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Sinus washouts were an operation of the past, where a large trochar was placed through the nose into the maxillary sinus low on the lateral nasal wall.The sinus was then aspirated and then washed out.Things have significantly developed with our understanding of the way that the sinus anatomy and physiology functions. This procedure is rarely performed nowadays as we have changed practice to open the natural openings of the sinuses to encourage their natural drainage rather than just making a hole which would typically seal over.

This new type of physiologically correct surgery is called FESS (functional endoscopic sinus surgery) and is aimed at using the bodies normal sinus physiology and encouraging it to work better to help the sinuses drain. An endoscope is used to visualise within the nose and specially designed instruments can be used to open up the nasal anatomy.

An endoscope is an integral piece of equipment required to look in the nose as part of a diagnostic or therapeutic procedure.

In sinus surgery also referred to as functional endoscopic sinus surgery (FESS) a ridgid endoscope is used by the surgeon in order to visualise the anatomy of the sinuses. The openings to the sinus system can then be directly visualised or indirectly visualised on a TV screen to allow the ENT surgeon to open the drainaige pathway of the sinuses or to open the sinus up itself.

The endoscope is a glass rod system developed to aid surgeons in keyhole surgery. The rod system is often called a Hopkins rod and has an attachment for a light source whilst also having a viewing end. The endoscope is placed in the nose and the eyepiece may be attached to the camera system to view where the endoscope is.

Endoscopes are now made with flexible fibres and are often used in the Outpatient setting to look in the nose and also to visualise the voice box.

Functional Endoscopic Sinus Surgery (FESS)

Anatomy / Physiology

TThe anatomy of the sinuses has not changed for many years, but our understanding of the physiology of the nose and sinuses has evolved significantly in more recent years. Our concept of how sinuses naturally drain has been the source from which we have adapted our surgical techniques in order to improve these natural drainage patterns.

There are a number of sinuses.

• Maxillary sinus x2
• Anterior ethmoid sinus x2
• Posterior ethmoid sinus x2
• Frontal sinus x2 (variable in size and development)
• Sphenoid sinus x1 (often split into 2 by a bony septa)

The maxillary sinus (located under your cheek) drains into a narrow area between two bony folds in the lateral wall of the nose, called the middle meatus (area between the middle and inferior turbinates). In addition the anterior ethmoids and the frontal sinus drains here too. This is a crucial area of confluence referred to as the osteomeatal complex and is where a lot of problems exist with respect to sinusitis. Surgery is often focused here to improve the drainage.

FESS

The surgery is referred to as Functional as you are not just anatomically looking at creating a solution but you are improving on the normal function / physiology of the sinus drainage pathway.

The surgery is referred to as Endoscopic as the surgeon uses fine telescopes intranasally to give an excellent visualization of the nose. With the use of fine instruments too the surgeon can rectify any anatomical or pathological anomalies in order to improve the natural drainage of the sinuses.

The surgeon almost always uses a CT scan as a map through the nose and sinus and this will have been performed preoperatively to help with the diagnostic workup of the patient.

Preoperative CT Scan showing opacification of the left maxillary and ethmoid sunuses.

Access sometimes has to be improved with an additional procedure of a Septoplasty to allow visualization of areas obstructed by a deflected nasal septum.

This surgery can often be performed as a day case but occasionally warrants an overnight stay. The nose may be dressed with small soft intranasal packs that are removed after a set length of time depending on the surgeon.

It is not uncommon to feel blocked in the nose for approximately a week as the swelling intranasally goes down and regular nasal douching with appropriate products as recommended by your surgeon should be used to flush out any crusts or blood from the nose. It strongly advised not to blow your nose in the postoperative period.