Overview of Sinus Endoscopic Surgery
Endoscopic Sinus Surgery (ESS) is a procedure that has greatly evolved since it was first used. ESS involves using a special viewing tube to visually examine the sinuses and was first introduced as a concept in 1902. However, it wasn’t until the 1970s that it became a regular practice, with new techniques constantly being developed and improved due to technological advancements in surgical tools, imaging and navigation.
The idea of sinus surgery came from studies by Messerklinger who was researching how the movement of mucus in our sinuses affects sinusitis. The purpose of ESS is to treat sinusitis by making the openings to the sinuses larger. This method will improve airflow within the sinuses, allowing the mucus to move properly and providing better ways for topical treatments to reach the affected areas. However, every ESS operation can be challenging due to the differences in individual anatomy and the range and severity of the diseases that need to be treated. Therefore, careful planning before the surgery is key to achieving the best possible outcome and avoiding any potential complications.
ESS is mainly used to treat sinus diseases and is the best practice for dealing with chronic rhinosinusitis (long-term inflammation of the sinuses). As technology keeps growing, so do the applications of ESS. Now, it has widened its scope and is even used in the treatment of sinus tumors and other conditions extending beyond the sinuses.
Anatomy and Physiology of Sinus Endoscopic Surgery
Understanding the structure of the nose and surrounding areas is essential for safe sinus surgery, especially as everyone’s anatomy varies. Doctors often use imaging techniques before surgery to get a clear understanding of each individual’s nasal structure.
Your nose consists of external and internal parts. Externally, there are nasal bones and cartilages. Inside, the nose has two cavities separated by a vertical structure named the septum. The roof and floor of these nasal cavities are formed by different parts of your skull bones and facial bones.
The septum, which divides your nose into two parts, is made of bone and cartilage. It is very firm and has a rich supply of blood. Several arteries nourish the septum. The intersection of these arteries results in a region known as the “Kiesselbach’s plexus” or “Little’s area” is a common site of nosebleeds.
The sidewalls of your nose have bone extensions called turbinates, which help filter, humidify, and regulate the airflow you breathe in. Underneath each turbinate, there is a passage or ‘meatus.’ One of these passages allows your tears to drain into your nasal cavity. Some air-filled spaces called ‘paranasal sinuses’ also drain into your nasal cavity via other passages. An essential tiny structure, called the uncinate process, helps with this drainage.
Your ‘ethmoid sinuses,’ one type of paranasal sinuses, are divided into anterior and posterior parts. These are bordered by thin bone layers and drain to different areas of the nose. Your maxillary sinuses, another type of paranasal sinuses, are located close to the floor of your eye sockets and have openings into the nose as well.
The paired sphenoid sinuses are located within a bone in your skull and separated by a septum. This sinus is surrounded by several vital structures, including arteries, nerves, and sinuses. It provides doctors a pathway to access important areas like the base of the skull, the pituitary gland, and the optic nerve during certain surgeries.
The frontal sinuses are situated within the frontal bone of your skull. They drain through a recess into your nose. Anatomists classify sinus structures based on their location in relation to the front of the head, above the eye socket, or the central divider (septum).
Blood supply to these various regions comes from different arteries, while the blood return or venous drainage is directed to various veins.
Why do People Need Sinus Endoscopic Surgery
Functional endoscopic sinus surgery, also known as FESS, is the process where doctors use special instruments, a tiny camera and a light to access and operate on your sinus and skull areas. They can see and treat a range of problems, like inflammation, tumors or other diseases that are hard to reach with traditional surgery.
We usually need to do FESS when a patient has chronic rhinosinusitis, a long-lasting inflammation of the sinuses. We can categorize rhinosinusitis into three groups most commonly: Acute rhinosinusitis which lasts less than 4 weeks, subacute rhinosinusitis that goes on between 4 to 12 weeks, and chronic rhinosinusitis lasting longer than 12 weeks. In the U.S alone, chronic rhinosinusitis costs about $8.3 billion a year to treat, which shows how common this problem is.
Rhinosinusitis can affect your quality of life significantly, both emotionally and physically. Doctors diagnose this condition based on symptoms and physical exams, using tools like a nasal endoscope – a thin tube with a light and camera, or computed tomography scans – a sophisticated x-ray mechanism. The initial management usually involves nasal sprays or saltwater nasal rinses, but if those don’t work, we employ a surgery called endoscopic sinus surgery. The timing and specifics of when to opt for surgery can vary between patients and hospitals. However, studies show that FESS can improve the quality of life of people with chronic rhinosinusitis significantly.
Besides chronic rhinosinusitis, FESS also helps manage severe cases of acute rhinosinusitis, which may show up as inflammations around the eye area or blood flow problems in the eye’s veins. FESS plays a critical role when there is a visual impairment, higher eye pressure, situations where medicine doesn’t show improvement, and when drainage of an abscess – a pocket of pus, is required. FESS also helps in treating conditions related to the eyes areas due to its close location.
Additionally, FESS is now the go-to procedure for a variety of conditions such as mucoceles – a mucus-filled cyst, types of fungal sinusitis, silent sinus syndrome – a rare disorder affecting the maxillary sinuses, pituitary tumors located at the base of the brain, leaks of cerebrospinal fluid – the fluid around the brain and spinal cord, and several benign and malignant – cancerous and non-cancerous, tumors. Often, the surgery becomes necessary when such issues involve the nasal areas, paranasal spaces or areas at the front of the skull base.
We now use navigation-guided endoscopic sinus surgery, which uses a specific tracking system to help surgeons see and better operate on the sinus areas. It helps surgeons have a more elaborate and complete view of the sinuses, clear tumor borders for effective treatment and lowers the risk of surgical complications. The navigation system is particularly useful in situations involving previous surgeries, unusual sinus structures, benign or malignant tumors, repairs of leaks around the skull or brain, near vital structures like eye nerve, skull base or major blood arteries, conditions involving frontal, sphenoid, or ethmoid sinuses – certain types of sinuses, and extensive swellings or growings in the nose.
When a Person Should Avoid Sinus Endoscopic Surgery
There are certain situations where a patient should not undergo Functional Endoscopic Sinus Surgery (FESS):
First, if the patient cannot receive general or local anesthesia safely – these are drugs used to make you numb or sleep during a surgery.
Second, the surgery should not be done if the patient has disease or damage that stretches into the palate (the top part of your mouth), skin or soft tissues, into or above the orbit (the socket where the eye sits), the side parts of the frontal sinus (air-filled spaces in your forehead), or has advanced involvement within the skull. This is because these conditions can make the surgery more complex or risky.
In circumstances where the disease or damage is larger or more extensive, a combined technique might be needed. This uses both the endoscopic method (a tube with a camera is used) and an open method (where a cut is made to access the sinuses).
Equipment used for Sinus Endoscopic Surgery
The operating room should be set with specific equipment. This includes a TV monitor, a guiding system (if in use), a camera, and a specialized tray for a procedure called sinus endoscopy. This tray contains a variety of tools, such as curettes (small medical instruments used for cleaning or scraping), down-biters and backbiters (special surgical tools used to reach deep within the body), elevators (surgical tools used to lift or hold tissues), ball-tip probes, and through-cut instruments.
Other tools include Kerrison rongeurs, which are a type of forceps used for removing bone or tissue, giraffe instruments, sinus forceps with various bending angles, punch instruments, and endoscopes (tiny cameras used to look inside the body) with 0-, 30-, 45-, and 70-degree scopes and also reverse scopes.
Finally, a powered debrider, a device used to cut and remove tissue, equipped with straight and angled blades, is also necessary.
Who is needed to perform Sinus Endoscopic Surgery?
Functional Endoscopic Sinus Surgery is a procedure where a specially trained doctor, known as an otolaryngologist, works with a team to treat sinus problems. This team usually includes a scrub technician (a person who assists with getting instruments ready), a nurse, and an anesthesiologist (a doctor who helps you sleep during the surgery).
For some specialized cases, like removing a pituitary tumor through a method called a transsphenoidal approach, or removing tumors that have spread to the brain, a neurosurgeon (a doctor specializing in brain and nerve surgery) is also present during the surgery to work alongside the otolaryngologist.
Preparing for Sinus Endoscopic Surgery
When it’s time for the operation, the patient is carefully positioned on the operating table, facing a TV monitor. For comfort and a better surgical angle, the head of the bed is raised, putting the patient in a tilted-back position known as “reverse Trendelenburg.”
The tube helping the patient breathe, known as the endotracheal tube, is placed securely in the corner of the patient’s mouth on the left side.
To keep the patient’s eyes safe, they are either covered with a see-through protection or partially covered. This is so the doctor can easily check for any swelling in the eye area, a sign of a medical condition known as “orbital hematoma.”
To help prepare the nasal passages for surgery, both are filled with cotton soaked in a medication called oxymetazoline, which helps to clear them out. Then, the patient is covered with a sterile cloth, leaving only the surgical area exposed.
If a special tool known as a navigation system is used, images taken before the surgery would be loaded onto it. This tool is then aligned with the patient’s body and checked to make sure it’s properly set up before the surgery starts. This allows the surgeon to better see and navigate the surgical area.
How is Sinus Endoscopic Surgery performed
Having a nasal endoscopy involves using a thin viewing instrument known as a scope, like a telescope, to thoroughly examine the inside of your nose. The doctor will numb a portion of your nasal wall with a solution of a local anesthetic (lidocaine mixed with epinephrine) and use a syringe for this purpose. After that, they will place cotton pieces soaked in medication (oxymetazoline) to better prepare the inside of your nose for surgery.
The decision on which side of the nose to operate first usually depends on the side that has a more significant issue or the side that tends to be more open because of a curved septum.
Concha Bullosa excision: Sometimes, a kind of air-filled cavity within your middle nose curve, known as concha bullosa, might be present. So, the surgeon will first remove it to better navigate inside your nose.
Uncinectomy: the medical term for removing a part of your nose called the uncinate process. Here, the doctor uses precise tools to carefully remove the uncinate to avoid damaging the surrounding structures.
Maxillary Antrostomy: It is a procedure where the surgeon creates an opening in a sinus cavity (maxillary sinus) for therapeutic purposes such as draining the sinus or treating it. It might be necessary to enlarge this natural opening to do this, making sure not to affect nearby important structures like the eye socket, and the tear ducts.
Ethmoidectomy: This is the surgical procedure of removing one or more of the ethmoidal air cells or the whole of the ethmoid bone. It’s essential to be careful not to damage any vital structures while removing these cells
Sphenoidotomy: it involves creating a surgical opening into the sphenoid sinus, one of your sinus cavities, to drain it or give it a better opening. This procedure requires excellent caution as any mishap could affect important brain structures.
Frontal Sinusotomy: This is the surgical process to create a more significant passage in your sinus cavities (frontal sinuses) located near your forehead. By doing this, the doctor facilitates the draining of your sinuses.
All through these series of procedures, it’s crucial to preserve the vital parts of your nose as much as possible. This is to reduce the chances of post-operative complications like scarring.
At the end of the whole process, the surgeon ensures that good blood control is achieved, and then a soluble packing may be inserted in your nose to help keep the newly operated structures in place while healing occurs.
Possible Complications of Sinus Endoscopic Surgery
Undergoing endoscopic sinus surgery (ESS) carries a small risk of complications, mainly due to the close proximity of the sinuses to other critical parts of the body.
An orbital injury, or damage to the eye area, can occur during the surgical procedure, especially given that the maxillary and ethmoid sinuses sit beneath and beside the eye socket. The surgeon uses a procedure called uncinectomy to carefully remove parts of these sinuses, taking great care not to harm the surrounding tissues and structures. CT scans are helpful in planning the surgery, as they can show the surgeon a detailed view of the skull’s interior and help identify any potential risks. If injury occurs and it leads to increased pressure inside the eye, immediate responses such as eye massage, medication, or emergency eye procedures may be required to reduce the pressure.
A skull-base injury, which can potentially result in cerebrospinal fluid leaks (CSF leaks), is another possible complication. This fluid surrounds and cushions the brain and spinal cord, and can leak if injury occurs during the surgery. Using a CT scan before the surgery, the surgeon will carefully study the thickness and height of the sinuses to minimize the risk. During the surgical procedure, if a CSF leak is noted, the surgeon will quickly identify and repair the leak to prevent infections and long hospital stays. If identified postoperatively, a CSF leak is diagnosed using specific tests for substances found in the fluid and imaging techniques.
Another potential complication is nosebleeds, or “epistaxis,” which is normal for a few days after the surgery. However, a heavy nosebleed may require further intervention like medications, packing the nose, cautery (using heat or chemicals to stop bleeding), or surgical ligation (tying off a blood vessel).
Lastly, there is a risk of your sinus disease returning, which can be a result of various factors like inadequate surgery, obstruction of sinus drainage, or lack of proper after-surgery cleaning.
What Else Should I Know About Sinus Endoscopic Surgery?
Functional endoscopic sinus surgery is a common treatment for Chronic RhinoSinusitis (CRS), which is a long-term swelling and irritation of the sinuses. This surgery has become more effective now because doctors have access to precise tools and clear imaging techniques, which help them perform the surgery more thoroughly.
However, it’s important to note that doctors, specifically rhinologists who specialize in noses and sinuses, should not just depend on these tools and images. They should also understand the structure of the sinuses and be aware of all potential problems, both big and small.
To ensure safe surgery, doctors need to follow the step-by-step procedures of the endoscopic sinus operation, and they need to correctly identify consistent landmarks, or recognizable features, at every stage of the surgery. This acts as a roadmap and helps the doctors steer clear of any problems during the surgery.
