Functional Endoscopic Sinus Surgery(FESS)

BY:DR.PREETI .S. RAGA II YEAR PG DEPT. OF E.N.T KIMS

WHAT IS FESS?
Trans nasal endoscopic Sinus surgery. Minimally invasive surgical procedure performed with the

aim of: 1.Re-establishing mucosal drainage channels of PNS. 2. Re-establishing ventilation and mucocilliary clearance of PNS thereby reversing the disease mucosa to normal which occurs over a period of time

HISTORY

Endoscopy first performed by Hirschmann (1903)by using a modified Nitze cystoscope which he used in the nasal cavity and the maxillary sinus via a tooth scoket.

Maltz-(1925) used the term sinoscopy and discribed techniques for endoscopically examining the maxillary sinuses via both inferior meatus and canine fossa routes.

HH Hopkins-(1950)-Professor of optics ,invented rod optic telescope which now universally utilized for nasal endoscopy. Rhinology and sinus surgery have undergone a tremendous expansion since the discourses of Messerklinger and Wigand in the late 1970s.

Professor Walter Messerklinger the Father of Modern Sinus Surgery.

Osteomeatal complex
This is 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.

Osteomeatal complex
Osteomeatal complex: bounded 1. medially: middle turbinate. 2. Laterally: the lamina papyracea. 3. superiorly and posteriorly: the basal lamella. 4. The inferior and anterior borders of the osteomeatal complex are open.

Mucociliary Blanket
Maxillary and frontal sinuses Mucosa or mucociliary blanket follows a genetically predetermined pathway

for drainage through natural ostium of sinuses to nasal cavity.

PRECHAMBERS
Ethmoidal infundibulum Frontal recess

Advantages of FESS
Improves diagnostic accuracy. Excellent visualization. Minimum bleeding. Minimal trauma to vital structures.

Diagnostic nasal endoscopy

1.To diagnose diseases of nose and PNS.

2.To diagnose source of epistaxis. 3.To take biopsy. 4.To assess the medical and surgical results Method: First pass. Second pass. Third pass.

First pass
In this the endoscope is introduced

along the floor of the nasal cavity.

Look forStatus of inferior meatus and tubinate. Patency of the nasolacrimal duct orifice. As the endoscope is advanced

posteriorly on the lateral surface of the nasopharynx the pharyngeal end of Eustachian tube, torus tubaris, adenoids(if present) can be identified.

Second pass
The scope is gently inserted

between inferior and middle turbinate. Middle meatus,bulla ehthmoidalis, if any accessory maxillary ostia are examined. Normal ostium is actually not visible during diagnostic nasal endoscopy.

Second pass
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
The scope is gently slipped

medial to the middle turbinate. The sphenoid ostium comes into view.

Indications
Recurrent rhino sinusitis that is resistant to adequate medical treatment.

Fungal Sinusitis.
Multiple or recurrent Sinonasal polyposis. Recurrent sinusitis caused by an anatomical

variations. Management of complications of rhinosinusitis. Mucocele or pyomucocele. Management of Epistaxis.

Excision of tumors.

Extended use of FESS:

Dacryocystorhinostomy (DCR) . Endoscopic repair of CSF leak.

Orbital decompression.
Optic nerve decompression.

Choanal atresia repair. Trans-sphenoidal hypophysectomy. Sphenopalatine artery ligation. Trans-nasal endoscopic excision of nasopharyngeal angiofibroma after embolization of feeding vessel.

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

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 .

The use of CT-Navigation in Endoscopic Sinus Surgery

A Computed Tomography (CT)Navigation system is a tool that is used by surgeons to better correlate surgical anatomy with preoperative CT imaging.

A computer is used to identify the 3-dimensional location of a probe tip placed within the patient's nose or sinuses. The computer will then identify the spot on the CT image where the surgeons probe is

placed.

RECENT ADVANCES

Surgical techniques
Messerklings technique:

anterior to posterior approach. Wigands technique: posterior to anterior approach.

INFUNDIBULOTOMY

Incision on uncinate process

Incision completed

UNCINECTOMY

Uncinate process removed

MIDDLE MEATAL ANTROSTOMY

Antrostomy is broadly defined as,

widening the natural ostium of maxillary sinus . The opening should be made anteriorly and inferiorly by Stammbergers back biting forceps. If accessory ostium is present should be widened and combined with the natural ostium.

Natural & accessory ostia exposed

Middle meatal antrostomy done

ANTERIOR ETHMOIDECTOMY

Opening of bulla ethmoidalis

Bulla ethmoidalis removed

POSTERIOR ETHMOIDECTOMY

Opening made on basal lamella

Basal lamella removed

Posterior ethmoidectomy done

SPHENOIDOTOMY
Sphenoidotomy

is defined as:widening the sphenoid ostium. Ostium lies approximately 1 to 1.5 cm above the superior border of the choana.

Anterior sphenoid sinus wall

Interior of sphenoid sinus

FRONTAL RECESS AND SINUS:

Are exposed using 30 and 70 degree endoscopes.
Agger nasi(anterior most anerior ethemoidal cells)are removed to drain frontal sinus through frontal recess.

Frontal recess opened

Final FESS cavity

Complications
Bleeding.

Synechiae formation.

CSF leak. Orbital complication

Hematoma. Orbital injury. Diplopia. Blindness.

Postoperative Care
Nasal pack is removed 24hrs Systemic antibiotics and local decongestants

are given for 5 days Topical steroids are given for 3 weeks Regular follow up is done at 1st , 2nd , 4th postoperative weeks. At each visit cavity is cleaned under endoscopic guidance

Conclusion
The procedure should be Tailor made to suit

the individual patient and the sinus pathology.

THANK YOU