FESS - Standard

• • • Gently medialize the middle turbinate with the Freer

    • Place 4% Cocaine pledgets x 2 into the middle meatus

    • Uncinectomy (multiple techniques) 

      • Place the angled ball-tip probe (maxillary sinus seeker) into the semilunar hiatus and medialize the uncinate 

      • Place the MicroFrance 90 degree through-cutting forceps at the inferior aspect of the uncinate and dissect sharply to the superior insertion of the uncinate

      • Straight  or angled microdébrider to remove the uncinate

      • KEY: Remove the superior attachment of the uncinate

    • Enlarge the antrostomy

      • May switch to 30-degree endoscope 

      • Downbiter or angled microdébrider to take down the inferior uncinate process to the superior border of the inferior turbinate

    • Pediatric backbiter to remove lateral wall anteriorly to the thick bone over the nasolacrimal duct

    • Straight through-cutter to excise the fontanelle posterior to the natural ostium

    • Remove maxillary disease

    • Curved suction and angled microdébrider, débride polypoid tissue from the sinus

• • Ethmoidectomy

  • Anterior ethmoidectomy

    • 0-degree endoscope to identify the medial border of the ethmoid bulla

      • J-curette to fracture the bulla in an anterolateral direction starting from the space medial to the bulla and posterior to the bulla (retrobullar space)

    • Straight microdebrider (or Blakesley forceps) to remove all bony fragments

    • Angled through-cutter or J-curette to dissect along the medial orbital wall to remove the lateral partitions of the ethmoid bulla and identify the lamina papyrecea 

  • Posterior ethmoidectomy

    • • J-curette to perforate the medial-inferior basal lamellae at the height of the roof of the maxillary sinus

      • REMEMBER: The roof of the maxillary sinus serves as a vertical landmark for dissection as you progress from anterior to posterior through the ethmoid cavity

    • Straight microdebrider and through-cutting instruments to dissect the basal lamella inferiorly to the horizontal portion and superiorly to the height of the roof of the maxillary sinus

    • Angled thru-cutting instruments (and/or rotating Kerrison) to remove ethmoid bony partitions laterally attached to the medial orbital wall and posteriorly until the anterior face of the sphenoid sinus is reached

  • Posterior to anterior dissection

    • 30-degree endoscope to identify the skull base superiorly and begin to dissect posterior to anterior along the skull base

    • Curved suction tools (with image guidance, if available) and upbiting through-cutters to remove bony partitions attached to the skull base

      • KEY: If you can see in front of a bony partition and feel behind it, then it is safe to cut with a through-cutting instrument

    • Dissect along the skull base in a posterior to anterior direction until the roof of the ethmoid bulla and suprabullar recess are reached

      • REMEMBER: This marks the area of the anterior ethmoid artery and the beginning of the frontal recess dissection

  • Sphenoidotomy

    • 0-degree endoscope to identify the superior turbinate and its horizontal lamellae, upon completion of the posterior ethmoidectomy

    • Straight through-cutter to remove the lower half of the superior turbinate

  • Sraight image guided suction to identify the natural os of the sphenoid sinus

  • J-curette to enter the natural os and then dilate the os by fracturing the anterior sphenoid face in a lateral direction

  • Kerrison punch or straight mushroom punch to remove bony fragments and enlarge the sphenoid antrostomy 

  • Frontal sinusotomy

    • Reverse 45-degree (and potentially 70-degree) endoscope

    • Draf I: removal of the superior uncinate with preservation of the agger nasi

    • Draf IIa: removal of all cells within the frontal recess

    • Identify the anterior ethmoid artery, usually at the beginning of the frontal recess as one moves posterior to anterior

      • REMEMBER: This signals the beginning of the frontal dissection; When the frontal recess is viewed, the most common arrangement is the agger nasi cell anteriorly and the supraorbital ethmoid and ethmoid bulla posteriorly

    • Identify the natural drainage pathway by the appearance of a transition zone, usually the pathway is medial-posterior to the posterior wall of the agger nasi

    • Curved suction or frontal sinus curette to dilate this space and remove the bone surrounding it

    • 45-degree front-to-back through-cutting giraffe forceps to remove the posterior wall of the agger nasi cell

      • Front-to-back and side-to-side through-cutting giraffe forceps to cut the medial wall of the agger nasi cell

      • The skull base is located posterior to the dissection 

    • Frontal sinus Kerrison punch (Bachert forceps) or 45-degree mushroom punch to remove the cap of the agger nasi cell all the way anteriorly to the nasofrontal bone 

      • 45-degree mushroom punch or through-cutting giraffe forceps to remove the posterior frontal recess bone

        • KEY: Identifying the anterior ethmoid artery more posteriorly before this move will provide greater confidence in working in the posterior frontal recess

    • 45-degree mushroom or Hosemann punch to removed some of the medial floor of the frontal recess and perform finishing touches to maximize the opening into the frontal sinus

    • Draf IIb: Draf IIa dissection plus removal of the ipsilateral floor of the frontal recess

    • Draf III: bilateral Draf IIb dissection plus removal of the intersinus septum and the superior nasal septum to create a single common opening

Sample operative report

Post-op

• Dr. Liang's post op patient instructions 

  • • .jlpifess

    • .jlpisaline

• RTC

• • POD 7

  • POD 2-3 weeks 

  • If Propel implant placed 

    • POD 10-14 - May remove the implant on the first visit; It will be more tedious to remove at future visits 

    • POD 3-4 weeks 

• Antibiotic

• • Non-polyps - 10 days

    • Amoxicillin-Pot Clavulanate (AUGMENTIN) 875-125 mg Oral Tab 20 0/0

      • • Sig : Take 1 tablet orally 2 times a day for 10 days

    • Polyps - same 

• Prednisone

• • Non-poylps - 12 day taper

    • predniSONE (DELTASONE) 10 mg Oral Tab (30 tabs)

      • • Sig : After your procedure take 4 tablets orally daily for 3 days, then take 3 tablets daily for 3 days, then take 2 tablets daily for 3 days, then take 1 tablets daily for 3 days, then stop.

    • Polyps - 16 day taper

    • predniSONE (DELTASONE) 10 mg Oral Tab (40 tabs)

      • • Sig : After your procedure take 4 tablets orally daily for 4 days, then take 3 tablets daily for 4 days, then take 2 tablets daily for 4 days, then take 1 tablets daily for 4 days, then stop.

• Sinonasal irrigation, starting POD 1

  • • All patients 

    • Neil-med Saline bottle - starting POD 1

• • Polyps / allergic fungal 

    • Budesonide - starting POD 7

• Analgesic: Tylenol #2

• Colace

Pearls & Pitfalls

High-Yield

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