Functional Endoscopic Sinus Surgery (FESS)

Primary objective:
restore paranasal sinus function by re-establishing the physiologic pattern of ventilation
and mucociliary clearance

Goal: Remove diseased mucosa and bone, preserve normal tissue, and judiciously widen the true natural ostia of the sinuses

Preoperative Assessment
History
Specific review of symptoms such as:
facial pain
congestion
nasal obstruction
drainage
hyposmia

History of associated diseases and their treatment is obtained.

Allergy
Asthma
Polyps
Aspirin sensitivity
Rhinitis medicamentosa.

Exposure to smoking and environmental irritants is explored. Smoking
causes mucosal inflammation and is associated with worse outcomes
after ESS. Patients are counseled on the possibility of a poorer surgical
outcome if they continue to smoke and are advised to stop smoking. 67
The patients response to medical therapy, previous operations, and
preexisting comorbidities influence their candidacy for surgery.
Examination
Office examination comprises a complete head and neck examination,

3 types:
1. basic ocular examination
2. anterior rhinoscopy
Anterior rhinoscopy detects any significant septal deviation that may
cause problems with nasal endoscopy
. The condition of the mucosa,
drainage, masses, and polyps are grossly visualized

3.nasal endoscopy.
conducted in a systematic fashion with a rigid or flexible endoscope.

.
With rigid scopes, the examination is divided into three passes.68
The nasal floor, nasolacrimal duct, and nasopharynx are examined on
the first pass. The second pass is carried out at a 30-degree angle with
the nasal floor to examine the middle meatus, OMC, and sphenoethmoid
recess. Lastly, the scope is directed superiorly toward the frontal
recess. The character of the mucosa, appearance of the sinus drainage
pathways, and the presence of anatomic variations, structural abnormalities,
purulent drainage, and polyps is noted

Other Preoperative Preparation

Antibiotics- started 7 to 10 days before surgery ( to reduce

Inflammation) This reduction helps diminish
bleeding during surgery.

Preoperative steroids- can also help decrease

inflammation,
- For maximum benefit, oral steroid therapy should be
started at least 10 days prior to surgery.

Choice of Anesthesia
The choice of anesthesia for ESS is determined by variables such as the
extent of surgery, age and health of the patient, experience of the
anesthesiologist, and patient choice.
Local Anesthesia
ESS using purely local anesthesia can be performed. The biggest drawback
of local anesthesia is poor sedation. A talented, interested, and
experienced anesthesiologist is required for good sedation. Without this
key medical colleague, general anesthesia should be used. Sedation with
local anesthesia calms patients, stabilizes blood pressure, and minimizes
bleeding. ESS with use of local anesthesia may, in theory, improve
safety because awake patients can report manipulation of the orbital
periosteum or dura. Local anesthesia works well for young patients
undergoing primary sinus surgery that lasts less than 2 hours.
General Anesthesia
The principal advantages of general anesthesia are independence from
patient cooperation and the control of the airway. Reasons to choose
general anesthesia include patient anxiety, operation in a child, and
anticipation of a long procedure.88 General anesthesia is also indicated
if computer-assisted navigation systems are used, because any patient
movement may disrupt the reference device. Even if general anesthesia
is used, topical nasal decongestant sprays and local injections are still
helpful for vasoconstriction and postoperative pain.

Polyps
In a primary procedure, polyps are easy to approach endoscopically
because they are gelatinous and have minimal blood supply. Revision
polyp surgery is technically more difficult. Polyps obstruct visualization
and often cause heavy bleeding. A Microdebrider can help reduce blood
loss and improve visualization by quickly removing nasal polyps. The
instrument also suctions blood, keeping the surgical field clear.97,98 In
all cases with extensive polyposis, it is advisable to clear the polyps
anteriorly and inferiorly until the middle turbinate and other landmarks
can be identified. Surgery should progress only when the orbit and skull

base have been identified. Primary polyp surgery can be conducted

without marked blood loss. Sinuses should be opened widely except for
the frontal sinus. Polyps tend to recur first in the upper frontal area,
but most patients have asymptomatic disease in the frontal recess.
Manipulation of the frontal recess is not necessary and may create
problems, particularly if there is any surrounding osteitis and if the
frontal ostium appears narrow on sagittal CT scans. The middle turbinate
is involved in most cases of polyposis, and if it is, removal of the
middle turbinate is appropriate.
Antrochoanal polyps have traditionally been treated through a
Caldwell-Luc approach to the maxillary sinus or through a combined
endoscopic and transcanine approach.99 The creation of an endoscopic
inferior meatal antrostomy affords better access for polyp removal along
with the wide middle meatal antrostomy created by the disease process.
This avoids the need for a Caldwell-Luc procedure. Endoscopes and
curved powered or grasping instruments are very helpful in removal of
the maxillary portion of the polyp, which is the key to avoiding
failure.100

Sinonasal Polyposis
Nasal polyps that erode through the skull base or the lamina papyracea
must be removed to prevent impending complications. A relative indication
for surgery is polyps that cause nasal obstruction and do not
respond to medical therapy. However, polyps cannot be eradicated, and
the goal of surgery is to provide a nasal passage for airway and drainage.
Surgery is adjunctive to medical therapyfor instance, with topical and
systemic steroids. Polyps can often be cured by surgery in patients
without asthma but frequently recur in patients with asthma. Polyps
in patients with Samters triad (nasal polyps, asthma, and aspirin sensitivity)
are very difficult to treat.