Functional Endoscopic Sinus Surgery

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What is FESS?

Functional endoscopic sinus surgery. The goal of “functional” endoscopic sinus surgery is to correct underlying anatomic abnormalities or obstructions while preserving mucosa in order to restore mucociliary flow and normal sinus function. The term functional is directly related to techniques used to preserve the natural drainage pathway. The field of rhinology has undergone great advances in recent years with advances in endoscopic technology, instrumentation, image guidance, and understanding of the anatomy and pathophysiology of rhinosinusitis.

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What is the role of surgical intervention in rhinosinusitis?

Medical management is the primary, and often only, treatment modality in the majority of patients. When medical therapy fails to control symptoms adequately, surgery may be indicated. In cases of chronic or recurrent rhinosinusitis, surgical intervention should be directed at improving the natural drainage pathways of the sinuses and facilitating delivery of topical therapies such as saline rinses and topical steroid sprays. In cases of acute rhinosinusitis, surgical intervention is directed at decompression of the acutely infected sinus associated with possible complications, such as abscess formation.

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What measures should be taken prior to surgical intervention for the treatment of rhinosinusitis?

A detailed history and physical examination should be performed on any patient to help determine which patients would sufficiently benefit from surgical intervention. Nasal endoscopy should be performed preoperatively to evaluate the specific nasal anatomy along with assessment of the nasal mucosa. Fine-cut computed tomography (CT) is an important objective measure performed to identify a patient’s specific anatomy used in preparation for sinus surgery. Imaging should ideally be studied in triplane (axial, coronal, and sagittal) orientation. As with any surgery, all preoperative medications (including over-the-counter medications) should be discussed with each patient to identify any medications that can increase the risk of bleeding.

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What are the main goals of functional endoscopic sinus surgery?

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  Thorough anatomic dissection of the paranasal sinuses to restore the normal drainage pathways. This dissection should be complete and apply mucosal-sparing techniques.

• 2.

  Avoidance of complications. The paranasal sinuses reside in close proximity to critical structures including the orbit, skull base, carotid artery, and optic nerve.

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What are the most common causes of nasal airway obstruction and how are they addressed surgically?

Deviated nasal septum and inferior turbinate hypertrophy are two of the most common causes of nasal airway obstruction that can be surgically corrected. Septoplasty is a procedure performed to straighten the deviated septum. Reduction and outfracture of the obstructing inferior turbinates are commonly performed to improve the nasal airway.

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How should one proceed through dissection of the paranasal sinuses?

Based on its anterior location, the maxillary sinus is often addressed first. Osteomeatal complex obstruction is addressed by performing a maxillary antrostomy. The natural ostium of the maxillary sinus is exposed by removing the uncinate process. The natural ostium is enlarged (this ostium is enlarged to include accessory ostia when present). The anterior ethmoid cells are then addressed by opening the ethmoid bulla and proceeding anterior to posterior. The basal lamella of the middle turbinate is identified, which is the anatomic division between the anterior and posterior ethmoid sinuses. Dissection is then carried posteriorly until the anterior face (rostrum) of the sphenoid sinus is encountered, marking the posterior limit of the posterior ethmoid sinus in the absence of an Onodi cell (posterior ethmoid cell pneumatizing superiorly to the sphenoid sinus). Medially, the superior turbinate can be used to identify the sphenoid ostium in the sphenoethmoidal recess. If necessary, the inferior third of the superior turbinate may be removed to expose the sphenoid ostium. The sphenoid ostium is enlarged with care to avoid injury to the skull base superiorly and septal artery (medial terminal branch of the sphenopalatine artery) inferiorly. The remaining ethmoid partitions are dissected in a posterior to anterior direction from the anterior face of the sphenoid sinus along the ethmoid skull base superiorly with the limits of dissection including the lamina papyracea laterally, middle turbinate medially, and frontal recess anteriorly.

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