FESS-Functional Endoscopic Sinus Surgery Functions of sinuses.

Ventilation Drainage

WHAT IS FESS?
Trans nasal endoscopic Sinus surgery. The principle is that if the underlying cause of disease is identified and corrected, secondary disease in the maxillary and frontal sinuses will often improve spontaneously

Indications of diagnostic nasal endoscopy:

To diagnose diseases of nose and PNS. To diagnose source of epistaxis. To take biopsy. To assess the medical and surgical response Anesthesia

The process of examination.

1. First pass / inferior pass 2. Second pass 3. Third pass. pass 2. Second

3. Third pass.

First pass

First pass: In this the endoscope is introduced along the floor of the nasal cavity. Middle turbinate is the first structure to come into view. As the endoscope is slid posteriorly the adenoid tissue comes into view. On the lateral surface of the nasopharynx the pharyngeal end of eustachean tube can be identified. Its function can be assessed by asking the patient to swallow. The endoscope is now turned 90 degrees in the opposite direction, the uvula and soft palate comes into view. The endoscope is again rotated by 90 degrees in the same direction, the opposite side pharyngeal end of eustachean tube is visualised. In this field both eustachean tubes become visible.

Second pass
After the first pass is over, the scope

is gently withdrawn out and slide medial to the middle turbinate. The relation ship between the middle turbinate and nasal septum is studied. The scope is gently slipped medial to the middle turbinate. The sphenoid ostium comes into view. Secretions if any from the ostium is noted.

Second pass
After the first pass is over, the scope

is gently withdrawn out and slide medial to the middle turbinate. The relation ship between the middle turbinate and nasal septum is studied. The scope is gently slipped medial to the middle turbinate. The sphenoid ostium comes into view. Secretions if any from the ostium is noted.

Second Phase

Third pass

Third pass: Is the most important of all the three passes. This pass studies the crucial middle turbinate area. The middle turbinate is evaluated for its shape and size as well as its relationship to the lateral nasal wall and septum. A bulge just above and anterior to the attachment of the middle turbinate suggests an enlarged agge nasi cell. A middle turbinate that is concave medially rather than laterally is considered paradoxical. But paradoxical turbinate which is symptomatic needs to be treated. If the middle turbinate is enlarged due to the presence of a large air cell inside the middle turbinate it is known as concha bullosa. The attachment of the uncinate process is carefully noted. Discharge if any from this area is also recorded. Accessory ostium is present more posteriorly. Normal ostium is actually not visible during diagnostic nasal endoscopy. Accessory ostium is spherical in shape and oriented anteroposteriorly, while the natural ostium of maxillary sinus is oval in shape and oriented transversely.

Third pass

Third pass

Advantages of Fess

The lateral nasal wall is primary site for sinus pathology and that can be approached by endoscopes which are of various degrees 0,30 45 90 degrees

FESS
The diseases of sinuses are rhinogenic Ethmoid sinuses are primarily diseased and frontal and maxillary sinuses are secondarily involved through pre chambers ethmoidal infundibulm, and frontal recess

Indications

Recurrent rhino sinusitis that is resistant to adequate medical treatment. Fungal Sinusitis. Recurrent sinusitis caused by an anatomical deformity or malformation. Complications of rhino sinusitis, Pituitary Surgery.

Indications
Multiple or recurrent Sino nasal polyposis. Mucocele or pyomucocele. Chronic anterior headache secondary sinus disease due to anatomical deformities or due to Para nasal sinus disease.

Indications

Excision of selected tumors Cerebrospinal fluid (CSF) leak closure Orbital decompression (e.g., Graves ophthalmopathy) Optic nerve decompression Dacryocystorhinostomy (DCR) Choanal atresia repair

Indications
Foreign body removal Epistaxis.

Contraindications
Intraorbital complications or intrcranial complications of acute sinusitis, such as 1) orbital abscess 2) frontal osteomyelitis with Potts puffy tumor.

Anatomy

Anatomy

Surgical Anatomy of Nose

The superior, middle and inferior turbinates. A small supreme turbinate may be present in some individuals. Among these turbinates the superior and the middle turbinates are components of the ethmodial complex where as the inferior turbinate is a separate bone.

Anatomy

Uncinate Process Ethmoidal bulla Basal lamella Sphenoid sinus

Uncinate Process

Uncinate process : actually forms the first layer or lamella of the middle meatus. The uncinate process is a wing or boomerang shaped piece of bone. It attaches anteriorly to the posterior edge of the lacrimal bone, and inferiorly to the superior edge of the inferior turbinate. Superior attachement of the uncinate process is highly variable, may be attached to the lamina papyracea, or the roof of the ethmoidal sinus, or sometimes to the middle turbinate.

Ethmoidal Bulla

Agger nasi cells

A prominence may be seen at the anterior attachment of the middle turbinate. This prominence is known as the agger nasi cell. This prominence varies in size in different individuals. These agger nasi cells overlie the lacrimal sac, separated from it just by a thin layer of bone.

Hiatus semilunaris

The hiatus semilunaris is a halfmoon-shaped groove in the lateral wall of the nasal cavity. It is bounded inferiorly and anteriorly by the sharp concave margin of the uncinate process of the ethmoid bone, superiorly by the ethmoidal bulla, and posteriorly by the ethmoidal process of the inferior nasal concha. Following the curve anteriorly leads into the infundibulum of the frontonasal duct, which drains the frontal sinus.

Ostiomeatal complex

Ostiomeatal complex: bounded by the middle turbiante medially, the lamina papyracea laterally, and the basal lamella superiorly and posteriorly. The inferior and anterior borders of the osteomeatal complex are open. The contents of this space are the aggernasi, nasofrontal recess (frontal recess), infundibulum, bulla ethmoidalis and the anterior group of ethmoidal air cells.

Ostiomeatal complex

This is infact a narrow anatomical region consisting of : 1. Multiple bony structures (Middle turbinate, uncinate process, Bulla ethmoidalis) 2. Air spaces (Frontal recess, ethmoidal infundibulum, middle meatus)

3. Ostia of anterior ethmoidal, maxillary and frontal sinuses.

In this area, the mucosal surfaces are very close, sometimes even in contact causing secretions to accumulate. The cilia by their sweeping movements pushes the nasal secretions. If the mucosa lining this area becomes inflamed and swollen the mucociliary clearance is inhibited, eventually blocking the sinuses.

Mucociliary Blanket

Maxillary and frontal sinuses Mucosa or mucociliary blanket follows a genetically predetermined pathway for drainage through natural osteum of sinuses to nasal cavity

Imaging Studies
A Para nasal sinus CT scan is often obtained after maximal medical therapy for chronic sinusitis in order to ascertain the contribution of confounding factors If surgery is to be performed, careful preoperative review of CT scans is essential for safe and complete performance of endoscopic sinus surgery

Sinusitis
C.T.Scan Nasal Endoscopy

Surgical techniques
Stammbergers technique, Wigands technique.

Surgical Technique

After suitable vasoconstriction the middle turbinate is identified. This is the most important landmark for the procedure. Uncinotomy .on the lateral wall of the nose at the level of the anterior end of the middle turbinate lies the uncinate process. Bullectomy . This is removed exposing the ethmoid bulla and the opening called the hiatus semilunaris, into which the frontal and maxillary sinuses drain

Surgical Technique

The anterior ethmoid air cells are then opened, allowing better ventilation but leaving the bone covered with mucosa. Following this, Identification of the maxillary ostium and, if obstructed, opened by means of a middle meatal antrostomy This minimal surgery will often be sufficient to greatly improve the function of the osteomeatal complex and therefore provide better ventilation of the maxillary, ethmoid and frontal sinuses. Sphenoidotomy

Ethmoidectomy

is defined as the excision of the cells of the ethmoid sinus or ethmoid bone

Antrostomy

Antrostomy is broadly defined as making an opening into the maxillary sinus for the purpose of drainage.

Sphenoidotomy

Sphenoidotomy is defined as creating an opening into the anterior, or front, wall of the sphenoid sinus.

Sphenoidotomy

The sphenoid sinus is bordered above by the brain and pituitary gland and laterally, or on its sides, by the optic nerves and the major blood to the anterior brain. Therefore, all surgical approaches to this sinus have evolved from various procedures that are performed through the nose or involve the nasal cavity.

Orbital decompression

Orbital decompression is the partial or complete removal of one or more, of the four walls of the orbit (eye socket). This procedure is primarily performed for Graves disease (thyroid eye disease). Graves disease frequently includes some combination of thyroid disease, bulging of the eyes (exophthalmos), lid lag, retraction of the eye lids and double vision (diplopia).

Orbital decompression

Coronal cadaver section illustrating the four types of orbital decompression. These are: (1) removal of the superior wall (Naffziger), (2) medial wall removal (Sewell), (3) lateral wall removal (Krnlein), and (4) removal of the floor of the orbit.

Optic nerve decompression

Optic nerve decompression is the partial or complete removal of the bone surrounding the optic nerve. This procedure is controversial, and is primarily employed for trauma to the optic nerve resulting in compromised vision. Even less frequent, partial optic nerve decompression is utilized in thyroid eye disease with optic neuropathy.

C.S.F. Rhinorrhea

Coronal cadaver section illustrating potential sites of CSF rhinorrhea. A breach in the anterior cranial fossa floor (ACF) or middle cranial fossa floor provides a route for drainage of CSF to the nose. These routes include via the posterior wall of the frontal sinus (FS), roof of the ethmoid sinus (ES), sphenoid sinus (SS), and middle cranial fossa through the roof of the middle and inner ear to the eustachian tube (ET) to the nasopharynx (the space behind the nose which communicates with the throat).

Intraoperative

Intraoperative photograph of skull base defect through the brain (1) can be seen with the dura (2) and mucous membrane (3) of the ethmoid sinus in the foreground.

Adipose tissue placement of tissue glue

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Complications

Blindness - . Injury of the Nasolacrimal Duct with Tearing. Leakage of Cerebral Spinal Fluid (Brain Fluid). Bleeding, Infection. Injury to the Carotid Artery which can cause massive Bleeding, Stroke and death. Meningitis, Stroke, Death. Chronic Pain. Rarely, chronic facial pain has been reported to be associated with sinus surgery. PerioSrbital Ecchymosis or Emphysema

Postoperative Care

Normal function usually returns within one to two months. In patients with gross inflammation or polyps, a short course of systemic steroids combined with antibiotics may hasten postoperative recovery. Topical steroids are used postoperatively in patients who have had polyps removed

Outcome

P.O. FESS

Blindness . Injury of the Nasolacrimal Duct with Tearing. Leakage of Cerebral Spinal Fluid (Brain Fluid). Bleeding, Infection. Injury to the Carotid Artery which can cause massive Bleeding, Stroke and death. Meningitis, Stroke, Death. Chronic Pain. Rarely, chronic facial pain has been reported to be associated with sinus surgery.

Complications
. The most catastrophic complication of FESS is blindness resulting from damage to the optic nerve. However, the evidence indicates that the frequency of this complication is extremely low

Complications

Cerebrospinal fluid leak is the single most common major complication of FESS, occurring in about 0.2 percent of cases. The leak is usually recognized at the time of surgery and can easily be repaired; it should be suspected if there is a clear nasal discharge postoperatively. Unless the discharge is contaminated with blood, the presence of glucose means that it is most likely to be cerebrospinal fluid . Absolute confirmation may be obtained by having a sample tested for the presence of beta2 transferrin.

Complications
Other, less serious, but still rare complications include orbital hematoma and nasolacrimal duct stenosis. It should be emphasized that all of these complications also may occur with "conventional" sinus surgery and, therefore, patients are not undergoing a new treatment with complications that are more serious or more frequent than those in other surgeries.

Balloon sinuplasty

Balloon sinuplasty is an endoscopic surgical procedure for the treatment of blocked nasal sinuses. Balloon sinuplasty is an endoscopic, catheter-based system for patients suffering from sinusitis. It uses a small, flexible balloon catheter to enlarge sinus passageways. When the balloon is inflated, it restructures and widens the walls of the sinus passageway, with the goal of restoring normal sinus drainage without damaging the sinus lining.

Balloon sinuplasty

Conclusion

Endoscopic Sinus surgery is a diagnostic procedure and during this procedure if any abnormality is detected it is corrected by minimal invasive procedure.

Surgical Procedures

Ethmoidectomy Antrostomy Sphenoidotomy Frontal Sinusotomy Additional sinus surgeries include: Caldwel Luc Osteoplastic Frontal Sinusotomy Orbital Decompression for Thyroid Eye Disease Optic Nerve Decompression Closure of Cerebral Spinal Fluid Fistulas to the Nose Cranio Facial Tumor Surgery

Why Fess?
The diseases of sinuses are rhinogenic Ethmoid sinuses are primarily diseased and frontal and maxillary sinuses are secondarily involved through pre-chambers ethmoidal infundibulm, and frontal recess.

Osteomeatal complex of nose

Ostiomeatal complex: This term is used by the surgeon to indicate the area bounded by the middle turbiante medially, the lamina papyracea laterally, and the basal lamella superiorly and posteriorly. The inferior and anterior borders of the osteomeatal complex are open. The contents of this space are the aggernasi, nasofrontal recess (frontal recess), infundibulum, bulla ethmoidalis and the anterior group of ethmoidal air cells.

Sphenoid sinus

Mucocele

FESS

Functional Endoscopic Sinus Surgery-

Endoscopy

Nasal polyps

Anterior rhinoscopy