Functional endoscopic sinus surgery.

The paranasal sinuses serve to provide lubrication to the upper respiratory tract, pneumatize the skull to lighten the load on the neck, and provide resonance to the voice. The sinuses are lined by pseudostratified ciliated columnar respiratory epithelium with goblet cells. When the sinus ostia are blocked, infection may ensue. Blockage of the sinus ostia (Box 1) can occur as a result of swelling due to allergy, viral inflammation, and local irritation from tobacco smoke or other physical or chemical irritants. Abnormal anatomy such as a paradoxically bent middle turbinate, septal deformity (Fig. 1), nasal polyps (Fig. 2), or other intranasal masses or tumors may also cause sinus obstruction. Other causes of obstruction include nasogastric or nasotracheal tubes in hospitalized patients, nasal packing for epistaxis management, and nasal foreign bodies. ‘‘Rhinosinusitis’’ is the current terminology for inflammation of the nose and paranasal sinuses. This term was adopted to emphasize that the nasal and sinus membranes are confluent; rarely does a disease process affect one area without the other. Rhinosinusitis can be acute, subacute, or chronic based on the length of symptomatology, major and minor factors (Box 2). Acute rhinosinusitis has duration of less than 4 weeks. Chronic rhinosinusitis is an infection that has been ongoing for 12 or more weeks. Subacute rhinosinusitis covers those patients who fall between the acute and chronic timelines. In addition, a category known as recurrent acute rhinosinusitis has also been recognized and includes patients having acute rhinosinusitis that clears with medical therapy but recurs on the order of four to five times a year, primarily due to intranasal anatomic variations that preclude to ostial blockage. Sinus surgery has been performed in one form or another for over 100 years. Functional endoscopic sinus surgery (FESS), however, has been practiced widely only in the last 2 decades. Following the work of Messerklinger and others [1,2], it was recognized through a series of elegant smoke circulation studies that the paranasal sinuses drain in a consistent, fixed pattern into an area that is called the ostiomeatal complex. The ostiomeatal complex (Fig. 3) is made up of the maxillary sinus ostia with the uncinate process of the maxilla, the anterior ethmoidal air cells including the bulla ethmoidalis and agger nasi cells, and the frontal recess. This small area within the paranasal sinuses measures approximately 3 to 5 mm in greatest dimension, and when obstructed, is the source of both acute and chronic sinus problems. The ostiomeatal complex is tucked away under the middle turbinate laterally and directly above the root of the inferior turbinate. All of the paranasal sinuses drain into this region either directly or, in the case of the posterior ethmoid and sphenoid sinuses, indirectly. Recurrent acute rhinosinusitis and chronic rhinosinusitis are managed surgically when medical therapy fails. Chronic rhinosinusitis is the most common chronic ailment in the United States today. Failure of medical therapy is the most common indication for surgical management. Other indications for endoscopic sinus surgery include nasal polyposis, sinus