Basic Surgical Techniques in Endoscopic Sinus Surgery


Basic Surgical Techniques in Endoscopic Sinus Surgery

Hesham Saleh and Reza Nouraei


Patients with chronic rhinosinusitis (CRS) who have not responded to maximal medical therapy are commonly managed surgically. The majority of these patients present with disease in the maxillary and ethmoid sinuses and can be managed with basic endoscopic sinus surgery (ESS) techniques directed to these sinuses. In this chapter, we discuss the indications for surgery, detailed techniques, possible complications, and outcomes of surgery.


Rhinosinusitis encompasses a wide spectrum of inflammatory and infective conditions of the nose and paranasal sinuses, which range in duration and severity from the ubiquitous common cold to CRS and life-threatening ascending orbital and intracranial infections, respectively.1 Rhinosinusitis is primarily a clinical diagnosis ( Table 19.1 ) and can be classified as acute or chronic based on whether the symptoms last for less or more than 12 weeks.

There is a paucity of reliable epidemiological data for both acute and chronic rhinosinusitis. Acute rhinosinusitis (ARS) has been reported to affect 8.4% of the general population and to account for 2% of visits by men and 3.3% of visits by women to a general practitioner.1 ARS is managed medically in the overwhelming majority of cases; it is the reason for 9% of pediatric and 21% of adult antibiotic prescriptions,2 but leads to < 0.007% of hospital admissions.

CRS has an incidence of 11% (range 7–27%) in the general population.3,4 Its first-line management is also medical, with most patients receiving the combination therapy of nasal douching and topical corticosteroids in addition to long-term antibiotics if considered necessary.1 For patients with concomitant nasal polyposis, a course of oral corticosteroids may also be considered.1 Those patients who fail to respond to maximal medical therapy are considered for sinus surgery. This chapter provides an overview of the common surgical techniques used for the endoscopic treatment of rhinosinusitis.

Diagnostic criteria for rhinosinusitis*

Obligatory symptoms

1. Nasal blockage/obstruction/congestion

2. Nasal discharge (anterior or posterior: postnasal discharge)

Possible symptoms

3. Facial pain/pressure

4. Reduction in or loss of the sense of smell

*Clinical diagnosis of rhinosinusitis requires two or more of these symptoms, with at least one of the symptoms highlighted in bold, to be present.

Adapted from Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, et al. European Position Paper on Rhinosinusitis and Nasal Polyps 2012. Rhinol Suppl. 2012 Mar(23): 1–298, with permission.

Indications/Patient Selection

The most common indication for performing ESS is CRS with or without nasal polyposis ( Figs. 19.1 and 19.2 ) following failure of aggressive medical therapy. Preoperative computed tomography (CT) is mandatory for confirming sinus mucosal disease and for delineating variations in surgical anatomy that can affect operative safety. It is essential when planning surgery that it be tailored to the extent of disease and specific sinuses involved. Those patients with persistent symptoms of rhinosinusitis and consistent CT findings after medical therapy ( Fig. 19.3 ) are candidates for sinus surgery.


Sinus surgery is indicated for patients with CRS with or without nasal polyposis who fail to respond to medical therapy.

Tips and Tricks

Assess the height of the lateral lamellae of the cribriform plate and the presence of atypical cells (infraorbital, sphenoethmoidal, or frontal cells). In sagittal images, the slope of the skull base can be identified and the frontal recess anatomy noted. Frontal sinus drainage should also be reviewed in axial images.

Patient Information/Consent

Paranasal sinus surgery is performed in close anatomical proximity to vital structures, including the brain, orbits, and carotid arteries, and although the risk to these structures is very low, given the potentially grave consequences it is mandatory that patients are made aware of both the common and the rare but potentially life- and vision-threatening risks of sinus surgery. We provide our patients with a standardized list of the surgical risks and provide a more detailed and itemized explanation of these risks in the patient information sheet ( Table 19.2 ).

Indications for endoscopic sinus surgery (ESS).

Patient Positioning and Anesthesia

Surgery is performed under local or general anesthesia (see Chapter 30) with the patient in the supine position. The airway is secured with a classic laryngeal mask airway, and a throat pack is inserted if preferred. The alternative is to use an endotracheal tube, which, in the authors’ practice, is mostly used in patients with underlying lung disease (e.g., cystic fibrosis [CF]) where high ventilatory pressures are anticipated. The nose is then decongested. (For details on local anesthesia, see Chapter 30.) Different preparations can be used to achieve this; we favor Moffat′s solution (2 mL of 10% cocaine, 1 mL of 1:1000 adrenaline, and 2 mL of sodium bicarbonate) applied on nasal Merocel dressing or sprayed into the nasal cavity. The positions of the patient, surgeon, camera system, and, when present, sinus navigation system are shown in Fig. 19.4.

Basic Surgical Instruments for Endoscopic Sinus Surgery

The endoscopes used routinely during surgery include 0-, 30-, 45-, and occasionally 70-degree Hopkins rods. Recently, an endoscope with variable angles from 10 to 90 degrees has become available and may in the future replace the use of multiple endoscopes. The main types of instruments used in ESS are soft tissue elevators, bone curettes, suction, sinus probes, bone/soft tissue punch forceps and through-cutting instruments. These instruments have been designed and angulated to provide optimal access to the different sinuses ( Fig. 19.5 ). In general, through-cutting instruments are preferred to grasping forceps (e.g., Blakesley forceps) when removing soft tissue or bone to avoid mucosal stripping or uncontrolled bone fracturing. In addition to these, powered microdebriders are frequently used in basic sinus surgery. By providing concurrent cutting and suction, the surgeon can achieve polyp and diseased tissue removal with minimal mucosal stripping. Many endoscopic surgeons use the microdebrider for the initial bone and soft tissue removal during ethmoidectomy and handheld through-cutting forceps to complete the dissection when close to the skull base and orbit. Descriptions of more specialized instruments designed predominantly to be used for extended applications of sinus surgery are beyond the scope of this chapter.

A more detailed two-center breakdown of indications for ESS.
Coronal computed tomography scan showing pansinusitis with nasal polyposis.

The list of benefits and risks provided to patients undergoing endoscopic sinus surgery

Intended benefits

To reduce symptoms of chronic rhinosinusitis and, if present, to remove polyps

Common and important risks


Around 1 in 4 patients experience a degree of bleeding after the procedure, but this usually subsides. In a small number of patients, excessive bleeding during the procedure requires it to be abandoned. Excessive bleeding after the operation is uncommon but if it occurs, it may necessitate packing of the nose and may prolong hospital stay.


The risk of developing a postoperative infection is around 1 in 20, but this can be reduced by regularly cleaning the nose by douching after the surgery. Most infections occur within the first week of surgery. Patients may experience increasing facial pain, bleeding, fever, or an offensive nasal discharge. Antibiotics may be needed to treat this.

Olfaction change

A temporary reduction in the sense of smell is common, but a permanent loss is very rare.

Eye swelling

Swelling around the eye may be due to air bubbles in the tissues as a result of the surgery. It usually subsides.

Damage to the orbit, eyes, or optic nerve

These are very rare. Some degree of damage to the bone that separates the eye from the nose occurs in ~1 in 500 cases, but it is usually without significant consequence. Bleeding into the eye socket, double vision, and blindness are extremely rare but have been described with this surgery.

Brain/carotid artery injuries

The sinuses are very close to the brain and carotid arteries. The risk of injury to these structures is extremely low, but if they do occur, their consequences can be potentially life-threatening.

Cerebrospinal fluid leak/meningitis

The sinuses are very close to the bone at the base of the brain. Injury to the skull base is < 1 in 1000, and most cases are recognized during the operation and are repaired. Very occasionally, however, injury to the skull base could allow bacteria to move up and cause infection of the lining of the brain (meningitis). This can often be successfully treated with intravenous antibiotics.

Failure of surgery

There may be failure to relieve all of the symptoms if there is remaining disease. Nasal polyps will almost always come back after a few years and often require revision surgery.

Tips and Tricks

Use the 0-degree endoscopes until the essential landmarks have been identified; angled endoscopes can then be used as needed.

Operative Steps

The principal objective of sinus surgery is to reestablish unimpeded mucociliary flow and remove irreversibly changed mucosa and, when present, nasal polyps. Maxillary, frontal, and ethmoid sinuses physiologically drain to the region of the ostiomeatal complex (OMC), which is bound anteriorly by the uncinate bone, laterally by the lateral nasal wall, superiorly and posteriorly by ethmoid air cells, and medially by the medial aspect of the middle turbinate. The first step of surgery is therefore to gain access to this region.

Tips and Tricks

The extent of surgery reflects the extent of disease.


If excessive bleeding is difficult to control during surgery, it is best to err on the side of safety and stop the operation.

Basic surgical and patient setup for ESS.
Basic surgical instruments used in ESS. 0. A basic sinus surgery tray. 1. Freer elevator. 2. Sickle knife. 3. Bone curettes with two different angulations. 4. Sinus ball probes for maxillary (top) and frontal (bottom) sinuses. 5. Suctions of different sizes and angulations. 6. Blakesley tissue-grabbing forceps. 7–12. Different types of bone-cutting forceps: 7. Backbiting forceps. 8. Down-biting forceps. 9. MackayGrunwald bone-cutting forceps. 10. Sphenoid “mushroom” punch. 11. Frontal sinus “mushroom” punch. 12. Frontal sinus side-biter.

Establishing and Optimizing Access to the Ostiomeatal Complex

Access to the OMC complex is achieved through the middle meatal cleft ( Fig. 19.6 ); this is helped by maximal decongestion. Decongestion is preferably initially performed in the anesthetic room, then by placement of 1:10,000 adrenaline-soaked Merocel sponges in the nasal cavity and under the middle turbinate. In some cases, access is hindered by a deviated nasal septum or paradoxical curvature ( Fig. 19.6a ) or pneumatization ( Fig. 19.7 ) of the middle turbinate.

In our experience, some patients require additional surgical maneuvers to optimize access. This includes septoplasty (3%), partial middle turbinectomy (3%), and concomitant septoplasty and partial middle turbinectomy (1.5%). Care must be exercised not to amputate the middle turbinate, as it is the key landmark for the sinuses, and its removal makes any subsequent surgery riskier. When indicated, only partial resection of the middle turbinate should be performed, with the aim to preserve the horizontal attachment and anterior buttress. A severely polypoid or unstable turbinate with risk of lateralization is a common indication for resection. When there is a risk of olfactory obstruction by a scarred turbinate, resection is indicated.

Endoscopic anatomy of the left ostiomeatal complex (OMC). a Cadaveric dissection. b, c Clinical images. 1 Lateral nasal wall. 2 Uncinate process. 3 Bulla ethmoidalis. 4 Middle turbinate. 5 Nasal septum. The bottom image shows adrenaline solution being applied to the middle meatus region to achieve decongestion.
Coronal CT scan demonstrating bilateral pneumatization of the middle turbinates (concha bullosa) and the uncinate processes.

Tips and Tricks

Minimize bleeding by preparing the nose with Moffat′s solution or equivalent and the intraoperative use of Merocel sponges soaked in 1:10,000 adrenaline placed into the middle meatus.

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Jun 28, 2020 | Posted by in OTOLARYNGOLOGY | Comments Off on Basic Surgical Techniques in Endoscopic Sinus Surgery

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