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

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

Patients should undergo at least 3 months of optimal medical therapy before considering FESS, and surgery should only be pursued when symptoms persist despite appropriate medical management. 1

Medical Management Before Considering Surgery

• Nasal saline irrigation should be used as first-line treatment, with high-volume nasal douches being more effective than sprays for distributing solution to the maxillary sinus and frontal recess 1
• Intranasal corticosteroids are essential standard medical therapy that must be tried before considering surgical intervention 1
• Medical therapy should be continued for a minimum of 3 months in uncomplicated chronic rhinosinusitis (CRS) before surgical options are considered 1
• A strong patient history for sinus symptoms is the most important indication for FESS when medical therapy fails 2

Proper Patient Selection for FESS

• FESS is indicated only when patients remain symptomatic despite optimal medical therapy 1
• Preoperative CT scanning is mandatory to evaluate sinus anatomy and disease extent before proceeding with surgery 1
• Nasal endoscopy must be performed to assess the ostiomeatal complex and document presence of polyps, purulence, or anatomical abnormalities 1
• Patients with asthma and medically unresponsive sinusitis may particularly benefit from FESS, with studies showing 80% of such patients experiencing asthma improvement following surgery 3

Surgical Approach Recommendations

• The extent of surgery should address all involved sinuses as identified on preoperative CT imaging 1
• Consider administering preoperative corticosteroids (oral or intranasal) to reduce surgical bleeding and improve visualization of the surgical field 1
• Partial middle turbinectomy can be safely performed during the procedure when indicated 2
• Most FESS procedures can be performed on an outpatient basis, with studies showing over 84% of cases successfully completed without hospitalization 2

Postoperative Care Protocol

• Postoperative nasal saline irrigation is essential and should be started within 24-48 hours after surgery for optimal healing 1
• Postoperative intranasal corticosteroids may improve wound healing, particularly in patients with nasal polyps 4
• Regular endoscopic follow-up is necessary to assess healing, remove crusts, and address any signs of recurrent disease 1
• Even after successful FESS, some patients (approximately 41.5%) may still require ongoing medical therapy 2

Outcomes and Special Considerations

• FESS has a success rate of approximately 88% (symptom-free or improved) with proper patient selection 2
• Patients with extensive polyposis require more aggressive surgery and have higher recurrence rates 1
• Revision FESS has a lower success rate (65%) compared to primary FESS 5
• Anatomic variations must be identified preoperatively to reduce risk of complications 1
• Complication rates are generally low (8% minor complications, <1% major complications) when performed by experienced surgeons 2

Limitations and Caveats

• Evidence from systematic reviews suggests that FESS may not be superior to medical treatment with or without sinus irrigation in some patients with chronic rhinosinusitis 6
• Patients should be informed that FESS is not a cure-all, and some may require ongoing medical therapy or even revision surgery 2, 5
• Distorted or missing anatomic landmarks in revision cases make these procedures more technically challenging, though complication rates need not increase with meticulous technique 5