The diagnosis of chronic sinusitis is based upon a thorough history and a complete physical examination, including nasal endoscopy. Patients with chronic or recurrent symptoms typically report nasal congestion, purulent drainage, postnasal drip, facial pressure or headache, diminished sense of smell, and nasal obstruction.

For many years, head and neck surgeons dealt with chronic sinus inflammation by using open operations to strip the lining ("mucosa") from the affected sinuses. In more recent times, a "functional" approach has been taken, based upon the idea that opening of the natural pathways of drainage will return the sinuses and their linings to health.

The endoscope has provided the surgeon with a technical means to access the sinus openings within the nose in a minimally invasive way. In "Functional Endoscopic Sinus Surgery (FESS)," the surgeon inserts a thin, fiberoptic endoscope into the nasal cavities to guide his use of tiny instruments in the removal of obstructing tissues. Because there are no external incisions, there is no visible scarring produced by the procedure.

FESS is reserved for patients with documented rhinosinusitis in whom appropriate medical treatment has failed. Patients with nasal polyposis commonly have poor results with medical therapy alone, and so, surgical intervention may be considered earlier. Also, antrochoanal polyps require surgical removal.

Although the use of endoscopic technique brings clear advantage, the complex anatomy of the sinuses and surrounding regions create a need for great care on the part of the surgeon. The sinuses lie in close proximity to the eye, major blood vessels and the brain itself. In order to more precisely navigate the maze of tissues and passageways doctors have introduced the use of sophisticated imaging techniques and the computer for what is called "image-guided surgery."This has allowed surgeons to perform more complex procedures with increased safety.

Before surgery a standardized headset is placed on the patient as a reference device. A CT scan is obtained with the device in place and the scan is loaded into a computer which creates from the scan data 1 mm image cuts in three different planes. When the patient arrives in the operating room, the same headset is used to "zero" and standardize instrument position, allowing the surgeon to confirm the position of his instruments to within a tolerance of about 1 mm.

This added precision is always helpful, but is particularly important in revisional surgery, CSF leak repairs, frontal sinus surgery, endonasal tumor surgery and in patients with anatomical anomalies.

Dr. Caruana has extensive experience with image-guided endoscopic surgery using the VTI "InstaTrak" system. He performs complex FESS procedures as well as transnasal orbital decompression for thyroid ophthalmopathy.

Note: The image to the left show a 3-plane CT view together with the endoscopic view (lower right) that is projected for the surgeon by the computer system.