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Functional Endoscopic Sinus Surgery (FESS)



F.E.S.S. Patient Information Booklet


GUIDELINES FOR ENDOSCOPIC SINUS SURGERY

In general, endoscopic sinus surgery is intended for people with chronic sinus problems who do not respond to medical therapy. Symptoms of sinus disease may include facial pain or a feeling of fullness, difficulty breathing through the nose, a persistent bad smell in the nose, post nasal discharge, and occasionally headaches. Occasionally, sinus problems may cause hoarseness or cough, or a variety of other symptoms, but all of these problems can also occur in the absence of sinus disease. The diagnosis of a sinus problem must therefore be based on the assessment by your doctor.

In the majority of people with sinus problems, surgery is not indicated. Most people with sinus complaints can be successfully treated medically. This plan may consist of treatment for allergies, antibiotics or other medications, or environmental control (such as stopping smoking). The type of medical treatment chosen is based on your doctor’s assessment of the cause.

Unless your doctor finds a problem which clearly requires surgical intervention, one or more forms of medical treatment are used as primary therapy for most sinus problems. In some people however, surgery is indicated. This may be because of an infection or inflamed area that does not clear with antibiotics, or which keeps returning when the antibiotics are stopped, or for other reasons which you should discuss with your physician.

EVALUATION AND FOLLOW UP TREATMENT IN ENDOSCOPIC SINUS SURGERY

At the initial consultation, it is helpful if you bring a letter from your primary care provider describing your history and treatment up to this time. Previous x-rays are also often helpful if these are available. Special x-rays (CT Scans) are frequently required to accurately assess the areas involved. In some cases, these may be prearranged at the time of the initial visit based upon information supplied by you or your physician in advance. They may also be performed at a later time. Remember to bring these scans with you to your appointment with your sinus specialist.

If, after the consultation, it is believed that you would benefit from endoscopic surgery, a date will be arranged for the procedure. In many cases, the surgery can be performed on an outpatient basis under local or general anesthesia. However, it is important to be prepared to be admitted to the hospital should this prove necessary at the time of surgery.

BEFORE SURGERY

Most patients who have smoked in the past have learned that this makes their sinus symptoms worse and have previously stopped smoking. Smoking in the weeks before or after the surgery can seriously interfere with the success of this type of surgery, resulting in excessive scarring and a possible poorer outcome of the operation. It is therefore essential that you stop smoking at least three weeks before the surgery date.

Aspirin, even in small quantities, can result in significantly increased bleeding during surgery and the postoperative period. You should not take any aspirin or salicylate-containing analgesics for at least ten days before surgery. Ibuprofen (Advil, Motrin) will also increase bleeding but the effect of these medications is shorter. You should not take these medications for at least five days before the surgery. Tylenol (acetaminophen) does not affect surgical bleeding and may be taken up to the day of surgery.

If you are on oral steroids for asthma or for your sinus disease, we will normally recommend that you increase the dosage several days before prior to surgery. You should discuss this with your primary care provider. Occasionally we will also recommend starting oral steroids or antibiotics in the presurgical period. If you catch a cold or get a significant increase in your sinus infection in the week(s) before surgery, you should contact us. It may be better to postpone the surgical procedure.

Do not eat or drink anything (even water) beginning at midnight before surgery. If you are on medications, you should ask us during the presurgical evaluation if you should take these on the morning of surgery.

FUNCTIONAL ENDOSCOPIC SINUS SURGERY

Functional endoscopic sinus surgery differs somewhat from the conventional surgical approach to this problem, in that it involves a careful diagnostic workup to try to identify the underlying cause of the problem. Sinusitis frequently begins in the anterior ethmoid area near the area of the openings of the maxillary and frontal sinuses. Sometimes the endoscopic exam, or the detailed CT scans, may reveal a problem which could not be identified by other means.

The principle of behind treatment is that the underlying cause of the disease is identified and corrected, then the secondary disease in the maxillary and frontal sinuses will often improve spontaneously.

The advantage is that it is generally a less extensive surgery. There is often less tissue removed and the surgery can frequently be performed on an outpatient basis without the necessity for nasal packing. The endoscopes allow better visualization and allow problems in other sinuses to be viewed directly, and, in many cases, for diseased tissue to be removed.

Recent developments include the use of balloon dilators to open narrowed sinus pathways without the need to remove any tissue. This results in a very rapid recovery and prompt return to normal activities.

FOLLOWING SURGERY

Careful postoperative care is essential to the success of this surgery. We will provide you with instructions addressing postoperative care following the surgery. A follow-up visit, in approximately two to seven days, is necessary to clean crusts from the surgical site. Further follow-up visits are then scheduled in two to six weeks. At each of these visits, any persistent inflammation or scar tissue will be removed under local anesthesia. For your comfort, we recommend that you take a dose of your prescribed pain reliever immediately before these visits. Occasionally, further minor endoscopic procedures, or rarely, more radical surgical procedures may be required if a resolution of symptoms does not occur.

RISKS OF SURGERY

Bleeding
Bleeding is a potential risk in most forms of sinus surgery, although the risk of bleeding appears to be reduced with this technique. On occasion, significant bleeding may require termination of the procedure and the placement of nasal packing. Bleeding following surgery may require packing and hospital admission. A blood transfusion is rarely required.

Blood Transfusion
Blood transfusion is rarely required, but if necessary, carries a risk of adverse reaction or the transfer of infection.

Failure to Cure the Problem or Recurrent Disease
As in all sinus surgeries, it is possible that the disease may not be cured by the operation or that recurrent disease may occur at a later time. In this case, subsequent medical or surgical therapy might be required.

Postoperative Discharge
Some bloody nasal discharge may occur for approximately two weeks after this procedure. Later, the discharge of blood and mucus may have a thick brown quality. This is normal and slowly improves. It does not indicate an infection. You should not blow your nose for approximately one week following the procedure.

Spinal Fluid Leak
All operations on the ethmoid sinus carry a rare chance of creating a leak of spinal fluid (the fluid that surrounds the brain). Should this rare complication occur, it creates a potential pathway for infection which could result in meningitis. If a spinal fluid leak should occur, it would extend your hospitalization and might require further surgery for its closure, if it doesn’t close spontaneously. In general, the risk of a spinal fluid leak is considered somewhat higher when ethmoid surgery is performed through the nose rather than by an external incision. However, the use of endoscopes allows improved visualization, and therefore should potentially reduce the risk of this complication.

Loss of Vision
Occasional reports of vision loss have been reported after sinus surgery. Although the loss of vision would usually involve only one side, the potential for recovery is not good. Fortunately, such a complication is extremely rare. Temporary or prolonged double vision has also been reported after sinus surgery.

Risks of Anesthesia
One advantage of the endoscopic technique is that it can occasionally be performed under local anesthesia. Adverse reactions to local anesthesia are very uncommon. If general anesthesia is required, you would be subject to the usual risks for general anesthesia. Adverse reactions to general anesthesia do occasionally occur, and although unusual, could be serious. You may discuss this further with your anesthesiologist, if you so desire.

Other Risks
Tearing of the eye can occasionally result from sinus surgery or from sinus inflammation and may be persistent.  Numbness or discomfort in the upper teeth may occur for a period of time after some procedures.

Occasionally some swelling, bruising or temporary numbness of the lip, or swelling or bruising of the area around the eye may occur. Blowing your nose in the early postoperative period might result in a temporary collection of air under the skin and facial swelling for a period of time.

The purpose of the surgery is to reduce or eliminate the symptoms of chronic sinus disease. Should it not be successful, the symptoms could be unchanged or become worse. These symptoms include further sinus pain or discomfort, increased nasal obstruction, or a prolonged increase in postnasal discharge. A decreased sense of smell is also a possibility.

ALTERNATIVES TO SURGERY

Usually, medical therapy is the first form of treatment for sinus disease, and in most cases, it is possible to continue to treat the disease medically. Alternative forms of surgery are also available. You may discuss these options further with your surgeon if you wish.

 


 

 

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