Endoscopic Sinus surgery – for Sinusitis and/or Nasal Polyps
What are sinuses and what is sinusitis?
Sinuses are hollow cavities in the skull and facial skeleton. There are four groups of sinuses:
1. Frontal sinuses (in the forehead)
2. Ethmoid sinuses (between the eyes)
3. Maxillary sinuses (in the cheekbone area)
4. Sphenoid sinuses (in the middle of the head, behind the eyes)
They communicate via narrow passages called ostia with the nasal cavity. They naturally produce mucus, which is wafted by means of cilia (microscopic hairs) through these ostia and into the nasal cavity. In certain conditions, (e.g. allergies, common colds, structural abnormalities) these ostia may become blocked and then mucus dams up within the affected sinus. Since it remains there, static, it eventually becomes infected, producing “sinusitis”. If this does not resolve properly, this sepsis destroys the mucus-transporting ciliary pathways, producing further mucus stasis and hence further sepsis. Thus a “vicious cycle” is set up and the condition, now known as “chronic sinusitis” becomes permanent.
Image Copyright Health Ed 2004, reproduced with permission
FESS "Functional Endoscopic Sinus Surgery"
FESS is the use of a fibre optic instrument (endoscope) to carry out precise and minimally invasive surgery in sinus air cells under direct visualisation. The goal of this procedure is to restore sinus ventilation and their ostea “drainage”
function as much as possible. We know which sinuses are diseased by looking at the CT scan, and so we can operate on those that are diseased and leave alone those that are not.
In cases in which medical treatment alone (antibiotics, nasal drops, sprays and decongestants) have failed to clear the problem, it is likely that the sinuses are physically obstructed and blocked. In this event, it is advisable to undergo surgery to unblock these passages.
An endoscope “telescope” is inserted into the nose allowing the surgeon to visualise the operative field.
The diseased sinuses are identified and are opened up step-by-step using special forceps. If there are any polyps in the nose, they are removed. The natural pathways of mucus drainage are enlarged to prevent blockage and diseased sinus lining (“mucosa”) is removed.
The operation takes about 1.5 to 2 hours usually. This depends on the extent of the disease that must be treated.
If the disease is extensive, the surgery is also quite extensive – even though this may not be apparent from the outside (no facial incisions or bruising), but internally a lot of work has been done!
A surgeon performing endoscopic sinus surgery
Sinusitis (left) with pus draining out of the middle meatus.
Post-surgery (right) after the sinus passages have been opened.
Complications of endoscopic sinus surgery
1) Bleeding - A small amount of “spotting” of blood on your hanky after the operation is normal but a severe nosebleed may occur within 12 days of the operation. This only occurs in 1-2% of patients. Placement of nasal packing or return to theatre and hospital admission may be needed in a few patients. Blood transfusion is rarely required.
2) Infection- About 1% of patients develop infection and may require antibiotic treatment.
3) Orbital damage/ loss of vision- The orbits because of their close anatomical proximity to the operative field are theoretically at risk. Such complications are extremely rare, but must be mentioned because of the severe potential consequences. Orbital haematoma and nasolacrimal duct stenosis “blocked tear duct” are also rare complications.
4) Cerebrospinal fluid (CSF) leak- the base of the brain is in close vicinity to the
operative field. Therefore there is a theoretical risk of leakage of the fluid from
the surrounding sac of the brain. This creates a potential pathway for infection
which could lead to meningitis. If CSF leak occurs the sight of leakage may
require a surgical sealing/ grafting procedure. Hospital stay may need to be
5) Failure to improve all the symptoms or recurrence of the disease
Outlook after the surgery
FESS is highly successful at improving the symptoms of nasal blockage, runny nose and sometimes facial pain. FESS is not aimed to improve the sense of smell; however there may be some improvement.
It may not offer a permanent complete cure because the mucus drainage mechanism has already been badly damaged by the infection. Artificially created pathways never work as well as natural ones, but are better than none at all.
Polyps often come back after surgery over time, however medication prescribed may help to prevent or reduce the rate of recurrence. At 5 years there is an 80% chance of being free of polyp.
Even after successful surgery, the patient will be more prone to bouts of sinus trouble than the average person, but usually this will still be better than if they had never had their sinus operation. Most often, even if sinusitis recurs in somebody who has had FESS, it can be brought under control medically (rather than surgically) using various antibiotics, sprays/drops, decongestants or anti-inflammatory steroids. Therefore, most patients who undergo FESS although not completely cured, are a lot better.
Expectations and advice following Endoscopic sinus surgery / FESS
·You may awake with some packing in your nose to stop any bleeding. If present, this should be left alone and will be removed by your nurse when appropriate, usually the following morning. It is probable that you will have to breathe through your mouth and thus get a very dry mouth.
·You may get a blood stained/ pinkish discharge for a few days. The bleeding gets less and less as the days go by, but there may still be a little "spotting" on your handkerchief even up to a few weeks after the surgery. Don't worry, this is normal.
·Avoid all moderate and heavy physical activity, including sport for ten days after the operation. Avoid bending down to pick things up, especially heavy weights. Active sport should not be commenced for four weeks after the surgery, and even then, slowly at first with gradual build up.
·It is normal for the nose to be quite blocked for several days (even a couple of weeks) after the surgery, while all the internal swelling settles.
·You must irrigate your nose frequently “Douching” (at least 3 times a day) with the solution provided (i.e. saline) to clear away scabs and crusting which occurs after the operation. There are excellent commercial devices available to do this.
·Only gently blow your nose after nasal irrigation, avoid heavy nasal blowing for 10+ days after your operation.
·Avoid smoky and dusty atmospheres if possible, as this may irritate the nasal lining.
·Avoid very hot baths and showers. Take these quite cool. It may lead a nose bleed.
·If you take asprin, please discuss this with your doctor, as you may need to avoid taking aspirin for a few days prior and after the operation. Aspirin can potentially increase the risk of nasal bleeding.
·Two weeks off work/ school is strongly recommended. A sick-note will be provided.
·Do not drive for 48 hours (because of the effect of the general anaesthetic).
·You should not plan to go away on holiday for at least two weeks after your operation.
·Flying should be avoided for the first two weeks after your operation.
·Despite surgery, the diseased lining of the nose cannot be completely cured and it is possible you may require some nose spray / drops for a prolonged period postoperatively. You may need antibiotics from time to time.
·Further nasal surgery may be required for some patients in the future
In case of Emergency...
Whilst every effort has been made to ensure that the information contained on this website is accurate you should always discuss the risks, limitations and complications of your specific operation with the relevant surgeon.
Mr Behrad Elmiyeh MRCS DO-HNS