Strategies for Improving FESS Outcomes

You look at the anatomy, and predict from the CT scan what the anatomy is going to be like-see where the difficult and tricky spots are going to be, Dr. Wormald said. Work out the frontal sinus drainage pathway, have a plan for tackling each cell, and work out the alternatives before starting surgery.

Rodney Schlosser, MD, Associate Professor of Otolaryngology at the Medical University of South Carolina, added that he would also go back and look at the sagittal plane to determine if the cell is diseased or not.

The key point with frontal sinus surgery cases is that the otolaryngologist needs to understand the anatomy in three dimensions so one can complete a frontal recess dissection, Dr. Palmer said.

Some pitfalls can be revealed by 3D CT imaging, such as ISSC narrowing of the ostium and a large bulla frontalis cell obstructing the ostium-as was the case in one example presented. A 3D rendering of the anatomy helps with the surgical plan.

However, one should have a number of alternatives up your sleeve if things don’t go according to plan, Dr. Wormald said.

When it comes to the maxillary sinus, it takes a 70-degree scope to see the Haller cell, which drains the maxillary sinus, Dr. Palmer said. The scope reveals far more than a 30-degree scope can, and helps show how much disease is present in the front cells. Infection is a potential problem in the maxillary sinus if there is recirculated mucus.

Furthermore, it’s important to know exactly where the anterior ethmoid artery is, he said. Injury of the artery can lead to a significant swelling and discoloration around the eye.

Panelists discussed a case presented by Dr. Schlosser of a 22-year-old female who had unilateral cheek pressure for three months, but had failed multiple courses of antibiotics, and had a CT reading of S-P maxillary antrostomy with mucosal thickening.

Dr. Wormald described the case as potentially dangerous if it doesn’t appear regular on a CT scan, and one where a lot of trouble can happen. When it comes to surgery, the technique here is very important, he said

The patient was successfully treated endoscopically with Caldwell-Luc, a ball-tipped probe using a retrograde technique, and a mucocele was drilled out. However, where possible, it’s a good idea to preserve mucosal tissue.

Preoperative reviews of CT scans should include looking for potential CSF leaks, potential orbital injuries (such as lamina papyracea dehiscence and anterior ethmoid neurovascular bundles), and sphenoid complications. The pathology should be reviewed too, Dr. Schlosser said.