Functional Endoscopic Sinus Surgery
Functional Endoscopic Sinus Surgery (FESS) was introduced in the 1980’s as a minimally invasive, more effective surgical technique to address chronic sinusitis that failed maximal medical therapy. Prior to the introduction of FESS, sinus surgery involved external facial incisions that resulted in significant pain, long recovery periods and poor results. Patients also required significant packing and experienced frequent bleeding.
Endoscopic view of a frontal recess that scarred with no visible opening to the frontal sinus. This patient has had 2 previous endoscopic surgeries.
With the introduction of nasal telescopes, FESS is performed through the nostrils without facial incisions. Patients do not require extensive packing, there is minimal post-operative pain and recovery period is less than open approaches.
Indications for sinus surgery include chronic sinus infections that have not resolved with antibiotic therapy, recurrent acute infections, nasal polyps, tumors, csf leaks, nasolacrimal duct obstruction, choanal atresia and orbital swelling.
Endoscopic view of frontal recess 6 months after successful computer image-guided endoscopic sinus surgery. The opening to the frontal sinus is clearly visible.
Your doctor may place you on pre-operative steroids and/or antibiotics to maximize the health of the sinus lining during surgery. This will decrease bleeding during surgery and allow for a thorough cleaning of the sinuses.
Sinus surgery is routinely performed under general anesthesia in the operating room. The goal of surgery is to identify and enlarge the narrow openings (ostia) of the sinuses to improve mucus flow into the nose. FESS also allow for excellent visualization and preservation of normal sinus mucosa and turbinate structures. Surgical times vary from as little as one hour to 4 hours depending upon degree of disease and how many sinuses are accessed.
Endoscopic view of actively leaking spinal fluid. In this situation the spinal fluid was injected with a fluorescent material to make for easier identification and repair.
Sometimes, sinus surgery also requires repair of a deviated septum (septoplasty). The septum functions to divide the nose into two separate passageways. A deviated septum is straightened to allow adequate access to the sinuses. When a septoplasty is required, nasal stents are rountinely placed in the nose to maintain a straight nasal septum.
Packing is not used after sinus surgery except for small sponge spacers. Patients are able to breathe through the nose after surgery and experience very little discomfort or bleeding. Please refer to the section on post-operative instructions for further details.
Results after sinus surgery are outstanding and symptomatic improvement is achieved in the majority of patients. Co-morbid conditions can reduce surgical success rates. These include asthma, nasal polyps, aspirin allergy, cystic fibrosis, immotile cilia syndrome, allergies, fungal sinusitis, tobacco use and other environmental irritants.
Complications of sinus surgery are rare but patients must be aware of the risks associated with operating near the eyes and brain.
Postoperative bleeding is the most common complication we encounter after surgery. Aspirin, ibuprofen and certain supplements can increase the risk of bleeding. Patients are instructed to discontinue aspirin containing products one week prior to surgery. Lab work is obtained pre-operatively to evaluate for bleeding disorders and the sinus cavity is treated with thrombin (a substance which promotes clotting) during surgery to avoid post-operative bleeding.
Alteration in the sense of smell can occur after sinus surgery. This is rarely permanent and returns to the pre-operative state within 3 months of surgery.
Sinuses play a role in vocal resonance. Vocal professionals should be aware that potential changes of voice can occur with sinus surgery and should only be considered when medical therapy has been exhausted. The newest technique of balloon sinuplasty is a better option for vocal professionals as less normal sinus tissue is removed from the nose. Please refer to our information on balloon sinuplasty.
The roof of the ethmoid sinus serves to separate the sinus cavity from the brain. In certain patients, the bone is thinner than a potato chip. If this layer is traumatized, cerebrospinal fluid (CSF) can leak from the brain into the sinus cavity. This is usually repaired at the time of surgery to avoid further complications of meningitis and brain abscess. Some sinus conditions such as mucoceles, fungal infections and tumors can cause erosion of this thin bone and present with clear fluid (CSF) leaking out of the nose. These conditions must be addressed to avoid further life-threatening complications.
The eye is enclosed in bony cavity that is also separated from the sinuses by thin bone. Trauma to the bone or blood vessels which supply the eye can cause bleeding in the eye. Some patients will experience bruising around the eye. Vision loss and loss of eye mobility have been reported but are extremely rare.
Complications are rare in modern day endoscopic sinus surgery. It is important for to understand that failure to treat sinus conditions may place the patient at an even greater risk. Untreated infections can spread to the eye or brain leading to blindness, brain abscess or even death.
This is a patient with untreated frontal and ethmoid sinusitis that developed an infected mucus pocket next to the eye. The patient experienced eye pain, double vision and severe headache.
