ENDOSCOPIC SINUS SURGERY
What is an endoscope? What is Endoscopic Sinus Surgery?
Endoscope is an instrument with light and optical lenses at the end, in this way gives the opportunity to see the image on the other end directly when viewed from one end. Endoscopes of different thicknesses and lengths are used in many branches such as Gastroenterology, Urology, Orthopedics, General Surgery, Obstetrics, Thoracic Surgery and especially ENT. The endoscope diameters commonly used in ENT practice are 4mm and 2.7mm. There are endoscopes with 0º, 30º, 45º, 70º, 90º, and 120º angles according to the placement of the lens at the tip of the tool. Endoscopes provide a clear view of dark spaces, normal anatomical structures, and pathological tissues that we cannot see directly in the nose. Endoscopes are connected with a camera system, the image is transferred simultaneously to the computer or monitor. Images can be zoomed in and recorded in HD quality as needed. Surgeries performed on the sinuses around the nose by using endoscopes are called Endoscopic Sinus Surgery. This operation has been widely applied all over the world and in Turkey for many years.
When Do Endoscopy And Endoscopic Sinus Surgery Performed?
Endoscopes are used in the diagnosis and surgical treatment of many diseases involving the nose, sinuses, and surrounding areas, such as :
• Chronic Sinusitis (Not responding to drug therapy)
• Recurrent Sinusitis
• Nasal Polyps
• Antrochoanal Polyps
• Concha Reduction
• Sinus Mucoceles
• Nose and Sinus Tumors
• Cerebrospinal Fluid Leak (Cerebrospinal Rhinorrhea)
• Orbital Decompression (Rescuing the eye from pressure in thyroid ophthalmopathy)
• Optic Nerve Decompression (Rescuing the optic nerve from pressure)
• Dacryocystorhinostomy (opening of a blocked tear duct)
• Choanal Atresia Repair
• Removal of Foreign Bodies in the Nose
• Nosebleed Control
• Pituitary Gland Tumors
• Skull Base Surgery
• Septal Crest (Endoscopic Septoplasty)
• Eustachian Tube Problems
Advantages Of Endoscopic Sinus Surgery
Thanks to endoscopes, surgery can be performed completely inside the nose without making any incisions on the nose and face. In addition, the areas that we cannot reach or see well with classical methods can be reached much more easily with endoscopes. It provides surgical intervention for only diseased tissues without damaging healthy tissues. Endoscopic surgery both reduces the risk of complications and shortens the recovery period.
How Is Endoscopic Sinus Surgery Performed?
The surgery can be performed under general anesthesia, local anesthesia, or sedation. The duration, scope, risks, and the preference of the patient are important in the decision of anesthesia type. For example, general anesthesia is used in the case of diffuse nasal polyp or tumor, while the foreign body or septal crest treatment can be performed with local anesthesia. Before the operation, some examinations are carried out and the anesthesiologist assesses contraindications to general anesthesia and possible risks. Sinus CT scan of the patient is carried out prior to the surgery. Tomography images are transferred to the operating room where the surgeon can see them any time. When necessary, tomography is checked during the surgery to control the position in the nose and to avoid complications. In the surgery, the endoscope is entered through the nostril, and the necessary procedures are performed directly seeing the tissues with precision instruments developed for endoscopic surgery. The extent of the procedure to be performed varies according to the disease. For example, in chronic sinusitis clogged sinus channels are opened, damaged tissues are cleaned without damaging healthy tissues. In nasal polyp cases, all polyp tissues that fill the inside of the nose and sinuses are cleaned without touching the healthy mucosa. In tumors, some healthy tissue is removed along with the tumor tissue. The duration of the surgery varies according to its scope. For example, surgery for chronic sinusitis takes an average of 1.5 hours. In endoscopic surgery, systems that shorten the duration of the operation and increase its safety can be used, apart from conventional instruments.
In the microdebrider system tissues are shaved on one hand and removed from the surgical area by vacuuming on the other. It is frequently used, especially in common nasal polyps, as it reduces both the operation time and bleeding.
Surgical Navigation (Image Guided Surgery); Imagine the navigation device used in cars. Just as the navigation device always shows where we are, we can see the 3D location of the surgical instruments we use in the nose with the navigation system in endoscopic sinus surgery. There are 2 systems: Electromagnetic and Optical (Infrared) systems. In the surgical navigation system, the patient's sinus tomography (more than 1 mm sensitive) is taken and loaded into the system before the operation, and a special headgear is placed on the patient's head during the surgery. In this way, we can see the position of our surgical instruments on the monitor with more than 1 mm precision during the operation. The most important advantage of surgical navigation is that it removes the diseased tissues close to the skull base and brain, eye and optic nerve, great vessels, while reducing the risk of damaging these structures and thus reducing serious complications. Surgical navigation is not necessary in routine endoscopic sinus surgery. Personally I use it when necessary in common recurrent nasal polyps that have undergone nasal polyp surgery and in which normal anatomical structures have changed, in sinus tumors near the skull base and near the eye, in repair of cerebrospinal fluid leak, optic nerve decompression, pituitary surgery (with neurosurgery) when necessary. The disadvantage of surgical navigation is that it prolongs the time due to preoperative preparation and increases the cost.
Recovery Process After Endoscopic Sinus Surgery And What Should Be Considered?
There may be mild pain after the surgery, which can be easily relieved with painkillers. In endoscopic surgery, there is no change in the shape of the nose, swelling or bruising. At the end of the operation, dissolvable tampons are placed in the operation area. The nostrils remain open. However, if one or more procedures such as rhinoplasty (nose aesthetics), septoplasty (deviation surgery), concha surgery have been performed together with endoscopic surgery, flexible pads made of soft silicone are placed into the nose (doyle splint). These tampons have a hole in the middle and if they are not blocked with dried mucus or clots, patient can breath through the nose. If only septoplasty is performed, the tampons are removed in 2-3 days. If the nasal concha (concha surgery) is also performed or if it is done together with nasal aesthetics, the tampons are removed after 3-5 days.The process of removing tampons is painless and takes 10-15 seconds. According to the postoperative monitoring, it may be necessary to stay in the hospital for 1 day. There may be blood leakage for 1-2 days after the operation.For the next few days, there will be mucus-mixed discharge, and then crusting in the nose. Depending on the scope of the surgery, crusting may take 2-6 weeks. These crusts can be cleaned by softening with physiological saline. In this process, frequent control and intranasal dressings are very important for a healthy recovery. Rest is recommended for 7-10 days after surgery.
Success Of Endoscopic Sinus Surgery
The success rates of endoscopic surgery vary according to the disease. The success rate in chronic or recurrent sinusitis is between 80-90%. Nasal polyps tend to recur in 20-30% in those with polyps only and 70% in those with polyp+asthma+aspirin allergy (Sampter syndrome). The recurrence time varies from person to person. In some patients, the polyp may recur within 6 months after surgery, while in others it may recur 5 years later. The average success rate in antrochoanal polyp is 95%.Additionaly to the disease, the experience of the surgeon is also very important for the good results.
Possible Complications In Endoscopic Sinus Surgery
The nose and surrounding sinuses are anatomically adjacent to the eye and tear duct on the sides, the cerebral cortex and brain tissue at the ceiling, the carotid vein going to the brain at the back, and the optic nerve going to the eye. Due to these neighborhoods, there is a possibility of damage in endoscopic sinus surgery. Complications are divided into major and minor according to their severity. The likelihood of complications depends on the extent of the disease and the surgeon's experience.
• Orbital hematoma (blood accumulation in the orbital socket), optic nerve (optic nerve) damage; vision loss and blindness
• Injury of the eye muscles; double vision
• Overflow of tears as a result of tear duct injury (Epiphora)
• Injury to the meninges or brain tissue;
• Cerebrospinal fluid leakage (CSF fistula) (most common major complication), Meningitis, Brain abscess, Cerebral hemorrhage, Presence of air in the intracranial space (Pneumocephalus)
• Great vessel injury and bleeding
• Edema around the eyes, bruising, air leak
• Adhesion is the most common minor complication
• Nose bleeding
• Loss of smell
What Is Ballon Sinuplasty And In What Situations It Is Performed?
Balloon sinuplasty is the process of opening narrowed sinus channels with the help of a catheter, just like balloon angioplasty applied to open vascular occlusions. The balloon at the tip of the catheter is placed in the sinus canal and inflated, the canal is widened and the sinuses are drained. The procedure can be performed endoscopically under general or local anesthesia. It can be combined with traditional endoscopic sinus surgery techniques. The procedure can be applied in chronic sinusitis affecting the Frontal (forehead), Maxillary (cheek) and Sphenoid (base of the skull) sinuses. It has no efficacy in polyps or other diseases affecting the sinuses. Bleeding is not common after the procedure, the patient can go home on the same day and return to work the next day. Crusting, which is observed after endoscopic sinus surgery and lasts for a few weeks, does not occur in this procedure. The disadvantage of balloon sinuplasty is that it can only be applied to certain sinuses and sinusitis cases and has additional cost. Personally, I prefer this method in isolated frontal sinusitis that does not respond to drug therapy.