Functional Endoscopic Sinus Surgery (FESS)

Functional Endoscopic Sinus Surgery (FESS)

The sinuses are air filled spaces in the skull. Most people do not realize these spaces exist in the skull until a problem develops, and they begin to experience the symptoms of sinusitis.

There are four pairs of sinuses - one pair over the cheeks (maxillary), forehead (frontal), between the eyes (ethmoid), and a last pair deep in the center of the head (sphenoid). The sinuses are connected to the nose, and nasal cavity by way of small openings called ostia. Except for the ethmoid sinuses between the eyes, the other sinuses are poorly developed at birth. They normally commence development in later childhood to attain their adult size at the onset of puberty.

Interestingly, no one fully understands the purpose for the existence of the sinuses. One explanation is that the sinuses, being air filled spaces, cause the skull to weigh less than if it had consisted of solid bone. Another reason may be that the sinuses act as a protective buffer zone in injuries of the face, by preventing force from being transmitted to the vital structures in the skull. Whatever its benefits, one thing is for sure - the sinuses can be the cause of a lot of trouble.

Individuals who do not have a particular sinus will not develop sinusitis in that area. For example, ten percent of people in the general population will have small underdeveloped frontal sinuses. This makes it impossible for them to suffer from the severe headaches of frontal sinusitis.

Mr. Warren first realized how troublesome sinusitis can be when he first contracted the infection two years ago. The symptoms first started as a flu, which caused a blocked nose, runny nose, and pain over the cheeks. The pain got worse, and reached a crescendo 3 days later, when it was so painful that he was unable to go to sleep. He would wake up in the mornings feeling that he had not slept at all. The pain of the cheeks has also extended to involve the forehead, and the top of his head. By this time, his nose was s blocked that he had to open his mouth to breath. He would wake up the next day with a very dry, and sore throat. Furthermore, he could not enjoy his meals as his sense of smell, and taste had gone. Initially he thought that the symptoms would go away in a week. However, when the symptoms continued to persist, and his ability to work was affected, Mr. Warren became desperate.

Over the next few months, he went around consulting many different doctors and was given a myriad of different medications. One of the doctors he consulted decided to perform an endoscopic examination of his nose, and found some swelling on the side wall of both noses. He went through a computed tomographic scan (CT scan) which demonstrated that he had sinusitis of both his maxillary and frontal sinuses. Sinus surgery was performed under general anesthesia. One week later, his symptoms of pain, sore throat, and inability to smell had disappeared. Since then, he has been enjoying very restful and peaceful nights of sleep. Fortunately, many people suffer from sinusitis, but few need surgery for resolution of their symptoms. Most sinusitis can be treated with medications like antibiotics, decongestants and antihistamines. Others may need simple outpatient procedures like a washout of their sinuses to flush away the pus and to open up the sinus ostia.


The most common cause of sinusitis is allergic rhinitis (allergy of the nose), which accounts for up to 80% of sinusitis cases. The allergic response occurs as a result of an over-exaggerated response by the body's immune system to substances that enter the body from the outside environment. The reaction causes the lining of the nose to become inflamed, and swell up (rhinitis), resulting in obstruction of the sinus ostia, and poor drainage of the sinuses. Secretions build up, acting as a good growth medium for bacteria, allowing them to flourish in an unimpeded fashion within the sinus. Pus forms, and accumulates under pressure, allowing some of it to squeeze, and escape through the narrowed ostium into the nasal cavity. This gives rise to the yellow nasal discharge that is seen in sinusitis.

Sinusitis can have a variety of other causes. The common final pathway by which all these other diseases cause sinusitis is through obstruction of the sinus ostia resulting in poor sinus drainage. Thus, deviation of the nasal septum, foreign bodies, cancer and nasal polyps can cause obstruction to the sinus ostia, giving rise to sinusitis. As allergic rhinitis is the most common cause of sinusitis, it is imperative that an allergic process is assumed, and the offending allergen searched for in all cases of sinusitis. The allergen, or the substance that causes allergy, can come into our bodies through the air that we breathe in or from the foods that we eat. Inhalant allergens, or the allergic substances that we are exposed to in the air, is tested very simply through a blood test. This is sent to an allergy laboratory for analysis.

Testing for food allergens, however, can be a little bit more cumbersome. This is because food allergens are tested using a series of skin tests, which may require half a morning or more for its completion. If the offending inhalant or food allergen is identified, and the appropriate treatment measures taken, a dramatic improvement in sinusitis usually occurs, obviating the need to medications, antibiotics and surgery.

In those patients who are unable to benefit from anti-allergic measures, and medications, surgery becomes an important consideration in management. The most simple form of surgery is a sinus washout done under local anesthesia in the outpatient setting. The check sinuses are irrigated to wash out pus within the sinus, and to open up the ostia by forcing the irrigation fluid through it. Other procedures include the Caldwell-Luc operation which involves opening up the cheek sinuses through a hidden incision underneath the upper lip. With the recent advent of the Hopkin's endoscopic rod, we are now entering a new era of improved visualization of the body's interior, and minimally invasive key-hole surgery. The endoscope enables us to make more accurate diagnosis of the causes of sinusitis, and to identify new disease processes which could not have been identified before. It has also enhanced our ability to perform sinus surgery by peering through the nostrils instead of having to make unsightly facial incisions.

The new sinus operation that is done through the endoscope is called Functional Endoscopic Sinus Surgery (FESS), pronounced "fest" as in "food-fest". It is an operation that is done on the sinuses using an endoscope with the objective of restoring normal function to the diseased, and obstructed sinuses. Since its debut into the medical world in the 1970s, its has been gaining widespread popularity among Ear Nose Throat Surgeons worldwide. This stems from the fact that many surgeons recognized the great leap forward that Functional Endoscopic Sinus Surgery (FESS) enabled them to make. Functional Endoscopic Sinus Surgery (FESS) gave surgeons the power to see, and operate better in the little confined spaces of the nose, and sinuses to achieve the objectives of diseases resolution and symptom improvement in an more effective way.

Many new refinements have also been made with Functional Endoscopic Sinus Surgery (FESS) surgery. In the past, FESS surgeons had to peer directly into the endoscope by leaning over the anaesthetized patient lying on the operating table. Surgeons tired out easily as they were operating in an uncomfortable, and awkward position. Many began to develop neck ache from the many hours straining the neck during FESS surgery. Nowadays, doctor are doing their operations through a video attachment to the endoscope that allows surgeons to look at a video monitor. It is less of a physical strain. The Functional Endoscopic Sinus Surgery (FESS) surgeon can spend a longer time on the operation without tiring out. This translates into increased safety, and better outcomes for the patient.

Another refinement is to use a microdebrider during FESS surgery. The microdebrider is a surgical instrument that works like a hybrid between a vacuum cleaner, and a grass cutter. The cutter chops off unwanted abnormal tissues while the vacuum cleaner sucks it away from the area of operation. The microdebrider has the advantage of allowing the surgeon to remove diseased tissue in a precise manner, cutting it sharply, without tearing, and shearing that would have occurred with conventional sinus surgery instruments. This reduces unnecessary damage to the sinus tissues, resulting less scarring, and better healing.

During surgery, blood accumulation in the operating site cause blurring and reducing visibility with potentially disastrous consequences. Especially in the enclosed confined spaces of the sinuses, complications resulting from such a lack of visibility is exponentially magnified. The microdebrider allows timely, and 'on-line' removal of blood, and tissue, keeping the operation site clean so that the Functional Endoscopic Sinus Surgery (FESS) surgeon can proceed safely, and smoothly under conditions of good visibility.

What about the laser? Does it offer any benefits or advantages in Functional Endoscopic Sinus Surgery (FESS) ? Unfortunately, while the laser is indispensable in certain procedures, the tongue for instance, it has no real advantage in sinus operation. In fact, the laser may actually increase surgical risk when used in conjunction with Functional Endoscopic Sinus Surgery (FESS). It may cause inadvertent laser burns, and damage to important nearly structures around the sinuses, like the eye, brain and carotid vessels.

Functional Endoscopic Sinus Surgery (FESS) is still in the process of evolving. Controversy, and changing opinions continue to characterize its present state of knowledge. It will be quite a long time more before all the relevant issues are sorted out for it to become a "mature" operation. The medical world is till on the learning curve with newer, and better instruments and techniques coming onto the market in an attempt to improve patient safety and surgical outcome.

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