JOURNAL READING

FUNCTIONAL ENDOSCOPIC
SINUS SURGERY (FESS)
Consulant:
dr. Agus Sudarwi, Sp. THT-KL
dr. Afif Zjauhari, Sp. THT-KL
Presentant:
Yunita Widyaningsih (40------)
Julianthy Suento (40613814-)
Fritzky Wandy Thedjakusuma (406138147)

Abstract
Functional

Endoscopic sinus surgery (FESS)

a minimally invasive surgical procedure that
opens up the sinus air cells and the sinus ostia
with an endoscope.
FESS

The

has now become widely accepted

term functional to distinguish this type

of endoscopic surgery from the nonendoscopic
more conventional sinus procedure.

FESS

is being done regularly at TU Teaching Hospital from 2003

March 2003 - December 2005 94

Maximum number of FESS was done for nasal polyps 80 patients

Ethmoidal polyp 47 patients

Antrochoanal polyps 33 patients.

Chronic maxillary sinusitis 8 patients

Fungal sinusitis 5 patients

Endoscopic medial maxillectomy for inverted papilloma 1 patient.

Introduction

FESS still a new technique in our country many centers do not have the instruments
for FESS and many surgeons are not trained in this field.

Intranasal endoscopic surgery has two main goal

1. Maximum preservation of mucosa
2. Secure communication between the nasal cavity and the paranasal sinuses via the
natural channels.

There are many indications for FESS :

1. Chronic maxillary sinusitis, ethmoiditis, sphenoiditis
2. Nasal polyps both ethmoidal and antrochoanal
3. Frontoethmoidal mucocoele
4. Limited inverted papillomas
5. Endoscopic DCR

No absolute contraindication to FESS but

uncontrolled hypertension, bleeding disorder, acute
infection, where there is chance of excessive
haemorrhage during surgery better to go by
conventional method.

Investigation

required for FESS

1. Nasal Endoscopy to assess the disease, and also

to confirm the diagnosis of nasal polyps.
2. CT scan of nose and paranasal sinuses both
axial and coronal section, to know the origin and
extent of the disease.

Instruments
Microdebrider

(shaver) is the recent advances in the field of Endoscopic Sinus

Surgery.
The

advantages of microdebrider over the use of Forceps

1. It eats up the polyps, so the bleeding is less, we can visualize the normal
structure like turbinate.
2. There is suction attached to it, which sucks the blood as well as the soft
tissue eaten by the debrider, so the operating field is clean.
3. There is irrigation attached to it, which flushes the area continuously for
better visualization.

There are major complications and minor complications :

Major

Minor

1. Excessive haemorrhage
requiring blood transfusion.

1. Periorbital ecchymosis.
2. Periorbital Emphysema.

2. Orbital haematoma.

3. Minimal bleeding.

3. Blindness.
4. Diplopia.
5. CSF Leak.
6. Meningitis.
7. Carotid artery injury.

4. Adhesion.
Computed tomographic scan.
Black arrows show bony
defect in the ethmoidal wall
of the left orbit post
functional endoscopic sinus
surgery. The white arrow
indicates air in the orbit.

5. Stenosis of ostia.
6. Most unavoidable
complication is recurrence of
nasalpolyps.

Materials and Methods

1. Cleaning and draping
2. 1:20,000 xylocain with adrenalin were
injected in the uncinate process, base of
middle turbinate, and in the polyps
3.Nasal cavity was packed with 1:1
preparation of N/ sline and adereline
cottonoids
4.Wait for 5 minutes.

All the patients were taken up from the

Department Of ENT and Head and Neck
surgery, TU Teaching Hospital.
Duration of study was 26 months.
Total patients were 94.

In case of antrochoanal polypes,

uncinectomy was done first and
widening of the natural ostia of the
maxillary sinus was done by removing
the anterior and posterior fontanel.
Polypes was pulled out from the
maxillary antrum, nasal cavity and
choana and removed in toto

In case of ethmoidal polyp, if

there is massive polypes,
debulking was done first
followed by widening of the
natural ostia, then polypes
from the maxillary antrum were
removed.

Ethmoid is opened by
opening the bulla
ethmoidalis, disease
is removed from
anterior ethmoid
then the basal
lamella is opened to
enter the posterior
ethmoids.

Sphenoid is opened by
entering through
sphenoidal ostium for
the middle turbinate is
our landmark. Any
polyps or fluid in
sphenoid is removed.

If CT scan shows opacity of the frontal

sinus, we approach through frontal
recess but mucosa of the frontal recess
is left intact to prevent the stenosis.

Haemostasis is achieved by
packing the nose with adrenalin
and saline solution. Finally BIPP
packing was done which is
removed after 48 hours.

Result
In patients where nasal polyps were associated with
deviated nasal septum (DNS), septoplasty was done first
followed by FESS for better exposure to the operating
field.

Age Distribution

No. Of Patients

<10 years

11-20 years

12

31-40 years

33

41-50 years

41

>60 years

Sex Distribution

No. Of Patients

Male

54

Female

40

Disease Pattern

No. Of Patients

Ethmoidal Polyps

47

Antrochoanal Polyps

33

B/L Chronic Maxillary Sinusitis

B/L Fungal Sinusitis

Inverted Papilloma

Complications

No. Of Patients

Synechia

15

Orbital Ecchymosis

Orbital fat pulled out

Recurrence of nasal polyp

Excessive hemorrhage

Restricted eye movement

In our study

Discussion

80 patients of nasal polyps ethmoidectomies with or without

sphenoidotomy 47 patients
Antrostomy alone was done for antrochoanal polyps in 33 patients.
Recurrence of polyp after ethmoidectomies with or wihtout
sphenoidotmy 7 patients
Complications (during and after the surgery)
Synechiae
Orbital ecchymosis
Accidental removal of orbital fat
Bleeding during surgery
Recurrence of polyps

Endoscopic After Care Follow up

First visit after one week when we remove the blood clot, crust, the
secretions, release the synechaie
if excessive oedema keep the steroid pack for few days.
Subsequent follow ups were after 2, 3 and 12 months to detect any recurrence.

The after care is an important as surgery as there may be excessive crusting, causing nasal
blockage, nasal bleeding, synechiae formation, recurrence of polyps.
Excessive crusting will lead to poor visualization of operated area and detection of residual
polyps.
Regular nasal douching with sodium chloride and soda bicarbonate compulsory after FESS.
Removal of crust and clots should be done whenever patients come for follow up using
endoscope.

Division of synechiae should be done in out patient if the synechiae is small

if it is large division under general anesthesia is necessary.
Treatment of infection using oral ciprofloxacin for two weeks.
In case of ethmoidal polyps
oral steroid in the dose of
15 mg once a day (OD) for first seven days 10mg OD for seven days
5mg OD for next seven days reduce edema and to minimize or prevent
the recurrence of polypes.
Regular follow up for at least 2 years is necessary.

Conclussion
Total number of FESS done from Oct 2003 - 2005 94.
Some minor complications
Synechiae 15 patients
Orbital eccymosis 8 patients
Orbital fat pulled out 7 patients
Recurrence of nasal polyp 7 patients.
FESS safe procedure with few complication in experienced surgeons
hand but severe complications (blindness, orbital haematoma, CSF leak,
carotid artery rupture) can occur if surgeon has little experience in FESS.

Recommendation
1. Study
2. Long

should be done in large series.

term follow up is recommended to know the

late complications like recurrence of polypes after
disease free interval.

MERCI
XIE-XIE

THANK YOU

TERIMA
KASIH