Endoscopic Sinus Surgery

Endoscopic surgery has made a great contribution towards
management of sinus disease. Indications for conventional
operations like those of Caldwell-Luc, frontal sinus operations,
external ethmoidectomy have greatly reduced.
Endoscopic surgery is minimally invasive surgery and does
not require skin incisions or removal of intervening bone
to acces, the disease. In the sinuses, ventilation and
drainage of the sinuses is established preserving the nasal
and sinus mucosa and its function of mucociliary clearance.
Advances in endoscopic surgery have been possible due to;
1. Development of better optics.
2. Improved brighter illumination.
3. Development of microsurgical instruments to work
with the endoscopes and precise removal of tissue
with sharp cuts without stripping the mucosa.
4. Concomitant developments in imaging techniques
like CT and MRI to precise ly define the area of
pathology.
5. Introduction of powered instrumentation in the form
of sofr-t i ~s ue shavers also called micro-debriders (to
remove n asa l polyps, soft-tissue masses or mucosa)
help reduce bleeding to a great extent while bonecutting
drills help endoscopic surgery of frontal sinus,
hcrimal sac , etc. to remove bony obstruction.
6. The lar ' t advancement has been the computerassisted
image-guided navigational surgery in difficult
cases or revisional surgery when landmarks are
not easy to identify.
Indications
1. Chronic bacterial sinusitis unresponsive to adequate
medical treatment.
2. Recurrent acute bacterial sinusitis.
3 . Polypo id rhinosinusitis (diffuse nasal polypos is) .
4. Fungal sinusitis with fung<11 ball or nasal polypi.
5. Antrochnanal p()lyp.
6. Mucoce le 0 frontoethmo id or sph enoid sinus.
7. Con trol oi epistclx is by endoscopic cautery.
8. Remova l of foreign body from the nose or sinus.
9. Endoscopic se ptoplasty.
Advanced Nasal Endoscopic Techniques
1. Removal of benign tumours, e.g. in ert d papillomas
or angiufibromas.
2. Orbital abscess or cellulitis management.
3. Dacryocystorhinostomy.
4 Repair of CSF leak.
5. Pituitary surgery.
6. Optic nerve decompress ion.
7. Orbital decompression for Graves disease.
8. Control of posterior epistaxis (endoscopic clipping
of sphenopalatine artery).
9. Choanal atresia.
Contra i nd icati ons
1. Inexperience and lack of proper instrumentation.
2. Disease inaccess ible by endoscopic procedures, e.g.
lateral front al sinus disease and stenosis of internal
opening of frontal sinus.
3. Osteomyelitis.
4. Threatened intracranial or intraorbital complication.
Anaesthesia
General anaesthesia is preferred by most of the surgeons.
Local anaesthesia with i.v. sedation can be used in
when limited work is to be done.
Position
Patient lies flat in supine position with head rest ing ,m a
ring or head rest. Some also prefer to raise it by IS°
Techniques
Two surgical techniques are followed;
(a) Anterior to posterior (Stammberger's technique ); In
this technique surgery proceeds from uncinate
process backward to sphenoid sinus. Advantage of
this technique is to tailor the extent of surge ry to
the extent of disease.
(b) Posterior to anterior (Wigand's techniq ue ); Surgery
starts at the sphenoid sinus and proceecls anteriorly
along the base of skull and medial orbital wall. This
is mostly done in extensive polyposis or in revisional
sinus surgery.
Steps of Operation
1. Remove the pledgees of cotton kept for nasal decongestion
and topical anaesthesia.
2. Inspect the nose with 4 m.m 0° endoscope or do
complete nasal endoscopy if not a lready done.
3 . Inj ect submucosa lly 1 % lignocaine with 1:100, 00
adrenaline under endoscopic control (Fig. 861):
(a) On the lateral wall, near the upper end of midelk
turbinate.
(b) On the la teral wall, just below the first
inj ect ion.
(c) On the la teral \vall, just above the inferior
turbinate.
(d) In the middle turbinate, posterior aspec t.
(e) Posterior aspect of nasal septum.
4. Replace cotton pledgets and repe at injections on
the opposite side if bilateral FESS is to be done.Medialise the middle turbinate and identify the unc inate
process and bulla ethmoida lis. If middle turbinate is large ,
partial or total turbinectomy is performed . In case of concha
bullosa, lateral lamella is removed. Definitive surgical
steps include:
1. Uncinectomy. Uncinate process is incised with
sickle knife and remo ved with Blakesley forceps.
2. Identification and enlargement of maxillary
ostium. Maxillary ostium lies above the inferior
turbinate and posterior to lower third of uncinate
process. Once localised, it is enlarged anteriorly with
a back-biting forceps or pos teriorly with a through
cut-s tra ight forceps.
3. Bullectomy. Bulla ethmoidal is is penetrated with
curette or Blakesley forceps and removed. Avoid
injury to medial orbital wa ll, skull base or anterior
ethmoidal artery.
4. Penetration of basal lamella and removal of posterior
ethmoid cells. Basa l lame lla is the dividing thin
bony septum between anterior and posterior ethmoid
cells. It is penetrated in the lower and medial part
with a sma ll curette and then removed with Blakesley
forceps. Posterior ethmoid cells are exenterated. Optic
nerve is at risk if Onodi cell is present. Onodi ce ll is
a pos terior ethmoid cell which extends into the sphenoid
bone late ral and superior to the sphenoid sinus.
5. Clearance of frontal recess and frontal sinusotomy.
Iffrontal sinus is clear on CT scan and patient
also does not suffer from fremea I h eCldaches, nothing
need to be done. In the event of fron tal sinus disease
, front al recess is cleared and frontal sinus
drainage established.
Opening of frontal sinus is situated lateral to
attachment of middle turbinate, medial to medial
orbital wa ll, anterior to anterior ethmoidal artery
and posterior to agger nasi cell{s). Surgery in the area
of frontal recess is challenging as any d isrespect to
the mucosa in this area would lead to stenosis of
frontal sinus opening with mucocele formation o r
recurrent frontal sinusitis6. Sphenoidotomy. This step is done after clearance of
pos terior ethmo id cells or Clfter frontal sinuso tomy.
It is omitted if sinus is hea lthy. In this procedure
ante rior wall of sphe noid sinus is removed, and pus
and inspi ssa ted mat erial from wit hin the sinus
removed. There are two ways to remove the anterior
sinus wa ll:
(a ) By entering the sphenoid s inus anterior and
inferior to the ethmo id cavity created by the
above steps.
(b) By enlarging the opening of sphenoid sinus with
Bla kesley forceps or J -curette. Sinus opening is
identified after removal of the posterior-inferior
portion of superior turbinate near the nasal septum
and about 1.0 cm above the upper border of
posterior choana.
7. Nasal packs. Fina lly the nasal packs are aprlied, if
septal surge ry has also been done with FESS o r to
stop any bleed ing from the nasa l cavity.
Post-operative Care
It is individua lised according to the exten t of surgery
done.
I. Removal of nasal packs. Nasa l packs, if kept, are
removed at the time of discharge 24 hours
operation.
2. Antibiotics. An intraopera tive intravenous antibi otic
(amoxyclav, cephalosporin or quinolone) is
administered and then continued for 7-10 days by
oral ro ute.
3. Antihistaminics. For a llergic patients.
4 . Analgesics. For re lief of post-opera ti ve pa in.Nasal irrigations. Saline irrigations are started after 1
week post-operatively to remove blood clots, crusts and
secretions and continued once or twice a day for 1 week.
Steroid nasal sprays. Required in cases of nasal
allergy or those operated fo r nasa l polyps.
Endoscopic toilet. Blood clots, crusts and debris are
removed by suction and forceps from the ethmoid area lateral
to middle turbinate. Any adhesion fonl1ation in the
nose is di vided with suction. Healthy mucosa should not
be disturbed. Suction can be done from within the maxillary
sinus wirh a curved cannula. Since the endoscopic
clearance is a painful process, topical nasal anaesthetic
with a decongestant is sprayed before the procedure.
Patient pays weekly visits for inspection of the cavity
for 4 weeks and there after as required till mucosalisation
of the cavity is complete.
Complications
They are similar to conventional surgery of ethmoid complex
and can be divided into major and minor. Mostly they
involve orbit or skull base, or are of general nature
Major
1. Orbital haemorrhage
2. Loss of vision/ blindness
3. Diplopia
4. (SF leak
5. Meningitis rhinitis or sinusitis
6. Brain abscess
7. Massive haemorrhage
8. Intracranial haemorrhage
and direct brain trauma
9. Anosmia
10. Injury to internal carotid
artery in sphenoid sinus
11. Injury to nasolacrimal
duct and epiphora
12. Death

Minor:
1. Periorbital ecchymosis2. Periorbital emphysema 3. Post-operative epistaxis4. Post-operative infection:5. Adhesions6. Stenosis of maxilla ry 0r frontal sinus
requiring blood transfusion7. Exacerbation of asthma8. Hyposmia9. Dental pain