Maximizing Results and Minimizing Complications during FESS

“The workhorse procedure for a basic frontal sinus case is an endoscopic Draf IIA,” he said. The keys are to know the anatomy, identify the cells that block the frontal recess, find natural drainage pathways around the cells, and remove the cells.

In his own practice, Dr. Chiu defines the borders, and plans on how to make the frontal recess as big as possible. “There’s no such thing as small hole frontal sinusotomy. You want to make it as big as possible while sparing the mucosa around the recess. It will scar down in the postoperative period,” he said.

The first step in frontal surgery is to identify the skull base, and the safest to identify it is posteriorly in the sphenoid sinus or posterior ethmoid.

Approach the frontal recess from a posterior-to-anterior direction. Locate the anterior ethmoid artery, which will appear in preoperative CT scans. As you move anteriorly, be prepared to identify a supraorbital ethmoid cell and remove the bony wall between this cell and the frontal recess to maximally enlarge the sinusotomy.

Moving anteriorly, don’t forget about the agger nasi and the uncinate process, “which is by far the most common cause for revision surgery,” Dr. Chiu said. Finally, he said, dissect out the frontal recess cells and visualize the top of the frontal sinus to confirm that “you have the true recess dissected out and are not looking at a cap of an agger nasi or frontal recess cell.”

Postoperative Care

Rakesh K. Chandra, MD, Clinical Assistant Professor at the University of Tennessee in Memphis, discussed postoperative care after endoscopic surgery.

Post-op care begins in the operating room after the dissection is complete. “It has to do with the quality of mucosal preservation as well as the use of any packing. Medical management is also very important,” he said.

The goals of debridement have to be considered in light of the fact that mucociliary clearance after surgery can take up to six weeks to recover.

“During this six-week period it is important to suction your dependent sinuses, culture any purulence, remove crusted clots, lysis of adhesions, resect foci of recurrent polyp or change, remove osteitic bone, and then address middle turbinate lateralization, and most importantly ensure patency in the frontal recess,” he said.

Dr. Chandra said he performs debridement at follow-up visits, usually at either weeks one, two, and four or weeks one, three, and five post-op. “The appearance of the cavity is more important than the patient’s symptoms,” he said.