Sinusitis-Functional Endoscopic sinus surgery

What is Sinus?

Human skull contains four pairs of hollow air filled cavities connected to the space between nostril and nasal passage; these are called Sinuses (or Para Nasal Sinuses). Sinuses help insulate the skull, reduce its weight and add resonance to voice.

There is 4 major pair of Sinuses–

  • Frontal (in the forehead)

  • Maxillary (behind the cheek bones)

  • Ethmoid (between the eyes)

  • Sphenoid (behind the eyes)

Most of the sinuses drain into a key area (Osteo-Meatal complex). Thus treatment of sinusitis is focused on this area.

What is Sinusitis

Infection of Sinuses is called Sinusitis–acute or chronic based on the time span. Sinusitis may be caused by anything that interfere with airflow into the sinuses and mucous drainage out of the sinuses, usually follow a viral infection, allergy, or irritants. Most common bacteria involved are streptococcus pneumonae, Haemophilus influenzae, and moraxella catarhalis.

How to Diagnose Sinusitis? Symptoms of Sinusitis

Symptoms depend on which sinus is involved–usually present with

  • Nasal congestion and discharge or post nasal drip

  • Headache, or facial pain/pressure , or pain under or around the eyes

  • Fever

Chronic sinusitis may present with

  • Reduced /absent smeel sensation (anosmea)

  • Fever and bad smeel from mouth (halitosis)

  • Cough (worse when lying down)

How to Treat Sinusitis

Maxillary sinus is most commonly involved followed by ethmoid,frontal and sphenoid.

Aims of management are:

  • To achieve normal healthy sinuses

  • To decrease duration of the symptom

  • To prevent complications

  • To prevent development of acute sinusitis

Most patients of acute sinusitis can be benefitted without many investigations as diagnosis is mainly clinical.

Nasal Endoscopy for proper visualization of nose and sinuses is important for appropriate management. Endoscopic assessment of nose guide therapy and at the same time accurate pus-swab can be obtained for bacteriological examination.

Sometimes if symptoms persist for longer duration further investigation may be required like examination of mucocilliary mechanism, allergic and immune status of patient and computerized tomography (CT scan) of sinuses.

Medical Management of Sinusitis

Analgesics, antibiotics and decongestants are given to reduce swelling and thus increase clearance and drainage from the sinuses.

Antibiotics studies have confirmed that acute bacterial sinusitis treated with antibiotics have more rapid resolution of symptoms.

Antibiotics should be effective and should cover wide range of organisms.In general antibiotics are required for 10 days but in some cases especially recurrent cases up to 2 weeks course may be given.

Usually amoxicillin, ampicillin, co-amoxyclav and cephalosporins are primary drugs of choice. If first line drugs fail then second line treatment is based on culture and sensitivity report of pus aspirated from sinuses by antral lavage…

Nasal Decongestant Drops : Nasal decongestant or steroid drops or sprays are used to decongest sinus osteum and thus encourage drainage.

Clinicians prefer long acting preparation because of less rebound phenomena. Topical decongestant drops should not be used for long duration as it back fires and person develops “rhinitis medicamentosa.”

Oral Decongestant or Mucolytics : may be used to reduce mucosal inflammation. In general antihistamines are to be avoided in acute bacterial sinusitis because it will thicken and dry the secretion.

Analgesics : any suitable and safe pain killer medicine acetaminophen or ibugesic are prescribed to relieve pain.

Steam Inhalation : plain water or medicated steam with menthol provides relief from symptoms and helps in improving sinus drainage.

Hot Fomentation : application of warm cloth, hot water bottle or gel pack to face for 5-10 minutes relieves pain and inflammation to some extent.

Saline Irrigation : nose and sinuses should be washed by ¼ tsf salt in 1 cup water using bulb syringe or commercially available saline nasal sprays can be used.

  • Avoidance of allergy if any

  • Use of Humidifier

  • Avoidance of Irritants

Surgical Management of Sinusitis

Usually acute sinusitis is treated by medicines. Most cases of acute maxillary sinusitis resolve with effective and proper medical management. Very rarely when medical treatment fails surgical approach is required.

Surgical treatment is reserved for

  • Failure of medical management

  • Severe Pain

  • Impending complications

Antral lavage

This is opd procedure under local anaesthesia where medial wall of maxillary sinus is punctured in the region of inferior meatus, sinus is drained and irrigated. Now this technique is rarely employed and endoscopic enlargement of middle meatus is preferred.

Frontal sinuses wash outs

This is done in general anaesthesia. Small incision is given below eyebrow medially.

Functional Endoscopic sinus surgery

FESS procedure

Endoscopic surgery is minimally invasive surgery. It does not require any skin cut and done by endoscope inserted through nose.

Endoscope is attached to a light and camera. ENT Surgeon operates inside nose while visualizing magnified images from nose and sinuses on the monitor.

Procedure can be done under General anaesthesia or local anaesthesia.

Goal of sinus surgery is to eliminate physical blockage of the sinuses and nose and to enlarge sinus openings. ENT surgeon removes diseased mucosa, polyps, cysts.

ENT surgeon opens drainage pathway of sinuses usually in following sequence

  • Uncinectomy and Middle meatus antrostomy- view maxillary sinuses

  • Anterior and posterior ethmoidectomy

  • Spehnoidectomy

  • Frontal sinus work

  • Hemostasis is achieved

  • Nasal cavity packed.

Indications for Sinus Surgery- FESS

  • Recurrent sinusitis or chronic sinusitis not responding to medicine

  • Patient with nose block and facial pain/heaviness

  • Anosmea (NO Smell sensation)- may improve.

  • Nasal Polyposis

  • Nasal Mass

  • Antrochoanal polyps

  • Sinus Mucoceles

  • Cerebrospinal fluid (CSF) leak closure

  • Orbital decompression

  • Optic nerve decompression

  • Dacryocystorhinostomy (DCR)

  • Choanal Atresia repair

  • Epistaxis control

Preparation for Sinus Surgery

  • CT scanning and prior course of antibiotics/steroid is must before surgery.

  • Blood thinner/smoking to be stopped 3-7 days prior to surgery

  • Pre surgery investigations are done, fitness for anesthesia and surgery may be taken

  • Fasting is required 6 hours prior to surgery

Post op FESS What to expect?

Avoid nose blowing/sneezing with mouth closed.

Food: Liquid and soft diet at room temperature for first day, normal diet can be resumed second day onwards.

Medicine: Pain killers such as acetaminophen given after surgery for 1-2 days. Ibuprofen and Aspirin are avoided for 2 week after surgery.

Antibiotics are given for 7-10 days to prevent any infection.

Saline nasal spray are given to clear nasal crusting , rinsing of nose is done by nasal spray 3-4 times a day 3 days after surgery.

Pain: headache, and facial pain is common for 1-2 days after surgery.

Bruising/puffiness around eyes

Blood mixed Nasal discharge: for 1-2 days it may be red which slowly will change to brownish and may be present for 2 wks.

Nasal congestion: there may be stuffy nose for 7-10 days after FESS.

Activity: There are no activity restrictions but swimming are to be avoided for 2 wks.

Heavy weight lifting and strenuous activity should be avoided for 7-10 days after endoscopic sinus surgery.

Nasal congestion: Flying to be avoded 3-4 days after surgery.

Return to work and desk job may be in 3-4 days time when patient is without any pain medicine.

Follow up visit: If nasal packing is done, a follow up visit 2 days to remove nasal pack is required.

Next visit in 5 days and 10 day following surgery is necessary to remove crusts from nose and sinuses.

Further follow up visit may be schedules as required in 2-6 wks.

One thing to be remembered-meticulous postoperative cleaning is equally important for success as is the expertise of surgeon.

Complication of FESS (Endoscopic Sinus Surgery)

Bleeding- Risk of bleeding though less then conventional but it may be there at times. Failure or Recurrent disease: Disease may not be cured by the operation or may re occur at later date. Subsequent medical management may be required. Cerebrospinal fluid (CSF) leak: rare complication, but it may extend hospital stay and require further surgery to repair leak Loss of vision: extremely rare

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