FUNCTIONAL ENDOSCOPIC SINUS SURGERY

Introduction

ndoscopic sinus surgery (ESS) is a recent addition in the management of chronic sinusitis. Surgical treatment of chronic sinusitis, until late, has been based on the concept that diseased sinus mucosa should be radically removed to enable new healthy mucosa to grow in its place for which most popular operation in the past has been Caldwell-Luc procedure. Messerklinger’s work on sinus mucosa and mucociliary transport has now shown that pathology is not primarily in larger sinuses, but is always secondary to impaired drainage caused by the disease in the ethmoidal air cells blocking their natural ostia in the middle meatus^1,2.

 It has now been clearly established that if the ostium of the unhealthy sinus is unblocked surgically by removal of diseased ethmoidal air cells, the rest of the diseased mucosa reverts back to normal. Functional endoscopic sinus surgery is a set of minimally invasive surgical techniques which permit direct visual examination and opening of the sinuses for the treatment of chronic rhinosinusitis which has not improved by medical treatment^3,4. The use of FESS allows for a much less invasive and traumatic surgery, consequent in shorter surgery and healing times, less postoperative awkwardness, and littler surgical complications.

 Rhinosinusitis is inflammation of the mucosal membrane lining the nasal cavities and the paranasal sinuses. Rhinosinusitis lasting more than 12 weeks is classified as chronic rhinosinusitis (CRS)^5,6.

 The aims of treating CRS are to remove underlying causes, diminish sinus inflammation, and drain nasal passages. Medical treatment is the first-line treatment for CRS. Treatment options may include nasal saline sprays, nasal lavage, antibiotic therapy, nasal corticosteroids, oral or injected corticosteroids, decongestants, over-the-counter pain relievers, leukotriene modifiers, and antihistamines. Patients who do not respond to medical therapy are candidates for sinus surgery⁷.

 The aim of present study is to evaluate the effectiveness of FESS for the treatment of nose & paranasal sinus diseases, and to address the postoperative complications.

Patients and Methods

 This prospective study was performed at Department of Otorhinolaryngology in Basrah Teaching Hospital,   in the period from January 2016 to August 2019. The study included one hundred twenty six patients who were clinically, endoscopically and radiologically suggestive to have sinonasal diseases and not responded to usual medical treatment. Malignant diseases of nose and paranasal sinuses were excluded. Preoperative CT of sinus and nasendoscopy serves as a road map for surgery. Surgery was performed usually under general anesthesia except in 5 patients (2 pregnant women in first trimester and 3 patients with uncontrolled DM, and hypertension). Patients were put in supine position with elevation of head. After proper nasal mucosal decongestion, the 0o and 30o endoscopes were commonly used along with special Blakesly straight and angled forceps. Following the Ist pass (examination of nasopharynx and inferior meatus), the scope was moved medial to middle turbinate to see sphenoethmoidal recess, opening of posterior ethmoids and sphenoidal sinus (second pass). Third pass, when endoscope was passed into middle meatus to see OMC also called key area.

 Uncinate process, ethmoidal bulla, hiatus semilunaris and frontal recess were visualized, uncinectomy was done to visualize the opening of maxillary sinus, ethmoidal bulla if enlarged is also removed by opening at its medial and inferior portion with a Blakesley’s forceps.

 Posterior ethmoidectomy was done by identifying the ground lamella posterior to the bulla, which was pierced by a upcutting forceps, any other pathology was also dealt likewise, merocele pack was kept to be removed after 24 hours^8,9, then patients were followed-up for 6 months.

Results

 The study included 126 patients, 71 of them were males and 55 were females, male to female ratio was 1.29:1, their age ranged from 9 to 74 years,  the commonest operated upon age group was 41-50 years , this is clearly demonstrated in table I.

Table I: Demographic characteristics of the studied patients.

 Table II, shows the presenting symptoms of the studied patients, the commonest symptom was nasal obstruction, congestion or blockage (85.7%), followed by nasal discharge, headache and facial pain (69% and 66.6%) respectively.                       

Table II: The presenting symptoms of included patients.

 The commonest indication of FESS in the present series was chronic rhinosinusitis (78 patients, 61.6%) of the studied patients, 42 patients have rhinosinusitis without nasal polyps, while 36 have chronic rhinosinusitis with nasal polyps, as shown in table III.

Table III: Indications of functional endoscopic sinus surgery

 The majority of the patients were operated upon for the first time (primary cases), which involved 98 patients that equal to (77.7%), while revision surgery was performed for 28 patients (22.2%), this is clearly illustrated in figure 1.

 Table IV, display the main causes of revision surgery, the commonest cause was recurrent nasal polyposis which comprised 28.5%, followed by persistent anterior ethmoid cells (21.4%).

Table IV: Causes of revision surgery.

 Figure 2, shows the results of FESS performed for the studied patients, the majority (112 patients, more than 88%) were improved, in 59.5% (75 patients), the recovery was complete and 29.3% (37 patients), was partial, while 14 patients (11%), there was no improvement.

 The complications of FESS occurred in 19 patients (15%). The majority were minors (12 patients, 9.5%), most of them were synechia, while in 7 patients (5.5%), the complications were majors and common major complications were severe intraoperative and postoperative bleeding, this is shown in table V.

Table V: Complications of  FESS.

Discussion