Endoscopic Sinus Surgery
Endoscopic Sinus Surgery
Definition
Purpose
Demographics
Description
Diagnosis/Preparation
Aftercare
Risks
Normal results
Morbidity and mortality rates
Alternatives
Definition
Functional endoscopic sinus surgery (FESS) is a minimally invasive surgical procedure that opens up sinus air cells and sinus ostia (openings) with an endoscope.
The use of FESS as a sinus surgical method has now become widely accepted, and the term “functional” is meant to distinguish this type of endoscopic surgery from nonendoscopic, more conventional sinus surgery procedures.
Purpose
The purpose of FESS is to restore normal drainage of the sinuses. This function requires ventilation through the ostia (mouth-like opening) and is facilitated by a mucociliary transport process that maintains a constant flow of mucus out of the sinuses. All sinuses need ventilation to prevent infection and inflammation, a condition known as sinusitis. In healthy individuals, sinus ventilation occurs through the ostia into the nose. The sinuses open into the middle meatus (curved passage in each nasal cavity) under the middle turbinate (thin, bony process that is the lower portion of the ethmoid bone in each nasal cavity), which together are known as the osteomeatal complex, the key area of the nose. The hair-like cilia direct the flow of mucus toward the ost
Sinusitis develops when there is a problem in the area where the maxillary and frontal sinuses meet near the nose or, occasionally, a dental infection. When sinusitis occurs, the cilia work less efficiently, preventing the flow of mucus. The mucous membranes of the sinuses become engorged, resulting in ostia closure. Poor ventilation and accumulation of mucus then produce the conditions required for bacterial infection.
Demographics
Sinusitis is a very common condition, affecting 31 million Americans each year; 30% of the U.S. population have sinusitis at some point in their lives. The average adult has three to four upper respiratory infections a year; 1% of these infections are complicated by sinusitis, accounting for 16 million visits to the doctor each year.
Description
After inducing adequate vasoconstriction with cocaine or ephedrine, the surgeon locates the middle turbinate, the most important landmark for the FESS procedure. On the side of the nose at the level of the middle turbinate lies the uncinate process, which the surgeon removes. The surgeon opens the back eth-moid air cells, to allow better ventilation, but leaves the bone covered with the mucous membrane. Following this step, the ostium located near the jaw is checked for obstruction and, if necessary, opened with a middle meatal antrostomy. This surgical procedure often greatly improves the function of the osteomeatal complex and provides better ventilation of the sinuses.
FESS offers several advantages:
KEY TERMS
Antrostomy— The operation of opening an antrum for drainage.
Antrum— The cavity of a sinus.
Caldwell-Luc procedure— A surgical procedure in which the surgeon enters the maxillary sinus by making an opening under the upper lip above the teeth.
Cilia— Short hairlike processes that are capable of a lashing movement.
CT scan— A sectional imaging of the body constructed by computed tomography.
Endoscope— An instrument for visualizing the interior of a hollow organ.
Ethmoid sinuses— Paired labyrinth of air cells between the nose and eyes.
Maxillary sinuses— Sinuses located in the cheek under the eye next to the ethmoid sinus.
Meatus— A general term for an opening or passageway in the body.
Middle meatus— A curved passage in each nasal cavity located below the middle nasal concha and extending along the entire superior border of the inferior nasal concha.
Middle turbinate— The lower of two thin bony processes on the ethmoid bone on the lateral wall of each nasal fossa that separates the superior and middle meatus of the nose.
Mucociliary— Involving cilia of the mucous membranes of the respiratory system.
Mucous membrane— A membrane rich in mucous glands that lines body passages and cavities comunicating directly or indirectly with the exterior of the body (as for example, the alimentary, respiratory, and genitourinary tracts). Mucous membranes functions in protection, support, nutrient absorption, and secretion of mucus, enzymes, and salts.
Mucus— A viscous, slippery secretion that is produced by mucous membranes which it moistens and protects.
Nasal concha— Any of three thin bony plates on the lateral wall of the nasal fossa on each side with or without their covering of mucous membrane.
Ostia— A mouth-like opening in a bodily part.
Polyp— A projecting mass of swollen and hypertrophied or tumorous tissue.
Sinus— A cavity in a bone of the skull that usually communicates with the nostrils and contains air.
Sinusitis— Inflammation of a sinus.
Stenosis— Narrowing of a duct or canal.
Turbinate— Relating to a nasal concha.
Uncinate process— A downwardly and backwardly directed process of each lateral mass of the ethmoid bone that joins with the inferior nasal conchae.
Vasoconstriction— Narrowing of blood vessels, especially as a result of vasomotor action.
- It is a minimally invasive procedure.
- It does not disturb healthy tissue.
- It is performed in less time with better results.
- It minimizes bleeding and scarring.
Diagnosis/Preparation
As with many diseases, the history of a patient with sinusitis represents a key part of the preoperative evaluation. Before considering FESS, the ear, nose and throat (ENT) specialist will proceed with a thorough diagnostic examination. The development of such diagnostic tools as the fiberoptic endoscope and CT scanning has greatly improved the treatment of sinus disease. The fiberoptic endoscope is used to examine the nose and all its recesses thoroughly. The specific features that the physician must examine and evaluate are the middle turbinate and the middle meatus, any anatomic obstruction, and the presence of pus and nasal polyps.
CT scanning can also be used to identify the diseased areas, a process that is required for planning the surgery. It shows the extent of the affected sinuses, as well as any abnormalities that may make a patient more susceptible to sinusitis.
FESS is usually performed under local anesthesia with intravenous sedation on an outpatient basis with patients going home one to two hours after surgery. It usually does not cause facial swelling or bruising, and does not generally require nasal packing.
Aftercare
FESS usually does not cause severe postoperative sinus pain. After the procedure, it is important to keep the nose as free from crust build-up as possible. To
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
This procedure is usually performed on an outpatient basis by an ear, nose, and throat (ENT) specialist, such as an otolaryngologist or an ophthalmic surgeon. ENT physicians are graduates of a school of medicine and typically undergo an otolaryngology residency with further specialization in sinus disease and endoscopic sinus surgery.
achieve this, the surgeon may perform a lengthy cleaning two to three times per week, or the patient may perform a simple nasal douching several times a day. Normal function usually reappears after one or two months. In patients with severe sinusitis or polyps, a short course of systemic steroids combined with antibiotics may quicken recovery.
Risks
The most serious risk associated with FESS is blindness resulting from damage to the optic nerve. However, the chances of this complication occurring are extremely low. Cerebrospinal fluid leak represents the most common major complication of FESS, but it occurs in only about 0.2% of cases in the Unites States. The leak is usually recognized at the time of surgery and can easily be repaired. Other less serious and rare complications include orbital hematoma and nasolacrimal duct stenosis. All of these complications are also associated with conventional sinus surgery and not only with FESS.
Normal results
The FESS procedure is considered successful if the patient’s sinusitis is resolved. Nasal obstruction and facial pain are usually relieved. The outcome has been compared with that of the Caldwell-Luc procedure and, although both methods are considered effective, there is a strong patient preference for FESS. The extent of the disease before surgery dictates the outcome, with the best results obtained in patients with limited nasal sinusitis.
Morbidity and mortality rates
According to the American Academy of Family Physicians (AAFP), FESS usually has a good outcome, with most studies reporting an 80–90% rate of
QUESTIONS TO ASK THE DOCTOR
- Why is sinus surgery required?
- What are the risks involved?
- How many endoscopic sinus surgeries do you perform in a year?
- How much time will I need to recover from the procedure?
- Is the procedure painful?
- What are the alternatives?
success. Good results have also been obtained in patients who have had previous sinus surgery.
Alternatives
- Image-guided endoscopic surgery. This method uses image guidance techniques that feature a three-dimensional mapping system combining CT scanning and real-time data acquisition concerning the location of the surgical instruments during the procedure. It allows surgeons to navigate more precisely in the affected area. The surgeon can monitor the exact location of such vital organs as the brain and eyes as well as positively identifying the affected areas.
- Caldwell-Luc procedure. This procedure is improves drainage in the maxillary sinus region located below the eye. The surgeon reaches the region through the upper jaw above one of the second molars. He or she creates a passage to connect the maxillary sinus to the nose in order to improve drainage.
Resources
BOOKS
Bhatt, N. J. The Frontal Sinus: Advanced Surgical Techniques. Independence, KY: Singular Publishing Group, 2002.
Marks, S. C. and W. A. Loechel. Nasal and Sinus Surgery. Philadelphia: W. B. Saunders Co., 2000.
PERIODICALS
Engelke, W., W. Schwarzwaller, A. Behnsen, and H. G. Jacobs. “Subantroscopic laterobasal sinus floor augmentation (SALSA): an up-to-5-year clinical study.” International Journal of Oral and Maxillofacial Implants 18 (January-February 2003): 135–143.
Graham, S. M., and K. D. Carter. “Major complications of endoscopic sinus surgery: a comment.” British Journal of Ophthalmology 87 (March 2003): 374–377.
Larsen, A. S., C. Buchwald, and S. Vesterhauge. “Sinus barotrauma—late diagnosis and treatment with computer-aided endoscopic surgery.” Aviation & Space Environmental Medicine 74 (February 2003): 180–183.
Ramadan, H. H. “Relation of age to outcome after endoscopic sinus surgery in children.” Archives of Otolaryngology & Head and Neck Surgery 129 (February 2003): 175–177.
Wormald, P. J. “Salvage frontal sinus surgery: the endoscopic modified Lothrop procedure.” Laryngoscope 113 (February 2003): 276–283.
ORGANIZATIONS
American Academy of Otolaryngology-Head and Neck Surgery. One Prince St., Alexandria, VA 22314-3357. (703) 836-4444. http://www.entnet.org/.
Association for Research in Otolaryngology. 19 Mantua Rd., Mt. Royal, NJ 08061. (856) 423-0041. (301) 733-3640. http://www.aro.org/index.html.
North American Society for Head and Neck Pathology. Department of Pathology, H179, P.O. Box 850, Milton S. Hershey Medical Center, Penn State University School of Medicine, Hershey, PA 17033. (717) 531-8246. http://www.headandneckpathology.com/.
OTHER
“Factsheet: Sinus Surgery.” American Academy of Otolaryngology—Head and Neck Surgery. http://www.entnet.org/HealthInformation/SinusSurgery.cfm [Accessed April 11, 2008].
Monique Laberge, PhD
Laura Jean Cataldo, RN, EdD
Endoscopic Sinus Surgery
Endoscopic sinus surgery
Definition
Functional endoscopic sinus surgery (FESS) is a minimally invasive surgical procedure that opens up sinus air cells and sinus ostia (openings) with an endoscope.
The use of FESS as a sinus surgical method has now become widely accepted; and the term "functional" is meant to distinguish this type of endoscopic surgery from nonendoscopic, more conventional sinus surgery procedures.
Purpose
The purpose of FESS is to restore normal drainage of the sinuses. Normal function of the sinuses requires ventilation through the ostia (mouth-like opening) and is facilitated by a mucociliary transport process that maintains a constant flow of mucus out of the sinuses. All sinuses need ventilation to prevent infection and inflammation, a condition known as sinusitis. In healthy individuals, sinus ventilation occurs through the ostia into the nose. The sinuses open into the middle meatus (curved passage in each nasal cavity) under the middle turbinate (thin, bony process that is the lower portion of the ethmoid bone in each nasal cavity), which together are known as the osteomeatal complex, the key area of the nose. The hair-like cilia direct the flow of mucus toward the ostia.
Sinusitis develops when there is a problem in the area where the maxillary and frontal sinuses meet near the nose or, occasionally, by dental infection. When sinusitis occurs, the cilia work less efficiently, preventing the flow of mucus. The mucous membranes of the sinuses become engorged, resulting in ostia closure. Poor ventilation and accumulation of mucus then produce the conditions required for bacterial infection.
Demographics
Sinusitis is a very common condition, affecting 31 million Americans each year; 30% of the United States population have sinusitis at some point in their lives. The average adult has three to four upper respiratory infections a year; 1% of these infections are complicated by sinusitis, accounting for 16 million visits to the doctor each year.
Description
After inducing adequate vasoconstriction with cocaine or ephedrine, the surgeon locates the middle turbinate, the most important landmark for the FESS procedure. On the side of the nose at the level of the middle turbinate lies the uncinate process, which the surgeon removes. The surgeon opens the back ethmoid air cells, to allow better ventilation, but leaves the bone covered with the mucous membrane. Following this step, the ostium located near the jaw is checked for obstruction and, if necessary, opened with a middle meatal antrostomy. This surgical procedure often greatly improves the function of the osteomeatal complex and provides better ventilation of the sinuses.
FESS offers several advantages:
- It is a minimally invasive procedure.
- It does not disturb healthy tissue.
- It is performed in less time with better results.
- It minimizes bleeding and scarring.
Diagnosis/Preparation
As with many diseases, the history of a patient with sinusitis represents a key part of the preoperative evaluation. Before considering FESS, the ear, nose and throat (ENT) specialist will proceed with a thorough diagnostic examination. The development of such diagnostic tools as the fiberoptic endoscope and CT scanning has greatly improved the treatment of sinus disease. The fiberoptic endoscope is used to examine the nose and all its recesses thoroughly. The specific features the physician must examine and evaluate are the middle turbinate and the middle meatus, any anatomic obstruction, and the presence of pus and nasal polyps.
CT scanning can also be used to identify the diseased areas, a process that is required for planning the surgery. It shows the extent of the affected sinuses, as well as any abnormalities that may make a patient more susceptible to sinusitis.
FESS is usually performed under local anesthesia with intravenous sedation on an outpatient basis with patients going home one to two hours after surgery. It usually does not cause facial swelling or bruising, and does not generally require nasal packing.
Aftercare
FESS usually does not cause severe postoperative sinus pain. After the procedure, it is important to keep the nose as free from crust build-up as possible. To achieve this, the surgeon may perform a lengthy cleaning two to three times per week or the patient may perform a simple nasal douching several times a day. Normal function usually reappears after one or two months. In patients with severe sinusitis or polyps, a short course of systemic steroids combined with antibiotics may quicken recovery.
Risks
The most serious risk associated with FESS is blindness resulting from damage to the optic nerve. The chances of this complication occurring, however, are extremely low. Cerebrospinal fluid leak represents the most common major complication of FESS, but it occurs in only about 0.2% of cases in the Unites States. The leak is usually recognized at the time of surgery and can easily be repaired. Other less serious and rare complications include orbital hematoma and nasolacrimal duct stenosis. All of these complications are also associated with conventional sinus surgery and not only with FESS.
Normal results
The FESS procedure is considered successful if the patient's sinusitis is resolved. Nasal obstruction and facial pain are usually relieved. The outcome has been compared with that of the Caldwell-Luc procedure and, although both methods are considered effective, there is a strong patient preference for FESS. The extent of the disease before surgery dictates the outcome, with the best results obtained in patients with limited nasal sinusitis.
Morbidity and mortality rates
According to the American Academy of Family Physicians (AAFP), FESS usually has a good outcome, with most studies reporting an 80–90% rate of success. Good results have also been obtained in patients who have had previous sinus surgery.
Alternatives
- Image-guided endoscopic surgery. This method uses image guidance techniques that feature a three-dimensional mapping system combining CT scanning and real-time data acquisition concerning the location of the surgical instruments during the procedure. It allows surgeons to navigate more precisely in the affected area. The surgeon can monitor the exact location of such vital organs as the brain and eyes as well as positively identifying the affected areas.
- Caldwell-Luc procedure. This procedure is directed at improving drainage in the maxillary sinus region located below the eye. The surgeon reaches the region through the upper jaw above one of the second molars. He or she creates a passage to connect the maxillary sinus to the nose in order to improve drainage.
Resources
books
Bhatt, N. J. Endoscopic Sinus Surgery: New Horizons. Independence, KY: Singular Publishing Group, 1997.
Bhatt, N. J. The Frontal Sinus: Advanced Surgical Techniques. Independence, KY: Singular Publishing Group, 2002.
Marks, S. C., and W. A. Loechel. Nasal and Sinus Surgery. Philadelphia: W. B. Saunders Co., 2000.
periodicals
Engelke, W., W. Schwarzwaller, A. Behnsen, and H. G. Jacobs. "Subantroscopic laterobasal sinus floor augmentation (SALSA): an up-to-5-year clinical study." International Journal of Oral and Maxillofacial Implants 18 (January-February 2003): 135–143.
Graham, S. M., and K. D. Carter. "Major complications of endoscopic sinus surgery: a comment." British Journal of Ophthalmology 87 (March 2003): 374–377.
Larsen, A. S., C. Buchwald, and S. Vesterhauge. "Sinus baro trauma—late diagnosis and treatment with computeraided endoscopic surgery." Aviation & Space Environmental Mediciine 74 (February 2003): 180–183.
Ramadan, H. H. "Relation of age to outcome after endoscopic sinus surgery in children." Archives of Otolaryngology & Head and Neck Surgery 129 (February 2003): 175–177.
Wormald, P. J. "Salvage frontal sinus surgery: the endoscopic modified Lothrop procedure." Laryngoscope 113 (February 2003): 276–283.
organizations
American Academy of Otolaryngology-Head and Neck Surgery. One Prince St., Alexandria, VA 22314-3357. (703) 836-4444. <http://www.entnet.org/>.
Association for Research in Otolaryngology. 19 Mantua Rd., Mt. Royal, NJ 08061. (856) 423-0041. (301) 733-3640. <http://www.aro.org/index.html>.
North American Society for Head and Neck Pathology. Department of Pathology, H179, P.O. Box 850, Milton S. Hershey Medical Center, Penn State University School of Medicine, Hershey, PA 17033. (717) 531-8246. <http://www.headandneckpathology.com/>.
other
"Factsheet: Sinus Surgery." American Academy of Otolaryn gology—Head and Neck Surgery [cited May 5, 2003]. <http://www.entlink.org/healthinfo/sinus/sinus_surgery.cfm>.
Slack, R. and G. Bates. "Sinus Surgery." American Family Physician. 1 September 1998 [cited May 5, 2003]. <http://www.aafp.org/afp/980901ap/slack.html>.
Monique Laberge, Ph.D.
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
This procedure is usually performed on an outpatient basis by an ear, nose, and throat (ENT) specialist, such as an otolaryngologist or an ophthalmic surgeon. ENT physicians are graduates of a school of medicine and typically undergo an otolaryngology residency with further specialization in sinus disease and endoscopic sinus surgery.
QUESTIONS TO ASK THE DOCTOR
- Why is sinus surgery required?
- What are the risks involved?
- How many endoscopic sinus surgery procedures do you perform in a year?
- How much time will I need to recover from the procedure?
- Is the procedure painful?
- What are the alternatives?