Functional Endoscopic Sinus Surgery (FESS)

How many sinus surgeries are performed each year in the U.S.?

According to estimates about 200,000 sinus surgeries are performed every year in the U.S.

Why is endoscopic surgery performed?

When there are anatomical abnormalities that affect the sinusitis and when other treatments have failed. These anatomical abnormalities can be corrected with surgery. Endoscopic methods allow Otolaryngologist to diagnose and treat such problems more easily than before, allowing proactive action on nasal anatomical abnormalities.

When is endoscopic surgery appropriate?

Surgery needs to be done when medication has failed to relieve the patient of the symptoms of sinusitis, also when there are serious complications from sinusitis. That is where the condition is not alleviated by medication, and is associated with problems of the lower respiratory tract such as chronic bronchitis and asthma.

Basically, patients receiving all medication that fails to help are suitable candidates to undergo such surgery.

What is the surgical procedure?

Functional Endoscopic Sinus Surgery (FESS). The surgical procedure (FESS) has virtually replaced the traditional “old-fashioned” interventions for the treatment of sinusitis. The FESS aims to maintain normal sinus drainage and natural sinus openings.

With special cameras and endoscopes, narrow anatomical regions of the nasal sinuses can be visualised and accessed precisely for surgery. The FESS has brought rapid positive developments in the surgical treatment of sinusitis.

What is the key concept behind minimal invasive endoscopic sinus surgery – FESS?

The key nasal pore space is located in the area between the middle concha and the lateral nasal wall. This is the key area for drainage of anterior ethmoid cells, the maxillary antrum (sinus) and frontal sinuses.

The blockage of the nasal canals creates a vicious cycle that leads to chronic sinusitis. Functional endoscopic sinus surgery (FESS) opens the natural sinus openings to allow them to drain and function normally.

Can you tell me more about the FESS?

During FESS, an endoscope is required to view the nasal cavity and sinuses, which generally reduces the need for external incision. The endoscopy allows better visualization of the anatomy and pathology of these regions. An endoscopy, in conjunction with detailed radiographic study can diagnose a problem which had not previously been evident.

FESS enables the removal of abnormal tissues that obstruct the normal openings of the sinuses and thus improve their drainage.

How to assess the patient’s condition for such surgery?

The decision to conduct the FESS will be based on the patient’s history and examination by an Otolaryngologist. A CT scan is also required to assess the exact anatomy of the region. If you have not done so before your first visit to the doctor, you’ll need to do one.

How should patients prepare for surgery?

Before surgery, it is important for the patient to undergo blood tests and possibly other tests such as EKG tests and chest X-rays. These tests are performed if deemed necessary based on the patient’s history and age. There can be no action without performing a CT scan before.

If the patient has rapidly worsening symptoms of sinusitis or there is any infection before surgery, the surgeon should be informed. The surgeon will choose the most appropriate treatment. In some cases, surgery may be postponed.

Dos and Don’ts before surgery.

  • Tell your surgeon if you have any medical problem that requires preventive antibiotics before surgery (e.g. prolapsed mitral valve or prosthetic valve).
  • Read informative material about the surgery to understand the process, including the reasons for which it is recommended. Learn about the expected recovery process, the benefits and potential risks.
  • Stop taking aspirin at least 10 days before surgery. Aspirin in low doses can significantly increase bleeding during surgery and postoperatively.
  • Stop taking non steroidal anti-inflammatory drugs (Ibuprofen,) at least 5 days before surgery. These substances also create bleeding but less than that caused by aspirin.
  • Do not eat or drink anything from midnight before surgery. If you are on medication, ask if they can be taken the morning of surgery.

What will happen during surgery?

The surgery generally does not cause discomfort and should not be an unpleasant experience. It is usually done under general anaesthesia, after drifting off the next thing you’ll remember is waking in the recovery room and the surgery will be done.

Can I learn more about microsurgery instruments and devices used in FESS?

Powered microsurgical instruments also known as soft tissue shavers used in FESS, are the latest developments in endoscopic surgery. The use of these tools is generally a standard in sinus surgery as it offers surgeons safe and accurate precision. The soft tissue shaver sucks the tissue into the lateral opening and then the cuts or “shaves” it with an oscillating or rotating metal blade. Because the blade is protected, the tool provides excellent control for precise surgical removal of soft tissue without damaging other surrounding tissues. Most modern blades enable surgeons to remove both soft tissue and bone. Simultaneously, continuous suction removes blood, abnormal tissue keeping the surgical field clear. These powered microsurgical tools mean less trauma and bleeding, reducing duration of surgery and speeding up recovery.

The biggest advantage of using the powered microsurgical instruments has been identified in the case of nasal polyps. Traditionally, the surgery of nasal polyps was done with manually operated tools by pulling the polyp. This causes the rupture of tissues including normal mucosa and increased bleeding; in some cases surgeons abandon the procedure before the removal of all polyps. These patients usually require nasal packing for at least 24 hours.

The powered microsurgical instruments help to make this process routine surgery. Continuous suction allows us to have a clean surgical field and thus perform the surgery with great precision. Capping (gauze in the nose) is usually not required.

What is computer assisted or image guided sinus surgery (neuro-navigation) during FESS.

Application of neuro-navigation for FESS is available at Aretaeio Hospital. This system allows surgeons to locate with great accuracy the tip of the surgical instrument in the nasal sinuses. The neuro-navigation assists especially when working in or near difficult areas such as the frontal sinuses, the skull base and orbit. Computer assisted endoscopic sinus surgery is used mainly in cases where there are not enough surgical landmarks due to scarring or previous surgeries.

These systems are not available everywhere. While useful in specific cases, it is not always essential for an experienced and skilled surgeon who can perform difficult surgeries.

What can the patient expect after surgery?

Patients usually leave the clinic the next day. The doctor usually does not use packing (gauze) after FESS.

Postoperative care is as important as the surgery. Patients must use brine several times a day for cleansing the crusts and clots. This way maintaining a healthy environment to improve healing. Periodic cleansing is required during the first stage of recovery to prevent formation of granulation tissue and scarring. Usually the nasal mucosa heals within 6 weeks.

The patient should be prepared for nasal bleeding a few days after the operation and after every visit to the doctor for debridement. This is normal and slowly decreases. When bleeding occurs in the front of the nose or on the back of the neck, the patient should sit up with the head tilted back and gently breathe through the nose. If bleeding continues for a long period of time, contact your doctor’s office.

As the sinuses begin to clean themselves after two to three weeks, the patient should expect viscous, brown nasal discharge. This consists of mucus and old blood and is expected, it is not a sign of infection. After the surgery the patient may feel discomfort due to manipulation and inflammation.

What are the Dos and Don’ts after surgery?

  • You should not blow your nose until you are given permission to do so (usually a week after the surgery).
  • Do not lift weights for a week after surgery. Do not participate in exercise activities until the completion of your recuperation.
  • If you need to sneeze or cough, do so with your mouth open.
  • Do not use products containing aspirin until you talk with your doctor. Usually you can restart them 7 to 10 days after surgery.

What happens after surgery?

The patient should be periodically seen by his doctor until treatment is completed (usually 4-6 weeks). During the postoperative visits, any persistent inflammation or scar tissue will be removed under local anaesthesia. Although the chance of complications in this case is rare, the potential risk is identical to the operation. Consent for surgery should include the consent of the patient for postoperative care.

Thorough postoperative care is necessary for the success of the procedure and patients should be supplied with instructions for follow up care. It is extremely important the patient follows these instructions among those given by the surgeon, as it will help the healing process and reduce the risk of complications.

Can functional endoscopic sinus surgery cure sinusitis?

The majority of patients have shown significant improvement from the operation in conjunction with ongoing medical management. According to the literature, the success rate of FESS in acute and chronic sinusitis is 75 to 95%.

Sinusitis is a chronic problem so if the symptoms improve or even disappear if after surgery, there is the possibility that the nose and sinuses may be irritated by pollen, dust, air pollution, etc. It should be understood that medication after surgery is usually necessary; this helps to control the possible recurrence of the disease.

There is a possibility that the disease might not be treated with surgery, or may reappear at a later stage. If this happens further surgery may be required.

Risks presented in FESS?

Possible complications of FESS are the same as the complications involved in traditional surgery for treatment of sinusitis. There are possible serious risks from surgery in this region, even an excellent surgeon can find surgical complications, however the impact of these risks are minimal.

Bleeding. Although the risk of bleeding is reduced with FESS, significant bleeding may require stopping the process and packing the sinuses. Blood transfusions are rarely required. Postoperative bleeding is not common with FESS, but is possible if resection of the lower turbinate is done.

Leakage of cerebrospinal fluid (CSF): In all treatments of the sinus there is a small risk of causing leakage of cerebrospinal fluid (the fluid that surrounds the brain). However, since the endoscope used allows improved visibility, the risk of complications is reduced. Should complications occur there is possibility of contamination which can lead to meningitis (inflammation of the brain or brain abscess). If a CSF leak is identified, it’s usually repaired during surgery. A possible leak will extend patients stay at the hospital and the patient may require additional surgery to repair.

Impaired sense of smell: After surgery there may be reduced or permanent loss of smell. However, in many patients, it is already reduced before surgery so usually improves after surgery.

Vision problems: While extremely rare, there are occasional reports of visual loss after sinus surgery. Usually the loss of vision only includes the one side and the chance of recovery is low. Temporary or prolonged double vision has also been reported after sinus surgery.

Risks of anaesthesia: As commonly used general anaesthesia, the patient is subject to the risks involved in anaesthesia. Adverse reactions to anaesthesia can be discussed further by the anaesthesiologist.

Other hazards: Occasionally eye tearing can occur from sinus surgery or sinus inflammation. The patient may experience numbness or discomfort over the front teeth for a time. Swelling, bruising and temporary numbness of the lips may occur as well as swelling or bruising around the eye.

A few words about the FESS technique.

The endoscopic sinus intervention is performed in either direction from front to back or from back to front. The technique from front to back is better for limited disease involving the frontal, sieve cells, the jaw antrum and frontal sinuses. The technique of back to front can be used for patients with pansinusitis (inflammation in all cavities of the nose) or patients who had sinus surgery previously resulted significant anatomical scarring. A skilful surgeon familiar with both techniques and can apply them as the need arises.

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