Maximizing Results and Minimizing Complications during FESS

Dr. Sindwani encouraged audience members to use navigation devices for preoperative planning as well as in surgery. In addition to providing accurate and reliable localization during surgery, the next generation of more compact image-guided surgery platforms offer a user-friendly interface and quick patient data transfer optimizing surgeon workflow during the preoperative planning session, which can easily be performed in almost any operating room environment. Imaging and navigation data sets are transferable and may be fused. The otolaryngologist can take preoperative CT and MRI scans and download both data sets into the image guidance system, which fuses them together so “you can navigate during the procedure using only CT, CT and MRI superimposed, or only MRI,” he said.

Maxillary Sinus Issues

Eric Holbrook, MD, Assistant Professor at Harvard Medical School, discussed the maxillary sinus and approaches to it, along with pitfalls that can lead to failures.

It is important to identify the uncinate and the natural ostium. “Really take your time to find it—it can save you a lot of headaches and potential complications,” he said.

Failures can be caused by being too aggressive around the middle turbinate and the lateral aspect of it can be traumatized causing scar formation. Too aggressive an antrostomy can be problematic too.

When performing an antrostomy, the uncinate needs to be addressed and the natural ostium identified. An incomplete uncinectomy won’t solve an obstructive problem, and recurrence can occur. A posterior antrostomy that doesn’t address the natural outflow can lead to persistent pathology.

Take time to observe the natural osteum, although it can be difficult to see in some cases. It should be behind the lower third of the uncinate and can be identified with the use of a 30-degree endoscope and gentle probing with a ball-probe sinus seeker.

“When you figure out where the natural osteum is and determine that enlargement is necessary, use a through-cut forceps to widen it in a posterior and inferior direction,” Dr. Holbrook said. Cutting instruments avoid tearing and stripping the mucosa.

Preventing Ethmoidectomy Complications

Joseph Han, MD, Assistant Professor at the University of Virginia, provided tips on avoiding ethmoidectomy complications. Key points are to know the endoscopic ethmoid anatomy, understand how the anatomy may appear altered through an endoscope, and be aware of different anatomic variations.

When performing FESS, Dr. Han breaks down his approach into “segmental sinus surgery”—maxillary antrostomy, anterior ethmoidectomy, posterior ethmoidectomy, sphenoidotomy, skull base dissection, and frontal sinusotomy. “I define boundaries. [For instance], before I do a posterior ethmoidectomy, I would make sure I had the boundaries of the anterior ethmoid cavity dissected,” he said. Use CT scans, and correlate them to the endoscopic anatomy.