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Transnasal sinus surgery began in 1886, when Miculicz reported on the endonasal fenestration of the maxillary sinus.¹ A transnasal approach to performing an ethmoidectomy was first in 1915 by Halle.² Even then, it was immediately apparent that a trans-nasal ethmoidectomy posed significant inherent risks for the patient. Indeed, these risks were best paraphrased by Mosher in 1929, when he described intranasal ethmoidectomy as being “one of the easiest operations to kill a patient.”³ Further reports have also shown the wide variability in distances and dimensions among virtually all the intranasal anatomical structures.^4–10

Hirshman made the first attempt at nasal and sinus endoscopy in 1901 using a modified cysto-scope.¹¹ In 1925, Maltz, a New York rhinologist, used the term sinoscopy and advocated the technique for diagnosis.¹² However, endoscopic sinus surgery (ESS) was introduced in the European literature in 1967Messerklinger,¹³ and was then further popularized by others.^14–21 In 1985, Kennedy introduced the technique of functional endoscopic sinus surgery (FESS) into the United States.²² Since then, there has been an ongoing effort to refine and redefine ESS technique and to identify consistent anatomical landmarks to navigate within the ethmoid sinuses and facilitate safe entry into the maxillary, sphenoid, and frontal sinuses.^23–32 This has led to further refinement in transnasal endoscopic surgical technique beyond the confines of the sinus cavities to address complicated inflammatory and neoplastic processes of the skull base and orbit.

Although exceptions do exist, nowadays most rhinologists agree that ESS for chronic rhinosinusitis should be a “disease-directed” and a mucosal-sparing operation, recognizing the principle of the potential for reestablishing drainage and mucosal recovery of the dependent sinuses.^13,14,16 The ostiomeatal complex theory states that most inflammatory conditions of the maxillary, ethmoid, and frontal sinuses arise from this common drainage pathway.¹⁵ Therefore, the surgical procedure, when combined with appropriate medical management, can be limited to an absolute minimum and correction of ethmoid disease usually results in reestablishment of drainage and mucosal recovery of the larger (dependent) sinuses.

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