Specialist ENT FUNCTIONAL ENDOSCOPIC SINUS SURGERY FESS

ANTRAL PUNCTUREFUNCTIONAL ENDOSCOPIC SINUS SURGERY (FESS)

Functional Endoscopic Sinus Surgery (FESS) permits the direct visualization and treatment of various parts of the nasal cavities and sinuses which are otherwise inaccessible surgically. History: Dr Hirschmann (1903) is considered the father of endoscopy. Dr David Kennedy, MD, and Karl Storz, MD, of Johns Hopkins University developed instruments for use in endoscopic sinus surgery, and coined the term Functional Endoscopic Sinus Surgery. Prof. Stammberger from Austria is considered father of modern Functional Endoscopic Sinus Surgery.
Specialist ENT Screenshot 2020 11 28 Ganpati nose
Indications:
Diagnostic:
  1. Cases of sinusitis, anosmia, nasal obstruction.
  2. Biopsy of nasal and nasopharyngeal tumors.
  3. Evaluation of epistaxis of unknown origin.
  4. Evaluation of cerebrospinal fluid rhinorrhea.
  5. To evaluate the nasal cavity after surgery and surgical resections like radical maxillectomy, and other post-operative cases.
Therapeutic:
  1. Chronic sinusitis.
  2. Antrochoanal and Ethmoidal polyposis.
  3. Cauterization of bleeders in epistaxis.
  4. Closure of CSF rhinorrhea leaks.
  5. Optic nerve de-compression.
  6. Rhinolith and foreign body removal.
  7. Intranasal Dacryocystorhinostomy (DCR).
  8. Removal of nasal masses such as Rhinosporidiosis, Angiofibroma, Inverted papilloma.
  9. Choanal atresia.
  10. Turbinoplasty.
  11. As an approach for Trans-Sphenoidal Pituitary tumors and Anterior skull base tumors.
Contraindications: a. Inexperience and lack of proper instrumentation.
b. Disease inaccessible by endoscopic procedures, e.g. very lateral frontal sinus and disease encasing the Internal carotid system.
c. Osteomyelitis.
d. Threatened intracranial or intraorbital complications.
Aim of Functional Endoscopic Sinus Surgery (FESS):
  • Remove the diseased mucosa to relieve obstruction.
  • Restoration of nasal patency, without excessive exposure. Excessive nasal patency is reportedly associated with a syndrome of ‘empty nose’ characterized by dryness, crusting, subjective obstruction and sometimes pain.
  • Improved delivery of medications and washes.
  • Improved exposure to olfactory stimuli.
  • Clearance of inflammatory foci (opacified cells and sinuses).
  • Maintenance and restoration of natural mucociliary pathways.
Anesthesia: General anesthesia is preferred by most of the surgeons. Local anesthesia with intravenous sedation can be used in adults when surgery is limited and cooperative patients. Position: Patient lies flat in supine position with head resting on a ring or head rest and raised it by 15 degree (reverse Trendelenberg position). Techniques: Two surgical techniques are followed: i. Anterior to posterior (Stammberger’s technique)- In this technique surgery proceeds from uncinate process backward to sphenoid sinus. Advantage of this technique is to tailor the extent of surgery to the extent of disease. ii. Posterior to anterior (Wigand’s technique)- Surgery starts at the sphenoid sinus and proceeds anteriorly along the base of skull and medial orbital wall. This is mostly done in extensive polyposis or in revisional sinus surgery. Steps: I. Intranasal preparation-
  • Topical decongestion is used in the form of cocaine and adrenaline, +/− sodium bicarbonate (‘Moffat’s solution’) soaked on neuro-patties, ribbon gauze or pledgets. The use of co-phenylcaine which is a combination of lignocaine 5% and phenylephrine 0.5%, is also effective.
  • Local anesthetic infiltration of the middle turbinate, nasal septum and frontal process of the maxilla is done with 1 to 2 ml of 1% lignocaine with 1 in 80000 adrenaline.
II. Eye preparation– The eyes are kept open with lubrication. III. Uncinectomy and Middle meatal antrostomy-
  • The free edge of the uncinate process can be identified in most cases by the use of a Freer’s elevator.
  • Either adult or pediatric back-biting is used for safer uncinate incision.
  • The uncinate process can then be removed using angled through-biting forceps or can be dislocated forward using a double right-angled ball probe and then cautiously removed with the microdebrider or through-biting forceps.
  • Any rough edges can be removed using a 2mm Kerrison’s punch.
  • The horizontal part of the uncinate which extends inferior to the natural ostium of the maxillary sinus is then addressed. The bone of the horizontal portion can be dissected free from the mucosa and the natural ostium can simply be stretched open with an angled probe or sucker, without removing any mucosa.
  • Middle meatal antrostomy done by enlargement of the natural opening of the maxillary sinus.
Specialist ENT Screenshot 2020 11 28 Ganpati nose
Specialist ENT Screenshot 2020 11 28 Ganpati nose

IV. Removal of the ethmoidal bulla

  • The natural ostium of the ethmoidal bulla sits posteromedial to the anterior face. The ostium can be located and a double right angled ball probe or 45° antral curette can then be used to fracture the anterior face forwards.
  • A microdebrider can then be used to remove the bulla, aiming for complete removal of partitions between the lamina papyracea and the middle turbinate. 
  • When removing the bulla superiorly, it is important to recognize the location of the anterior ethmoidal artery.
Specialist ENT Screenshot 2020 11 28 Ganpati nose

V. Posterior ethmoidectomy

  • The ground lamella of the middle turbinate defines the junction between the anterior and posterior ethmoid sinuses.
  • The ground lamella is perforated in the infero-medial quadrant to avoid inadvertent injury to the skull base or lamina papyracea. 
  • Once the posterior ethmoids are opened, the roof of the maxillary sinus can be used as a guide to the superior limit of dissection within the posterior ethmoid.
  • A microdebrider, Kerrison’s punch or through-biting instruments can be used to remove the partitions between the posterior ethmoid cells. 
  • Care should be taken in the posterior ethmoid as the optic nerve may traverse through an Onodi cell.

IV. Sphenoidotomy-

  • The natural sphenoid ostium is located in the sphenoethmoidal recess, medial to the superior turbinate and at the height of the antral roof. 
  • It is not always possible to pass an endoscope medial to the superior turbinate to identify the ostium, so part of the middle turbinate can be resected with back-biting forceps to enter the superior meatus and locating the forward projection of the superior turbinate from within the posterior ethmoid cavity. The inferior third of the superior turbinate can then be resected in order to gain access to the sphenoethmoidal recess. 
  • If the sphenoid ostium can still not be located using this method, an artificial opening to the sphenoid can be made through the posterior ethmoid and then extended medially to incorporate the natural sphenoid ostium.

VII. Frontal sinus surgery– 

  • The Agger nasi cell can be a key landmark to all approaches to the frontal recess. Using a Kerrison’s punch in the axilla of the middle turbinate, the anterior portion of the Agger nasi can be removed.
  • Curettes and angled instruments can then be used to remove the posterior wall and roof of the Agger nasi to expose the frontal recess.
Specialist ENT Screenshot 2020 11 28 Ganpati nose
Post-Operative Management
  • High volume saline irrigations to clean the nose of mucopus, blood clot and other diseased tissue.
  • If mucopus is found at the time of surgery, a swab should be taken and targeted antibiotic treatment should then be prescribed.
  • Oral prednisolone can be given daily for 10 days with / without tapering.
  • Eosinophils can last up to 3 weeks in the tissues and if there is extensive eosinophilic disease then an extended course of steroids is used for 3 weeks or longer. In this case, the steroid dose will need to be tapered off to avoid an Addisonian crisis.
  • It is important to emphasize to patients with severe disease that they may require regular post-operative topical steroid sprays or irrigation for extensive disease to prevent recurrence of their nasal polyps.
Complications of Functional Endoscopic Sinus Surgery (FESS)
Minor complications: Major complications:
  1. Septal or mucosal adhesions.
  2. Orbital emphysema.
  3. Epiphora.
  4. Bleeding.
  1. Blindness or loss of vision.
  2. CSF leak.
  3. Meningitis.
  4. Intracranial bleed.
  5. Damage to the internal carotid artery.
  6. Vasovagal collapse.
However, it must be noted that complications are markedly reduced in skillful hands, with good instruments and advanced imaging techniques.

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