Functional Endoscopic Sinus Surgery & Conventional Sinus Surgery in Inflammatory Sinonasal Diseases

Background: Functional endoscopic sinus surgery is a minimally invasive technique used to restore sinus ventilation and normal function. The most suitable candidates for this procedure have recurrent acute or chronic infective sinusitis, and an improvement in symptoms of up to 90 per cent may be expected following the procedure. Objective: The study has been designed to compare the clinical outcome of functional endoscopic sinus surgery and conventional surgery in the management of inflammatory sinonasal diseases. Study design: This was a prospective study. A combine of both quantitative and qualitative methods was used in conducting the study. Method: Here, a survey method was used to obtain quantitative data from the patients and complication of the operation was observed to obtain qualitative data. Data was collected from a sample that was determined through a semi-purposive method. Results: In the series 9% had synaechia during post operative period and it was 3.3% for FESS and 26.7% for conventional surgery. FESS procedure shows better relief of obstruction, better pain relief and quicker relief of clot than Conventional surgery. In FESS, 56.7% patients reported complete recovery and 43.3% were found symptoms free while in conventional surgery only very few of the patients reported complete recovery. and rest of the patients (93.3%) were symptoms free. Conclusion: The study had shown significant benefits from FESS over conventional surgery. 1. Junior Consultant, ENT & Head-Neck Surgery Deptt. Shaheed, Suhrawardy Medical College Hospital, Dhaka-1207 2. RS (ENT), Shaheed Suhrawardy Medical College Hospital 3. Assistant Director (Research), Bangladesh Institute of Research for Promotion of Essential & Reproductive Health and Technologies (BIRPERHT) 3. United Hospital, Dhaka, Functional Endoscopic Sinus Surgery & Conventional Sinus Surgery in Inflammatory Sino Nasal Diseases Address of Correspondence: Dr. A K M Shaif Uddin, Junior Consultant, ENT & Head-Neck Surgery Deptt. Shaheed, Suhrawardy Medical College Hospital, Dhaka-1207 Introduction Inflammatory sinonasal diseases are common and well recognized clinical syndrome affecting patient of all ages and gender. Medical treatment is first choice of management. Surgical treatment usually done in those cases who are refractory to medical treatment. Cases of chronic sinus infection, nasal polyps, headache, nasal stuffiness and post nasal discharge are quite common. Severe nasal obstruction was perceived within sixty percent of the study populations before surgery. Twenty percent suffered from moderate type of nasal obstruction and rest of them had mild nasal obstruction before operation. Concerning preoperative nasal discharge, 60% reported about moderate type of nasal discharge before surgery and a very few of them complained of severe nasal discharge. However 38% had mild type of nasal discharge. Before surgery nearly 57% patients were suffering from moderate type of anosmia and one-fourth had severe anosmia. However, 18.3% had mild anosmia before surgery. Among the patients 65% had the symptoms of moderate headache before surgery and 25% patients were suffering from severe headache. Mild headache was reported by 10% patients before surgery. A recent, new and revolutionary method known as Nasal Endoscopy and Functional Endoscopic Sinus Surgery (FESS) is now available, both for early and precise diagnosis and treatment. The old myth that sinus infections are not curable needs to be changed now with the availability of endoscopic sinus surgery. Hardly there is any cavity in the body, which had remained unexplored in the present era of endoscopies. The hidden areas inside nose can be precisely visualized, assessed and effectively treated with the help of nasal telescopes. The state of art of new technology of endoscopic sinus surgery is very significant contribution in the recent times to cure sinusitis and nasal polyps & sinus headaches1 .The aim of the endoscopic sinus surgery is to clear the polyps and diseased ethmoid cells to reestablish ventilation and drainage of the frontal, sphenoid and maxillary sinuses through their enlarged passages. The polyps from nasal cavity and from all the involved sinuses can be removed endoscopically. Endoscopic surgery is performed under Local Anaesthesia or General Anaesthesia. Many anatomical variations in the nasal cavity will predispose to recurrence of disease in the sinuses e.g. concha bullosa, deviated nasal septum, enlarged uncinate process etc. In these cases Endoscopic Sinus Surgery becomes essential. Throughout history, results form paranasal sinus surgery have been far from satisfactory. This is because of the impossibility of re-establishing anatomophysiological normality when using an external approach and in the case of endonasal surgery, because of the great difficulty in doing it with an adequate light2. The theoretic principles of FESS, and the detailed diagnostic and anatomic information about the ostiomeatal complex may be beneficially applied to the general management of patient with sinusitis. Thus principles have application both in the medical management of patients and in nonedoscopic surgical techniques3.The concepts of FESS differ considerably from those of the more traditional technique. Functional techniques in contrast, stress the crucial role of sinus obstruction in the pathogenesis of sinusitis4. The restoration of ventilation and the reestablishment of mucociliary clearance are considered key to the resolution of disease and maintenance of healthy sinus mucosa5. The surgery is therefore aimed at the removal of obstruction within the ostiomeatal complex. The aim of the study, is to establish the clinical and medical results achieved with the use of FESS and comparing them with the results from traditional surgical procedures in the management of inflammatory sinonasal diseases. Methods This comparative study was carried out at the Department of Otolaryngology and Head 9 Functional Endoscopic Sinus Surgery & Conventional Sinus Surgery AKM Shaif Uddin et al


Introduction
Inflammatory sinonasal diseases are common and well recognized clinical syndrome affecting patient of all ages and gender.Medical treatment is first choice of management.Surgical treatment usually done in those cases who are refractory to medical treatment.Cases of chronic sinus infection, nasal polyps, headache, nasal stuffiness and post nasal discharge are quite common.Severe nasal obstruction was perceived within sixty percent of the study populations before surgery.Twenty percent suffered from moderate type of nasal obstruction and rest of them had mild nasal obstruction before operation.Concerning preoperative nasal discharge, 60% reported about moderate type of nasal discharge before surgery and a very few of them complained of severe nasal discharge.However 38% had mild type of nasal discharge.Before surgery nearly 57% patients were suffering from moderate type of anosmia and one-fourth had severe anosmia.However, 18.3% had mild anosmia before surgery.Among the patients 65% had the symptoms of moderate headache before surgery and 25% patients were suffering from severe headache.Mild headache was reported by 10% patients before surgery.
A recent, new and revolutionary method known as Nasal Endoscopy and Functional Endoscopic Sinus Surgery (FESS) is now available, both for early and precise diagnosis and treatment.The old myth that sinus infections are not curable needs to be changed now with the availability of endoscopic sinus surgery.Hardly there is any cavity in the body, which had remained unexplored in the present era of endoscopies.The hidden areas inside nose can be precisely visualized, assessed and effectively treated with the help of nasal telescopes.The state of art of new technology of endoscopic sinus surgery is very significant contribution in the recent times to cure sinusitis and nasal polyps & sinus headaches 1 .The aim of the endoscopic sinus surgery is to clear the polyps and diseased ethmoid cells to reestablish ventilation and drainage of the frontal, sphenoid and maxillary sinuses through their enlarged passages.The polyps from nasal cavity and from all the involved sinuses can be removed endoscopically.
Endoscopic surgery is performed under Local Anaesthesia or General Anaesthesia.Many anatomical variations in the nasal cavity will predispose to recurrence of disease in the sinuses e.g.concha bullosa, deviated nasal septum, enlarged uncinate process etc.In these cases Endoscopic Sinus Surgery becomes essential.Throughout history, results form paranasal sinus surgery have been far from satisfactory.This is because of the impossibility of re-establishing anatomophysiological normality when using an external approach and in the case of endonasal surgery, because of the great difficulty in doing it with an adequate light 2 .The theoretic principles of FESS, and the detailed diagnostic and anatomic information about the ostiomeatal complex may be beneficially applied to the general management of patient with sinusitis.Thus principles have application both in the medical management of patients and in nonedoscopic surgical techniques 3 .The concepts of FESS differ considerably from those of the more traditional technique.Functional techniques in contrast, stress the crucial role of sinus obstruction in the pathogenesis of sinusitis 4 .The restoration of ventilation and the reestablishment of mucociliary clearance are considered key to the resolution of disease and maintenance of healthy sinus mucosa 5 .The surgery is therefore aimed at the removal of obstruction within the ostiomeatal complex.The aim of the study, is to establish the clinical and medical results achieved with the use of FESS and comparing them with the results from traditional surgical procedures in the management of inflammatory sinonasal diseases.

This comparative study was carried out at the Department of Otolaryngology and Head
Neck surgery of Dhaka Medical College Hospital, Dhaka between the period of November 2007 to October 2008.After obtaining approval from the Hospital Ethical Committee, a total of 60 patients having chronic sinusitis, antrochoanal and ethmoidal polyp were admitted for FEES and conventional surgery, matching the inclusion & exclusion criteria.
The data was recorded in a predesigned questionnaire in terms of demographic and clinical variables.Each of the patient admitted in the Hospital for FESS and conventional surgery and was followed up at 1 st postoperative day, at 7 th postoperative day and subsequently patient was followed up at 1 st month, 3 rd month and 6 th month.During each visit they were subjected to routine ENT examination such as intranasal examination.But special attention was given on important symptoms like crust, clot, orbital complication, nasal obstruction, CSF leakage etc.The subjective and objective evaluations were carried out by asking the patients whether the symptoms are present or not.
The data was analysed using Statistical Package for Social Science version 12 (SPSS 12.0).Mean and standard deviation for continuous variables was computed.Proportion & percentages were computed for categorical variables and a chi square test of significance was applied.A p-value of <0.05 was taken to be statistically significant.The results after FESS are good, with most studies reporting an 80 to 90 percent rate of success [6][7][8][9] .Good results also have been obtained in patients who have had previous sinus surgery.

Fig.-1: Age distribution of the respondents
The procedure is considered successful if the majority of the patient's symptoms are resolved.Nasal obstruction and facial pain are most likely to be relieved, although postnasal drip often remains a challenge.The technique has been compared with the Caldwell-Luc procedure and although both methods were found to be effective, there was a strong patient preference for FESS 10 .
Moreover when looking at our sample we noticed ,Post-operative period, only 6.7% patient complained of haemorrhage post operatively and majority (93.3%) had no haemorrhage in FESS.However in conventional surgery nearly 17.0% patient had haemorrhage at post operative period but 83.3% did not complain about haemorrhage.
In the study subjects, out of 60, 9% had synechia during post operative period and it

Conclusion
FESS and conventional surgery both are effective treatment for inflammatory sinonasal diseases which fails to respond to adequate medical treatment.This study reveal that FESS procedure had better relief of nasal obstruction, pain, crust and clot than conventional surgery.In the study, recurrence of the diseases was seen very few in FESS than conventional surgery.For the relief of subjective symptoms there appears to be a remarkable trend in favour of FESS.FESS as currently practiced is a safe surgical procedure.More randomized controlled trials comparing FESS with other treatments, with long term follow-up are required.

Table - I
Type of operation vs. Age of patients Symptomatic relief of symptoms after both type of surgery were observed among the patients but analytical data shows better relief of symptoms after FESS.

Table - II
Symptomatic relief of symptoms after both type of surgery Although by 2 nd follow up all the patients in both the groups clot disappeared, in FESS the relief was sharper.The study finding demonstrates quicker relief of clot in FESS than Conventional surgery.In FESS, 56.7% patients reported complete recovery and 43.3% were found symptoms free.While in conventional surgery only very few of the patients reported complete recovery and rest of the patients (93.3%) were symptoms free.