6/19/2017 Functional Endoscopic Sinus Surgery: Overview, Preparation, Technique

FunctionalEndoscopicSinusSurgery
Updated:Mar02,2016
Author:AnkitPatel,MDChiefEditor:ArlenDMeyers,MD,MBAmore...

OVERVIEW

Overview
IntroductiontoFunctionalEndoscopicSinusSurgery
Rhinologyandsinussurgeryhaveundergoneatremendousexpansionsincethediscoursesof
MesserklingerandWigandinthelate1970s.[1,2,3]Imagingadvances,increasedunderstandingof
theanatomyandthepathophysiologyofchronicsinusitis,andimageguidedsurgeryhaveallowed
surgeonstoperformmorecomplexprocedureswithincreasedsafety.

Outstandingshortandlongtermresultshavebeenreportedintheliterature.Senioretalreported
thatsymptomsimprovedin66of72(91.6%)patientsfollowingendoscopicsinussurgery,witha
meanfollowuptimeof7.8years.[4]Inaddition,endoscopicsinussurgerysignificantlyinfluences
qualityoflifeDammetalreportedanimprovementinqualityoflifefor85%oftheirpatient
population,withameanfollowuptimeof31.7months.[5]

Althoughfunctionalendoscopicsinussurgeryistheprimaryapproachusedtodayforthesurgical
treatmentofchronicsinusitis,thetimehonoredexternalapproachesstillplayarole.Therefore,
familiaritywithendoscopicandexternalapproaches,inconjunctionwithapreciseunderstandingof
theanatomy,ensuresoptimalpatientcareandoutcome.

Arecentlydevelopedalternativetofunctionalendoscopicsinussurgeryisballoonsinuplasty.This
techniqueusesballooncatheterstodilatethemaxillary,frontal,andsphenoidnaturalostiawithout
boneorsofttissueremoval.Reportsshowpersistentpatientsymptomimprovementandsinus
ostiapatency.Furtherstudyandlongtermoutcomeswiththistechnologywilldetermineitsrolein
endoscopicsinussurgery.[6]

IndicationsforEndoscopicSinusSurgery

Endoscopicsinussurgeryismostcommonlyperformedforinflammatoryandinfectioussinus
disease.Themostcommonindicationsforendoscopicsinussurgeryareasfollows:

Chronicsinusitisrefractorytomedicaltreatment
Recurrentsinusitis
Nasalpolyposis
Antrochoanalpolyps
Sinusmucoceles
Excisionofselectedtumors
Cerebrospinalfluid(CSF)leakclosure
Orbitaldecompression(eg,Gravesophthalmopathy)
Opticnervedecompression
Dacryocystorhinostomy(DCR)
Choanalatresiarepair
Foreignbodyremoval
Epistaxiscontrol
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Typically,endoscopicsinussurgeryisreservedforpatientswithdocumentedrhinosinusitis,based
onathoroughhistoryandacompletephysicalexamination,includingCTscansifappropriate,and
inwhomappropriatemedicaltreatmenthasfailed.

Medicaltherapyalonemaybeinadequatefortreatmentofnasalpolyposis.Aukemaetalfoundthat
although12weeksoftreatmentwithfluticasonepropionatenasaldropsreducedtheneedforsinus
surgeryinpatientswithnasalpolyposisandchronicrhinosinusitis,14of27patientsstillrequired
surgery.[7]Similarly,antrochoanalpolypsrequiresurgicalremoval.

Nasalmasses
Increasingly,selectednasalmassesandtumorsarebeingremovedendoscopically.Endoscopic
removalofinvertedpapillomaiscontroversial.Endoscopicsurgerycanbeperformedforlimited
lesionsinwhichdefinitivecontrolandmarginscanbeobtainedendoscopicallythiscircumstance
canbepredictedpreoperativelyvianasalendoscopyandimaging.

Moreextensivelesionsshouldbeapproachedexternallyeitheralateralrhinotomymethodora
midfacialdeglovingmethodcanbeusedforenbloctumorremoval.Furtherresearchwithlong
termmonitoringinthisareawillbetterdelineatetheoptimaltreatmentforthesepatients.

Cerebrospinalfluidleaks

CSFleaksassociatedwithCSFrhinorrheacanbemanagedendoscopically.Successratesof80%
havebeenreportedintheliteraturewithprimaryendoscopicattemptssuccessratesincreaseto
90%ifrevisionendoscopicclosuresareincluded.

WithendoscopicrepairofCSFleaks,themoreextensiveneurosurgicalexternalapproachesvia
craniotomycanbeavoided.Incertainclinicalsettings,endonasalencephalocelesarerepairedvia
endoscopicapproaches.

Ophthalmicprocedures
Endoscopicapproachesmayalsobeappliedforophthalmicprocedures,includingorbital
decompression,endoscopicDCR,andopticnervedecompressionfortraumaticindirectoptic
neuropathy.Traditionally,theseprocedureswereperformedthroughexternalapproaches,butas
clinicalexperienceinnasalendoscopictechniqueshasincreased,theyarenowperformed
endoscopically.Onlysurgeonswithextensivetrainingin,andexpertisewith,endoscopic
techniquesshouldperformtheseprocedures.

ContraindicationstoEndoscopicSinusSurgery

Certainsinusconditionsmaynotrespondcompletelytoendoscopictreatmenttheseinclude
intraorbitalcomplicationsofacutesinusitis,suchasorbitalabscessorfrontalosteomyelitiswith
Pottspuffytumor.Anopenapproach,withorwithoutadditionalendoscopicassistance,maybe
preferableintheseinstances.AcarefulreviewofpreoperativeCTormagneticresonanceimaging
(MRI)scanshelpsguidethesurgeon.

After2failurestoendoscopicallymanageCSFleaksassociatedwithCSFrhinorrhea,patients
shouldbereferredtoaneurosurgeonforclosureusinganeurosurgicalapproach.Likewise,after
failuretoendoscopicallymanagefrontalsinusdisease,openapproachesshouldbeconsidered.

ClinicalEvaluation

Thecornerstoneofaccuratediagnosisandtreatmentofchronicsinusitisisathoroughhistoryand
acompletephysicalexamination,includingnasalendoscopy.Surgeryshouldnotbeconsidered

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unlesstheevaluationclearlyidentifieschronicsinusitisasthecauseofthepatient'sconstellationof
symptoms.

Thehistoryshouldelucidatethefrequencyofinfections,thetypeandthedurationofsymptoms,
andtheresponsetomedicaltherapy.Patientswithchronicorrecurrentsymptomstypicallyreport
thefollowingsymptoms:

Nasalcongestion
Purulentdrainage
Postnasaldrip
Facialpressureandheadache
Hyposmiaoranosmia
Nasalobstruction

However,otherconditionscanmimicchronicsinusitis,causing1ormoreoftheabovesymptoms.
Therefore,rulingoutotheretiologiesforthepatient'ssymptomsisimperative.Forexample,
patientswithallergicrhinitismayhavesimilarproblems,suchassneezing,wateryeyes,itchyeyes,
nasalcongestion,andpostnasaldrip.Ifthepatient'sonlyproblemisallergicrhinitis,then
endoscopicsinussurgeryisnotthesolution,andpropermedicaltreatmentshouldbeprescribed.

Aphysicalexaminationisanexcellentadjuncttopatienthistoryindiagnosingorexcludingchronic
sinusitis.Acompleteheadandneckexamination,alongwithanteriorrhinoscopy,shouldbe
performed.Iffurthernasalexaminationisrequired,afullnasalendoscopyshouldbecarriedout.
Thepatientshouldbeassessedforthefollowingconditions:

Septaldeviation
Turbinatehypertrophy
Nasalpolyps
Nasalairwayproblems,includingdynamicinternalorexternalvalvecollapse
Ostiomeatalcomplex,ifvisible
Adenoidalhypertrophy

Rigidnasalendoscopywithmildseptaldeviationisdepictedinthevideosbelow.

0:00 / 0:20

Rigidnasalendoscopyperformedintheclinic.Amildleftseptaldeviationisseenanteriorly.Theleftmiddle
turbinateandmiddlemeatusarenormal.VideocourtesyofVijayRRamakrishnan,MD.

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ViewMediaGallery

0:00 / 0:50

Rigidnasalendoscopy.Therightsidecontainsnormalturbinatesandmiddlemeatuswithasmallamountof
mucusintheinferiormeatus.Theendoscopyconcludeswithvisualizationofthesoftpalate,nasopharynx,and
Eustachiantubeorifices.VideocourtesyofVijayRRamakrishnan,MD.
ViewMediaGallery

Percussionofthesinusestoelicittendernessmayprovideadditionalinformationhowever,thisis
animperfecttechniqueintermsofsensitivityandspecificity.

Patientswithsuspiciousfindingsonhistoryandphysicalexaminationshouldundergocomputed
tomography(CT)scanning.InpatientswithnormalfindingsonparanasalsinusCTscansandno
changeinsymptomsafterundergoingmedicaltreatment,adiagnosisofchronicsinusitisissuspect
atbest.Thesepatientsshouldnotbeofferedfunctionalendoscopicsinussurgeryasatreatment
fortheirsymptoms.

RelevantAnatomy

Intimateknowledgeandunderstandingoftheanatomyofthelateralnasalwallandthesinuses
(seetheimagebelow),inconjunctionwithacarefulpreoperativereviewofCTscans,are
paramountinthesafeandcompleteperformanceofendoscopicsinussurgery.Thefollowing
descriptionofendonasalanatomyisroughlybasedontheorderofdissectionduringnasal
endoscopyandsurgery.

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Lateralnasalwallanatomyandparanasalsinusostia.
ViewMediaGallery

Nasalseptumandinferiorturbinate
Immediatelyuponenteringthenasalcavity,thefirststructuresencounteredarethenasalseptum
andtheinferiorturbinate.Thenasalseptumconsistsofthequadrangularcartilageanteriorly,
extendingtotheperpendicularplateoftheethmoidboneposterosuperiorlyandthevomer
posteroinferiorly.

Recognizingdeflectionsofthenasalseptumpreoperativelyisimportantbecausetheymay
significantlycontributetonasalobstructionandlimitendoscopicvisualizationduringsurgery.As
appropriate,patientswithseptumdeflectionsmaybecounseledregardingtheneedforseptoplasty
inconjunctionwithfunctionalendoscopicsinussurgery.

Theinferiorturbinateextendsalongtheinferiorlateralnasalwallposteriorlytowardthe
nasopharynx.Inpatientswithasignificantallergiccomponenttotheirproblems,theinferior
turbinatesmaybeedematous.Thesepatientsmaybenefitfromaturbinatereductionatthesame
timeastheendoscopicsinussurgery.Theinferiormeatus,wherethenasolacrimalductopens,is
locatedapproximately1cmbeyondthemostanterioredgeoftheinferiorturbinate.

Middleturbinate

Astheendoscopeisfurtheradvancedintothenose,thenextstructureencounteredisthemiddle
turbinate.Themiddleturbinateisakeylandmarkinendoscopicsinussurgery.Ithasavertical
component(lyinginthesagittalplane,runningfromposteriortoanterior)andahorizontal
component(lyinginthecoronalplane,runningfrommedialtolateral).

Superiorly,themiddleturbinateattachestotheskullbaseatthecribriformplate.Assuch,care
shouldalwaysbetakenwhenmanipulatingthemiddleturbinate.

Thehorizontalcomponentofthemiddleturbinateisreferredtoasthebasal(orgrand)lamella,and
itrepresentsthedividingpointbetweenanteriorandposteriorethmoidaircells.Posteriorlyand
inferiorly,themiddleturbinateattachestothelateralnasalwallatthecristaethmoidalis,just
anteriortothesphenopalatineforamen.

Uncinateprocess
Theuncinateprocessisthenextkeystructuretobeidentifiedinendoscopicsinussurgery.ThisL
shapedboneofthelateralnasalwallformstheanteriorborderofthehiatussemilunaris,orthe
infundibulum.Theinfundibulumisthelocationoftheostiomeatalcomplex,wherethenatural
ostiumofthemaxillarysinusopens.

Forpatientswithsinusdisease,apatentostiomeatalcomplexiscriticalforimprovementof
symptoms.Anteriorly,theuncinateprocessattachestothelacrimalbone,andinferiorly,the
uncinateprocessattachestotheethmoidalprocessoftheinferiorturbinate.

Naturalmaxillaryostium

Oncetheuncinateprocessisremoved,thenaturalmaxillaryostiumcanbeseen,typicallyjust
posteriortotheuncinateprocess,roughlyonethirdofthedistancealongthemiddleturbinatefrom
itsanterioredge.Itliesatapproximatelytheleveloftheinferiorborderofthemiddleturbinate,
superiortotheinferiorturbinate.

Thenaturalmaxillaryostiumisthedestinationforthemucociliaryflowwithinthemaxillarysinus.
Therefore,foroptimalresults,thesurgicallyenlargedmaxillaryantrostomymustincludethenatural

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ostium.Infact,failuretoincludethemaxillaryostiuminendoscopicsurgicalantrostomyisoneof
thekeypatternsoffailureinfunctionalendoscopicsinussurgery.

Themaxillarysinus,approximately1415mLinvolume,isborderedsuperiorlybytheinferiororbital
wall,mediallybythelateralnasalwall,andinferiorlybythealveolarportionofthemaxillarybone.

Ethmoidbulla
Thenextstructuretobeencounteredistheethmoidbulla,whichisoneofthemostconstant
anteriorethmoidalaircells.Itisjustbeyondthenaturalostiumofthemaxillarysinusandformsthe
posteriorborderofthehiatussemilunaris.

Thelateralextentofthebullaisthelaminapapyracea.Superiorly,theethmoidbullamayextendall
thewaytotheethmoidroof(theskullbase).Alternatively,asuprabullarrecessmayexistabovethe
roofofthebulla.Acarefulpreoperativereviewofthepatient'sCTscanclarifiesthisrelationship.

Ethmoidsinus

Theethmoidsinusconsistsofavariablenumber(typically715)ofaircells.Themostlateralborder
oftheseaircellsisthelaminapapyracea,andthemostsuperiorborderofthesecellsistheskull
base.Supraorbitalethmoidcellsmaybepresent.Areviewofthepatient'sCTscanalertsthe
surgeontothesevariations.

Thebasallamellaofthemiddleturbinateseparatestheanteriorethmoidcellsfromtheposterior
ethmoidcells.Anteriorethmoidcellsdraintothemiddlemeatus,andtheposteriorcellsdraininto
thesuperiormeatus.

Sphenoidsinus
Exenterationoftheposteriorethmoidcellsexposesthefaceofthesphenoid.Thesphenoidsinusis
themostposterioroftheparanasalsinuses,sittingjustsuperiortothenasopharynxandjust
anteriorandinferiortothesellaturcica.Theanteriorfaceofthesphenoidsitsapproximately7cm
fromthenasalsillona30axisfromthehorizontal.

Severalimportantstructuresarerelatedtothesphenoidsinus.Theinternalcarotidarteryis
typicallythemostposteriorandmedialimpressionseenwithinthesphenoidsinus.Inapproximately
7%ofcases,theboneisdehiscent.

Theopticnerveanditsbonyencasementproduceananterosuperiorindentationwithintheroofof
thesphenoidsinus.In4%ofcases,thebonesurroundingtheopticnerveisdehiscent.Therefore,
controlledopeningofthesphenoidsinus,typicallyatitsnaturalostium,iscriticalforasafe
outcome.

Thelocationofthenaturalostiumofthesphenoidsinusisvariable.Inapproximately60%of
people,theostiumislocatedmedialtothesuperiorturbinate,andin40%,itislocatedlateraltothe
superiorturbinate.

Frontalrecess

Thefrontalrecess,orthefrontalsinusoutflowtract,isthetractthatleadsfromthefrontalsinusinto
thenasalcavity.Often,theethmoidbullaistheposteriorborderofthefrontalsinusoutflowtract.

Anteriorly,thefrontalsinusoutflowtractisborderedbytheuncinateprocessortheaggernasicells
(frontalanteriorethmoidaircells).Ifanyofthesecellsareenlargedorifscarringispresentfroma
previoussurgery,resultantoutflowtractobstruction,leadingtofrontalsinusitis,mayoccur.
Typically,themedialwallofthefrontalrecessisformedbythelaminapapyracea.

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Formoreinformationabouttherelevantanatomy,seeParanasalSinusAnatomy,NasalAnatomy,
andSkullBaseAnatomy.

Preparation
AnesthesiaforEndoscopicSinusSurgery
Patientsmayundergofunctionalendoscopicsinussurgeryunderintravenoussedationandlocal
anesthesiaorundergeneralanesthesia.Theauthors'institutionalpreferenceisgeneral
anesthesia.

Technique
OverviewofEndoscopicSinusSurgery

Theprocedurebeginswithdecongestionofthenoseandinfiltrationoflidocainewithepinephrine
(1%lidocainewith1:100,000epinephrineisusedforinjection).Thelateralnasalwallnearthe
uncinateprocessisinjected.Usinga3mLsyringewhileplacingaslightbendtothe27gauge
needlefacilitatestheinjection.

Next,thesuperiorinletandtheanteriorfaceofthemiddleturbinateareinjectedsubmucosally.If
thepossibilityofseptoplastyexists,theseptumshouldalsobeinjected.

Next,4mLof4%cocaineisplacedontopledgets,whichareplacedbilaterallyinthenares.A
throatpackmaybeplaced,oralternatively,thestomachmaybesuctionedpriortoextubationupon
completionoftheprocedure.

Thepatientisthendrapedforsurgery.Ifimageguidedsurgeryistobeused,theappropriate
headsetapparatusshouldbeappliedatthistime.

EndoscopicUncinectomy
Functionalendoscopicsinussurgerymaybeginwithuncinectomy.Iftheuncinateprocesscanbe
initiallyvisualizedwithoutmanipulatingthemiddleturbinate,uncinectomycanbeperformed
directly.Otherwise,themiddleturbinateisgentlymedialized,carefullyusingthecurvedportionof
theFreerelevatortoavoidmucosalinjurytotheturbinateandtoavoidforcefulmedializationand
fractureoftheturbinate.

Next,uncinectomymaybeperformedviaanincisionwitheitherthesharpendoftheFreerelevator
orasickleknife.Theincisionshouldbeplacedatthemostanteriorportionoftheuncinateprocess,
whichissofteronpalpationincomparisontothefirmerlacrimalbone,wherethenasolacrimalduct
islocated.Then,aBlakesleyforcepsisusedtograspthefreeuncinateedgeandtoremoveit.

Completeuncinectomyisimportantforsubsequentvisualization.Incompleteuncinectomyisa
commonreasonforfailurewithprimarysurgery.Thebackbitermayalsobedirectlyusedtotake
downtheuncinateprocess.

MaxillaryAntrostomy/Ethmoidectomy

Oncetheuncinateprocessistakendown,thetruenaturalostiumofthemaxillarysinusshouldbe
identified.Theprotectedeyemaybepalpatedatthisjuncturetoensurethatthereisnodehiscence
ofthelaminapapyraceaandtoconfirmthelocationofthelamina.Thenaturalostiumistypicallyat
theleveloftheinferioredgeofthemiddleturbinateaboutonethirdofthewayback.

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Atruecuttinginstrumentisusedtocircumferentiallyenlargethenaturalostium.Theoptimal
diameterforthemaxillaryantrostomyiscontroversialtypically,adiameterof1cmallowsfor
adequateoutflowandforpostoperativemonitoringintheoffice.Careshouldalwaysbetakento
avoidpenetratingthelaminapapyracea.

AnteriorEthmoidectomy
Next,theethmoidbullashouldbeidentifiedandopened.AJshapedcurettemaybeusedtoopen
thebullaatitsinteriorandmedialaspect.Oncethecellisentered,thebonyportionsmaybe
carefullyremovedusingamicrodebrideroratruecuttingforceps.Completeresectionofthelateral
bullafacilitatespropervisualizationanddissectionposteriorly.Again,careshouldbetakenlaterally
tomaintainanintactlaminapapyracea.

TheremainderoftheanteriorethmoidcellsmaybeuncappedinitiallywithaJcuretteandfurther
openedwithamicrodebrideroratruecuttingforceps.Usingacuretteinitiallyallowsfortactile
sensationanddeterminationofthethicknessofboneandverifiesproperorientationpriortofurther
openingofcellswithpoweredinstrumentation.Careshouldalwaysbetakentoavoidmucosal
stripping,becausemucosalpreservationresultsinsuperiorpostoperativeoutcomes.

Anteriorethmoidcellsshouldbeclearedtotheskullbase,withthesurgeonexercisingcaution
whenapproachingtheethmoidroofandmaintainingconstantreferencetotheendoscopicviewand
tothepreoperativeCTscan.Imageguidedsurgeryorcomputeraidedsurgeryalsoguidesthe
surgeonastothedistancetotheskullbase,butitdoesnotreplacetheneedforanintimate
knowledgeoftheanatomy.

Whilemovingposteriorlytonewaircells,thesurgeonshouldalwaysenterinferiorlyandmedially
andthensubsequentlyopenlaterallyandsuperiorlyoncethemoredistalanatomycanbejudged
byvisualizationandpalpation.Anteriorethmoidectomyiscompleteuponreachingthebasallamella
ofthemiddleturbinate.

Ifthesinusdiseaseislimitedtotheanteriorethmoidcellsandthemaxillarysinus,theprocedure
mayendwithsimpleanteriorethmoidectomyandmaxillaryantrostomy.If,however,significant
radiographicandclinicaldiseaseoftheposteriorethmoidandsphenoidispresent,thendissection
shouldcontinuetoexenteratetheposteriorethmoidcellsandtoperformadequatesphenoidotomy
asappropriate.

PosteriorEthmoidectomy

Posteriorethmoidectomybeginswithperforatingthebasallamellajustsuperiorandlateraltothe
junctionoftheverticalandhorizontalsegmentsofthemiddleturbinate.Caremustbetakento
preservetheposteriorsagittalsectionofthemiddleturbinateandtheinferiorportionofthecoronal
segmentofthebasallamella.PreservingthisLshapedstrutensuresthestabilityofthemiddle
turbinate.Thelateralandsuperiorportionsofthebasallamellamaythenberemovedusingthe
microdebrider.

Furtherposteriorethmoidcellsmaybetakendowninasimilarfashion,keepinginmindthe
locationoftheskullbaseandthelamina.Thesurgeonmustbecognizantthattheskullbase
typicallyslopesinferiorlyatanapproximately30anglefromanteriortoposterior.Thus,theskull
baselieslowerposteriorlythananteriorly.Thisdissectionistakenbacktothefaceofthesphenoid.

EnlargementoftheNaturalOstiumoftheSphenoidSinus
IntheabsenceofOnodicells,thesphenoidostiumliesmedialandposteriortothefinalposterior
ethmoidcell.Aroughguideisthatthefaceofthesphenoidisapproximately7cmfromthenasal
sillata30anglefromthehorizontal.Identifyingthesuperiorturbinateaidsintheconfirmationof
position.Thesuperiorturbinateinsertsontheanteriorfaceofthesphenoidsinus.

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ThesphenoidsinusisenteredjustmedialandinferiortoitsnaturalostiumwithaJcuretteoran
olivetippedsuction.Oncethesinusisenteredsafely,theostiumcanbeenlargedusinga
mushroompunchforceps.Caremustbetakennottoaggressivelyenterthesinusbecause
dehiscencesmaybepresentinthebonycoverageofthecarotidarteryortheopticnerve.

FrontalSinusWork
Frontalsinusworkistypicallyreservedfortheendofthesurgicalprocedurebecausemanipulation
maycreatebleedingandobscurefurtherposteriorwork.Iffrontalsinusworkisindicated,a45ora
70telescopeprovesuseful.

Typically,anaggernasiorfrontalcellisthecauseoffrontaloutflowobstruction.Usinganangled
scopeforvisualization,afrontalsinuscuretteispassedabovethecellandthenpulledanteriorly,
thusbreakingposteriorandsuperiorcellwalls.

Particularcaremustbeexercisedwhenworkinginthefrontalrecess,becausethelaminaandthe
skullbasesitinimmediateproximitytotheoutflowtract.Imageguidedandnavigationalsystems
forcomputeraidedsurgeryandintimateknowledgeoftheanatomyarecriticalforsafefrontalsinus
work.KuhnandJaverprovidefurtherdiscussionofendoscopicfrontalsinussurgery.[8]

NasalPackingandSpacerPlacement

Oncedissectioniscompleteandhemostasisisachieved,abacitracincoatedTelfaorAfrinsoaked
pledgetisplacedintothenostril.SomesurgeonsalsoplaceGelfilmoradissolvablespacerwithin
themiddlemeatustokeepthespaceopenandtopreventlateralizationofthemiddleturbinateand
synechiaeformation.

PostProcedure
Nasalpackingisremovedpriortodischargeofthepatient.Thepatientisdischargedwithsaline
nasalspray(eg,OCEANNasalSpray)andantibiotics,aswellasinstructionsforafollowupvisitin
1week.Ifaspacerwasplacedinthemiddlemeatus,itshouldberemovedorsuctionedawayon
thefirstpostoperativevisit.

OutcomeandPrognosis
Outstandingshortandlongtermresultshavebeenreportedforendoscopicsinussurgery.Inone
study,symptomsimprovedin66of72patientsfollowingthissurgery,withameanfollowuptimeof
7.8years.[1]Inanotherreport,qualityoflifeimprovedfor85%ofthepatientpopulation,witha
meanfollowuptimeof31.7months.[2]

Complications

Allrisksandbenefitsshouldbecandidlydiscussedwithpatientsaspartoftheinformedconsent
processpriortosurgery.Apatientshouldneverundergosurgerywithoutafulldiscussionofall
possiblecomplications.

Risksassociatedwithendoscopicsinussurgeryareasfollows:

Bleeding
Synechiaeformation
Orbitalinjury
Diplopia
Orbitalhematoma
Blindness

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CSFleak
Directbraininjury
Nasolacrimalductinjury/epiphora

Alargeretrospectivestudyofthecomplicationsassociatedwithfunctionalendoscopicsinus
surgeryfoundanoverallcomplicationrateof0.50%theratesofCSFleakage,orbitalinjury,
hemorrhagerequiringsurgery,bloodtransfusion,andTSSwere0.09%,0.09%,0.10%,0.18%,and
0.02%,respectively.[9]

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