**1. Introduction**

Endoscopy is the examination and inspection of the interior of body organs, joints or cavities through an endoscope. Endoscopic surgery uses scopes that go through small incisions or natural body openings to diagnose and treat disease. Another popular term is minimally invasive surgery (MIS), which emphasizes that diagnosis and treatment can be done with reduced body invasion. Endoscopes are revolutionary surgical tools that provide detailed video images, allowing visualization of internal structures through a skin incision the width of a thumb and an entry into the organ smaller than a pushpin. Small instruments that can cut, sample, or destroy abnormal tissue or tumors can also be passed through these tubes, allowing intricate surgery to be performed with little or no trauma. Endoscopy allows physicians to peer through the body's passageways.

**Construction** An endoscope uses two fiber optic lines. A "light fiber" carries light into the body cavity and an "image fiber" carries the image of the body cavity back to the physician's viewing lens. The portion of the endoscope inserted into the body may be rigid or flexible, depending upon the medical procedure. There is also a separate port to allow for administration of drugs, suction, and irrigation. This port may also be used to introduce small folding instruments such as scalpels, scissors, forceps, brushes, snares and baskets for tissue excision (removal), sampling, or other diagnostic and therapeutic work. They are inserted through different incisions and are used to perform the operation. Endoscopes may be used in conjunction with a camera or video recorder to document internal mages. New endoscopes have digital capabilities for manipulating and enhancing video images (Figures 1 and 2).

© 2015 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and eproduction in any medium, provided the original work is properly cited.

as scalpels, scissors, forceps, brushes, snares and baskets for tissue excision (removal), sampling,

or other diagnostic and therapeutic work. They are inserted through different incisions and are

used to perform the operation. Endoscopes may be used in conjunction with a camera or video

**Figure 1.** This figure shows an endoscope. The "image fiber" leads from the ocular (eye piece) to the inserted end of the scope. The "light fiber" is below and leads from the light source to the working end of the endoscope. **to the inserted end of the scope. The "light fiber" is below and leads from the light source to**

**Figure 1**: **This figure shows an endoscope. The "image fiber" leads from the ocular (eye piece)**

**Figure 2: Endoscopic surgery equipment and instruments Figure 2.** Endoscopic surgery equipment and instruments

#### **1.1. Endoscopic plastic surgery**

**the working end of the endoscope.**

2

Endoscopic plastic surgery is one of the newest plastic surgery techniques. It allows surgeons to operate with fewer conspicuous incisions, reducing obvious scars. Improvements in technology have enabled surgeons to use endoscopy for many cosmetic procedures, including facelifts, forehead lifts, etc. Endoscopy can also be used in some reconstructive procedures. In many cases, the use of endoscopy results in shorter recovery.

Candidates must be in good health, have no active diseases or serious pre-existing medical conditions, and must have realistic expectations of the outcome of the surgery. Smoking, having recently quit smoking and being exposed to second-hand smoke are all contraindica‐ tions. Primary and secondary smoking decreases blood flow to the body's tissues. This can result in prolonged wound healing, skin loss, infection, increased scarring, and a number of other complications depending on the kind of procedure performed.

The endoscope is merely a new tool to better achieve just that objective. Outcome enhance‐ ments initially predominated in aesthetic applications, but widespread use also in reconstruc‐ tive endeavors has proved that today there is indeed a broad scope for minimally invasive surgery.

**Figure 1.** This figure shows an endoscope. The "image fiber" leads from the ocular (eye piece) to the inserted end of the

Endoscopic plastic surgery is one of the newest plastic surgery techniques. It allows surgeons to operate with fewer conspicuous incisions, reducing obvious scars. Improvements in

scope. The "light fiber" is below and leads from the light source to the working end of the endoscope.

**Figure 1**: **This figure shows an endoscope. The "image fiber" leads from the ocular (eye piece)**

**to the inserted end of the scope. The "light fiber" is below and leads from the light source to**

as scalpels, scissors, forceps, brushes, snares and baskets for tissue excision (removal), sampling,

or other diagnostic and therapeutic work. They are inserted through different incisions and are

used to perform the operation. Endoscopes may be used in conjunction with a camera or video

recorder to document internal mages. New endoscopes have digital capabilities for

manipulating and enhancing video images (**Figures 1 and 2**).

488 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

**Figure 2: Endoscopic surgery equipment and instruments Figure 2.** Endoscopic surgery equipment and instruments

**1.1. Endoscopic plastic surgery**

**the working end of the endoscope.**

2

The goal of what today would be considered minimally invasive surgery may be to even surpass the outcomes possible with traditional open techniques, with diminished patient morbidity including accelerated recovery time and, at the same time, reducing overall healthcare costs. Initially conceived as a means to allow the direct examination of internal organs while avoiding large incisions, the origins of the clinical application of this concept can be traced back to Hippocrates in ~400 BC who used a rectal speculum to examine hemorrhoids. [1] The centuries to follow fostered slow, incremental improvements in instrumentation and light sources that would eventually allow the requisite access as well as proper illumination of the operative field. However, not until the 1950s did the advent of fiber-optic technology permit the transmission of light from an external light source along long, flexible glass or plastic threads so that a clear image could be obtained, yet now without risk of thermal injury.[1]

In 1990, ongoing research efforts at the University of Alabama at Birmingham culminated in reports of a broad clinical experience in endoscopy including endoscopic brow lift.[2] Nowhere were the early demands for minimally invasive surgery so prevalent than in cosmetic surgery.[3]

The interest in aesthetic endoscopic plastic surgery still predominates today, [4]-[11] and there is a concomitant explosion of novel applications in reconstructive surgery. An early thrust of the latter included relatively simple maneuvers such as the removal of benign lesions, decompressive fasciotomy for extremity compartment syndrome,[14] or retrieval of spare body parts such as tendon,[15] vein,[16] or nerve[17],[18] grafts. Congenital deformities such as torticollis[19] especially in the pediatric age group, [13] have been well suited to endoscopic correction, as the cosmetic result often is a major consideration. Acquired defects like facial fractures[20] may be directly or indirectly repaired. More complex indications for various tissue manipulations have included the safe placement of tissue expanders [21], [22] or harvest of local[23] or free adipofascial, muscle, and visceral flaps using endoscopic assistance. The realm in the future may be endoscopic robotic surgery for even greater precision, including not just the difficult and safe dissection of the vascular pedicles of all flaps but also the performance even of the microanastomoses themselves.[23], [24] The capability for all these tissue manipulations could someday then be routinely performed in any distant land or even on another planet, where the immediate availability and skills of a surgeon will no longer be a concern!

## **2. Endoscopic sinus surgery**

The sinuses are air-filled holes in the skull. They are connected to the nose and can get infected leading to discharge, pain, etc. This may be caused by allergies, polyps, abnormal shape or swelling inside the nose. Medical therapies, such as antibiotics, steroids, nasal sprays and decongestants will often cure bouts of sinusitis. Sinus surgery is advocated in those patients who fail to improve after medication. There are circumstances when immediate sinus surgery is warranted. Tumors of the sinuses, whether benign or malignant, often require surgical removal. Surgery may be the only option for some patients whose sinus condition aggravates other medical problems such as asthma. Cancer or immunocompromised patients may require drainage for culture or for treatment of a fungal infection. In the past, surgeries requiring an incision under the lip (Caldwell-Luc) or face (external ethmoidectomy) were used to drain sinus cavities. Most procedures are now performed using endoscopic technology (via small cameras through the nose), eliminating the need for external incisions. Endoscopic sinus surgery uses small rods of light with a camera (endoscope) to operate through the nostrils into the sinuses (Figure 3). performed using endoscopic technology (via small cameras through the nose), eliminating the need for external incisions. Endoscopic sinus surgery uses small rods of light with a camera (endoscope) to operate through the nostrils into the sinuses (**Figure 3**).

**Figure 3.** Entry to the sinus from the nostrils

the septum to improve nasal airflow.

**Functional Endoscopic Sinus Surgery**

5

**Figure 3: Entry to the sinus from the nostrils** This does not involve any incisions on the face, but may be combined with other external This does not involve any incisions on the face, but may be combined with other external approaches, which may involve cuts. This surgery is usually done under general anesthesia for patient comfort. A CT scan will serve as a road map for the surgeon. ESS has presented a new philosophy allowing the surgeon to target the ostiumeatal complex (OMC). Obstruction of the OMC can lead to subsequent infection of the maxillary, frontal and sphenoid sinuses.

approaches, which may involve cuts. This surgery is usually done under general anesthesia for

patient comfort. A CT scan will serve as a road map for the surgeon. ESS has presented a new

philosophy allowing the surgeon to target the ostiumeatal complex (OMC). Obstruction of the

OMC can lead to subsequent infection of the maxillary, frontal and sphenoid sinuses.

Accordingly, ESS removes thickened and diseased tissue blocking the OMC. Most of the healthy

tissue in the sinuses is undisturbed allowing for faster and better overall recovery. Endoscopic

surgery can also be utilized for removal of polyps, nasal masses and sometimes straightening

Functional endoscopic sinus surgery (FESS) is the mainstay in the surgical treatment of **sinusitis**

and **nasal polyps**, including bacterial, fungal, recurrent, acute and chronic sinus problems. FESS

is a relatively recent surgical procedure that uses nasal **endoscopes** (using **Hopkins rod lens**

**technology**) through the nostrils to avoid cutting the skin. FESS came into existence through the

pioneering work of Drs. Messerklinger (in 1960 to 1970's) and his assistant Stamberger who

Accordingly, ESS removes thickened and diseased tissue blocking the OMC. Most of the healthy tissue in the sinuses is undisturbed allowing for faster and better overall recovery. Endoscopic surgery can also be utilized for removal of polyps, nasal masses and sometimes straightening the septum to improve nasal airflow.

### **2.1. Functional endoscopic sinus surgery**

Functional endoscopic sinus surgery (FESS) is the mainstay in the surgical treatment of **sinusitis** and **nasal polyps**, including bacterial, fungal, recurrent, acute and chronic sinus problems. FESS is a relatively recent surgical procedure that uses nasal **endoscopes** (using **Hopkins rod lens technology**) through the nostrils to avoid cutting the skin. FESS came into existence through the pioneering work of Drs. Messerklinger (in 1960 to 1970's) and his assistant Stamberger who became chief of the ENT department in Graz, Austria. Other surgeons have made additional contributions (first published in the USA by Kennedy in 1985).[25]

By the early 1990's endoscopic sinus surgery become one of the most popular procedures. In their 1990 publication, Stamberger [26] mentioned operating 4500 patients, roughly 450 patients annually. Most procedures were very limited surgical procedures; diseased ethmoid compartments were operated on (usually the ethmoidal bulla), stenotic clefts were widened (uncinate process) and prechambers (agar nasi cells) to the frontal and maxillary sinuses were freed from disease.

#### **2.2. Indications**

tissue manipulations could someday then be routinely performed in any distant land or even on another planet, where the immediate availability and skills of a surgeon will no longer be

The sinuses are air-filled holes in the skull. They are connected to the nose and can get infected leading to discharge, pain, etc. This may be caused by allergies, polyps, abnormal shape or swelling inside the nose. Medical therapies, such as antibiotics, steroids, nasal sprays and decongestants will often cure bouts of sinusitis. Sinus surgery is advocated in those patients who fail to improve after medication. There are circumstances when immediate sinus surgery is warranted. Tumors of the sinuses, whether benign or malignant, often require surgical removal. Surgery may be the only option for some patients whose sinus condition aggravates other medical problems such as asthma. Cancer or immunocompromised patients may require drainage for culture or for treatment of a fungal infection. In the past, surgeries requiring an incision under the lip (Caldwell-Luc) or face (external ethmoidectomy) were used to drain sinus cavities. Most procedures are now performed using endoscopic technology (via small cameras through the nose), eliminating the need for external incisions. Endoscopic sinus surgery uses small rods of light with a camera (endoscope) to operate through the nostrils into

performed using endoscopic technology (via small cameras through the nose), eliminating

the need for external incisions. Endoscopic sinus surgery uses small rods of light with a

This does not involve any incisions on the face, but may be combined with other external

This does not involve any incisions on the face, but may be combined with other external approaches, which may involve cuts. This surgery is usually done under general anesthesia for patient comfort. A CT scan will serve as a road map for the surgeon. ESS has presented a new philosophy allowing the surgeon to target the ostiumeatal complex (OMC). Obstruction of the OMC can lead to subsequent infection of the maxillary, frontal and sphenoid sinuses.

approaches, which may involve cuts. This surgery is usually done under general anesthesia for

patient comfort. A CT scan will serve as a road map for the surgeon. ESS has presented a new

philosophy allowing the surgeon to target the ostiumeatal complex (OMC). Obstruction of the

OMC can lead to subsequent infection of the maxillary, frontal and sphenoid sinuses.

Accordingly, ESS removes thickened and diseased tissue blocking the OMC. Most of the healthy

tissue in the sinuses is undisturbed allowing for faster and better overall recovery. Endoscopic

surgery can also be utilized for removal of polyps, nasal masses and sometimes straightening

Functional endoscopic sinus surgery (FESS) is the mainstay in the surgical treatment of **sinusitis**

and **nasal polyps**, including bacterial, fungal, recurrent, acute and chronic sinus problems. FESS

is a relatively recent surgical procedure that uses nasal **endoscopes** (using **Hopkins rod lens**

**technology**) through the nostrils to avoid cutting the skin. FESS came into existence through the

pioneering work of Drs. Messerklinger (in 1960 to 1970's) and his assistant Stamberger who

camera (endoscope) to operate through the nostrils into the sinuses (**Figure 3**).

a concern!

**2. Endoscopic sinus surgery**

490 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

the sinuses (Figure 3).

**Figure 3: Entry to the sinus from the nostrils**

**Figure 3.** Entry to the sinus from the nostrils

the septum to improve nasal airflow.

**Functional Endoscopic Sinus Surgery**

5

The most common indication for endoscopic sinus surgery is "chronic rhinosinusitis". Chronic rhinosinusitis is a term applied to various nasal processes which involve inflammation of the nose and sinuses that do not adequately improve with medical management. Less common indications include (but are not limited to): recurrent infections (rather than chronic inflam‐ mation), complications of sinus infections, nasal polyps, mucoceles, chronic sinus headaches, impaired sense of smell, tumors of the nasal and sinus cavities, cerebrospinal fluid leaks, nasolacrimal duct obstruction, choanal atresia, and the need to decompress the orbit. Addi‐ tionally, recent advances in endoscopic techniques allow the operator to provide access to areas of the brain and pituitary gland for neurosurgeons or to the orbits (eye sockets) for certain ophthalmology procedures.

#### **2.3. Technique**

The frontal, maxillary, and anterior ethmoid sinuses drain into the middle meatus. Posterior ethmoids drain into the superior meatus. Sphenoid sinuses drain into the sphenoethmoid recess. Telescopes with diameters of 4mm (adults) and 2.7mm (pediatrics) and with a variety of viewing angles (0 to 30, 45, 70, 90, and 120 degrees) provide good illumination of the inside of the nasal cavity and sinuses. High-definition cameras, monitors and a host of tiny articu‐ lating instruments aid in identifying and restoring the proper drainage and ventilation relationships between the nose and sinus cavities. Cultures and biopsies can be easily obtained to yield valuable diagnostic information to guide postoperative therapy for optimal long term results.

All the sinuses can be accessed at least to some degree by means of this device: The frontal sinuses located in the forehead, the maxillary sinuses in the cheek bones, the ethmoid sinuses between the orbits, and the sphenoid sinuses are located in the back of the nasal cavity at the base of the skull.

## **2.4. Extended approaches**

Endoscopic access to pituitary tumors has been successfully accomplished for many years. More recently, further advanced techniques have allowed the paranasal sinuses to be a relatively low-morbidity approach to selected tumors even inside the skull or brain.

### **2.5. Benefits of ESS**

The overall goal of sinus surgery is to improve the drainage pathway of the sinuses. By opening the natural drainage pathway of the diseased sinus, the frequency, duration and severity of infections should be reduced. Sinus surgery is not without risk, but it does have major benefits. Sinus issues left uncorrected may lead to abscess formation, permanent loss of sense of smell vision, or even death. Benefits of sinus surgery include asthma relief, polyps and fungus removal and less recurrence of sinus infections.

Although there are patients who have mechanical obstruction due to their particular anatomy, many patients have an intrinsic problem with the lining (mucous membrane) of their nose and sinuses. While the patients with mechanical obstruction, will receive the maximal benefit from surgery, the benefit for patients with mucous membrane disease is also tangible because the larger opening created during surgery will allow better drainage and more medication and rinses to get into the sinuses and help treat the diseased lining.

One of the most important benefits of surgery is the ability to deliver medications (e.g. sprays, rinses, nebulized drugs) to the lining of your sinuses after they have been accessed. Therefore, surgery is an adjunct to, not a replacement for, proper medical management. It is important to note, however, that if you are one of the patients who have diseased mucous membranes or form nasal polyps, no amount of surgery can change this fact. So although surgery plays a role in managing the disease, it may not cure sinus disease with polyps or other types of chronic inflammation. Therefore, it should be emphasized that surgery is one of the multiple steps in managing the disease.

#### **2.6. Possible risks and complications related to functional endoscopic sinus surgery**

Extreme care is required with this surgery due to the proximity of the sinuses to the eyes, optic nerves, brain and internal carotid arteries. However, these serious risks are rare occurrences and there are many potential benefits from a well-performed endoscopic sinus surgery with appropriate indications. All surgical procedures have risks and complications namely:

**1.** Bleeding from the nose in the days following the operation

**2.** Infection

to yield valuable diagnostic information to guide postoperative therapy for optimal long term

All the sinuses can be accessed at least to some degree by means of this device: The frontal sinuses located in the forehead, the maxillary sinuses in the cheek bones, the ethmoid sinuses between the orbits, and the sphenoid sinuses are located in the back of the nasal cavity at the

Endoscopic access to pituitary tumors has been successfully accomplished for many years. More recently, further advanced techniques have allowed the paranasal sinuses to be a

The overall goal of sinus surgery is to improve the drainage pathway of the sinuses. By opening the natural drainage pathway of the diseased sinus, the frequency, duration and severity of infections should be reduced. Sinus surgery is not without risk, but it does have major benefits. Sinus issues left uncorrected may lead to abscess formation, permanent loss of sense of smell vision, or even death. Benefits of sinus surgery include asthma relief, polyps and fungus

Although there are patients who have mechanical obstruction due to their particular anatomy, many patients have an intrinsic problem with the lining (mucous membrane) of their nose and sinuses. While the patients with mechanical obstruction, will receive the maximal benefit from surgery, the benefit for patients with mucous membrane disease is also tangible because the larger opening created during surgery will allow better drainage and more medication and

One of the most important benefits of surgery is the ability to deliver medications (e.g. sprays, rinses, nebulized drugs) to the lining of your sinuses after they have been accessed. Therefore, surgery is an adjunct to, not a replacement for, proper medical management. It is important to note, however, that if you are one of the patients who have diseased mucous membranes or form nasal polyps, no amount of surgery can change this fact. So although surgery plays a role in managing the disease, it may not cure sinus disease with polyps or other types of chronic inflammation. Therefore, it should be emphasized that surgery is one of the multiple steps in

**2.6. Possible risks and complications related to functional endoscopic sinus surgery**

Extreme care is required with this surgery due to the proximity of the sinuses to the eyes, optic nerves, brain and internal carotid arteries. However, these serious risks are rare occurrences and there are many potential benefits from a well-performed endoscopic sinus surgery with appropriate indications. All surgical procedures have risks and complications namely:

relatively low-morbidity approach to selected tumors even inside the skull or brain.

results.

base of the skull.

**2.5. Benefits of ESS**

managing the disease.

removal and less recurrence of sinus infections.

492 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

rinses to get into the sinuses and help treat the diseased lining.

**1.** Bleeding from the nose in the days following the operation

**2.4. Extended approaches**


#### **2.7. CT navigation**

**Computed tomography** (CT) navigation is a tool that may be used by surgeons to better correlate surgical anatomy with pre-operative CT imaging. A computer is used to identify the 3-dimensional location of a probe tip placed within the patient's nose or sinuses.

Definitive proof that CT navigation improves outcomes and decreases complications is lacking. A Swedish study of 212 patients undergoing sphenoethmoidectomy published in 2008 concluded that the clinical success of the procedure was similar with or without the use of CT navigation, and that the rate of complications might be slightly reduced.[27]
