final fess
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BY:DR.PREETI .S. RAGA
II YEAR PG
DEPT. OF E.N.T
KIMS
Functional Endoscopic Sinus
Surgery(FESS)
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WHAT IS FESS? Trans nasal endoscopic Sinus surgery.
Minimally invasive surgical procedure performed with theaim of:
1.Re-establishing mucosal drainage channels
of PNS.
2. Re-establishing ventilation and mucocilliary
clearance of PNS thereby reversing the disease mucosa
to normal which occurs over a period of
time
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HISTORY
Endoscopy first performed by Hirschmann (1903)byusing a
modified Nitze cystoscope which he used in the nasal cavity and the
maxillary sinus via a tooth scoket.
Maltz-(1925) used the term sinoscopy and discribed techniques for
endoscopically examining the maxillary sinuses via both inferiormeatus and canine fossa routes.
HH Hopkins-(1950)-Professor of optics ,invented rod optic
telescope which now universally utilized for nasal endoscopy.
Rhinology and sinus surgery have undergone a tremendous
expansion since the discourses of Messerklinger and Wigand in the
late 1970s.
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Professor WalterMesserklinger the
Father of Modern
Sinus Surgery.
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Osteomeatal complex
This is a narrow anatomical region consisting of :1. Multiple bony structures (Middle turbinate, uncinateprocess, Bulla ethmoidalis)2. Air spaces (Frontal recess, ethmoidal infundibulum, middle
meatus)3. Ostia of anterior ethmoidal, maxillary and frontal sinuses.In this area, the mucosal surfaces are very close, sometimeseven in contact causing secretions to accumulate.
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Osteomeatal complex
Osteomeatal complex:bounded
1. medially: middleturbinate.
2. Laterally: the lamina
papyracea.3. superiorly and posteriorly:
the basal lamella.
4. The inferior and anteriorborders of theosteomeatal complex are
open.
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Mucociliary Blanket
Maxillary and frontalsinuses Mucosa or
mucociliary blanket
follows a genetically
predetermined pathwayfor drainage throughnatural ostium of sinuses
to nasal cavity.
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PRECHAMBERS
Ethmoidal infundibulum Frontal recess
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Advantages of FESS
Improves diagnostic accuracy. Excellent visualization.
Minimum bleeding.
Minimal trauma to vital structures.
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Diagnostic nasal endoscopy
1.To diagnose diseases of nose and PNS.2.To diagnose source of epistaxis.
3.To take biopsy.
4.To assess the medical and surgical results Method: First pass.
Second pass.
Third pass.
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First pass
In this the endoscope is introducedalong the floor of the nasal cavity.
Look for-
Status of inferior meatus and tubinate.
Patency of the nasolacrimal duct orifice.As the endoscope is advanced
posteriorly on the lateral surface of the
nasopharynx the pharyngeal end of
Eustachian tube, torus tubaris,
adenoids(if present) can be identified.
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Second pass
Accessory ostium isspherical in shape andorientedanteroposteriorly, while
the natural ostium ofmaxillary sinus is oval inshape and orientedtransversely.
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Third pass
The scope is gently slippedmedial to the middleturbinate.
The sphenoid ostium comes
into view.
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Indications
Recurrent rhino sinusitis that is resistant to adequate
medical treatment.
Fungal Sinusitis.
Multiple or recurrent Sinonasal polyposis.
Recurrent sinusitis caused by an anatomicalvariations.
Management of complications of rhinosinusitis.
Mucocele or pyomucocele.
Management of Epistaxis.
Excision of tumors.
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Extended use of FESS:
Dacryocystorhinostomy (DCR) .
Endoscopic repair of CSF leak.
Orbital decompression.
Optic nerve decompression.
Choanal atresia repair.
Trans-sphenoidal hypophysectomy.
Sphenopalatine artery ligation.
Trans-nasal endoscopic excision ofnasopharyngeal angiofibroma after
embolization of feeding vessel.
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Contraindications
Intraorbital complications or intracranialcomplications of acute sinusitis, such as1) orbital abscess
2) frontal osteomyelitis with Potts puffy tumor.
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Imaging Studies
A Para nasal sinus CT scan is often obtainedafter maximal medical therapy for chronicsinusitis in order to ascertain the contribution
of confounding factors. If surgery is to be performed, careful
preoperative review of CT scans is essential forsafe and complete performance of endoscopicsinus surgery .
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The use of CT-Navigation in Endoscopic
Sinus Surgery
A Computed Tomography (CT)Navigation
system is a tool that is used by surgeons to
better correlate surgical anatomy with pre-
operative CT imaging.
A computer is used to identify the 3-dimensionallocation of a probe tip placed within the patient's
nose or sinuses. The computer will then identify the spot on the
CT image where the surgeons probe is
placed.
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RECENT ADVANCES
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Surgical techniques
Messerklings technique:
anterior to posterior approach.
Wigands technique:posterior to anterior approach.
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INFUNDIBULOTOMY
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Incision on uncinate process
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Incision completed
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UNCINECTOMY
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MIDDLE MEATAL ANTROSTOMY
Antrostomy is broadly defined as,widening the natural ostium of maxillarysinus .
The opening should be made anteriorlyand inferiorly by Stammbergers backbiting forceps.
If accessory ostium is present should
be widened and combined with the
natural ostium.
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Natural & accessory ostia
exposed
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Middle meatal antrostomy
done
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ANTERIOR ETHMOIDECTOMY
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Opening of bulla ethmoidalis
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POSTERIOR ETHMOIDECTOMY
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Opening made on basal lamella
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Basal lamella removed
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Posterior ethmoidectomy
done
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SPHENOIDOTOMY
Sphenoidotomyis definedas:widening the
sphenoid ostium.
Ostium lies
approximately 1 to
1.5 cm above the
superior border ofthe choana.
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Anterior sphenoid sinus wall
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Interior of sphenoid sinus
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FRONTAL RECESS AND SINUS:
Are exposed using30 and 70 degree
endoscopes.
Agger nasi(anterior
most anerior
ethemoidal cells)are
removed to drain
frontal sinus throughfrontal recess.
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Frontal recess opened
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Final FESS cavity
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Complications
Bleeding. Synechiae formation.
CSF leak.
Orbital complication Hematoma.
Orbital injury.
Diplopia. Blindness.
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Postoperative Care
Nasal pack is removed 24hrs Systemic antibiotics and local decongestants
are given for 5 days
Topical steroids are given for 3 weeks
Regular follow up is done at 1st, 2nd, 4thpostoperative weeks.
At each visit cavity is cleaned under
endoscopic guidance
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Conclusion
The procedure should be Tailor made to suitthe individual patient and the sinuspathology.
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THANK YOU
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