Sinusitis Surgery: An Overview of the Different Technologies
Updated: 8 hours ago
Traditional Open Surgery | FESS | TFSE surgery | Debriders | Image Guided Sinus Surgery | Endoscopic Balloon Sinuplasty | FAQs
Suppose you or a loved one is suffering from sinusitis. In that case, sinus surgery can improve health and quality of life if antibiotics are not working.
This guide will provide information on the types of sinus surgery available, including traditional surgery, FESS procedures, and the latest techniques.
Although we didn’t mention any costs here, you can decide what technologies to choose according to your available options and budget.
If you want to read about the treatment for sinusitis and when a doctor suggests surgery. Please refer to our "Treatment for Sinusitis- Acute, Chronic & Subacute stages."
Traditional Open Sinus Surgery
Traditionally, open sinus surgery involves cutting into the skin to access the sinuses. The mucosa (the sinus lining) is also removed along with the disease. This surgery often resulted in facial scars and disfigurement. The surgery had a 90% failure rate within 2-3 years. We, doctors, did not always address the underlying causes of sinusitis. The recurrence of the disease was very common.
Functional Endoscopic Sinus Surgery (FESS) or Messerklinger Technique
The use of endoscopes in sinus surgery began in the mid-1980s. The use of endoscopes gave a deeper understanding of sinus physiology and its functions.
These findings have helped Stammberger develop the Messerklinger or Functional Endoscopic Sinus Surgery technique. Functional Endoscopic Sinus Surgery, in short, is called FESS. FESS emphasized preserving the mucosa and clearing blockages in the osteomeatal complex area.
Although this technique was developed around 1985, in India, we started using it in the early 1990s. This was the time I was pursuing my masters. So all the department staff members learned about this surgery simultaneously.
We were initially happy that FESS avoided scarring and disfigurement. But 70% of patients were reinfected with a sinus infection within 3 to 4 years. So, the success rate was 30%, on the bright side, three times more than the previous method.
Why did Messerklinger’s Technique or FESS Fail?
There are around 40 sinuses in our body. But as per Messer Klinger, only 4 or 5 sinuses in the osteomeatal complex area or OMC needs an operation. This led to partial results as we surgeons did not open the 30+ sinuses. Messer Klinger states that these 30+ sinuses should clear themselves over time which happened only in 30% of the patients.
TFSE Surgery
TFSE surgery's full form is Total Fronto Spheno Ethmoidectomy surgery, which was developed to overcome the limitations of FESS. TFSE surgery, all 30 to 40 sinuses are opened for better results. On the contrary, in FESS, only 4 or 5 sinuses are opened. This increased the success rate from 30% to around 90%.
However, in early TFSE procedures, we used grabbing instruments, which resulted in mucosa loss. The loss of mucosa resulted in scarring. Scarring is the healing process of mucosa that can result in the contraction of the sinus opening.
To rectify the issue, we replaced grabbing tools with cutting tools. These tools and methods aided in maintaining the mucosa. However, the surgical time significantly extended to 4 to 6 hours. Prolonged surgeries beyond 4 hours may result in inconsistent outcomes. The speed of the surgery is crucial to achieving optimal results.
Debriders in sinus surgery
To shorten the surgery time, we switched to using powered instruments called debriders. These tools have evolved with technology, offering features like rotatable and angled blades. As a result, the use of debriders in TFSE surgery has improved our success rate from 90% to 95%.
Yet, there is still a 5% chance of failure due to each person’s sinuses’ unique and complex structure. Sinus structures are distinct for every person, like a fingerprint. Even with a CT scan available in the operating room, human error by the surgeon can still occur.
Navigation Systems guided Sinus Surgery
We improved the accuracy of our surgeries by using a navigation system. It is also called image-guided sinus surgery. This system is like a 3D version of Google Maps, with a precision of 0.5mm. The CT scans are transformed into a 3D format by the software. This software requires a high-performance computer, which is costly (around 30,000 USD or 25,00,000 INR).
During surgery, all instruments are under the control of an Electromagnetic (EM) field for tracking. The navigation software calculates unique values for each point in the EM field and maps them onto the CT scan. This allows us to see the exact location of the instrument tip in the patient’s head.
Using navigation-guided instruments gives us access to information about the proximity to critical structures such as the optic nerve, brain, eye, and others. This has increased our success rate from 95% to 98%.
Endoscopic Balloon Sinuplasty (EBS)
The last bit of setbacks in sinus surgery, 2%, happens because of scarring during recovery. This scarring process can block sinus openings of close to the tiny sinuses, which have limited space.
Most surgeons are aware that in many cases, a 10mm opening created during sinus surgery will naturally decrease to just 5mm due to scarring within a few years. However, in critical areas such as the frontal recess areas (which are located above the eye, between the eye and brain, or between the eyes), the space is much smaller, sometimes as little as 6mm, making it impossible to create a larger incision.
Endoscopic Balloon Sinuplasty (EBS) is a solution to this problem. It uses a balloon to open up the sinus passages, reducing scarring and the likelihood of blockages. It moves up the success rate to over 99.9%.
Why do we have 0.1% of failures still left?
Although with the use of the latest equipment success rate is high. All anatomical anomalies are corrected in this surgery.
But anatomical anomalies are not the only reason for sinusitis. Allergy and less immunity toward bacteria can also be the cause of sinusitis.
Even after surgery, patients with allergies must take anti-allergic medication to prevent infection. Individuals with lesser immunity must take care of their health by having adequate sleep and eating a balanced diet with a good amount of protein and spices.
FAQs
Is sinus surgery a serious surgery?
Yes, sinus surgery is a serious procedure.
It involves a delicate area near the eyes, brain, optic nerve (responsible for vision), and numerous major blood vessels that supply blood to the brain. However, with the expertise of skilled surgeons and advanced medical equipment, surgery can be performed safely and effectively. With over 20,000 successful surgeries performed in the past 30 years, the author has a proven track record of success and has not encountered any complications involving vital organs, nerves, or blood vessels.
A physician must possess a comprehensive understanding and knowledge of the specific sinus structures of a patient. To achieve this, they must thoroughly review the patient's CT scan before the surgery. A thorough grasp of anatomy is crucial in avoiding potential complications during sinus surgery, even in image-guided sinus surgery.
In the author's experience, one out of a thousand has bleeding in the first ten days, which will require hospitalization and IV antibiotics. It happens when a patient misses a few doses of antibiotics prescribed after the surgery at the discharge time.
Is sinus surgery a permanent fix?
Yes, sinus surgery can be a permanent fix when done precisely with leading technologies like the navigation system, debriders, and balloon sinuplasty. These technologies, when used carefully, can give over a 99.9% success rate for a lifetime.
But unfortunately, due to some technical and economic reasons, some surgeons are forced to do suboptimal surgery. In this scenario, the results are also suboptimal.
Along with surgery, it is necessary to take care of underlying issues that caused this infection.
How long is recovery from sinus surgery?
The recovery from sinus surgery can vary depending on the case to case and line of work of the patient. For those who work from home, it is possible to return to work within 24 hours of the procedure. However, some individuals might return in 2 hours. A person who has physical work might take as long as two days. In the worst-case scenario, it may take up to 5 days for a person to fully recover from sinus surgery.
The effects of general anesthesia during sinus surgery typically wear off within an hour. Following the procedure, half of the patients may require a dressing in the nose, which can be a gel, ribbon gauge, or cotton. The dressing may cause discomfort, but not pain, and is typically left in place for 2 to 5 days.
Is sinus surgery very painful?
Sinus surgery is not very painful. Under general anesthesia, sinus surgery is entirely pain-free. However, when performed with monitored anesthesia, there may be occasional mild discomfort during certain parts of the procedure, but it is generally a comfortable experience.
How long is recovery from sinus surgery?
The recovery from sinus surgery can vary depending on the case to case and line of work of the patient. For those who work from home, it is possible to return to work within 24 hours of the procedure. However, some individuals might return in 2 hours. A person who has physical work might take as long as two days. In the worst-case scenario, it may take up to 5 days for a person to fully recover from sinus surgery.
The effects of general anesthesia during sinus surgery typically wear off within an hour. Following the procedure, half of the patients may require a dressing in the nose, which can be a gel, ribbon gauge, or cotton. The dressing may cause discomfort, but not pain, and is typically left in place for 2 to 5 days.
How many hours does sinus surgery take?
Sinus surgery takes 1 hour to 4 hours, depending on the type of surgery. FESS,i.e., the Messerklinger technique, will take 1 hour or less. TFSE can take 2 to 4 hours.
Note: FESS is a very loosely used term, a term being used for a wide variety of surgeries due to its popularity.
Read the above article to know exactly about the technologies used in sinus surgery. This will help you question your doctor to understand what surgery technique was chosen for you by him and what to expect from it. It will help you make an educated choice.
How much does sinus surgery cost in India?
A typical FESS sinus surgery costs from 100,000 to 200,000 INR in India. However, if debriders are employed, the cost can increase by an additional 40,000 to 50,000 INR. Utilizing navigation systems (image-guided surgery) can add another 50,000 INR to the overall cost. Including Endoscopic Balloon Sinuplasty (EBS) can raise the price by 70,000 INR. Hence, the total sinus surgery cost can be estimated to be between 100,000 to 350,000 INR (1,250 to 4250 USD).
Is sinus surgery a risk?
No, sinus surgery is not inherently risky. In the past, there was a significant risk of death in cases where the surgeon lacked experience. However, this risk has been greatly diminished with the advent of advanced technology, modern equipment, improved visualization techniques, and endoscopes. In the 20,000 cases performed by the author, there have been no incidents of death due to the surgery.
What is the full form of FESS?
The full form of FESS is Functional Endoscopic Sinus Surgery. It is also called Messerklinger's Technique. It was implemented and made popular by Heinz Stammberger based on Messer Klinger's proposed concepts.
What is the FESS procedure?
FESS is Functional Endoscopic Sinus Surgery. It just indicates that Endoscopy is used in sinus surgery. FESS is a popular term being loosely used for various procedures these days. Although traditionally, FESS was first used for Messerklinger’s Technique, that has only a 30% success rate.
Please refer to the above article to understand various types of technologies used in sinus surgery and their results. It will enable you to discuss your surgery with your surgeon better.
What does FESS mean in ENT?
FESS is Functional Endoscopic Sinus Surgery, i.e., sinus surgery using an endoscope to improve the functionality of the sinuses. This technique was designed to replace open sinus surgery that caused a scar on the face or deformity on the face. The success rate was triple when compared to open sinus surgery.
Read the above article for more details.
What is TFSE sinus surgery in full form?
TFSE surgery's full form is Total Fronto Spheno Ethmoidectomy surgery. It is a sinus surgery technique developed to overcome FESS or Messerklinger Techique's shortcomings.
Click here to learn more about TFSE Surgery.
What does TFSE mean?
TFSE, also known as Total Fronto Spheno Ethmoidectomy surgery, is meant to be a game-changing sinus surgery technique that aims to improve upon the shortcomings of FESS.
Initially, FESS showed promise as a sinus surgery method, assuming that clearing 4-5 sinuses in the osteomeatal complex or OMC areas would resolve sinusitis problems. However, within just 3-4 years, 70% of patients experienced a recurrence of sinusitis, resulting in a success rate of just 30%.
To overcome these limitations, TFSE was introduced. Unlike FESS, TFSE involves the clearance of all the sinuses, resulting in a drastic increase in the success rate, from 30% to an impressive 90%. With this technique, patients can experience long-lasting relief from sinusitis symptoms, leading to a better quality of life.
What is endoscopic sinus surgery with navigation?
Navigation systems are specially designed for endoscopic sinus surgery. These machines act like 3D google maps with higher precision.
Every person has sinuses in unique numbers, shapes, and dimensions, making it impossible for ENT surgeons to have a standard way to navigate through every sinus. These machines convert a CT scan of a person into a 3D map and make it easy for the ENT surgeon to reach out to every sinus in the head and perform TFSE. They even notify the doctor if they are close to critical structures like the optic nerve, eye, or brain.