Functional endoscopic sinus surgery (FESS), or functional endoscopic sinus surgery, is a procedure that is used to treat sinusitis and other conditions that affect the sinuses. Sinusitis is an inflammation of the sinuses that can cause symptoms such as congestion, headaches, and difficulty breathing through the nose.
FESS is a minimally invasive procedure that is performed using an endoscope, a thin, rigid tube with a camera on the end. The endoscope is inserted through the nostrils, allowing the surgeon to visualize the inside of the nasal passages and sinuses. The surgeon can then remove any tissue or obstruction that is blocking the sinuses, such as swollen or infected tissue.
FESS is generally considered to be a safe and effective treatment for sinusitis and other conditions that affect the sinuses. It can help to alleviate symptoms and improve the overall functioning of the sinuses. However, as with any medical procedure, there are potential risks and complications that should be discussed with a healthcare provider.
History
The first recorded instance of endoscopy being used for visualization of the nasal passage was in Berlin, Germany in 1901.
Alfred Hirschmann, who designed and made medical instruments, modified a
cystoscope
Cystoscopy is endoscopy of the urinary bladder via the urethra. It is carried out with a cystoscope.
The urethra is the tube that carries urine from the bladder to the outside of the body.
The cystoscope has lenses like a telescope or microscope ...
to be used in the nasal cavity. In October 1903, Hirschmann published "Endoscopy of the nose and its accessory sinuses." In 1910, M. Reichart performed the first endoscopic sinus surgery using a 7 mm endoscope. In 1925, Maxwell Maltz, MD created the term "sinuscopy," referring to the endoscopic method of visualizing the sinuses. Maltz also encouraged the use of endoscopes as a diagnostic tool for nasal and sinus abnormalities.
![TSESI](https://upload.wikimedia.org/wikipedia/commons/4/4a/TSESI.jpg)
In the 1960s,
Harold Hopkins, PhD at
Reading University
The University of Reading is a public university in Reading, Berkshire, England. It was founded in 1892 as University College, Reading, a University of Oxford extension college. The institution received the power to grant its own degrees in 192 ...
used his background in physics to develop an endoscope that provided more light and had drastically better resolution than previous endoscopes. Hopkins' rod optic system is widely credited with being a turning point for nasal endoscopy.
Utilizing Hopkins' rod optic system, Austrian doctor Walter Messenklinger visualized and recorded the anatomy of the paranasal sinuses and the lateral nasal walls in cadavers. Specifically, Messerklinger focused on mapping out mucociliary routes.
In 1978, Messerklinger published the book titled "Endoscopy of the Nose" on his findings, and his proposed methods to utilize nasal endoscopy for diagnosis.
Professor
Heinz Stammberger,
a
head and neck surgeon who worked at the University of Graz with Professor Messerklinger was captivated by the technique and the implications for pathophysiology and treatment of sinus disease. He adopted the technique and became identified with it. He travelled the world advocating and popularizing the technique and he carried out multiple courses both at University of Graz and around the world. He later met David Kennedy, MD, of
Johns Hopkins University
Johns Hopkins University (Johns Hopkins, Hopkins, or JHU) is a private university, private research university in Baltimore, Maryland. Founded in 1876, Johns Hopkins is the oldest research university in the United States and in the western hem ...
, and together, they worked with the surgical instrument maker, Karl Storz to develop instruments for use in endoscopic sinus surgery, and coined the term Functional Endoscopic Sinus Surgery.
Stammberger and Kennedy published multiple papers on FESS use and technique, and in 1985 the first North American course on FESS was taught at Johns Hopkins Medical Center.
Heinz Stammberger, the chair of
otolaryngology
Otorhinolaryngology ( , abbreviated ORL and also known as otolaryngology, otolaryngology–head and neck surgery (ORL–H&N or OHNS), or ear, nose, and throat (ENT)) is a surgical subspeciality within medicine that deals with the surgical a ...
at University of Graz, and Kennedy, refined the techniques and provided hands-on teaching courses on the techniques throughout the world. Professor Stammberger retired from his position as the chair of the department in Graz and moved to Dubai where he worked with Professor
Muaaz Tarabichi, also known as the father of
endoscopic ear surgery
Endoscopic ear surgery (EES) is a minimally invasive alternative to traditional ear surgery and is defined as the use of the rigid endoscope, as opposed to a surgical microscope, to visualize the middle and inner ear during otologic surgery. Du ...
, to establish TSESI: Tarabichi Stammberger Ear and Sinus Institute, a center dedicated to the advancement of endoscopic ear and sinus surgery. Professor Stammberger died in 2018.
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Medical applications
Functional endoscopic sinus surgery is most commonly used to treat chronic rhinosinusitis (CRS), only after all non-surgical treatment options such as antibiotics, topical
A topical medication is a medication that is applied to a particular place on or in the body. Most often topical medication means application to body surfaces such as the skin or mucous membranes to treat ailments via a large range of classes ...
nasal corticosteroids
Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex of vertebrates, as well as the synthetic analogues of these hormones. Two main classes of corticosteroids, glucocorticoids and mineralocorticoids, are involve ...
, and nasal lavage with saline solution
Saline (also known as saline solution) is a mixture of sodium chloride (salt) and water. It has a number of uses in medicine including cleaning wounds, removal and storage of contact lenses, and help with dry eyes. By injection into a vein it ...
s have been exhausted. CRS is an inflammatory condition in which the nose and at least one sinus become swollen and interfere with mucus drainage. It can be caused by anatomical factors such as a deviated septum or nasal polyps (growths), as well as infection. Symptoms include difficulty breathing through the nose, swelling and pain around the nose and eyes, postnasal drainage down the throat, and difficulty sleeping. CRS is a common condition in children and young adults.
The purpose of FESS in treatment of CRS is to remove any anatomical obstructions that prevent proper mucosal drainage. A standard FESS includes removal of the uncinate process, and opening of the ethmoid air cells and Haller cells as well as the maxillary ostium, if necessary. If any nasal polyps obstructing ventilation or drainage are present, they are also removed. In the case of paranasal sinus/nasal cavity tumors (benign or cancerous), an otolaryngologist can perform FESS to remove the growths, sometimes with the help of a neurosurgeon
Neurosurgery or neurological surgery, known in common parlance as brain surgery, is the medical specialty concerned with the surgical treatment of disorders which affect any portion of the nervous system including the brain, spinal cord and peri ...
, depending on the extent of the tumor. In some cases, a graft of bone or skin is placed by FESS to repair damages by the tumor.
In the thyroid disorder known as Graves' ophthalmopathy
Graves’ ophthalmopathy, also known as thyroid eye disease (TED), is an autoimmune inflammatory disorder of the orbit and periorbital tissues, characterized by upper eyelid retraction, lid lag, swelling, redness (erythema), conjunctivitis, and b ...
, inflammation and fat accumulation in the orbitonasal region cause severe proptosis
Exophthalmos (also called exophthalmus, exophthalmia, proptosis, or exorbitism) is a bulging of the eye anteriorly out of the orbit. Exophthalmos can be either bilateral (as is often seen in Graves' disease) or unilateral (as is often seen in ...
. In cases that have not responded to corticosteroid treatment, FESS can be used to decompress the orbital region by removing the ethmoid air cells and lamina papyracea. Bones of the orbital cavity or portions of the orbital floor may also be removed.
The endoscopic approach to FESS is a less invasive method than open sinus surgery, which allows patients to be more comfortable during and after the procedure. Entering the surgical field via the nose, rather than through an incision in the mouth as in the previous Caldwell-Luc method, decreases risk of damaging nerves which innervate the teeth. Because of its less-invasive nature, FESS is a common option for children with CRS or other sinonasal complications.
It has been suggested that one of the main objectives in FESS surgery is to allow for the introduction of local therapeutic agents (such as steroids) to the sinuses. Research has shown that a special modification of the nozzle of the nasal spray in patients who had FESS allows for better delivery of local therapeutic agents into the ethmoid sinuses.
Outcomes and complications
Functional Endoscopic Sinus Surgery is considered a success if most of the symptoms, including nasal obstruction, sleep quality, olfaction and facial pain, are resolved after a 1-2 month postoperative healing period. Reviews of FESS as a method for treating chronic rhinosinusitis have shown that a majority of patients report increased quality of life after undergoing surgery. The success rate of FESS in treating adults with CRS has been reported as 80-90%, and the success rate in treating children with CRS has been reported as 86-97%. The most common complication of FESS is cerebrospinal fluid leak
A cerebrospinal fluid leak (CSF leak or CSFL) is a medical condition where the cerebrospinal fluid (CSF) surrounding the brain or spinal cord leaks out of one or more holes or tears in the dura mater. A cerebrospinal fluid leak can be either crani ...
(CSFL), which has been observed in about 0.2% of patients. Generally, CSFL arises during surgery and can be repaired with no additional related complications postoperatively. Other risks of surgery include infection
An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable dise ...
, bleeding, double vision usually lasting a few hours, numbness of the front teeth, orbital hematoma, decreased sense of smell, and blindness. The medial rectus muscle
The medial rectus muscle is a muscle in the orbit near the eye. It is one of the extraocular muscles. It originates from the common tendinous ring, and inserts into the anteromedial surface of the eye. It is supplied by the inferior division of t ...
may be damaged. Blindness is the single most serious complication of FESS, and results from damage to the optic nerve during surgery. Serious complications such as blindness occur in only 0.44% of cases, as determined by a study performed in the United Kingdom. A Cochrane review
Cochrane (previously known as the Cochrane Collaboration) is a British international charitable organisation formed to organise medical research findings to facilitate evidence-based choices about health interventions involving health professi ...
in 2006 based on three randomized control trial
A randomized controlled trial (or randomized control trial; RCT) is a form of scientific experiment used to control factors not under direct experimental control. Examples of RCTs are clinical trials that compare the effects of drugs, surgical te ...
s concluded that FESS has not been shown to provide significantly better results than medical treatment for chronic rhinosinusitis. Another Cochrane review looked at postoperative care of patients after FESS using debridement (removal of blood clots, crusts, and secretions from the nasal and sinus cavities under local anaesthetic), but the evidence from the available clinical trials was uncertain. The debridement procedure after FESS may make little or no difference to health‐related quality of life or disease severity. There may be a lower risk of adhesions but whether this has any impact on long‐term outcomes is unknown. Functional sinus surgery had been grossly overutilized as a way of treating headache based on an assumption of a sinus etiology of the different types of primary headache. Many patients, primary care providers, and even specialists confuse any frontal migraine for sinus disease. Multiple attempts at further definition of primary headache and or sinus headache has been suggested by the International Headache Society and the American Academy of Otolaryngology-Head and Neck Surgery. It has been suggested early on that such a confusion might be a cause of failure of functional endoscopic sinus surgery.
References
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Endoscopy
Otorhinolaryngology
Sinus surgery