Full House FESS with Image Guidance
Surgery, Capture, Editing, & Narration - Martyn Barnes, UK
Supervisor - Prof. Richard Douglas, New Zealand
Surgery, Capture, Editing, & Narration - Martyn Barnes, UK
Supervisor - Prof. Richard Douglas, New Zealand
An instructional video on the surgical technique of a 'Full House' FESS (a combination of a full uncinectomy, middle metal antrostomy, full ethmoidectomy, sphenoidotomy and frontal pathway clearance - in this case a Draf 1 dissection).
The use of preoperative imaging and intra-operative image guidance are demonstrated.
The use of preoperative imaging and intra-operative image guidance are demonstrated.
In the video I refer to a Draf IIa dissection. There is a lot of confusion in these terms, until recently myself included. In the video I am referring to a complete clearance of the nasofrontal recess (Agger and all nasofrontal (Kuhn) cells). Strictly speaking, when there are no cells passing above the frontal beak, these cells are adequately cleared by a Draf I dissection and this video is such a case. In other words, the current video should be classified as a Draf I dissection. Thanks to Anshul Sama for this clarification.
On one occasion, while discussing the septal branch (of the sphenopalatine artery), I refer to it as the 'sphenoid branch'. Hopefully the error is clear.
Apologies for these errors, but I am prioritising work on the website over these video corrections for now! MB
On one occasion, while discussing the septal branch (of the sphenopalatine artery), I refer to it as the 'sphenoid branch'. Hopefully the error is clear.
Apologies for these errors, but I am prioritising work on the website over these video corrections for now! MB
1. Indications for sinus surgery and the extent dictated.
These are subjects of much debate and a little research. I have chosen not address these here, but they will be explored in our textbook (pending).
Indeed, some surgeons (including some of our peer reviewers) consider a full house FESS to be too extensive surgery for the case presented - this is a point of contention that I recognise.
2. Post-Operative Management
Peer reviewers suggested that follow-up after a 4 month period was adequate. I too have changed to this since returning to the UK, but only where I think that adhesions (medial and lateral wall wounds) and extensive crusting (turbinectomies) are unlikely.
3. Middle Turbinate Medialisation
I tend to suture medalise the middle turbinates after debriding them and the adjacent septum to ensure optimal exposure of the middle meatus for medication and douche delivery.
However, this may compromise exposure of the sphenoethmoid recess, and I would not do this in a case where the disease burden is small, especially not in occasional cases where hyposmia is the main symptom.
Nasopore within the middle meatus was both recommended and cautioned by the peer reviewers.
These are subjects of much debate and a little research. I have chosen not address these here, but they will be explored in our textbook (pending).
Indeed, some surgeons (including some of our peer reviewers) consider a full house FESS to be too extensive surgery for the case presented - this is a point of contention that I recognise.
2. Post-Operative Management
Peer reviewers suggested that follow-up after a 4 month period was adequate. I too have changed to this since returning to the UK, but only where I think that adhesions (medial and lateral wall wounds) and extensive crusting (turbinectomies) are unlikely.
3. Middle Turbinate Medialisation
I tend to suture medalise the middle turbinates after debriding them and the adjacent septum to ensure optimal exposure of the middle meatus for medication and douche delivery.
However, this may compromise exposure of the sphenoethmoid recess, and I would not do this in a case where the disease burden is small, especially not in occasional cases where hyposmia is the main symptom.
Nasopore within the middle meatus was both recommended and cautioned by the peer reviewers.
Welcome to one of our most important videos - this is my own technique, with a lot of credit to those that have trained me - primarily Richard Douglas, Sal Nair, PJ Wormald, and Paul White.
The full house FESS is my most common surgical intervention for CRS patients.
It involves breaking down the ethmoid honeycomb and enlarging the natural pathways that connect the major sinuses to the now combined nasal and ethmoid cavities. The procedure is consistent with the general principals of functional endoscopic sinus surgery.
My objective during the operation is to optimise drainage and ventilation, while facilitating sinus washing and medication delivery. I tell my patients that they will not be cured of the predisposition to sinus disease, but that their disease, their symptoms, and any flares should be more easily controlled by their medications and washes once they have recovered from operation itself. I believe it is essential in these patients to control all focuses of their disease. Our surgical approach should achieve this while mostly preserving a single mucosa lined drainage pathway from each sinus. Any co-existing lower airway disease should also be addressed. I do not routinely use image guidance in this sort of surgery, but I have done so here to demonstrate the anatomy to you.
You’ve just seen me prepare the nose with local anaesthetic and adrenalin (epinephrine if you prefer) and here I am taking specimens for histology since this is a primary case. Before any of this however, I have studied the patient’s scan.
In this patient, the cribriform plate is fairly shallow, symmetrical and even.
There is intact bone from the lamina, all the way through to the sphenoid.
The anterior ethmoid arteries are vulnerable - hanging in a mesentery within the nose.
Finally there are large Onodi cells, which puts the optic nerve at risk in the posterior ethmoids and also very low-set sphenoid sinuses, which is certainly as you will see in the surgery.
The agger complex is unremarkable - on each side there is an agger and a single Kuhn cell.
Here on the left, and on the right.
On the right side, the frontal drainage pathway passes down into an inter-septal sinus cell, and the pathway proper, displaced posteriorly by the agger complex, and then medially by a suprabullar cell. On the left the pathway passes posteriorly over the agger complex and then passes medially to it.
Do have a look at our other videos detailing patient and theatre preparations, how to make the most of your endoscopic view, and more detail on the separate elements of this procedure. For now though let’s get on with the surgery.
Our first operative step is an uncinectomy, this is safest performed by a low retrograde approach. By this, I mean that the uncinate is divided from its lateral to its medial surface using an instrument that has been very gently passed into the hiatus semi-lunaris - this may be a small backbiter, or as shown here; a sickle knife.
Once the maxillary antrum is identified, the bone of the lower half of the uncinate is disarticulated from the inferior turbinate and removed. The upper half of the uncinate contributes to the frontal recess. I believe that this should only be removed if you intend to complete at least a Draf IIa dissection, as indeed we do in this case. Again, it is mobilised in a retrograde manner and avulsed or debrided as high as possible from its insertion to the frontal process. This will usually open any agger cell present. As we do this, we keep the debrider orientated vertically so that we can see all tissue entering the debrider port. This is after all the most common site to breach the orbit.
The debrider is a useful tool then to tidy any residual soft tissue and small fragments of bone, completing our uncinectomy and clearly opening the maxillary sinus and agger cell while exposing the frontal recess for further dissection.
Now I can take the image guidance and remind myself that we have opened the first cell of the frontal recess - the agger cell, and that we must clear this and the Kuhn cell above it before we have completed our Draf IIa dissection of the frontal sinus drainage pathway.
I do what I can of this dissection before I take down the ethmoid bulla, because I like to preserve it as a landmark to guide me to the drainage pathway. The pathway can be found between the lamella of the bulla, the uncinate process, and the middle turbinate. The tract itself is quite variable; potentially displaced or narrowed by cells on three sides - anterolaterally by any agger or Kuhn cells beyond the uncinate, posterolaterally by suprabullar cells behind the bulla lamella, or medially by pneumatisation of the middle turbinate; a concha bullosa.
At this point in the dissection, the anatomy is clear - the agger is open, and the cut edges of the uncinate process are seen medially. The pathway lies between these and the middle turbinate and bulla lamella behind.
If the probe will not pass, as in this case, the cells can be dissected out in sequence as we will demonstrate, but orientation and mucosal preservation may then be more difficult.
Here, I’m taking away the top of the Agger, which allows us to see into the Kuhn cell beyond, for which I change to a 45˚ endoscope. The cut edge of the uncinate is still visible as the medial wall of the Kuhn cell. Our position is confirmed again with the image guidance.
The pathway remains medial, and further dissection continues with a suction curette to remove this second cell and enter the frontal sinus proper above. The uncinate in this case was a little more solid bone than typical and the dissection more difficult, since I did not wish to use undue forces so medially on the skullbase.
As you will see - I actually first entered the sinus through a fenestration of the cap of the Kuhn cell rather than by removal of the cell intact.
At this point I remove the uppermost part of the bulla lamella to open the space more widely and then use the guidance to demonstrate that we are probing through to the frontal sinus cavity, not a further Kuhn cell.
However you do it, angled endoscopes and specific frontal sinus instruments are needed to reliably perform the dissection, and when you do so, great care should be taken; probing with minimal force, and while dissecting, directing any forces in an anterior or lateral direction. Always remember that this is an area crowded with critical structures. The lateral lamella of the cribriform plate is at risk medially, the anterior ethmoid artery lies just beyond the bulla posteriorly, and the lamina and trochlear insertion lie laterally. It may also be safer to push rather than twist any instruments to avoid leverage injuries to the medial skull base.
Once the frontal sinus is clearly identified, I take down the ethmoid bulla, and proceed through the ground lamella to the posterior ethmoids. Until the anatomy is clear, it is important to keep all dissection as inferomedial as possible - the initial penetration of the bulla and ground lamella are made below the level of the orbital floor. This is easily visualised within the open maxillary sinus. Further clearance of septations above this level are achieved once an airspace in front and behind is visualised - this ensures that neither the skullbase not the orbit will be compromised.
Within the posterior ethmoid cavity, we identify and preserve at least the upper two thirds of the superior turbinate (as shown here), while breaking down all other septations of the posterior ethmoid air cells. This part of the dissection is usually straight forward.
The superior turbinate leads us to the sphenoid ostium - located just medial to its inferior third. The ostium is first enlarged with a freer. The same principals of safe FESS apply as in the ethmoids - the sphenoid face is removed from the ostium outwards, with each bite of bone only taken when there is a proven airspace in front and behind. In this task, the Hajek Koffler punch serves as both a probe and a rongeur, and is an excellent tool for safe dissection. When initial access is limited, a mushroom punch can facilitate slower but equally safe progress.
In dissecting the sphenoid, it must be remembered that the optic nerve and carotid artery, as well as the second or maxillary branch of the trigeminal nerve are immediately adjacent. These structures are not infrequently found within a mesentry, or entirely dehiscent within the sinus walls or cavity. Our preoperative review of the CT scan is absolutely essential preparation. The septations within each sphenoid sinus typically insert into the sphenoid wall directly overlying the carotid arteries and must be handled with care. Powered instruments should not be used within the sinus.
Roughly a centimetre beneath the ostium is the septal branch of the sphenopalatine artery. In fact in this dissection, the SPA itself is clearly visualised as I push down the mucosa of the sphenoid face in order to protect the septal branch while more widely opening the sphenoid. In cases without such small, low-set sphenoid sinuses, a wide sphenoidotomy is possible while staying above the septal branch, so this manoeuvre is unnecessary.
The sphenoid sinus is often the easiest location to find the level of the skullbase. In fact, in cases where the frontal pathway has been more difficult to identify, I often complete this dissection before fully visualising the frontal sinus cavity. I can then follow the skullbase forwards from the sphenoid, until the posterior table of the frontal sinus is identified and the anatomy becomes more apparent. Particular care must be taken with this approach between the ground and bulla lamellae not to damage the anterior ethmoid artery.
All that now remains of the dissection is to tidy up any remaining septations to fully clear both the skullbase and the lamina papyracea. I tend to then inspect all cavities with a 45˚ endoscope and washout with saline.
At the end of surgery, unless the middle turbinates are solidly maintaining a medial position, I tend to secure them to the septum with a 3/0 vicryl suture. This can be used to quilt any access septoplasty that has been performed - no septoplasty was required in this particular case however.
Finally, I place neuropatties within the frontal, sphenoid and maxillary cavities which are secured over the nasal bridge and removed 2 to 4 hours post-operatively, at which point the patient performs their first saline douching. They are advised to continue douching at least four times daily for the next month. Patients are discharged the same day, with analgesia and a sinus rinse bottle. In frankly mucopurulent cases I provide 2 weeks of doxycycline, and in cases with significant polyposis I recommend prednisone for 10 days. All patients are reviewed 2 weeks later to allow for debridement and occasional division of adhesions.
Thanks for watching this video. We hope you have found it helpful. As I have said before, this is my own technique, but it will almost certainly change with time. All our videos remain a work in progress - if you think you have any useful tips to add, a different technique, or any other contribution please do get in touch with us through SurgTech.net.
The full house FESS is my most common surgical intervention for CRS patients.
It involves breaking down the ethmoid honeycomb and enlarging the natural pathways that connect the major sinuses to the now combined nasal and ethmoid cavities. The procedure is consistent with the general principals of functional endoscopic sinus surgery.
My objective during the operation is to optimise drainage and ventilation, while facilitating sinus washing and medication delivery. I tell my patients that they will not be cured of the predisposition to sinus disease, but that their disease, their symptoms, and any flares should be more easily controlled by their medications and washes once they have recovered from operation itself. I believe it is essential in these patients to control all focuses of their disease. Our surgical approach should achieve this while mostly preserving a single mucosa lined drainage pathway from each sinus. Any co-existing lower airway disease should also be addressed. I do not routinely use image guidance in this sort of surgery, but I have done so here to demonstrate the anatomy to you.
You’ve just seen me prepare the nose with local anaesthetic and adrenalin (epinephrine if you prefer) and here I am taking specimens for histology since this is a primary case. Before any of this however, I have studied the patient’s scan.
In this patient, the cribriform plate is fairly shallow, symmetrical and even.
There is intact bone from the lamina, all the way through to the sphenoid.
The anterior ethmoid arteries are vulnerable - hanging in a mesentery within the nose.
Finally there are large Onodi cells, which puts the optic nerve at risk in the posterior ethmoids and also very low-set sphenoid sinuses, which is certainly as you will see in the surgery.
The agger complex is unremarkable - on each side there is an agger and a single Kuhn cell.
Here on the left, and on the right.
On the right side, the frontal drainage pathway passes down into an inter-septal sinus cell, and the pathway proper, displaced posteriorly by the agger complex, and then medially by a suprabullar cell. On the left the pathway passes posteriorly over the agger complex and then passes medially to it.
Do have a look at our other videos detailing patient and theatre preparations, how to make the most of your endoscopic view, and more detail on the separate elements of this procedure. For now though let’s get on with the surgery.
Our first operative step is an uncinectomy, this is safest performed by a low retrograde approach. By this, I mean that the uncinate is divided from its lateral to its medial surface using an instrument that has been very gently passed into the hiatus semi-lunaris - this may be a small backbiter, or as shown here; a sickle knife.
Once the maxillary antrum is identified, the bone of the lower half of the uncinate is disarticulated from the inferior turbinate and removed. The upper half of the uncinate contributes to the frontal recess. I believe that this should only be removed if you intend to complete at least a Draf IIa dissection, as indeed we do in this case. Again, it is mobilised in a retrograde manner and avulsed or debrided as high as possible from its insertion to the frontal process. This will usually open any agger cell present. As we do this, we keep the debrider orientated vertically so that we can see all tissue entering the debrider port. This is after all the most common site to breach the orbit.
The debrider is a useful tool then to tidy any residual soft tissue and small fragments of bone, completing our uncinectomy and clearly opening the maxillary sinus and agger cell while exposing the frontal recess for further dissection.
Now I can take the image guidance and remind myself that we have opened the first cell of the frontal recess - the agger cell, and that we must clear this and the Kuhn cell above it before we have completed our Draf IIa dissection of the frontal sinus drainage pathway.
I do what I can of this dissection before I take down the ethmoid bulla, because I like to preserve it as a landmark to guide me to the drainage pathway. The pathway can be found between the lamella of the bulla, the uncinate process, and the middle turbinate. The tract itself is quite variable; potentially displaced or narrowed by cells on three sides - anterolaterally by any agger or Kuhn cells beyond the uncinate, posterolaterally by suprabullar cells behind the bulla lamella, or medially by pneumatisation of the middle turbinate; a concha bullosa.
At this point in the dissection, the anatomy is clear - the agger is open, and the cut edges of the uncinate process are seen medially. The pathway lies between these and the middle turbinate and bulla lamella behind.
If the probe will not pass, as in this case, the cells can be dissected out in sequence as we will demonstrate, but orientation and mucosal preservation may then be more difficult.
Here, I’m taking away the top of the Agger, which allows us to see into the Kuhn cell beyond, for which I change to a 45˚ endoscope. The cut edge of the uncinate is still visible as the medial wall of the Kuhn cell. Our position is confirmed again with the image guidance.
The pathway remains medial, and further dissection continues with a suction curette to remove this second cell and enter the frontal sinus proper above. The uncinate in this case was a little more solid bone than typical and the dissection more difficult, since I did not wish to use undue forces so medially on the skullbase.
As you will see - I actually first entered the sinus through a fenestration of the cap of the Kuhn cell rather than by removal of the cell intact.
At this point I remove the uppermost part of the bulla lamella to open the space more widely and then use the guidance to demonstrate that we are probing through to the frontal sinus cavity, not a further Kuhn cell.
However you do it, angled endoscopes and specific frontal sinus instruments are needed to reliably perform the dissection, and when you do so, great care should be taken; probing with minimal force, and while dissecting, directing any forces in an anterior or lateral direction. Always remember that this is an area crowded with critical structures. The lateral lamella of the cribriform plate is at risk medially, the anterior ethmoid artery lies just beyond the bulla posteriorly, and the lamina and trochlear insertion lie laterally. It may also be safer to push rather than twist any instruments to avoid leverage injuries to the medial skull base.
Once the frontal sinus is clearly identified, I take down the ethmoid bulla, and proceed through the ground lamella to the posterior ethmoids. Until the anatomy is clear, it is important to keep all dissection as inferomedial as possible - the initial penetration of the bulla and ground lamella are made below the level of the orbital floor. This is easily visualised within the open maxillary sinus. Further clearance of septations above this level are achieved once an airspace in front and behind is visualised - this ensures that neither the skullbase not the orbit will be compromised.
Within the posterior ethmoid cavity, we identify and preserve at least the upper two thirds of the superior turbinate (as shown here), while breaking down all other septations of the posterior ethmoid air cells. This part of the dissection is usually straight forward.
The superior turbinate leads us to the sphenoid ostium - located just medial to its inferior third. The ostium is first enlarged with a freer. The same principals of safe FESS apply as in the ethmoids - the sphenoid face is removed from the ostium outwards, with each bite of bone only taken when there is a proven airspace in front and behind. In this task, the Hajek Koffler punch serves as both a probe and a rongeur, and is an excellent tool for safe dissection. When initial access is limited, a mushroom punch can facilitate slower but equally safe progress.
In dissecting the sphenoid, it must be remembered that the optic nerve and carotid artery, as well as the second or maxillary branch of the trigeminal nerve are immediately adjacent. These structures are not infrequently found within a mesentry, or entirely dehiscent within the sinus walls or cavity. Our preoperative review of the CT scan is absolutely essential preparation. The septations within each sphenoid sinus typically insert into the sphenoid wall directly overlying the carotid arteries and must be handled with care. Powered instruments should not be used within the sinus.
Roughly a centimetre beneath the ostium is the septal branch of the sphenopalatine artery. In fact in this dissection, the SPA itself is clearly visualised as I push down the mucosa of the sphenoid face in order to protect the septal branch while more widely opening the sphenoid. In cases without such small, low-set sphenoid sinuses, a wide sphenoidotomy is possible while staying above the septal branch, so this manoeuvre is unnecessary.
The sphenoid sinus is often the easiest location to find the level of the skullbase. In fact, in cases where the frontal pathway has been more difficult to identify, I often complete this dissection before fully visualising the frontal sinus cavity. I can then follow the skullbase forwards from the sphenoid, until the posterior table of the frontal sinus is identified and the anatomy becomes more apparent. Particular care must be taken with this approach between the ground and bulla lamellae not to damage the anterior ethmoid artery.
All that now remains of the dissection is to tidy up any remaining septations to fully clear both the skullbase and the lamina papyracea. I tend to then inspect all cavities with a 45˚ endoscope and washout with saline.
At the end of surgery, unless the middle turbinates are solidly maintaining a medial position, I tend to secure them to the septum with a 3/0 vicryl suture. This can be used to quilt any access septoplasty that has been performed - no septoplasty was required in this particular case however.
Finally, I place neuropatties within the frontal, sphenoid and maxillary cavities which are secured over the nasal bridge and removed 2 to 4 hours post-operatively, at which point the patient performs their first saline douching. They are advised to continue douching at least four times daily for the next month. Patients are discharged the same day, with analgesia and a sinus rinse bottle. In frankly mucopurulent cases I provide 2 weeks of doxycycline, and in cases with significant polyposis I recommend prednisone for 10 days. All patients are reviewed 2 weeks later to allow for debridement and occasional division of adhesions.
Thanks for watching this video. We hope you have found it helpful. As I have said before, this is my own technique, but it will almost certainly change with time. All our videos remain a work in progress - if you think you have any useful tips to add, a different technique, or any other contribution please do get in touch with us through SurgTech.net.
Pending...
If you have references that you think we should add, or any other recommendations for this page, just let us know!
If you have references that you think we should add, or any other recommendations for this page, just let us know!
Thanks to our
peer reviewers
peer reviewers
Kim Ah-See
Martyn Barnes
Jochen Bretschneider
Mike Davison
Prof. Richard Douglas
Prof. Wytske Fokkens
Quentin Gardiner
Iain Hathorn
Claire Hopkins
Christopher McCann
Gerald McGarry
Dirk Jan Menger
Mohammed Miah
Salil Nair
Peter Ross
Anshul Sama
Pavol Surda
Nolst Trenité
May Yaneza
Hadé Vuyk
See us on Google+
Martyn Barnes
Jochen Bretschneider
Mike Davison
Prof. Richard Douglas
Prof. Wytske Fokkens
Quentin Gardiner
Iain Hathorn
Claire Hopkins
Christopher McCann
Gerald McGarry
Dirk Jan Menger
Mohammed Miah
Salil Nair
Peter Ross
Anshul Sama
Pavol Surda
Nolst Trenité
May Yaneza
Hadé Vuyk
See us on Google+