TORONTO-Although functional endoscopic sinus surgery (FESS) is a commonly used and well-established tool for the treatment of chronic rhinosinusitis, between 10% and 20% of patients will have recurrent disease and require further surgery. But there are some common problems that can often be avoided by using appropriate imaging and taking the time to understand the anatomy in each case.
Explore this issue:January 2007
This was the key message from ENT surgeons on a panel at the annual AAO-HNS conference who provided tips on how to improve outcomes in FESS. Panel members discussed cases and addressed common difficulties seen in revision surgery, along with tactics to help reduce potential problems.
When it comes to the nuts and bolts of successful FESS, key points include being able to see what you’re doing, having appropriate medical and anesthetic strategies for your surgery, working in such as way as to have minimal blood loss, and making sure the patient is stable, said James Palmer, MD, Assistant Professor of Rhinology at the University of Pennsylvania.
Tips for preoperative preparation include use of short-term oral corticosteroids to help stabilize the mucosa and decrease blood loss. Oral antibiotics can help decrease inflammation.
Blood loss should be considered ahead of time -what is the total amount of loss that’s acceptable and should the surgery be staged? Consider too the use of pledgets and whether injections are intranasal or intraoral.
For cases with chronic rhinosinusitis, there are six main categories for the approach to antibiotic use: no prior surgeries, perioperative use, antibiotics that are used immediately post surgery, cases where remote surgery is performed (such as for acute exacerbations), inflammatory basis for disease (presence of polyps), and infectious-based cases, Dr. Palmer said.
Peter J. Wormald, MD, Professor of Otolaryngology at the University of Adelaide in Australia, discussed why 3D imaging is highly useful for planning for surgery.
I’ll look at a series of scans, do a 3D reconstruction, identify the drainage pathways and develop a surgical plan….We essentially do a simulated surgery, then see if it works on the patient, he said. Plus, the scans can always be referred back to during surgery.
The Importance of Imaging
Imaging is vital for various types of sinus surgeries, whether it’s frontal, maxillary, or ethmoid.
Dr. Wormald described treatment planning for the case of a 27-year-old male patient who had failed medical treatment and still had significant frontal pain and pressure, along with nasal obstruction and rhinorrhea on the right side. This was a frontal sinus surgery case.