What are the indications for Functional Endoscopic Sinus Surgery (FESS)?

Indications for Functional Endoscopic Sinus Surgery (FESS)

Functional Endoscopic Sinus Surgery (FESS) should be offered to patients with chronic rhinosinusitis (CRS) who have failed appropriate medical management, when the anticipated benefits exceed nonsurgical management alone. 1

Primary Indications

• Failure of appropriate medical therapy in chronic rhinosinusitis:

  • Persistence of symptoms despite 8-12 weeks of:
    • Topical saline irrigation
    • Topical and/or systemic corticosteroids
    • Appropriate antibiotic therapy (when indicated)
    • Allergy management (if allergic component present) 1

• Specific pathological conditions:

  • CRS with nasal polyps refractory to medical treatment
  • CRS with fungal disease
  • CRS with osteitis or bony erosion
  • CRS with significant tissue hyperplasia 1, 2

Secondary Indications

• Complications of acute rhinosinusitis that don't respond to medical therapy:

  • Orbital complications
  • Intracranial complications
  • Mucoceles
  • Fungal sinusitis 1

• Anatomic abnormalities contributing to sinus obstruction:

  • Significant septal deviation affecting the ostiomeatal complex
  • Concha bullosa causing obstruction
  • Other structural abnormalities affecting sinus drainage 1

• Specific disease entities:

  • Benign or malignant sinonasal tumors
  • Cerebrospinal fluid leaks
  • Orbital decompression 1

Patient Selection Considerations

1. Symptom burden:

   • Significant impact on quality of life
   • Persistent symptoms despite medical management 3

2. Objective findings:

   • Endoscopic evidence of disease (polyps, purulence, edema)
   • CT scan showing sinus opacification or mucosal thickening 1
   • Note: Surgery should not be planned solely based on arbitrary criteria of minimal mucosal thickening or sinus opacification on CT 1

3. Patient understanding:

   • Clear expectations about outcomes
   • Understanding of long-term disease management requirements
   • Awareness of potential for recurrent disease or revision surgery 1

Contraindications and Cautions

• Relative contraindications:

  • Acute sinusitis (unless complicated)
  • Uncontrolled medical conditions
  • Patients who haven't received adequate medical therapy

• Special considerations:

  • Higher complication risk in revision cases (9.9% vs. primary FESS) 4
  • Lower success rates in revision surgery (65% improvement vs. 88% in primary FESS) 3, 4

Expected Outcomes

• Success rates:

  • 88% of patients report being symptom-free or improved after FESS 3
  • However, 41.5% still require some ongoing medical therapy 3

• Complication rates:

  • Minor complications: approximately 8%
  • Major complications: less than 1% 3

Important Clinical Pearls

1. Extent of surgery should be tailored to disease extent rather than using arbitrary criteria 1

2. Preoperative CT scan is essential for surgical planning and should include cuts through the ostiomeatal complex 2

3. Patient education about postoperative care is crucial, including:

   • Pain control expectations
   • Need for debridement
   • Ongoing medical management
   • Activity restrictions
   • Follow-up requirements 1

4. Postoperative follow-up should occur between 3-12 months to assess:

   • Symptom relief
   • Quality of life
   • Complications
   • Adherence to therapy
   • Need for rescue medications 1

FESS has evolved to become the primary surgical approach for chronic rhinosinusitis refractory to medical management, with high success rates and relatively low complication rates when performed by experienced surgeons. However, it should be viewed as part of a comprehensive management strategy rather than a standalone curative intervention for this chronic inflammatory condition.