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Functional endoscopic sinus surgery (FESS) has been performed for more than 20 years in the United States. The main purpose of FESS is to restore natural sinus drainage and function.1,2 The surgery is used primarily to treat chronic rhinosinusitis (CRS), a complex disease process that affects approximately 14% of the U.S. population.1 Nearly 32 million cases of chronic sinusitis are reported to the CDC annually.3
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FESS is performed when CRS is refractory or unresponsive to medical management. The long-term success rate of FESS for symptomatic improvement in these patients is approximately 90%.4 With the advent of more sophisticated endoscopic surgical experience and instrumentation, FESS is now the gold standard treatment of CRS.4
Indications
FESS is also a treatment for allergic fungal sinusitis, nasal polyposis with or without aspirin sensitivity, chronic sinus headaches, impaired sense of smell, inverted papillomas, chronic hyperplastic sinusitis, cerebrospinal fluid (CSF) leaks, nasolacrimal duct obstruction, choanal atresia, sinonasal paraganglioma, dysthyroid orbitopathy, traumatic optic neuropathy, and posterior medial orbital lesions. 5–8 The goal of FESS is to remove diseased bony partitions to widen the natural sinus ostia, expose the sinus mucosa, and restore the pathways and mucociliary clearance. Failure to remove diseased bone may result in infection and inflammation, as well as the formation of thickened bone.8
CRS occurs when the following symptoms last longer than 3 months: facial pressure and pain, purulent nasal discharge, nasal congestion, hyposmia (diminished sense of smell), tooth pain, and poor response to decongestants.1 Patients with CRS may experience symptoms so severe that they are unable to function socially, thus affecting quality of life and ability to work.
Common causes of CRS include nasal polyps or tumors and a deviated nasal septum.4 Although the exact mechanism that causes CRS is unknown, there's some correlation to environmental, host, or iatrogenic factors. Environmental factors, including air pollutants, allergens, tobacco smoke, and mold are known triggers for mucosal inflammation and may cause toxicity to the mucociliary apparatus. Similarly, some host factors result in excessive inflammation or decreased mucociliary clearance such as in systemic diseases, including asthma, aspirin intolerance, immunodeficiencies, cystic fibrosis, granulomatous disease, primary ciliary dyskinesia, and neoplasia. These environmental and host factors need to be addressed before surgery. Iatrogenic disease may be caused by poor surgical technique, inadequate postoperative cavity debridement, or inadequate postoperative medical care.4
Benefits and risks of FESS
FESS improves the use of topical medications when trying to access diseased mucosa within the paranasal sinuses and is a superior procedure for the management of thick eosinophilic mucin. It also allows the assessment of diseased bone in cases of CRS and results in better short- and long-term subjective and objective outcomes.4 Many patients have reported improvement in symptom severity, such as reduction in nasal obstruction, hyposmia, headache, and fewer provider visits.9
Major complications from FESS, such as hyposmia/anosmia (decreased ability to detect odors/complete lack of smell, respectively), exposure of orbital fat, vascular damage, blindness, exposure of dura, CSF leak, intracranial injury, intraoperative damage to the optic nerve and hemorrhage resulting in irreversible compressive optic neuropathy, central retinal artery occlusion, persistent double vision, or death occur in up to 1.5% of cases.6,10 Minor complications, such as bleeding, infection, crusting, synechia formation (abnormal union of body parts), ostial stenosis, and tooth or lip numbness, or recurrence of disease occur in 1.1% to 20.8% of cases.11 Image-guided systems can increase safety during surgery.12 Real-time computed tomography images intraoperatively provide navigation for complicated endoscopic procedures and decrease the need for revision surgeries.10
Preparation for surgery
The patient should avoid medications that may cause or prolong bleeding, such as aspirin or nonsteroidal anti-inflammatory drugs (ibuprofen), anticoagulants (warfarin [Coumadin]), and prescription antiplatelet agents such as (clopidogrel [Plavix]), and certain vitamins (vitamin E) and herbal medications (gingko biloba, garlic, or green tea) for at least 1 week before the procedure.5,11 Serum coagulation labs should be drawn; if the lab results are abnormal, the otolaryngologist may cancel or postpone the procedure. Some surgeons may prescribe antibiotics or corticosteroids before surgery to reduce intraoperative inflammation and perioperative bleeding.2 While the patient is in the surgery prep room, a topical decongestant oxymetazoline (Afrin), may be sprayed in both nostrils as ordered.11
Intraoperative considerations
The circulating nurse and scrub person or surgical technician should set up the room according to the surgeon's preference. Video monitoring equipment should be placed at the head of the bed so the surgeon and surgical assistant have optimal visualization of the surgical field; however, the video monitoring equipment must not interfere with the anesthesia equipment or other intraoperative devices. There should be enough space around the equipment to allow the scrub person unobstructed access to the sterile field. Surgical navigation equipment is also usually placed at the head of the bed, but positioning may vary according to the surgeon's preference.
The patient should be positioned with his head at the foot of the OR bed to allow enough room underneath as most otolaryngologists sit at the patient's head during the procedure.2 Routinely, the patient's bed will be turned 180 degrees after intubation. By turning the bed, the surgeon has free access around the patient's head. As the patient is being turned, the lines and tubes should remain in place and the endotracheal tube shouldn't become dislodged. The patient's arm that faces the surgeon should be tucked securely at his side, ensuring that the fingers and hand aren't compressed or touching metal. The elbow should be padded to protect the patient from ulnar nerve damage. A pillow should be placed under the knees. Legs should be uncrossed and padding placed under the heels. The patient may be placed in the Trendelenburg position, and the bed rotated toward the surgeon to reduce blood loss and provide more comfortable access for the surgical team.2
The electrosurgical unit dispersive pad should be placed as close to the operative field as possible on a fleshy, muscular part of the body. Bony areas such as the ribs should be avoided, as well as overlapping the pad. A urinary drainage catheter may need to be inserted depending on the length of the surgery.
To prepare the nasal passages, 4% cocaine hydrochloride topical solution, oxymetazoline, 1% lidocaine with epinephrine, and cotton nasal pledgets should be available.2 Facial preparation may be requested. The face should be draped so the nose and eyes are exposed—the surgeon will continually monitor the eyes for any sign of orbital damage.
Surgical equipment includes the 0, 30, 45, and 70 degrees sinus scopes; rhinology instrumentation; power equipment, such as the sagittal saw; and the microdebrider. A defogger must be available in case the scopes become cloudy.
The surgeon may sit or stand during the procedure. The scrub nurse or surgical technician should stand on the same side as the surgeon. The mayo stand should be positioned over the patient for easier and faster access to the instruments.2 Foot pedals for the microdebrider and electrocautery should be placed at the head of the bed on the floor for easy access to the surgeon or surgical assistant. Power cords should be placed out of the way of direct traffic.
Postanesthesia care and complications
The postanesthesia care unit nurse must assess the patient for signs of periorbital swelling, proptosis (orbital bulging), blurred vision, double vision, blindness, or ecchymosis (bruising).11 Intracranial injury may manifest itself with any abnormal neurologic signs; for example, hypertension, unequal pupil size, or altered level of consciousness. Excessive bleeding, change in neurologic status, changes in vision, and CSF leak must be reported immediately.
Postoperative care should promote hemostasis, prevent infection, and boost the healing process.11 The head should be elevated to minimizing bleeding, swelling (ice may be applied to the area to decrease swelling), and congestion.2 The patient can receive pain medication as needed. Nasal packings will remain in place according to the extent of surgery and the surgeon's preference—if the packing remains in place, and/or the patient has purulent drainage, antibiotics may be prescribed.2 Postoperative discomfort, drainage, and congestion should improve after the first few postoperative days, with mild symptoms lasting weeks after surgery.5 To prevent dryness and discomfort, the nasal passages should be treated with normal saline spray. The patient should be advised to use a humidifier at home, especially during the winter months until the mucous membranes are healed. Depending on surgeon preference, the patient may be placed on a routine sinus rinse or steroids.2
The patient should avoid nose blowing, bending over, and strenuous activity, and should sneeze with the mouth open. The patient can expect a series of follow-up visits for evaluation and sinus debridement to promote healing of the nasal mucosal lining and restore normal mucociliary function.2,11,13 The patient may miss several days, or even weeks, from work.
Postoperative complications can include minimal bleeding, headache, hyposmia, periorbital ecchymosis, dental or facial pain, and formation of synechia. Major complications include major hemorrhage, diplopia, orbital hematoma, blindness, and intracranial injury.2 Strict hemostasis and nasal packing can decrease bleeding or avoid altogether; however, patients may experience blood-tinged discharge approximately 1 to 2 days postoperatively. If a major hemorrhage occurs, the patient should be promptly scheduled for exploration.2 Nasal congestion is typical, but should disappear when the nasal packing is removed. Headaches, postnasal drainage, and fatigue may be experienced, but these symptoms will improve during the first few days after surgery.13 Complications from general anesthesia are rare, but may cause cardiac or pulmonary issues. Discomfort or pain is easily managed by pain medication. CSF leaks may occur as the cribriform plate, which is several millimeters thick, is the ceiling of the ethmoid sinus. The cribriform plate can be ruptured easily, and if so, it's usually repaired at the time of surgery. Intraorbital complications such as vision loss and blindness are rare, but have been reported. Sense of smell usually improves, however, it may diminish depending on the severity of the underlying disease and extent of surgery. Numbness may be transient in the front upper teeth, lip or nose, and is usually associated with septoplasty. Infection, such as abscesses and meningitis, may occur whether or not the patient had surgery.14
REFERENCES
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