Functional endoscopic sinus surgery ENT

Endoscopic Sinus Surgery (FESS)

📌 Definition: Minimally invasive surgery to establish ventilation and drainage of sinuses while preserving mucosa and mucociliary clearance.
Replaces: Caldwell-Luc, External Ethmoidectomy.

Advances Enabling FESS

  • Better Optics & Brighter Illumination.
  • Microdebriders (Shavers): Precise removal of polyps/tissue; reduces bleeding.
  • CT/MRI: Precise definition of pathology.
  • Image-Guided Navigation: For revisional/difficult cases.

Indications

A. General

  • Chronic Bacterial Sinusitis (unresponsive to meds).
  • Recurrent Acute Sinusitis.
  • Nasal Polyposis / Antrochoanal Polyp.
  • Fungal Sinusitis.
  • Mucocele.
  • Epistaxis control (Endoscopic cautery).
  • Foreign Body removal.

B. Advanced Techniques

  • Tumour removal (Inverted Papilloma, Angiofibroma).
  • Dacryocystorhinostomy (DCR).
  • Repair of CSF Leak.
  • Orbital Decompression (Graves' Disease).
  • Optic Nerve Decompression.
  • Pituitary Surgery.
  • Control of Posterior Epistaxis (SPA Ligation).

Surgical Approaches

Technique Description
1. Stammberger's
(Anterior to Posterior)		 Proceeds from Uncinate Process → Backward to Sphenoid.
Advantage: Tailor surgery to extent of disease.
2. Wigand's
(Posterior to Anterior)		 Starts at Sphenoid → Proceeds Anteriorly.
Use: Extensive polyposis or Revisional surgery.

Steps of Operation

  1. Preparation: Decongestion (Cocaine/Adrenaline) + Infiltration (Lignocaine + Adrenaline).
  2. Uncinectomy: Incise Uncinate process → Remove.
  3. Maxillary Ostium: Identify and enlarge (lying post. to lower 1/3 of uncinate).
  4. Bullectomy: Bulla ethmoidalis is penetrated and removed.
  5. Posterior Ethmoids: Penetrate Basal Lamella to enter posterior cells.
    ⚠ Beware of ONODI CELL!
    (Post. ethmoid cell extending lat/sup to Sphenoid)
    Risk to Optic Nerve.
  6. Frontal Sinusotomy: Clear frontal recess. (Challenging step; risk of stenosis).
  7. Sphenoidotomy: Remove anterior wall of sphenoid sinus.

Complications

Can be Major or Minor. Mostly involve Orbit or Skull Base.

Category Complications
Ophthalmic
  • Orbital Haemorrhage
  • Loss of Vision / Blindness
  • Diplopia
  • Nasolacrimal duct injury (Epiphora)
Intracranial
  • CSF Leak
  • Meningitis / Brain Abscess
  • Direct Brain Trauma
  • Intracranial Haemorrhage
Vascular/Other
  • Massive Haemorrhage
  • Internal Carotid Artery Injury (in Sphenoid)
  • Anosmia
  • Death

Post-Operative Care

  • Pack Removal: After 24 hrs.
  • Meds: Antibiotics (7-10 days), Analgesics, Antihistamines.
  • Nasal Irrigation: Saline wash (start after 1 week).
  • Endoscopic Toilet: Weekly visits (4 weeks) to remove clots/crusts and divide adhesions.
📚 Ref: Diseases of Ear, Nose & Throat (Dhingra), 8th Ed.

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