About FESS – Functional Endoscopic Sinus Surgery
FESS differs from traditional sinus surgery is that a thin rigid optical telescope, called an endoscope, is used in the nose to view the nasal cavity and sinuses. FESS generally eliminates the need for an external incision. The endoscope allows for better visualization and magnification of diseased or problem areas. This endoscopic exam, along with CT scans, may reveal a problem that was not evident before.
Another difference is that FESS focuses on treating the underlying cause of the problem. The ethmoid sinuses are usually opened. This permits direct visualization of the maxillary, frontal, and sphenoid sinuses and diseased or obstructive tissue can be removed if necessary. There is often less removal of normal tissue and surgery can frequently be performed on an outpatient basis without the need for painful packing that was used in the past. Generally, there are not external scars, little swelling, and only mild discomfort.
The goal of FESS is to open the sinuses more widely. Normally the openings to the sinuses are long narrow bony channels covered with mucosa or the lining of the sinuses. If this lining swells from inflammation, the sinuses can become blocked and an infection can develop. FESS removes some of these thin bony partitions and creates larger openings into the sinuses. After FESS, patients can still develop inflammation from allergies or viruses, but hopefully when the sinus lining swells, the sinus will still remain open. This will permit easier treatment of subsequent exacerbations with more rapid resolution and less severe infections.
Powered instrumentation can be useful during FESS to precisely remove polyps and other diseased tissue, while sparing the surrounding normal sinus lining and adjacent structures. The latest generation of hand instruments allows the surgeon to meticulously open the sinuses, while avoiding the “grab and tear” techniques of the past. Once the diseased tissue is removed and the inflammation subsides, the injured sinus lining often returns to a normal state with time.
Thick nasal secretions in a case of chronic sinusitis
The endoscope is passed gently through the nostrils under local anaesthetic in the out-patients to diagnose the problem.
It is also used in the operating theatre, usually under general anaesthetic, to
• guide precise surgical removal of bone and polyps
• enlarge the natural openings of the sinuses
• improve ventilation and mucociliary clearance
The main use of the endoscope is in the out-patient clinic, in diagnosis and follow-up.
In the operating theatre, much of the work can be done under direct vision with a powerful headlight. The angled endoscope is useful for seeing around corners
A scan on its own does not diagnose sinus problems. It does provide some additional information. That information must be weighed and interpreted by the ENT specialist, in the light of the history, examination and endoscopic findings.
A scan is a snapshot of the state of the nose and sinuses on the day it was taken.
If you recently had a head cold, the soft tissue lining of the nose and sinuses will be swollen and the scan will look abnormal.
On the contrary, if you get recurrent episodes of sinusitis, but haven’t had one for a few weeks, your scan might look completely normal.
The only thing that will not change is the bone structure, and the relationship of the eye and brain to the sinuses.
The bone structure is important to us if we are considering an operation on the sinuses. People vary. Sometimes the optic nerve takes a short cut through the sphenoid sinus on its way to the brain. It is better to know this in advance. There is a risk of blindness from damaging the stray optic nerve during surgery.
A good radiologist will
• know the sort of information that the ENT specialist needs from the scan
• make sure the slices are done the best way to provide that information
• report the scan in focussed and clinically relevant way
MRI scans are less useful than CT for most sinus problems, because they don’t show fine bone detail. “Abnormalities” in the sinuses are often picked up as incidental findings on MRI scans carried out for other reasons, even when there is no real problem. Unless you are getting symptoms of sinus problems, we don’t normally need to do anything about a sinus abnormality on an MRI scan. An MRI may be needed in some rare cases of sinus tumours.
Between 80 and 90% of patients get great relief of their symptoms and are very pleased with the results of FESS.
Where the principal symptoms are blockage of the nose, facial pain or headache, the results are good.
If the principal complaint is of post-nasal catarrh, the results are less encouraging – only around 50% of patients experience worthwhile improvement.
The sense of smell can usually be restored by FESS, but this may take several months and further post-operative treatment with nasal steroids.
If there are polyps present, they may recur in up to 30% of patients. This can happen many years after initially successful surgery.
Nasal and sinus operations are very safe procedures in modern medical practice. But no operation is totally risk free.
At worst, you could die or suffer brain damage – but you are more likely to be injured in a road accident.
A general anaesthetic carries a minimal risk, with consultant anaesthetists using modern drugs and monitoring equipment.
There is a risk of excessive bleeding, either during or up to two weeks after the operation.
About 2% of patients may need a second operation to control bleeding, readmission to hospital, or a blood transfusion.
If you are having a septoplasty (straightening of the central partition between the nostrils) there is a small risk of cosmetic deformity.
Operations for the removal of polyps and opening of the sinuses carry a small risk of damage to the surrounding structures, including the eyes and the brain.
At worst this could mean blindness, or a leakage of CSF (fluid around the brain) with meningitis and death. The risk of any of these serious complications happening is less than 1:1000.
Long term medication with antibiotics, antihistamines, and steroids helps many people with nasal and sinus problems. Operations are normally only considered when these treatments have already been tried and failed. Other surgical operations for rhinosinusitis include:
A sinus washout was the mainstay of diagnosis and treatment of sinusitis before FESS came along. It is a simple operation which can be done either under local or general anaesthetic. A large needle is passed into the nostril, and pushed through the bone into the maxillary sinus in the cheek. Any pus or mucus in the sinus is sucked out. Salt water is then injected into the sinus until it runs out through the natural opening, back into the nose. This washes the lining of the sinus. A sinus washout can be very useful in the short term, it can break the “vicious circle” of infection, inflammation, swelling, narrowing, blockage and more infection. The recovery time is very quick, you may be able to go back to work later the same day if done under local anaesthetic. But it does nothing either to diagnose or correct any underlying abnormalities obstructing the sinus drainage, so the problem may well recur. Although it is not normally painful, it is a rather unpleasant experience under local anaesthetic and not something for the squeamish.
If you smoke, you should give up, because smokers are more likely to suffer complications after operation.
Partners should also consider giving up, as patients must not be exposed to passive smoking during recovery.
Do not plan anything important during the two weeks after operation.
Remember to bring any medicines with you to hospital. You will not be allowed anything to eat for about six hours before operation, but you can drink clear fluids up to two hours before. The six hour rule does not apply to medicines – these should be taken as usual. When you come into hospital, you will be seen by a doctor , questions will be asked by the Resident Medical Officer, and possibly by the anaesthetist. Please don’t get upset if you are asked the same question several times. This is a routine to help avoid mistakes – like an airport checking your travel documents more than once. You will be examined and checks made to ensure you are fit for anaesthetic. If you have any worries or questions, this is a good time to ask.
After the operation, you will wake up in the recovery area, where a nurse will look after you. There will be a pack in your nose which means you will have to breathe through your mouth. There may be blood in the mouth or nose. This is quite normal and will stop after a while. When you are sufficiently awake, you will return to the ward. You will stay in bed for several hours. Your throat will feel sore, your nose will be blocked, you will feel thirsty and tired, and you may be sick. Spit out any blood or secretions; if swallowed it will make you feel sick. The nurse will attend you frequently to check your pulse and breathing. If you are in any discomfort, please let the nurse know as she can you an injection to help relieve it. You will be allowed to drink as soon as the nurse is happy with your condition. You will be advised not to have too much initially as it might make you sick. Food is started as soon as you are able.
Expect to feel as if you have a bad cold or ‘flu for the first 1 – 2 weeks. This is because the lining of your nose will swell up following the trauma of surgery, like the swelling which occurs in viral infections of the nasal lining following a cold. You may well notice large amounts of dark red, brown or green sticky material coming from the back of your nose into the throat, or when you blow your nose, for up to three months after the operation. This is normal and nothing to worry about.
Take all medicines as prescribed, especially antibiotics or nose drops.
Attend your follow-up appointments – Important treatment will be given.
Steam inhalations – at least three times daily for two weeks:
Put a large container e.g. a washing up bowl on the table
Take about 1 liter of boiling water into it (take sensible precautions against splashing/accidents)
Add a small amount of Karvol or Menthol & Eucalyptus oil.
Sit down in front of the bowl with a towel over your shoulders
Pull the towel over your head to form a “tent” over the bowl
Breathe the steam in through your nose, out through your mouth for five minutes
If nose drops have also been prescribed, use them before the inhalations.
Smoking, or any smoky, dirty or dusty atmosphere
Heavy physical work, including fitness training
Blowing the nose hard (gentle blowing is acceptable but try a steam inhalation first)
Close contact with people suffering from cold or flu (avoid large crowds for this reason)
Excessive Alcohol (up to three units per day at meal times is acceptable)
Swimming and diving
Athletic . sexual exertion. Gentle activities are OK if you feel up to it
A minor degree of bleeding – a few spots on a handkerchief, some bloodstained discharge from the nose – is normal and nothing to worry about. You may get a few large dark red or brown clots coming from the nose, or going back into the throat, in the first 1 – 2 weeks; again this is normal and nothing to worry about. If you get a profuse amount of bright red blood, this is not normal. You should
Sit down in a chair, pinch the nose and breathe through the mouth.
If there is someone else around, ask them to put some ice in a plastic bag, and hold it over the bridge of your nose.
If it doesn’t stop within five minutes you should contact us advice.