Functional Endoscopic Sinus Surgery

By

Dr. T. Balasubramanian M.S. D.L.O.



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.

Complications of FESS:

1. Bleeding

2. CSF rhinorrhoea

3. Synechiae formation

4. Injury to orbit and its contents 

 

 

 




 

 

Surgical clipping showing FESS being done

 

 

 

 

 

 

 

 

 

 



 






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