J Nep Med Assoc 2006; 45: 337-341

Functional Endoscopic Sinus Surgery (FESS)

Pradhan B*, Thapa N*

* TU Teaching Hospital, Maharajgunj, Kathmandu, Nepal.

abstract
Functional Endoscopic sinus surgery (FESS) is a minimally invasive surgical procedure that opens
up the sinus air cells and the sinus ostia with an endoscope. The use of FESS as a sinus surgical
method has now become widely accepted and the term functional is meant to distinguish this type
of endoscopic surgery from the nonendoscopic more conventional sinus procedure.
Functional Endoscopic sninus surgery is being done regularly at TU Teaching Hospital from 2003.
Total number of cases done from March 2003 till December 2005 were 94. Maximum number of
FESS was done for nasal polyps, which was carried out in 80 patients, out of which, FESS for ethmoidal polyp was done in 47 patients and for antrochoanal polyps in 33 patients. Other conditions
where FESS was carried out were chronic maxillary sinusitis in 8 patients, fungal sinusitis in 5
patients, and endoscopic medial maxillectomy for inverted papilloma in 1 patient.

Key Words: FESS, operative procedure, complication, endoscopic after care.

Introduction
Endoscopic sinus surgery is still a new technique in our
country, many centers do not have the instruments for
FESS and many surgeons are not trained in this field.
FESS is a minimally invasive surgical procedure that opens
up the sinus air cells and sinus ostia with an endoscope.

The use of FESS as a sinus surgical method has now

become widely accepted and the term functional is meant
to distinguish this type of endoscopic surgery from non
endoscopic more conventional sinus procedure.1
Intranasal endoscopic surgery has two main goal1
1. Maximum preservation of mucosa
2. Secure communication between the nasal cavity and
the paranasal sinuses via the natural channels.

Address for correspondence :

Dr. Bibhu Pradhan
TU Teaching Hospital, Maharajgunj, Kathmandu, Nepal
Email: bibhuduga@yahoo.com
Received Date : 3rd Aug, 2005
Accepted Date : 24th Sep, 2006
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There are many indications for FESS1

1. Chronic maxillary sinusitis, ethmoiditis, sphenoiditis
2. Nasal polyps both ethmoidal and antrochoanal
3. Frontoethmoidal mucocoele
4. Limited inverted papillomas
5. Endoscopic DCR
There has been many reports of angiofibromas being
removed endoscopically. There is no absolute contraindication to FESS, but uncontrolled hypertension, bleeding
disorder, acute infection, where there is chance of excessive haemorrhage during surgery, it is better to go by
conventional method.2,8
Investigation required for FESS
1. Nasal Endoscopy to assess the disease, and also to
confirm the diagnosis of nasal polyps.
2. CT scan of nose and paranasal sinuses both axial and
coronal section, to know the origin and extent of the
disease.
INSTRUMENTS
Microdebrider (shaver) is the recent advances in the field
of Endoscopic Sinus Surgery.
The advantages of microdebrider over the use of Forceps

338

as well as the soft tissue eaten by the debrider, so the

operating field is clean.
3. There is irrigation attached to it, which flushes the area
continuously for better visualization.
There are major complications and minor complications.
Major
1. Excessive haemorrhage requiring blood transfusion.
2. Orbital haematoma.
3. Blindness.
4. Diplopia.
5. CSF Leak.
6. Meningitis.
7. Carotid artery injury.
Minor
1. Periorbital ecchymosis.
2. Periorbital Emphysema.
3. Minimal bleeding.
4. Adhesion.
5. Stenosis of ostia.
6. Most unavoidable complication is recurrence of nasal
polyps.
The objective of this study is to introduce the functional
outcome of FESS done in our institution so far
Materials and Methods
All the patients were taken up from the Department Of
ENT and Head and Neck surgery, TU Teaching Hospital
who were admitted for the FESS. Duration of study was
from October 2003 till December 2005 (26months). Total
number of patients were 94.

Fig. 1 : Microdebrider (shaver)

1. It eats up the polyps, so the bleeding is less, we can
visualize the normal structure like turbinate.
2. There is suction attached to it, which sucks the blood

All cases were performed under G.A. After cleaning and

draping 1:20,000 xylocain with adrenalin were injected in
the uncinate process, base of middle turbinate, and in the
polyps , nasal cavity was packed with 1:1 preparation of N/
sline and adereline cottonoids, and waited for 5 minutes. In
case of antrochoanal polypes, uncinectomy was done first
and widening of the natural ostia of the maxillary sinus
was done by removing the anterior and posterior fontanel.
Polypes was pulled out from the maxillary antrum, nasal
cavity and choana and removed in toto,

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Pradhan et al. Functional Endoscopic Sinus Surgery

leaving the oedematous mucosa of the maxillary sinus

intact if any. In case of ethmoidal polyp, if there is massive
polypes, debulking was done first followed by widening of
the natural ostia, then polypes from the maxillary antrum
were removed. Ethmoid is opened by opening the bulla
ethmoidalis, disease is removed from anterior ethmoid then
the basal lamella is opened to enter the posterior ethmoids.
Sphenoid is opened by entering through sphenoidal ostium
for the middle turbinate is our landmark, if middle turbinate is missing or removed then superior turbinate is the
landmark. Any polyps or fluid in sphenoid is removed. If
CT scan shows opacity of the frontal sinus, we approach
through frontal recess but mucosa of the frontal recess is
left intact to prevent the stenosis. Haemostasis is achieved
by packing the nose with adrenalin and saline solution.
Finally BIPP packing was done which is removed after
48 hours.
Result
FESS is being done regularly at T.U. teaching hospital
after the Rhinology unit was established in 2003. Total

number of FESS done from October 2003 till Dec. 2005

were 94. Maximum number of FESS was done for nasal
polyps which comprises 80 patients, of which ethmoidal
polyps was seen in 47 patients and antrochoanal polyp
in 33 patients. Other conditions where FESS was carried out were Chronic Bilateral Maxillary sinusitis in 8
patients. Bilateral Fungal sinusitis in 5 patients, inverted
papilloma in 1 patient.
In patients where nasal polyps were associated with deviated nasal septum (DNS), septoplasty was done first followed by FESS for better exposure to the operating field.
In our practice we encountered the following complications. Excessive hemorrhage in 2 patients where we had
to abandon the surgery. In the first patient, she was in oral
contraception, which could be the reason for the bleeding. In second patient platelet count was only 90,000 and
was under investigation for bleeding disorder. Orbital fat
pulled out was seen in 7 patients. Periorbital ecchymosis
in 8 patients. One patient developed temporary restricted
movement of the eye, which recovered after pack removal

Table I: Age Distribution

Table II: Sex Distribution

Table III: Disease Pattern

Table IV: Laterality for Inverted papilloma and Antrochoanal polypes

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340

Fig.2 : CT Scan of Paranasal Sinuses showing polyps involving B/L nasal cavities, B/L ethmoids and
left frontal sinus and mucosal thickening of B/L maxillary antrum
Table V: Complications of FESS

and use of oral steroid. Fifteen patients developed synechiae after one month of follow up, which was released
under local anaesthesia in out patient department. Out of
47 patients of ethmoidal polyps, 7 patients came with the
recurrence of polyps, after 22 months of follow up. Three
patients responded to oral steroid and steroid nasal sprey,
4 patients required revision FESS. No patients required
nasal packing after pack removal for bleeding.
Discussion
In our study out of 80 patients of nasal polyps, ethmoidectomies with or without sphenoidotomy was performed
in 47 patients, and antrostomy alone was done for antrochoanal polyps in 33 patients. Recurrence of polyp after
ethmoidectomies with or wihtout sphenoidotmy was seen
in 7 patients, which is comparable with other studies.1,3,4 We
encountered some minor complications during and after
the surgery, like synechiae, orbital ecchymosis, accidental

removal of orbital fat, bleeding during surgery, recurrence

of polyps. Sun et al reported no serious complications in
his study.5 Dalziek et al encountered major complications
in 0-1.5% of cases and minor complications in 1.1-20.8%
of cases.7,8 We followed up the patients for atleast 1 year
to detect the recurrence, which was seen in other studies
also.1,4
Endoscopic After Care Follow up
The first visit is after one week when we remove the blood
clot, crust, the secretions, release the synechaie and if
excessive oedema, we keep the steroid pack for few days.
Subsequent follow ups were after 2, 3 and 12 months to
detect any recurrence.
The after care is an important as surgery as there may be
excessive crusting, causing nasal blockage, nasal bleeding, synechiae formation, recurrence of polyps. Excessive
crusting will lead to poor visualization of operated area

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Pradhan et al. Functional Endoscopic Sinus Surgery

and detection of residual polyps. Regular nasal douching

with sodium chloride and soda bicarbonate is compulsory
after FESS. Removal of crust and clots should be done
whenever patients come for follow up using endoscope.
Division of synechiae should be done in out patient if the
synechiae is small but if it is large, division under general
anesthesia is necessary.

References
1. Matte Erik Wigand, W. Hosemann. Endoscopic Surgery of the
Paranasal sinuses and anterior skull base. 2nd Edition, 1990; 4.
2. Darling P, Petersen CG. Results of functional endoscopic sinus
surgery. Ugeskr Laeger. 2006 Mar 6; 168(10): 1034-7.

Treatment of infection is done by using oral ciprofloxacin

for two weeks. In case of ethmoidal polyps we give oral
steroid in the dose of 15 mg once a day (OD) for first seven
days followed by 10mg OD for seven days followed by
5mg OD for next seven days, this is to reduce edema and
to minimize or prevent the recurrence of polypes. Regular
follow up for at least 2 years is necessary.

3. Haque MR, Hossain MM, Kundu SC et al. A study of functional

Conclusion

5. Sun H, Tan G, Xiao J. Endoscopic sinus surgery, clinical aspect with

endoscopic sinus surgery technique. Mymensingh Med J. 2004

Jan; 13(1): 39-42.
4. Jakobsen J, Svendstrup F. Functional endoscopic sinus surgery in
chronic sinusitis--a series of 237 consecutively operated patients.
Acta Otolaryngol Suppl. 2000; 543: 158-61.

69 cases. Zhonghua Er Bi Yan Hou Ke Za Zhi. 1996; 31(1): 18-9.

Total number of FESS done from Oct 2003 till 2005 were
94. Nasal polyps outnumbered the other diseases (80 patients). We faced some minor complications like Synechiae
in 15 patients, orbital eccymosis in 8 patients, orbital fat
pulled out in 7 patients, recurrence of nasal polyp in 7
patients. Endoscopic sinus surgery is a safe procedure
with few complication in experienced surgeons hand but
severe complications like blindness, orbital haematoma,
CSF leak, carotid artery rupture can occur if surgeon has
little experience in FESS.

6. Frisch T, Arndal H, Fons M. Outcome for the first 85 patients treated

with the functional endoscopic sinus surgery technique. Rhinology.
1995 Dec; 33(4): 236-9.
7. Levine HL. Functional endoscopic sinus surgery: evaluation,
surgery, and follow-up of 250 patients. Laryngoscope. 1990 Jan;
100(1): 79-84.
8. Dalziek, Stein K, Round A, Garside R, Royale P. Endoscopic sinus
surgery for the excision of nasal polyp: A systematic review of safety

Recommendation

and effectiveness. American Journal of Rhinology. 2006 sept-oct,

20(5): 506-19.

1. Study should be done in large series.

2. Long term follow up is recommended to know the late
complications like recurrence of polypes after disease
free interval.

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