FESS Procedure

What is Functional Endoscopic Sinus Surgery (FESS)?

Functional Endoscopic Sinus Surgery (FESS) is a minimally invasive surgical procedure that is done to open up the sinuses using an endoscope and clear paranasal pathways and improve drainage of the sinuses (pockets) that surround the nasal cavity. Normal drainage of the sinuses is important for the prevention of infections, as the main function of the mucus that is produced by these sinuses is to trap pollutants, microbes, dust particles, etc. The advantage of FESS over open surgery is that it is minimally invasive, causes less bleeding and scarring, the recovery time is less, and it does not damage healthy tissue.

Alternate names

FESS

Is this procedure an elective or an emergency procedure?

FESS is an elective procedure.

Types of procedure

Functional endoscopic sinus surgery may be of the following types.

• Functional Endoscopic Sinus Surgery: Done without balloon catheters
• FESS with Balloon Sinuplasty: Done with balloon catheters without bone or soft tissue removal

Indications for FESS

The indications for a FESS include the following.

• Chronic sinusitis not responding to medical treatment.
• Recurrent sinusitis
• Nasal polyps
• Antrochoanal polyps
• Sinus mucoceles
• Excision of some tumors
• Closure of Cerebrospinal fluid (CSF) leak
• Orbital decompression (such as in Graves ophthalmopathy)
• Decompression of the optic nerve
• Dacryocystorhinostomy (DCR)
• Choanal atresia repair
• Foreign body removal
• Epistaxis control

Contraindications and risk factors

Some contraindications for FESS include the following.

• Intraorbital complications of acute sinusitis: such as orbital abscess
• Frontal osteomyelitis with Pott puffy tumor
• Failure to manage CSF leakage after 2 attempts via FESS: A 3rdendoscopic procedure is not advised
• Failure to treat frontal sinusitis via FESS: A second surgery should be an open surgery

Investigations before the procedure

The following investigations are usually done before a FESS procedure.

• Laboratory tests
  • CBP & ESR
  • Coagulation profile & Blood typing
  • Basic Metabolic Panel
  • Liver and Renal Function tests
• Imaging tests
  • X-Ray skull
  • CT Scan
  • MRI scan: usually in complicated cases
  • Fibre Optic Endoscopy of the nasal cavities and the sinuses
• Thorough ENT evaluation

Preoperative advice for FESS

Before performing a FESS, the following are done.

• The risks and benefits of the procedure are explained.
• Cessation of smoking
• Anticoagulants may be stopped a week before the procedure

Intraoperative details

• Duration: Functional Endoscopic Sinus Surgery can last between 2-4 hours
• Anaesthesia: FESS is usually done under local anaesthesia. Some procedures may be done under general anaesthesia.

How is functional endoscopic sinus Surgery done? 

With the individual lying down (or in a seated position) and after the local anaesthetic has taken effect, and restriction of blood flow through ephedrine is achieved, the middle turbinate is located using the fiber optic endoscope. Next, a bone called the uncinate process, which lies on the side of the nose and at the level of the middle turbinate, is removed. The ethmoidal bone is moved to allow for better visualization of the sinuses. The opening of the osteomeatal complex into the jaw is checked and it is cleared if there is any obstruction. Depending on the procedure that is being done, the anterior ethmoid cells, the posterior ethmoid cells, or both, the sphenoid sinus, and lastly, the frontal sinus are worked upon, and the corresponding ostia (openings) are cleared or enlarged to provide for better drainage and flow of the mucus.

In addition to the management of chronic sinusitis, nasal masses such as nasal polyps and antrochoanal polyps are also removed via FESS. Cerebrospinal fluid (CSF) leakage, as seen in CSF Rhinorrhea, can also be managed via functional endoscopic sinus Surgery. Besides, FESS is also used in certain ophthalmic procedures, such as optic nerve decompression in traumatic neuropathy, orbital decompression, and DCR procedures. A spacer may be placed in the middle meatus, and nasal packing is done.

Postoperative details for FESS

After a FESS procedure, the following is usually done.

• If the procedure was done under general anaesthesia, the individual is shifted to a recovery room and monitored till awake and stable.
• The nasal packing is removed before discharge.

Discharge: Usually shortly after the procedure is complete. Medications: Saline nasal spray, antibiotics, and corticosteroid drops may be prescribed as required.
Review: Usually 1 week after the surgical procedure. In some cases, it is every 2- 3 days for cleaning the nasal pathways for up to a week.
Resumption of normal activities: Usually with some restrictions a week after the procedure

Role of Diet/Exercise/Lifestyle changes

Some measures that may be needed to be taken after a functional endoscopic sinus Surgery include

• Keeping the nose free from crusting: This is done by using the saline nasal spray or simple nasal cleaning via douching
• Avoiding blowing the nose and sneezing
• Avoid strenuous activity for 7-10 days
• Cessation of smoking
• Avoid exposure to pollution, smoke, fumes

Complications in FESS

Some complications that may be seen after a FESS may include

• Bleeding
• Infections
• Orbital injury
• Double vision
• Blood clot formation in the orbit
• Blindness
• CSF leak
• Direct brain injury
• Nasolacrimal duct injury/epiphora

Prognosis

The prognosis of FESS is excellent, and the results are often very good, although based on the underlying condition that is being treated.

Indications for hospitalization if required

Hospitalization is not required for a FESS procedure.

Suggested clinical specialist/Department to consult for the procedure

FESS is done by specialists from the Department of Otorhinolaryngology