Functional endoscopic sinus surgery

Functional endoscopic sinus surgery (FESS) is performed intranasally using a rigid endoscope. Its primary objective is to restore physiological ventilation and mucociliary transport 1.

Sinus imaging is crucial in preoperative planning and is increasingly being used intraoperatively.

Indications for endoscopic sinus surgery include

Certain ophthalmic procedures can also be carried out via endoscopic approach, including

Endoscopy can not satisfactorily correct certain conditions; in such cases, an open technique is used. These include

CT is the modality of choice for sinonasal surgery planning. A presurgical CT scan is now mandatory before every endoscopic sinus operation, in the interest of minimising potential complications (see "complications" below).

An axial CT scan (1.5 mm slices or thinner) with coronal reformation is performed for delineating both sinonasal anatomy and disease extent.

Anatomy 

Particular attention should be given to the following structures and anatomic variants, as failure to do so may result in serious complications 3,4,5:

Pathology

The Lund-Mackay score 6 is widely used for the radiologic staging of chronic rhinosinusitis.

CT cannot reliably differentiate between desiccated secretions and allergic fungal sinusitis (AFS), since both are hyperattenuating.

Endoscopic sinus surgery technique is based on the anterior-to-posterior approach of Messerklinger 9 and the posterior-to-anterior approach of Wigand for ethmoidectomy completion. In practice, most surgeons use a combination of both.

Summarily, the procedure consists of the following steps 7, implemented as dictated by patient's anatomy and extent and severity of disease:

  • patient is positioned, with head to the right and the examiner on patient's right
  • diagnostic nasal endoscopy 8 is performed with 30° rigid nasal endoscopes
  • topical anaesthetics are injected; general anaesthasia is best used for the pediatric or anxious patient and for long procedures
  • medialisation of the middle concha to expose the ostiomeatal complex
  • uncinectomy performed with a 0° endoscope
  • maxillary antrostomy
  • removal of ethmoid bulla
  • removal of inferomedial part of the vertical middle concha basal lamina for entering posterior ethmoidal sinus
  • etmoidectomy; it is important to stay low, so as not to breach the skull base
  • identification of sphenoid face and posterior skull base
  • skull base clearance posterior-to-anterior, with ethmoidal partition removal
  • sphenoid sinusotomy
  • frontal sinusotomy; frontal work reserved for last, lest bleeding from frontal intervention obscure sinonasal anatomy
  • medialisation of middle nasal concha and/or middle meatal spacer placement

In general, patient outcomes are excellent 2 and complication rates are very low, especially in the hands of experienced surgeons.

Major complications

The rate of major complications is less than 0.5%. Complications include 10:

  • internal carotid artery (ICA) injury
  • skull base penetration with resultant intracranial haemorrhage, brain injury or cerebrospinal fluid leak
  • blindness, due do optic nerve injury or failure to promptly treat orbital haematoma
  • massive epistaxis
  • meningitis
Minor complications
  • adhesions (synechiae)
  • minor epistaxis
  • nasolacrimal duct obstruction; treated with dacryocystorhinostomy
  • anosmia or hyposmia; virtually all cases resolve
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Article Information

rID: 51779
System: Head & Neck
Section: Approach
Synonyms or Alternate Spellings:
  • FESS

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