Sinuses are empty spaces in the facial bones and forehead bone. They contain air and are lined with the same mucus membrane that lines the nasal passages. They connect with the nose passage through small openings called ostia. Typically these ostia are 1-2 mm in size and are they only means of clearing the sinuses into the nasal passage. The mucous membranes make mucus and kept the cavities moist and have small cilia or hair lining the mucus membranes that beat towards the openings.


Sinusitis is a term used for inflammation of the sinus mucus membranes. Inflammation may be caused by infection, allergies, smoke, pollution, bacteria, fungi or viruses. Some conditions such as HIV, immune deficiencies or connective tissue diseases such as sarcoidosis, Wegener’s granulomatosis or ciliary problems make it more likely to have sinus inflammation.



What happens with sinus inflammation?

When sinuses get inflammed, they get swollen and congested, produce more secretions that may become very thick that plug up the sinuses. Irritation of nerve endings and blockage of the small sinus openings may result in further infection and inability of the sinuses to clear themselves causing symptoms of sinusitis

What are the symptoms of acute sinusitis?

In an acute infection of the sinuses, typically facial pain or headache, fever or thick yellowish or green nasal discharge is noted. Cough, postnasal drip and sinus congestion and nasal obstruction are common. Acute sinusitis may occur after a virus infection or a cold that lasts longer than 7-10 days.

How long can symptoms of acute sinusitis last?

They may last up to 4 weeks but generally last less than that.

What is the treatment for acute sinusitis?

For mild acute sinusitis, generally symptomatic treatment is adequate. Saline nasal irrigation may help along with decongestants and pain medications. For moderate to severe acute sinusits, antibiotic therapy and intranasal with or without oral steroids may be offered. Sometimes intravenous antibiotics may be considered. When acute sinusitis results in complications, then surgery is indicated. Or when acute sinusitis fails to respond to antibiotics over many weeks, a CT scan of the sinuses should be considered.

What is chronic sinusitis?

When symptoms persist for longer than 12 weeks then the term chronic sinusitis is used. Most individuals with chronic sinusitis have had symptoms for years.

What are the symptoms of chronic sinusitis?

Nasal obstruction or stuffy nose, sinus pressure or facial or forehead headaches or even headaches in the back of the head may be present. Discolored discharged may be noted from the nose with possible foul smell or reduced smell.

How do you diagnose chronic sinusitis?

In addition to a history and exam, a nasal endoscopy and/or a CT scan of the sinuses will probably be recommended. If nasal endoscopy shows pus or polyps then chronic sinusitis is confirmed. However even a negative nasal endoscopy does not rule out sinusitis. After having reviewed his own experience over the years and that of others, Dr Khetarpal is currently of the opinion that a CT scan performed upfront for diagnostic reasons is the best use of money and in reducing usage of unnecessary antibiotics and medications, although this is not necessarily the policy adopted by some insurance carriers.

Are there any tests that may be performed?

Yes, a blood test may be ordered

Are there different types of chronic sinusitis?

Yes there are at least two types of chronic sinusitis with some additional variants of this disease. In one type of chronic sinusitis, polyps are not seen in the sinuses or the nose passage whereas in the second variety polyps are commonly noted either on nasal exam or on CT scan. A variety of chronic sinusitis with polyps is one in which fungus is present in the sinuses.

How do you treat chronic sinusitis?

In the variety without polyps, antibiotics for 3 or more weeks may be prescribed with or without nasal and oral steroids. In chronic sinusitis with polyps, nasal and oral steroids may be prescribed first to assess response. Antibiotics generally have no role in this type of disease. If allergic fungal sinusitis is suspected then surgery would be necessary.
Saline sprays or irrigation is good for both conditions and for reducing the impact of allergies. Baby shampoo diluted in water and used for nasal irrigation is helpful particularly in patients with repeat sinus problems despite previous surgery.

What if my symptoms persist despite medical treatment?

A CT scan will be ordered and assessed for persistent sinusitis. Endoscopic sinus surgery may be recommended if necessary.

What is the latest in surgical treatment?

We are excited to offer you the latest surgical treatment for chronic sinusitis. This procedure called balloon sinuplasty allows obstructed sinuses to be opened in the office under local anesthesia in a minimally invasive fashion without removing tissue. Details of this procedure and some video demonstrations are available in another section of the website and on you tube under “thesinuscenter”.

What is the latest in medical treatment for chronic sinusitis and polyps?

Prolonged usage of antibiotics and steroids may lead to drug resistance and moderate side effects. Intolerance is an issue as is usage of steroids in diabetics or those with hypertension, glaucoma, ulcer disease and a few other conditions. Intranasal irrigations with steroids may be helpful and drug eluting stents may be placed after surgery to reduce the recurrence of polyps. Several double blind studies have indicated benefit with anti-IgE antibody and anti-IL5 antibody but widespread use has not occurred yet due to cost and duplication of these studies. Intranasal and oral antifungal therapy has resulted in conflicting results. In our practice we are assessing the role of certain antibiotics and anti-inflammatory agents that have anecdotally shown benefit in some of our patients and in some studies in Europe.

How do I prepare for sinus surgery?

Avoid Vit E, aspirin, blood thinners 5-7 days before surgery. Gingko biloba and some herbal as well as over the counter products may interfere with healing and result in increased bleeding during and after surgery. Therefore, avoid herbal products before surgery. Any sort of illegal drug usage is prohibited at least two weeks before surgery. Alcohol should be avoided the week before surgery. If you are used a steroid nasal spray such as Nasonex or Flonase or Omnaris, please continue using it even during the day of surgery. Oral steroids may be prescribed before surgery and sometimes after surgery. Please adhere to the schedule for usage of steroids. The night before surgery do not eat or drink anything after midnight. Other medications such as blood pressure and diabetes medications should be continued prior to surgery.

What are the side effects of steroids?

Oral steroids such as prednisone can cause stomach upset, acidity and heartburn, increase blood sugar especially in diabetics, increase blood pressure and may cause water retention and weight gain when used for a longer duration. Glaucoma and peptic ulcer disease may get worse during steroid usage. If you are taking acid reflux medication already you may need to increase the dosage during steroid use. Milk of magnesia is our preferred antacid for immediate relief. Rarely skin reactions and acne may get worse. Discuss these with us prior to using steroids.

When are oral steroids used?

Typically in situations of nasal polyps, or prior to surgery. In allergic fungal sinusitis, steroids may be used long term for 2-3 months at a time.

How is endoscopic sinus surgery performed?

During endoscopic sinus surgery, rigid endoscopes about 3 – 4 mm in size are passed into the nasal passage and sinuses are opened with the assistance of powered shavers or cutting instruments to open the sinuses. Polyps if present will be removed and if the septum is deviated that may be need to be corrected. Typically the turbinates may be reduced in size during surgery to improve the air passage. We rarely use packing in the nose after surgery.

What should I expect after endoscopic sinus surgery?

Most individuals will experience some headache and nasal congestion the first week after surgery lasting up to three weeks after. This is related to scabs and blood clots in the nose and due to congestion of the mucus lining and irritation of the nerves. As the sinuses heal the headaches and congestion should improve. In the first week after surgery you will notice some bleeding down the front of the nose and in the back of the throat . Change the nasal gauze as often as is necessary. Old blood may drain into the back of the throat for up to 3 weeks after surgery depending on the extent of surgery. It is rare to see significant bleeding after surgery but if this is noted, packing may be placed for a few days. Rarely, controlling bleeding in the operating room may be necessary. If nasal congestion is severe, then Afrin Nasal spray may be used on an as needed basis three sprays on each side but not more than twice a day or for more than 3 days continuously.

What should I do after surgery?

Ice cool compresses to the nose and face should be applied for the first 4-5 days every 2-3 hours for about 10-15 minutes at a time. Do not eat hot or spicy foods after surgery for about a week. Sleep with back up about 30 degrees or on a recliner for the first few days. Sneeze with mouth open if necessary. Do not blow your nose aggressively as this may result in bleeding.

Which symptoms will improve after sinus surgery and septum correction?

Typically we would expect improvement in nasal congestion, sinus pressure or facial pain, improvement in sinus headache and some improvement in chronic fatigue and body pain. We have found that in many of our patients, migraine headaches tend to improve after sinus surgery. Postnasal drip and smell may be difficult to improve. Of course allergy related symptoms such as clear runny nose, sneezing, itchy nose and eyes will not improve with surgery.

What is Dr Khetarpal’s experience with sinus surgery?

Dr Khetarpal has extensive experience with simple and complex sinus surgery for over 15 years. A few times over the past 10 years he has taken the patient back to the operating room for bleeding control. No patient has had eye muscle or vision problems. He has operated on very complex sinus polyps or Allergic fungal sinusitis and many revision cases requiring drilling within the sinuses or even open sinus surgery. He is very comfortable with revision sinus surgery.

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Dr Khetarpal is one of a limited number of sinus surgeons across the country performing comprehensive sinus surgery with balloon sinuplasty in the office and also pioneering the use of image guided endoscopic sinus surgery in the office. Dr Khetarpal has performed complex endoscopic sinus surgeries for more than 20 years without any nasal packing. Dr Khetarpal is a perfectionist, whether he is doing sinus surgery, ear surgery or rhinoplasty. Dr. Khetarpal’s Trademarked PIVA Office Balloon Sinuplasty Procedure is performed in-office.


He is currently involved in research projects trying to identify causes of chronic sinusitis and devising newer treatments. He has a Western Institutional Review Board approval for performing research on chronic sinusitis, allergic fungal sinusitis, nasal polyps and allergic rhinitis as well as on data collection and clinical research on these patients. He is also conducting research on the impact of endoscopic sinus surgery or balloon sinuplasty on on sinus headaches. Dr Khetarpal did his residency training in Syracuse, New York and has extensive clinical and research experience at Massachusetts Eye and Ear Infirmary, Brigham and Women’s Hospital and Harvard Medical School in Boston. In addition to his interest in sinus disease and allergies, Dr Khetarpal is Board certified in Sleep Medicine and also has a tremendous interest in rhinoplasty and facial plastic surgery. He brings his ear surgery and facial plastic surgery expertise into sinus surgery as well.

Dr Khetarpal spent many years in the Rio Grande Valley treating the underprivileged, uninsured and indigent patients with severe sinus conditions and significant Ear, Nose and Head and Neck and thyroid disease. He is in the process of publishing his experience with allergic rhinitis in chronic sinus disease as well as his experience with fungal sinus disease. His multimedia presentations on Chronic Sinusitis, Allergic Fungal Sinus disease and balloon sinuplasty have received praise from fellow physicians.