FUNCTIONAL ENDOSCOPIC SINUS SURGERY (FESS)

Most people who undergo endoscopic sinus surgery do so as part of the treatment of chronic sinus problems that have not responded to maximal medical therapy.

Symptoms of sinus disease include facial pain or pressure, a blocked nose, a decreased sense of smell, a persistent foul smell in the nose or nasal discharge.  Less commonly sinus problems cause headaches, hoarseness, cough and a variety of other symptoms.  For this reason sinus problems are frequently confused with other medical conditions.

Most people with sinus problems can be successfully treated medically, without the need for surgery.  Prolonged courses of antibiotics, often in association with Prednisone, nasal sprays, and saline irrigations, are frequently effective.

Treatment of underlying allergies and avoidance of exposure to environmental triggers such as cigarette smoking may also be helpful.  The medical treatment chosen will depend on my assessment of the cause.

If the above medical therapy fails or you have a problem which is clearly not amenable to medical therapy, then surgery may be required.

The Operation

The operation will usually be performed under general anaesthetic.  General anaesthetic carries minimal risk in otherwise healthy patients.  You will have the chance to discuss this with your anaesthetist pre-operatively.

I will usually prescribe Prednisone and antibiotics around the time of the surgery as this improves the results.  In some cases the surgery can be performed on an outpatient basis without the need for nasal packing.

The surgery is done with the use of an endoscope. The principle of the surgery is to unblock the obstructed openings (ostia) of the sinuses, to allow drainage of secretions, and to allow air to enter the sinuses (i.e. for ventilation of the sinuses)- this returns the sinuses to normal health

General points – after surgery

• There is usually mild pain only – Paracetamol and an anti- inflammatory should be sufficient in most cases.
• Packing of the nose is usually required for the first night  postoperatively- the packing is removed the next morning.
• A blocked nose is common for 2-4 weeks due to swelling and crusts, which improves after cleaning at the postoperative visit(s).
• Healing takes approximately 6-12 weeks to be complete, longer if there is postoperative infection.
• There is usually some bleeding for several days after surgery,  and after each cleaning.
• Thick brown mucus may drain from the nose for 3-4 weeks or more.
• Avoid hard nose blowing for 4-7 days following the surgery.
• Saline irrigations will help to clear clots and mucous.  A syringe or saline squeeze bottle and advice regarding saline irrigations will be provided.
• Take antibiotics and/or Prednisone as prescribed.
• Usually patients require 7-10 days off work.
• Avoid bending, lifting and straining for 3 weeks after surgery.  Exertion may precipitate bleeding.

A follow-up visit is arranged one to two weeks after the surgery to clean crusts from the surgical site.  Further follow-up visits are arranged at approximately weekly or fortnightly intervals until the area is healed at around 6 – 8 weeks.  At each of these visits and at subsequent follow-up examinations, any persistent scar tissue may be removed under local anaesthetic.

Results of Surgery

Sinus disease is usually due to a complex combination of structural, mucosal (lining) and environmental factors.  In general, FESS is successful in up to 80% of patients.

In some patients, there will be persisting disease, which requires ongoing medical treatment.  Allergic mucosa may require the permanent use of nasal corticosteroid sprays.  Severe polyposis with sinusitis has a high rate of recurrence (>50%).

Risks of Surgery

Although there are potentially very serious risks from surgery in this area, the incidence is very low.

1] Bleeding – Bleeding is a potential risk in all forms of sinus surgery.  Although the risk of bleeding appears to be reduced with the endoscopic technique, on occasion significant bleeding may require stopping of the procedure and placement of nasal packing.  Bleeding following surgery may also require the placement of packing and hospital admission.  Blood transfusion is very rarely required.

2] Post-operative discharge – Blood-stained nasal discharge may occur for approximately three weeks after the procedure.  This is normal and slowly improves.

3] Cerebrospinal fluid leak – This is a rare complication (<1% of all sinus surgery patients).All operations on the sinuses carry a risk of intra-cranial penetration, which may result in a leak of cerebrospinal fluid (or CSF, the fluid that surrounds the brain).  Should this rare complication occur, it creates a potential pathway for infection which could result in meningitis.  This would extend your hospitalisation as further surgery would be required for closure of the leak.

4] Visual problems– these complications are extremely rare, though double-vision and loss of vision have been reported in the literature

5] Other risks – Watering of the eye can occasionally result from sinus surgery or from sinus inflammation.  This is usually temporary but can be persistent and may require surgery to correct it.  Swelling or bruising around the eye may occur and blowing the nose in the post-operative period may result in a temporary collection of air under the skin causing facial swelling for a period of time.

Septoplasty – In some cases, it may be necessary to straighten the nasal septum at the time of surgery.  This is usually done to allow access to the sinuses during the operation.  A separate blog is available regarding this procedure.

A follow-up visit is arranged one to two weeks after the surgery to clean crusts from the surgical site.  Further follow-up visits are arranged at approximately weekly or fortnightly intervals until the area is healed at around 6 – 8 weeks.  At each of these visits and at subsequent follow-up examinations, any persistent scar tissue may be removed under local anaesthetic.

YOUR CONSULTATION

If you have troublesome sinusitis which has been resistant to medication, please call 031 201 3118 for an appointment.

A complete history of your problem will be taken, followed by a thorough examination of the nasal passages (including nasal endoscopy). A CT scan of the sinuses may be required for further information.

Further management will depend on the clinical findings, and will be in keeping with best ENT specialist practice guidelines.