Changing Trends in

sinusitis

D. Balakrishnan

Civil Surgeon/ Asst Prof, Madras Medical College

ENT Surgeon, Kanchi Kamakoti Childs Trust Hospital
Editor & Treasurer, National Headquarters
Assn. of Paediatric Otolaryngologists of India
 I passed my MS (ENT) in 1981 and joined the illustrious
ranks of my seniors. Our armamentarium for sinusitis at
that time were Antral wash and Caldwel Luc surgery.
Now,
Quarter century later, FESS rules the day

1981 - Antral Lavage 2004 - FESS

A road too far……..

 A common refrain

Nasal block, Cough, Headache, Fever

Diagnosis: Sinusitis
Rx: Antihistamine, antibiotic, nasal drops, analgesic
Short term relief: Good

Cure: Mostly elusive….

 Why sinusitis does not resolve easily?

The opening of the maxillary

sinus is higher than the floor of
the nasal cavity – hence gravity
drainage does not occur. The
fluid gets locked up in the sinus.

The drainage paths of other sinuses are tortuous and

may be impeded by septal deflections or allergic oedema
How to improve drainage ?

The earlier solutions were to

Drain by trocar : Antral puncture
Drain by a window in the inferior
meatus : Caldwel – Luc 1901

No method worked satisfactorily. Why ?

 The discovery of Messerklinger 1969
The miracle of the cilia and the mucus transport

These tiny brushes push the mucus against gravity towards the
natural ostium, even if there is a huge inferior meatal window
Hence a correct solution will be to Create
a larger opening at the natural ostium

Do not fight nature. Employ it to your advantage. This,

then, is the basis of FESS
 The basic surgical anatomy of the nose

The sinuses drain into the middle meatus at the infundibulum by various
pathways. The boundaries impede the drainage
 The basic surgical anatomy of the nose

The uncinnate process is the anterior boundary of the

Maxillary ostium
 Middle meatal antrostomy
Uncinnectomy

Incision

Mobilisation
 Middle meatal antrostomy
Uncinnectomy

Removal

Note the enlarged ostium

 Welcome to the new world of FESS

FESS creates good drainage for each individual sinus without

affecting the innate function of the ciliary apparatus – hence it is
called Functional. An endoscope is used for visualisation. This
justifies the inclusion of the word Endoscopic in the phrase.

Albert David works in The Great

Ormond Street Hospital and is a
pioneer in the use of the endoscopes
in children and in airway diseases
FESS does not stop at the Maxillary sinus

Maxillary
Frontal
Ethmoid
Sphenoid
The basic surgical anatomy of the nose

The ethmoids are two boxes,

suspended from a central pole. The pole
is the septum. The boxes are the
ethmoids. They are roofed by the
frontal. On the sides, the orbit is above
and the maxillary sinus is below.
The basic surgical anatomy of the nose
The Frontal recess
 The basic surgical anatomy of the nose

The anterior ethmoids are just in front of the frontal recess

Posterior ethmoids highlighted

Probes in the openings of the

maxillary and the frontal sinuses
 The drainage routes of other sinuses

The trick is to enlarge these paths thus establishing

good function
The basic surgical anatomy of the nose
The second step of FESS

The Ethmoidal cells have been cleared in

addition to the uncinnectomy
Other surgeries with Nasal endoscope

Removal of the agger nasi cells exposes the

lacrimal sac : Dacryo cysto rhinostomy (DCR)
 Other surgeries with Nasal endoscope

The left middle concha is pneumatised. This is

called Concha Bullosa. The treatment is removal
of the lateral wall of the concha - Conchaplasty
Other surgeries with Nasal endoscope

When the frontal sinus drainage path is

blocked, the antero medial wall of the bulla
ethmoidalis is removed. This opens up the
drainage – This is called Bullectomy or Anterior
ethmoidectomy
Other surgeries with Nasal endoscope

Polyps are easily removed under vision : Endoscopic

polypectomy. When the septate ethmoidal cells are also
removed, this becomes Endoscopic ethmoidectomy
Other surgeries with Nasal endoscope

Allergic Fungal Rhino Sinusitis

The treatment is removal of polyp, mucin and

the bony septae : highly rewarding results
However 20 percent recur
Other surgeries with Nasal endoscope

This was removed in 1990, by me, before the

advent of the endoscope. Notice the three portions
of an Antro Choanal Polyp.
Other surgeries with Nasal endoscope

Trans nasal route to the sphenoid and to the

pituitary is commonly employed now.
Thank You for the patient listening
This was removed in 1990, by me, before the
advent of the endoscope. Notice the three portions
of an Antro Choanal Polyp.
D. Balakrishnan