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S. Ganesan et al.
Take Home Messages
• Chronic rhinosinusitis (CRS) comprises
a group of disorders that arise from
complex inammatory processes with
varied presentations.
• Environmental and exogenous factors
play major role in etiology.
• Tremendous burden on healthcare system with signicant negative impact on
patients physical, psychological, and
social functioning.
• The chapter is intended for all clinicians
who are likely to diagnose and manage
adult patients with CRS and applies to
all settings.
• Aim to improve diagnostic accuracy,
reduce inappropriate use of radiological
investigations and antibiotics use.
• There are many guidelines for management of CRS and the recommendation
by EPOS2020 paper is the latest and has
been widely used.
• EPOS2020 steering group has introduced a new classication for CRS:
Primary and Secondary CRS with localized and diffuse subgroups, based on
anatomical distribution and endotype
dominance.
• No standardized therapy for CRS and it
should be treated with appropriate medical therapy. Surgery is considered for
patients who have failed medical
treatment.
• Substantial level 1a evidence suggests
that topical corticosteroids improve outcomes in patients with CRS, including
subgroups with and without nasal
polyps.
• Topical saline nasal irrigation with isotonic saline is highly recommended—
Level 1a evidence.
• Dupilumab, (anti IL-4Receptor alpha)
monoclonal antibody has been introduced in 2019 to treat patients with CRS
with polyps who meet the criteria.
• Endoscopic sinus surgery aims to eradicate the inammatory tissues and osteitis, improve adequate drainage and
ventilation, restore mucociliary function, increase the access for topical, and
to improve the quality of life.
• Approximately 15–20% of patients
require revision sinus surgery.
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https://doi.
https://doi.
AL GRAWANY
Functional Endoscopic Sinus
Surgery
EmadAl Duhirat, HamadAl Saey,
MansourAl Sulaiti, ShanmugamGanesan,
andAhmedShaikh
26
26.1 Introduction
Indications for ESS:
• Chronic rhinosinusitis (CRS) with or without
nasal polyposis not responding to medical
therapy
• Allergic fungal sinusitis
• Orbital decompression
• Endoscopic Dacryocystorhinostomy (DCR)
• Sinus mucoceles
• Cerebrospinal uid leak and skull base
reconstruction
• Control of epistaxis
• Choanal atresia/stenosis
• Neoplastic diseases
• Part of skull base surgery
E. Al Duhirat (*)
Otolaryngology-Head and Neck Surgery Division,
Department of Surgery, Hamad Medical Corporation,
Doha, Qatar
e-mail: EAlDuhirat@hamad.qa
H. Al Saey · M. Al Sulaiti · S. Ganesan
Otolaryngology-Head and Neck Surgery Division,
Department of Surgery, Hamad Medical Corporation,
Doha, Qatar
Department of Otolaryngology-Head and Neck
Surgery Division, Weill Cornell Medicine-Qatar,
Doha, Qatar
e-mail: Halsaey@hamad.qa; Malsulaiti1@hamad.qa;
sganesan@hamad.qa
A. Shaikh
Hamad Medical Corporation, Doha, Qatar
e-mail: Ashaikh4@hamad.qa
Majority of rhinologists agree that ESS for
chronic rhinosinusitis should be a “diseasedirected” and mucosal-sparing operation, giving
the sinuses the chance to normally restore the
mucosa and the drainage pathways [1–3].
It is important to review the CT scan before
the surgery thoroughly to assess the important
structures and landmarks to plan a safe surgery;
in order not to forget any important detail, the
following mnemonic can be followed:
CLOSE
• C: Cribriform plate
• L: Lamina papyracea
• O: Onodi cell
• S: Sphenoid sinus
• E: Anterior Ethmoid artery
Orbital fat herniation
© Springer Nature Switzerland AG 2021
A. Al-Qahtani et al. (eds.), Textbook of Clinical Otolaryngology,
https://doi.org/10.1007/978-3-030-54088-3_26
285
286
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Palpating the uncinate
26.2 Uncinectomy
E. Al Duhirat et al.
Anterior-to-posterior uncinectomy using sickle knife
The uncinate is a sickle-shaped bone divided into
three parts: the middle portion of the uncinate
process attaches to the lacrimal bone and lamina
papyracea, and the horizontal portion attaches to
the ethmoidal process of the inferior turbinate
and palatine bone. The superior portion of the
uncinate extends to a varying degree into the
frontal recess and may insert into the lamina papyracea, skull base, middle turbinate, or combination of these [4–7].
It projects posteriorly forming a gutter (the
infundibulum), and it has a free edge that creates
a space between this free edge and the bulla ethmoidalis (hiatus semilunaris) [7].
26.2.1 The Anterior Posterior
Approach
• Incise the uncinate process at the level of its
middle and inferior third using a sickle knife
or a Freer’s elevator.
• Extend the incision inferiorly and posteriorly
along its horizontal aspect.
• Remove the uncinate with a straight biting
Blakesley forceps [8].
• Enlarge the incision superiorly (if indicated)
to open the infundibulum toward the frontal
outow tract after making sure that there is a
safe distance from the orbit.
• Remaining superior and inferior attachments
of the uncinate can be cut with a through-
cutting forceps.
• Identify the natural ostium of the maxillary
sinus, the recessus terminalis, if any, and the
frontal recess.
• This anteroposterior approach has a higher
risk of orbital penetration. Exposed orbital fat
should be left alone and should not be manipulated [9–12].
26.2.2 The Posterior Anterior
Approach
• Identify the uncinate process, hiatus
semilunaris, and infundibulum using an
angled probe.
• Gently fracture the uncinate process with the
angled probe.
• Pass the pediatric backbiter into the middle
meatus which is easier to be introduced
about the midway up the middle portion of
the uncinate before it is slid down the free
edge until it comes to rest on the transition of
the middle and horizontal parts of the
uncinate.
• Rotate the backbiter so that the biting blade is
opened upward, in the vertical plane of the
meatus.
• Then rotate it horizontally to engage the posterior free edge of the uncinate process.
• The uncinate is cut using sequential bites of
the backbiter.
• The upper uncinate process (most superior
extension) can be dislocated with a ball probe
AL GRAWANY
26 Functional Endoscopic Sinus Surgery
and gently dissected with a biting forceps if
exposure of the frontal recess is indicated.
• In order to expose the natural ostium of the
maxillary sinus and avoid its blockage, the tail
of the uncinate needs to be removed either
using a backbiter, side biter, or microdebrider,
with paying attention not to injure the inferior
turbinate.
287
This approach is safer as one moves away
from the orbit when dissecting, and thus the risk
of inadvertently entering the orbit is reduced
[13–17].
26.3 Complications
ofUncinectomy
The two areas at risk during uncinectomy are the
orbit and the nasolacrimal duct.
• Gently use the backbiter anteriorly while
going toward the lacrimal sac/duct (the bony
resistance will increase here): medialize the
uncinate before biting.
• An uncinate process that is atelectatic and
pressed against the lamina has a higher risk of
injury to the orbit especially when using the
anterior-to-posterior approach [18–20].
26.4 Middle Meatal Antrostomy
• When the uncinate process is intact, the height
of the lower one-third of the middle turbinate
approximates the location of the natural
ostium.
• Once the most anterior-inferior aspect of the
uncinate has been removed, the natural ostium
of the maxillary sinus can be seen.
• The ostium lies at the junction of the anterior
and inferior walls of the ethmoidal bulla.
• A curved suction, with its tip directed inferolaterally away from the lamina papyracea, can
be passed through the natural ostium into the
maxillary sinus.
• The superior border of the natural ostium
demarcates the junction of the medial orbital
oor with the lamina papyracea.
Widening the maxillary antrum anteriorly using
backbiter
Relation of the posterior wall of the maxillary sinus to
sphenopalatine artery
An accessory ostium is located within the posterior fontanelle of the maxillary sinus behind the
natural ostium. Cadaveric studies have shown
that 10% of the general population have an accessory ostium [21].
• There is no absolute need to enlarge the maxil-
lary ostium for just inammatory diseases.
• In advanced disease (such as allergic fungal
rhinosinusitis and nasal polyps) and revision
surgery, a wide antrostomy may be justied
[22–24].
This can be achieved by widening the ostium
toward the posterior fontanelle. Widening the
ostium will uncover the medial orbital oor,
which corresponds to the superior horizontal
bony ridge of the antrostomy. Keeping the dissection below the level of the medial orbital oor
helps in guiding the surgeon to a safe direction
below the level of the skull base [25–27].
288
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E. Al Duhirat et al.
If identication of the natural ostium is difcult or not possible, palpate the posterior fontanelle area with the tip of a curved suction tube
and enter smoothly into the sinus while checking
the orbit during that. Entering the sinus should be
performed pointing toward the oor of the sinus
cavity while leaning on posterior third of the
inferior turbinate.
Inability of the surgeon to locate the proper
natural maxillary sinus ostium at surgery may
result in the creation of a posterior fontanelle
ostium, which is a common cause for ESS failure
[
28–30], because of the circular ow of mucus
from the natural ostium of the maxillary sinus
into the posterior fontanelle ostium [16, 17].
Identifying the posterior wall of the maxillary
sinus should be done by the surgeon as it is an
important landmark demarcating approximately
the anterior wall of the sphenoid sinus which is
almost 7cm from the columella, adjacent to the
nasal septum posteriorly.
Does enlarging the maxillary sinus ostium
affect the long-term results. The role of nitric
oxide (NO) in the sinuses is the main reason for
this controversy [31]. NO is produced by nitric
oxide synthase (NOS) in the mucosa of the
sinuses [32, 33]. NO is believed to enhance the
mucosa defense by stimulating the ciliary motility and by inhibiting infection by bacteria,
viruses, and fungi [34]. Kennedy et al. [11]
described the natural size of the maxillary ostium
to be 5mm by 5mm; enlarging the ostium may in
some patients cause dilution of the concentration
of the sinus NO to allow colonization of the sinus
by bacteria [35].
26.6 Anterior Ethmoid
The anterior ethmoids are the cells that lie anterior to the basal lamella, consist of the ethmoid
bulla, agger nasi cell, and the cells that lie against
the medial orbital wall anterior to the basal
lamellae.
The ethmoid bulla, visible directly behind the
free edge of the middle and horizontal portions of
uncinate process, the bulla ethmoidalis, like all
sinuses, drains via a natural ostium. This is usually found on its posteromedial aspect in the
retro-bulla recess, surrounded by the following:
The lamina papyracea laterally.
•
• Posteriorly the vertical aspect of the basal
lamella of the middle turbinate and the retro-
bulbar recess.
• Anteriorly the ethmoid infundibulum and the
vertical aspect of the uncinate process.
Steps of opening the ethmoid bulla:
• Enter the ethmoidal bulla, at a safe distance
from the orbit, medially and inferiorly.
• Use a J-curette or a straight-forward suction
device to do so.
• Inferior and medial walls are resected, while
the posterior wall is attempted to keep
intact.
• Follow the anterior wall of the ethmoid bulla,
and identify the frontal recess, the roof of the
26.5 Mega-Antrostomy
In this surgery, the posterior part of the antrostomy is lowered to the oor of the nose with preserving the nasolacrimal duct.
In patients who have persistent chronic maxillary sinus infections and in cystic brosis patients
(abnormal ciliary movement), the antrostomy can
be lowered to the oor of the nose thereby to
facilitate gravity-dependent drainage and better
sinus irrigation.
CT scan coronal section showing opacied left ethmoid
bulla
AL GRAWANY
26 Functional Endoscopic Sinus Surgery
CT scan coronal section showing the right ethmoid bulla
Anatomical identication of the left ethmoid bulla
289
CT scan coronal section showing the right agger nasi
• The retrobulbar recess lies behind the bulla,
and the skull base forms its superior limit.
• If a posterior ethmoidectomy is to be performed in addition to opening the bulla, none
of its anterior wall is retained. Removing the
bulla entirly gives improved access to the posterior ethmoid complex but also allows the
lamina papyracea to be identied.
• The superior wall of the ethmoid bulla can
extend up to the skull base or may be separated from it by one or more suprabullar cells
[36].
Dissection the left ethmoid bulla
ethmoid, and the anterior ethmoid artery
(located at the most superior attachment of the
anterior wall of the bulla at the roof or right
behind).
• Identify the lamina papyracea. The oor of the
orbit and the maxillary strut are helpful landmarks to identify the papyracea.
The agger nasi cell is the most anterior ethmoid cell and is present in 98.5% of patients [37].
It is usually seen on the CT scan anterior to the
middle turbinate [37, 38].
The major part of the agger nasi cell is placed
anterior to the uncinate, and the posterior half of
the agger nasi cell is closely related to the upper
extension of the uncinate process [39].
Mostly the uncinate/medial wall of agger nasi
cell attached to the lamina papyracea. The
anterior wall of the agger nasi is formed by the
insertion of the middle turbinate into the medial
orbital wall anteriorly (the “axilla” of the middle
turbinate). The agger nasi is positioned between
the nasal bones, the lacrimal bones, and the
ascending process of the maxilla.
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E. Al Duhirat et al.
Safe exenteration of agger nasi cells may be
accomplished with angled forceps parallel to the
lamina papyracea which allows exposure of the
frontal outow tract. If the microdebrider is used,
then the opening is pointed perpendicular or
away from the lamina papyracea until the latter is
clearly identied.
26.7 Posterior Ethmoid
The posterior ethmoid cells are bounded
• Anteriorly by the basal lamella of the middle
turbinate.
• Posteriorly by the anterior wall of the sphe-
noid sinus.
• Medially by the superior turbinate.
• Laterally by the orbital apex.
• Superiorly by the skull base.
Enter the superior meatus through the ground
lamella in a region. To do this, mark the transition
from the posterior horizontal ground lamella to
the vertical ground lamella at the point where it
turns vertically, next to the middle turbinate or
through the basal lamella at the middle third
(below imaginary horizontal line drawn at the
level of the posterior medial orbital oor to the
nasal septum), then the microdebrider or straight
Blakesley is pushed through the ground lamella.
Widen this point until the superior meatus and
anterior edge of the superior turbinate are identied with certainty.
The low, medial entry through the basal
lamella minimizes the potential risk of damage to
the skull base which may occur if entry is made
higher on its vertical portion or above the level of
the posterior medial orbital oor [25, 40].
Once the posterior ethmoids are entered
through the ground lamella, the superior meatus
and superior turbinate are identied and the
recess that one can see from the nasal cavity
between the superior and middle turbinates as
seen from the septal side. This space is the common outow tract for the posterior ethmoid cells.
The safe way to perform complete ethmoidectomy is
• Early identication of the lamina papyracea.
• Remove the inferior anterior and posterior
ethmoid cells until the sphenoid face is
reached.
• Identify the skull base at the posterior ethmoid
or sphenoid sinus roof.
• Dissect along the skull base from a posterior
to anterior direction.
• It is safer to make the superior ethmoid dissection after sphenoidotomy. This allows safer
identication of the posterior ethmoid roof
and the posteromedial orbital wall, by following the sphenoid roof (planum) and the lateral
sphenoid wall; this is done retrogradely
(posteroanterior).
•
Identication of the superior turbinate makes
it easier to identify the sphenoid ostium which
lies medial to the superior turbinate in an
uncomplicated case [41–44].
• In revision and severe polyposis cases in
which the superior turbinates can’t be identied or the anatomy is distorted, the posterior
medial orbital oor provides an important
landmark to help the surgeon in nding the
level of initial entry into the sphenoid sinus
ostium area, next to the posterior nasal septum. An inferior ethmoidectomy should be
completed to identify the inferior portion of
the lamina papyracea and its junction with the
medial orbital oor [23–25].
• The posterior ethmoid air cells that extend
inferolaterally along the slope of the lamina
papyracea into the retromaxillary area should
be cleared [
45].
• Regularly palpate the eye prior to removing
any additional ethmoidal cells.
• The posterior ethmoidal artery and nerve can
be identied in the sphenoethmoidal recess, in
front and above the anterior wall of the sphenoid sinus.
Be aware that the skull base slants downwards
as the posterior ethmoid is approached.
• Identify the presence of an Onodi cell preoperatively as well as intraoperatively to avoid
injury to the orbital apex.
• Dissect from “known to unknown” during ethmoidectomy and check around (especially)
behind the bony partitions before removing
them.
AL GRAWANY
26 Functional Endoscopic Sinus Surgery
CT scan coronal section showing the posterior ethmoid
artery
291
• The roof of the maxillary sinus is an important
landmark so keep it in mind when dissecting
through the ethmoid cavity.
• Learn to “zoom out.” To avoid getting lost in
the ethmoid cavity, intermittently bring the
endoscope out of the ethmoid cavity anterior
to the middle turbinate to get an overall picture of where dissection is occurring and to
reorient yourself during ethmoidectomy to the
proper direction.
• Avoid mucosal stripping.
26.8 Sphenoethmoidal Cell
(Onodi Cell)
The posterior most ethmoidal air cell extends
posteriorly to lie superolateral to the sphenoid
sinus and thus in close proximity to the optic
nerve and internal carotid artery [46].
The incidence of Onodi cell can be as high as
42% [47].
On the coronal cut of a CT scan identify the
solid bony rim of the posterior choanae, the cell
sitting directly above this is the sphenoid sinus.
Any horizontal bony septation above this cell
would be suspicious that there may be Onodi cell
present.
CT scan coronal section showing Onodi cell
CT scan coronal section showing the anterior ethmoid
artery
26.9 The Anterior Ethmoid Artery
Runs from lateral to medial across the fovea ethmoidalis at a 45° angle. Mostly it is found behind
the upward continuation of the bulla ethmoidalis.
When a suprabullar recess is present, the anterior
Anatomical dissection of the anterior ethmoid artery and
nerve
ethmoidal artery will be in the frontal recess. The
anterior ethmoidal artery may lie hanging in a
mesentery from the skull base in 14–43% of
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patients. Reviewing the CT preoperatively is an
important step to locate the anterior ethmoid
artery and avoid its injury [48].
26.10 The Middle Turbinate
The middle turbinate should be preserved. And
not to be destabilized during surgery. The most
common cause for destabilization of the middle
turbinate is fracturing its anterior vertical insertion from the skull base or cutting the horizontal
portion of the basal lamellae.
Excessive manipulation may fracture the tur-
binate’s insertion to the skull base and makes it
oppy, which might lead to lateralization of the
middle turbinate and obstruction of the middle
meatus and frontal recess postoperatively.
Resection of the inferior portion of the basal
lamellae may injure a branch of the sphenopalatine artery. Bleeding in this area can be controlled
using bipolar/monopolar diathermy.
26.11 Concha Bullosa (Middle
Turbinate Pneumatization)
Identied in 35% (range 14–53%) of patients.
Resection the lateral lamella of the middle tur-
binate (concha bullosa) improves access to the
middle meatus and to clear the disease inside the
concha bullosa if found.
• A scalpel or sickle knife is used to incise the
anterior face of the concha bullosa vertically.
• Endoscopic scissor is used to complete the
incision inferiorly to the lateral insertion of
the turbinate on the lateral nasal wall, care
must be taken as a branch of the sphenopalatine artery might be encountered here.
• To complete the superior incision posteriorly
as high as possible, keeping in mind down
slope of the skull base and the turbinate.
26.12 Sphenoidectomy
Sphenoid sinuses are paired and most posteriorly
located, endoscopic approaches are least morbid
and most preferred approaches. The sphenoid
sinus is also the gateway to many extended endonasal procedures, including approaches to pituitary lesions, other sellar and parasellar lesions,
and petroclival lesions amenable to an endonasal
approach.
The two main endoscopic pathways to the
sphenoid sinus are the transseptal and transethmoid approaches. Both require identication of
the natural sphenoid ostium.
26.12.1 Anatomical Landmarks
Superior Turbinate: the most consistent landmark for identication of natural osteum of sphenoid sinus. The ST is identied after lateralization
of middle turbinate. The sphenoid osteum is seen
5–10mm above and medial to the attachment of
ST.
Planum Sphenoidale: The sphenoid ostium is
on average 11mm inferior to the skull base and is
approximately halfway between the oor of the
sphenoid sinus and planum sphenoidale.
Choana: The sphenoid ostium is typically
found 2cm superior to the arch of the choana.
Onodi Cells: pneumatized posterior most eth-
CT scan coronal section showing right concha bullosa
moidal cell which is always lateral and superior
to the sphenoid sinus.
AL GRAWANY
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