 Namaste everyone. I am Dr. Jayanthi Shastri, ENT head and neck surgeon, Manipal Hospital, Maleshwaram, Bangalore. Today I would like to speak about functional endoscopic sinus surgery. Actually I would like to go through what it is done for and what are the symptoms for which the patient should approaches for this surgery and everything. To begin with let me explain what are sinuses. Sinuses are air spaces in the skull. There are four sets of sinuses sphenoid sinus, frontal sinus, ethmoidal sinus and maxillary sinus. So they are connected to the nose through small meia tie. Meia tie means there are small holes in the nose which connect these sinuses to the nose. The importance of these sinuses are that they are supposed to make the lead light weighted and also it helps in the keeping the nose moist because it keeps producing the sinus linings keeps producing mucus which keeps the nose moist which is very important to protect the body against bacteria and other pollutants. Also it helps in these sinuses help in a particular circular motion of the mucus so that everything is thrown out through the holes in the nose. They are called meia tie. So now let me tell you what is sinusitis. Sinusitis means blocked inflamed or infected sinuses are called sinusitis. You can see in the picture that on the left side there is inflamed sinus on the right side it is a healthy sinus. This is a schematic diagram of the face which shows the different sinuses. What are the symptoms of sinusitis? First of all there is discharge from the nose or it can be from the posterior end of the nose into the throat. This is called post nasal drip. What happens with the post nasal drip is that it irritates the throat and hence the patient may have a hacking cough. Hacking cough in the sense it may be a dry cough which is a very irritating cough. The next symptom is this nasal congestion. What will happen? The lining of the nose gets swollen and there is inflammation in the lining of the nose and there is collection of mucus because of which there is a lot of nasal congestion. That means to say there is a kind of a blockage in the nose and there is pain and tenderness. As shown in the picture it is the pain and tenderness is in this area normally. That is because the congested nose actually causes pressure on the nerves of the nose surrounding nerves and thus causes pain in these areas. Then comes dizziness. Dizziness is because one thing is that the mucus is collected in the sinuses and hence the face becomes heavy and when you lift the face sometimes the patient can go off balance. That is one of the reasons. The second reason is that there is a congestion in the tube running between nose and the ear called the eustachian tube which in turn causes negative pressure in the ear causing there is a balancing apparatus in the ear which balances our body. The pressure is in turn exerted on that hence there can be a loss of balance. Then comes headache. Why congestion and inflammation actually causes the muscles around the head to tighten up and that is the reason why there will be headache. There is decreased sense of smell because as such as I said the lining of the nose is all swollen up so the smell sensation is difficult to reach the nerves in the which is present at the root of the nose and hence there can be a loss of sense of smell. So if there is loss of sense of smell there will be loss of sense of taste also because it will be salt and sweet can be tasted but there will be a kind of a bland flat taste to the food during this time. Bad breath. There can be bad breath because the patient basically because of the nasal blockage he breathes through the mouth and that is one of the reasons for the bad breath. The other reason is there is collection of mucus in the sinuses in which the bacteria grows that can cause also bad breath. Also there can be sometimes fungal infection in this mucus which is especially true in a patient who has diabetes and that is actually an emergency to do FES also functional endoscopic sinus surgery. I will come to it later and also because of the post nasal drip there can be a foul odor from the mouth. Then there will be a normally there will be a low grade fever in acute infections just when there is when the infection starts there will be a low grade fever and because as I said cough because of the post nasal drip there can be a hacking cough in this patients. Fatigue that is another very important symptom because one thing is there won't be proper sleep because of the nasal blockage and the patient will be breathing through the mouth because of that and also there will be a loss of appetite because of which the patient will be very fatigued and because of the infection itself that bacteria and virus would have worn out the patient so much that they will be feeling tired always. So what are the few causes I am just eliminating a few causes of the sinusitis these are for because of mechanical obstruction I am just telling you about the mechanical obstruction. As you can see in the first picture there is a deviated nasal septum that is DNS I have written there is a deviated nasal septum to the right. In this case what happens the septum actually goes and occludes that area where the sinus opens and hence there will be collection of mucus in that area and causes sinusitis. The second picture you can see there is a hypertrophied inferior turbinate. The inferior turbinate is there are three turbinates first of all in the nose there are three turbinates superior middle and inferior. The inferior turbinate is the one which actually is exposed to all the allergens and things like that on the pollutants. So when an allergen settles on it slowly to kill the allergen it will start increasing in size. So in people who have a lot of allergy the inferior turbinate would have increased in size so much key that it will be blocking the nose in such a way that it also will block the entrance to the sinuses and hence causes sinusitis. And in people who have a lot of allergy what happens the sinus linings they will start becoming so thickened that they will start protruding out of the holes in the between the nose and the sinuses and cause something like a bunch of grips it will appear like like the third picture which shows it is called the nasal polyp. So all these things can actually be the cause of sinusitis it develops into a chronic sinusitis that means to say a sinusitis which is lasting for more than three months or recurrent sinusitis that means to say at least four or five attacks of sinusitis in one year. So when this happens what we should do so first of all when the patient comes to us we take a proper history asking how many times how many attacks in a year and how long does the attack stay and how sick is the patient will he be able to work or not work and what is his sleep pattern during this time whether he will be able to sleep well or not or is this disturbing his sleep and is there any snoring and we take all this history and finally do the examination. When I do an examination first of all a simple examination of the nose which tells us whether there is any deviated nasal septum whether there is any hypertrophied inferior turbinates whether there is any nasal polyps or any allergic rhinitis allergic rhinitis means we can make it out with the help of these turbinates as I said it would have swollen and there will be a pale mucosa and things like that. Also in children and we look for adenoid hypertrophy. Adenoid is a gland which is present behind the nose and it enlarges in size and it is present up to 13 years of age. It enlarges in size and causes occlusion of the airway. So many patients which are operated when they are even 16 17 years many times you can find this adenoids and at that time when we operate for the nose deviation and things like that we also remove the adenoids so that extra blockage problem will not be there. So after doing this basic examination then we go ahead with the diagnostic endoscopy. As shown in the picture the diagnostic endoscopy consists of an endoscope cable light cable camera and a monitor. So with the help of and in it is an office procedure with diagnostic endoscopy is an office procedure wherein we introduce about 10% xylokene into the nose and then after making the patient comfortable we introduce an endoscope into the nose and monitor it on the see it on the monitor and check out for all this whatever I said DNS nasal polyps and things like that which is leading on to this kind of acute sinusitis. So when we find out that this is an acute sinusitis and it is not a very long term long standing case that time we give treatment with medications like antibiotics, antihistaminics, decongestants and sometimes mild steroids, a few nasal sprays etc these things are the basic treatment. When the patient does not respond to this medical line of treatment then what do we have to do? If we repeated medical line of treatment maybe two or three times if it the patient is not responding then we go ahead and do a further investigation called CT scan of the paranesal sinuses. This CT scan is taken in three planes that is the coronal plane, axial plane and the sagittal plane as shown in the picture. In the coronal plane you can see in this picture that the right sided sinus is completely filled and the left side is free. So also in this axial picture also you can see one sinus is filled and one sinus is free. In the sagittal picture you can see that all the sinuses are free. So this is how we correlate how the sinusitis is and where all it is present and depending on that we will have to go ahead with the surgery. So now in some cases before going to FESS before telling you that in all cases we cannot do a medical line of treatment because especially in patients with diabetes and who are having fungal sinusitis an immediate surgery is required or sometimes even with bacterial sinusitis which is threatening to open into the eyes or into the brain then also immediate surgery is required. So now let me tell you what is FESS? FESS it started in the early 1990s. It is called functional endoscopic sinus surgery. It is a minimally invasive surgery and it is effective in removing all these obstructions. As I said we can do septoplasty that is straightening of the septum. We can remove the polyps and we can open up the sinuses to remove all the deceased mucosa and things like that with the help of this one without opening from outside. So how is it done? The instruments required as shown in the picture those the OT setup will be like this and the doctor is standing the patient is lying down the doctor stands on the right side and introduces the nasal endoscope into the nose and with the help of the camera the whole picture appears on the monitor and seeing the monitor we actually operate in the nose. So actually there won't be any outside incisions or scars or anything of that sort. The instrument set you can see on the other side is a very precise tiny instruments which go into the nose to remove all this unwanted disease. Recovery phase the patient will have a minimal swelling and mild to and pain for about week or so there will be mild congestion in the nose and the patient will be discharged normally on the same day of the surgery. Sometimes if the patient is tried on the next day and within 15-20 days almost the patient will be able to breathe well and most of them can resume duty within a week. So what is the benefits of this surgery? It is a minimally invasive surgery. It is has got long lasting results. It has minimal pain nose scar on the nose and there is little or no post surgical bleeding that is after surgery there may be little bleeding but not much and the there is less tissue removal. By less tissue removal I mean to say we don't remove the normal tissues we remove only the diseased tissue. So that is a big advantage in this kind of surgery. So thank you you can see a plate filled with food there. If you want to taste the food nicely having with aroma then getting rid of the sinus disease is very very important. If you have any questions regarding the talk I just now give you can put it in the comment box. I will try to answer that and if you like this talk you can share it to others so that others also will be benefited and if you follow our Manipal Hospital page we can meet in further sessions like this. Thank you.