FUNCTIONAL ENDOSCOPIC SINUS

SURGERY (FESS)Consulant:

dr. Agus Sudarwi, Sp. THT-KLdr. Afif Zjauhari, Sp. THT-KL

Presentant:Yunita Widyaningsih (40------)Julianthy Suento (40613814-)

Fritzky Wandy Thedjakusuma (406138147)

JOURNAL READING

AbstractFunctional Endoscopic sinus surgery (FESS) a minimally invasive surgical procedure that opens up the sinus air cells and the sinus ostia with an endoscope.

FESS has now become widely accepted

The term functional to distinguish this type of endoscopic surgery from the nonendoscopic more conventional sinus procedure.

FESS is being done regularly at TU Teaching Hospital from 2003 March 2003 - December 2005 94

Maximum number of FESS was done for nasal polyps 80 patients

Ethmoidal polyp 47 patients

Antrochoanal polyps 33 patients.

Chronic maxillary sinusitis 8 patients

Fungal sinusitis 5 patients

Endoscopic medial maxillectomy for inverted papilloma 1 patient.

Introduction FESS still a new technique in our country many centers do not have the

instruments for FESS and many surgeons are not trained in this field.

Intranasal endoscopic surgery has two main goal1. Maximum preservation of mucosa2. Secure communication between the nasal cavity and the paranasal sinuses via the natural channels.

There are many indications for FESS :1. Chronic maxillary sinusitis, ethmoiditis, sphenoiditis2. Nasal polyps both ethmoidal and antrochoanal3. Frontoethmoidal mucocoele4. Limited inverted papillomas5. Endoscopic DCR

No absolute contraindication to FESS but uncontrolled hypertension, bleeding disorder, acute infection, where there is chance of excessive haemorrhage during surgery better to go by conventional method.

Investigation required for FESS1. Nasal Endoscopy to assess the disease, and also

to confirm the diagnosis of nasal polyps. 2. CT scan of nose and paranasal sinuses both axial

and coronal section, to know the origin and extent of the disease.

InstrumentsMicrodebrider (shaver) is the recent advances in the field of Endoscopic Sinus Surgery.

The advantages of microdebrider over the use of Forceps1. It eats up the polyps, so the bleeding is less, we can visualize

the normal structure like turbinate.2. There is suction attached to it, which sucks the blood as well as

the soft tissue eaten by the debrider, so the operating field is clean.

3. There is irrigation attached to it, which flushes the area continuously for better visualization.

There are major complications and minor complications :

Major1. Excessive haemorrhage requiring blood transfusion.2. Orbital haematoma.3. Blindness.4. Diplopia.5. CSF Leak.6. Meningitis.7. Carotid artery injury.

Minor1. Periorbital ecchymosis.2. Periorbital Emphysema.3. Minimal bleeding.4. Adhesion.5. Stenosis of ostia.6. Most unavoidable complication is recurrence of nasalpolyps.

Computed tomographic scan. Black arrows show bony defect in the ethmoidal wall of the left orbit post–functional endoscopic sinus surgery. The white arrow indicates air in the orbit.

All the patients were taken up from the Department Of ENT and Head and Neck surgery, TU Teaching Hospital.Duration of study was 26 months.Total patients were 94.

Materials and Methods1. Cleaning and draping2. 1:20,000 xylocain with adrenalin were injected in the uncinate process, base of middle turbinate, and in the polyps3.Nasal cavity was packed with 1:1 preparation of N/ sline and adereline cottonoids4.Wait for 5 minutes.

In case of antrochoanal polypes, uncinectomy was done first and widening of the natural ostia of the maxillary sinus was done by removing the anterior and posterior fontanel. Polypes was pulled out from the maxillary antrum, nasal cavity and choana and removed in toto

In case of ethmoidal polyp, if there is massive polypes, debulking was done first followed by widening of the natural ostia, then polypes from the maxillary antrum were removed.

Ethmoid is opened by opening the bulla ethmoidalis, disease is removed from anterior ethmoid then the basal lamella is opened to enter the posterior ethmoids.

Sphenoid is opened by entering through sphenoidal ostium for the middle turbinate is our landmark. Any polyps or fluid in sphenoid is removed.

If CT scan shows opacity of the frontal sinus, we approach through frontal recess but mucosa of the frontal recess is left intact to prevent the stenosis.

Haemostasis is achieved by packing the nose with adrenalin and saline solution. Finally BIPP packing was done which is removed after 48 hours.

In patients where nasal polyps were associated with deviated nasal septum (DNS), septoplasty was done first followed by FESS for better exposure to the operating field.

Result

Age Distribution No. Of Patients<10 years 2

11-20 years 1231-40 years 3341-50 years 41>60 years 6

Sex Distribution No. Of PatientsMale 54

Female 40

Disease Pattern No. Of PatientsEthmoidal Polyps 47

Antrochoanal Polyps 33B/L Chronic Maxillary Sinusitis 8

B/L Fungal Sinusitis 5Inverted Papilloma 1Complications No. Of Patients

Synechia 15Orbital Ecchymosis 8

Orbital fat pulled out 7Recurrence of nasal polyp 7

Excessive hemorrhage 2Restricted eye movement 1

Discussion In our study

80 patients of nasal polyps ethmoidectomies with or without sphenoidotomy 47 patients Antrostomy alone was done for antrochoanal polyps in 33

patients.

Recurrence of polyp after ethmoidectomies with or wihtout sphenoidotmy 7 patients

Complications (during and after the surgery) Synechiae Orbital ecchymosis Accidental removal of orbital fat Bleeding during surgery Recurrence of polyps

Endoscopic After Care Follow up

First visit after one week when we remove the blood clot, crust, the secretions, release the synechaie

if excessive oedema keep the steroid pack for few days. Subsequent follow ups were after 2, 3 and 12 months to detect any

recurrence.

The after care is an important as surgery as there may be excessive crusting, causing nasal blockage, nasal bleeding, synechiae formation, recurrence of polyps. Excessive crusting will lead to poor visualization of operated area and detection

of residual polyps. Regular nasal douching with sodium chloride and soda bicarbonate compulsory

after FESS. Removal of crust and clots should be done whenever patients come for follow

up using endoscope.

Division of synechiae should be done in out patient if the synechiae is small

if it is large division under general anesthesia is necessary.

Treatment of infection using oral ciprofloxacin for two weeks.

In case of ethmoidal polyps oral steroid in the dose of

15 mg once a day (OD) for first seven days 10mg OD for seven days 5mg OD for next seven days reduce edema and to minimize or prevent the recurrence of polypes. Regular follow up for at least 2 years is necessary.

Conclussion Total number of FESS done from Oct 2003 - 2005 94. Some minor complications

Synechiae 15 patients Orbital eccymosis 8 patients Orbital fat pulled out 7 patients Recurrence of nasal polyp 7 patients.

FESS safe procedure with few complication in experienced surgeons hand but severe complications (blindness, orbital haematoma, CSF leak, carotid artery rupture) can occur if surgeon has little experience in FESS.

Recommendation

1.Study should be done in large series.

2.Long term follow up is recommended to know the late complications like recurrence of polypes after disease free interval.

THANK YOU

XIE-XIE

TERIMA KASIH

MERCI