Sinus Surgery (FESS)

Introduction

If you are reading this, you have probably been living with sinus problems for a long time. Months, maybe years, of a blocked nose, facial pressure, repeated infections, thick discharge, headaches, poor sleep, or a reduced sense of smell. You have likely tried sprays, antibiotics, steroid tablets, saline rinses, and allergy medications. Some of these may have helped a little, or for a while, but the symptoms keep coming back. Your ENT doctor has now discussed sinus surgery with you.

This guide explains what sinus surgery — most commonly Functional Endoscopic Sinus Surgery, or FESS — actually involves. It covers who is considered a candidate, what alternatives may have been tried or are still available, how the operation is performed, what recovery looks like week by week, what the risks are, and what life tends to be like afterwards. The goal is to help you walk into your next conversation with your ENT surgeon feeling informed and prepared, not to make the decision for you. That decision belongs to you and your doctor together.

What Is Sinus Surgery (FESS)?

The sinuses are a connected set of air-filled spaces inside the bones of your face and skull. There are four pairs: the maxillary sinuses (in the cheeks), the ethmoid sinuses (between the eyes), the frontal sinuses (above the eyebrows), and the sphenoid sinuses (deep behind the nose). Each sinus drains into the nose through a small natural opening. When these openings become blocked — by swollen tissue, polyps, thickened mucus, or anatomical narrowing — the sinuses cannot drain or ventilate properly, and inflammation and infection can become chronic.

Functional Endoscopic Sinus Surgery (FESS) is a minimally invasive operation that uses a thin telescope, called an endoscope, passed through the nostrils to reach the sinuses. The surgeon views the inside of the nose and sinuses on a high-definition screen and uses fine instruments to open the natural drainage pathways, remove polyps or diseased tissue, and improve airflow.

The word functional is important. The aim is not to remove as much tissue as possible. It is to restore the sinuses' normal function — drainage and ventilation — while preserving as much healthy mucous membrane as possible. Modern sinus surgery is built on the idea that opening the natural openings and reducing the disease load allows the body and ongoing medical treatment (sprays, rinses, and where needed, allergy or biologic therapy) to control sinus inflammation in the long term.

FESS is performed entirely through the nostrils. There are no external cuts and no facial scars.

Why Is Sinus Surgery Performed?

Sinus surgery is considered when sinus disease is persistent, recurrent, or causing complications, and when reasonable medical treatment has not given adequate control. The most common reasons doctors consider FESS include:

• Chronic rhinosinusitis (CRS) — sinus inflammation lasting twelve weeks or longer that has not responded sufficiently to nasal steroid sprays, saline rinses, and other medical therapy. CRS is usually divided into two main forms: with nasal polyps (CRSwNP) and without nasal polyps (CRSsNP).
• Nasal polyps causing blockage, loss of smell, or pressure symptoms that medication has not controlled.
• Recurrent acute sinusitis — multiple distinct sinus infections in a year, where imaging or examination suggests a structural or drainage problem.
• Fungal sinus disease, including fungal balls and allergic fungal rhinosinusitis.
• Mucoceles — cysts of trapped mucus that can expand and press on surrounding structures.
• Complications of sinusitis, such as infection spreading toward the eye or, rarely, the brain.
• Anatomical issues contributing to blockage, such as a severely narrowed sinus opening or a concha bullosa (an air pocket within a turbinate).
• Access for other procedures, such as tear duct surgery, removal of certain tumours, repair of cerebrospinal fluid leaks, or pituitary surgery (where the sinus is used as the route to the deeper area).

Major ENT societies, including the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) and the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS), describe surgery as appropriate when adequate medical therapy has been tried and symptoms or disease persist on examination and imaging. The exact threshold is a clinical judgement made together with your surgeon.

Who Is a Candidate?

Sinus surgery is not for occasional sinus infections, a common cold, or short-lived sinus pressure. It is generally considered for people who have a confirmed chronic or recurrent sinus problem and whose quality of life is being meaningfully affected.

Doctors typically look for a combination of:

• Persistent symptoms for at least twelve weeks (in CRS) or repeated, well-documented sinus infections (in recurrent acute sinusitis)
• Findings on nasal endoscopy — such as pus, polyps, or swelling around the sinus openings
• Findings on a CT scan of the sinuses showing inflammation, blockage, or anatomical issues that fit the symptoms
• A trial of appropriate medical treatment that has not given adequate relief
• No medical condition that makes anaesthesia or surgery unsafe at this time

Conditions that may need to be addressed or stabilised before surgery include uncontrolled asthma, bleeding disorders, poorly controlled diabetes, and use of blood-thinning medications. People with conditions such as aspirin-exacerbated respiratory disease, cystic fibrosis, or primary ciliary dyskinesia may still be good candidates for surgery, but they often need a more comprehensive long-term plan because their underlying disease will continue after the operation.

Whether sinus surgery is the right next step for you is a clinical decision made with your ENT surgeon after reviewing your history, examination, scans, and previous treatment response.

Alternatives and What May Be Tried First

For most sinus conditions, surgery is not the first option. Before recommending FESS, doctors typically work through several layers of medical treatment. Many readers will have been through some of these already. Understanding where they fit helps clarify why surgery is now being considered.

Maximal Medical Therapy

For chronic rhinosinusitis, current guidelines describe a stepwise approach that may include:

• Daily saline nasal irrigation using a large-volume rinse bottle or neti pot, which is a foundation of treatment
• Intranasal steroid sprays to reduce inflammation in the nasal lining
• Steroid rinses, where steroid is added to the saline irrigation, for more severe inflammation
• Short courses of oral steroids in selected cases, particularly with nasal polyps
• Antibiotics for confirmed acute bacterial infections, used in a targeted way rather than repeatedly
• Treatment of allergies, including antihistamines, allergen avoidance, and in some patients allergen immunotherapy
• Treatment of underlying conditions such as asthma or gastro-oesophageal reflux, which can drive sinus symptoms

Biologic Medications

For people with severe chronic rhinosinusitis with nasal polyps that has not responded to standard medical therapy, newer biologic drugs (such as dupilumab, omalizumab, and mepolizumab) target specific inflammatory pathways. These have changed the picture for some patients who would previously have had repeated surgeries. Biologics are typically prescribed by an allergist or ENT specialist, are given as injections, and are continued long-term. Whether biologics or surgery comes next — or whether both are used — is an individual decision that depends on the disease type, severity, response to previous treatment, and patient preference.

Balloon Sinuplasty

Balloon sinuplasty is a less invasive procedure in which a small balloon is passed into a blocked sinus opening and inflated to widen it. It can be done alone for selected sinus openings (most commonly the maxillary, frontal, and sphenoid) or combined with FESS as a hybrid procedure. Balloon sinuplasty does not remove tissue or polyps, so it is generally not suitable as a standalone treatment for extensive polyp disease, ethmoid disease, or fungal sinus disease. Whether balloon dilation, FESS, or a combination is appropriate depends on the location and extent of the disease.

Watchful Waiting

For mild or fluctuating symptoms, continuing medical therapy and reviewing periodically is reasonable. Sinus surgery is not urgent in most situations and can be planned at a time that suits you.

Types and Extent of Sinus Surgery

Sinus surgery is not a single fixed operation. The surgeon plans which sinuses to open based on your CT scan and examination. The aim is to address all the sinuses that are diseased, while leaving healthy areas untouched. The operation may include one or several of the following components.

Uncinectomy

The uncinate process is a thin bony flap that partially covers the natural drainage area of the maxillary sinus. Removing it is usually the first step of FESS and exposes the natural sinus openings.

Maxillary Antrostomy

The natural opening of the maxillary (cheek) sinus is widened to improve drainage. This is one of the most common steps in sinus surgery.

Ethmoidectomy

The ethmoid sinuses are a honeycomb of small air cells between the eyes. In ethmoidectomy, the thin walls between these cells are carefully removed to open the area into a single drainage cavity. This is often needed in chronic rhinosinusitis and nasal polyp disease.

Sphenoidotomy

The natural opening of the sphenoid sinus, which sits deep behind the nose, is identified and widened where this sinus is diseased.

Frontal Sinusotomy

The drainage pathway of the frontal sinus, above the eyebrow, is opened. The frontal area is anatomically complex and close to the eye and skull base, so frontal surgery requires particular care and experience.

Polypectomy

Nasal polyps are carefully removed where present, often in combination with the steps above.

Adjunctive Procedures

Several procedures may be performed at the same time as FESS when relevant:

• Septoplasty — straightening of a deviated nasal septum to improve access and breathing.
• Turbinate reduction — reducing the size of enlarged inferior turbinates that block airflow.
• Balloon dilation of selected sinus openings, used in hybrid cases.
• Image guidance (computer-assisted navigation) — not a separate procedure but a technology that gives the surgeon real-time GPS-like guidance using your CT scan. It is commonly used for revision surgery, frontal sinus surgery, extensive disease, or cases close to the eye or skull base.

Your surgeon will explain which combination is planned for you and why, based on your imaging.

Preparing for Sinus Surgery

Good preparation helps the operation go smoothly and supports a better recovery.

Before the Date Is Set

• A recent CT scan of the sinuses is usually required so the surgeon can plan the operation accurately.
• Your medical history, current medications, allergies, and previous surgeries will be reviewed.
• Tell your surgeon about any bleeding tendency, blood thinners (including aspirin, clopidogrel, warfarin, and newer anticoagulants), supplements such as fish oil, vitamin E, ginkgo, or high-dose turmeric, and any herbal medicines. Many of these can increase bleeding and may need to be stopped for a period before surgery.
• If you have asthma, allergies, or polyps, your doctor may prescribe a course of oral or nasal steroids before surgery to reduce inflammation and bleeding.
• An anaesthesia review will assess your fitness for general anaesthesia.

In the Days Before Surgery

• Continue prescribed nasal sprays and rinses unless told otherwise.
• Avoid smoking, ideally for as long as possible before and after surgery. Smoking impairs healing of the sinus lining.
• Arrange for someone to bring you home after the procedure and stay with you for the first night.
• Follow fasting instructions — usually no food for several hours before surgery, with clear fluids allowed up to a specified time.

What Happens During Sinus Surgery

FESS is most often performed under general anaesthesia, meaning you are fully asleep and feel nothing. In selected cases, particularly limited procedures, it can be done under sedation with local anaesthesia. The operation typically takes between one and three hours, depending on how many sinuses are being addressed and the complexity of the disease.

After you are asleep, the surgeon places a decongestant inside the nose to shrink the lining and reduce bleeding. The endoscope is then passed through one nostril, and the relevant sinuses are opened in turn using fine instruments. A small powered shaver (microdebrider) is often used to remove polyps and diseased tissue precisely. Image guidance may be used to confirm the position in complex cases.

At the end of the operation, the surgeon checks for bleeding and may place dissolvable spacers or, less often, a soft nasal packing to support healing and reduce bleeding. Many modern packings dissolve on their own and do not need to be pulled out later. Your surgeon will tell you what was used in your case.

You wake up in a recovery area. Most patients go home the same day, although an overnight stay is sometimes recommended — for example, after extensive surgery, in patients with significant other medical conditions, or if there are concerns about bleeding.

Recovery and Healing

Recovery from FESS is generally well tolerated. Pain is usually mild to moderate and described more as pressure or congestion than sharp pain. However, the inside of your nose has just had an operation, and it needs time to heal. Sinus healing happens in stages, and how you take care of your nose in the first few weeks influences the long-term result.

The First Week

• Expect a blocked nose, mild bloody discharge, and crusting. Most bleeding is minor and settles quickly.
• Avoid blowing your nose. If you need to sneeze, do so with your mouth open.
• Sleep with your head elevated on two or three pillows to reduce swelling.
• Use saline sprays or gentle saline rinses as instructed. Most surgeons start saline rinses within the first few days — these are important for keeping the new pathways clear.
• Pain relief usually involves paracetamol and sometimes mild opioid medication for a few days. Avoid aspirin and certain anti-inflammatory drugs unless your surgeon approves them, as they can increase bleeding.
• Avoid strenuous activity, heavy lifting, bending forward, and hot showers in the first few days.

Weeks Two to Four

• Crusting and discharge gradually reduce. Your sense of smell may fluctuate.
• You will usually return to the clinic for a debridement — gentle cleaning of crusts and debris from the sinus cavities using the endoscope in the office. This may be done one or more times. It is uncomfortable but not usually very painful and is important for healing.
• Most people return to office-based work within one to two weeks. Physically demanding work, exercise, and air travel are typically delayed for two to four weeks, based on your surgeon's advice.
• Continue saline rinses daily — this remains one of the most important parts of recovery.

Months One to Three

• The sinus lining gradually returns to a healthier state. Smell often improves over weeks to months.
• Steroid sprays or rinses are usually restarted and continued long-term, especially in chronic rhinosinusitis with polyps.
• Follow-up endoscopy checks healing and looks for any early signs of recurrence.

Beyond Three Months

Most patients have settled into their new baseline by three to six months. Long-term care — saline rinses, steroid sprays, and management of allergies or asthma — continues to be important. The surgery is best thought of as creating the conditions in which medical treatment can work; it is not usually a one-and-done cure.

Risks and Complications

FESS is generally a safe procedure when performed by experienced ENT surgeons, but like any operation it carries risks. The risks are low overall, but they deserve a clear discussion.

Common, Usually Minor

• Bleeding — usually minor and self-limiting. Significant bleeding requiring further intervention is uncommon.
• Pain, pressure, or headache for a few days.
• Crusting and temporary nasal blockage.
• Temporary changes in smell or taste.
• Infection — uncommon and usually managed with antibiotics.

Less Common but Important

• Synechiae (adhesions) — scar tissue forming between surfaces inside the nose, which can sometimes need to be released in clinic.
• Recurrence of disease — polyps and chronic inflammation can come back over time, particularly in patients with severe underlying disease, asthma, or aspirin sensitivity. Revision surgery is sometimes needed.
• Persistent symptoms — some patients improve less than hoped, especially when symptoms have multiple contributing causes.
• Dryness or atrophic changes in the nasal lining.

Rare but Serious

• Eye complications — including bruising, double vision, or, very rarely, vision loss from injury to the eye or optic nerve.
• Cerebrospinal fluid (CSF) leak — a tear in the thin layer separating the sinuses from the brain, causing leakage of brain fluid. Usually recognised and repaired during the same operation, but occasionally requires a further procedure.
• Major bleeding requiring transfusion or further surgery.
• Infection of structures near the brain — extremely rare.

The risk of serious complications is reduced by careful surgical technique, modern endoscopic equipment, and, where appropriate, image guidance. Your surgeon will discuss the risks specific to your anatomy and disease.

Life After Sinus Surgery

Most people who have FESS for the right reasons experience meaningful improvement in their symptoms. Studies and clinical experience consistently show better nasal breathing, fewer infections, less facial pressure, improved sleep, and a better sense of smell in many patients. Quality-of-life scores typically improve substantially.

That said, sinus surgery is not a permanent cure for chronic sinus disease, and it is important to have realistic expectations.

• Polyps can come back. In chronic rhinosinusitis with nasal polyps, recurrence over years is common. Ongoing nasal steroid sprays or rinses, and in some cases biologic medications, help control this.
• Underlying conditions continue. Allergies, asthma, and aspirin sensitivity do not go away with sinus surgery. Managing them is part of long-term care.
• Saline rinses become a habit. Most ENT surgeons advise long-term, often lifelong, saline irrigation as part of sinus care. It keeps the wider sinus pathways clean and reduces inflammation.
• Smoking and irritants matter. Smoking is strongly associated with worse outcomes and revision surgery. Avoiding tobacco and reducing exposure to occupational irritants supports better long-term results.
• A small proportion need revision surgery. If symptoms return despite optimal medical care, repeat FESS may be considered, often with image guidance.

Your follow-up plan will usually include endoscopy visits to monitor healing and disease control, prescription nasal steroids, allergy or asthma care where relevant, and a clear plan for what to do if symptoms flare.

Sinus Surgery in Children

Sinus surgery in children is approached more cautiously than in adults. The sinuses are still developing through childhood, and many paediatric sinus problems improve with time and medical treatment.

In children, doctors generally try medical treatment for longer and often consider adenoidectomy (removal of the adenoid tissue at the back of the nose) as the first surgical step for persistent sinus symptoms, because enlarged or chronically inflamed adenoids are a frequent contributor. Adenoidectomy alone improves symptoms in many children with chronic rhinosinusitis.

FESS in children is considered for:

• Chronic rhinosinusitis that has not improved with thorough medical treatment and adenoidectomy
• Nasal polyps, particularly in conditions such as cystic fibrosis
• Complications of sinusitis (such as infection spreading to the eye socket)
• Antrochoanal polyps, fungal sinus disease, or certain anatomical abnormalities

When FESS is performed in children, it is generally more conservative than in adults, with the aim of preserving as much normal tissue and anatomy as possible. Recovery in children is often quicker, but post-operative care, including saline rinses and follow-up endoscopy, is just as important. Decisions about paediatric sinus surgery are best made by an ENT surgeon experienced in treating children.

Frequently Asked Questions

Will I have black eyes or facial bruising after surgery?

Because FESS is done through the nostrils, external bruising is uncommon. Some patients notice mild puffiness around the eyes for a few days, but visible black eyes are not typical.

Will my sense of smell come back?

Loss of smell is one of the most distressing symptoms of chronic sinus disease, especially with polyps. Many patients regain a significant amount of smell after surgery, although the timing varies from weeks to several months. Recovery of smell is generally better when surgery is combined with ongoing steroid sprays or rinses.

How soon can I fly after sinus surgery?

Most surgeons advise avoiding air travel for one to two weeks, sometimes longer, depending on the extent of surgery and how healing is progressing. Pressure changes during flying are uncomfortable when the sinuses are healing. Your surgeon will give a specific recommendation for your situation.

Will I still need nasal sprays after surgery?

Yes, in most cases. Sinus surgery improves how well topical medications reach the sinus lining. Ongoing nasal steroid sprays, saline rinses, and sometimes steroid rinses are usually continued long-term, particularly for chronic rhinosinusitis with nasal polyps.

Can sinus disease come back after surgery?

Yes. Chronic sinusitis and polyps are inflammatory diseases, and surgery does not eliminate the underlying tendency to inflammation. Recurrence rates depend on the type and severity of disease and on how consistently long-term medical care is followed. Some patients have a single surgery and stay well for many years; others need further treatment over time.

How is FESS different from balloon sinuplasty?

Balloon sinuplasty widens a sinus opening with an inflatable balloon but does not remove tissue. It is suitable for some patients with limited disease but is not generally enough for extensive polyp disease, ethmoid disease, or fungal sinusitis. FESS allows removal of diseased tissue and treatment of all sinuses. The two can also be combined in hybrid procedures.

Is FESS painful?

Most patients describe the discomfort after FESS as mild to moderate — more like pressure, fullness, or a heavy cold than sharp pain. It is usually well controlled with paracetamol and, for a few days, mild prescription pain relief if needed.

How long until I feel the full benefit?

Some improvements, such as better breathing, are noticeable within a few weeks once swelling settles. Other improvements, such as full return of smell or reduced infection frequency, become clearer over three to six months as the sinus lining heals and medical therapy takes effect.

What if my symptoms do not improve?

If symptoms persist, your surgeon will look for ongoing inflammation, scarring, untreated allergies or asthma, or other contributing conditions. Adjusting medical therapy, adding biologic treatment, or, less commonly, revision surgery may be considered. Persistent symptoms after FESS are best evaluated with repeat endoscopy and sometimes a new CT scan.

Conclusion

Sinus surgery, most commonly FESS, is a well-established treatment for chronic and recurrent sinus disease that has not responded to medical care. By opening the natural drainage pathways and removing diseased tissue while preserving healthy lining, it aims to reduce infections, improve breathing and smell, and make ongoing medical treatment more effective. It is not a single-step cure for an inflammatory disease, but for the right person, it can make a meaningful difference to daily life.

Whether sinus surgery is the appropriate next step, and which specific procedures to include, are decisions to make together with an ENT surgeon who knows your history, has reviewed your imaging, and understands what matters most to you. Going into that conversation with a clear picture of what FESS is, what it can and cannot do, and what recovery involves is the best preparation you can have.