Endoscopic sinus surgery

Definition

Functional endoscopic sinus surgery (FESS) is a minimally invasive surgical procedure that opens up sinus air cells and sinus ostia (openings) with an endoscope.

The use of FESS as a sinus surgical method has now become widely accepted; and the term "functional" is meant to distinguish this type of endoscopic surgery from nonendoscopic, more conventional sinus surgery procedures.

Purpose

The purpose of FESS is to restore normal drainage of the sinuses. Normal function of the sinuses requires ventilation through the ostia (mouth-like opening) and is facilitated by a mucociliary transport process that maintains a constant flow of mucus out of the sinuses. All sinuses need ventilation to prevent infection and inflammation, a condition known as sinusitis. In healthy individuals, sinus ventilation occurs through the ostia into the nose. The sinuses open into the middle meatus (curved passage in each nasal cavity) under the middle turbinate (thin, bony process that is the lower portion of the ethmoid bone in each nasal cavity), which together are known as the osteomeatal complex, the key area of the nose. The hair-like cilia direct the flow of mucus toward the ostia.

Sinusitis develops when there is a problem in the area where the maxillary and frontal sinuses meet near the nose or, occasionally, by dental infection. When sinusitis occurs, the cilia work less efficiently, preventing the flow of mucus. The mucous membranes of the sinuses become engorged, resulting in ostia closure. Poor ventilation and accumulation of mucus then produce the conditions required for bacterial infection.

During endoscopic sinus surgery, a doctor uses an endoscope to view the inner cavities of the nose (A and B). Using special instruments, the doctor opens the sinuses to alleviate problems with sinusitis (C and D). (

Illustration by GGS Inc.

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Demographics

Sinusitis is a very common condition, affecting 31 million Americans each year; 30% of the United States population have sinusitis at some point in their lives. The average adult has three to four upper respiratory infections a year; 1% of these infections are complicated by sinusitis, accounting for 16 million visits to the doctor each year.

Description

After inducing adequate vasoconstriction with cocaine or ephedrine, the surgeon locates the middle turbinate, the most important landmark for the FESS procedure. On the side of the nose at the level of the middle turbinate lies the uncinate process, which the surgeon removes. The surgeon opens the back ethmoid air cells, to allow better ventilation, but leaves the bone covered with the mucous membrane. Following this step, the ostium located near the jaw is checked for obstruction and, if necessary, opened with a middle meatal antrostomy. This surgical procedure often greatly improves the function of the osteomeatal complex and provides better ventilation of the sinuses.

FESS offers several advantages:

• It is a minimally invasive procedure.
• It does not disturb healthy tissue.
• It is performed in less time with better results.
• It minimizes bleeding and scarring.

Diagnosis/Preparation

As with many diseases, the history of a patient with sinusitis represents a key part of the preoperative evaluation. Before considering FESS, the ear, nose and throat (ENT) specialist will proceed with a thorough diagnostic examination. The development of such diagnostic tools as the fiberoptic endoscope and CT scanning has greatly improved the treatment of sinus disease. The fiberoptic endoscope is used to examine the nose and all its recesses thoroughly. The specific features the physician must examine and evaluate are the middle turbinate and the middle meatus, any anatomic obstruction, and the presence of pus and nasal polyps.

CT scanning can also be used to identify the diseased areas, a process that is required for planning the surgery. It shows the extent of the affected sinuses, as well as any abnormalities that may make a patient more susceptible to sinusitis.

FESS is usually performed under local anesthesia with intravenous sedation on an outpatient basis with patients going home one to two hours after surgery. It usually does not cause facial swelling or bruising, and does not generally require nasal packing.

Aftercare

FESS usually does not cause severe postoperative sinus pain. After the procedure, it is important to keep the nose as free from crust build-up as possible. To achieve this, the surgeon may perform a lengthy cleaning two to three times per week or the patient may perform a simple nasal douching several times a day. Normal function usually reappears after one or two months. In patients with severe sinusitis or polyps, a short course of systemic steroids combined with antibiotics may quicken recovery.

Risks

The most serious risk associated with FESS is blindness resulting from damage to the optic nerve. The chances of this complication occurring, however, are extremely low. Cerebrospinal fluid leak represents the most common major complication of FESS, but it occurs in only about 0.2% of cases in the Unites States. The leak is usually recognized at the time of surgery and can easily be repaired. Other less serious and rare complications include orbital hematoma and nasolacrimal duct stenosis. All of these complications are also associated with conventional sinus surgery and not only with FESS.

Normal results

The FESS procedure is considered successful if the patient's sinusitis is resolved. Nasal obstruction and facial pain are usually relieved. The outcome has been compared with that of the Caldwell-Luc procedure and, although both methods are considered effective, there is a strong patient preference for FESS. The extent of the disease before surgery dictates the outcome, with the best results obtained in patients with limited nasal sinusitis.

Morbidity and mortality rates

According to the American Academy of Family Physicians (AAFP), FESS usually has a good outcome, with most studies reporting an 80–90% rate of success. Good results have also been obtained in patients who have had previous sinus surgery.

Alternatives

• Image-guided endoscopic surgery. This method uses image guidance techniques that feature a three-dimensional mapping system combining CT scanning and real-time data acquisition concerning the location of the surgical instruments during the procedure. It allows surgeons to navigate more precisely in the affected area. The surgeon can monitor the exact location of such vital organs as the brain and eyes as well as positively identifying the affected areas.
• Caldwell-Luc procedure. This procedure is directed at improving drainage in the maxillary sinus region located below the eye. The surgeon reaches the region through the upper jaw above one of the second molars. He or she creates a passage to connect the maxillary sinus to the nose in order to improve drainage.

Resources

BOOKS

Bhatt, N. J. Endoscopic Sinus Surgery: New Horizons. Independence, KY: Singular Publishing Group, 1997.

Bhatt, N. J. The Frontal Sinus: Advanced Surgical Techniques. Independence, KY: Singular Publishing Group, 2002.

Marks, S. C., and W. A. Loechel. Nasal and Sinus Surgery. Philadelphia: W. B. Saunders Co., 2000.

PERIODICALS

Engelke, W., W. Schwarzwaller, A. Behnsen, and H. G. Jacobs. "Subantroscopic laterobasal sinus floor augmentation (SALSA): an up-to-5-year clinical study." International Journal of Oral and Maxillofacial Implants 18 (January-February 2003): 135–143.

Graham, S. M., and K. D. Carter. "Major complications of endoscopic sinus surgery: a comment." British Journal of Ophthalmology 87 (March 2003): 374–377.

Larsen, A. S., C. Buchwald, and S. Vesterhauge. "Sinus baro trauma—late diagnosis and treatment with computeraided endoscopic surgery." Aviation & Space Environmental Mediciine 74 (February 2003): 180–183.

Ramadan, H. H. "Relation of age to outcome after endoscopic sinus surgery in children." Archives of Otolaryngology & Head and Neck Surgery 129 (February 2003): 175–177.

Wormald, P. J. "Salvage frontal sinus surgery: the endoscopic modified Lothrop procedure." Laryngoscope 113 (February 2003): 276–283.

ORGANIZATIONS

American Academy of Otolaryngology-Head and Neck Surgery. One Prince St., Alexandria, VA 22314-3357. (703) 836-4444. http://www.entnet.org/ .

Association for Research in Otolaryngology. 19 Mantua Rd., Mt. Royal, NJ 08061. (856) 423-0041. (301) 733-3640. http://www.aro.org/index.html .

North American Society for Head and Neck Pathology. Department of Pathology, H179, P.O. Box 850, Milton S. Hershey Medical Center, Penn State University School of Medicine, Hershey, PA 17033. (717) 531-8246. http://www.headandneckpathology.com/ .

OTHER

"Factsheet: Sinus Surgery." American Academy of Otolaryn gology—Head and Neck Surgery [cited May 5, 2003]. <http://www.entlink.org/healthinfo/sinus/sinus_surgery.cfm> .

Slack, R. and G. Bates. "Sinus Surgery." American Family Physician . 1 September 1998 [cited May 5, 2003]. http://www.aafp.org/afp/980901ap/slack.html .

Monique Laberge, Ph.D.

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

This procedure is usually performed on an outpatient basis by an ear, nose, and throat (ENT) specialist, such as an otolaryngologist or an ophthalmic surgeon. ENT physicians are graduates of a school of medicine and typically undergo an otolaryngology residency with further specialization in sinus disease and endoscopic sinus surgery.

QUESTIONS TO ASK THE DOCTOR

• Why is sinus surgery required?
• What are the risks involved?
• How many endoscopic sinus surgery procedures do you perform in a year?
• How much time will I need to recover from the procedure?
• Is the procedure painful?
• What are the alternatives?