Functional endoscopic sinus surgery

9 min read Last updated April 8, 2026

Surgical approach

  • Endoscopic transnasal approach using rigid endoscopes (0–70°) via nostrils; no external incisions
  • Local infiltration and topical vasoconstrictors (e.g. lidocaine + adrenaline; phenylephrine/oxymetazoline) to reduce bleeding and improve view
    • Often includes nasal pledgets/packs soaked in vasoconstrictor; may be repeated intra-op
  • Procedures may include uncinectomy, middle meatal antrostomy, ethmoidectomy (anterior/posterior), sphenoidotomy, frontal sinusotomy; polypectomy
  • Powered instruments (microdebrider), suction diathermy; occasional image-guidance/navigation
  • At end: suction clearance, haemostasis; possible nasal packing/splints; sometimes postoperative debridement planned

Anaesthetic management

  • Type of anaesthesia: General anaesthesia (almost always)
    • TIVA commonly used to improve surgical field and reduce PONV (propofol + remifentanil)
  • Airway: cuffed oral ETT preferred (shared airway; blood/irrigation; throat pack)
    • RAE/oral reinforced tube may help access; secure well; protect eyes; avoid nasal instrumentation with ETT
    • SGA generally avoided due to aspiration risk and need for controlled ventilation; may be used only for very limited cases with low bleeding risk and experienced team
  • Duration: typically 1–2 hours (range 30 min to 3+ hours depending on extent/revision surgery)
  • Pain: usually mild–moderate (more discomfort/pressure than severe pain); revision/extensive disease can be more painful
    • Analgesia often achievable with paracetamol + NSAID (if appropriate) ± small opioid
  • Key intra-op goals: excellent surgical field (bloodless), stable haemodynamics, immobile patient, low PONV, safe emergence with minimal coughing/straining

Indications and patient factors

  • Indications: chronic rhinosinusitis (± nasal polyposis), recurrent acute sinusitis, fungal sinusitis, mucoceles, complications of sinusitis, access for skull base/CSF leak repair (extended endoscopic surgery)
  • Comorbidities: asthma/aspirin-exacerbated respiratory disease (AERD), OSA, obesity, GERD, allergic rhinitis; consider difficult airway history
    • AERD: higher bronchospasm risk; avoid NSAIDs if history of aspirin/NSAID sensitivity
  • Infection: acute URTI may increase bronchospasm/laryngospasm risk; balance urgency vs postponement

Preoperative assessment and preparation

  • Airway assessment: mouth opening, neck movement; plan for shared airway and potential blood contamination
  • Bleeding risk: anticoagulants/antiplatelets; hypertension; coagulopathy; ask about herbal supplements (e.g. ginkgo, garlic)
  • Discuss with surgeon: desired MAP target, use of topical vasoconstrictors/adrenaline, expected packing, extent (routine FESS vs skull base/CSF leak)
  • Premedication: avoid heavy sedation if OSA; consider anxiolysis; consider antisialagogue if significant secretions (case dependent)

Monitoring and positioning

  • Standard monitoring; consider arterial line for prolonged/complex cases or deliberate hypotension with tight control
  • Position: head-up 10–20° (reverse Trendelenburg) to reduce venous pressure and bleeding; ensure secure patient and pressure area care
  • Eye protection is critical (taping; avoid pressure); surgeon working close to orbit
  • Temperature management and active warming (often cool theatre, exposed head/neck)

Induction and airway strategy

  • Secure cuffed oral ETT; confirm bilateral air entry; secure tube away from surgical field; consider bite block
  • Throat pack commonly used to reduce blood trickle into stomach/airway; must be documented and removed before extubation
    • Use a visible label and WHO-style sign-out check; suction oropharynx before removal
  • Ventilation: controlled ventilation; avoid high airway pressures; maintain normocapnia (or mild hypocapnia only if specifically requested and safe)

Techniques to improve surgical field (reduce bleeding)

  • Optimise venous drainage: head-up, neutral head/neck, avoid tight ETT ties/venous obstruction
  • Controlled hypotension: individualise; typical target MAP ~60–70 mmHg in fit adults (avoid in cerebrovascular/coronary disease); ensure organ perfusion
    • Methods: TIVA (propofol/remifentanil), volatile + remifentanil, beta-blocker (esmolol), vasodilators (GTN), alpha-2 agonist (dexmedetomidine), magnesium (selected cases)
    • Avoid excessive hypotension: risk of myocardial/cerebral/renal hypoperfusion; consider age and comorbidity
  • Depth of anaesthesia and analgesia: prevent sympathetic surges (incision, infiltration, packing) that increase bleeding
  • Consider antifibrinolytic: tranexamic acid may reduce bleeding in sinonasal surgery (local policy; assess thrombosis risk)
  • Avoid factors increasing bleeding: hypertension, hypercapnia, coughing/straining, inadequate paralysis (if used), hypothermia

Analgesia and PONV

  • Analgesia: paracetamol + NSAID (if appropriate) ± low-dose opioid; consider local infiltration by surgeon
  • Avoid heavy opioids when possible (PONV, respiratory depression esp. OSA); remifentanil-based technique may require longer-acting analgesic before end
  • PONV prophylaxis: high priority (blood swallowing, opioids, ENT surgery). Use multimodal: dexamethasone + ondansetron ± droperidol; consider TIVA
    • Avoid dexamethasone if specific contraindication; consider glucose monitoring in diabetics

Emergence and extubation

  • Aim: smooth emergence to avoid coughing/straining (bleeding, surgical disruption). Options: deep extubation in selected low-risk patients, lidocaine (IV/topical), short-acting opioid, dexmedetomidine
    • Deep extubation: only with low aspiration risk, minimal bleeding, experienced team, and clear plan for airway rescue
  • Before extubation: remove throat pack, suction pharynx, ensure haemostasis communicated, consider gastric suction if significant blood swallowed
  • Post-op airway: beware obstruction (OSA, blood, packs). If bilateral nasal packs: patient must mouth-breathe; consider humidified O2 and close observation

Complications relevant to anaesthesia

  • Bleeding: can be brisk; risk of aspiration, hypovolaemia; may need packing, cautery, conversion/abandonment
  • Orbital complications: lamina papyracea breach → orbital haematoma, proptosis, raised IOP, optic nerve ischaemia (time-critical)
    • Signs: sudden swelling, tense orbit, bradycardia (oculocardiac reflex), reduced vision (if awake), increased airway pressures if severe facial swelling
    • Management: urgent surgeon action (release pressure/canthotomy), stop hypotension, ensure normoxia/normocapnia; call for help
  • Intracranial complications: skull base breach → CSF leak, pneumocephalus, intracranial haemorrhage, meningitis; may present with sudden bleeding, clear fluid, haemodynamic changes
    • If suspected: inform surgeon, avoid high airway pressures and nitrous oxide; consider CT and neurosurgical input
  • Venous air embolism: rare but possible in head-up position with open venous channels
    • Signs: sudden drop ETCO2, hypoxia, hypotension; manage with 100% O2, flood field, aspirate via CVC if present, support circulation
  • Local anaesthetic/vasoconstrictor toxicity: systemic absorption of adrenaline/phenylephrine/cocaine (where used) → hypertension, tachyarrhythmias, myocardial ischaemia; local anaesthetic toxicity if large doses
    • Communicate total doses; treat arrhythmias/ischaemia; manage LAST per guidelines (lipid rescue)
  • Trigeminocardiac reflex (nasocardiac): nasal manipulation → bradycardia, hypotension, asystole (rare)
    • Management: stop stimulus, deepen anaesthesia, anticholinergic (glycopyrrolate/atropine) if persistent; correct hypoxia/hypercapnia

Postoperative care

  • Observation for bleeding, airway obstruction, PONV; ensure patient understands not to blow nose; manage hypertension and coughing
  • If packs in situ: consider higher level observation in OSA/opioid use; humidified oxygen; mouth care
  • Analgesia usually simple; avoid NSAIDs if AERD or surgeon preference due to bleeding concerns (local practice varies)
You are asked to anaesthetise an adult for FESS. What are your main anaesthetic aims and why?

Focus on surgical field quality and safe shared-airway management.

  • Provide a still patient with controlled ventilation and secure airway (blood/irrigation risk; shared airway)
  • Optimise surgical field: reduce bleeding via head-up position, stable low-normal MAP, avoid tachycardia/hypertension, avoid hypercapnia
  • Minimise PONV (ENT surgery + swallowed blood) and ensure smooth emergence (avoid coughing/straining → bleeding)
  • Prevent and rapidly recognise complications (orbital haematoma, CSF leak, vasoconstrictor toxicity, reflex bradycardia)
How would you achieve a good surgical field for FESS? Include pharmacological and non-pharmacological methods.

Combine positioning, anaesthetic technique, haemodynamic control, and avoidance of provoking factors.

  • Position: 10–20° head-up; neutral head/neck; avoid venous obstruction (tight ties, extreme rotation)
  • Anaesthetic technique: TIVA (propofol/remifentanil) often improves field vs volatile; ensure adequate depth/analgesia
  • Controlled hypotension (selected patients): aim MAP ~60–70 mmHg; avoid in significant IHD/CVD; ensure perfusion and monitor closely
  • Drug options: remifentanil, esmolol, GTN, dexmedetomidine; consider TXA per policy
  • Avoid: hypertension, tachycardia, coughing/straining, hypercapnia, hypothermia; ensure good IV access and timely treatment of surges
  • Coordinate with surgeon regarding topical vasoconstrictors and total adrenaline dose; treat systemic effects promptly
Discuss your airway plan for FESS. Would you use an SGA?

Prioritise protection from blood/irrigation and ability to control ventilation.

  • Preferred: cuffed oral ETT (often reinforced/RAE) secured away from field; controlled ventilation
  • Throat pack commonly used; must be documented and removed before extubation; suction before wake-up
  • SGA: generally avoided due to aspiration risk and poorer protection from blood; may be considered only for very minor, low-bleeding cases with experienced surgeon/anaesthetist and clear rescue plan
  • Extubation strategy: smooth emergence; consider deep extubation only in selected low-risk patients
The surgeon requests deliberate hypotension. How do you decide if it is appropriate and how would you deliver it safely?

Assess patient risk, set targets, choose controllable agents, and monitor end-organ perfusion.

  • Assess suitability: age, baseline BP, IHD, cerebrovascular disease, renal disease, anaemia; discuss acceptable MAP with surgeon
  • Set target: often MAP 60–70 mmHg in healthy adults; avoid large drops from baseline; titrate to field quality
  • Technique: TIVA + remifentanil; add esmolol for tachycardia; consider GTN if hypertensive; dexmedetomidine as adjunct
  • Monitoring: consider arterial line; ensure adequate IV access; frequent BP checks; maintain normoxia, normocapnia, normothermia
  • Safety: treat excessive hypotension promptly (reduce agents, fluids, vasopressors as needed); document rationale and targets
What are the important complications of FESS and how might they present to the anaesthetist?

Think bleeding/aspiration, orbital injury, intracranial injury, reflexes, and drug toxicity.

  • Bleeding: rising suction losses, blood in oropharynx/ETT, haemodynamic instability; aspiration risk
  • Orbital injury/haematoma: sudden periorbital swelling/proptosis; possible bradycardia (oculocardiac reflex); time-critical vision threat
  • Skull base breach: CSF leak (clear fluid), sudden bleeding, pneumocephalus; later meningitis; avoid N2O if suspected
  • Reflex bradycardia: trigeminocardiac/oculocardiac during nasal manipulation
  • Vasoconstrictor/adrenaline effects: hypertension, tachyarrhythmias, ST changes; local anaesthetic systemic toxicity if high doses
During infiltration with adrenaline-containing local anaesthetic, the patient becomes tachycardic and hypertensive with ST depression. What do you do?

Treat as catecholamine surge with possible myocardial ischaemia; stop the trigger and stabilise physiology.

  • Immediate actions: ask surgeon to stop infiltration/remove pledgets; confirm dose/concentration; increase FiO2; check depth of anaesthesia
  • Assess: ECG (ST changes), BP, ETCO2; consider arterial line if ongoing instability; send ABG if needed
  • Treat haemodynamics: short-acting beta-blocker (esmolol) for tachycardia if appropriate; deepen anaesthesia/opioid; consider GTN for hypertension/ischaemia (case dependent)
  • Consider differential: inadvertent IV injection, light anaesthesia, hypercapnia, pain; manage accordingly
  • If arrhythmia/instability persists: follow ALS/arrhythmia algorithms; consider cardiology/ICU; document event and total adrenaline dose
How do you manage suspected orbital haematoma during FESS?

This is a time-critical emergency to prevent permanent visual loss.

  • Call it early: alert surgeon immediately; stop surgery; request urgent orbital decompression (e.g. release of pressure/canthotomy as per surgeon)
  • Physiology: stop deliberate hypotension; restore normotension; ensure 100% oxygen and normocapnia
  • Support circulation and treat reflex bradycardia if present (anticholinergic); ensure adequate IV access
  • Prepare for escalation: possible imaging, ophthalmology input, ICU; document timeline/actions
You suspect a CSF leak or skull base breach. What are the anaesthetic implications?

Avoid worsening pneumocephalus and minimise pressure gradients across the skull base.

  • Inform surgeon; stop/modify surgical manoeuvres; anticipate need for repair and longer case
  • Avoid nitrous oxide (can expand intracranial air and worsen pneumocephalus)
  • Avoid high airway pressures and coughing/straining; ensure smooth controlled ventilation and emergence
  • Maintain normocapnia and stable haemodynamics; consider antibiotics/steroids as per surgical plan; plan postoperative monitoring
How would you plan PONV prophylaxis for FESS and why is it important?

PONV is common and clinically significant due to bleeding and aspiration risk.

  • Risk factors: ENT surgery, swallowed blood, opioids, volatile agents; consider patient factors (female, non-smoker, prior PONV/motion sickness)
  • Strategy: TIVA where possible + multimodal antiemetics (e.g. dexamethasone + ondansetron ± droperidol) and opioid-sparing analgesia
  • Importance: vomiting/retching increases venous pressure → bleeding; aspiration risk; patient discomfort and delayed discharge
What is the trigeminocardiac reflex in FESS and how do you manage it?

A brainstem reflex causing bradycardia/hypotension triggered by trigeminal nerve stimulation.

  • Trigger: nasal mucosal manipulation, packing, traction; exacerbated by light anaesthesia, hypoxia, hypercapnia
  • Presentation: sudden bradycardia ± hypotension ± arrhythmias; rarely asystole
  • Management: ask surgeon to stop stimulus; deepen anaesthesia; correct hypoxia/hypercapnia; give glycopyrrolate/atropine if persistent

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