Patient Selection, Counseling Can Prevent FESS Failures, Disappointments

Informed consent should include any possible complications, as well as the expected outcome of the surgery. Patients will be more likely to comply with medications and not be frustrated with the ongoing need for medications if they know this is likely ahead of time, Dr. Senior said. Explain to patients that they are having surgery because their disease can’t be managed with medications and that the goal of surgery is to make the disease manageable with medications again.

There are many different reasons for chronic rhinosinusitis. Most of the time it’s not an infection, but inflammation due to several causes.
-Stilianos Kountakis, MD, PhD

Dr. Senior said that FESS failures are typically due to one of two problems. First, the surgeon may not have taken the patient’s anatomy fully into account, so that inadequate tissue is removed, or the surgery is not adequate for treating a patient’s particular disease. Technical surgical problems can occur intraoperatively, also. Second, some patients have aggressive disease that doesn’t respond to even good surgery.

Therefore, the surgeon should be alert to patients with recalcitrant disease, whose computed tomography (CT) scans often predict worse FESS outcomes, he said. If the CT is a complete white-out, with the sinuses completely blocked and inflamed, the patient will do less well with surgery, will have more surgeries in the future, and will require more medications, he said.

Dr. DelGaudio agreed. The surgeon should make sure that the underlying disease would respond to FESS. If the patient undergoes surgery for a reason not due to sinus disease, the symptoms may not improve postoperatively, Dr. DelGaudio said.

For example, for primary headache, FESS would be a poor approach. A good percentage of patients diagnosed with sinus headache have underlying migraine, Dr. DelGaudio said. Therefore, a patient with headache in and of itself is not a good candidate for FESS. Similarly, postnasal drip without significant sinus symptoms is not an indication for FESS because acid reflux may be the underlying problem.

The most common indication for FESS is chronic inflammatory disease of the sinuses that is not responsive to maximal medical therapy, including antibiotics as well as topical and systemic steroids, Dr. DelGaudio said. Another major indication is acute complications of sinusitis.

The burden and extent of the patient’s preoperative disease can help predict the success of the surgery, according to Dr. Sillers. We separate patients into those with and without polyps, and those with polyps tend to do worse, he said.

Preventing Failure

The best way to prevent FESS failure is in the quality of the surgery, according to Dr. Senior. We get caught up talking about FESS failure from the medical standpoint, he said. We need the right regimen of medications to keep them feeling well after the surgery, but good, high-quality surgery can make a difference, even in the patients with severe disease. Such surgeries would involve meticulous, mucosal-sparing procedures with removal of all ledges and septations in the particular inflamed sinus cavity.