Chapter 28 - FESS

Question 1

Keros olfactory fossa depth

Answer 1

I: 1-3mm (26%)
II: 4-7mm (73%)
III: 8mm + (1%)

Question 2

Most common complication of sinus surgery

Answer 2

hemorrhage

Question 3

Where sphenoethmoidal recess is in relation to superior turbinate

Answer 3

Inferomedial

Question 4

Artery than can be injured when enlarging sphenoid os

Answer 4

posterior septal artery (medial terminal branch of sphenopalatine artery) located inferiorly
However, should enlarge it inferomedially to avoid SB injury

Question 5

Steps to FESS

Answer 5

Turbinate/Maxillary antrostomy
Anterior ethmoids
Posterior ethmoids
Sphenoid open inferomedially
Then remaining ethmoids P --> A, limits being lamina lateral, middle turb medial, frontal recess anterior

Question 6

Draf procedures

Answer 6

Draf I- anterior ethmoidectomy, dissect all cells within frontal recess
IIa- wide open frontal ostium
IIb- resect floor of frontal sinus from septum to lamina
III/mod lorthrop/transseptal frontal sinusotomy- connect two frontal sinuses, remove each floor, inferior portion of frontal intersinus septum, superior nasal septum

Question 7

What is the basal lamella

Answer 7

horizontal component of MT

Question 8

Minor complications of sinus surgery

Answer 8

Bleeding, hyposmia, numbness (nose, upper lip, central upper teeth, self-limited), nasal obstruction, adhesions, crusts (regular rinses)
Only 1% have bleeding requiring intervention

Question 9

Major complications of sinus surgery

Answer 9

Orbital injury - violation of lamina leading to anisicoria/ophthalmoplegia/proptosis –> prompt action!

Intracranial- CSF leak, meningitis, carotid artery, tension pneumo

Hemorrhage- ethmoid, sphenopal, ICA

<1% have one

Question 10

How to treat increased IOP during FESS

Answer 10

mannitol, steroids

lateral canthotomy cantholysis

Question 11

How you injure NLD with FESS

Answer 11

overly aggressive anterior dissection with maxillary antrostomy

Question 12

Where does sphenopalatine artery enter nose

Answer 12

Maxillary artery courses through PPF (posterior to max sinus)

SPA (terminal br) enters via SPF into the inferior portion of the basal lamella of MT

Question 13

When to use image-guidance for surgery

Answer 13

polyps, revision, frontal/sphenoid, orbital, skull base, CSF leak

Question 14

Benefits of TIVA

Answer 14

Lower heart rate –> low MAP, avoid excess fluid shifts, lower CVP

Inhalation anesthetics –> vasodilation

Question 15

Concentration of epi for pledgets

Answer 15

1:1000

Complication 0.001%, but caution with peds, high BP, CV risks

Question 16

Local anesthesia for sinus surgery

Answer 16

1% with 1:100,000 epi
Anterior: root of middle turbinate (max, ant ethm, frontal)
Posterior: SPF or intraoral greater palatine foramen, for post ethmoid, sphenoid

Question 17

When is anterior ethmoid more likely to be injured?

Answer 17

When running below SB

Question 18

What’s bad about tall maxillary sinuses?

Answer 18

Relatively short ethmoids –> may disorient during surgery (SB may be lower than anticipated)

Question 19

Caldwell-Luc

Answer 19

Remove maxillary sinus mucosa, create gravity-dependent drainage
Sublabial approach
Rarely done now