Functional Endoscopic Sinus Surgery (FESS) including balloon sinuplasty
Mr James W Fairley BSc MBBS FRCS MS
Consultant ENT Surgeon
© 1993 – 2019 JW Fairley Content last updated 10 May 2019
- What is FESS?
- Rigid Nasal Sinus Endoscopy (FESS telescope)
- CT Scan of the sinuses
- How is the operation done?
- Balloon sinuplasty
- What is the success rate of surgery?
- What are the risks?
- What other treatment options are there?
- Before coming into hospital
- Before the operation
- After the operation
- When you go home after FESS
What is FESS?
Rigid Nasal Sinus Endoscopy under local anaesthetic
Normal opening into left maxillary sinus (the natural ostium) seen through a nasal endoscope.
mt = middle turbinate
mm = middle meatus
it = inferior turbinate
Functional Endoscopic Sinus Surgery is a term coined by an American ENT Surgeon, Dr David Kennedy in 1985 to describe the diagnosis and treatment of diseases of the nose and sinuses using endoscopes and CT scans. Kennedy was introduced to sinus endoscopy in Graz, Austria by Professors Messerklinger and Stammberger. FESS is not one operation, but rather a range of diagnostic and treatment procedures carried out with the help of rigid nasal endoscopes. Most patients having FESS will only need diagnostic procedures, not a surgical operation. I began using these techniques in 1987, and helped Stammberger & Kennedy run their first UK FESS course in London in 1988. I have carried out over 2,000 surgical procedures falling under the broad umbrella term of FESS. In 1996 I was awarded a Master of Surgery degree by the University of London for my work in this field. My early clinical research on the outcome of FESS operations, carried out in Sheffield between 1990 and 1992, was one of only three Randomised Controlled Trials (RCT’s) to be accepted for the Cochrane Review of FESS in 2006. The systematic review covered over two thousand papers on FESS published in the world medical literature. Only three studies met their strict quality criteria for inclusion in the evidence base.
Rigid nasal sinus endoscopy (FESS telescope)
The rigid nasal endoscope is a small instrument, like a silver pencil with a light on the end, 4 millimetres or less in diameter. With a range of angled lenses to see around corners, and a powerful fibreoptic light source, the surgeon gets detailed close-up views of the internal nose and sinuses. The examination looks into all the nooks and crannies of the nose, showing the exact location of any narrowings, bony deformities, polyps and the source of any pus drainage. This helps us make a plan for treatment. In most cases, medical treatment will be sufficient. Only a minority of patients with sinus problems need an operation.
- The endoscope is passed gently through the nostrils under local anaesthetic in the out-patients to diagnose the problem.
- It is also used in the operating theatre, usually uon nder general anaesthetic, to
- The main use of the endoscope is in the out-patient clinic, in diagnosis and follow-up.
- In the operating theatre, much of the work can be done under direct vision with a powerful headlight. The angled endoscope is useful for seeing around corners.
Diagnosis with the endoscope does have some limitations. Although we can see the narrow areas where the sinuses open into the nose, we can’t usually see inside the sinuses themselves, unless the openings have already been enlarged. Usually, we can see enough to diagnose the problem with the endoscope. To make a plan for surgery, and see the deeper recesses of the sinuses, we may need a CT Scan.
CT scan showing a thin vertical slice through the face at the level of the eyelids. Air is black, bone is white, soft tissues and fluids are shades of grey. Healthy sinuses appear black, with a white outline. This is because they contain air, and the soft tissue lining is very thin. This slice lies in just front of the maxillary sinuses, so they don’t show. The sphenoid sinuses are much further back.
f = frontal sinus
e = ethmoid sinus
s = nasal septum
it = inferior turbinate
CT scan showing a thin vertical slice behind the eyeballs, toward the back of the nose. The roof of the sinuses is the floor of the brain. The bone separating the sinuses from the eye sockets is paper thin – like an eggshell. The left posterior ethmoid (right on picture) is abnormal. Its lower half is grey. It is half full of thick treacle-like fluid. The fluid level shows as horizontal curved meniscus, with black air above. The middle and inferior turbinates project into the nasal cavity. The inferior turbinates are bigger than normal, they are swollen due to chronic inflammation. The maxillary sinuses (antra) are seen above the roots of the teeth, both have grey swollen linings indicating inflammation. The sphenoid sinuses are just a little further back.
b = brain
o = orbit (eye socket)
pe = posterior ethmoid sinus
mt = middle turbinate
it = inferior turbinate
ma = maxillary antrum sinus
CT Scan of the sinuses
A CT scan is a form of X-Ray imaging which allows us to see the body in much clearer detail than plain X-Rays. Before CT scanning, in the 1980’s, plain X-rays were used to help us diagnose sinus problems. In a plain X-Ray picture, things often look blurred, because all the layers are superimposed on top of each other. Only severe changes – like a sinus full of pus – tend to show up on a plain X-Ray. The CT scan splits the image into thin layers, sliced like a salami, so that we can see much greater detail and pinpoint exactly what is happening at any given point. Modern scanners can produce slices in any direction. Most ENT surgeons prefer thin vertical slices, starting at the tip of the nose and progressing backwards. This matches the view we get when looking directly at the patient face-to-face, and the view we get when passing the endoscope through the nostrils.
Although CT scanning is a great advance, There are important limitations on what the scan can tell us.
- A scan on its own does not diagnose sinus problems. It does provide some additional information. That information must be weighed and interpreted by the ENT specialist, in the light of the history, examination and endoscopic findings.
- A scan is a snapshot of the state of the nose and sinuses on the day it was taken.
- If you recently had a head cold, the soft tissue lining of the nose and sinuses will be swollen and the scan will look abnormal.
- On the contrary, if you get recurrent episodes of sinusitis, but haven’t had one for a few weeks, your scan might look completely normal.
- The only thing that will not change is the bone structure, and the relationship of the eye and brain to the sinuses.
- The bone structure is important to us if we are considering an operation on the sinuses. People vary. Sometimes the optic nerve takes a short cut through the sphenoid sinus on its way to the brain. It is better to know this in advance. There is a risk of blindness from damaging the stray optic nerve during surgery.
- A good radiologist will
- know the sort of information that the ENT specialist needs from the scan
- make sure the slices are done the best way to provide that information
- report the scan in focussed and clinically relevant way
The only way the radiologist will know for sure what is required is by regular feedback and discussion of cases with the surgeon. Equally, the radiologist will keep the surgeon updated with advances in imaging. The patient will get the best quality service from a radiologist who works closely and regularly with the surgeon.
- MRI scans are less useful than CT for most sinus problems, because they don’t show fine bone detail. “Abnormalities” in the sinuses are often picked up as incidental findings on MRI scans carried out for other reasons, even when there is no real problem. Unless you are getting symptoms of sinus problems, we don’t normally need to do anything about a sinus abnormality on an MRI scan. An MRI may be needed in some rare cases of sinus tumours.
How is the operation done?
Functional Endoscopic Sinus Surgery under general anaesthetic using combination Storz debrider with Killian nasal speculum and Welch Allyn headlight.
KTP LASER inferior turbinates during FESS
FESS with 30 degree 4mm Storz Hopkins rigid nasendoscope.
Most FESS operations are done under general anaesthetic (fully asleep) in the operating theatre. The anaesthetist usually sends you to sleep by injection. You will be asleep within a few seconds. The anaesthetist then puts a plastic tube through your mouth into the trachea (windpipe) so that you can breathe during the operation.
- Further information on General Anaesthesia for children
- Further information on General Anaesthesia for adults
Normally there is no external cut, the surgery is done through the nostrils.
- A powerful headlight and angled telescopes to see around corners are used.
- Using specially designed fine bone – cutting instruments, and powered suction debriders when appropriate, the sinus openings will be enlarged and anything blocking the sinuses, such as swollen mucosa or polyps, will be removed.
- Other procedures such as septoplasty and LASER vapourization of inferior turbinates are often done at the same time as FESS.
- If you need stitches, they will be internal and self-dissolving.
- Most FESS operations take less than an hour to do.
- At the end of the operation it is usual to have a pack (sponge dressing) in each nostril to soak up any blood. This is kept in for a few hours. If you have an afternoon operation it will normally stay in overnight, if you have a morning operation it may be removed in the afternoon.
Balloon catheter dilatation for sinusitis – Balloon sinuplasty
In 2005, a new method for enlarging narrowed sinus openings was introduced. The idea came from heart surgery. Balloon catheters have been successfully used to stretch open (dilate) narrowed arteries for over 25 years. In angioplasty, the narrowed segment of a blood vessel is dilated by inflating a balloon from inside the artery. It is a minimally invasive alternative to major open heart surgery.
In balloon sinuplasty, the aim is to stretch and widen narrowed openings into the sinuses.
- Using specially designed instruments, the surgeon gently guides a narrow, flexible wire up the nose and into the sinus.
- A balloon catheter is slid over the wire, until in sits in the sinus opening.
- The balloon is then inflated with liquid, stretching and widening the sinus opening.
- Once the opening has been enlarged, the wire and balloon are removed.
- The enlarged opening usually stays open.
- If needed, washouts and medicines can be put into the sinus through the enlarged opening.
- Several sinuses can be treated in one sitting.
Using a flexible wire and balloon instead of standard cutting and biting instruments means less cutting, less trauma, less bleeding less raw areas left behind. Patients can get back to normal activities more quickly with the minimally invasive technique.
In the UK, balloon sinus dilatation was given official approval as a safe and effective procedure to treat chronic sinusitis by NICE (National Institute of Clinical Excellence) in September 2008.
What is the success rate of surgery?
Polyps and persistent thick sticky secretions in the ethmoid two years following FESS, seen through an endoscope. This asthmatic patient was pleased with the improvement in his ability to breathe through the nose, but still suffered from thick postnasal catarrh.
Between 80 and 90% of patients get great relief of their symptoms and are very pleased with the results of FESS.
- Where the principal symptoms are blockage of the nose, facial pain or headache, the results are good.
- If the principal complaint is of post-nasal catarrh, the results are less encouraging – only around 50% of patients experience worthwhile improvement.
- The sense of smell can usually be restored by FESS, but this may take several months and further post-operative treatment with nasal steroids.
- If there are polyps present, they may recur in up to 50% of patients. This can happen many years after initially successful surgery.
What are the risks?
Nasal and sinus operations are very safe procedures in modern medical practice. But no operation is totally risk free.
- At worst, you could die or suffer brain damage – but you are more likely to be injured in a road accident.
- A general anaesthetic carries a minimal risk, with consultant anaesthetists using modern drugs and monitoring equipment.
- There is a risk of excessive bleeding, either during or up to two weeks after the operation.
- About 2% of patients may need a second operation to control bleeding, readmission to hospital, or a blood transfusion.
- If you are having a septoplasty (straightening of the central partition between the nostrils) there is a small risk of cosmetic deformity.
- Operations for the removal of polyps and opening of the sinuses carry a small risk of damage to the surrounding structures, including the eyes and the brain.
- At worst this could mean blindness, or a leakage of CSF (fluid around the brain) with meningitis and death. The risk of any of these serious complications happening is less than 1:1000.
What other treatment options are there?
Long term medication with antibiotics, antihistamines, and steroids helps many people with nasal and sinus problems. Operations are normally only considered when these treatments have already been tried and failed. Other surgical operations for rhinosinusitis include:
- Sinus washouts / antral lavage
A sinus washout was the mainstay of diagnosis and treatment of sinusitis before FESS came along. It is a simple operation which can be done either under local or general anaesthetic. A large needle is passed into the nostril, and pushed through the bone into the maxillary sinus in the cheek. Any pus or mucus in the sinus is sucked out. Salt water is then injected into the sinus until it runs out through the natural opening, back into the nose. This washes the lining of the sinus. A sinus washout can be very useful in the short term, it can break the “vicious circle” of infection, inflammation, swelling, narrowing, blockage and more infection. The recovery time is very quick, you may be able to go back to work later the same day if done under local anaesthetic. But it does nothing either to diagnose or correct any underlying abnormalities obstructing the sinus drainage, so the problem may well recur. Although it is not normally painful, it is a rather unpleasant experience under local anaesthetic and not something for the squeamish.
Intranasal antrostomy, left inferior meatus, seen through a 30 degree rigid nasendoscope.
s = nasal septum
mm = middle meatus
it = inferior turbinate
ina = intranasal antrostomy
- Intranasal antrostomy
An intranasal antrostomy was a very common procedure for sinusitis before FESS came along in the 1980’s. Antrostomy means making an opening into the antrum – the maxillary sinus. Like FESS, the operation is done through the nostrils, with no external cut, usually under general anaesthetic. Intranasal antrostomy gave pretty good results for maxillary sinusitis. It is now regarded as old fashioned and un-physiological. The opening is made in the inferior meatus – the lower part of the nose – not the middle meatus which is where the natural mucociliary clearance pathways go. The reason for making the hole lower down is to be further away from the eye, a safer place to put it. My randomized controlled trial compared conventional inferior meatal intranasal antrostomy with FESS – endoscopic middle meatal antrostomy. The results, measured by reduction in patient symptom scores, were good with either operation. FESS was slightly better than INA, but the difference was not statistically significant. There were 33 patients in the trial. This wasn’t enough to know if the small difference was real, or just a chance finding. Those 33 patients were selected out of 167 seen in the nasal research clinic. The main reason I could not recruit enough patients for the surgical trial was because so many of them got better on medical treatment and simple sinus washouts. Only a small proportion needed either FESS or INA. We still occasionally carry out inferior meatal intranasal antrostomy, for patients who have a mucociliary clearance defect.
- Caldwell-Luc operation (sublabial antrostomy)
The Caldwell Luc operation is also carried out on the maxillary sinus. It is more radical than the intranasal antrostomy. The sinus is opened by through a cut between the gum and the upper lip, above the canine tooth. A hole is chiselled or drilled through the cheek bone. The lining of the sinus is scraped out. A large intranasal antrostomy is also made. The Caldwell Luc operation was done for almost 100 years, and can give good results for severe chronic maxillary sinusitis. It can cause severe interference with nerves to the teeth and face. One third of patients having Caldwell Luc surgery will have permanent numbness. Many will have painful sensitive nerve endings in the teeth or face. Caldwell Luc surgery is rarely done nowadays, but still has its place occasionally.
Scars through both eyebrows and across the top of the nose one year following osteoplastic flap obliteration of the frontal sinus. There is also a right fronto-ethmoidectomy scar, curved vertically between the eye and the nose, from a previous operation. The patient had suffered chronic frontal sinusitis for many years and had failed to improve following FESS and external fronto-ethmoidectomy. The osteoplastic flap obliteration procedure was successful.
- External fronto-ethmoidectomy
Before FESS, most UK ENT surgeons believed it was too dangerous to operate on the ethmoid sinuses through the nose (intranasal ethmoidectomy) because of the risks of damaging the eyes, brain and arteries. It was thought safer to open the ethmoids via an external cut, between the eyes and the nose. The external fronto-ethmoidectomy is still done for some cases of frontal sinusitis. A cut is made from the eyebrow down to the side of the nose. The contents of the eye socket can be kept in sight by the surgeon throughout the procedure. There is invariably a “black eye”. The frontal sinus opening is enlarged. A plastic tube may be left in place for several months to hold it open. The scar is not usually too noticeable in the long run.
- Osteoplastic flap obliteration of frontal sinus
This is a radical operation for severe chronic frontal sinusitis which won’t settle by other means. A cut is made through both eyebrows, joining together across the bridge of the nose. The scalp is lifted up. The bone of the forehead overlying the frontal sinus is temporarily taken out. The lining of the sinus is completely removed. The cavity is filled with fat taken from the abdomen, and the bone is replaced. The operation is effective, but it takes months for the swelling to go down and there is permanent numbness afterwards.
Before coming into hospital
- If you smoke, you should give up, because smokers are more likely to suffer complications after operation.
- Partners should also consider giving up, as patients must not be exposed to passive smoking during recovery.
- Make sure you have supplies of soluble paracetamol and Karvol or menthol & eucalyptus for steam inhalations for when you come home.
- Do not plan anything important during the two weeks after operation.
Before the operation
Remember to bring any medicines with you to hospital. You will not be allowed anything to eat for about six hours before operation, but you can drink clear fluids up to two hours before. The six hour rule does not apply to medicines – these should be taken as usual. When you come into hospital, you will be seen by the nurse who will ask various questions about your general health and attach an identity bracelet to your wrist. Similar questions will be asked by the Resident Medical Officer, and possibly by the anaesthetist. Please don’t get upset if you are asked the same question several times. This is a routine to help avoid mistakes – like an airport checking your travel documents more than once. You will be examined and checks made to ensure you are fit for anaesthetic. If you have any worries or questions, this is a good time to ask.
After the operation
After the operation, you will wake up in the recovery area, where a nurse will look after you. You will be asked to spit out the plastic tube in your mouth. There will probably be a pack in your nose which means you will have to breathe through your mouth. There may be blood in the mouth or nose. This is quite normal and will stop after a while. When you are sufficiently awake, you will return to the ward. You will stay in bed for several hours. Your throat will feel sore, your nose will be blocked, you will feel thirsty and tired, and you may be sick. Spit out any blood or secretions; if swallowed it will make you feel sick. The nurse will attend you frequently to check your pulse and breathing. If you are in any discomfort, please let the nurse know as she can you an injection to help relieve it. You will be allowed to drink as soon as the nurse is happy with your condition. You will be advised not to have too much initially as it might make you sick. Food is started as soon as you are able.
When you go home after FESS
Expect to feel as if you have a bad cold or ‘flu for the first 1 – 2 weeks. This is because the lining of your nose will swell up following the trauma of surgery, like the swelling which occurs in viral infections of the nasal lining following a cold. You may well notice large amounts of dark red, brown or green sticky material coming from the back of your nose into the throat, or when you blow your nose, for up to three months after the operation. This is normal and nothing to worry about.
Things to do
- Take all medicines as prescribed, especially antibiotics or nose drops.
- Attend your follow-up appointments – Important treatment will be given.
- Steam inhalations – at least three times daily for two weeks:
- Put a large container e.g. a washing up bowl on the table
- Pour 3 pints of boiling water into it (take sensible precautions against splashing/accidents)
- Add a small amount of Karvol or Menthol & Eucalyptus (from the pharmacist)
- Sit down in front of the bowl with a towel over your shoulders
- Pull the towel over your head to form a “tent” over the bowl
- Breathe the steam in through your nose, out through your mouth for five minutes
- If Otrivine nose drops have also been prescribed, use them before the inhalations.
Things to avoid (for two weeks)
- Smoking, or any smoky, dirty or dusty atmosphere
- Heavy physical work, including fitness training
- Blowing the nose hard (gentle blowing is acceptable but try a steam inhalation first)
- Close contact with people suffering from cold or flu (avoid large crowds for this reason)
- Excessive Alcohol (up to three units per day at meal times is acceptable)
- Swimming and diving
- Athletic sexual exertion. Gentle activities are OK if you feel up to it
A minor degree of bleeding – a few spots on a handkerchief, some bloodstained discharge from the nose – is normal and nothing to worry about. You may get a few large dark red or brown clots coming from the nose, or going back into the throat, in the first 1 – 2 weeks; again this is normal and nothing to worry about. If you get a profuse amount of bright red blood, this is not normal. You should
- Sit down in a chair, pinch the nose and breathe through the mouth.
- If there is someone else around, ask them to put some ice in a plastic bag, and hold it over the bridge of your nose.
- If it doesn’t stop within five minutes you should contact us or the hospital where you had your procedure for advice.
Although we will do our best to help, we are not a 24/7 service. Also, the private hospitals are set up for planned, elective surgery, not for emergency admissions. The emergency on-call rota for ENT in East Kent is based in the NHS Rotary Ward at the William Harvey Hospital, Ashford.
- In a more urgent situation, you may need to use the 24/7 NHS emergency ENT Service based on the Rotary Ward, William Harvey Hospital.
- William Harvey is the only hospital in East Kent which maintains 24 hour emergency ENT cover.
- You should phone the Rotary ward and speak to the nurse in charge or the on-call ENT doctor.
Rotary Ward Direct tel. (3 lines)
- In case of severe bleeding or airway / breathing problems, call 999 for an ambulance or go directly to your nearest Accident & Emergency department.
- Do not waste time by attempting to contact your GP surgery, they will only refer you to hospital.
All information and advice on this website is of a general nature and may not apply to you. There is no substitute for an individual consultation. We recommend that you see your General Practitioner if you would like to be referred.