Sinusitis Surgery: An Overview of the Different Technologies

Dr. K. R. Meghanadh

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 surgery for sinusitis 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."

NOTE: It's important to know that surgery for fulminant fungal sinusitis (such as mucormycosis) differs from surgery for other types of sinusitis.

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 after surgery was very common.

Functional Endoscopic Sinus Surgery (FESS) or Messerklinger Technique

The use of endoscopes in sinus surgery began in the mid-1980s. Using endoscopes gave us a deeper understanding of sinus physiology and its functions.

These findings have helped Stammberger develop the Functional Endoscopic Sinus Surgery technique. Functional Endoscopic Sinus Surgery, in short, is called FESS. As the surgery was based on concepts proposed by Messerklinger, FESS was even called the Messerklinger technique. Messerklinger emphasized preserving the mucosa and clearing blockages in the osteomeatal complex area, which was followed in FESS.

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 master's. 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 Messerklinger says that only 4 or 5 sinuses in the osteomeatal complex area or OMC need 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. In 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%. This means that there is still a 10% failure chance of sinus surgery with basic TFSE.

Understanding the 10% of TFSE Procedures that Don't Succeed

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.

The success rate of the surgery is currently reduced by 10%. This is due to factors such as the length of the surgery, scarring, and difficulties reaching every sinus in the head. However, other technologies mentioned in this article can help achieve an additional 9.9% success rate and increase the overall success rate to over 99.9%. To learn more, read on.

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).

Dr. K. R. Meghanadh performing Image Guided Sinus Surgery using Navigation system

During surgery, all instruments are controlled by 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.

Navigation-guided instruments give 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.

Dr. K. R. Meghanadh

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.

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 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 surgery 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 or deformity on the face. The success rate was triple when compared to open sinus surgery.

Read the above article for more details.

Is FESS a minor surgery?

No, FESS is not a minor surgery due to the sinuses' location.

In 1929 Dr. H. P. Mosher said, "The easiest way for a surgeon to kill a patient is during a sinus operation.".

Although with lots of technological advancements, the surgery got a lot more efficient and safer, it doesn't change the fact that sinuses are located in close proximity to the eye, brain, optic nerve, and other critical structures.

Every person has around 30 to 40 sinuses located in different places in different shapes and sizes. Creating a standardized way to reach these sinuses is tough. To understand how to navigate, a surgeon should read a patient's CT scan multiple times before the surgery. Human errors are still possible after the utmost care by an experienced ENT surgeon also.

However, the manual errors got sporadic with the proposal of FESS that came into use. Thankfully inventions that came in later, like the navigation system, have made it impossible for a surgeon to make these mistakes.

Is FESS surgery risky?

Yes, FESS surgery can be risky. Although there are multiple reasons why FESS surgery can have risks, the likelihood of experiencing such troubles is relatively low these days due to technological advancements.

Secondary hemorrhage or bleeding can occur in one out of every thousand individuals, typically on the seventh day following surgery. The bleeding mostly happens in patients who have not taken prescribed antibiotics.

Due to the sinuses' proximity to the brain, eyes, vision nerves, and important blood vessels, the sinuses subject to surgery require a skilled and experienced surgeon to perform the procedure safely. The author, having completed over 20,000 surgeries over the past 23 years, has not encountered any complications involving these critical areas.

What anesthesia is used for FESS?

General anesthesia is used for FESS.

During General Anesthesia, the patient's breathing is controlled by a machine, and they do not breathe on their own. The patient will be in a state of deep sleep and will not experience any pain during General Anesthesia. Thanks to modern technology, we have access to exceptional equipment that can continuously monitor multiple vital signs and effectively manage any complications with suitable medications. Anesthetists can accurately maintain the depth of anesthesia with precise drug dosages, which can vary from person to person based on their vital signs. This modern approach to anesthesia, called balanced anesthesia, is considered highly safe.

How long is functional endoscopic sinus surgery?

Functional Endoscopic Sinus Surgery (FESS), also known as the Messerklinger technique, typically takes about 1 hour or less.

Is functional endoscopic sinus surgery safe?

Functional Endoscopic Sinus Surgery (FESS) is generally considered safe, but like any surgical procedure, it carries some risks. The sinuses are located close to vital structures such as the brain, eyes, vision nerves, and important blood vessels. Therefore, performing surgery in this area requires a skilled and experienced surgeon to ensure the safety and success of the procedure. Moreover, technological advancements have lowered the likelihood of complications.

What is sinus endoscopy?

Sinuses are extensions from the nose in the form of a cavity. There is an opening between the sinuses and the nose. We make a puncture for a 2.4mm diameter endoscope to go from the nose into the sinuses to check them.

Sinus endoscopy is used for the maxillary sinus and rarely for the frontal sinus.

However, using CT scans has significantly reduced the need for sinus endoscopy. This procedure is now reserved for rare cases such as tumors, sinus bleeding, and nose or sinus fractures.

Who needs endoscopic sinus surgery?

Patients who mainly don't respond to the antibiotic course given as per their stage of sinusitis need endoscopic sinus surgery.

Using endoscopy for sinus surgery was introduced by a technique called FESS. These days all sinus surgeries use endoscopy. Using endoscopy for surgery is very basic. More technologies are being used along with endoscopy these days. Please check the above article for more details about sinus surgery.

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.

What is image guidance for sinus surgery?

Sinus surgery can be a complex and delicate procedure due to the sinuses' critical location near the brain, eyes, vital nerves, and blood vessels. Not to mention, each patient's sinuses are unique in shape and size, making it challenging for ENT surgeons to navigate through them safely and precisely.

This is where image guidance technology comes into play, providing a 3D map of the patient's sinuses during the surgery. Think of it like using Google Maps to navigate a new city rather than relying on an old physical map - it's more accurate and efficient.

The image guidance system tracks every instrument used in navigation surgery and maps it onto the 3D format of a CT scan. This enables the surgeon to navigate the sinuses more accurately and efficiently, avoiding critical structures.

Image guidance systems also come equipped with alarms that go on when approaching critical structures, similar to the parking sensors in our cars, reducing the risk of accidents during surgery.

So, the next time you or someone you know requires sinus surgery, make sure to ask your ENT surgeon about image guidance technology. It's a game-changer!

If you're considering sinus surgery, you're likely wondering about the best ways to ensure a safe and successful procedure. Look no further! The document above, written by Dr. K. R. Meghanadh, who has 30 years of experience, provides all the essential details on the latest technologies and techniques that can help optimize your surgical experience. From cutting-edge image guidance systems to innovative surgical tools, there are plenty of options available to help ensure a smooth and effective procedure. Don't miss out on this valuable information - take a few minutes to read through and discover the possibilities for safer, more successful sinus surgery.

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