FESS (Functional Endoscopic Sinus Surgery)
Patient phenotype
Chronic sinusitis refractory to medical therapy, nasal polyposis, mucocele. Often adult 30-60. Some have aspirin-exacerbated respiratory disease (Samter triad: asthma + polyps + ASA sensitivity).
Procedure
Endoscopic transnasal approach, opening of involved sinus ostia (maxillary, ethmoid, sphenoid, frontal). 60-120 min depending on extent.
Anesthetic plan
GETA. RAE oral or south-facing tube + throat pack. Controlled hypotension (MAP 60-70) for surgical visibility. Multimodal pain. Smooth emergence to avoid bleeding.
Setup
- ·Standard ASA + Foley if long
- ·PIV
- ·Oral RAE ETT 6.5-7.5 + throat pack
- ·Eye protection (taped)
- ·Reverse Trendelenburg slight (head up 15°)
- ·Vasoactive: remifentanil + dex for controlled hypotension
- ·Topical decongestant on nasal mucosa (oxymetazoline)
Biggest concerns by phase
Asthma + ASA sensitivity (Samter triad)
Look for triad. If present, AVOID NSAIDs (severe bronchospasm, can be fatal). Pre-op bronchodilator + steroid optimization. Skin testing for ASA desensitization sometimes done pre-op for chronic management.
ETT placement + throat pack
Oral RAE bends out of way of nasal surgical field. Throat pack absorbs blood + secretions, prevents aspiration. CRITICAL: count pack in + count pack out. Documented removal before extubation.
Controlled hypotension for surgical view
Surgeon needs bloodless field. MAP 60-70 typical (lower if young + healthy, higher if elderly/CAD). Tools: remifentanil 0.05-0.2 mcg/kg/min, dex infusion, deepen volatile (within MAC limits), reverse Trendelenburg slight (gravity drains face).
Topical vasoconstrictor — cocaine, oxymetazoline
Surgeon applies topical to nasal mucosa for vasoconstriction + decongestion. Cocaine 4% (max 3 mg/kg, monitor for HTN/arrhythmia) or oxymetazoline. Systemic absorption can be significant.
Orbital + intracranial complications (rare)
Surgeon working near orbit + skull base. Watch for: orbital trauma (CSF rhinorrhea via cribriform plate), retrobulbar hematoma. Communicate any sudden change.
Smooth emergence — coughing causes bleeding
Coughing/bucking → venous congestion → re-bleeding. Lidocaine 1.5 mg/kg pre-extubation. Verify throat pack OUT (count). Suction posterior pharynx well. Sit up to 30°.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
FESS patient mid-case, MAP 65, surgeon complains 'can't see — too much bleeding.' You're on remifentanil 0.15 mcg/kg/min + sevo 0.7 MAC. What's your approach?
What an examiner probes for
- ▹Reverse Trendelenburg slight (head up 15-20°)
- ▹Lower MAP further to 55-60 (if cardiac OK)
- ▹Increase remi infusion or add dex
- ▹Verify topical vasoconstrictor adequately applied
- ▹Temporal/local epi infiltration by surgeon
- ▹Don't let MAP drop below limit safe for end-organ perfusion
Sources
- Miller's Ch 66 (ENT)
- AAO-HNS FESS guidelines
Anatomy reference
Sourced reference images. 4 matches for "sinus nasal facial".
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