Orris

Wigand fess technique, messenkinger fess technique and other such fess techniques according to standard ENT textbook in simplified manner, also give fess complications in detail

Reading File
Finding Sources
Finding Sources
Reading File
Reading File
Reading File
Reading File
Reading File
Finding Sources
Finding Sources
Reading File
Reading File
Finding Sources
Finding Sources
Finding Sources
Finding Sources
Reading File
Reading File
Finding Sources
Searching Images

FESS functional endoscopic sinus surgery technique diagram

Searching Images

endoscopic sinus surgery uncinectomy maxillary antrostomy

This diagnostic endoscopic clinical photograph captures an intraoperative view of a middle meatal antrostomy performed during Functional Endoscopic Sinus Surgery (FESS). The visual field focuses on the surgically widened natural ostium of the maxillary sinus. Central to the frame is the sinus interior, characterized by a pale, smooth mucosal surface with visible fine vascularity. The periphery shows the margins of the antrostomy, where the tissue appears erythematous, raw, and hemorrhagic due to recent uncinectomy and surgical manipulation. Areas of active bleeding and pooled bright red blood are visible across the mucosal surfaces, reflecting the acute surgical setting. Some fleshy, finger-like projections of inflamed mucosa or polyps are evident near the drainage pathway. The image demonstrates the goal of establishing improved sinus ventilation and drainage while attempting to preserve as much healthy Schneiderian membrane as possible to maintain mucociliary clearance in the treatment of odontogenic sinusitis.

This diagnostic endoscopic clinical photograph captures an intraoperative view of a middle meatal antrostomy performed during Functional Endoscopic Sinus Surgery (FESS). The visual field focuses on the surgically widened natural ostium of the maxillary sinus. Central to the frame is the sinus interior, characterized by a pale, smooth mucosal surface with visible fine vascularity. The periphery shows the margins of the antrostomy, where the tissue appears erythematous, raw, and hemorrhagic due to recent uncinectomy and surgical manipulation. Areas of active bleeding and pooled bright red blood are visible across the mucosal surfaces, reflecting the acute surgical setting. Some fleshy, finger-like projections of inflamed mucosa or polyps are evident near the drainage pathway. The image demonstrates the goal of establishing improved sinus ventilation and drainage while attempting to preserve as much healthy Schneiderian membrane as possible to maintain mucociliary clearance in the treatment of odontogenic sinusitis.

This clinical photograph displays an intraoperative endoscopic view of the left nasal cavity during revision endoscopic sinus surgery (ESS) and uncinectomy. The image captures key anatomical structures including the middle turbinate (MT) and the lamina papyracea (LP). The operative field shows fresh blood and evidence of surgical manipulation. A white arrow points to a distinct bulge in the sinonasal mucosa. This visual finding is significant as it demonstrates a connection to an orbital defect; the bulging occurs when surgical instrumentation is applied through the orbital floor. The image serves as an educational tool for identifying iatrogenic orbital injury and the topographical relationship between the maxillary sinus, ethmoid cavity, and the medial orbital wall. It highlights the importance of precise anatomical localization during antrostomy to avoid injury to the orbital floor and adjacent structures like the inferior rectus muscle.

This clinical photograph displays an intraoperative endoscopic view of the left nasal cavity during revision endoscopic sinus surgery (ESS) and uncinectomy. The image captures key anatomical structures including the middle turbinate (MT) and the lamina papyracea (LP). The operative field shows fresh blood and evidence of surgical manipulation. A white arrow points to a distinct bulge in the sinonasal mucosa. This visual finding is significant as it demonstrates a connection to an orbital defect; the bulging occurs when surgical instrumentation is applied through the orbital floor. The image serves as an educational tool for identifying iatrogenic orbital injury and the topographical relationship between the maxillary sinus, ethmoid cavity, and the medial orbital wall. It highlights the importance of precise anatomical localization during antrostomy to avoid injury to the orbital floor and adjacent structures like the inferior rectus muscle.

Here is a comprehensive, simplified breakdown of FESS techniques and complications based on Cummings Otolaryngology and Scott-Brown's Otorhinolaryngology.

FESS - Functional Endoscopic Sinus Surgery

Background

FESS was developed from the pioneering work of Messerklinger and Wigand in the 1970s-80s, and was popularized in the English-speaking world by Stammberger and Kennedy. The central philosophy is to restore normal sinus drainage and ventilation by targeting the ostiomeatal complex (OMC) - the critical drainage pathway - rather than radical removal of mucosa.

The Two Core Techniques

1. Messerklinger Technique (Anterior-to-Posterior Approach)

This is the most widely used technique today, developed by Walter Messerklinger of Graz, Austria.
Philosophy: Disease in the sinuses is secondary to obstruction at the OMC (the "key area"). If you open the drainage pathways, the sinuses heal themselves.
Direction: Starts anteriorly and moves posteriorly.
Step-by-step sequence:
  1. Diagnostic nasal endoscopy - Identify landmarks, polyps, pus, anatomical variants
  2. Uncinectomy - Remove the uncinate process (the key first step; opens access to the infundibulum)
  3. Maxillary antrostomy - Identify and enlarge the natural maxillary ostium using a 30-45 degree endoscope
  4. Anterior ethmoidectomy - Open ethmoid bulla and anterior ethmoid cells
  5. Basal lamella perforation - Enter posterior ethmoid through the inferomedial quadrant of the ground lamella
  6. Posterior ethmoidectomy - Remove posterior ethmoid cells
  7. Sphenoidotomy - If needed, via the sphenoethmoidal recess
  8. Frontal recess - Approached last (most technically difficult)
Key principle: Every step is guided by landmarks. The "inferomedial rule" applies when breaching any bony partition - always perforate in the inferomedial quadrant to avoid skull base or orbital injury.

2. Wigand Technique (Posterior-to-Anterior Approach)

Developed by Wigand as a "total ethmoidectomy" approach.
Direction: Starts posteriorly (at the sphenoid) and moves anteriorly.
Philosophy: By first identifying the sphenoid (a fixed, reliable landmark), the surgeon establishes a safe posterior reference point and then works forward.
Step-by-step sequence:
  1. Sphenoid sinus identification - The sphenoid ostium is located first, medial to the superior turbinate in the sphenoethmoidal recess, at the level of the antral roof
  2. Posterior ethmoidectomy - Working forward from the sphenoid
  3. Anterior ethmoidectomy - Continue anteriorly
  4. Uncinectomy and maxillary antrostomy - Completed last
Advantage: Sphenoid provides a fixed, reliable posterior landmark that orients the surgeon throughout the operation - helpful in revision cases or where anatomy is distorted.
Disadvantage: Less commonly used as a routine primary approach; more technically demanding for trainees.

Comparison Table

FeatureMesserklingerWigand
DirectionAnterior → PosteriorPosterior → Anterior
Starting pointUncinate process / infundibulumSphenoid sinus
Landmark anchorOstiomeatal complex (OMC)Sphenoid (fixed reference)
Scope of surgeryTargeted (based on disease extent)Total ethmoidectomy
Common usePrimary sinus surgeryRevision / distorted anatomy
Mucosal preservationStrong emphasisMay be more radical

Stammberger Modification

Stammberger refined and popularized the Messerklinger technique globally. His key contributions:
  • Emphasized the importance of mucociliary transport patterns and the role of OMC obstruction in sinus pathogenesis
  • Stressed that surgery should be targeted, minimally traumatic, and aimed at restoring physiological drainage - not radical mucosa removal
  • Advocated meticulous preservation of the middle turbinate and mucosa

Kennedy Modification (United States)

David Kennedy introduced FESS to the USA and added:
  • The term "Functional Endoscopic Sinus Surgery"
  • A more systematic, stepwise approach emphasizing endoscopic visualization with a camera monitor system (rather than looking directly through the scope)
  • Emphasis on wide surgical corridors and image-guided surgery

Balloon Sinusotomy (Modern Addition)

A newer technique where a balloon catheter is passed into a sinus ostium over a guidewire and inflated to dilate the natural ostium without tissue removal.
  • Can be used for maxillary, frontal, or sphenoid ostia
  • "Hybrid procedure" when combined with conventional FESS
  • Best for mild-moderate disease without polyps or fungal sinusitis
  • Avoids mucosal trauma and may reduce scarring
  • Contraindicated if there are skull base or orbital dehiscences
(- Cummings Otolaryngology Head and Neck Surgery)

Basic Steps of FESS (Universal Sequence)

From Cummings Otolaryngology (Box 44.4):
  1. Patient positioning (reverse Trendelenburg 10-20 degrees, head turned to surgeon)
  2. CT review (mandatory - always displayed during surgery)
  3. Diagnostic nasal endoscopy + topical anesthetic injections
  4. Medialization of middle turbinate to expose the OMC (optional basal lamella relaxing incision)
  5. Uncinectomy with 0-degree endoscope
  6. Maxillary antrostomy - 30 or 45 degree scope; identify floor of orbit, follow medially to lamina papyracea
  7. Removal of ethmoid bulla; identify lamina papyracea in its medial wall
  8. Identify basal lamella (horizontal + oblique segments)
  9. Perforate inferomedial basal lamella → enter posterior ethmoid
  10. Ethmoidectomy - stay low, between superior turbinate medially and lamina papyracea laterally
  11. Frontal recess dissection (Draf I / II / III as needed)
  12. Sphenoidotomy if indicated
  13. Middle turbinate management (preserve as default; partial resection in severe polyposis only)

Intraoperative Anesthesia and Vasoconstriction

  • Pledgets soaked in cocaine/adrenaline (Moffat's solution), co-phenylcaine, or oxymetazoline
  • Injection of 1% lidocaine with 1:80,000-1:100,000 adrenaline into the axilla of the middle turbinate, septum, and lateral nasal wall
  • Greater palatine block - reduces posterior sinonasal bleeding during posterior ethmoidectomy and sphenoidotomy (38.3% reduction in nasal blood flow with head elevation vs. only 4.7% from palatine injection)
  • Allow vasoconstrictors time to work before cutting; systemic epinephrine effects (tachycardia, brief worsening of field) dissipate before mucosal vasoconstriction peaks
(- Scott-Brown's Otorhinolaryngology Head and Neck Surgery, Vol 1)

FESS Complications

Complications are classified as major (serious) and minor, and by timing (intraoperative vs. postoperative).

Major Complications

1. Orbital Complications

The lamina papyracea (paper-thin orbital wall) is at immediate risk during ethmoidectomy.
ComplicationMechanismRecognitionManagement
Orbital fat herniationBreach of lamina papyraceaFat appears in surgical fieldStop surgery, no further manipulation; observe
Medial rectus injuryDirect trauma during ethmoidectomyProlapse of muscle into fieldUrgent ophthalmology; may cause permanent diplopia
Orbital haematomaBleeding into orbital compartmentProptosis, periorbital ecchymosis, loss of pupil reactivitySurgical emergency - lateral canthotomy + cantholysis; decompression
Blindness / Vision lossOptic nerve trauma or vascular injuryLoss of light perceptionOphthalmic emergency; prognosis often poor
Intraoperative warning signs of orbital involvement:
  • Resistance to microdebrider that changes with eye pressure (pressing the globe increases resistance)
  • Swelling of the eyelid or medial canthus
  • Herniation of fat into the field
Prevention: Always identify the lamina papyracea before removing ethmoid cells. Respect its medial border.

2. CSF Leak / Skull Base Breach

The skull base (fovea ethmoidalis and cribriform plate) is a risk during ethmoidectomy. The cribriform is the lowest point and most vulnerable.
  • Cause: Instrument directed superiorly into the skull base; confusion of skull base with ethmoid partitions; blind use of microdebrider superiorly
  • Recognition: Clear watery fluid, "halo sign" on pledgets, positive beta-2-transferrin
  • Complication of CSF leak: Ascending meningitis, pneumocephalus
  • Management: Small dural tears may be repaired endoscopically with fat/fascia/mucosal grafts and fibrin glue. Large tears may require intracranial repair.
  • Prevention: Always perforate the basal lamella in the inferomedial quadrant. Stay low. Review skull base height and asymmetry on preoperative CT (Keros classification of olfactory fossa depth).
(- Bailey and Love's Short Practice of Surgery; Scott-Brown's)

3. Intracranial Complications

More severe extensions of skull base injury:
  • Meningitis - from CSF leak with contamination
  • Encephalocele / Meningoencephalocele - herniation of brain tissue through dural defect
  • Intracranial haemorrhage - from anterior or posterior ethmoidal artery injury with retraction

4. Ethmoidal Artery Injury

  • Anterior ethmoidal artery - runs in the supraorbital recess, occasionally within the anterior wall of the ethmoid bulla (can be injured by microdebrider superiorly)
  • Posterior ethmoidal artery - lies close to the optic nerve
  • Risk: If the artery retracts into the orbit, it can cause an orbital haematoma - a surgical emergency
  • Prevention: Identify and avoid the artery; do not blindly use the microdebrider superiorly

Minor / Less Severe Complications

5. Haemorrhage (Intraoperative / Postoperative)

  • Most common complication
  • Sources: anterior ethmoidal artery, sphenopalatine artery, septal branches
  • Management: Bipolar diathermy, hemostatic agents (Surgicel, Gelfoam), nasal packing
  • Prevention: Adequate vasoconstriction, controlled hypotension under GA, head-up position, meticulous technique

6. Synechia (Adhesions)

  • Middle turbinate lateralizes and adheres to lateral nasal wall → blocks drainage
  • Most common cause of surgical failure and need for revision
  • Prevention: Preserve middle turbinate attachment, use spacers/stents, meticulous postoperative debridement
  • Management: Division in clinic/office under local anesthesia during follow-up

7. Middle Turbinate Destabilization / Loss

  • Aggressive manipulation → fracture at the skull base, lateralization, or loss of the turbinate
  • Prevention: Gentle medialization; if relaxing incision performed, do it under direct vision

8. Anosmia / Hyposmia

  • Injury to olfactory epithelium (roof of olfactory cleft, cribriform area)
  • Can be temporary (mucosal edema) or permanent
  • Prevention: Avoid manipulation of the olfactory cleft roof; preserve mucosa

9. Nasolacrimal Duct Injury

  • During uncinectomy, if the bone anterior to the uncinate (lacrimal bone) is breached
  • Presentation: Epiphora (watering eye)
  • Prevention: Retrograde uncinectomy stops at the "anterior maxillary line" (junction of uncinate with lacrimal bone). Penetrating harder lacrimal bone = warning sign.

10. Optic Nerve Injury (Onodi Cell)

  • An Onodi cell (posterior ethmoid cell) may pneumatize around the optic nerve
  • Unrecognized Onodi cell → drilling or instrumentation directly on the optic nerve
  • Prevention: Preoperative CT identification of Onodi cells; always know exact location in posterior ethmoid
(- Scott-Brown's Otorhinolaryngology Head and Neck Surgery)

11. Infection / Toxic Shock Syndrome

  • Rare but serious
  • Can occur postoperatively, especially with packing
  • Prevention: Remove packing within 24-48 hours; perioperative antibiotics in active infection

12. Persistent/Recurrent Sinusitis

  • Due to incomplete surgery, scarring, synechia, or residual disease
  • Most common "complication" in functional terms
  • Requires thorough postoperative care: saline irrigations, topical steroids, office debridement

Intraoperative Orbital Haematoma - Emergency Protocol

This is the most feared acute complication:
  1. Immediately stop the surgical procedure
  2. Reverse any controlled hypotension
  3. Assess eye: increasing proptosis, chemosis, loss of pupillary reaction, visual loss
  4. Lateral canthotomy and inferior cantholysis - bedside decompression (within minutes)
  5. IV mannitol and IV dexamethasone
  6. Emergent ophthalmology consult
  7. Formal orbital decompression if no improvement

Summary of Complications by Category

CategoryExamples
OrbitalHaematoma, fat herniation, medial rectus injury, blindness
IntracranialCSF leak, meningitis, encephalocele, haemorrhage
VascularEthmoidal artery injury, epistaxis
FunctionalSynechia, restenosis, anosmia, epiphora
StructuralMiddle turbinate destabilization, nasolacrimal injury
InfectiveToxic shock syndrome, meningitis
Sources:
  • Cummings Otolaryngology Head and Neck Surgery - Chapter 44 (Basic Techniques: Messerklinger and Wigand)
  • Scott-Brown's Otorhinolaryngology Head and Neck Surgery Vol 1 - Chapter on FESS for rhinosinusitis
  • Bailey and Love's Short Practice of Surgery 28th Ed. - Chapter 51 (Management of CRS/polyps)
Middle meatal antrostomy during FESS - widened natural ostium of maxillary sinus
Intraoperative endoscopic view of a middle meatal antrostomy during FESS showing the widened natural ostium of the maxillary sinus after uncinectomy
Orbital bulge during revision ESS showing relationship of lamina papyracea to ethmoid cavity
Endoscopic view during revision ESS showing the medial orbital wall (lamina papyracea, LP) and middle turbinate (MT) - the white arrow demonstrates orbital bulging when pressure is applied, a sign of orbital involvement
This is a shared conversation. Sign in to Orris to start your own chat.