Functional Endoscopic Sinus Surgery (FESS) is done to remove an obstruction form the sinuses or to enlarge the ostia or openings of the paranasal sinuses, to remove dead tissue from sinus mucosal lining or bone, or to remove polyps or tumours from the sinus cavity. It is done by using an endoscope; an instrument made up of a slim fibre-optic cable with a camera and a light source at one end. The purpose of FESS is to achieve good drainage of and remove diseased tissue from the paranasal sinuses.
Who are the candidates for Endoscopic Sinus Surgery?
Patients with intractable sinusitis who do not respond to medications and other conservative measures benefit from FESS. Patients with polyps or tumors inside the sinus cavity may benefit as well. Recently, the paranasal sinuses have been used as portals into the anterior and posterior cranial fossa, thus the procedure can be used for removal of pituitary gland tumors. This is possible because of the relatively smaller tissue disturbance with the use of the endoscope.
What are the advantages of Endoscopic Sinus Surgery?
Functional Endoscopic Sinus Surgery involves less disturbance of normal healthy tissues, a shorter operative time and convalescence, and no scarring since the small incisions are made inside the nose. It also involves lesser anaesthesia risks since it can be done in a shorter time and can even be performed under local anaesthesia.
How to Prepare for Endoscopic Sinus Surgery?
A careful and thorough investigation of the sinus disease and anatomy of sinuses is required. This is usually done by taking a thorough medical history, a careful physical examination, and diagnostic tests such as a Computed Tomography or CT scan of the affected area, rhinomanometry and nasal cytology, and smell testing. Other laboratory tests may be done to ascertain whether the patient is fit for surgery, especially if the patient is elderly or has co-existing medical conditions. This may include a complete blood count, platelet and coagulation function tests, kidney and liver function tests etc. Use of certain medications that can cause prolonged bleeding such as aspirin should be restricted.
How is Endoscopic Sinus Surgery done?
FESS can be performed either as an outpatient procedure or with an overnight hospital stay. It usually lasts for one to four hours depending on the amount of tissue removal needed. General anaesthesia is commonly used but it can also be done under sedation and local anaesthesia.
Cocaine or ephedrine may be used for vasoconstriction to minimize bleeding of the nasal mucosa. An endoscope along with special endoscopic instruments is passed through the nostrils and the middle turbinate (a bony projection into the sinus cavity) is located. This is the most important landmark for sinus surgery. The middle meatus (opening) is identified and cleared of obstruction and even widened by trimming the tissues around it and removing some part of the bone. The endoscope is passed further into the involved sinus and the sinus cavity and its lining is inspected. Polyps and diseased mucosa are removed. Saline washing of the cavity may be done. If there is bleeding, the nose will be packed.
I have found a great website that provides videos on the various aspects of sinus surgery. This video explains in great detail exactly how Endoscopic sinus surgery is undertaken.
What are the risks of Endoscopic Sinus Surgery?
By nature of the proximity of the sinuses to the cranial fossa and the orbit, sinus surgery, carries some risk of damage to the brain, the eyes, a major artery, and the optic nerve. The risks depend on the complexity of the procedure and the structures involved.
The possible complications include:
- Hemorrhage into the orbit
- Abscess formation in the orbit
- Blindness due to damage to the optic nerve
- Leaking of cerebrospinal fluid
- Meningitis
- Haemorrhage and abscess into the cranial bone
- Extensive scarring and stenosis of the sinus opening
- Adhesions and injury to the lacrimal duct
- Anosmia caused by injury to the olfactory epithelium
What to expect after Endoscopic Sinus Surgery?
Immediately after the operation, there will be pain when the effect of the anaesthetic wears off. The pain is mild to moderate and the patient may need a pain-reliever for up to one week after the surgery. The patient may feel like he has a head cold, with congestion, nasal discharge and headache. The nasal discharge may be blood-tinged for up to a week or two. The discharge may drip down the nostrils or at the back of the throat. Nasal decongestant sprays may be of help. A nasal pack may have been placed after surgery to stop bleeding and will be removed before discharge from the hospital.
Antibiotics are prescribed as a prophylactic measure against infection. Nasal irrigation may be advised and patient is instructed as to its use. The patient may also be advised to avoid bending over and lying down flat. The patient is also advised to avoid hot food and soups for a few days to prevent bleeding and to avoid strenuous activities for at least two weeks. Patient is warned to watch out for signs of infection and to follow-up closely with his surgeon.
Prognosis of endoscopic sinus surgery is good, though it depends on the extent of the disease and is best in those with limited sinusitis. The symptoms of sinus pressure and tenderness are relieved. However, the patient is advised to benefit from having FESS by avoiding the factors that might trigger another attack of sinusitis.
