Endoscopic Sinus Surgery(FESS): Type, Procedure and Recovery

What is Sinus Surgery

Sinus surgery is the surgical drainage and treatment in patients with severe sinus infections. Often sinus infections are medically managed in mild to moderate cases, but for severe cases, surgical intervention is considered for long-term relief.

Sinuses are pneumatic cavities in the skull located around the eyes and nose. They make the skull lighter and produce mucus that moistens the nasal passages and protects them from the entry of pollutants, dirt, and infectious organisms. Since sinus cavities are constantly in contact with infectious organisms, they often get infected, leading to sinusitis.

Why is Sinus Surgery Required?

Sinus surgery is generally required only in patients suffering from severe sinusitis who have not received adequate relief from maximum medical management of their condition. Patients with the following symptoms should consider getting sinus surgery:

• Nasal pain and inflammation
• Thick, discoloured discharge with drainage in nose and throat areas
• Sore throat with nasal congestion and sinus pressure
• Headaches with pain, tenderness, and swelling in the cheeks, nose, and forehead
• Ear and jaw pain
• Reduced taste and smell sensations
• Difficulty in breathing through the nose

If the patients have tried conservative management options like antibiotics, nasal sprays, corticosteroids, lifestyle modifications, etc., without adequate relief from the above symptoms, then they need sinus surgery.

Patients with the following conditions are also good candidates for sinus surgery:

• Chronic sinusitis, i.e., sinus infections that have lasted over 12 weeks
• Recurrent acute sinusitis (RARS), i.e., over 4 instances of rhinosinusitis in a year
• Severely deviated nasal septum leading to breathing issues
• Nasal polyps blocking the airway and increasing sinus drainage and infection
• Allergic rhinosinusitis, i.e., allergic disorders affecting the nose and related sinus areas

Pre-operative preparation for sinus surgery

Since sinus issues are mostly treated medically, patients should undergo a thorough diagnosis to ensure that surgery is the right course of treatment for them. This includes imaging tests like CT or MRI scans, sinus endoscopy, allergy tests, and tissue cultures. You should also follow the given guidelines for pre-operative preparation:

• Discuss your medical history with your surgeon, and if you are taking blood thinners, you may need to stop them 2-3 days before the surgery.
• If you are asthmatic, you should diligently take your medicines, even if your asthma seems under control.
• Avoid un-prescribed medicines like aspirin, NSAIDs, Vitamin E supplements, etc., before the surgery, as they increase the risk of hemorrhage during the surgery.
• Stop smoking at least 3 weeks before the surgery as smoking and tobacco use impede the healing process and increase the chances of post-operative complications.
• Don’t eat anything after midnight on the day before the surgery.

Day Before Surgery

Here are a few things you should do before going to the hospital for your sinus surgery:

• Pack an overnight bag in case you need to stay overnight in the hospital. Make sure you pack loose comfortable clothes that will not impede or control your movements.
• You won’t be able to drive for at least a couple of days afterward, so arrange for someone to drive you home after the surgery.
• You may have trouble performing your daily activities for a day or so after the surgery, so arrange for someone to take care of you.

Procedure Day

On the day of the surgery, you will be admitted to the hospital, and your vitals will be recorded. The patient’s base vitals, like body temperature, BP, heart rate, etc., help determine if the patient is healthy enough to undergo surgery.

Once that is done, they will be anesthetized and moved to the operation theatre for the surgery. The surgery can be done under both general and local anesthesia, based on the surgeon and patient preference. The exact surgery procedure will differ based on the type of surgery being performed.

Once the surgery is done, any incisions that were performed will be closed through absorbable sutures and then covered with absorbent bandages to limit bleeding and discharge from the surgical area. Most patients are discharged on the same day, but in severe cases, or if the surgery has been performed with another surgery like septoplasty, etc., the patient may need to stay at the hospital for overnight observation.

Types of Sinus Surgery

FESS (Functional endoscopic sinus surgery) is the most common type of sinus surgery that is performed nowadays, but there are several other types of sinus procedures that may be carried out as well. The most common types of sinus surgeries are:

• FESS surgery: It is carried out using an illuminated thin-fiber optic tube called an endoscope that is guided to the sinuses through the nose. Then, other surgical instruments are passed through the endoscope to remove obstructive tissues and other blockages to clear the sinuses with little to no scarring. It is an outpatient procedure that is usually performed under local anesthesia. In addition to draining the sinuses, it restores the normal mucosa integrity and function without extensive destruction of the tissues surrounding the sinuses.
• Image-guided surgery: Image-guided surgeries are usually recommended if the patient has severe sinus blockages or if they have undergone unsuccessful sinus surgeries in the past. The surgeon uses CT scans and infrared signals to get a 3D map of the nasal and paranasal structures, along with an endoscope to increase the accuracy and effectiveness of the procedure.
• Caldwell-Luc operation: This procedure is not performed commonly as it is more invasive and is only recommended if the patient has a growth in the sinus cavity. The surgeon makes a cut in the maxilla to enter the sinuses and remove the growth and drain the sinus cavity.

Your ENT surgeon will carefully assess your condition and evaluate the kind of surgery you need. FESS is usually the most common procedure as it does not damage the tissues and leads to very few postoperative complications.

Post Procedure

Most patients notice immediate relief from their sinus issues after the surgery. They can return to work within a week of the surgery, and complete FESS recovery usually takes around 3-4 weeks. If the patient has nasal splints after the surgery, they will be removed in about 8-10 days. You can follow the given tips to improve your recovery after the surgery:

• Take your medicines as prescribed to minimize post-operative bleeding and prevent infections.
• Avoid hot foods and drinks and strenuous exercises for a couple of weeks or till the incisions have healed.
• Use salt-water nasal sprays or douches to clean the mucus in the nose and congealed blood thoroughly.
• Avoid blowing your nose for a few days. If there is too much bleeding or discharge from the nose, then consult your ENT specialist immediately.
• Do not fly or swim for at least 2 weeks after the surgery.

Risks and Complications

While sinus surgery is generally very safe and effective, occasionally, it can lead to surgical complications as described below:

• Bleeding and infection
• Vision loss due to damage to the eye or its surrounding tissues
• Temporary (or prolonged) double vision
• Cerebral Spinal Fluid (CSF) leak
• Decreased sense of smell or taste
• Swelling, bruising, or temporary numbness of the lip and eye
• Anesthesia-related risks
• Change in voice
• Scarring and decreased nasal airflow