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term studies were recommended to more accurately identify patients who would benefit from the procedures as well as to determine if balloon sinuplasty alone would provide a better outcome as compared with functional endoscopic sinus surgery. II. Criteria: CWQI HCS-0158X A. Sinus surgery is requested for 1 or more of the following: a. Functional endoscopic sinus surgery (FESS) is indicated for 1 or more of the following: i. Suspected allergic fungal sinusitis with evidence of disease by CT imaging that indicates but not limited to ALL of the following: 1. Nasal polyposis 2. Eosinophilic mucus Moda Health Medical Necessity Criteria Sinus Surgery Page 8/8 3. Computerized Tomographic (CT) scanning consistent with ARS (e.g. bony erosion or thinning, partial or complete opacification) ii. Antrochoanal polyp documented by CT imaging iii. Cerebrospinal fluid (CSF) rhinorrhea or conditions in which there is a skull base defect iv. Chronic rhino-sinusitis (with or without nasal polyps) with all of the following; 1. Lasted longer than 12 weeks 2. Persistent symptoms that have failed maximal medical treatment such as saline irrigations, antibiotics therapy, and intra-nasal corticosteroids 3. Objective evidence of disease by CT imaging as evidenced by ostial obstruction or infection (e.g. but not limited to, air fluid levels, air bubbles, mucosal thickening, pansinusitis or diffuse opacification) v. Complications of sinusitis, including abscess (brain and sub-periosteal) and extension to adjacent structures vi. Endonasal endoscopic hypophysectomy for pituitary adenoma vii. Endoscopic orbital decompression for Graves ophthalmopathy, with or without optic nerve decompression viii. Para-nasal sinus mucocele documented by CT imaging (excluding benign, asymptomatic mucus retention cysts) ix. Recurrent acute rhino-sinusitis (RARS) with all of the following; 1. Two or more of the following symptoms a. Nasal obstruction b. Headache, pressure, facial pain (other causes have been ruled oendoscopic sinus surgery in management of light and severe chronic rhinosinusitis of the frontal sinus: a multicenter 6 prospective randomized study. Eur Rev Med Pharmacol Sci. J Purpose of Review To discuss strategies to avoid, identify and deal with both minor and major complications, as well as indications for revision sinus surgery. Recent Findings Complication rates from endoscopic sinus surgery are low and have improved with increased surgical experience and new technology. Early extensive surgery in patients with complex sinonasal disease can improve long-term outcomes. Summary A majority of patients undergoing endoscopic sinus surgery have a positive outcome. The surgeon must be competent in recognising and dealing with potential complications, as well as approaching complex revision cases. Introduction Functional endoscopic sinus surgery (FESS) is one of the commonest procedures performed by a rhinologist. Over 250,000 FESS cases are performed annually in the USA alone, the majority for chronic rhinosinusitis with or without nasal polyposis [1]. Complication rates have reduced as training, experience and comfort with endoscopes and powered instruments have increased. In experienced hands, minor complication rates of 5% and major complication rates below 1% are cited [2,3,4]. While the majority of patients undergoing FESS will require a single operation, 10–19% of patients will require revision surgery [5,6,7]. We discuss strategies to avoid, identify and deal with both minor and major complications, as well as indications for revision sinus surgery. Anatomy The FESS surgeon must have an intricate understanding of sinonasal anatomy, including potential physiological and pathological variations. This knowledge can then be applied to the individual patient’s pathology. High-resolution computed tomography (CT) of the paranasal sinuses with triplanar reconstructions is accepted as the minimum standard for visualisation of sinonasal disease. The CLOSE mnemonic is a well-known adjunct (Table 1, reprinted with permission from [8]) for assessing CT scans for potential surgical pitfalls [8]. Nevertheless, the surgeon must be prepared to encounter unexpected pathology during surgery, especially if there has been a delay between the CT scan and FESS [9]. CLOSE mnemonic to assess for anatomical abnormalities during FESS Experience As with all surgical skills, there is a “learning curve” associated with FESS. The FESS surgeon should be competent with undertaking emergency procedures to stabilise patients and rectify acute complications such as intra-orbital haematoma. Trainees should participate in cadaveric dissection courses and then perform diagnostic endoscopic procedures, allowing them to become comfortable with the endoscope, camera, orientation
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