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[[File:Mani Zadeh MD Endoscopic Sinus Surgery.jpg|thumb|Otolaryngologist performing Functional Endoscopic Sinus Surgery. An endoscopic view of the nasal cavity is displayed in real-time on the monitor.]]
[[File:Mani Zadeh MD Endoscopic Sinus Surgery.jpg|thumb|Otolaryngologist performing Functional Endoscopic Sinus Surgery. An endoscopic view of the nasal cavity is displayed in real-time on the monitor.]]
'''Functional endoscopic sinus surgery''' ('''FESS''') is a minimally invasive surgical treatment which uses nasal endoscopes to enlarge the nasal drainage pathways of the paranasal sinuses to improve sinus ventilation.<ref name=":24">{{Cite journal|last=Slack|first=R.|last2=Bates|first2=G.|date=1998-09-01|title=Functional endoscopic sinus surgery|url=https://www.ncbi.nlm.nih.gov/pubmed/9750539|journal=American Family Physician|volume=58|issue=3|pages=707–718|issn=0002-838X|pmid=9750539}}</ref><ref name=":53">{{Cite web|url=https://www.med.unc.edu/ent/patient-care/clinical-services/sinus-and-allergy-1/functional-endoscopic-sinus-surgery/|title=Functional Endoscopic Sinus Surgery {{!}} UNC Otolaryngology/Head and Neck Surgery|website=www.med.unc.edu|language=en-US|access-date=2018-06-09}}</ref> This procedure is generally used to treat inflammatory and infectious sinus diseases, including [[Sinusitis|chronic rhinosinusitis]] that doesn't respond to drugs,<ref name=":33">{{Cite journal|last=Cazzavillan|first=Alessandro|last2=Castelnuovo|first2=Paolo|last3=Berlucchi|first3=Marco|last4=Baiardini|first4=Ilaria|last5=Franzetti|first5=Andrea|last6=Nicolai|first6=Piero|last7=Gallo|first7=Stefania|last8=Passalacqua|first8=Giovanni|date=2012-07-04|title=Management of chronic rhinosinusitis|url=http://doi.wiley.com/10.1111/j.1399-3038.2012.01322.x|journal=Pediatric Allergy and Immunology|language=en|volume=23|pages=32–44|doi=10.1111/j.1399-3038.2012.01322.x|issn=0905-6157}}</ref><ref name=":63">{{Cite journal|last=Sukato|first=Daniel C.|last2=Abramowitz|first2=Jason M.|last3=Boruk|first3=Marina|last4=Goldstein|first4=Nira A.|last5=Rosenfeld|first5=Richard M.|date=2018-2|title=Endoscopic Sinus Surgery Improves Sleep Quality in Chronic Rhinosinusitis: A Systematic Review and Meta-analysis|url=https://www.ncbi.nlm.nih.gov/pubmed/29065273|journal=Otolaryngology--Head and Neck Surgery: Official Journal of American Academy of Otolaryngology-Head and Neck Surgery|volume=158|issue=2|pages=249–256|doi=10.1177/0194599817737977|issn=1097-6817|pmid=29065273}}</ref> [[Nasal polyp|nasal polyps]],<ref name=":72">{{Cite journal|date=2018-04-05|title=Functional Endoscopic Sinus Surgery: Overview, Preparation, Technique|url=https://emedicine.medscape.com/article/863420-overview#showall}}</ref><ref name=":33" /> some cancers,<ref>{{Cite journal|last=Meccariello|first=Giuseppe|last2=Deganello|first2=Alberto|last3=Choussy|first3=Olivier|last4=Gallo|first4=Oreste|last5=Vitali|first5=Daniele|last6=De Raucourt|first6=Dominique|last7=Georgalas|first7=Christos|date=2015-09-03|title=Endoscopic nasal versus open approach for the management of sinonasal adenocarcinoma: A pooled-analysis of 1826 patients|url=http://doi.wiley.com/10.1002/hed.24182|journal=Head & Neck|language=en|volume=38|issue=S1|pages=E2267–E2274|doi=10.1002/hed.24182|issn=1043-3074}}</ref> and decompression of eye sockets/[[optic nerve]] in [[Graves ophthalmopathy]].<ref name=":24" />
'''Functional endoscopic sinus surgery''' ('''FESS''') is a minimally invasive surgical treatment which uses nasal endoscopes to enlarge the nasal drainage pathways of the paranasal sinuses to improve sinus ventilation.<ref name="Slack_1998">{{cite journal | vauthors = Slack R, Bates G | title = Functional endoscopic sinus surgery | journal = American Family Physician | volume = 58 | issue = 3 | pages = 707–18 | date = September 1998 | pmid = 9750539 }}</ref><ref name="UNC">{{Cite web|url=https://www.med.unc.edu/ent/patient-care/clinical-services/sinus-and-allergy-1/functional-endoscopic-sinus-surgery/|title=Functional Endoscopic Sinus Surgery | work = UNC Otolaryngology/Head and Neck Surgery |access-date=2018-06-09}}</ref> This procedure is generally used to treat inflammatory and infectious sinus diseases, including [[Sinusitis|chronic rhinosinusitis]] that doesn't respond to drugs,<ref name="Cazzavillan_2012">{{cite journal | vauthors = Cazzavillan A, Castelnuovo P, Berlucchi M, Baiardini I, Franzetti A, Nicolai P, Gallo S, Passalacqua G | title = Management of chronic rhinosinusitis | journal = Pediatric Allergy and Immunology | volume = 23 Suppl 22 | pages = 32–44 | date = August 2012 | pmid = 22762852 | doi = 10.1111/j.1399-3038.2012.01322.x }}</ref><ref name="Sukato_2018">{{cite journal | vauthors = Sukato DC, Abramowitz JM, Boruk M, Goldstein NA, Rosenfeld RM | title = Endoscopic Sinus Surgery Improves Sleep Quality in Chronic Rhinosinusitis: A Systematic Review and Meta-analysis | journal = Otolaryngology--Head and Neck Surgery | volume = 158 | issue = 2 | pages = 249–256 | date = February 2018 | pmid = 29065273 | doi = 10.1177/0194599817737977 }}</ref> [[Nasal polyp|nasal polyps]],<ref name="Patel_2016">{{cite journal | vauthors = Patel A |date= 2 March 2016 |title=Functional Endoscopic Sinus Surgery: Overview, Preparation, Technique|url=https://emedicine.medscape.com/article/863420-overview#showall}}</ref><ref name="Cazzavillan_2012" /> some cancers,<ref>{{cite journal | vauthors = Meccariello G, Deganello A, Choussy O, Gallo O, Vitali D, De Raucourt D, Georgalas C | title = Endoscopic nasal versus open approach for the management of sinonasal adenocarcinoma: A pooled-analysis of 1826 patients | journal = Head & Neck | volume = 38 Suppl 1 | issue = S1 | pages = E2267-74 | date = April 2016 | pmid = 26335008 | doi = 10.1002/hed.24182 }}</ref> and decompression of eye sockets/[[optic nerve]] in [[Graves ophthalmopathy]].<ref name="Slack_1998" />


In the surgery, an [[Otorhinolaryngology|otolaryngologist]] removes the [[Uncinate process of ethmoid bone|uncinate process of the ethmoid bone]], while visualizing the nasal passage using a fiberoptic endoscope.<ref name=":2">{{Cite journal|last=Slack|first=R.|last2=Bates|first2=G.|date=1998-09-01|title=Functional endoscopic sinus surgery|url=https://www.ncbi.nlm.nih.gov/pubmed/9750539|journal=American Family Physician|volume=58|issue=3|pages=707–718|issn=0002-838X|pmid=9750539}}</ref> FESS can be performed under local anesthesia as an outpatient procedure.<ref name=":7">{{Cite journal|date=2018-04-05|title=Functional Endoscopic Sinus Surgery: Overview, Preparation, Technique|url=https://emedicine.medscape.com/article/863420-overview#showall}}</ref> Generally patients experience only minimal discomfort during and after surgery. The procedure can take from 2 to 4 hours to complete.<ref name=":5">{{Cite web|url=https://www.med.unc.edu/ent/patient-care/clinical-services/sinus-and-allergy-1/functional-endoscopic-sinus-surgery/|title=Functional Endoscopic Sinus Surgery {{!}} UNC Otolaryngology/Head and Neck Surgery|website=www.med.unc.edu|language=en-US|access-date=2018-06-09}}</ref>
In the surgery, an [[Otorhinolaryngology|otolaryngologist]] removes the [[Uncinate process of ethmoid bone|uncinate process of the ethmoid bone]], while visualizing the nasal passage using a fiberoptic endoscope.<ref name="Slack_1998" /> FESS can be performed under local anesthesia as an outpatient procedure.<ref name="Patel_2016" /> Generally patients experience only minimal discomfort during and after surgery. The procedure can take from 2 to 4 hours to complete.<ref name="UNC" />


== History ==
== History ==
The first recorded instance of endoscopy being used for visualization of the nasal passage was in Berlin, Germany in 1901.<ref name=":0">{{Cite journal|last=Tajudeen|first=Bobby A.|last2=Kennedy|first2=David W.|date=2017-06|title=Thirty years of endoscopic sinus surgery: What have we learned?|url=http://linkinghub.elsevier.com/retrieve/pii/S2095881116300403|journal=World Journal of Otorhinolaryngology - Head and Neck Surgery|volume=3|issue=2|pages=115–121|doi=10.1016/j.wjorl.2016.12.001|issn=2095-8811|pmc=PMC5683659|pmid=29204590}}</ref> Alfred Hirschmann, who designed and made medical instruments, modified a [[Cystoscopy|cytoscope]] to be used in the nasal cavity. In October 1903, Hirschmann published "Endoscopy of the nose and its accessory sinuses."<ref>{{Cite journal|last=Hirschmann|first=Alfred|date=1903-10|title=Endoscopy of the nose and its accessory sinuses|url=http://doi.wiley.com/10.1288/00005537-190310000-00015|journal=The Laryngoscope|language=en|volume=13|issue=10|pages=810–810|doi=10.1288/00005537-190310000-00015|issn=0023-852X}}</ref> In 1910, M. Reichart performed the first endoscopic sinus surgery using a 7 mm endoscope. In 1925, Maxwell Maltz, MD created the term "sinuscopy," referring to the endoscopic method of visualizing the sinuses. Maltz also encouraged the use of endoscopes as a diagnostic tool for nasal and sinus abnormalities.<ref name=":0" /><p>In the 1960s, [[Harold Hopkins (physicist)|Harold Hopkins]], PhD at [[University of Reading|Reading University]] used his background in physics to develop an endoscope that provided more light and had drastically better resolution than previous endoscopes. Hopkins' rod optic system is widely credited with being a turning point for nasal endoscopy.<ref name=":0" /></p><p>Utilizing Hopkins' rod optic system, Austrian doctor Walter Messenklinger visualized and recorded the anatomy of the paranasal sinuses and the lateral nasal walls in cadavers. Specifically, Messerklinger focused on mapping out mucociliary routes.<ref name=":1">{{Cite journal|last=Kane|first=Kevin J.|date=2018-01-17|title=The early history and development of endoscopic sinonasal surgery in Australia: 1985–2005|url=http://www.theajo.com/article/view/3997|journal=Australian Journal of Otolaryngology|language=en|volume=1|issue=1|doi=10.21037/ajo.2018.01.08}}</ref> In 1978, Messerklinger published the book titled "Endoscopy of the Nose" on his findings, and his proposed methods to utilize nasal endoscopy for diagnosis.<ref>{{Cite book|url=https://www.worldcat.org/oclc/3447558|title=Endoscopy of the nose|last=Walter.|first=Messerklinger,|date=1978|publisher=Urban & Schwarzenberg|isbn=0806712112|location=Baltimore|oclc=3447558}}</ref></p>After learning of Messenklinger's endoscopic techniques, David Kennedy, MD, and Karl Storz, MD, of [[Johns Hopkins University]] developed instruments for use in endoscopic sinus surgery, and coined the term Functional Endoscopic Sinus Surgery.<ref name=":1" /> Kennedy published multiple papers on FESS use and technique, and in 1985 the first course on FESS was taught at Johns Hopkins Medical Center.<ref name=":0" />
The first recorded instance of endoscopy being used for visualization of the nasal passage was in Berlin, Germany in 1901.<ref name="Tajudeen_2017">{{cite journal | vauthors = Tajudeen BA, Kennedy DW | title = Thirty years of endoscopic sinus surgery: What have we learned? | journal = World Journal of Otorhinolaryngology - Head and Neck Surgery | volume = 3 | issue = 2 | pages = 115–121 | date = June 2017 | pmid = 29204590 | pmc = 5683659 | doi = 10.1016/j.wjorl.2016.12.001 | url = http://linkinghub.elsevier.com/retrieve/pii/S2095881116300403 }}</ref> Alfred Hirschmann, who designed and made medical instruments, modified a [[Cystoscopy|cytoscope]] to be used in the nasal cavity. In October 1903, Hirschmann published "Endoscopy of the nose and its accessory sinuses."<ref>{{Cite journal|last=Hirschmann|first=Alfred | name-list-format = vanc |date= October 1903 |title=Endoscopy of the nose and its accessory sinuses |journal=The Laryngoscope |volume=13|issue=10|pages=810–810|doi=10.1288/00005537-190310000-00015|issn=0023-852X}}</ref> In 1910, M. Reichart performed the first endoscopic sinus surgery using a 7 mm endoscope. In 1925, Maxwell Maltz, MD created the term "sinuscopy," referring to the endoscopic method of visualizing the sinuses. Maltz also encouraged the use of endoscopes as a diagnostic tool for nasal and sinus abnormalities.<ref name="Tajudeen_2017" /><p>In the 1960s, [[Harold Hopkins (physicist)|Harold Hopkins]], PhD at [[University of Reading|Reading University]] used his background in physics to develop an endoscope that provided more light and had drastically better resolution than previous endoscopes. Hopkins' rod optic system is widely credited with being a turning point for nasal endoscopy.<ref name="Tajudeen_2017" /> Utilizing Hopkins' rod optic system, Austrian doctor Walter Messenklinger visualized and recorded the anatomy of the paranasal sinuses and the lateral nasal walls in cadavers. Specifically, Messerklinger focused on mapping out mucociliary routes.<ref name="Kane_2017">{{Cite journal|last=Kane|first=Kevin J. | name-list-format = vanc |date=2018-01-17|title=The early history and development of endoscopic sinonasal surgery in Australia: 1985–2005|url=http://www.theajo.com/article/view/3997|journal=Australian Journal of Otolaryngology |volume=1|issue=1|doi=10.21037/ajo.2018.01.08}}</ref> In 1978, Messerklinger published the book titled "Endoscopy of the Nose" on his findings, and his proposed methods to utilize nasal endoscopy for diagnosis.<ref>{{cite book | url = https://www.worldcat.org/oclc/3447558 |title=Endoscopy of the nose|last=Walter.|first=Messerklinger | name-list-format = vanc |date=1978|publisher=Urban & Schwarzenberg|isbn=0806712112|location=Baltimore|oclc=3447558}}</ref></p>After learning of Messenklinger's endoscopic techniques, David Kennedy, MD, and Karl Storz, MD, of [[Johns Hopkins University]] developed instruments for use in endoscopic sinus surgery, and coined the term Functional Endoscopic Sinus Surgery.<ref name="Kane_2017" /> Kennedy published multiple papers on FESS use and technique, and in 1985 the first course on FESS was taught at Johns Hopkins Medical Center.<ref name="Tajudeen_2017" />


== Medical applications ==
== Medical applications ==
[[File:CHOANAL_POLYP_PerfectlyClear.jpg|link=https://en.wikipedia.org/wiki/File:CHOANAL_POLYP_PerfectlyClear.jpg|thumb|Large nasal polyp (round mass, center), which is commonly treated and removed by FESS.]]Functional Endoscopic Sinus Surgery is most commonly used to treat chronic rhinosinusitis,<ref name=":22">{{Cite journal|last=Slack|first=R.|last2=Bates|first2=G.|date=1998-09-01|title=Functional endoscopic sinus surgery|url=https://www.ncbi.nlm.nih.gov/pubmed/9750539|journal=American Family Physician|volume=58|issue=3|pages=707–718|issn=0002-838X|pmid=9750539}}</ref> only after all non-surgical treatment options such as antibiotics, topical nasal corticosteroids, and nasal lavage with saline solutions<ref name=":32">{{Cite journal|last=Cazzavillan|first=Alessandro|last2=Castelnuovo|first2=Paolo|last3=Berlucchi|first3=Marco|last4=Baiardini|first4=Ilaria|last5=Franzetti|first5=Andrea|last6=Nicolai|first6=Piero|last7=Gallo|first7=Stefania|last8=Passalacqua|first8=Giovanni|date=2012-07-04|title=Management of chronic rhinosinusitis|url=http://doi.wiley.com/10.1111/j.1399-3038.2012.01322.x|journal=Pediatric Allergy and Immunology|language=en|volume=23|pages=32–44|doi=10.1111/j.1399-3038.2012.01322.x|issn=0905-6157}}</ref> have been exhausted. Chronic rhinosinusitis (CRS) is an inflammatory condition in which the nose and at least one sinus become swollen and interfere with mucus drainage.<ref name=":32" /> It can be caused by anatomical factors such as a deviated septum or nasal polyps (growths), as well as infection. Symptoms include difficulty breathing through the nose, swelling and pain around the nose and eyes, postnasal drainage down the throat, and difficulty sleeping.<ref>{{Cite news|url=https://www.mayoclinic.org/diseases-conditions/chronic-sinusitis/symptoms-causes/syc-20351661|title=Chronic sinusitis - Symptoms and causes|work=Mayo Clinic|access-date=2018-06-09|language=en}}</ref> CRS is a common condition in pediatric patients and young adults.<ref name=":4">{{Cite journal|last=Makary|first=Chadi A.|last2=Ramadan|first2=Hassan H.|date=2013-01-29|title=The role of sinus surgery in children|url=http://doi.wiley.com/10.1002/lary.23961|journal=The Laryngoscope|language=en|volume=123|issue=6|pages=1348–1352|doi=10.1002/lary.23961|issn=0023-852X}}</ref>
[[File:CHOANAL_POLYP_PerfectlyClear.jpg|link=https://en.wikipedia.org/wiki/File:CHOANAL_POLYP_PerfectlyClear.jpg|thumb|Large nasal polyp (round mass, center), which is commonly treated and removed by FESS.]]Functional Endoscopic Sinus Surgery is most commonly used to treat chronic rhinosinusitis,<ref name="Slack_1998" /> only after all non-surgical treatment options such as antibiotics, topical nasal corticosteroids, and nasal lavage with saline solutions<ref name="Cazzavillan_2012" /> have been exhausted. Chronic rhinosinusitis (CRS) is an inflammatory condition in which the nose and at least one sinus become swollen and interfere with mucus drainage.<ref name="Cazzavillan_2012" /> It can be caused by anatomical factors such as a deviated septum or nasal polyps (growths), as well as infection. Symptoms include difficulty breathing through the nose, swelling and pain around the nose and eyes, postnasal drainage down the throat, and difficulty sleeping.<ref>{{Cite news|url=https://www.mayoclinic.org/diseases-conditions/chronic-sinusitis/symptoms-causes/syc-20351661|title=Chronic sinusitis - Symptoms and causes|work=Mayo Clinic|access-date=2018-06-09|language=en}}</ref> CRS is a common condition in pediatric patients and young adults.<ref name="Makary_2013">{{cite journal | vauthors = Makary CA, Ramadan HH | title = The role of sinus surgery in children | journal = The Laryngoscope | volume = 123 | issue = 6 | pages = 1348–52 | date = June 2013 | pmid = 23361382 | doi = 10.1002/lary.23961 }}</ref>


The purpose of FESS in treatment of CRS is to remove any anatomical obstructions that prevent proper mucosal drainage. A standard FESS includes removal of the uncinate process, and opening of the anterior ethmoid air cells and Haller cells<ref>{{Cite journal|last=Levine|first=Corinna G.|last2=Casiano|first2=Roy R.|date=2017-02|title=Revision Functional Endoscopic Sinus Surgery|url=http://linkinghub.elsevier.com/retrieve/pii/S0030666516301700|journal=Otolaryngologic Clinics of North America|volume=50|issue=1|pages=143–164|doi=10.1016/j.otc.2016.08.012|issn=0030-6665}}</ref> as well as the maxillary ostium, if necessary. If any nasal polyps obstructing ventilation or drainage are present, they are also removed.<ref name=":22" /><p>In the case of paranasal sinus/nasal cavity tumors (benign or cancerous), an otolaryngolist or ENT surgeon can perform FESS to remove the growths, sometimes with the help of a [[Neurosurgery|neurosurgeon]], depending on the extent of the tumor. In some cases, a graft of bone or skin is placed by FESS to repair damages by the tumor.<ref>{{Cite web|url=http://care.american-rhinologic.org/surgery_tumors|title=Treatment of Sinus Tumors|website=care.american-rhinologic.org|access-date=2018-06-09}}</ref></p>In the thyroid disorder known as [[Graves' ophthalmopathy|Graves Ophthalmopathy]], inflammation and fat accumulation in the orbitonasal region cause severe proptosis.<ref>{{Cite journal|last=Cury|first=Sarah Santiloni|last2=Oliveira|first2=Miriane|last3=Síbio|first3=Maria Teresa|last4=Clara|first4=Sueli|last5=Luvizotto|first5=Renata De Azevedo Melo|last6=Conde|first6=Sandro|last7=Jorge|first7=Edson Nacib|last8=Nunes|first8=Vania dos Santos|last9=Nogueira|first9=Célia Regina|date=00/2018|title=Graves’ ophthalmopathy: low-dose dexamethasone reduces retinoic acid receptor-alpha gene expression in orbital fibroblasts|url=http://www.scielo.br/scielo.php?script=sci_abstract&pid=S2359-39972018005002010&lng=en&nrm=iso&tlng=en|journal=Archives of Endocrinology and Metabolism|issue=AHEAD|doi=10.20945/2359-3997000000044|issn=2359-3997}}</ref> In cases that have not responded to corticosteroid treatment, FESS can be used to decompress the orbital region by removing the ethmoid air cells and lamina papyracea. Bones of the orbital cavity or portions of the orbital floor may also be removed.<ref name=":02">{{Cite journal|last=Tajudeen|first=Bobby A.|last2=Kennedy|first2=David W.|date=2017-06|title=Thirty years of endoscopic sinus surgery: What have we learned?|url=http://linkinghub.elsevier.com/retrieve/pii/S2095881116300403|journal=World Journal of Otorhinolaryngology - Head and Neck Surgery|volume=3|issue=2|pages=115–121|doi=10.1016/j.wjorl.2016.12.001|issn=2095-8811|pmc=PMC5683659|pmid=29204590}}</ref>
The purpose of FESS in treatment of CRS is to remove any anatomical obstructions that prevent proper mucosal drainage. A standard FESS includes removal of the uncinate process, and opening of the anterior ethmoid air cells and Haller cells<ref>{{cite journal | vauthors = Levine CG, Casiano RR | title = Revision Functional Endoscopic Sinus Surgery | journal = Otolaryngologic Clinics of North America | volume = 50 | issue = 1 | pages = 143–164 | date = February 2017 | pmid = 27888911 | doi = 10.1016/j.otc.2016.08.012 | url = http://linkinghub.elsevier.com/retrieve/pii/S0030666516301700 }}</ref> as well as the maxillary ostium, if necessary. If any nasal polyps obstructing ventilation or drainage are present, they are also removed. <ref name="Slack_1998" /> In the case of paranasal sinus/nasal cavity tumors (benign or cancerous), an otolaryngolist or ENT surgeon can perform FESS to remove the growths, sometimes with the help of a [[Neurosurgery|neurosurgeon]], depending on the extent of the tumor. In some cases, a graft of bone or skin is placed by FESS to repair damages by the tumor.<ref>{{Cite web|url=http://care.american-rhinologic.org/surgery_tumors|title=Treatment of Sinus Tumors|website=care.american-rhinologic.org|access-date=2018-06-09}}</ref></p>In the thyroid disorder known as [[Graves' ophthalmopathy|Graves Ophthalmopathy]], inflammation and fat accumulation in the orbitonasal region cause severe proptosis.<ref>{{cite journal | vauthors = Cury SS, Oliveira M, Síbio MT, Clara S, Luvizotto RA, Conde S, Jorge EN, Nunes VD, Nogueira CR, Mazeto GM | title = Graves' ophthalmopathy: low-dose dexamethasone reduces retinoic acid receptor-alpha gene expression in orbital fibroblasts | journal = Archives of Endocrinology and Metabolism | issue = AHEAD | date = May 2018 | pmid = 29791662 | doi = 10.20945/2359-3997000000044 | url = http://www.scielo.br/scielo.php?script=sci_abstract&pid=S2359-39972018005002010&lng=en&nrm=iso&tlng=en }}</ref> In cases that have not responded to corticosteroid treatment, FESS can be used to decompress the orbital region by removing the ethmoid air cells and lamina papyracea. Bones of the orbital cavity or portions of the orbital floor may also be removed.<ref name="Tajudeen_2017" />


The endoscopic approach to FESS is a less invasive method than open sinus surgery, which allows patients to be more comfortable during and after the procedure. Entering the surgical field via the nose, rather than through an incision in the mouth as in the previous Caldwell-Luc method, decreases risk of damaging nerves which enervate the teeth.<ref name=":22" /> Because of its less-invasive nature, FESS is a common option for children with CRS or other sinonasal complications.
The endoscopic approach to FESS is a less invasive method than open sinus surgery, which allows patients to be more comfortable during and after the procedure. Entering the surgical field via the nose, rather than through an incision in the mouth as in the previous Caldwell-Luc method, decreases risk of damaging nerves which enervate the teeth.<ref name="Slack_1998" /> Because of its less-invasive nature, FESS is a common option for children with CRS or other sinonasal complications.


== Outcomes and complications ==
== Outcomes and complications ==
Functional Endoscopic Sinus Surgery is considered a success if most of the symptoms, including nasal obstruction, sleep quality, olfaction and facial pain, are resolved after a 1-2 month postoperative healing period.<ref name=":23">{{Cite journal|last=Slack|first=R.|last2=Bates|first2=G.|date=1998-09-01|title=Functional endoscopic sinus surgery|url=https://www.ncbi.nlm.nih.gov/pubmed/9750539|journal=American Family Physician|volume=58|issue=3|pages=707–718|issn=0002-838X|pmid=9750539}}</ref><ref>{{Cite journal|last=Prasad|first=Shashi|last2=Fong|first2=Eric|last3=Ooi|first3=Eng H.|date=2017-07-01|title=Systematic review of patient-reported outcomes after revision endoscopic sinus surgery|url=https://www.ncbi.nlm.nih.gov/pubmed/28716176|journal=American Journal of Rhinology & Allergy|volume=31|issue=4|pages=248–255|doi=10.2500/ajra.2017.31.4446|issn=1945-8932|pmid=28716176}}</ref><ref name=":62">{{Cite journal|last=Sukato|first=Daniel C.|last2=Abramowitz|first2=Jason M.|last3=Boruk|first3=Marina|last4=Goldstein|first4=Nira A.|last5=Rosenfeld|first5=Richard M.|date=2018-2|title=Endoscopic Sinus Surgery Improves Sleep Quality in Chronic Rhinosinusitis: A Systematic Review and Meta-analysis|url=https://www.ncbi.nlm.nih.gov/pubmed/29065273|journal=Otolaryngology--Head and Neck Surgery: Official Journal of American Academy of Otolaryngology-Head and Neck Surgery|volume=158|issue=2|pages=249–256|doi=10.1177/0194599817737977|issn=1097-6817|pmid=29065273}}</ref> Reviews of FESS as a method for treating chronic rhinosinusitis have shown that a majority of patients report increased quality of life after undergoing surgery.<ref>{{Cite journal|last=Soler|first=Zachary M.|last2=Jones|first2=Rabun|last3=Le|first3=Phong|last4=Rudmik|first4=Luke|last5=Mattos|first5=Jose L.|last6=Nguyen|first6=Shaun A.|last7=Schlosser|first7=Rodney J.|date=2018-3|title=Sino-Nasal outcome test-22 outcomes after sinus surgery: A systematic review and meta-analysis|url=https://www.ncbi.nlm.nih.gov/pubmed/29164622|journal=The Laryngoscope|volume=128|issue=3|pages=581–592|doi=10.1002/lary.27008|issn=1531-4995|pmc=PMC5814358|pmid=29164622}}</ref><ref>{{Cite journal|last=Prasad|first=Shashi|last2=Fong|first2=Eric|last3=Ooi|first3=Eng H.|date=2017-07-01|title=Systematic review of patient-reported outcomes after revision endoscopic sinus surgery|url=https://www.ncbi.nlm.nih.gov/pubmed/28716176|journal=American Journal of Rhinology & Allergy|volume=31|issue=4|pages=248–255|doi=10.2500/ajra.2017.31.4446|issn=1945-8932|pmid=28716176}}</ref> The success rate of FESS in treating adults with CRS has been reported as 80-90%,<ref>{{Cite journal|last=Stammberger|first=H.|last2=Posawetz|first2=W.|date=1990|title=Functional endoscopic sinus surgery. Concept, indications and results of the Messerklinger technique|url=https://www.ncbi.nlm.nih.gov/pubmed/2180446|journal=European archives of oto-rhino-laryngology: official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS): affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery|volume=247|issue=2|pages=63–76|issn=0937-4477|pmid=2180446}}</ref> and the success rate in treating children with CRS has been reported as 86-97%.<ref name=":42">{{Cite journal|last=Makary|first=Chadi A.|last2=Ramadan|first2=Hassan H.|date=2013-01-29|title=The role of sinus surgery in children|url=http://doi.wiley.com/10.1002/lary.23961|journal=The Laryngoscope|language=en|volume=123|issue=6|pages=1348–1352|doi=10.1002/lary.23961|issn=0023-852X}}</ref><p>The most common complication of FESS is [[cerebrospinal fluid leak]], which has been observed in about 0.2% of patients. Generally, CSFL arises during surgery and can be repaired with no additional related complications postoperatively. Other risks of surgery include [[infection]], bleeding, double vision usually lasting a few hours, numbness of the front teeth, [[Hematoma|orbital hematoma]], decreased sense of smell, and blindness.<ref name=":52">{{Cite web|url=https://www.med.unc.edu/ent/patient-care/clinical-services/sinus-and-allergy-1/functional-endoscopic-sinus-surgery/|title=Functional Endoscopic Sinus Surgery {{!}} UNC Otolaryngology/Head and Neck Surgery|website=www.med.unc.edu|language=en-US|access-date=2018-06-09}}</ref><ref>{{Cite news|url=https://med.uth.edu/orl/2012/09/07/functional-endoscopic-sinus-surgery/|title=Functional Endoscopic Sinus Surgery - Otorhinolaryngology - Head & Neck Surgery|last=School|first=McGovern Medical|date=2012-09-07|work=Otorhinolaryngology - Head & Neck Surgery|access-date=2018-06-11|language=en-US}}</ref> Blindness is the single most serious complication of FESS, and results from damage to the optic nerve during surgery. Serious complications such as blindness occur in only 0.44% of cases, as determined by a study performed in the United Kingdom.<ref name=":23" /></p>A [[Cochrane review]] in 2006 based on three [[Randomized control trial|randomized control trials]] concluded that FESS has not been shown to provide significantly better results than than medical treatment for chronic rhinosinusitis.<ref>{{Citation|last=Khalil|first=Hisham|title=Functional endoscopic sinus surgery for chronic rhinosinusitis|date=2006-07-19|url=http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD004458.pub2/full|work=The Cochrane Library|publisher=John Wiley & Sons, Ltd|language=en|doi=10.1002/14651858.cd004458.pub2|accessdate=2018-06-11|last2=Nunez|first2=Desmond A.}}</ref>
Functional Endoscopic Sinus Surgery is considered a success if most of the symptoms, including nasal obstruction, sleep quality, olfaction and facial pain, are resolved after a 1-2 month postoperative healing period.<ref name="Slack_1998" /><ref name = "Prasad_2017">{{cite journal | vauthors = Prasad S, Fong E, Ooi EH | title = Systematic review of patient-reported outcomes after revision endoscopic sinus surgery | journal = American Journal of Rhinology & Allergy | volume = 31 | issue = 4 | pages = 248–255 | date = July 2017 | pmid = 28716176 | doi = 10.2500/ajra.2017.31.4446 }}</ref><ref name="Sukato_2018" /> Reviews of FESS as a method for treating chronic rhinosinusitis have shown that a majority of patients report increased quality of life after undergoing surgery.<ref>{{cite journal | vauthors = Soler ZM, Jones R, Le P, Rudmik L, Mattos JL, Nguyen SA, Schlosser RJ | title = Sino-Nasal outcome test-22 outcomes after sinus surgery: A systematic review and meta-analysis | journal = The Laryngoscope | volume = 128 | issue = 3 | pages = 581–592 | date = March 2018 | pmid = 29164622 | pmc = 5814358 | doi = 10.1002/lary.27008 }}</ref><ref name = "Prasad_2017" /> The success rate of FESS in treating adults with CRS has been reported as 80-90%,<ref>{{cite journal | vauthors = Stammberger H, Posawetz W | title = Functional endoscopic sinus surgery. Concept, indications and results of the Messerklinger technique | journal = European Archives of Oto-Rhino-Laryngology | volume = 247 | issue = 2 | pages = 63–76 | date = 1990 | pmid = 2180446 }}</ref> and the success rate in treating children with CRS has been reported as 86-97%.<ref name="Makary_2013" /> The most common complication of FESS is [[cerebrospinal fluid leak]], which has been observed in about 0.2% of patients. Generally, CSFL arises during surgery and can be repaired with no additional related complications postoperatively. Other risks of surgery include [[infection]], bleeding, double vision usually lasting a few hours, numbness of the front teeth, [[Hematoma|orbital hematoma]], decreased sense of smell, and blindness.<ref name="UNC" /><ref>{{cite news | url = https://med.uth.edu/orl/2012/09/07/functional-endoscopic-sinus-surgery/|title=Functional Endoscopic Sinus Surgery - Otorhinolaryngology - Head & Neck Surgery| publisher = McGovern Medical School |date=2012-09-07|work=Otorhinolaryngology - Head & Neck Surgery|access-date=2018-06-11 }}</ref> Blindness is the single most serious complication of FESS, and results from damage to the optic nerve during surgery. Serious complications such as blindness occur in only 0.44% of cases, as determined by a study performed in the United Kingdom.<ref name="Slack_1998" /> A [[Cochrane review]] in 2006 based on three [[Randomized control trial|randomized control trials]] concluded that FESS has not been shown to provide significantly better results than than medical treatment for chronic rhinosinusitis.<ref>{{cite journal | vauthors = Khalil HS, Nunez DA | title = Functional endoscopic sinus surgery for chronic rhinosinusitis | journal = The Cochrane Database of Systematic Reviews | issue = 3 | pages = CD004458 | date = July 2006 | pmid = 16856048 | doi = 10.1002/14651858.cd004458.pub2 }}</ref>


== References ==
== References ==

Revision as of 06:00, 24 June 2018

Otolaryngologist performing Functional Endoscopic Sinus Surgery. An endoscopic view of the nasal cavity is displayed in real-time on the monitor.

Functional endoscopic sinus surgery (FESS) is a minimally invasive surgical treatment which uses nasal endoscopes to enlarge the nasal drainage pathways of the paranasal sinuses to improve sinus ventilation.[1][2] This procedure is generally used to treat inflammatory and infectious sinus diseases, including chronic rhinosinusitis that doesn't respond to drugs,[3][4] nasal polyps,[5][3] some cancers,[6] and decompression of eye sockets/optic nerve in Graves ophthalmopathy.[1]

In the surgery, an otolaryngologist removes the uncinate process of the ethmoid bone, while visualizing the nasal passage using a fiberoptic endoscope.[1] FESS can be performed under local anesthesia as an outpatient procedure.[5] Generally patients experience only minimal discomfort during and after surgery. The procedure can take from 2 to 4 hours to complete.[2]

History

The first recorded instance of endoscopy being used for visualization of the nasal passage was in Berlin, Germany in 1901.[7] Alfred Hirschmann, who designed and made medical instruments, modified a cytoscope to be used in the nasal cavity. In October 1903, Hirschmann published "Endoscopy of the nose and its accessory sinuses."[8] In 1910, M. Reichart performed the first endoscopic sinus surgery using a 7 mm endoscope. In 1925, Maxwell Maltz, MD created the term "sinuscopy," referring to the endoscopic method of visualizing the sinuses. Maltz also encouraged the use of endoscopes as a diagnostic tool for nasal and sinus abnormalities.[7]

In the 1960s, Harold Hopkins, PhD at Reading University used his background in physics to develop an endoscope that provided more light and had drastically better resolution than previous endoscopes. Hopkins' rod optic system is widely credited with being a turning point for nasal endoscopy.[7] Utilizing Hopkins' rod optic system, Austrian doctor Walter Messenklinger visualized and recorded the anatomy of the paranasal sinuses and the lateral nasal walls in cadavers. Specifically, Messerklinger focused on mapping out mucociliary routes.[9] In 1978, Messerklinger published the book titled "Endoscopy of the Nose" on his findings, and his proposed methods to utilize nasal endoscopy for diagnosis.[10]

After learning of Messenklinger's endoscopic techniques, David Kennedy, MD, and Karl Storz, MD, of Johns Hopkins University developed instruments for use in endoscopic sinus surgery, and coined the term Functional Endoscopic Sinus Surgery.[9] Kennedy published multiple papers on FESS use and technique, and in 1985 the first course on FESS was taught at Johns Hopkins Medical Center.[7]

Medical applications

Large nasal polyp (round mass, center), which is commonly treated and removed by FESS.

Functional Endoscopic Sinus Surgery is most commonly used to treat chronic rhinosinusitis,[1] only after all non-surgical treatment options such as antibiotics, topical nasal corticosteroids, and nasal lavage with saline solutions[3] have been exhausted. Chronic rhinosinusitis (CRS) is an inflammatory condition in which the nose and at least one sinus become swollen and interfere with mucus drainage.[3] It can be caused by anatomical factors such as a deviated septum or nasal polyps (growths), as well as infection. Symptoms include difficulty breathing through the nose, swelling and pain around the nose and eyes, postnasal drainage down the throat, and difficulty sleeping.[11] CRS is a common condition in pediatric patients and young adults.[12] The purpose of FESS in treatment of CRS is to remove any anatomical obstructions that prevent proper mucosal drainage. A standard FESS includes removal of the uncinate process, and opening of the anterior ethmoid air cells and Haller cells[13] as well as the maxillary ostium, if necessary. If any nasal polyps obstructing ventilation or drainage are present, they are also removed. [1] In the case of paranasal sinus/nasal cavity tumors (benign or cancerous), an otolaryngolist or ENT surgeon can perform FESS to remove the growths, sometimes with the help of a neurosurgeon, depending on the extent of the tumor. In some cases, a graft of bone or skin is placed by FESS to repair damages by the tumor.[14]

In the thyroid disorder known as Graves Ophthalmopathy, inflammation and fat accumulation in the orbitonasal region cause severe proptosis.[15] In cases that have not responded to corticosteroid treatment, FESS can be used to decompress the orbital region by removing the ethmoid air cells and lamina papyracea. Bones of the orbital cavity or portions of the orbital floor may also be removed.[7]

The endoscopic approach to FESS is a less invasive method than open sinus surgery, which allows patients to be more comfortable during and after the procedure. Entering the surgical field via the nose, rather than through an incision in the mouth as in the previous Caldwell-Luc method, decreases risk of damaging nerves which enervate the teeth.[1] Because of its less-invasive nature, FESS is a common option for children with CRS or other sinonasal complications.

Outcomes and complications

Functional Endoscopic Sinus Surgery is considered a success if most of the symptoms, including nasal obstruction, sleep quality, olfaction and facial pain, are resolved after a 1-2 month postoperative healing period.[1][16][4] Reviews of FESS as a method for treating chronic rhinosinusitis have shown that a majority of patients report increased quality of life after undergoing surgery.[17][16] The success rate of FESS in treating adults with CRS has been reported as 80-90%,[18] and the success rate in treating children with CRS has been reported as 86-97%.[12] The most common complication of FESS is cerebrospinal fluid leak, which has been observed in about 0.2% of patients. Generally, CSFL arises during surgery and can be repaired with no additional related complications postoperatively. Other risks of surgery include infection, bleeding, double vision usually lasting a few hours, numbness of the front teeth, orbital hematoma, decreased sense of smell, and blindness.[2][19] Blindness is the single most serious complication of FESS, and results from damage to the optic nerve during surgery. Serious complications such as blindness occur in only 0.44% of cases, as determined by a study performed in the United Kingdom.[1] A Cochrane review in 2006 based on three randomized control trials concluded that FESS has not been shown to provide significantly better results than than medical treatment for chronic rhinosinusitis.[20]

References

  1. ^ a b c d e f g h Slack R, Bates G (September 1998). "Functional endoscopic sinus surgery". American Family Physician. 58 (3): 707–18. PMID 9750539.
  2. ^ a b c "Functional Endoscopic Sinus Surgery". UNC Otolaryngology/Head and Neck Surgery. Retrieved 2018-06-09.
  3. ^ a b c d Cazzavillan A, Castelnuovo P, Berlucchi M, Baiardini I, Franzetti A, Nicolai P, Gallo S, Passalacqua G (August 2012). "Management of chronic rhinosinusitis". Pediatric Allergy and Immunology. 23 Suppl 22: 32–44. doi:10.1111/j.1399-3038.2012.01322.x. PMID 22762852.
  4. ^ a b Sukato DC, Abramowitz JM, Boruk M, Goldstein NA, Rosenfeld RM (February 2018). "Endoscopic Sinus Surgery Improves Sleep Quality in Chronic Rhinosinusitis: A Systematic Review and Meta-analysis". Otolaryngology--Head and Neck Surgery. 158 (2): 249–256. doi:10.1177/0194599817737977. PMID 29065273.
  5. ^ a b Patel A (2 March 2016). "Functional Endoscopic Sinus Surgery: Overview, Preparation, Technique". {{cite journal}}: Cite journal requires |journal= (help)
  6. ^ Meccariello G, Deganello A, Choussy O, Gallo O, Vitali D, De Raucourt D, Georgalas C (April 2016). "Endoscopic nasal versus open approach for the management of sinonasal adenocarcinoma: A pooled-analysis of 1826 patients". Head & Neck. 38 Suppl 1 (S1): E2267-74. doi:10.1002/hed.24182. PMID 26335008.
  7. ^ a b c d e Tajudeen BA, Kennedy DW (June 2017). "Thirty years of endoscopic sinus surgery: What have we learned?". World Journal of Otorhinolaryngology - Head and Neck Surgery. 3 (2): 115–121. doi:10.1016/j.wjorl.2016.12.001. PMC 5683659. PMID 29204590.
  8. ^ Hirschmann, Alfred (October 1903). "Endoscopy of the nose and its accessory sinuses". The Laryngoscope. 13 (10): 810–810. doi:10.1288/00005537-190310000-00015. ISSN 0023-852X. {{cite journal}}: Unknown parameter |name-list-format= ignored (|name-list-style= suggested) (help)
  9. ^ a b Kane, Kevin J. (2018-01-17). "The early history and development of endoscopic sinonasal surgery in Australia: 1985–2005". Australian Journal of Otolaryngology. 1 (1). doi:10.21037/ajo.2018.01.08. {{cite journal}}: Unknown parameter |name-list-format= ignored (|name-list-style= suggested) (help)CS1 maint: unflagged free DOI (link)
  10. ^ Walter., Messerklinger (1978). Endoscopy of the nose. Baltimore: Urban & Schwarzenberg. ISBN 0806712112. OCLC 3447558. {{cite book}}: Unknown parameter |name-list-format= ignored (|name-list-style= suggested) (help)
  11. ^ "Chronic sinusitis - Symptoms and causes". Mayo Clinic. Retrieved 2018-06-09.
  12. ^ a b Makary CA, Ramadan HH (June 2013). "The role of sinus surgery in children". The Laryngoscope. 123 (6): 1348–52. doi:10.1002/lary.23961. PMID 23361382.
  13. ^ Levine CG, Casiano RR (February 2017). "Revision Functional Endoscopic Sinus Surgery". Otolaryngologic Clinics of North America. 50 (1): 143–164. doi:10.1016/j.otc.2016.08.012. PMID 27888911.
  14. ^ "Treatment of Sinus Tumors". care.american-rhinologic.org. Retrieved 2018-06-09.
  15. ^ Cury SS, Oliveira M, Síbio MT, Clara S, Luvizotto RA, Conde S, Jorge EN, Nunes VD, Nogueira CR, Mazeto GM (May 2018). "Graves' ophthalmopathy: low-dose dexamethasone reduces retinoic acid receptor-alpha gene expression in orbital fibroblasts". Archives of Endocrinology and Metabolism (AHEAD). doi:10.20945/2359-3997000000044. PMID 29791662.
  16. ^ a b Prasad S, Fong E, Ooi EH (July 2017). "Systematic review of patient-reported outcomes after revision endoscopic sinus surgery". American Journal of Rhinology & Allergy. 31 (4): 248–255. doi:10.2500/ajra.2017.31.4446. PMID 28716176.
  17. ^ Soler ZM, Jones R, Le P, Rudmik L, Mattos JL, Nguyen SA, Schlosser RJ (March 2018). "Sino-Nasal outcome test-22 outcomes after sinus surgery: A systematic review and meta-analysis". The Laryngoscope. 128 (3): 581–592. doi:10.1002/lary.27008. PMC 5814358. PMID 29164622.
  18. ^ Stammberger H, Posawetz W (1990). "Functional endoscopic sinus surgery. Concept, indications and results of the Messerklinger technique". European Archives of Oto-Rhino-Laryngology. 247 (2): 63–76. PMID 2180446.
  19. ^ "Functional Endoscopic Sinus Surgery - Otorhinolaryngology - Head & Neck Surgery". Otorhinolaryngology - Head & Neck Surgery. McGovern Medical School. 2012-09-07. Retrieved 2018-06-11.
  20. ^ Khalil HS, Nunez DA (July 2006). "Functional endoscopic sinus surgery for chronic rhinosinusitis". The Cochrane Database of Systematic Reviews (3): CD004458. doi:10.1002/14651858.cd004458.pub2. PMID 16856048.
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