Sinus Surgery – Functional Endoscopic Sinus Surgery (FESS)

What are the sinuses?

The sinuses are a series of air-filled spaces present within the bones of the face and head, which are closely connected to the inside of the nose. The sinuses continuously drain into the nose through small openings allowing mucus to constantly clear debris away from being inhaled into the lungs. It is not known what other function they may serve – some people believe that they play a role in the precise sound of one’s voice, or in lightening the weight of the skull that would otherwise be much heavier than it already is.

The sinuses are very often involved in infections, including the common cold or ‘flu. An infection that primarily affects the sinuses is called sinusitis. This occurs when the sinuses become blocked and inflamed causing infected mucus to build up. Patients often complain of a blocked nose, pressure or congestion in the face, runny nose, headache and loss of the sense of smell (anosmia). Sinusitis can be difficult to diagnose and your specialist will want to examine your nose with a telescope in order to help find out what is wrong (nasal endoscopy).

Most patients with sinusitis get better without any specific treatment as the majority are due to viral infections. Treatment with antibiotics and/or nose drops/sprays are usually effective for more severe, prolonged infections. In a very small number of patients with severe sinusitis an operation may be needed. Rarely, if left untreated or in particularly severe cases, complications can occur including spread of the infection into the nearby eye socket or into the fluid around the brain.

What is Functional Endoscopic Sinus Surgery or FESS?

Functional Endoscopic Sinus Surgery (FESS) is the name given to a group of operations performed for severe sinus problems, which have not been adequately treated with medication alone. In the past, sinus operations were carried out through incisions or cuts in the face and mouth. However the development of the endoscope (similar to a telescope) has allowed the operation to be performed through the nose without the need for any external incisions.

What are the alternatives to having the operation?

Before any sinus operation, patients will be treated with steroid drops or sprays, antihistamine tablets, salt water douching and often antibiotics for several weeks if not months in an attempt to bring about improvement in the patient’s symptoms. If these treatments are unsuccessful, an operation such as FESS may become necessary. After an examination of your nose with an endoscope, your surgeon will discuss whether or not you will need to have a CT scan prior to taking a decision regarding the possible need for sinus surgery. In some patients an operation can be avoided by the use of antibiotics and steroid medicines, possibly even on an intermittent basis several times a year. The relative risks of this will need to be balanced against the surgical risks and again this should be discussed with your surgeon.

Endoscopic sinus surgery is a safe method of operating on the sinuses. There are some newer techniques becoming available including balloon sinuplasty, which involves placing a balloon to widen the entrance to the sinuses. This is arguably safer than even FESS but is not suitable in all patients.

Traditional operations involving external incisions in the face or mouth are very rarely required nowadays especially with the advent of improved minimally invasive surgical techniques and instrumentation. Whether such an approach is appropriate for you will depend on a number of factors specific to your case, which you should discuss with your surgeon.

Before the operation

Prior to any sinus surgery or FESS, many surgeons advocate the use of preoperative antibiotics and/or steroid medication. You will be advised about this during discussions with your specialist in the outpatient clinic.

The operation

Functional endoscopic sinus surgery is almost always carried out with you asleep under a general anaesthetic but very occasionally it can be done under a local anaesthetic. When using the endoscope, FESS is performed entirely through the nose with no external incisions. At the end of the operation it may be necessary to insert a light dressing into the nose to prevent further bleeding. This can either be a dissolvable dressing which will disappear on its own over the course of the next few days, or one which will need to be removed before going home. Occasionally a plastic sheet (splint) may also need to be inserted into the nose.

What to expect after FESS / endoscopic sinus surgery

Immediately after sinus surgery your nose will probably feel quite blocked. This may be because of a dressing or splint. Dressings, if used, will usually be dissolvable, which will melt away with time by themselves.

Very occasionally a dressing may have to be removed by the nursing staff before you go home, although such dressings are less and less required nowadays. In rare cases a soft silastic splint may have to be placed inside the nose to support the repair and these are typically removed in clinic approximately ten days after the surgery.

It is common to have a blocked nose due to swelling caused by the surgery, which happens in everyone and does not mean that the operation has not worked. It usually settles after two to three weeks.

The operation is not usually too painful although simple painkillers may be needed as required for the first couple of weeks after the operation.

It is important not to blow your nose for the first 48 hours following endoscopic sinus surgery. Your specialist will be able to advise you as to when it is safe for you to start to blowing your nose again. Some doctors recommend the use of nose drops, sprays, ointments and salt-water sprays after the operation. Salt water is particularly useful as it keeps the nasal passages clear during the healing process. This, along with other medications, will be given to you before you go home including specific instructions as to when to take them and how often. It is quite normal for some mucus and blood stained fluid to drain from your nose for the first week or two following the operation. It is also important to stay away from dusty and smoky atmospheres while you are recovering.

When can I go home after sinus surgery?

In almost all cases you will be able to go home on the same day as the sinus operation, although occasionally it is necessary to stay in overnight. This may be because of a slower than average recovery, or if the operation has finished late in the day, or if there are other medical reasons or problems that require closer monitoring. Rest assured that we will only let you go home once you are recovered from the immediate effects of the operation, when you are eating and drinking and feel well enough to travel home.

You will need to rest at home for one to two weeks and avoid heavy nose blowing, straining or heavy lifting. If your job involves heavy lifting and carrying, you should be off work for at least two weeks. You will be given instructions on when to return to the hospital for your follow-up visit.

Things that can go wrong after sinus surgery:

There is some element of risk when undergoing any operation. Some of the possible side effects are more common but not severe, whilst others are serious but extremely unlikely to occur. These risks will have been explained to you before giving consent to this treatment. You should discuss with your surgeon about the likelihood of problems in your case before you decide to go ahead with the operation.

Bleeding can occur after any operation. It is very common to experience small amounts of bleeding from the nose in the days following sinus surgery. Major bleeding is extremely uncommon and it is very rare for a transfusion to be required.

Infection is a risk that can occur even after perfectly successful and complete sinus surgery. It may be due to a pre-existing virus that was present before the surgery, or a new infection of the surgical site. Controlling your environment after the operation, taking your medications as prescribed and keeping healthy with a good balanced diet, can reduce the risk.

Eye problems: The sinuses are situated in a limited amount of space close to the wall of the eye sockets. Sometimes minor bleeding can occur into the eye socket and this is usually noticed as external bruising around the eye. This is usually minor and disappears within a few days without any special treatment, although it is important that you do not blow your nose as this could worsen the bruising. More serious bleeding into the eye socket is extremely unlikely to occur. This can cause more severe swelling of the eye and can even cause double vision. Loss of sight has been recorded in the textbooks but is nowadays almost unheard of. If such a serious eye complication did occur you would need to be seen by an eye specialist and may require further operations.

Brain or spinal fluid leak: The sinuses are situated very close to the bone at the base of the brain. Sinus surgery carries a small risk of damage to this thin bone that can cause leakage of fluid from around the brain into the nose. If this rare complication does happen you will have to stay in hospital a little longer and may require another operation to stop the leak. Other problems are also possible including an infection of the outer lining of the brain (meningitis) or even an intracranial abscess, although both of these are extremely unlikely.

Persistence or recurrence of symptoms: In some cases patients may continue to experience symptoms of chronic sinusitis, or may have an interval of no symptoms for a period of time after the surgery followed by a recurrence of the original problems sometime later. This can occur even after apparently successful sinus surgery at the first sitting, and may be due to a problem with the internal lining of the nose being inflamed or allergic rather than with the structure and/or drainage pathways of the sinuses. It is also possible that insufficient surgery was performed at the first operation. If you experience sinus symptoms after FESS or endoscopic sinus surgery, your surgeon will be happy to see you at any stage to re-examine your nose and assess whether any further surgery may be necessary.

Reduced sense of smell: Even in successful sinus surgery, it is not always possible to restore the sense of smell. This is because the sense of smell is particularly delicate and can become less acute both due to the original problem (be it sinusitis or nasal polyps) as well as due to the surgery. It is more likely to be affected after nasal polyp surgery than sinus surgery for rhinosinusitis alone, although in cases where the nasal polyps have already reduced the sense of smell before the surgery, sinus surgery does not always improve the sense of smell even if the nasal airway and breathing does improve.

It goes without saying that you will have ample opportunities to discuss these complications with your surgeon before the operation so that you have a good understanding of the procedure.

In general, major complications are very rare. In a survey of all ENT surgeons who do this type of operation in England and Wales, eye complications happened in one in every five hundred operations, but there was no associated loss of vision. Spinal fluid leaks occurred once in every thousand operations, but were detected and repaired during the same operation, so the additional risks arising from the leak were felt to be extremely small. Minor complications, including bleeding from the nose occurred more often. One in four patients reported mild persistent bleeding after the operation, which resulted in readmission to hospital in some cases. If you are particularly worried you should ask your surgeon about his or her experience of these complications.