OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD &

NECK OPERATIVE SURGERY

BASIC FUNCTIONAL ENDOSCOPIC SINUS SURGERY (FESS): A STEP-BY-STEP

GUIDE WITH SURGICAL VIDEOS AND ILLUSTRATION OF ANATOMICAL
LANDMARKS IN CADAVERIC DISSECTION
Yves Brand and Narayanan Prepageran

Gate System of Paranasal Sinuses Gate 2 (Figure 1 B): The bulla ethmoidalis
is found posterior to the uncinate process
We consider four important landmarks in (B). The anterior wall of bulla ethmoidalis
basic FESS. These landmarks are important is the gate to the anterior ethmoid.
to gain entry to the maxillary sinus, anterior
ethmoid, posterior ethmoid and the sphe- Gate 3 (Figures B, C): The ground lamella
noid sinus. Each landmark serves as a gate of the middle turbinate separates the ante-
to a defined space within the paranasal rior from the posterior ethmoid (B, C). The
sinuses. This chapter presents an overview ground or basal lamella of the middle turbi-
to better understand this Gate System. nate is the gate to the posterior ethmoid.

Nasal decongestion (Figure 1 A)

To visualise the different structures of the

nose, the nasal cavity is decongested. This
can be done with cotton ribbon gauze soak-
ed in Moffat’s solution (1ml adrena-line
1:1000, 2mls 10% cocaine, 4mls 8.4%
sodium bicarbonate, 13mls water/saline) for
several minutes. Alternatively, adrenaline
1:1000-soaked cotton ribbon gauze can be
used. It is important to pack the middle
meatus under endoscopic vision (A).

Gate 1 (Figures 1 B, C): The uncinate pro-

cess is the gate to the maxillary sinus (B). Gate 4 (Figures 1 D-F): The anterior wall
Once the uncinate is removed the maxillary of the sphenoid sinus is the gate to the
sinus can be seen through its natural ostium sphenoid sinus. The natural ostium is loca-
(C) ted between the superior turbinate and the
septum (D, E). It can also be entered
through the posterior ethmoid (F)

What to look for in a CT scan before

performing FESS

CT scans give important information to the

surgeon and should be carefully analysed
prior to surgery. The scans should be in the
operating theatre during the entire proce-
dure to consult them whenever necessary.
Always check the name of the patient on the
scan.

We use the mnemonic “CLOSE” to identify

and memorise important structures on the
CT scan.

C Cribiform plate: How low down is

it?
Carotid artery: Identify it. Does it
have any impression/dehiscence into
the lateral walls of the sphenoid
sinus?
L Lateral lamella: How long does it
extend down?
Lamina papyracea: Is there any
dehiscence?
O Orbit: Any dehiscence and relation
to the maxillary sinus?
Onodi cell: Is there one present,
position of carotid and optic nerve?
S Sphenoid sinus: Identify optic nerve,
carotid artery, pituitary, and optic
nerve location
E Ethmoidal arteries: Location of
anterior and posterior ethmoidal
arteries

Figures 1 A-F: Decongestion & Gates 1-4

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Figures 6 A-F: Mnemonic “CLOSE” is
used to identify and memorise important
structures

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Important things before starting surgery

1. Obtain written consent prior to surgery.

It is important that the patient is aware
of the surgery and its risks
2. Make sure the patient is aware that
follow-up care and saline irrigation are
important after surgery
3. Check for medical conditions that con-
traindicate surgery. Check whether the
patient is taking any drugs (e.g. anticoa-
gulants) or has any allergies
4. Review the CT scans prior to surgery. Figure 2: Monitor placed so easily viewed
Be aware of important anatomical land- by surgeon
marks. It is mandatory to have the scans
displayed within the operating room in
case they need to be consulted during
the procedure
5. The intubation tube should not be in the
surgeon’s way
6. Insert a throat pack once the patient is
intubated. Remember to remove the
throat pack at the end of the procedure.
Therefore, the throat pack must be
clearly visible for the surgeon and the
anaesthetist
7. Position the patient’s head in a slightly
flexed position for basic FESS. This is
important to avoid injury to the skull Figure 3: Endoscope anchored at the dome
base which can more easily happen if of the nose
the head is in an extended position
8. The surgeon must maintain a comforta-
ble position to avoid fatigue and pain in
the back and/or shoulder. Some sur-
geons prefer to sit while others prefer to
stand during surgery
9. Place the monitor in a way that it can be
easily viewed by the surgeon (Figure 2)
10. For most procedures a 0° (or 30°) endo-
scope should be used. For the beginner
the use of a 0° endoscope is easier
11. Anchor the endoscope at the dome of
the nose and insert the instruments
below (Figures 3, 4)

Figure 4: Instruments passed below the

endoscope

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12. Only a few instruments are required to Endoscopic evaluation of the nose
perform basic FESS (Figure 5). Make (Figures 6 A-E)
sure the basic instruments are available:
Freer elevator, backbiting forceps, suc- It is important to systematically inspect the
tion, through-cutting Blakesley forceps. nose prior to surgery. We recommend (as
Bipolar cautery is useful to control suggested by Prof Stammberger) 3 passes
bleeding through the nasal cavity.
13. Powered instrumentation is a useful ad-
junct, but not a necessity • Decongest the nose
14. Always remember that the surgery can • Inspect the nose with either a 0° or 30°
be stopped if orientation is lost, and endoscope
surgery becomes dangerous. It is al- • First pass
ways safer to pack the nose, wait and o Pass the endoscope through the wi-
regain orientation than to risk injury dest nasal passage. This is usually
along the floor of the nose
o Inspect the choana, vomer, opening
of the eustachian tube and the naso-
pharynx
• Second pass
o Pass the endoscope between the sep-
tum and turbinates (middle and
superior)
o This allows visualisation of the
sphenoethmoidal recess, the ostium
of the sphenoid sinus between the
septum and the superior turbinate,
and the olfactory region
• Third pass
o In acute and chronic pathology of
the sinuses this is usually the most
important step of the endoscopic
evaluation of the nose
o To achieve adequate visualisation
gently push the middle turbinate
medially with a Freer elevator
o Take care not to fracture the middle
turbinate
o The attachment of the middle turbi-
nate with its ground lamella, the un-
cinate process and the bulla ethmoi-
dalis can be seen
o The natural ostium of the maxillary
sinus is obstructed by the uncinate
process is usually not visible
o If an ostium is visible, it is usually
Figure 5: Instruments for basic FESS
an accessory ostium or from prior
surgery

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Figures 6 A-F: Endoscopic evaluation of
the nose

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Gate 1: Uncinate Process - Anterograde
Approach (Figures 7 A-F)

Step 1
• Pack the middle meatus with Moffat’s
solution or 1:1000 adrenaline packing
• Take care not to injure the mucosa to
avoid bleeding
• Gently push the middle turbinate me-
dially

Step 2
• After removing the pack visualise the
uncinate process, ethmoid bulla, and
ground lamella of the middle turbinate
• Now focus on the first gate: the uncinate
process (A)

Step 3
• Gently palpate the uncinate process
with a Freer elevator
• The uncinate process is a thin bone that
can be gently moved
• The anterior border of the uncinate pro-
cess is the lacrimal crest. It is a hard
bone and is identified by palpation

Step 4
• Use a Freer elevator to incise the unci-
nate process (B)
• The incision is made from superiorly
just below the height of the origin of the
middle turbinate, to inferiorly to a level
below the inferior end of the middle
turbinate (B+C)

Step 5
• Use a through-cutting Blakesley to cut
the uncinate process inferiorly (D) and
superiorly (E)
• Remove the uncinate

Step 6
• Once the uncinate process is removed
the maxillary sinus comes into view (F)

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 Gate 1: Uncinate Process - Retrograde
and Powered Instrumentation (Figures 8
A-F)

Retrograde uncinectomy using backbiting

forceps
• With a narrow ostiomeatal complex the-
re is a risk of injuring the orbit by per-
forming an anterograde uncinectomy
• This can be avoided by using backbiting
forceps, using the same steps as descri-
bed above for the anterograde approach
• However, the forceps are inserted with
closed prongs (A)
• Then the prongs are opened (B) and
turned behind the uncinate process (C)
to cut the uncinate process (D)
• It is important to be aware that the dis-
section should not go too far anteriorly
to avoid injuring the lacrimal duct
• If resistance is felt, there is a risk of
injuring the lacrimal duct

Retrograde uncinectomy using powered

instrumentation
• Powered instrumentation can help to re-
move parts of the uncinate (E, F)
• Powered instrumentation is a very use-
ful tool in FESS as it cuts mucosa and
applies suction at the same time; this al-
lows fast tissue removal and reduces
bleeding
• Remove the uncinate process either in
an anterograde fashion or with the help
of backbiting forceps
• However, it should never be used blind-
ly as it can easily cause damage to the
orbit and/or skull base
• Therefore, it is vital to check the preope-
rative CT scans for dehiscences of the
Figures 7 A-F: Gate 1: Uncinate Process - lamina papyracea and the configuration
Anterograde Approach of the skull base

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Figures 8 A-D: Gate 1 - Retrograde
uncinectomy with backbiter

Figures 9 E, F: Gate 1 - Retrograde unci-

nectomy with powered instrumentation

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Gate 2: Ethmoid Bulla (Figures 10 A-F)

Step 1
• Pack the nose as described before to ob-
tain adequate haemostasis
• After the uncinectomy has been per-
formed the ethmoid bulla can be visua-
lised (A)

Step 2
• Enter the bulla ethmoidalis inferome-
dially
• This is the safest area to enter it and it is
away from the orbit and the skull base
(B, C)

Step 3
• Always make sure it is really an air cell
(D)

Step 4
• Remove the bulla ethmoidalis with
through-cutting instruments such as a
through-cutting Blakesley or a microde-
brider (E, F)
• This avoids tearing and stripping of the
mucosa and reduces bleeding

Step 5
• Do not go superior to the attachment of
the middle turbinate to avoid injury to
the skull base or the anterior ethmoidal
artery
• Be aware not to enter the orbit laterally
by injuring the lamina papyracea
• The floor and the medial wall of the
orbit can be seen through the ostium of
the maxillary sinus (D)

Step 6
• At the end of the dissection the next gate
is visualised: the ground lamella of the
middle turbinate (F)

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 Gate 3: Ground Lamella of Middle
Turbinate (Figures 11 A-F)

Step 1
• Pack the nose as described to obtain
haemostasis if required
• Visualise the ground lamella of the
middle turbinate (A, B)

Step 2
• There may be a small air space behind
the posterior aspect of the ethmoid bulla
• However, the ground lamella can also
be part of the posterior wall of the eth-
moid bulla

Step 3
• The ground lamella has a horizontal and
a vertical segment (B)
• The posterior ethmoid is entered at the
junction of the horizontal and vertical
segments of the ground lamella C)

Step 4
• To maintain a stable non-floppy middle
turbinate, it is important to preserve the
horizontal segment of the ground
lamella (D)
• If the entire ground lamella (vertical and
horizontal segments) is removed the
middle turbinate is no longer stable

Figures 10 A-F: Gate 2: Ethmoid Bulla

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 • The air cell is removed
• Vertical bony ledges can be removed
with the help of a Kerrison punch

Step 6
• Important landmarks are the superior
turbinate medially, the lamina papyra-
cea laterally, and the skull base with the
anterior and posterior ethmoidal arteries
superiorly
• The floor of the dissection is formed by
the horizontal lamella of the middle
turbinate (F)
• From the CT scan it is important to be
aware of the course of the optic nerve
and the carotid artery - especially if an
Onodi cell is present

Step 5
• The air cells of the posterior ethmoid are
usually larger and fewer in number than
Figures 11 A-F: Gate 3: Ground Lamella of
the anterior ethmoid (E)
middle turbinate
• Usually there is only a single air cell

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 • Be aware that below the natural ostium
runs a branch of the sphenopalatine
artery that can bled briskly if injured
• Its relation to the posterior ethmoidal
complex can be seen
Gate 4 - Sphenoid Sinus (Figures 12 A-F)

• Always visualise and enter the sphenoid

sinus through the natural osmium be-
tween the superior turbinate and the
septum
• Do not enter the sphenoid through the
posterior ethmoidal complex - this is
potentially dangerous
• Only once the sphenoid sinus is located
it can be entered through the posterior
ethmoidal complex

Step 1
• Study the anatomy of the sphenoid sinus
• Always check the CT scan for the
course of the optic nerve and carotid
artery
• (A) illustrates the sphenoid keel after
the mucoperichondrium of the septum
has been elevated at the posterior end of
the bony septum
• The natural ostia are superior and lateral
(This is just to illustrate anatomy and it
is not necessary to expose the sphenoid
keel to enter the sphenoid sinus in
FESS)

Step 2
• The natural ostium of the sphenoid si-
nus is located between the septum and
the superior turbinate (B)
• It is important to decongest the spheno-
ethmoidal recess to gain adequate
access using packing soaked in either
Moffat’s solution or adrenaline 1:1000

Step 3
• Once the sphenoid sinus is visualised
through its natural ostium (C) the ex-
tent of surgery needed can be deter-
mined

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Step 4
• If there is a need to open the sphenoid
sinus through the posterior ethmoidal
complex this can now be done once the
relations of the posterior ethmoidal
complex and the sphenoid sinus are Frontal Recess (Figures 13 A-D)
known (D-F)
Surgery of the frontal sinus is challenging.
In many cases, it is better not to touch the
frontal sinus during initial surgery and to
simply do an uncinectomy and anterior eth-
moidectomy to clear the outflow tract of the
frontal sinus.

We only highlight the main anatomical

landmarks of the frontal recess. A detailed
description of frontal sinus surgery is be-
yond the scope of this chapter.

Step 1
• An uncinectomy, anterior and posterior
ethmoidectomy has already been per-
formed (A)

Step 2
• The lateral landmark is the orbit (B)

Step 3
• This patient had an osteoma at the
region of the frontal recess
• The skull base is visualised, and the
anterior ethmoidal artery can be seen
(C)

Step 4
• The anterior ethmoidal artery is seen
posterior to the frontal recess (D)

Figures 12 A-F: Gate 4: Sphenoid sinus

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Figures 13 A-D: Frontal Recess

Endoscopic Septoplasty (Figures 14 A-F)

Endoscopic septoplasty may be required for

symptomatic septal deviation or to gain
access and space to perform FESS

Step 1
• Pack the nasal cavity with 1:1000 adre-
naline
• Infiltrate the nasal septum with
1:100000 - 1:200000 adrenaline
• Infiltration helps to dissect the muco-
perichondium off the cartilage in a sub-
perichondrial plane (A)

Step 2
• Bipolar cautery is applied at the site of
the planned incision to reduce bleeding
(B)

Step 3
• Incise the mucosa with a blade without
cutting into the septal cartilage (C)

Step 4
• Elevate the mucoperichondrium with a
Freer elevator (D)

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Step 5
• Remove the deviated part of the septum
with a Blakesley
• Always remember to leave a dorsal strut
of cartilage to maintain stability of the
nose (E)

Step 6
• Replace the mucosa
• We do not routinely suture the mucosa
• Pack the nose at the end of surgery

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 Step 4
• Remember that the middle turbinate can
attach to the skull base
• Therefore, the lateral part should be re-
moved gently not to cause a CSF leak

Step 5
• Always remember that the middle turbi-
nate is an important landmark and
should not be removed completely

Step 6
• Use bipolar cautery and adrenaline
packs to achieve haemostasis
Figures 14 A-F: Septoplasty • When haemostasis is achieved addition-
al surgery can be continued (D)

Concha Bullosa (Figures 15 A-D)

A concha bullosa is seen in the preoperative

CT scans. It can make access to the osteo-
meatal complex difficult and therefore
should be addressed before doing FESS if
necessary

Step 1
• Pack the middle meatus with 1:1000
adrenaline

Step 2
• Puncture and split the concha bullosa
(A-C)
• It is important not to disturb the medial
part of the middle turbinate as this area
contains important olfactory epithelium
and can disturb the patient’s olfaction

Step 3
• The lateral part of the middle turbinate
can be removed (C)
• This can be done with through-cutting
instruments or with a microdebrider

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 Step 1
• Pack the middle meatus with 1:1000
adrenaline-soaked gauze
• Medialise the middle turbinate
• In this case an uncinectomy had already
been performed; it is not mandatory (A)

Step 2
• Elevate mucoperiostium 1cm anterior to
the posterior attachment of the middle
turbinate (B)

Step 3
• Control bleeding during dissection by
packing with 1:1000 adrenaline and/or
cautery (C)

Step 4
• Identify the ethmoidal crest; this is the
landmark for the sphenopalatine artery
• Remember that there may be several
branches of the sphenopalatine artery
• Cauterise the vessel(s) (D)

Step 5
• Pack the area with Surgicel (E)
• Usually, the entire nose does not need to
be packed if the bleeding is controlled
Figures 15 A-D: Septoplasty by cautery (F)

Sphenopalatine Artery Ligation (Figure

16 A-F)

Minor epistaxis can be stopped by packing

the nose and/or washing with warm saline.
Visible shooters can be stopped by either
bipolar or monopoly cautery. Significant
posterior bleeding can arise from the
sphenopalatine artery. Below is a step-by-
step instruction to cauterise the spheno-
palatine artery.

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Cadaveric Dissection

Precise knowledge of the surgical anatomy

is the key for any surgical procedure. It is
important to know key landmarks. This also
holds true for FESS.

Cadaveric dissections are an excellent

learning tool to gain a detailed knowledge
of surgical anatomy. The embedded video
shows a complete transnasal endoscopic
cadaveric dissection of the paranasal
sinuses, orbit, and the skull base.

List of Surgical Videos

• Video 1: Gate System of Paranasal

Sinuses: https://youtu.be/xMsiRT12Cjs
• Video 2: Endoscopic Evaluation of the
Nose: https://youtu.be/ryp3QGeubtY
• Video 3: Gate 1 - Uncinate Process:
https://youtu.be/9JhZgAdz4wQ
• Video 4: Gate 2 - Ethmoid Bulla:
https://youtu.be/-vGY5WExf2A
• Video 5: Gate 3 - Ground Lamella of
the Middle Turbinate:
https://youtu.be/VAqp97XoBiA
• Video 6: Gate 4 - Sphenoid Sinus:
https://youtu.be/P0b3-4ICbPo
• Video 7: Frontal Recess:
https://youtu.be/q6cgNjhR4vU
• Video 8: Endoscopic Septoplasty:
https://youtu.be/VI-YcEDoYtU
• Video 9: Concha Bullosa:
https://youtu.be/S6MZbV3KYCU
• Video 10: Sphenopalatine Artery:
https://youtu.be/nVs82GdDWZA
• Video 11: Cadaveric Endoscopic
Dissection of Paranasal Sinuses, Orbit,
and Skull Base: https://youtu.be/-
m6HXkGUBJ8

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Authors

Yves Brand MD
Former Clinical Fellow, Department of
Otorhinolaryngology, University of
Malaya, Medical Centre, Kuala Lumpur,
Malaysia
Chairman, Department of
Otorhinolaryngology, Cantonal Hospital
Graubunden, Chur, Switzerland
Associate Professor, University of Basel,
Basel, Switzerland
yves.brand@ksgr.ch

Prof Dato Dr Narayanan Prepageran

Senior Consultant
Department of Otorhinolaryngology
University of Malaya Medical Centre
Kuala Lumpur, Malaysia
prepageran@yahoo.com

Editor

Johan Fagan MBChB, FCS (ORL), MMed

Professor and Chairman
Division of Otolaryngology
University of Cape Town
Cape Town, South Africa
johannes.fagan@uct.ac.za

THE OPEN ACCESS ATLAS OF

OTOLARYNGOLOGY, HEAD &
NECK OPERATIVE SURGERY
www.entdev.uct.ac.za

The Open Access Atlas of Otolaryngology, Head & Neck

Operative Surgery by Johan Fagan (Editor)
johannes.fagan@uct.ac.za is licensed under a Creative
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