1. ENDOSCOPIC SINUS SURGERY Bakhshaee M, MD Rhinologist, Assistant Prof. MUMS

2. Course Plan Principles of Practice Patient Selection Optimizing Diagnosis, Medical Treatment, and Timing of Surgery Goals of Surgery in Patients with Rhinosinusitis Operative Procedures: A Step-by-Step Safe and Logical Approach Endoscopic Examination, Anatomical Variations, and Specific Conditions The Place of Radiology Preoperative Checklist Patient Consent and Information Preventing and Dealing with Complications Postoperative Management

3. Principles of Practice

4.  Accurate Diagnosis Is the Key to Success  A good surgeon is also a good physician  The best surgical results are often obtained by optimizing medical treatment both preoperatively and postoperatively.  Optimizing medical treatment before surgery makes it less traumatic, reduces the chances of complications, and helps preserve olfactory mucosa

5. Before TreatmentAfter Treatment

6. Mucosal Disease The surgeon needs to have a good understanding of mucosal disease 1. Erythema 2. Edema 3. Hyperplastic mucosa 4. Polyposis 5. Granular mucosa 6. Purulent secretion 7. Dry mucosa

7. Idiopathic rhinitis with erythema Hyperplastic mucosa due to allergic rhinitis

8. Severe hypertrophy with edema Polyposis in a nonatopic patient

9. Granular mucosaDry mucosa

10. Underlying pathology  In the light of history and examination, along with the relevant special investigations, the physician can obtain an idea of the underlying pathology.

11. Normal middle meatus Serous secretions in marked allergic rhinitis

12. Purulent bacterial secretions Purulent fungal secretions

13. Pathology of rhinosinusitis Infectious 1. Viral 2. Bacterial (including TB, leprosy, syphilis, etc.) 3. Fungal Noninfectious 1. Allergy [Seasonal (intermittent) Perennial (persistent)] 2. Idiopathic (no systemic evidence of allergy or local infection) 3. Rhinitis medicamentosa ( Excessive use of local sympathomimetic agents) 4. Hormonal ( High-estrogen contraceptive pill; pregnancy) 5. Autonomic 6. Sarcoidosis 7. Vasculitis (Wegener granulomatosis, systemic lupus erythematosis, overlap syndrome) 8. Drug induced

14. Focus on the Patient’s Main Complaint There are four primary symptoms that are always worth asking about: 1. Nasal obstruction 2. Sense of smell 3. Secretions 4. Pain or pressure

15. The amount of secretions produced per day

16. Dealing with the Patient’s Expectations The patient’s priorities may differ from what the surgeon can achieve. For example, the patient’s main concern might be their postnasal discharge, but the surgeon may only be able to improve the symptoms of obstruction with little alteration to the postnasal drip.

17. Optimize Medical Treatment Medical treatment 1. Will complement surgery in making the mucosa as healthy as possible 2. Can be a useful predictor of what can be achieved by surgery

18. Tailor the Surgery to Fit the Extent of the Problem There is a price to be paid for extensive tissue removal. That price may include : 1. The loss of olfactory mucosa 2. Frontonasal stenosis 3. Altered sensation 4. Dryness 5. An increased risk of violating the boundaries of the paranasal sinuses

19. Minimize Surgical Morbidity  Morbidity can be caused by poor surgical technique, but it can also arise from excessive tissue removal.  Good surgical technique is based on setting explicit goals and achieving these with the minimal amount of tissue trauma

20. Overzealous removal

21. How Can This Be Achieved? You must decide which step needs to be done next and then do this as less traumatically as possible. This means: 1. Punching tissue rather than tearing it 2. Preserving mucosal integrity in the frontonasal recess. 3. Respecting olfactory mucosa 4. Avoiding mucosal damage to adjacent surfaces

22. Sense of Smell Should Be Preserved at All Costs  Surgeons unfortunately often underestimate the importance of sense of smell to the patients

23. The Importance of Postoperative Treatment  Unfortunately, surgery on its own cannot achieve or maintain healthy nasal mucosa in most patients with noninfective rhinosinusitis.  Patients need to be made aware of the need for continuing treatment in order to achieve the best possible result and an improved quality of life