0:00

The understanding of the flow of mucus

0:03

through the perinasal sinuses was based in

0:06

work that was done largely at Johns Hopkins

0:10

Hospital by two of my good friends, David

0:13

Kennedy and Jim Zinreich, along with, uh,

0:17

scientists from Europe named Heinz Stammberger.

0:20

And what they found was that there is a

0:23

natural flow of the mucus that goes through the

0:25

various ostia that I've previously described.

0:29

This is probably better understood using

0:31

this sagittal reconstruction of a diagram

0:35

that you see on the right-hand side.

0:38

In this diagram, you see that the mucus of the

0:41

frontal sinus goes through that ostium that I

0:44

had previously mentioned, the frontal recess.

0:49

And from there, it goes into the common pathway,

0:52

which is that middle meatus that you will see

0:55

drains a number of the different

0:57

areas, including the maxillary sinus.

1:00

You notice also that the ethmoid sinuses

1:03

are also draining down and through and into

1:05

the middle meatus in the anterior portion.

1:09

The posterior ethmoid air cells, however,

1:12

have a separate drainage, and that is through

1:15

what's called the sphenoethmoidal recess.

1:18

However, even the sphenoethmoidal

1:19

recess, as you can see, drains downward and

1:22

posteriorly to the pharynx and into the back

1:26

of the posterior portion of the middle meatus.

1:29

This was very important work because

1:32

it substantiated the value in doing

1:35

functional endoscopic sinus surgery.

1:38

So this is abbreviated quite often as FESS.

1:41

You'll see "status post FESS" on your request slip.

1:46

Functional endoscopic sinus surgery

1:48

was a reaction to the failure of

1:51

the previously done surgery, which was called

1:53

the Caldwell-Luc procedure. The Caldwell

1:56

Luc procedure was one that was done under the

1:59

upper lip, creating a hole in the floor of the

2:02

maxillary sinus, which you see over here.

2:04

And then creating another opening in the inferior

2:09

aspect of the medial wall of the maxillary sinus.

2:12

The idea being that by opening up this

2:15

hole, the sinus material would then drain

2:19

inferiorly and then back into the pharynx.

2:22

In point of fact, that's not the way the

2:24

mucociliary clearance — the cilia beat

2:28

the mucus up and out and into the ostium.

2:31

So this surgery that was done for many, many years, 51 00:02:35,125 --> 00:02:37,674 was not very successful, and patients

2:37

kept coming back with chronic sinusitis

2:39

despite the Caldwell-Luc procedure, which

2:42

was the inferior maxillectomy and antrostomy,

2:46

functional endoscopic sinus surgery,

2:49

by contrast, generally opened up the narrow airways

2:55

in order to facilitate the

2:57

normal mucociliary clearance.

2:59

So what is typically done in this situation

3:02

is that the uncinate process is removed,

3:06

so that way there's a larger passageway

3:09

from the maxillary sinus into the middle

3:11

meatus, and that also facilitates the anterior

3:14

ethmoid sinus drainage as well as the

3:18

frontal sinus drainage, because the uncinate

3:20

process is frankly in the way, if you will.

3:23

Similarly, for sphenoid and posterior ethmoid

3:27

sinusitis, instead of opening up those sinuses

3:30

and taking down their walls, what people now

3:33

do is they do a sphenoidotomy, which is an opening

3:38

to that drainage pathway, so you're continuing

3:42

to use the normal mucociliary clearance of

3:45

the beating of those cilia, moving the mucus

3:49

the right way, but just through wider channels.

3:53

That is why it's functional

3:56

endoscopic sinus surgery.