Functional Endoscopic Sinus Surgery
FESS is a treatment procedures carried out with the help of rigid nasal endoscopes. Most patients having FESS will only need diagnostic procedures, not a surgical operation. I began FESS operation from 1987 when I started working at the Bahrain Defence Force hospital. One way 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. 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.
It has revolutionized the surgical treatment of chronic sinusitis. FESS generally eliminates the need for an external incision.
Preop CT Scan of the sinuses
A CT scan is a must before doing FESS. Plain X-ray has no value in defining sinus pathology.MRI scans are less useful than CT for most sinus problems, but MRI may be needed in some rare cases of sinus tumors.
How is the operation done?
Most FESS operations are done under general anesthetic in the operating theatre. Hypotensive anesthesia is a bonus. There is no external cut; the surgery is done through the nostrils.
A powerful headlight and angled telescopes to see around corners are used. Using specially designed fine bone -cutting instruments, and powered suction debriders when appropriate, the sinus openings will be enlarged and anything blocking the sinuses, such as swollen mucosa or polyps, will be removed.
Other procedures such as Septoplasty and LASER vaporization of inferior turbinates are often done at the same time as FESS. If you need stitches, they will be internal and self-dissolving. At the end of the operation it is usual to have a pack (merocel) in each nostril to soak up any blood. This is kept in for a day.
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.
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
Indications for FESS
Polyps-allergic nasal polyps, sinusitis-maxillary, ethmoid, frontal risks?
Nasal and sinus operations are very safe procedures in modern medical practice. But no operation is totally risk free. A general anesthetic carries a minimal risk, with consultant anesthetists using modern drugs and monitoring equipment. There is a low risk of bleeding, either during or up to two weeks after the operation.
Other treatment options?
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 rhino sinusitis now outdated-
- Sinus wash-Antral lavage
- Intranasal antrostomy
- Caldwell-Luc operation (sub labial antrostomy)
- External fronto-ethmoidectomy
Before the operation
Remember to bring any medicines with you to hospital. You will not be allowed anything to eat for about six hours before operation. 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 the nurse who will ask various questions about your general health and attach an identity bracelet to your wrist. Similar questions will be asked by the Resident Medical Officer, and possibly by the anesthetist. You will be examined and checks made to ensure you are fit for anesthetic. If you have any worries or questions, this is a good time to ask.
After the operation
After the operation, you will wake up in the recovery area, where a nurse will look after you. There will probably 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. 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.
Things to do
- 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.
- If Otrivine nose drops have also been prescribed, use them before the inhalations.
Things to avoid (for two weeks)
- 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)
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.
- In a more urgent situation, you may call the ENT doctor