1. Principles of Functional Endoscopic Sinus Surgery
Shahin Bastaninejad, MD
Assistant Prof. of ORL-HNS
TUMS
Amir’Alam Hospital

2. Outline
Definition
Anatomy
Patient evaluation
FESS Concepts of Surgery

3. Definition

4. Functional Endoscopic Sinus Surgery
Replaced old practice of obliterating sinuses and removing mucosa. Concept of irreversibly diseased mucosa refuted.
Functional aspect refers to:
Preserving normal structures
Removing only obstruction
Preserving mucosa
Attempt to restore function

5. Anatomy

6. Ethmoid anatomy Ethmoid anatomy is complex: Labyrinth Lamellae
1st - Uncinate
2nd - Ethmoid bulla
3rd - Basal lamella of middle turbinate
4th - Superior turbinate

7. Drainage Frontal, anterior ethmoid & maxillary – OMC
Posterior Ethmoids – Superior meatus
Sphenoid sinus – Sphenoid-ethmoidal recess

8. Middle Turbinate Three components
First – Anterior, oriented in a sagittal plane and attached to skull base
Second – Middle, oriented in a Vertical plane and attached to lamina papyracea (basal lamella and separates ant from post ethmoids)
Third – Posterior, oriented in a horizontal plane and attaches to perpendicular plate of palate (forms roof of middle meatus, anterior to sphenopalatine foramen)

9. Middle Turbinate

10. Ostiomeatal Complex (OMC)
Common drainage for frontal, maxillary and anterior ethmoid sinuses.

11. OMC

12. OMC
Infundibulum – funnel shaped area whereby the maxillary, ant ethmoid and frontal sinuses drains
Uncinate process– Sickle shaped bony ethmoidal structure
Hiatus Semilunaris – Half-moon shape opening of infundibulum

13. Uncinate Process Attaches to the following structures:
Inf & far post. – To ethmoid process of inf. Turb

14. Uncinate Process
Ant & far sup. – To lamina papyracea, skull base or mid turb

15. Laterally – Lamina papyracea and fontanelle area

16. Uncinate Process
52%

18. Bulla Ethmoidalis
The greatest anterior ethmoid air cell, attached to lamina papyrcea and usually open into lateral sinus

20. Sinus Lateralis = Suprabullar recess and retrobullar recess

21. Middle turbinate: Horizontal and vertical basal lamella
SBR
Sinus Lateralis
RBR

22. Sphenoid Ostium Medial to posterior sup. turbinate
Located between nasal septum and inferior aspect of sup. turbinate
Located at the same level as the roof of the maxillary sinus
Located 4 microdebrider/suction tip breaths above the choanae
Located 7cm from nasal crest at 30°

23. Sphenoid Ostium

24. Sphenoid Sinus Relationships of important structures:
Optic nerve – superior-lateral
Carotid artery/cav sinus – mid-lateral
Vidian nerve and maxillary nerve – inferior-lateral

25. Square – ant clinoid process, Circles – optic canals, triangle – vidian nerve
Asterisk – pneumatization of pterygoid process

26. Sphenoid Classification

27. Presellar
Sellar
Conchal
Post sellar

28. Onodi Cells or Sphenoethmoid cells

29. Optic Canal in Onodi Cells

30. anatomic keyhole in SBS

31. LOCR

32. Cribriform plate
Keros classification
1-3mm
3-7mm
7-16mm

33. Keros Classification
Type I
1-3mm
Type II
3-7mm
Type III
7-16mm

34. Fovea and Ethmoidal arteries

35. Lens 70 degree – End of surgery

36. Kuhn Cells
Frontal Cells

37. Frontal Recess Anatomic Boundries: Ant – unicate process & agger nasi
Post – bulla ethmoidalis and suprabullar lamella
Lateral – lamina papyracea
Medially – hiatus semilunaris or middle turb
Inf – Ethmoid infundibulum
Sup – Fovea ethmoidalis, supraorbital air cell, anterior ethmoid artery and frontal ostium

38. Draf IIA
Draf I

39. Draf III
Draf

40. Frontal Sinus – Mucociliary Pattern
 Save Mucosal Layer in Lateral part while performing Draf III opertation

41. Patient evaluation

42. Pre-op CT Evaluation CLOSE Technique C – Cribriform
L – Lamina Papyracea
O – Orbits, onodi cell, Optic Nerve
S – Sphenoid, Skull Base
E – Ethmoid Arteries

43. C - Cribriform
Assess the Keros type
Look for assymetry

45. L – Lamina Papyracea
Check for dehiscence or pathologic fractures

46. O – Orbit, Optic Nerve, Onodi Cells
Check for dehiscence
Assess for onodi cells (superior-lateral to sphenoid)
Orbital slope

47. S – Sphenoid, Skull base
Assess for Carotid dehiscence and aeration patterns
Conchal, Pre-sellar, & Sellar (thickness of clivus)

48. Skull base Assess slope of skull base
Assess if roof of sphenoid is level with skull base

49. E – Ethmoid Artery

50. FESS
Concepts of surgery

51. Role of surgery Should be considered as adjunctive to medical therapy
CRS is an inflammatory and multifactorial disease
Institute medical therapy first prior to surgery unless impending complications
Continued medical therapy is required following surgery to avoid recurrence

52. Defined surgical substeps are defined according to specific pathophysiologic obstruction that exist based on microanatomy

53. Antrostomy
Some speculate nitric oxide produced in maxillary sinus has bacteriostatic properties, therefore better to keep antrostomy small
Uncinate must be completely removed, source of recurrence.
Mucociliary clearance remains to natural os
Antrostomy must include the natural osium and accessory osium if present

54. Recirculation

55. Frontal Sinusotomy Question on to perform or not
Do as little as possible but as much as necessary
Some advocate ethmoid dissection and monitor
Graduated approach to frontal sinuses
Should evaluate with sagittal reconstruction
Evaluate A-P and Mediolateral dimensions, asses neo-osteogenesis and pneumatization

56. Ethmoidectomy & Sphenoidotomy
Continue operation Anteroposteriorly toward the Sphenoid sinus, then open it
Now it is time to go on with Posteroanterior approach with a 30 degree lens and cutting forceps

57. References Dr Quinn online Text book
Diseases of the Sinuses: Diagnosis and Management. Kennedy. Chapters 1, 2, 3, 15, and 16
Head and Neck – Otolaryngology. Bailey. Chapters 21, 25, 26.
 Endoscopic Sinus Surgery Dissection Manual With Cdrom. Casiano
Endoscopic Anatomy of the lateral nasal wall, ostiomeatal complex and anterior skull base, a step-by-step guide. Reda Kamel
Endoscopic diagnosis and surgery of the paranasal sinuses and the anterior skull base. Heinz Stammberger
Rhinology and Sinus Disease, a problem-oriented approach. Steven D. Schaefer
Nasal and Sinus Surgery. Steven Marks. Sections 1, 2, and 3.
Surgical anatomy and physiology for the skull base surgeon. Ameet Singh, et al. Operative Techniques in Otolaryngology (2011) 22,
FRONTAL SINUS SURGERY 2004: UPDATE OF CLINICAL ANATOMY AND SURGICAL TECHNIQUES. MICHAEL FRIEDMAN, et al. OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY—HEAD AND NECK SURGERY, VOL 15, NO 1 (MAR), 2004: PP 23-31

58. Thank You!