final fess

8/13/2019 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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