Nasal Endoscopy and FESS: maneuver, indications, aims, complications

Nasal endoscopy maneuver: In the semi-sitting position. A pack (decongestant & local anesthetic) is left for 5 minutes. The endoscope is introduced via the nostril to examine the nose, sinuses and nasopharynx.
The nasal endoscopy set is composed of: Nasal endoscope, light source, cable & monitor.

Features of nasal endoscopes:

  • Diameter: 2.7 mm (children) or 4 mm (adult)
  • Length: 19 cm
  • Angle: 0 º, 30 º, 45 ºor 70º

Indications of nasal endoscopy

I. Diagnostic:

  • Choanal atresia: to confirm the diagnosis.
  • Foreign body: to define site & nature of FB.
  • Epistaxis: to localize site of bleeding and handle it.
  • Chronic sinusitis: to visualize the pus & polyps (mainly middle meatus).
  • Endoscopic guided culture & sensitivity.

  • Sino-nasal polyps: to determine site & type of polyps.
  • Fungal sinusitis: to visualize polyps, mud & mucin.
  • Granuloma: to visualize nodules and masses.
  • Sino-nasal tumor (benign and malignant): to visualize masses.
  • Endoscopic guided biopsy.
  • CSF leak and meningocele: to identify the meningocele and determine site of leak.
  • Follow-up after ESS to achieve complete healing and to identify any residual and/or recurrence of the disease.

II. Therapeutic:

This is Endoscopic sinus surgery.

1. Basic techniques:
  • Foreign body: to extract the FB safely.
  • Epistaxis: to handle bleeding point/s.
  • Chronic rhino-sinusitis: FESS (functional endoscopic sinus surgery)
  • Mucocele: to marsupialise it.
  • Sino-nasal polyps: to remove all polyps from their roots and avoid recurrence.
  • Fungal rhino-sinusitis: to debride polyps, mud and mucin.

2. Advanced techniques:
  • Choanal atresia: to create neochoana.
  • Blow out fracture: to reduce the fracture.
  • CSF leak: to repair defect.
  • Meningocele: to ablate the meningocele and repair the defect.
  • DCR: to create a fistula between lacrimal sac and nasal cavity.
  • Benign tumors (e.g. inverted papilloma IP and juvenile angiofibroma JNA): to achieve complete resection.
  • Malignant tumors: to remove early and localized lesions.
  • Orbital decompression: in thyroid orbitopathy.
  • Optic nerve decompression in optic neuropathy & trauma.

3. Extended techniques:
  • Pituitary surgery: transnasal endoscopic pituitary surgery.
  • Meningioma- chordoma- craniopharyngioma- cholesterol cyst.
  • Hemangioma of orbital apex
  • glioma of orbital apex

FESS in chronic rhino-sinusitis with or without polyps:

Aims of FESS:
  1. Preservation of the internal and external configuration of the nose.
  2. Removal of the source of infection
  3. Removal of the polyps and their roots.
  4. Suction of the purulent discharge.
  5. Insurance of the patency of the maxillary, frontal and/or sphenoid sinus ostia.
  6. Preservation of all the maxillary, frontal and sphenoid sinuses mucosa.

N.B. Extent of FESS is tailored according to the affected sinus/es and or side/s. All the paranasal sinuses on both sides could be taken care of as one unit in one sitting.

N.B. Diseased mucosa of the maxillary and /or frontal sinuses returns to normal after the reestablishment of proper drainage and aeration of these sinuses.

Supplementary tools during ESS:

  • Shaver (microdebrider): to help shave polyps & diseased mucosa.
  • Image guided surgery (navigation system): to help orientation during ESS.

Complications of ESS:

Minor: bleeding and adhesions.
Major: orbital e.g. hematoma and cranial e.g. CSF leak.

Key points

  • The nasal endoscope is a tool used for diagnostic and therapeutic purposes. 
  • It offers excellent visualization of most of the sinonasal and nasopharyngeal cavities and recesses
  • It helps achieve early and precise diagnosis 
  • It helps in the management of most sinonasal lesions transnasally with no need for any external incisions -ESS replaced most traditional surgeries.
Nasal Endoscopy and FESS: maneuver, indications, aims, complications
Dr.Tamer Mobarak


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