Functional Endoscopic Sinus Surgery (FESS)

Dr. K. R. Meghanadh

What is FESS

The growth of sinus surgery took a significant turn in the mid-1980s with the introduction of endoscopes, providing a deeper insight into sinus physiology. Prof. Messerklinger postulated these insights. Dr. Heinz Stammberger capitalised on these insights and developed the Functional Endoscopic Sinus Surgery (FESS) technique, also known as Messerklinger’s technique.

FESS has become a widely used term for various procedures in recent times. Traditionally, FESS was associated with Messerklinger’s Technique. This technique focuses on preserving mucosa and addressing blockages of the sinuses in the osteomeatal complex area only.

Functional Endoscopic Sinus Surgery involves using an endoscope to enhance the functionality of the sinuses, which aims to alleviate sinus problems and restore normal sinus function without the need for traditional open sinus surgery, which is more invasive and prone to scarring and disfigurement of the face.

Risks

Sinus surgeries are generally very safe thanks to technological advancements, but like every surgery, there are few risks.

The sinuses are located near vital structures such as the eye, brain, and optic nerve. Moreover, They are in different shapes and sizes and located in different places within each individual, making it challenging for surgeons to navigate around the sinuses. So, to ensure accuracy, surgeons should carefully study the patient’s CT scan multiple times before the procedure.

Additionally, as the surgery involves anaesthesia, risks of anaesthesia could be added to the list.

So, here are the risks associated with FESS.

1. Damage to major nerves that control the eye, brain and face

2. Infection to the eye or brain

3. Anaesthesia risks like lung infection, requiring a ventilator for some time, and risk of death.

Thankfully all the risks are rare. In elderly people, the risk is 1 out of 10,000. In others, it is 1 out of 30,000.

Which Sinuses are operated in FESS?

The human body houses approximately 40 sinuses. According to Messerklinger, only 4 or 5 sinuses in the osteomeatal complex area (OMC) require surgical intervention. The remaining 30+ sinuses should naturally clear themselves over time.

So, when a doctor says he is performing FESS and doesn’t say explicitly that he will perform surgery on other sinuses, he is not obligated to work on other sinuses. However, doctors perform on other sinuses involved in the infection. So, we can say that the term FESS is being used loosely. So, you have to inquire about what sinuses will be operated on, especially when you want to compare the costs given by two different surgeons.

FESS Surgery Success Rate

FESS Surgery boasts a 30% success rate. The majority will experience relief within days, but 70% of them will have a relapse within three years. Notably, the remaining 30% enjoy a lifetime without relapse.

Instant Relief from FESS

In traditional FESS Surgery, the focus is on operating only 4 to 5 sinuses within the Osteomeatal Complex area (OMC). By addressing these significant sinuses, the procedure aims to remove infected fluids and clear any anatomical anomalies in the sinus drainage pathways.

This targeted approach leads to a gradual decrease in infection within the sinus walls, subsequently reducing existing swelling. As a result, the opening of other sinus drainage paths may occur, allowing for the drainage of additional infected fluids and further reduction of swelling. This natural process unfolds over a couple of days, providing patients with almost instant relief.

Why did Traditional FESS fail in 70%?

Despite not operating on all sinuses, FESS gives immediate relief. However, other factors can result in the recurrence of the disease. There could be anatomical anomalies in the other 35(approximately) sinuses. These anomalies could be responsible for triggering future reinfection.

Duration for FESS Surgery

FESS has become a widely used term for various procedures, although initially associated with Messerklinger’s Technique. The original surgery typically lasts for 45 to 60 minutes only, as only the major 4 to 5 sinuses are operated on.

But, if the doctor operates on other sinuses, then the surgery's duration will extend.

When do we need FESS?

FESS is commonly recommended for individuals suffering from:

1. Intense Sinus Infection: if you experience severe or recurring sinusitis. Surgery is recommended to treat the infection and prevent future infections in the sinus.

2. Ineffectiveness of Medication: The infection may persist even after an entire medical treatment course. In such cases, doctors may recommend surgery.

3. Complications: For persistent or recurrent complications, especially in cases of orbital cellulitis, orbital abscess, meningitis, or encephalitis, surgery may be recommended.

4. Fungal Sinus Infection: Doctors may advise sinus surgery for non-invasive or fulminant invasive fungal sinusitis.

To know more about when sinus surgery is recommended, read our article. "When do you need Sinus Surgery?" 

Benefits of FESS

1. Minimally Invasive: FESS is minimally invasive compared to traditional sinus surgeries, as it does not require external incisions.

2. Faster Recovery: Patients typically experience a quicker recovery time compared to open procedures, as there is less disruption to surrounding tissues. A person with WFH can start the work right after the general anaesthesia goes down, although they will have discomfort due to the nose pack.

3. Reduced Pain and Discomfort: Patients generally experience less pain and discomfort after FESS since there are no external incisions.

4. Minimised Scarring: FESS minimises scarring and disfigurement.

Complications of Functional Endoscopic Sinus Surgery

Despite its advantages, FESS has its challenges. Challenges arise as only specific sinuses in the osteomeatal complex area require an operation, leaving room for potential reinfection and complications in 70% of patients within 3 to 4 years. 

Additionally, there’s a rare occurrence of secondary bleeding, affecting one in a thousand individuals around the seventh-day post-surgery. This bleeding is more common in patients who have neglected post-opt care and prescribed antibiotics.

Continuous monitoring and follow-up care are essential to manage and address any emerging issues post-surgery.

FESS Cost

The full cost of traditional Functional Endoscopic Sinus Surgery (FESS) can reach up to 70,000 INR (around 850 USD). This covers everything, including anesthesia, surgical fees, ward rent, medical staff fees, medications, supplies, and operation theater charges. There shouldn't be any hidden costs beyond this. Across India, this price range should remain in the same ball park.

However, it's worth noting that FESS is a broad term. Surgeons may perform surgery on additional sinuses besides those in the osteomeatal complex (OMC). While this might increase the surgery's duration and cost, it can also improve the long-term success rate of the procedure.

When comparing prices between two doctors or hospitals, it's crucial to inquire about the surgeon's plan regarding potential additional sinuses to be operated on and ensure that all the costs mentioned earlier are included in the quote. This proactive approach helps avoid surprises and ensures transparency in pricing, allowing for informed decision-making regarding the choice of healthcare provider.

To know more about costs of other options available in sinus surgery, please check our article

Conclusion

FESS has revolutionised sinus surgery, offering an alternative to open procedures with improved success rates. While it has its share of challenges and complications, technological advancements continue to refine this technique, providing hope for better outcomes in the future.

Dr. K. R. Meghanadh