Evolution Of Endoscopic Sinus Surgeries

As the diagnostic tools in the nose and sinus areas have undergone marked revolution in the past 2 decades , so is the diagnosis of hidden sinus problems and treatment strategies have also made a roller-coaster ride taking the older generation ENT doctors by a storm.

Newer diagnostic tools like 2.7mm nasal endoscope, CT & MRI Scan have totally removed the diagnosis like Ethmoidal polyps, Rhinitis caseosa out of ENT dictionary and replaced them by new diagnosis like Sinonasal polyposis, Fungal Rhino Sinusitis.

Sinus surgeries like antral puncture, intranasal antrostomy, Caldwel-Luc , and External ethmoidectomies & External approach (Lateral Rhinotomy) medial maxillectomy which are the sinus surgeries of my post graduate days (in nineties) are thrown into the dustbin by the young ENT world . I haven’t done any of these procedures in the past decade.

After the introduction of Hopkin’s rod nasal telescope (endoscope) in the early nineties , FESS replaced the above mentioned blind sinus surgeries. Later FESS was done for all sinus pathologies. FESS means draining the blocked sinuses and removing sinus pathologies by widening all the sinus ostia using 4mm(adult) or 2.7mm(paediatric) endoscopes , thereby maintaining the normal anatomy and physiology of the sinuses. FESS are done under local or hypotensive General anesthesia. Drugs like clonidine, atenolol, metaprolol, nitroglycerine etc., are used to produce hypotension as low as 40 to 45 mm Hg mean blood pressure ( systolic 50 to 60 mm Hg) to have an excellent operating field thereby reducing the intra-op complications and operating time.

Now the diagnosis of sinus pathologies have attained a new dimensions with the help of CT Scan, the pathologies are grouped as osteomeatal complex (OMC) block, isolated maxillary or sphenoidal pathologies , Pan / chronic Sinusitis, more extensive SinoNasal Polyposis (SNP), isolated fungal sinusitis, Allergic fungal Sinusitis and polyposis (AFS) , Antral papillomas, Septal hemangiomas, malignancies, obstructive nasal conditions like Concha Bullosa (CB), Allergic Hypertrophied Infr.Turbinates (HIT) , deflected and dislocated nasal septums etc.

So also the use of endoscope has breached the frontiers of sinus surgeries and has entered the eye, skull base and intracranially. Endo ophthalmic surgeries like optic nerve decompression, medial orbital decompression (for orbital blow–out #,Axial proptosis of thyrotoxicosis) endoscopic DCR, intra orbital tumor removal, drainage of orbital abscess etc. Endoscopic Neuro surgeries include trans nasal-sphenoidal approach to pituitary and clival tumors, closure of CSF Rhinorrhoea, removal nasopharyngeal cysts and tumors, etc. are all scarless.Even the FESS has gone for a remodeling into a better term ESS (Endoscopic Sinus Surgeries) which has the following divisions :-

MISS (Minimally Invasive Sinus Surgeries) for isolated maxillary/ sphenoidal pathologies & OMC block, FESS (Functional Endoscopic Sinus Surgery) for pan and chronic sinusitis and RESS (Radical Endoscopic Sinus Surgeries) for AFS and SNP.Powered instruments also called microdebrider/ shaver systems are being used by modern ESS surgeons. Though the instrument and the disposable blades are very expensive they help very much in narrow working areas and excessive bleeding situations. The net result is least mucosal damage and excellent healing and postoperative results. The angled diamond burr used in debrider system helps to drill the hard frontal beak , making a wide frontal recess and good drainage.

Nowadays more and more sinus problems are detected early and treated endoscopically without morbidity and , thereby the sinusitis related complications have become obsolete.

For the most recent treatment of sinus related problems contact our Dept.