Functional Endoscopic Sinus Surgery (FESS)

Sinusitis is the inflammation and/or infection of the nasal sinuses (air pockets in the skull). It can be acute or chronic. Acute sinusitis is often resolved via medication. However, when acute sinusitis is recurrent or when the infection becomes chronic sinus surgery is advised.

Functional Endoscopic Sinus Surgery or FESS is a modern, minimally-invasive surgical procedure used to treat chronic or recurrent sinusitis. It involves using a flexible telescoping camera that is inserted through the nostril to visualise the internal anatomy of the sinuses. Using special instruments, the air cells are made larger so that more air flows in and the secretions produced in the air pockets can easily be drained out naturally.

Indications of the surgery are:

• Chronic and recurrent sinusitis, which is not getting controlled by medication
• Nasal polyps (a small protruding benign outgrowth of nasal tissues) in various areas of the nose and sinuses
• Nasal bone reconstruction due to a deviated nasal septum or trauma to the nose
• Removal of selected tumours in the nose and surrounding areas
• Orbital decompression (seen in people with hyperparathyroidism)
• Cerebrospinal fluid (CSF; brain fluid) leak closure
• To treat recurrent epistaxis (nose bleeding)
• To remove foreign bodies from the nose
• Dacryocystorhinostomy (to create a new passage for tears to drain from the eyes to the nose when the natural passage is blocked or diseased)

(Read more: Home remedies for sinusitis)

FESS is relatively contraindicated in the following scenarios:

• When the disease has spread from the sinuses to the surrounding structures, such as the brain or eyes
• If any malignant tumour has spread to the surrounding structures
• In individuals with pre-existing illnesses, such as diabetes, where the risk of surgery and anaesthetic complications increases along with a prolonged recovery period. Hence before the surgery, these conditions are to be kept under control

(Read more: Ayurvedic treatment for sinusitis)

FESS is usually done by an ENT surgeon.

A detailed history of the patient is taken which includes the symptoms of the patient, history of any other illnesses (comorbidities) and medication history. A physical local examination is done to help assess the issues that are to be corrected, for example, a deviated nasal septum may be the cause of recurrent sinusitis.

Medications for any pre-existing conditions may be altered or stopped as per the surgeon's orders before the surgery.

Investigations before surgery include:

• Complete blood count (CBC): to check the haemoglobin status and severity of infection
• Liver function tests and kidney function tests
• Coagulation profile
• Chest X-ray
• ECG
• An X-ray of the head will be taken in specific views to see the sinuses. In chronic sinusitis, certain changes are seen
• Head CT or MRI scan of the head: this helps accurately determine the exact location of the infection, the extent of spread of the disease and the surrounding structures the disease has affected.

The patient may require a couple of days of hospital stay.

Prior to the day of the surgery, the patient is told to fast overnight. On the day of the surgery, the patient arrives at the hospital with all the relevant investigations and documents and gets admitted. The patient changes into the hospital attire and a final review of the patient is done by the surgeon and nurses before clearing for surgery.

Written consent is taken from the patient after the surgeon has explained the technique of the surgery and the associated risks and complications. Any facial hair, if present, is shaved off to ensure a clean operation field. Nose hair is also trimmed. Thereafter, the patient is shifted into the operation theatre (OT).

The patient is asked to lie down supine (on their back) on the operating table. The head is elevated slightly to ensure better access to the operating field. A monitor is attached to track vitals (heart rate, blood pressure, oxygen saturation). An IV cannula is inserted through which medications for the procedure will be administered. The procedure is usually done under general anaesthesia.

Once the patient is unconscious, the surgeon passes a flexible camera through the nostril into the nasal cavity. The camera helps navigate through the nasal cavity and helps identify the structures that are diseased and require treatment. Using special tools, the diseased area is resected. The sinuses present in the bone are enlarged so that there is better clearance of the secretions formed in the sinuses.

Additionally, depending on the requirement, FESS is also used to treat:

• Nasal polyps
• Resect tumours
• Repair the base of the skull to stop CSF leakage
• Relieve pressure in the eyes by performing orbital decompression
• Remove foreign bodies
• Fix a deviated or broken nasal septum

The procedure takes about 1-3 hours for completion depending on the type of extent of surgery performed. After the surgery, the nose is packed with medicated gauze to stop the bleeding.

The advantages of FESS over other surgical methods are:

• Increased visibility: The endoscopic procedure gives the surgeon an enhanced ability to see within the nose and sinuses.
• Less invasive: FESS is performed through the nostrils, so there will be no outside scarring or evidence that surgery has been performed.
• Faster recovery: since the procedure is less invasive and shorter in duration, post-operative recovery is faster.
• Less pain: Since the surgery is less invasive, it causes less pain.
• Healthy tissue is preserved: The precision offered by FESS allows healthy nasal and sinus tissues to be preserved.
• Long-lasting relief: Since FESS is used to enlarge the nasal and sinus pathways and remove blockages, it provides significant, long-lasting relief from chronic sinusitis and its symptoms.
• Less reliance on medication: the patient will be able to stop taking medication or may be able to reduce the amount they need, thereby reducing the side effects of the medication.

(Read more: Homeopathic treatment for sinusitis)

Risks associated with FESS are rare but serious and include the following:

• Bleeding
• Injury to the eye or orbit that may result in double vision or loss of vision
• Injury to the brain or skull resulting in CSF leak
• Decreased sense of smell
• Injury to nasal bones
• Anaesthesia related complications

After the surgery, the patient is shifted from the OT and kept in an observation room for a few hours. The pain and swelling are controlled via analgesics. Here, the patient is also checked for postoperative bleeding.

Once the patient is stable, they are shifted into the ward. The head end of the patient is elevated so that the patient does not feel dizzy or nauseous. Some blood and mucous will be present as a postnasal discharge, which is normal. The nasal pack is checked for excessive soakage and is replaced the next day before the patient is discharged.

A discharge summary is prepared by the doctor that contains relevant medications and advice on wound care. These typically include

• Continuation of medication for pre-existing conditions, if any.
• Antibiotics and analgesics to prevent infection and pain, respectively. Topical preparations/ointments may be prescribed.
• Avoid blowing the nose for a week since it can irritate the healing nasal tissue.
• To sleep with the head raised to prevent pooling of secretions of the healing tissue and to prevent headache and nausea.
• Application of saline nasal sprays which help minimise the bleeding over time and also prevent excessive crusting in the nose.
• Once the normal sinus drainage is established the patient may blow out thick bloody mucous. This is normal.
• Ice packs can be applied two to three times a day to reduce the swelling and the bleeding

The doctor should be notified if the patient experiences any of the following symptoms:

• Excessive pain or swelling
• Excessive bleeding
• Decrease in sense of smell
• Visual problems, such as loss of vision or double vision
• Excessive watery discharge, suggestive of cerebrospinal fluid (CSF) leak
• Pus discharge from the nose, suggestive of infection
• Fever

The first follow-up visit usually occurs two to three days after discharge, when the nasal packing is removed. Subsequent visits are as per the surgeon’s advice to see the progression of healing.

Full return of nasal function and complete healing takes four to eight weeks depending on the complexity of the procedure performed. It is to be noted that in some cases despite having had surgery, the patient is still prone to develop sinusitis although the severity is much less. Hence, the medical treatment is continued in these patients.

Functional endoscopic sinus surgery is a modern, minimally-invasive surgical procedure commonly performed when medical management of chronic sinusitis fails. It is also used to treat various other pathologies of the nearby structures. The procedure is short in duration with extremely favourable results and limited complications. Postoperative recovery is often smooth and uneventful and the patient usually has a good remission from the disease. However, in some patients, medical treatment may be required even after surgical management.