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Endoscopic surgery was based on the work of Messerklinger in the sixties and Wigand in the seventies. It was then made more popular by Stammberger in the eighties. Messerklinger was able to recognize the relationship between disease in the osteomeatal complex and maxillary and frontal sinusitis. Moreover, when the osteomeatal disease resolved, the irreversible disease in the secondarily involved sinuses frequently regressed.

The nasal cavity is examined by using the endoscope, the sinuses are assessed by the computed tomography. The coronal CT is particularly good at showing the fine bone architecture of the paranasal sinuses as well as areas of mucosal thickening and obstruction. The CT examination is best performed after the sinusitis has been medically treated. CT should be performed in every patient before endoscopic sinus surgery in order to identify the extent of the disease, to obtain a clear map of the sinuses in relation to skull base and orbital structure and for medicolegal reasons.

Endoscopic sinus surgery is indicated with rhinoplasty when the patient presents with small nasal polyps, concha bullosa and or concha ethmoidalis. But Functional Endoscopic Sinus Surgery should be avoided in combination with rhinoplasty in patients with excessive polyposis and infected sinuses.

Functional Endoscopic Sinus Surgery is best performed following septoplasty and before starting rhinoplasty, except, trimming of middle turbinates which should be postponed until the end of the operation.

Recommended technique:

  1. Local anaesthesia and nose preparation by vasoconstrictors, cocaine or Xylocaine gel with adrenaline for twenty minutes. The operation may be performed under general anaesthesia with hypotensive technique.
  2. It is best to use a zero degree nasal endoscope throughout most of the procedure. The 300 or 700 are used at the maxillary ostium enlargement and frontal recess clearance.
  3. Take the sickle knife and make the “infundibulotomy incision” just anterior to the uncinate process between middle and inferior turbinates. When the cut is made too much to the anteriorly, the lacrimal duct will be damaged, too much to the posteriorly leaves the uncinate process intact and it gives a bad entrance to the ethmoid infundibulum. If the cut is too deep the ethmoid bulla will also be cut.

Fig. 15 – 1. (1) Apparent uncinate process and middle turbinate (2) Nasal polyps and maxillary purulent discharge in the left middle meatus. (3) Intranasal polyposis. (4) Nasal polyps and left nasal turbinates (5) Nasal polyps arising from the left superior recess (6 & 7) Removed nasal polyps (8) CT scan with deviated septum to the left, right conchal bullosa and enlarged inferior turbinates

 

Fig. 15 – 2. Bilateral extensive nasal polyposis.
Fig. 15 – 3. Cross-section of the anterior ethmoid.
1. Uncinate process
2. Infundibulum ethmoidale
3. Ostium of the maxillary sinus
4. Hiatus semilunaris
5. Bulla ethmoidalis
6. Frontal recess
7. Concha media
8. Roof of ethmoid
              S.M. – Maxillary sinus
S.F. – Frontal sinus
RIGHT – Status after endoscopic ethmoidectomy
* Permission from Prof. Grote.
  1. Remove the uncinate process and look in the ethmoid infundibulum. Looking upwards you will find the frontal recess. If obscured by disease, gently strip out the disease and polyps.
  2. Follow the disease. Do not remove mucosa, use small instruments.
  3. Locate the maxillary ostium (situated low in the infundibulum and just above the inferior turbinate). Remove disease around it, enlarge it downwards and backwards. Do not enlarge forwards to avoid lacrimal duct stenosis.
  4. Remove the bulla, taking care to leave the ground lamella intact. Sometimes the bulla is only a few millimeters deep. Also remove the lateral wall of the bulla. Keep following the disease. (Fig. 15 – 6)
  5. Now you look into the maxillary sinus and the frontal recess and perhaps the frontal sinus. Widen the maxillary ostium in inferior and posterior directions.
  6. Locate the ground lamella and penetrate it (low) with a small Blakesley forceps. If you do this too high you risk penetrating the ethmoid roof. Now one looks into the fewer but bigger cells of the posterior ethmoid. Remove the ground lamella and look carefully at this oblique position in the ethmoid. Clear the roof of the ethmoid. It is very important to look thoroughly at the ethmoid roof, cribriform plate and frontal recess. This is an accident prone region! The anterior part of the ethmoid roof is always situated at a higher level than the cribriform plate (four to six mm, sometimes more).
  7. Explore the region of the frontal recess. In most cases you can look with a zero degree (straight forward) lens into the frontal sinus. Do not operate on the frontal sinuses. Operate on the frontal recess. Remove disease from the recess, remove all polyps and obstructive disease. Open the sphenoid sinus, remove disease and try to locate the sella turcica and the impression of the carotid artery and optic nerve in its lateral wall. The optic nerve is occasionally dehiscent.
  8. Try to locate the anterior and posterior ethmoid artery. (Sometimes they are not surrounded by bone).
    Take care to leave the lamina papyracae intact. If in doubt of lamina papyracea push the eye down, if it is orbital fat, the eye will move.
  9. If there’s bleeding throughout the process use adrenaline tipped cotton to control it.
  10. If intraorbital bleeding happens, consider the external ethmoidectomy approach. Remove the lamina papyracea and incise the periostium to release the pressure from the optic nerve. This is an emergency situation. If happening postoperative, the patient complains of loss of vision. Surgical intervention should be done within ninety minutes without delay.

 

  1. Remove the uncinate process and look in the ethmoid infundibulum. Looking upwards you will find the frontal recess. If obscured by disease, gently strip out the disease and polyps.
  2. Follow the disease. Do not remove mucosa, use small instruments.
  3. Locate the maxillary ostium (situated low in the infundibulum and just above the inferior turbinate). Remove disease around it, enlarge it downwards and backwards. Do not enlarge forwards to avoid lacrimal duct stenosis.
  4. Remove the bulla, taking care to leave the ground lamella intact. Sometimes the bulla is only a few millimeters deep. Also remove the lateral wall of the bulla. Keep following the disease. (Fig. 15 – 6)
  5. Now you look into the maxillary sinus and the frontal recess and perhaps the frontal sinus. Widen the maxillary ostium in inferior and posterior directions.
  6. Locate the ground lamella and penetrate it (low) with a small Blakesley forceps. If you do this too high you risk penetrating the ethmoid roof. Now one looks into the fewer but bigger cells of the posterior ethmoid. Remove the ground lamella and look carefully at this oblique position in the ethmoid. Clear the roof of the ethmoid. It is very important to look thoroughly at the ethmoid roof, cribriform plate and frontal recess. This is an accident prone region! The anterior part of the ethmoid roof is always situated at a higher level than the cribriform plate (four to six mm, sometimes more).
  7. Explore the region of the frontal recess. In most cases you can look with a zero degree (straight forward) lens into the frontal sinus. Do not operate on the frontal sinuses. Operate on the frontal recess. Remove disease from the recess, remove all polyps and obstructive disease. Open the sphenoid sinus, remove disease and try to locate the sella turcica and the impression of the carotid artery and optic nerve in its lateral wall. The optic nerve is occasionally dehiscent.
  8. Try to locate the anterior and posterior ethmoid artery. (Sometimes they are not surrounded by bone).
    Take care to leave the lamina papyracae intact. If in doubt of lamina papyracea push the eye down, if it is orbital fat, the eye will move.
  9. If there’s bleeding throughout the process use adrenaline tipped cotton to control it.
  10. If intraorbital bleeding happens, consider the external ethmoidectomy approach. Remove the lamina papyracea and incise the periostium to release the pressure from the optic nerve. This is an emergency situation. If happening postoperative, the patient complains of loss of vision. Surgical intervention should be done within ninety minutes without delay.
Fig. 15 – 4. The lateral nasal wall (after fenestrating the medial concha).*
1. Margin of concha media
2. Uncinate process (medial wall of the infundibulum)
3. Hiatus semilunaris
4. Bulla ethmoidalis
5. Ground lamella (separation between anterior and posterior ethmoid)
6. Roof of ethmoid (rising in lateral direction)
7. Bony wall of lacrimal duct
8. Frontal recess
* Permission from Prof. Grote.
  1. According to the disease you may need to partially trim the middle or the inferior turbinates. Never pull the middle turbinate because it has a superior attachment to the floor of the anterior cranial fossae. Pulling may cause dural tear and CSF leak.Partial trimming of middle turbinate is required in a few situations. First, the middle turbinate may be a source of pathological obstruction (polyps) of the osteomeatal complex. Secondly, the middle turbinate may be displaced laterally in the postoperative period predisposing for adhesions which block the osteomeatal complex and natural ostiums. Thirdly, the middle turbinate may be enlarged enough to touch the nasal septum or lateral wall causing midfacial pain (Slutter’s syndrome).
  2. Use intranasal splints to avoid adhesions. The splint is usually kept in for ten days.
  3. Light Sofratulle nasal packs are used to control postoperative bleeding. The nasal packs are removed after twenty four hours.
  4. Patient receives three doses of intravenous antibiotics. In cases of fungal disease, antifungal agents are used.
  5. Close follow-up of the patients in out patient for six weeks to remove crusts and divide any adhesions.

Postoperative care:

  1. Nasal irrigations should be started immediately following pack removal, usually with normal saline, five times a day, and is continued for three months. In order to keep the operative site free of clots and crusts, it may be done effectively with 20cc syringe attached to a rubber bulb.
  2. Perioperative medication: our regime is as follows:
    • Zinnat (Cefuroxim) 500mg BID for ten days
    • Prednisolone 10mg once a day for two weeks
      Then reduce to 5mg for a further two weeks
    • Claretine (Loratadine) one tablet at bedtime for three months
      If the basic indication was chronic sinusitis, antibiotic treatment may be considered for a longer period according to culture and sensitivity.
  3. Long term medications:
    • Steroid nasal sprays: to be used indefinitely.
    • Nasal irrigations with normal saline are used permanently at least twice a day. The commercially available Sea or Ocean nasal washes are recommended.
    • In cases of polyposis: Predinisolone 5mg once a day for one week, this is repeated
Fig. 15 – 5. Drainage pathways of the paranasal sinuses (after opening the ethmoid and resection of the concha media).*
– Maxillary sinus
– Anterior ethmoid
– Posterior ethmoid
– Frontal sinus
– Sphenoid sinus
1. Infundibulum ethmoidale
2. Frontal recess
* Permission from Prof. Grote.

 

every five weeks for two years or may be for life in severe cases of allergic or vasomotor rhinitis with recurrent polyposis.
  • In cases of chronic purulent sinusitis despite surgery and antibiotic treatment, a fungus aetiology should be considered. Prolonged treatment with antifungal agent such as Sphoronox (Itraconazol) is recommended.

Possible complications of Functional Endoscopic Sinus Surgery

  1. Recurrence of disease: polyps, fungus or inverted nasal papilloma.
  2. Intranasal adhesions and stenosis of sinus ostium.
  3. Crustation and the need for regular nasal toilet.
  4. Impaired or loss of sense of smell which could be due to disease or surgery.
  5. Persistent postnasal discharge: this is due to allergic or vasomotor elements, limited surgery or fungus infection. Fungus causes mucopurulent discharge which is not responding to antibiotic treatment. Antifungal agents are given once diagnosis is confirmed.
  6. Virus rhinitis during first two weeks postoperative is really disappointing and may predispose for complications such as bacterial infection, adhesions, stenosis and prolonged postnasal drip. If this happens a long course of antibiotics and costicosteroid is indicated.
  7. Squint or double vision due to injury to the eye muscles, medial rectus muscle or superior oblique muscle.
  8. Impaired or loss of vision due to:
    • Intraorbital bleeding.
    • Injury to optic nerve.
  9. CSF leak and meningitis due to dural tear.
  10. Brain abscess due to spread of infection by emissary veins.

Superior overdissection, may lead to cerebrospinal fluid leak, due to penetration of the dura through the fovea ethmoidalis or cribriform plate. If this is recognized intraoperatively, it should be repaired with fat, fascia, mucosal flap, tissue glue and packing. If recognized postoperatively, conservative treatment is recommended unless it is too large to close spontaneously. Closure is obtained by endoscopic approach or by the external approach with the help of the neurosurgeon.

Lateral overdissection, may lead to penetration of the lamina papyracea. If orbital fat is noted, do not pull or remove the fat, just leave it alone. There will be no adverse effect other than some echymosis in the medial canthus area. Deeper entry into the orbit may result in damage to the medial rectus muscle or the optic nerve. If this occurs, an immediate ophthalmic consultation should be obtained. The surgeon should always be prepared to do an orbital decompression. This is most quickly obtained by lateral canthotomy, or during the procedure by removing the lamina papyracae and medial wall of the orbit.

 

Fig. 15 – 6. Basic endoscopic sinus surgery: excision of uncinate process, bullous Ethmoidalis, excentration of anterior ethmoid air cells, enlargement of natural maxillary ostium and partial trimming of middle turbinate.

Anterior overdissection,

can damage the nasolacrimal duct, spontaneous fistulization may occur. In case of obstruction, endoscopic intranasal dacrocystorhinostomy is indicated.

Based on the author’s experience of over 1,100 cases of Functional Endoscopic Sinus Surgery, the author recommends the following prophylactic means:

  1. The patient should stop aspirin or any anticoagulant a few days before the operation.
  2. The preoperative CT Scan should be available and positioned in front of the surgeon during the procedure.
  3. Immediate preoperative preparation of the nasal cavity by decongestant and local packing with Xylocaine gel and adrenaline 1:100,000 for twenty minutes.
  4. Do not cover the eye, observe and palpate during the procedure.
  5. Do not pull orbital fat, just leave it and continue your procedure.
  6. If any possibility of CSF leak, repair immediately with fat and fascia. Neurosurgical consultation is advised.
  7. Enter the sphenoid medially:
    The distance to the back of the sphenoid is nearly equal to the distance to the back of the nasopharynx.
  8. If there is much bleeding or if there is any question of distorted anatomy due to previous surgery, stop surgery and reassess, if you are still not sure, discontinue the operation or call a senior colleague.
  9. A right handed surgeon should start on the right side, because it is more difficult.
  10. At the end of the procedure, always use intranasal splints to reduce the incidence of adhesions.
  11. Perioperative medication. (p. 359)
(14)(15)
(16)
Fig. 15 – 7. (14) Pansinusitis (15) Chronic rhino-sinusitis, with maxillary polyposis. (16) Bilateral maxillary sinusitis right side, right frontal, ethmoid and partial sphenoid sinusitis, hypertropheid nasal turbinates with nasal polyps.

 

(17)
(18)(19)

 

(9)(10)
(11)
(12)(13)
Fig. 15 – 9. (9) Bilateral Haller’s cells (10) Left chronic sinusitis, with deviated septum to the right side and occlusion of bilateral ethmoidal meatal complexes (11) Right side had functional sinus surgery, left side blocked middle meatu complex. (12 & 13) Pan fungal sinusitis and polyposis.

 

Refrences
Functional Endoscopic Sinus Surgery
 

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2.Bhattacharyya N, Kepnes LJ: The microbiology of recurrent rhinosinusitis after endoscopic sinus surgery. Arch Otolaryngol Head Neck Surg 125:1117-1120, 1999.
3.Chambers DW, Davis WE, Cook PR, et al: Long term outcome analysis of FESS: correlation of symptoms with endoscopic examination findings and potential prognostic variables. Laryngoscope 107:504-510, 1987.
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10.Mitchell RB, Rareira KD, Yonnis RT, et al: Pediatric functional endoscopic sinus surgery: is a second look necessary? Laryngoscope 107:1267-1269, 1997.
11.Moses RL, Cornetta A, Atkins JP, et al: Revision endoscopic sinus surgery: the Thomas Jefferson University Experience. Ear Nose Throat J 77:193-195, 199-202, 1998.Rice DH, Schaefer . Endoscopic paranasal sinus surgery. New York, Raven Press 1988.
12.Stammberger H. Endoscopic endonasal surgery: concepts in the treatment of recurring rhinosinusitis: II. Surgical technique. Otolaryngol Head Neck Surg 94:147, 1986.
13.Stankiewicz JA. Complications of endoscopic nasal surgery: occurrence and treatment. AM J Rhinol 1:45, 1987.
14.Toffel PH. Secure endoscopic sinus surgery as an adjunct to functional nasal surgery. Arch Otolaryngol Head Neck Surg 115:822, 1989.
15.Toffel PH. Endoscopic surgery in chronic sinus disease. J Resp Dis 12:546-548, 1991.
16.Toffel PH. Chronic nasal obstruction. In Gats GA: editor: Current Therapy in Otolaryngology. Head and Neck Surg, Philadelphia, Decker 5:3383-391, 1994.
17.Toffel PH. Nasal Polyposis. Editor Gates GA. Current therapy in Otolaryngology Head and Neck Surgery. Fifthe edition, Copyright 1994; 3383-391.
18.Toffel PH. American Academy of Otolaryngology _ Head and Neck Surgery Instruction course 5:165-171, 1992.
19.Wigand ME, et al. Endonasal sinus surgery with endoscopic control: from radical operation to rehabilitation of the mucosa. Endoscopy 10:255, 1978.
20.Zinreich SJ, et al. Paranasal sinuses: CT imaging requirements for endoscopic surgery. Radiology 163:769, 1987.

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