What is the recommended approach for patients considering Functional Endoscopic Sinus Surgery (FESS)?

Recommended Approach for Patients Considering Functional Endoscopic Sinus Surgery (FESS)

Patients considering FESS should first undergo a trial of medical therapy including nasal saline irrigation and intranasal corticosteroids, with surgery reserved for those who fail medical management. 1

Pre-surgical Medical Management

• Nasal saline irrigation is an important first-line treatment for chronic rhinosinusitis (CRS), with isotonic saline showing better efficacy than hypertonic solutions 1
• High-volume nasal douches are more effective than sprays in distributing irrigation solution to the maxillary sinus and frontal recess 1
• Intranasal corticosteroids should be used as standard medical therapy before considering surgical intervention 1
• Medical therapy should be continued for at least 3 months before considering surgical intervention in uncomplicated CRS 1

Indications for FESS

• FESS should be considered when patients remain symptomatic despite optimal medical therapy 1, 2
• The strongest indication for FESS is a compelling patient history of chronic sinus symptoms that have failed medical management 2
• Preoperative CT scanning is essential to evaluate sinus anatomy and disease extent 1
• Nasal endoscopy should be performed to assess the ostiomeatal complex and document presence of polyps, purulence, or anatomical abnormalities 1

Surgical Approach

• Standard FESS techniques focus on the ostiomeatal complex and anterior ethmoid sinuses, the most common areas of pathology 2
• The extent of surgery should address all involved sinuses as identified on preoperative CT imaging 1
• Consider preoperative corticosteroids (oral or intranasal) to reduce surgical bleeding and improve visualization of the surgical field 1
• Partial middle turbinectomy may be safely performed when necessary for access without risk of atrophic rhinitis 2

Postoperative Care

• Postoperative nasal saline irrigation is essential for optimal healing and should be started within 24-48 hours after surgery 1
• Nasal corticosteroid sprays should be resumed approximately 2 weeks after surgery to improve wound healing, particularly in patients with nasal polyps 3
• Regular endoscopic follow-up is necessary to assess healing, remove crusts, and address recurrent disease 1
• Patients should be monitored for complications, which occur in approximately 8% of primary FESS cases (mostly minor) 2

Expected Outcomes and Follow-up

• Success rates for primary FESS are approximately 88% (symptom-free or improved), though 41.5% of patients still require some ongoing medical therapy 2
• Revision surgery rates range from 2% to 24%, with a 65% improvement rate for revision procedures 4
• Patients with asthma may experience improvement in both sinus and asthma symptoms following FESS when medical therapy has failed 5
• Long-term follow-up is essential as some patients may experience recurrence of disease requiring continued medical therapy or revision surgery 4, 6

Special Considerations

• Patients with extensive polyposis may require more aggressive surgery and have higher recurrence rates 1, 3
• Patients with comorbid conditions like asthma or aspirin-exacerbated respiratory disease may benefit from FESS but should be counseled about potential need for ongoing medical therapy 5
• Anatomic variations should be identified preoperatively to reduce risk of complications 1
• Most FESS procedures (>84%) can be safely performed on an outpatient basis 2