Scope of Functional Endoscopic Sinus Surgery

What Is the Scope of Functional Endoscopic Sinus Surgery (FESS)?

Endoscopic sinus surgery (ESS) is now a fundamental or core surgical procedure or treatment modality that was initially considered by otolaryngologists and surgeons only for the treatment of chronic rhinosinusitis. But with the rapid pace in sophistication and recent technology, since it was first introduced, indications now exist for several head and neck pathologies, including serious cancers.

Rhinosinusitis is a major inflammatory process or a pathologic sinus condition that impacts the paranasal sinuses. It may be grouped or categorized mainly based upon the duration or time span of these inflammatory processes:

• Acute Cases of Rhinosinusitis: Exist for less than four weeks.

• Subacute Rhinosinusitis: Exists between 4 to 12 weeks.

• Chronic Rhinosinusitis: Exists for longer than 12 weeks.

Endoscopic sinus surgery is considered a safe stepwise technique that addresses all the paranasal facial sinus pathologies and provides a good result in the long term. Initially, it was used only for treating chronic rhinosinusitis. With the recent advent and popularization of balloon sinuplasty as a less invasive and minimal dilatation surgery for sinus drainage in chronic rhinosinusitis, endoscopic sinus surgery is no longer the only option for surgeons to address chronic and extensive cases of rhinosinusitis. However, endoscopic sinus surgery is considered a wide and safe guide path, not just for the sinus pathologies but also when the lesions or pathology persists past the boundaries of the structure beyond the facial sinuses.

What Are the Goals of Functional Endoscopic Sinus Surgery?

The concept of functional endoscopic sinus surgery, as it is called in the medical or surgical literature, stems from the origin of Messerklinger's studies. This research focuses on mucociliary clearance and the lack of it as the leading factor in the pathogenesis of sinusitis. The goal of functional endoscopic sinus surgery (FESS) is to enlarge the sinus Ostia as well as restore the healthy aeration of the paranasal sinuses of the face and skull. The goal of the surgery would be to improve mucociliary transport and provide better aid for accessory topical therapies to promote faster healing in patients with both moderate and extended sinus pathologies.

What Are the Indications of Functional Endoscopic Sinus Surgery?

The main indications of ESS or Endoscopic sinus surgery are in the below-enlisted conditions majorly:

• Chronic Rhinosinusitis (CRS).

• Cancers of the pituitary gland (pituitary gland tumors).

• Defects of the skull base.

• Sinonasal tumors or cancers.

• Complicated or extensive cases of the acute form of rhinosinusitis.

• Mucoceles of known or unknown etiology.

• Invasive or non-invasive forms of fungal sinusitis.

• Silent sinus syndrome.

• In individuals with cerebrospinal fluid leaks.

• Benign or non-cancerous sinonasal tumors.

• Ventral lesions of the skull base.

• Lesions extending or of the petrous apex.

• Lesions of the pterygomaxillary fossa.

Endoscopic sinus surgery is also a very standardized and recommended procedure by most maxillofacial surgeons and otolaryngologists for extensive or long-spread severe cases of malignancies within the nasal and paranasal spaces or tumors that extend through the anterior skull base that would be life-threatening and possess the potential for distant metastasis.

What Is the Principle of Functional Endoscopic Sinus Surgery?

Functional endoscopic sinus surgery depends on the principle or technicality of endoscopic removal of the sinus pathology, lesion, or disease from the key areas, mainly in the anterior ethmoid and middle meatus region. In addition, this procedure can also offer the scope or possibility of performing sphenoethmoidectomy along with the preservation of the middle turbinate area.

Extracranial or intracranial complications are also common in patients who suffer from an acute attack of rhinosinusitis. In accordance with traditional research by Chandler's classification, as per the order of increasing severity or the potential sequelae of extracranial or intracranial complications, several extended pathologies would also be indicated for functional endoscopic sinus surgery. These are cellulitis, cellulitis of the orbits, subperiosteal abscess, orbital abscess, and cavernous sinus thrombosis.

Especially in cases of orbital cellulitis, functional endoscopic sinus surgery is mainly considered because the patient complains of visual impairment due to increased intraocular pressure. Also, functional endoscopic sinus surgery is suitable for any localized and irreversible disease that occurs in the maxillary sinus. The disease may therefore be removed endoscopically with very minimal trauma. Maxillofacial surgeons and otolaryngologists hence find this technique useful in terms of excellent visualization of the sinus pathology and also due to the minimal morbidity. The application of this procedure hence is beneficial highly for even managing sinus tumors and extended pathologies beyond the sinuses originating from them. However, the most common indication for functional endoscopic sinus surgery always remains chronic rhinosinusitis, for which it is a deemed gold standard technique for surgeons.

What Are the Contraindications of Functional Endoscopic Sinus Surgery?

The contraindications for functional endoscopic sinus surgery are :

• Patients who are in general contraindicated for either general or local anesthetic procedures prior to surgery.

• Lesions or oral pathologies that extend exclusively into the palate without any involvement of the paranasal sinuses.

• Lesions or tumors only of the skin or the soft tissues.

• Lesions or tumors exclusively penetrating laterally into or above the orbit region.

• In lateral recess lesions of the frontal sinus.

• In tumors or lesions that have an extended or advanced intracranial spread (in these severe cases that significantly extend into the cranium or the cranial base, surgeons may recommend a combined surgical approach of both endoscopic and open method approaches).

What Are the Post-Operative Protocols for Functional Endoscopic Sinus Surgery?

Postoperative care, as recommended by the surgeon, forms an essential protocol for the efficacy of this applied technique to decrease the rate of repeated risk of recurrence in chronic rhinosinusitis patients. In addition, your healthcare provider may also further recommend accessory medical therapy like nasal rinsing, application or intake of topical or oral corticosteroids, and post-operatively prescribed antibiotics in order to reduce the recurrence risk and inflammation.

Conclusion:

To conclude, endoscopic sinus surgery is a fundamental and gold standard treatment strategy adopted by most surgeons to target sinus pathology and also is the gold standard for treating chronic rhinosinusitis (CRS) despite the advent of procedures like balloon sinuplasty for complete elimination or to eliminate the recurrence risk of the lesions.