Aim of the surgical procedure: This
surgical procedure aims at widening the naturally present normal
ostium of the nasal sinuses, with conservation of normal nasal
and sinus mucosa. This surgical procedure also helps in
normalising the mucosal ciliary wave
pattern.
Indication:
1. Chronic sinusitis
resistant to medical treatment
2. As a treatment for nasal
polyposis
The paranasal sinuses can be divided into anterior
and posterior groups. The anterior group is always involved
during sinus infections before the posterior group of sinuses.
Infact the infected anterior group of sinuses predispose to
posterior sinus infections. Commonly the anterior ethmoidal
sinuses are involved first, causing a block in the drainage channels
of other sinuses. The clearance of the disesase should
hence start from the anterior ethmoidal group and proceed
further posteriorly.
This surgery is performed under local /
general anesthesia using a rigid nasal endoscope. Rigid nasal
endoscope is nothing but an optical telescope of 4 mm
diameter. Telescopes which are capable of angular
vision are also avialable. (30, 45, 70, 90
degrees). These angled telescopes can be used to visualise the
crevices inside the nasal cavity.
Procedure:
The nasal
cavities are decongested using 4% xylocaine mixed with 1 in 10,000
adrenaline soaked cotton pledgets. The aim of
decongesting the nasal mucosa is
1. To make the
nasal cavity roomy hence facilitating endoscopic
visualisation
2. To reduce bleeding during the surgical
procedure
General anesthesia is preferred in most of the
cases. Administration of hypotensive anesthesia using
Nitroglycerine infusion will help in reduction of bleeding
during surgery, thus improving visualisation.
Steps of
surgery:
1. The middle turbinate is gently medialised using a
septal elevator. This procedure helps to open up the middle
meatal area thus facilitating better visualisation.
2. The
next is to remove the uncinate process. This is the most
important step of Fess surgery. The incision can be made in
the most anterior portion of the uncinate process. The
uncinate bone is thin and soft when compared to the thicker and
firmer lacrimal bone. The uncinate process should be removed
completely. Incomplete removal of uncinate process is cited to
be most common cause of failure of Fess. A sickle knife can be
used to make the incision. A Blakesley forceps can be used to
totally remove the incised uncinate process. A back biting
forceps can also be used to completely remove the uncinate
process. While performing uncinectomy care should be taken
not to injure the mucosa over adjacent middle turbinate, because it
could cause bleeding making visibility difficult.
3.
Identification of natural ostium of maxillary
sinus:
The natural ostium of maxillary sinus should be identified
next. It is typically present at the level of the inferior
edge of the middle turbinate, about 1/3 of the way back. It
becomes visible after resection of the uncinate process. If it
is not visible even after uncinectomy then it could either be closed
by diseased mucosa or may be hidden behind the posterior remnant of
the uncinate process. This ostium should be
widened. Ideal size of natural ostium is 1 cm.
4.
Opening of Bulla ethmoidalis: Bulla should be opened in
its inferior and medial aspect using a J curette. A suction
tip can also be used to open the bulla. Anterior
ethmoidal cells are cleared gradually.
5. To clear
posterior ethmoids and sphenoid sinus the basal lamina should be
breached.
