Functional endoscopic sinus surgery

FESS IN ENT BY DR SMRUTI RANJAN

1. FUNCTIONAL ENDOSCOPIC SINUS SURGERY Dr. Smruti Ranjan Samal P.G. STUDENT, VIMSAR

2. FESS- Functional Endoscopic Sinus Surgery is often a non-invasive / minimal invasive surgical procedure that discloses sinus air cells and sinus ostia by having an endoscope. It restores the paranasal sinus function by re-establishing the physiologic pattern of ventilation & mucocilliary clearance The term FESS was coined by Kennedy in 1985 Father of FESS is Prof Mesenklinger Hirschmann 1 st described use of primitive endoscope to examine the maxillary sinus through an oroantral fistula

3. FESS- The Functional Aspects: Preserving normal structure Removing only obstruction Preserving mucosa Restoration of function Advantage over Open Sinus Procedure Safe , minimally invasive, no cuts Doesn’t disturb healthy tissue Performed in less time with better management No visible signs that surgery has been performed Quick recovery

4. Balloon Sinuplasty : Acclarent introduced balloon sinuplasty system that utilized a nonconformable balloon which was capable of creating microfratures in the bone surrounding the drainage pathways of the Frontal, Maxillary, Sphenoid sinus

5. Lateral wall Formed by bony, soft tissue & cartilage Bony – Ethmoid infundibulum & uncinate Perpendicular plate of palatine bone Medial plate of pterygoid process of sphenoid bone Medial surfaces of lacrimal bones and maxillae Inferior conchae

6. INFERIOR MEATUS: Runs along the whole length of lateral wall. Nasolacrimal duct opens in its anterior part. Largest of all meatus MIDDLE MEATUS Bulla ethmoidalis : Bulge produced by middle ethmoid cells Uncinate process: Superior extension of lateral nasal wall( medial wall of mxillary sinus). Medial & inferior to Bulla

7. Infundiblum : Air passage connecting the maxillary sinus ostium to middle meatus Hiatus Semilunaris : Medially it communicates with middle meatus. Laterally & inf it communicates with infundibulum Frontal sinus – Opens into the anterior part of hiatus semilunaris Maxillary sinus – Opens into the posterior part of hiatus semilunaris Anterior and middle ethmoidal cells – Opens into the upper margin of bulla ethmoidalis

8. Superior Meatus Limited only to posterior one third of lateral wall. Posterior ethmoidal sinus opens into it. Sphenoethmoidal recess Above the superior turbinate. It receives the opening of sphenoid sinus

9. SINUSES Air containing cavity in certain skull bones Develop as a diverticula/ outpouching from the lat wall of nose & extend into Maxilla, Ethmoid , sphenoid and frontal bones Four sinuses – Maxillary, Frontal, Ethmoid (Ant & Post) & Sphenoid

10. Maxillary Sinus - ( Antrum of Highmore ) Largest paranasal sinus Pyramidal in shape Base - towards lateral wall of nose Apex – towards zygomatic process of maxilla On average it has capacity of 14.75 ml (14-15)

11. Frontal Sinus Situated between the outer & inner table of frontal bone Asymmetrical Intervening bony septum which may be thin or deficiency The natural frontal sinus ostium is usually located in the posteromedial floor of the sinus (most dependent part). It opens into the middle meatus The ethmoidal infundibulum can act as a channel for carrying the secretions (and infection) from the frontal sinus to anterior ethmoid cells and the maxillary sinus or vice versa.

12. FRONTAL RECESS The frontal recess is an hourglass like narrowing between the frontal sinus and the anterior middle meatus through which the frontal sinus drains. The frontal recesses are the narrowest anterior air channels and are common sites of inflammation

13. AGGER NASI CELL It is present Anterior, lateral, and inferior to the frontal recess . It is aerated and represents the most anterior ethmoid air cell, usually lying deep to the lacrimal bone. It usually borders the primary ostium or floor of the frontal sinus. its size may directly influence the patency of the frontal recess and the anterior middle meatus.

14. Sphenoid sinus Occupies the body of sphenoid Right & left, seperated by a thin strip of bony septum (like frontal sinus) Ostium opens into spheno ethmoidal recess

15. ETHMOID SINUS Thin walled air cavities in the lateral masses of the ethmoid bone Varies from 3 – 18 Occupy the space between the upper third of the lateral nasal wall and the medial wall of orbit Clinically divided into anterior ethmoidal air cells & posterior ethmoidal air cells, by basal lamella (lateral attachment of middle turbinate to lamina papyracea )

16. Relations Roof – formed by the anterior cranial fossa Lateral wall - orbit Medial wall – nasal cavity Thin paper like bony part of the ethmoid separating the air cells from the orbit, called lamina papyracea , can be easily destroyed leading to spread of ethmoidal infections into the orbit Optic nerve forms a close relationship with the posterior ethmoidal cells & is at risk during ethmoidal surgery

17. OSTIO MEATAL COMPLEX The ostiomeatal complex is the key anatomic area addressed by endoscopic sinus surgeons. Blockage of the ostiomeatal complex prevents effective mucociliary clearance, thus leading to a stagnation of secretions and therefore leading to recurrent or chronic sinusitis .

18. OSTIO MEATAL COMPLEX Maxillary sinus ostium ethmoid bulla frontal recess uncinate process infundibulum hiatus semilunaris middle meatus.

19. Pattern of Sinus Disease: Sonkens ’ Classification acc. to Middle meatus obstruction OMC pattern- M,Ant.E,F Infundibular – isolated obst of Eth. Infudibulum Frontal recess inflammatory pattern Sinunasal polyposis pattern Sporadic pattern Lund-Mackay Score radiologic score of chronic rhinosinusitis Reading a CT scan of the PNS & OMC with assigns a score of 0- ( no abnormality) 1- (partial opacification ) 2- ( complete opacification ) Each side graded separately. A combined score of 24 is possible

20. Gliklich and Metson System Stage 0 : <2mm mucosal thickening on any sinus wall Stage 1 : all unilateral disease or anatomical abnormalities Stage 2 : bilateral disease limited to ethmoid or maxillary sinuses Stage 3 : bilateral disease with involvement at least 1 sphenoid or frontal sinus Stage 4 : Pansinus disease

21. Landmarks in FESS Middle turbinate Uncinate Process Bulla E thmoidalis Sphenoid O stium Skull Base Maxillary sinus ostium

22. MESSERKLINGER 5 LAMELLA 1 st Lamella- UP 2 nd Lamella- BE 3 rd Lamella- Ground Lamella Basal 4 th Lamella- Superior Turbinate 5 th Lamella- Supreme Turbinate

23. Indication of FESS: Chronic rhinosinusitis unresponsive to medical treatment Recurrent acute sinusitis Sinunasal polyposis Mucocoele Noninvasive fungal ball Invasive fungal rhinosinusitis CSF rhinorrohoea & anterior meningoencephalocele Sinonasal Tumour Severe Exopthalmus N LD obstruction

24. Patient selection: Pre-operative assessment History - Symptoms - Medical treatment - associated disease Examination of the Patient: (General & Local) - Anterior rhinoscopy - Septal deviation - Turbinate hypertrophy -Nasal airway Problem - Nasal Endoscopy - Character of mucosa & appearance of sinus drainage, anatomical variations, structural abnormalities

25. Radiological- Pre-operative X-rays, CT Scan(Gold Standard) Routine Blood Investigations Key Points to be reviewed on Pre-operative CT SCAN Disease: Extent and pattern & its clinical correlation Bony integrity- (Erosion, expansion ,dehiscence )- skull base, lamina papyracea , optic canal, carotid canal Skull Base- Height, symmetry, slope of cribriform plate & fovea ethmoidalis . Maxillary Sinus- location & attachment of uncinate process to medial orbital wall, pneumatisation & height Ethmoid Sinus – location of AEA,PEA, height of post.ethmoid cell Sphenoid Sinus- location of sphenoid ostium , septation & their relation to carotid canal Frontal Sinus- extent of pneumatisation, natural drainage pathway, presence of ager nasi & frontal cell

26. Strategic Approach to FESS Patient under general anaesthesia Local vasoconstriction of the nasal cavity Septoplasty and/or Rhinoplasty Management of Middle T urbinate Uncinectomy Maxillary Antrostomy Ethmoidectomy Frontal S inusotomy Sphenoidectomy Management of Inferior Turbinate

27. Nasal Preparation P reoperative oxymetazolline spray 3 times separated by 5-10min Once GA induced, nose is packed with topical epinephrine pledgets After draping , the nose is injected with a focus on MT in 3 loction - Over the axilla at the junction of the Turbinate & lateral wall - Inferomedially on the head of MT - Posteriorly along the inferior aspect of Turbinate

28. Nasal Septal Surgery If a DNS is present, obstructing the nasal cavity & limiting the nasal airway or access to the sinus cavities , a septoplsty is performed prior to beginning the sinus surgery B. Management of Middle Turbinate The anatomical variants of the middle turbinate may cause middle meatal obstruction like Choncha Bullosa where the head of MT is enlarged. Resection of CB is done by incising the inferior free border of MT along its length and carrying the incision up to the neck. The incision is further enlarged using microscisor & the lateral half of the concha is removed after elevating the mucosal flap from the lateral bony wall

29. Types of Uncinate Process: Acc. to superior attachment of uncinate Type I: UP bends laterally in its uppermost portion to be inserted into LP Type II: UP extends superiorly to the roof of the ETHMOID i.e. Skull Base Type III: Superior end of UP turns medially & attached to the MT 2. Medially bent uncinate process 3. Laterally bent uncinate process 4. Pneumatised uncinate process or Uncinate Bulla

30. C . Uncinectomy The MT is medialized using a Freer Elevator by applying firm pressure against the lateral aspect of the upper part of turbinate. Uncinectomy begins with an incision of the uncinate process at its anterior attachment. The incision is extended posteriorly and inferiorly , parallel to the upper of Hiatus Semilunaris & towards the natural ostium of maxillary sinus Uncinectomy exposes base of Infundibulum & anterior wall of Ethmoid bulla

31. Types of Uncinectomy : Classical / Anterograde Technique: Uncinectomy is performed via an incision with either the sharp end of freer elevator or a sickle knife. The incision should be placed at the most anterior portion of uncinate process which is softer on palpation in comparison to firmer lacrimal bone where also NLD located. Then by using blakeshly forcep the free uncinate edge is removed . More prone for Orbital Fat Prolapse. B. Swing door / Retrograde Technique : Reverse cutting forceps or backbiting forceps were used in this technique. Inferior free margin overlying the maxillary ostium is cut first & then incision is made in the superior margin to form a flap from a flap from the uncinate which is hinged on the anterior margin & can be moved with an elevator or ball probe This is followed by submucosal removal of the horizontal process of the uncinate . More prone for NLD injury

32. D. Maxillary Antrostomy Initial identification of the natural ostium - anterior & inferior within the middle meatus. Ostium usually at the same level as the inferior margin of the middle turbinate,anterior to ethmoid bulla Opening is further enlarged posteriorly to the posterior fontanelle with backward-biting punch forceps & anteriorly with upturned Blakesley -Wilde ethmoid forceps Antrostomy should be placed just above the inferior turbinate & not more anterior than the anterior end of the middle turbinate Polypoid tissue, diseased mucosa , mucous plug should be removed

33. Types of maxillary sinusotomy : (SIMMENS CLASSIFICATION) Type.I : O stium is opened posteriorly to a limited extent(<1cm in D) Type.II : Ostium is opened posteriorly & inferiorly (<2cm in diameter) Type.III : Wide exposure of opening of ostium in all direction i.e. anteriorly up to lacrimal crest, superiorly up to orbit, inferiorly to inferior turbinate, posteriorly to level of posterior wall of maxillary sinus

34. E. Ethmoidectomy Maxillary sinus is a single cavity with distinct ostium but the ethmoid sinus consists of multiple cavities of interconnected cells. The basal lamella of MT separates ethmoid labyrinth to two distinct anatomical and physiologic compartment. Anterior group of cells drains its secretion into infundibulum together with maxillary & frontal sinuses Posterior group of cells drains their mucus into superior meatus Main anatomical landmark for ethmoidectomy is identification of E thmoid Bulla Mucosa is dissected over the bony surface of Ethmoid Bulla The goal of anterior ethmoidectomy is complete exposure of anterior ethmoid cells

35. Posterior ethmoidectomy is done if involvement of posterior comaprtment . After dissecting the anterior ethmoid cells ,the basal lamella of the MT encountered. It is perforated medially & inferiorly. The posterior ethmoid cells are removed stepwise till the anterior wall of the sphenoid sinus is exposed. The posterior ethmoid artery can be seen & landmarks the anterior edge of most posterior ethmoid cells. Imp: a. Open the cells of anterior & posterior ethmoid region at their lowest portion parallel to floor of nasal cavity, i.e. parallel to skull base b. Dissection along the roof of the ethmoid bone most safely executed in a Posterior to Anterior direction after the ethmoid sinus opened in an Anterior – Posterior course

36. F. Frontal Sinusotomy Kuhn Classification of Frontal Recess & Frontal Sinus Cell Agger nasi cell Supraorbital ethmoid cell Frontal cell Type 1 – Single Frontal cell above agger nasi cell Type 2- Tier of cells in FR above agger nasi cell Type 3- Single massive cell pneumatising cephalad in to Frontal S Type 4- Isolated cell in Frontal Sinus Frontal Bulla Cell Suprabullar cell Interfrontal sinus septal cell

37. Acc.to Draf Endonasal Frontal Sinus Drainge Type I: Simple drainage Type II a/b: Extended drainage Type III: Endonasal Median Drainage= Endoscopic modified Lothrop pro

38. Type III: Endonasal Median Drainage= Endoscopic modified Lothrop procedure It is done by either Primary lateral approach: if previous ethmoid work incomplete & MT is intact as land mark Medial approach: if ethmoid has been cleared and/or if the middle turbinate is absent . This begins with resection of perpendicular plate of nasal septum

39. When the type III drainage is technically not possible (anterior-posterior diameter of the frontal sinus less than 0.8 cm) or has failed, osteoplastic frontal sinus obliteration must be considered Indications of Osteoplastic Frontal Sinus Obliteration:

40. Intranasal frontal sinusotomy is the potentially dangerous procedure as it is close to the Orbit & Skull base Imp. Landmark is anterior ethmoid artery which is posterior to frontal recess To visualise the frontal recess area, it is necessary to remove the ager nasi cells. Then the frontal recess is enlarged using sharp curette to break down anterior ethmoid cells, the spina nasalis frontalis ( nasofrontal ‘’beak”)

41. G . Sphenoidotomy The sphenoid sinus can be opened safely 10 mm above the choana just lateral to the midline septum at the rostrum of the sphenoid. After identification of ostium the opening enlarged in lateral & inferior direction. Initial opening is made with Straight Blakesley forceps. If the entire anterior wall of the sinus is thick & ostium is not visualised , an angulated hand piece with extra long diamond burr is used to make opening in ostium area Optic nerve & carotid artery located in lateral & posterior wall. Sella turcica situated medial & superior to the sinus & cavernous sinus located laterally Roof of sphenoid sinus is extremely thin- potential risk of a CSF leak

42. H. Management of inferior turbinate After taking care of septal deviation & parnasal sinus diease , last step is to treat IT hypertrophy Long nasal speculum is introduced along the IT & with endoscopic view the posterior third of turbinate is removed after being retracted medially with straight Blakesley forceps. The anterior & middle third of HIT treated with Radio Frequency Thermal Ablation

43. Post-operative Care Nasal packing : Packing used to control bleeding ,prevent adhesions Regular analgesia & vitals are carefully monitored Observe for epistaxis, headache, orbital swelling, diplopia, reduced visual acuity Remove nasal packing after 48 hours Post-operative Ambulatory Care Antibiotics are not routinely prescribed Instruct not to blow nose hard for at least 48 hours Commence topical decongestants for 5 days & saline spray for 6weeks Suction toilet of the nose Recommence long-term nasal steroids after 1 wk in nasal polyposis Decrust the nose with a rigid endoscope if necessary

44. Complications : Minor : Major: Orbital- Orbital - orbital emphysema Orbital hematoma orbital ecchymosis Optic nerve injury Nasolacrimal Duct Injury( epiphora ) CSF fistual Disturbance in olfaction Brain laceration Dental pain/lip pain or numbness Haemorrhage Ethmoid arteries Internal carotid artery Cavernous sinus fistula Sphenopalatine artery

45. Factors avoiding complications: Proper use of nasal endoscope True cut instrument Imaging Image guidance Through knowledge of anatomy Hypotensive anaesthesia Complications are common in: Revision FESS Surgery for nasal polyposis Type 3 kerio skull base Anatomical variants like asymmetrical low lying ethmoid roof

46. Some rules about FESS Avoid MT recessection Avoid classical uncinectomy Don’t be a destroyer of nose Retain B ulle till the very end Proceed from less vascular area to more vascular one Controlled hypotensive anaesthesia Stop surgery when bleeding is excessive Avoid nasal packing MESS: Marsupialization Endoscopic Sinus Surgery When a functional procedure can’t be performed , an attempt made to create a single ethmoid cavity in which frontal, maxillary, sphenoid can adequately drain