FESS Ayu Natakia

7/25/2019 FESS Ayu Natakia

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Functional endoscopic sinussurgery*

Concept, indications and results of theMesserklinger technique

H. Stammberger and W. osa!et"

#$%&Hospital, 'ni(ersity of )ra", &+- )ra", ustria


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The conceptFunctional endoscopic sinus surgery (FES) is

based on the clinical experience that mostinfections of the larger sinuses are rhinogenic:

i.e., disease spreads from the nose to theparanasal sinuses.

Although the clinically dominating symptoms maybe due to disease inside the frontal or the

maxillary sinuses, in most of the cases theunderlying causes are not to be found in theaected sinuses themsel!es, but in the lateralnasal !all.


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"ato#siologi sinusitisThe mucus produced in the maxillary sinus is

transported from the bottom the $oor of thesinus along the %all to%ards the natural ostium,

from there passing through the ethmoidalinfundibulum and entering the middle meatusthrough the hiatus semilunaris before beingtransported bac& to the nasopharynx.

The frontal and maxillary sinuses communicate%ith the nose !ia a complicated system of !erynarro% clefts %hich pro!ide their drainage andtheir !entilation.


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'f, ho%e!er, in these narro% areas extensi!e contact ofopposing mucosal surfaces occurs %hate!er the cause forthis may be the ciliary acti!ity can be impeded so that thespaces are completely bloc&ed

The secretion in bet%een such contact areas cannot betransported a%ay anymore, except around these areas.

'nfections can start here and spread to adacent sites,especially to the dependent larger sinuses. The larger sinuses%ill be aected more *uic&ly.

+epending on the indi!idual pathoanatomical situation,!entilation and secretion transport can be completely bloc&ed.This can result in the retention of secretions, poor !entilationof the aected sinus and in$ammation if superinfectionoccurs.


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Endoscopic diagnosisesser&linger de!eloped and published the

#rst comprehensi!e and systematic methodfor endoscopic diagnosis of the lateral nasal%all.

The rigid cold light endoscope in combination%ith con!entional and-or computedtomography ha!e pro!ed to be idealdiagnostic tools.


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hen e!aluating /T scans and con!entionaltomographs it is important to not only loo& formucosal thic&ening, soft tissue masses or foropaci#cations inside the sinus air cells orspaces, but to recogni0e and identify contactareas or other stenoses in &ey positions e!enif they are not signi#cantly diseased at thetime the scan %as performed.


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Fig. 1. a /T scan of patient %ith massi!e nasalpolyposis and recurring maxillary sinusitis.

There is only minimal s%elling of the mucosallining of the maxillary sinuses at the moment,but disease in the ethmoids is clearly present.

Asterisks indicate nasolacrimal duct.

b, c 2ie% into the left middle meatus in casesof polyposis.


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/ndications for F#S

3 "olypoid sinusitis(456)

3 /hronic and acute

recurring infections ofall sinuses

3 7asal obstruction

3 8eadaches

3 "ressure feelings3 "ostnasal discharge

3 Epiphora

3 Anosmia

3 ucoceles of all sinuses

3 9etention cysts

3 rbital complications3 Sinus mycoses

3 "ersisting complaints after/ald%ell;uc operations

or fenestrations

3 Tubal dysfunctions3 Adu!ant surgery to allergy

treatment

3 Antrochoanal polyps

3 uco!iscidosis


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'ndicationsThe general aim of surgery is to clear diseased ethmoid clefts

and compartments under guidance of the rigid endoscope andto reestablish !entilation and drainage of the diseased largersinus !ia their physiological routes.

The frontal and maxillary sinuses per se rarely re*uire moreextensi!e manipulations. 'f necessary, the maxillary sinusostium is enlarged at the expense of the anterior and-orposterior nasal fontanelle, resulting in a %indo% in itsphysiologic place in the middle nasal meatus.

'f the frontal sinus is diseased, clearing the frontal recess inmost cases of in$ammatory processes %ill also producehealing of the sinus %ithout the need for additionally enlargingthe sinus ostium itself.


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Except for children, the surgical procedure isperformed %ith the patient under sedation %ith topicaland local anesthesia. This pro!ides an excellent !ie%

of the area to be operated on and allo%s for carefuland atraumatic handling of the instruments.

't further helps to reduce any bleeding, so that nopac&ing is usually re*uired postoperati!ely.

The true ad!antage of our procedure is that it is basedon exact diagnosis, thus limiting any surgery re*uiredand a!oiding


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llergy and M%'n general, allergic disease of the upper

air%ays is not primary indication for surgery. 'fpatient do not respond to hyposensiti0ation oranti allergic therapy,

And there is obstruction(large concha bullosaor ethmoid bulla)a limited surgical proceduremay help considerably.

'n these cases, the T should be seen as anadu!ant therapy, %hich of course cannot healthe allergy but may help to impro!e the

patient=s symptoms in addition to further antialler ic treatment


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Septal de(iations and M%'f a >mm telescope plus the re*uired

instrument can pass the stenosis caused bythe septal de!iation, %e %ill al%ays treat theethmoid problem #rst. nly if the ethmoidcannot be reached due to the stenosis %ill %eperform a septoplasty #rst.

'f after a couple of %ee&s ethmoid diseasepersists, %e then correct the septum in asecond stage.


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0imitations and

contraindications to F#S?ony obstructions of the frontal sinus ostium

or stenoses caused by large bony changes orscarrings

'f in an acute sinusitis %ith orbitalcomplications only minimal or discrete signs

of meningitis or any other intracranialcomplication are present or if there is anosteitis or osteomyelitis of the frontal bone,%e regard these as contraindications for a

primary endoscopic approach.


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9ES@;TS%able 1. receding therapies 21

patients3

3 9epeated maxillary irrigations

3 B fenestrations and-or radical operations

(some multiple and bilateral)

3 C> septoplasties

3 41 patients %ith multiple pre!iouspolypectomies


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+iuse polypoid rhinosinopathyAected patients usually present %ith a

diuse polypoid s%elling of the entire nasaland paranasal sinus mucosa.

8yperplastic mucosa from the anteriorportion of the middle turbinate fre*uentlycannot be dierentiated from mucosaprotruding out of the middle or e!en superiornasal meatus.


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"atients %hose still produce a glueli&ehighly!iscosous secret that cant be transported outof the sinuses by the mucociliary acti!ity

Esp in asthmatic patients or patients %ithsinobronchial syndrome.


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complications'n about 6 of all patients follo%ed, !arying

degrees of synechiae %ere found mainlybet%een the anterior portion of the middle

turbinate and the lateral nasal %all.This is especially prone to occur if opposing

%ound areas ha!e been created during surgery.

"roblems usually arose %hen synechia led tostenosis of the middle meatus or bloc&ed theethmoidal recesses %here secretions %ereretained and ostia narro%ed or scarred.

/";'/AT'7S


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/";'/AT'7S


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/onclusionsThe esser&linger techni*ue is a primarily diagnosticendoscopic concept, %hich is based on theunderstanding of the pathophysiology of sinusitis.Additionally, the combination of diagnostic endoscopy

of the lateral nasal %all using rigid scopes %ithcon!entional or computed tomography in the coronalplane has pro!en to be the ideal tool for the

in!estigation of in$ammatory diseases of the paranasalsinuses.

ith mostly !ery limited surgical procedures, functionalendoscopic sinus surgery allo%s diseased ethmoidalcompartments to be cleared, stenotic clefts enlargedand the prechambers to the frontal and maxillary

sinuses freed from disease.


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E!en though it may not be as eecti!e in cases of diusepolypoid rhinosinopathy or muco!iscidosis, sometimesconsiderable impro!ement can be achie!ed in many of thesecases.

8o%e!er, as more radical surgical techni*ues do not ha!e anysigni#cantly better longterm results, the T may be morepreferable because of its less traumatic approach in thesecases.

The techni*ue of FES re*uires thorough training and a !ery

good %or&ing &no%ledge of ethmoid anatomy %ith all its manypossible !ariations, since it bears all of the ris&s and ha0ards ofendonasal ethmoid surgery.

Applied correctly %hen indicated, the techni*ue has a minimalcomplication rate in the hands of an experienced surgeon

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