ESS AC Neww

LITERATURE READING
ENDOSCOPIC SINUS
SURGERY
Achmad P
SUPERVISOR : Dr. Lina Lasminingrum dr., M.Kes, Sp.THT-KL (K)
Department of Otorhinolaryngology - Head & Neck Surgery

Faculty of Medicine Universitas Padjadjaran
Hasan Sadikin General Hospital
Bandung
2017
INTRODUCTION
Endoscopic Sinus Surgery
ESS
is a minimally
invasive The goal of this
technique in procedure is to
which sinus air restore sinus
cells and sinus ventilation and
ostia are normal function
opened under
direct
visualization. 2
.
-Stammberger H. Functional endoscopic sinus surgery: the Messerklinger technique. Philadelphia: Decker, 1991:283
-Kennedy DW, Zinreich SJ, Rosenbaum AE, Johns ME. Functional endoscopic sinus surgery. Theory and diagnostic evaluation. Arch Otolaryngol
1985;111:576-82.
HISTORY
1960 :
Prof. Messerklinger : the
technique for systematic
endoscopic.
1984 :
Kennedy introduce in the
United States.
Stammberger introduce in
the Europe
FESS-Endoscopic Diagnonis and Surgery of the Paranasal Sinuses and Anterior Skull Base, Prof.Heinz Stamberger,MD,
University Ear, Nose and Throat Hospital Graz, Austria 2004.
3
ANATOM PARANASAL SINUSES
Netter, Atlas Anatomy, 20047/4/2017 4

ANATOMY LATERAL NASAL WALL
Netter, Atlas Anatomy, 2004 7/4/2017 5

Walsh WE, Kern RC. Sinonasal Anatomy, Function, and Evaluation. In : Head 7/4/2017
and Neck Surgery-Otolaryngology. 6
Fourth Edition. Edited by: Bailey B.J. Lippincott Williams & Wilkin. 2006.
Anatomy
Osteomeatal Complex:
Uncinate process
Hiatus semilunaris
Bulla ethmoidalis
Ethmoidal
infundibulum
Maxillary sinus
ostium
7
Endoscopic Sinus Surgery
Indications
Chronic and recurrent rhinosinusitis when appropriate
medical therapy has failed to eradicate diseases.
Rhinosinusitis with complication
Mucoceles
Extensive nasal polyposis
Allergic or invasive fungal rhinosinusitis
Neoplasia
8
.
Endoscopic Sinus Surgery, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014
Contraindications
Osteomyelitis of the frontal bone

Absence of defined ostiomeatal abnormality
Inaccessible lateral frontal sinus disease
Persistent Frontal sinus disease with
recurrent stenoses of the ostium
9
Endoscopic Sinus Surgery, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th .
edition, 2014
Important Preoperation Evaluation
Detail anamnesis, systemic history and

physical examination
Detail drug history
Adequate imaging CT-Scan
Coronal reconstruction with 2 or 3 mm
sections are sufficient for most endonasal
surgery
Nasal Endoscopy
Kaluskar SK. Complications in Endoscopic Sinus Surgery.Jaypee Brothers.2002

Surgical Anatomy
Variations Clinical significance
Septum deviations, Contact points,

ridge, spurs potential narrowing of
nasal meatus
Agger nasi cell Depending on degree of
pneumatization,
constriction of the
frontal recess,
Uncinate process Laterally curved,

contact with the lamina
papiracea and resulting
atelectatic infundibulum
(hypoplastic maxillary
sinus), medially curved
and towards the front
(double middle
turbinate),
11
FESS-Endoscopic Diagnonis and Surgery of the Paranasal Sinuses and Anterior Skull Base, Prof.Heinz Stamberger,MD,
University Ear, Nose and Throat Hospital Graz, Austria 2004.
Variations Clinical significance
Middle turbinate Pneumatization (concha

bullosa), paradoxically
curved, contact with
uncinate process or septum
Ethmoidal bulla Extreme size due to

pneumatization ; fills up
entire middle nasal meatus;
contact points with middle
turbinate; overlapping the
hiatus semilunaris;
constriction of the frontal
recess; pressing the middle
turbinate againts the septum
or growing out of the middle
nasal meatus toward the
front
Hallers cells Constriction of the ethmoid
infundibulum and/or
maxillary sinus ostium
12
FESS-Endoscopic Diagnonis and Surgery of the Paranasal Sinuses and Anterior Skull Base, Prof.Heinz Stamberger,MD, University
Ear, Nose and Throat Hospital Graz, Austria 2004.
EQUIPMENT
EQUIPMENT
13
13
EQUIPMENT
14
KEROS TYPE
15
Levine, HL. Sinus Surgery: Endoscopic and Microscopic Approaches. Thieme Medical Publisher. New York. 2006
16
Simmen, D. (Daniel), Manual of endoscopic sinus surgery and its extended

applications, Georg Thieme Verlag, 2005
Position Instrument
17

ANESTESIA
18
LOCAL ANESTESIA
Sedation with narcotic

and a benzodiazepine.
Vasoconstriction and
topical anesthesia are
achieved.
19
20

LOCAL ANESTESIA
Intranasal injections :
2-inch 25-gauge needle
4-mm 00 telescope.
1% lidocaine
1:100,000 epinephrine.
The number of injection

sites.
21
.
Endoscopic Sinus Surgery, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014
GENERAL ANESTESIA
General anesthesia : patient comfort, anxiety decreased.
Blood pressures are maintained throughout the

procedure.
Halothane + vasoconstrictors : potential for cardiac

irritability.
Nausea and vomiting, which are common reactions to

general anesthesia.
22
SURGICAL TECHNIQUES
Operation Stage:
1. Infundibulotomy (Uncinectomy)
2.Dilation of maxillary sinus ostium
(Middle Meatal Antrostomy)
3.Etmoidectomy retrograde
(posterior-anterior)
4.Res. Frontal - frontal sinus
5.Sphenoidotomy
23
Buku Panduan Diseksi Kadaver, Bandung ORL-HNS Week Endoscopic Sinus Surgery Workshop Oct 12th - 13th 2013
Use teleskop 0 atau 30
24
Uncinectomy
Incision uncinate
process
1. Inspection
2. Identification
3. Palpation
4. Incision
25
Identification:
Uncinate process
Bulla ethmoidalis
Middle turbinate
Hiatus semilunaris
Frontal Recess
26
Palpation
27

Incision
28
29

30
31

Uncinectomy with sickle knife
32
Dilation of maxillary sinus ostium
(Middle Meatal Antrostomy)
Enlargement of the natural opening of the

maxillary sinus into the middle meatus
Identification
Ostium evaluation
Enlargement of ostium
Antrum evaluation
33
Identification
Simmen, D. (Daniel), Manual of endoscopic sinus surgery and its extended 34

Ostium evaluation
35
Enlargement of ostium & antrum evaluation
36
Ethmoidectomy retrograde
Identify / palpation of
the anterior wall of the
bulla etmoidalis
BE penetrated in
inferomedial then
removed
looks ground lamella
Identify ground lamella
Penetrated parts of
infero medial ground
lamella posterior
ethmoids
37
Identify skull base
(roof posterior etmoids)
Dissection etmoid
posterior cells
Fore the retrograde
dissection
wipe partition etmoid
anterior cells
38
39
40
Frontal recess and Frontal sinus
Frontal recess dissection
Landmark:
Anterior : agger nasi cell
Posterior : ethmoid bulla and
A.ant etmoid
Superior : skull base
Lateral : lamina papiracea
Medial : middle turbinate
Identify frontal sinus

ostium
41
If frontal sinus disease (+) frontal recess, ostium cleared.
42
SPHENOIDOTOMY
Identify anterior wall
sphenoid sinus at
posterior ethmoid sinus
Penetrated anterior wall
sphenoid sinus
- Trans ethmoid
- Trans nasal via sphenoid
sinus ostium
- Trans nasal via anterior
wall sphenoid sinus in
nasal cavity
43
Penetrate sphenoid sinus and remove at
superomedial and inferior wall
Avoid superior and lateral wall because there
are n.opticus and a.carotid
Evaluation sphenoid cavity
Manipulation in sphenoid sinus must be in
infero medial.
44
Sphenoidotomy
If sphenoid disease (+) enlarge natural ostium or anterior wall.
45
46
47
48
Weil-Blackesly ethmoid forceps Punch forceps are used to remove
are used for this purpose. the ant wall of the sphenoid sinus.
49
The sinus is then examine endoscopically.
Simmen, D. (Daniel), Manual of endoscopic sinus surgery and its extended applications, Georg Thieme Verlag,
2005 50
51
A Dissection Course on Endoscopic Endonasal Sinus Surgery, Hosemann W,MD. Fanghanel J,MD. Endo-Press, Tuttlingen, Germany, 2005
POST OPERATIVE CARE
General :
Not to blow the nose during 48 hours after
surgery.
If you must sneeze, do so with your mouth
open
Physical exertion must be avoided.
Do not lift heavy objects
Informed consent :
swelling and obstruction nasal passage.
Discomfort after surgery
POST OPERATIVE CARE
Medication :
Broad spectrum antibiotic.
Analgetik
Nasal irigation
Corticosteroid.
Antihistamines.
53
Postoperative Follow-up (4-6
weeks)
Nasal cleaning 2x/ week for 2 or 3 weeks,

then 1x/week for another 2 or 3 weeks
Polyposis patients (polyp is likely to recur):

follow up continues 1x/month for 1 year
Umar Said D, Post operative care in endoscopic sinus surgery, ENT Department Faculty of Medicine University of
Indonesia Dr.Cipto Mangunkusumo Hospital.
Schedule for follow up after care
MARK:
daily in the first ten day
twice weekly in the next 1 month
once a week until 3 months post.op
final check : 9 months post.op
KENNEDY:
1st,3rd &4th post.op days
weekly visit until healing completely
KUHN:
1st & 4th days and after 1,3 &7 week
Umar Said D, Post operative care in endoscopic sinus surgery, ENT Department Faculty of Medicine University of
Indonesia Dr.Cipto Mangunkusumo Hospital.
COMPLICATION
Perioperative Postoperative
Bleeding Bleeding
Fat herniation Adhesion
CSF leak Epiphora
Retro orbital haemorrhage Periorbital emphysema
Medial rectus damage Anosmia
Optic nerve lesion Frontal recess stenosis
Crusting
Infection
Osteitis
Neuropathic pain
56
CONCLUSION
Endoscopy Sinus Surgery (ESS) is surgical
technique which is minimally invasive to
repair ventilation and normal paranasal
sinuses function by opening the sinus air
cells and ostium under direct visualization
by restoring mucocilliary drainage function
57
CONCLUSION
Preoperative CT-scan can identify the
relation between anatomy and vital
structures towards the abnormal
area.This procedure also has importance
in surgical planning and to evaluate the
extent of the disease.
58
CONCLUSION
Complications should be avoided rather than
managed. A thorough preoperative examination
towards the patient such as preparation for
surgery, nasal endoscopy, reevaluation of CT-
scan, combined with factors that should be
monitored during the procedure and surgery will
decrease risk for complications.
59

ESS AC Neww

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LITERATURE READING

SUPERVISOR : Dr. Lina Lasminingrum dr., M.Kes, Sp.THT-KL (K)

Department of Otorhinolaryngology - Head & Neck Surgery

Netter, Atlas Anatomy, 20047/4/2017 4

Netter, Atlas Anatomy, 2004 7/4/2017 5

Osteomyelitis of the frontal bone

Detail anamnesis, systemic history and

Kaluskar SK. Complications in Endoscopic Sinus Surgery.Jaypee Brothers.2002

Septum deviations, Contact points,

Uncinate process Laterally curved,

Middle turbinate Pneumatization (concha

Ethmoidal bulla Extreme size due to

Simmen, D. (Daniel), Manual of endoscopic sinus surgery and its extended

Simmen, D. (Daniel), Manual of endoscopic sinus surgery and its extended

Sedation with narcotic

Simmen, D. (Daniel), Manual of endoscopic sinus surgery and its extended

2-inch 25-gauge needle

The number of injection

Blood pressures are maintained throughout the

Halothane + vasoconstrictors : potential for cardiac

Nausea and vomiting, which are common reactions to

Simmen, D. (Daniel), Manual of endoscopic sinus surgery and its extended

Simmen, D. (Daniel), Manual of endoscopic sinus surgery and its extended

Simmen, D. (Daniel), Manual of endoscopic sinus surgery and its extended

Enlargement of the natural opening of the

Simmen, D. (Daniel), Manual of endoscopic sinus surgery and its extended 34

Identify frontal sinus

If sphenoid disease (+) enlarge natural ostium or anterior wall.

Nasal cleaning 2x/ week for 2 or 3 weeks,

Polyposis patients (polyp is likely to recur):

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