Functional endoscopic sinus surgery (FESS) is used to treat chronic rhinosinusitis when medical therapy fails. Key steps include uncinectomy to enlarge the maxillary sinus ostium, removal of the ethmoid bulla and partitions, posterior ethmoidectomy using punches or microdebriders, and sphenoidotomy or frontal sinus surgery when indicated. Complications can include orbital injuries, CSF leaks, meningitis, and adverse nasal outcomes like adhesions, crusting, and mucous cysts. Careful technique and postoperative care can help prevent complications.

1. FUNCTIONAL ENDOSCOPIC
SINUS SURGERY (FESS)
BY-
DR SANTOSH JAISWAL
DLO,DNB TRAINEE

2. • INDICATIONS FOR SURGERY-
• ACUTE RHINOSINUSITIS-
• Mostly managed medically but complications are managed
surgically.
• CHRONIC RHINOSINUSITIS-
• If failure of maximal medical therapy.
FUNCTIONAL ENDOSCOPIC SINUS SURGERY

3. • Anaesthesia for surgery-
• LARYNGEAL MASK AIRWAY PREFERRED OVER
ENDOTRACHEAL TUBE.
• Hypotensive anaesthesia is preferred maintain systolic MAP of
90 mm hg which is achieved at maintaining heart rate at 60
bpm.
• SURGICAL POSITION-
• Patient should be in reverse Trendelenberg position.
• INTRANASAL PREPARATION-
• Topical decongestants in form of cocaine,adrenaline+/- sodium
bicarbonate(Moffat’s solution)soaked in neuropatties,ribbon
gauze /pledgets most commonly used.

4. • Lignocaine 5% and phenylephrine 0.5% is also effective.
• Oxymetazoline is also used alone.
• Local anaesthetic infiltration of middle turbinate,nasal septum
and frontal process of maxilla is performed using 1-2 mls of
1% lignocaine with 1 in 80000 adrenaline is utilised.
• Preop CT scan of patient is required.
• EYE PREPARATION-eyes left open with lubrication.

5. • PROCEDURE-
• UNCINECTOMY-The free edge of boomerang shaped
uncinate is identified.
• Using a back biting forceps the uncinate is fractured in middle
portion.
• It is always important to address the horizontal part of uncinate
which extends inferior to natural ostium of maxillary sinus.
• Bone of horizontal portion can be dissected free of mucosa and
natural ostium can be enlarged-middle meatal antrostomy.
MESSERKLINGER TECHNIQUE-

7. • REMOVAL OF ETHMOIDAL BULLA-
• Natural ostium of bulla sits posteromedial to anterior face.
• Double right angled probe can be used to fracture anterior face
forwards.
• Bulla can be removed aiming for complete removal of
partitions between lamina and middle turbinate.
• During removal of bulla superiorly taking care not to damage
anterior ethmoidal artery.(can be present in anterior wall of
bulla)
• Through biting forceps is preferred over Blakesley-Wells
forceps.

9. • POSTERIOR ETHMOIDECTOMY-
• Ground lamella is perforated in infero- medial quadrant.this
avoids injury to skull base/lamina.
• Once posterior ethmoid is opened. the roof of maxillary sinus
can be used as guide to superior limit of dissection within
posterior ethmoid.
• A microdebrider, Kerrison’s punch can be used to remove
partitions between posterior ethmoid cells.
• Care should be taken for optic nerve as it may traverse Onodi
cell.

10. • SPHENOIDOTOMY-
• Natural sphenoid ostium is located in sphenoethmoidal recess,
medial to superior turbinate and at height of antral roof.
Part of middle turbinate can be resected with back-biting
forceps entering superior meatus and locating forward
projection of superior turbinate from posterior ethmoid cavity.
Inferior third of superior turbinate can be resected in order to
gain access to sphenoethmoidal recess.
Alternative-artificial opening to sphenoid can be made through
posterior ethmoid and extended medially to incorporate natural
sphenoid ostium.

12. • FRONTAL SINUS SURGERY-
• Agger nasi is key to approach to frontal recess.
• Using a Kerrison’s punch in axilla of middle turbinate the
anterior portion of Agger nasi can be removed.
• Curretes and angled instruments can be used to remove
posterior wall and roof of Agger nasi to expose the frontal
recess.
• Agger nasi has been removed,any remaining fronto-
ethmoidal cells can be removed using biting
instruments,curretes.

13. • Care to be taken to avoid circumferential injury to mucosa-
stenosis of frontal recess.
• When dissecting frontal recess position of anterior ethmoidal
artery needs to be identified.
• Any inter-sinus septal cells or supra orbital ethmoidal cells
,needs to be addressed.
• Advanced frontal instrumentation such as giraffe forceps or
3.5 mm Hosemann punch may greatly facilitate surgery .

17. NASAL COMPLICATIONS ORBITAL COMPLICATIONS INTRACRANIAL
HAEMORRHAGE DAMAGE TO MEDIAL
RECTUS
CSF LEAK
ADHESIONS DAMAGE TO NLD MENINGITIS
CRUSTING INTRAORBITAL
HAEMORRHAGE
PNEUMOCEPHALUS
OSTEITIS OPTIC NERVE INJURY INTRACRANIAL BLEED
INFECTIONS DAMAGE TO PERIORBITA
MUCOUS CYST PERIORBITAL SURGICAL
EMPHYSEMA
RECIRCULATION OF MUCUS
COMPLICATIONS

18. DAMAGE TO PERIORBITA-
WHILE UNCINECTOMY as it is closely related to lamina.
Gentle pressure applied on the sclera of eyeball covered by skin
and look for transmitted movt of eyeball/protuding orbital fat
through endoscope.
AVOID NASAL PACKING AND FORCEFUL NOSE
BLOWING.
ORBITAL COMPLICATIONS

19. • PERIORBITAL SURGICAL EMPHSEMA
• Patient with history of dehisence of lamina payracea blows
nose forcefully in postop period.
• CLINICAL-periorbital swelling with discolouration.
• T/t-avoid nasal packing .
• Postop mild echymosis around the eye which subsides in 7-10
days.
• Forceful nose blowing to be avoided.

21. • DAMAGE TO NLD-
• Can occur while doing middle meatal antrostomy enlarging
ostium too anteriorly /widening frontal recess laterally/.
• CLINICALLY patient presents with epiphora.
• Investigations gentle probing and syringing.
• T/t- Dacrocystorhinostomy is treatment of choice.

22. • DAMAGE TO MEDIAL RECTUS-
• Postop complaint of diplopia and pain while eye movement.
• Mobility of eyeball and signs of intraorbital bleed must be
checked.
• Investigations-CT and MRI
• T/t-severe injury to muscle must be repaired immediately

23. • INTRAORBITAL HAEMORRHAGE-
• Most serious complication following endoscopic surgery.
• Intraoperative bleed –rapid proptosis, conjunctiva congestion,
scleral congestion, increased tension in globe, loss of direct
and consensual light reflex.
• Postop period-severe orbital pain ,restricted eyeball
movement,color blindness (red first).Fundoscopy reveals optic
nerve pallor.
PATHOLOGY-increase in intraorbital pressure more than 90
min results in ischaemia of retina nad damage to optic nerve.
TREATMENT-anti trendelenberg position
lateral canthotomy with /without cantholysis or orbital
decompression.

25. • Orbital decompression making multiple incisions on orbital
periosteum after removal of lamina papyracea which permits
herniation of orbital fat into ethmoidal sinuses and releives
intraorbital pressure.
• Decrease volume of orbital contents-mannitol,acetazolamide
and corticosteroids are given.
• OPTIC NERVE INJURY-red color appreciation is lost.
• Marcuss gunn pupil reacts poorly to direct light and
consensual light reflex is maintained.
• INVESTIGATIONS-CT and MRI scan.
• T/t- methylprednisolone loading 1gram iv f/b 250 mg iv 6
hourly.

27. • INTRACRANIAL COMPLICATIONS-
• Csf leak-lateral lamina of fovea ethmoidalis and from
cribiform plate.
• Meningitis-ascending infections from sinuses .
• Pneumocephalus-usually subarachanoid space,emergency.
• Ball valve mechanism air enters intracranial space and trapped
in meninges and brain.
• Sudden change in aletness,headache,nausea,vomiting,loss of
consciousness.
• Plain Xray /CT .
• T/t-needle aspiration after burr hole

29. • NASAL COMPLICATIONS-
Haemorrhage
ARTERIAL BLEED-
ANTERIOR ETHMOIDAL
ARTERY
POSTERIOR ETHMOIDAL
ARTERY
SPHENOPALATINE
ARTERY
INTERNAL CAROTID
ARTERY
MUCOSAL BLEED D/T-
TRAUMA
PREVENTION-
MORE USE OF NON
TEARING
INSTRUMENTS SUCH AS
TRUCUT.
IN CASE OF EXCESSIVE
BLEEDING PACK THE
NASAL CAVITY & OWAIT

31. • ADHESIONS-
• Occurs due to two raw opposing surfaces are in contact for a
long time .
• If pt is asymptomatic requires no immediate treatment.
• If symptomatic and obstruction of ventilation and drainage of
sinus occurs it needs lysis .
• Predisposing factors-
• Extensive tearing of mucous membranes
• Inadequate patient followup.
• Prevention -
• Avoid unnecessary damage to mucosa.
• Nasal pack(ribbon gauze) can be avoided if possible .

33. • INFECTION-
• In case of pus noted postop culture and senstivity should be
sent for.
• TOXIC SHOCK SYNDROME-
• Occurs due to staphlococcus infection.
• Symptoms include fever,rash,hypotension,renal,hepatic and
cns symptoms.
• Nasal pack is removed and pus culture and senstivity should
be sent.
• Iv fluids,systemic antibiotics should be started.

35. • CRUSTING-
• Crusts occurs mostly in early phase of postop period due to
temporary cessation of ciliary function due to effect of
vasoconstrictors,instrumentation and placement of nasal pack.
• Proper alkaline nasal douching must be explained to patient in
the postop period after pack removal.

37. ALKALINE NASAL DOUCHING

38. • MUCOUS CYST-
• If it is asymptomatic no treatment is required immediately.
• If it is large and symptomatic requires removal.

39. • RECIRCULATION OF MUCUS-
• Recirculation of mucus due to excessive trauma and resultant
scarring of natural ostium and in those cases where the
natural ostium is not connected to the accessory ostium.

40. • OSTEITIS-
• Due to aggressive mucous membrane removal during surgery
thus exposing the underlying bone
• It is prone to osteitis and results in permanent source of
infection.
• Treatment includes removal of sequestrum ,systemic
antibiotics and regular nasal douching and regular followup of
patient.

41. • Causes of failure of FESS-
• Polyps not adequately cleared d/t bleed.
• Fungal sinusitis
• Allergic component not dealt properly.
• WIGANDS TECHNIQUE-posterior to anterior approach
• Patients with extensive sinus diseases/for patients undergoing
sinus surgery when landmarks are unavailable.
• Advantages-plane of skull base identified early in procedure in
region of sphenoid and posterior ethmoid cells and mybe
safely followed anteriorly towards small anterior ethmoidal
cells.