Functional endoscopic sinus surgery
When is this procedure indicated?
FESS is indicated in a wide range of nasosinusal inflammatory disorders, with different degrees of urgency. These are the most common ones:
- invasive fungal sinusitis, a typical pathology of immunocompromised and very serious subjects;
- acute bacterial or fungal sinusitis, particularly if resistant to medical therapy or relapsing. In some cases, the origin is called odontogenic, which is due to an underlying dental pathology;
- chronic sinusitis, with or without development of inflammatory polyps;
- exeresis of benign or malignant lesions of the nasal passages and paranasal sinuses.
How is it performed?
The procedure is generally performed under general anesthesia and endoscopically, i.e., by passing the surgical instruments through the nasal passages, under endoscopic vision, using rigid optics.
After mucosal decongestion that increases the surgical working space, the surgeon directs the surgery to the affected structures by simultaneous viewing of the preoperative CT scan (not all sinuses are always affected). Depending on the anatomical condition of the patient and the pathology, various cutting, gripping and milling instruments can be used. In the most difficult cases, the surgeons operating in our structure can use an instrumentation that allows the neuronavigation, that is the visualization on monitor in real time of the position of the surgical instruments, in order to reach the surgical intent while preserving the noble endonasal structures.
In some cases, septoplasty and/or turbinoplasty may be combined, either for the patient's primary need, or to allow endonasal access to otherwise inaccessible structures. At the end of the operation, endonasal tamponade (rarely performed) or endonasal placement of devices to facilitate hemostasis may be necessary.
The patient must remain hospitalized for observation at least overnight following surgery. Any pain at the site of surgery (generally mild) is controlled with painkillers. During hospitalization, you should alert healthcare personnel to any new symptoms that appear, particularly the presence of nosebleeds. The morning after surgery, any nasal secretions are aspirated and any swabs removed, and the patient is generally discharged, with instructions to perform nasal washes and use nasal creams/sprays. The first post-operative check-up is generally scheduled after 7-10 days, on the basis of which any further checks are planned.The patient will experience a strong nasal respiratory obstruction for at least 10-15 days after surgery; for the same period it is possible the presence of nasal secretions, generally red/pinkish due to the presence of blood residue. You should avoid physical exertion, exposure to heat, smoking, use of medications that promote bleeding (unless they are considered necessary), blowing your nose and sneezing with your mouth closed for about 3 weeks (it is useful as a substitute to do lots of nasal washes and sneezing with your mouth open).
Complications of the surgery are variable, also based on the patient's comorbidities, the pathology for which the surgery is performed and which sinuses are affected; they are explained in detail before the surgery. The most common ones include:
- epistaxis, which should not be confused with the presence of secretions with minimal blood component. If this occurs during hospitalization, the health care providers should be notified; if the patient has already been discharged, it is generally indicated to compress the nasal pyramid, apply ice locally if possible and go immediately to the emergency room;
- surgical site infection, for which medical re-evaluation is required for proper medical or surgical management;
- formation of synechiae (scarring adhesions), reducing the space for respiratory flow;
- rarely, penetration into the orbit may develop, with consequent risk to visual capacity or ocular motility, or communication between the nose and cranial cavity may develop, with the possibility of passage of CSF into the nose, or development of meningitis.
The intervention of FESS may not be resolving, either for recurrence of inflammatory processes (in particular chronic polypoid rhinosinusitis) or for lack of surgical radicality in case of exeresis of neoplastic neoformations. Among the complications at a distance we can mention the development of neuralgia, or the empty nose syndrome, that is the perception of lack of air passage despite the presence of an amply sufficient space.