Vincent Cumberworth BSc FRCS Consultant Ear, Nose and Throat Surgeon
Clementine Churchill Hospital Sudbury Hill Harrow Middlesex HA1 3RX
Private Secretary: Tel: 020 8872 3866 Fax: 0208872 3861

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Functional Endoscopic Sinus Surgery

Endoscopic sinus surgery describes a procedure which is carried out internally in the nasal and sinus cavities to clear the nose of polyps and open out the sinus drainage pathways, clearing mechanical obstruction and polyps, to optimise drainage for the sinuses.  Typically this is of use in cases of extensive polyposis and rhinosinusitis.  It is necessary to have a preliminary diagnostic nasal endoscopy and CT scan of the paranasal sinuses; this helps to define the extent of disease and also shows the regional anatomy, including any “abnormalities” which might otherwise make the surgery slightly more hazardous.

The procedure is typically performed under general anaesthesia and requires dressings in the nose afterwards for a few hours and sometimes overnight.  Dissolving dressings avoid the need for the uncomfortable step of dressing removal.  It is normally a day-case procedure but occasionally an overnight stay may be required and at least one week’s absence from work would be recommended; in certain occupations it would be advisable to take a second week off for full recuperation.  It is usual for nasal drops to be taken to help to clear the nose, although it can be up to 6 weeks before the full benefit of the operation and in terms of improved airway and drainage, may be apparent.  Nasal irrigation or douching may be of assistance and it is common to have a bloodstained discharge, of variable intensity, for a few days after the procedure which may require a nasal bolster. It is also common to have a course of antibiotics after the operation and there sometimes may be a little fresh bleeding, which just occasionally can be sufficiently troublesome to need to return to theatre or even be re-admitted after discharge.

There are some small specific complications to the procedure.  Regarding major complications, these occur with a total incidence of just under 0.5%.  The commonest of these is of a CSF leak, leakage of fluid from around the brain, and this may settle spontaneously though sometimes can require another procedure to seal the leak.  There have been reports of complications affecting the eye and even vision.  In the event of extensive bruising behind the eye it is possible for there to be pressure which can affect the optic nerve and there have been rare episodes of damage to the optic nerve itself, and for both of these there have been reports of visual impairment or loss.  There are small risks that of trauma or bruising to the medial rectus muscle, which affects inward movement of the eye, resulting in double vision (diplopia).   Extremely rarely, there have been reports of damage to the optic nerve producing blindness in the affected eye and damage to the internal carotid artery producing dangerous bleeding.  Preliminary CT scanning helps to minimise risks of serious complications.

Less serious complications can involve swelling and bruising around the eye, which settles spontaneously over 7 – 10 days.  This can occur if there is any breach of the lamina papyracea, the thin paper-like bone which separates the ethmoid sinus from the eye, and it is advisable that nose blowing is avoided for two weeks after the operation.  There have been occasional reports of severe post-operative infection or even meningitis.

Temporary anosmia, loss of sense of smell, has been reported although this may be a reaction to medication used to prepare the nose.  I have also personally had a case of temporary blurring of vision in one eye, due to dilation of the pupil, which settled spontaneously over 3 hours and which was due to spread of a vasoconstrictor agent used during the surgery.  Fortunately this settled fully without any problems.

Watering of the eye (epiphora) may result from stenosis of the naso-lacrimal duct.

I have collected data across the UK in two separate series relating specifically to the major complications of this procedure and it is from these studies and, other published data, which indicates an overall total incidence of major complications from this procedure of below 0.5%.  The second questionnaire study which I collated also indicated that comparable risks can be in the region of 1% for more “traditional” intranasal ethmoid surgery and as high as just over 2% for external sinus procedures, although indications for the different approaches may vary.  This would indicate that the technique of endoscopic sinus surgery is certainly as safe and well validated.  A preliminary diagnostic nasal endoscopy and CT scan is advisable for all types of sinus approach in most cases.  As mentioned above, this not only indicates the full extent of disease but also does show any anatomical abnormalities or differences.

Overall, the complications of surgery need to be considered but, with preliminary CT scanning, these are certainly at least as low as with traditional procedures and these also need to be balanced against the problems due to symptoms and even risks in certain cases of not operating on disease.

Endoscopic sinus surgery appears to offer a significantly better chance of improvement of the pre-operative symptoms and a greater duration of this improvement.  In certain cases, particularly that of nasal polyposis where there is associated asthma and even associated aspirin sensitivity, it is likely that the problem may recur and this can, in the fullness of time, require further surgery, although often more limited than the original procedure, in order to maintain a nasal airway.  Medication may also be required to reduce the risk of recurrence of polyps and may also be used to treat further polyps.

The indications for surgery, the intended benefits and small potential risk of complications should be discussed with the appropriate surgeon.