine and check at the outpatient clinic, and diagnose chronic sinusitis(sinus infection). Then when the patient is necessary of a surgery, we set a appropriate surgery date considering the patient’s schedule and hospital circumstances.

About a week before the surgery, we proceed a screening in order to check if the patient’s general conditions are okay with undergoing surgery such as simple blood test, electrocardiogram, and chest radiograph. If abnormality is detected through these screening, you may receive a detailed examination on the corresponding medical departments.

Patients usually get hospitalized the day before the surgery, and prepare for the surgery by getting informed about the surgery through meeting the physician in charge. For adult sinusitis patients surgery is performed under local anesthesia or general anesthesia, and for children sinusitis patients surgery is performed under general anesthesia. Surgery is proceeded for about 30 minutes to 2 hours depending on the surgical situations. You’ll be returning to your ward in 2-3 hours including waiting time and anesthesia time.

For hemostasis after the surgery, we insert a gauze or soft inflatable cotton (Merocel). We remove the gauze 2-4 days after the surgery, depending on the patient's condition. There may be some bleeding during this process. Discharge will be decided according to the patient’s condition after the surgery, but patients are usually discharged on the 2nd day after the surgery.

After discharge patients should receive outpatient treatment on the surgical region for 4-6 weeks, 2-3 times a week. In order to prevent recurrence of sinusitis, the process of removing secretions including blood clots and making the mucous membrane regenerate is crucial. It usually takes 4 to 6 weeks for the surgery wound to heal, so you should keep this in mind when setting a date for the surgery.

You may experience nasal congestion because of constant coagulated blood and nasal discharge, and freezing feeling on the nose, pain in the eye during the outpatient treatment. These symptoms tend to disappear by the end of the outpatient treatment.

If you catch a cold after the surgery, you may show symptoms of sinusitis again. Since many of these cases are caused of acute inflammation, most patients recovers by drug administration without undergoing surgery again. However, if your a sinusitis patient accompanied with polyps, many have physical constitution of recurrence of sinusitis even all existing sinusitis lesions were removed through surgery. So a constant outpatient observation is required, and some may need re-operation.

Snoring can be caused by various reasons during sleep. When the patient could not breathe normally through the nose, they tend to breath through the mouth. But when the narrowness of the airway occurs in the mucous membrane that connects the nose and pharynx because of muscle relaxation during sleep, the effort to breathe intensifies causing the breathing noise which vibrates like a paper weather strip. Sleep apnea is when the patient stops breathing more than 10 seconds and then recovers breathing accompanied with severe snoring because the airways get completely blocked during sleep. It is a sleep disorder that surprises the people around you, since it usually repeats sleep interruption for several times.

Since the tension in the muscles that moves the soft palate, pharynx, and tongue are relaxed during sleep, these structures tend to partially obstruct the airway and cause vibration when you breathe in. Most adult patient’s snoring problems is caused by this. As drinking alcohol or taking drugs such as sleeping pills or tranquilizers reduce the tension in these muscles, it tends to worsen the symptoms. Even if you weren’t having snoring problems, you may be snoring while sleeping after drinking. Beside these reasons, you may be experiencing neoplasm on the throat blocking the breathing passages. Especially for children patients, snoring is caused because enlarged palatine tonsils or adenoids are interfering the breathing. Or the excessively long soft palate and uvula are narrowing the ross sectional area of ​​the nasopharynx making vibrations when breathing during sleep. The case of experiencing difficulties in breathing because of nasal congestion caused by disease of the nose itself such as rhinitis, septal deviation, sinusitis, etc, also leads to snoring since the airway narrow making excessive negative pressure in the pharyngeal cavity. In most of these cases, various causes are complexly effected.

• Central sleep apnoea : not only the intake in air by mouth or nose doesn’t proceed, there is also no breathing movement in the chest or abdomen. It is usually caused by disorders in the autonomic control on respiratory center of the central nervous system.
• Occlusive sleep apnoea : although there are no air intake through the nose or mouth, still there are breathing movements in the chest or abdomen. Mostly due to obstruction of the upper airway. Many cases of snoring patients accompanied with sleep apnea are applied as this type.
• Combined sleep apnea : When the two types of sleep apnoea stated above occurs at the same time.

1) Possibilities of other complications

A heavy snorer has high risk of hypertension and myocardial infarction occurrence. Especially for sleep apnea patients, may cause hypoxia and carbon dioxide retention while sleeping, since the repeated respiratory arrest affects supplying oxygen to the distal organs. Because of sleep interruption, patients may experience various physical and mental disabilities due to lack of sleep such as: headache when waking up, drowsiness during the day time, easily feeling tired, decrease of sexual desire, nocturnal enuresis, personality changes. If sleep apnea persists long, it may cause cardiopulmonary complications like arrhythmias, heart failure. And in the worst case, a heart attack while sleeping.

2) Social life matters

Although the snorer don’t have problems when sleeping, it may be causing a lot of problems in sleep disturbance. This may lead to potential problems in marital or group life. When sleep apnea is accompanied with snoring, it may interfere with social life because of drowsiness at work, and loss of mental concentration, memory. In worst cases, drowsiness may lead to accidents while driving.

Many snoring patients are obese, weighing more than 15% of their normal body weight. They have body types of thick and short neck with small chin. And with oral structure of large and drooping uvula, looks as if the tongue and uvula is contacted because of large tonsils and wrinkled pharyngeal mucosa, quite narrow throat when observed in a physical examination.

The essential test for diagnosing sleep apnea is polysomnogram that is proceeded during sleep. This test can make differential diagnosis in 3 types of sleep apnea and is a great help on the result determination after the treatment. But recently as many portable sleep testers are widely supplied in the purpose of plain snoring patients to proceed pretreatment test, examination can now be proceed at home too. Polysomnography which objectively evaluates the structure and function of sleep and events that occur during sleeping, is a latest state of the art examination that has been introduced in Korea less than 10 years. It comprehensively measures the patient’s brain wave, eye movement, electromyogram of the lower jaw, leg electromyography, electrocardiogram, snoring, blood pressure, breathing exercise, arterial oxygen saturation etc during 8 hours of sleep and makes a massive record of 1000 pages with video recording the patient's behavioral abnormalities during sleep.

Through detailed deciphering of this paper and video record by a sleep clinic technical engineer who has proceeded your sleeping test overnight and sleep medicine specialist, they reach to comprehensive results such as: how severe is the patient’s snoring or sleep apnea, whether arrhythmia occurs, whether the blood pressure rises or not, whether other problems do or do not occur during sleeping, in what ways is it different from a normal person’s sleeping.

1) Conservative method

The most important thing is to lose weight in general. Also since it is effective to sleep on your side, many use a pillow to maintain breathing. Drinking, taking sleeping pills and nerve stabilizers before bedtime are not recommended since it decreases the pharyngeal muscle tension.

Breathing apparatus : it is for patients who cannot undergo surgery because of various reasons or patients that cannot be treated with surgery. The mask-shaped device injects oxygen using the positive pressure at the nose while sleeping. But has cons of constantly wearing a mask while sleeping. Besides the methods stated above, you may also be treated by retainer or various oral apparatus.

2) Medicinal method

Although various drugs are used to promote the breathing during sleep such as sex hormones restriction drug, anti-depressants, etc, since the type of sleep apnea and drug side effects should be considered, it is only used in highly limited cases.

3) Operation method

If the snoring is caused by excessively enlarged tonsils, tonsillectomy should be applied first. Especially for many young children patients with snoring, the main causes are hypertrophy on the tonsils and adenoids. In these cases, tonsillectomy and adenoidectomy are appropriate. Patients with severe apnea symptoms and large tonsils and excessive soft tissue of the pharynx, we recommend the most common surgical method in sleep apnea, uvulo-palato pharyngoplasty. This surgery removes the both side of the tonsils under general anesthesia, then enlarge the space inside the throat by removing whole or partial of the uvula. As a surgical method that can widen the space inside the throat to the fullest, it is famous for having the advantage of being the most effective surgery in sleep apnea. Since it removes the tonsils and uvula it has high risk of bleeding after the surgery. And because of the edema on the surgical region spleen apnea may worsen in the early stages after the surgery, so an average of 4-5 days of hospitalization is required. 2-3 weeks for recovery is needed, as this surgery has the most severe post-surgery pain and the patient may complain about foreign body sensation.

Patients with plain snoring and mild apnea that has no tonsil hypertrophy and sleep apnea, goes through snoring laser surgery. This surgery removes or cauterize the causes of atresia which is soft tissues of the palate and pharynx, with a laser. Although compared to other surgeries the result of this surgery are not particularly great, there are several advantages such as: no need of hospitalization, simple surgery procedure, less bleeding during surgery, short surgery time, can be performed as an outpatient. Meanwhile the surgical effect of snoring laser surgery shows patient satisfaction over 90% when asked in the early stage after procedure, but decreases to approximately 70% when asked in the long-term follow-up.

As for the recently developed snoring surgery method using the coblation(high frequency surgical device), although the surgical method and effect are the same with snoring laser surgery, it differs in the surgical instrument which is coblation a device that uses high frequency. It is popular for having very little or no post-surgery pain compared to laser surgery. Laser snoring surgery was a very good surgical method when palatopharyngoplasty was performed under general anesthesia, but has had problems with pain that persists after surgery due to high fever and foreign body sensation on the pharyngeal area. Unlike the laser, surgery method using the coblation inserts a needle with a special electrode through the soft palate mucosa and shrink the tissues by generating high-frequency waves. Since high-frequency wave generates heat, it decomposes the tissue by colliding with the ions in tissue cells. The heat that is generated at this surgery, is considerably low than the laser. So it has mere effect on the surrounding mucous membranes, normal tissues, and has low pain with fast recovery period. Because it does not damage the mucous membrane, has less foreign body sensation on the pharyngeal area.

A tonsil tissue is an aggregation of follicles located inside the mucous membrane of the posterior wall(pharynx) in nose and mouth. It plays an important role as immunological defense mechanism from birth, that protects the body from outside substances entering the body. Among these aggregation of follicles, two of the most popular ones are the palatine tonsils which is the walnut-shaped tissue on both sides of the uvula commonly known as ‘tonsil’ and the pharyngeal tonsil called the adenoid which is hardly seen by the naked eye since it is located on the top of the uvula. Beside these two, other types of various tonsils are spread at the back of the mouth in a sphere shape.

When a inflammation occurs in these tonsil tissues, it is called a tonsillitis or amygdalitis. It is sorted into two types, acute and chronic tonsillitis depending on the occurrence period and time of onset. Acute tonsillitis usually means acute inflammation on the palatine tonsil, patients may experience symptoms like : difficulty in swallowing the food because of severe sore throat, high fever, general malaise, ear pain, melalgia. Chronic tonsillitis is a case that experiences interference in daily life because of frequent acute tonsillitis occurrence. Adult patients with chronic tonsillitis show symptoms like : frequently catches cold, swollen throat when you catch a cold, unable to eat because of ever and sore throat. Some patients experience a sudden pop up of a substance that is chronically yellow and has foul odor, when observed carefully on the mirror, this is caused by the inflammation on the holes in the surface of palatine tonsil.

In case of children patients with repeated occurrence of tonsillitis, a severe proliferation on the palatine tonsils or adenoids may occur. When the children patients have chronically enlarged tonsils, since it is hard to breath eating lumpy foods such as rice, they may refuge to eat lumpy foods at meal time. And when the tonsil tissues blocks the entrance of the ear canal that connects the throat and the ear, they tend to have difficulties in hearing because of the water in the ears and show these symptoms of otitis media which causes hearing loss: doesn’t respond to adult’s questions when asked, only talks on one’s own stories, put high volumes when watching the TV, watches the TV in a close distance. Also some patients may experience abnormalities in the teeth arrangement since they constantly breathe with their mouth opened or heavily snoring while sleeping because the the tonsils are too large. Patients with acute tonsillitis get similar treatment as cold treatments, but for patients with chronic tonsillitis tonsil and adenoid removal surgery is considered depending on the each patient's case.

For adult patients, we perform a surgery in these cases: severe suffer because of throat pain and fever whenever you catch a cold for 3 or more times a year, patients that have sleep apnea syndrome, severe breathing problems, snoring when sleeping, if the arthritis, heart, or kidney disease worsens due to tonsillitis. For children patients we perform a surgery when: frequent occurrence or slow recovery of otitis media or sinusitis(so-called sinus infection) because of tonsil hypertrophy, abnormalities in the teeth arrangement is caused by the tonsils. As it is usually appropriate to perform a insertion of ventilation tube in the eardrum or tonsil and adenoid removal surgery, most children patients undergoes surgery when they are over 3 years old.

Patients are usually hospitalized at the day before the surgery, and receive surgery the next day. After observing the progress for about a day or so, if you show good conditions you may be discharged 2 days after the surgery. Therefore, you get hospitalized for 3 or 4 days in average.

The surgery is usually performed under general anesthesia. A screening on the blood, urine, electrocardiograms, liver function, etc will be proceeded before the surgery. We tend to postpone the surgery in these cases because of high risks in surgery and anesthesia: if any abnormalities are detected during pre-surgery screening, having fever or a lot of sputum due to catching a cold before surgery.

Since there may be bleeding at the surgical region caused by complications after the surgery, we make the patient to lie on their side or on their stomach and spit out sputum, blood that are collected in the mouth. By doing this it helps to keep in tract of whether bleeding continues, and if a patient swallows a lot of blood or secretions it may lead to vomiting and stomachache. As for meal time on the day of surgery, if the medical attendant gives the permission, chilled soup with no solid ingredients such as meat broth or rice gruel is available. Starting from the 2nd day till 1 week after the surgery, chilled porridge is available to eat. Soft foods like ripe fish and castella are good to eat, but solid food like squid and chewy vegetables, salty or spicy stimulant food such as kimchi is better when avoided. Usage of the straw may stimulate the surgical regions and cause bleeding, so please try to avoid using a straw when drinking milk and eating rice gruel. Also soft drinks such as Coke and juice may cause pain so it is not appropriate to drink after the surgery. You might experience pain for about 1-2 weeks after the surgery. Although pain in the ears are normal, if the degree of pain is severe or feels like gradually worsening, you should receive examination. When you chew a gum starting from the day after the surgery, it may help reducing the pain.

After the surgery the surgical region tend to be covered with a white membrane as it heals. But do not worry as it is one of the normal healing process. It takes about 3 to 4 weeks to be fully healed. There may be high risks of bleeding up to 10 days after the surgery, so please avoid these things: excessive work or exercise, bathing for more than an hour. If you’re a patient that has received simultaneous operation on the ears by putting a tube in the eardrum, try not to get water in the ears. Many mis-thinks that having a tonsillectomy will avoid throat pain for the rest of your life, while you sure won’t get tonsillitis again, but pharyngitis and catching a cold may happen from time to time. However the symptoms will be much mild than the time accompanied with tonsillitis.

Many people think that the nasal septum stays straight unless they get injured or bumped into their nose, but even for non-patients it is rare to have straight nasal septum and even if you are not showing symptoms of nasal congestion you may have slightly curved nasal septum. As for the cause of septal deviation we usually think of congenital or developmental abnormalities, but a person with correctly positioned nasal septum when birth can also show a nasal septum curved to a particular side and irregular protrude depending on the growth. Beside the reasons stated above, trauma, hypertrophy on the nasal turbinate, deformities because of foreign body or tumor put pressure on the insides of the intranasal area may also be the reason of septal deviation. Most of the patients with septal deviation get along with it without any symptoms, but if you have symptoms like nasal congestion, post nasal drips causing headaches or have compensatory hypertrophy on the nasal turbinate and allergic rhinitis at the opposite side, this may worsen the symptoms of septal deviation and even lead to chronic sinusitis.

Diagnosis can be made by just parenteral examination, in these cases we recommend surgery: functional impairment in the nasal cavity due to septal malformation, when it is a interfering factor on the nasal surgery, cause or has the potential of complications in surrounding organs. Although usually the surgery is performed to patients over 17 years old, in desperate need it may be proceeded in a younger patient too.

In order to check for accompanied sinusitis and anatomy structures a X-ray is performed before the surgery. Depending on the patient’s symptoms, we also may proceed rhinomanometry too. Screening on the blood, urine, chest pictures, electrocardiograms are performed before the surgery. And when the surgery is performed under general anesthesia, liver function tests are added.

Since the surgery is performed under local anesthesia except for special occasions, during the surgery the patient can talk to the doctor and also hear everything that is being said. When first injecting anesthesia due to the needle entering, it may cause a bit of pain. After that the patient may feel some sense of touching, but not many of a pain. If you feel pain because anesthesia wore off, just ask for more anesthesia. The anesthetic medicine used on the surgery and blood may drip down to the back of the throat, do not swallow it and collect them in your mouth. Later the doctor will remove them. During the surgery you must breathe through your mouth, but because of the drugs that are used before surgery makes a synergistic effect, your mouth can be severely dry.

Tense body makes the heart rate increase and heavy bleeding, so try to loosen the body as much as possible. Although you may hear the sound of the bones being removed, there is nothing to be afraid of. Since you’ll be receiving surgery when lying down, please tell the staff if you feel uncomfortable and sick lying at the operating bed.

After the surgery, the operated nose are blocked. But even if it is blocked, blood mixed nasal discharges may occur. If this happens just spit it out often. If you’re experiencing massive bleeding of fresh red blood, please contact to your attending nurse. When this happens after discharge, visit the department of otolaryngology, outpatient clinic, emergency room for medical treatment.

You may feel a bit severe pain after the surgery when the anesthesia wears off, it’ll show improvement with pain killers or injections. Unless for special occasions, we remove the gauze stuck in the nose 2 days after the surgery. If it doesn’t bleeds anymore, normally discharge is available at the next day. Regular outpatient treatment and drug treatments are required for about 3 weeks after the surgery. Please avoid excessive exercise or saunas until about 3 weeks after the surgery. The more your symptoms improve, the less you receive treatments. A regularly check-up on the surgical region is necessary, the check-up period may differ depending on the patient's condition.

For the first few days after surgery, you may feel more congestion of the nose because of the edema on the surgical region, but as the wound heals these symptoms tend to gradually disappear. Some patients experience blood collection under the cartilage of the nasal septum, this will show improve by medical treatment. Rarely occurrence of nasal septum hole is possible, however, it actually doesn't cause much discomfort to the patient.