Return to: Paranasal Sinus Surgery Protocols
See also: Sinus Videos Instruction for FESS Fiberoptic Endoscopic Sinus Surgery

Note: Last updated prior to 2013

GENERAL CONSIDERATIONS

1. Indications
   1. Chronic sinusitis resistant to maximal appropriate medical treatment
   2. Multiple recurrent attacks of documented acute sinusitis
   3. Nasal polyposis
   4. Paranasal sinus mucoceles
   5. Biopsy of intranasal or paranasal sinus masses
   6. Orbital surgery (DCR, orbital decompression, optic nerve decompression, biopsy of lesions of orbital apex)
      • Treatment of selected nasal and paranasal tumors
2. Contraindications
   1. Abnormalities of the skull base or orbit that prevent a safe approach to the sinuses
   2. General medical conditions preventing local or general anesthesia
3. Preoperative Evaluation
   1. Essential for most cases
      1. Fine-cut coronal CT scan taken after maximal medical therapy (4-6 weeks of culture-directed antibiotic therapy; daily nasal saline irrigations, nasal steroid sprays)
      2. Nasal endoscopy
      3. Consider neurology referral for work up of atypical headache symptoms
   2. Consider for selected cases
      1. Axial CT scans or sagittal reconstruction (useful in the sphenoid and frontal sinuses, respectively)
      2. Allergy/immunology review
      3. Image-guidance

CONSENT

1. Description
   1. "Using small telescopes, we will open the sinuses, as well as remove diseased tissue. It may be necessary to operate on the nasal septum to allow access to the side wall of the nose."
   2. Additional consent for septoplasty may be necessary to improve access for surgical instrumentation in cases of severely deviated septum.
2. Potential Complications
   1. Surgical failure: the patient is as bad or worse after surgery
   2. General risks: anesthetic, bleeding, transfusion, embolism, infection
   3. Damage to adjacent structures: the brain (leading to CSF leak, meningitis or headache); the eye (leading to blindness, visual changes or double vision); anosmia, epiphora; carotid artery damage (leading to stroke or death)

NURSING CONSIDERATIONS

1. Room Setup
   1. See Nasal Endoscopy Room Setup
2. Instrumentation and Equipment
   1. Standard
      1. Nasal Prep Tray
      2. Sinoscopy Instrument Tray
      3. Endoscrub system
   2. Special
      1. Sinus Tray (available only)
      2. Endoscopic Frontal Sinus Instrument Tray
      3. Sphenoid Punch Tray
      4. Minor Instrument Tray, Otolaryngology (available only)
      5. XPS Straightshot Resector Tray
      6. Sinoscopy Telescope Instrument Basket
      7. Sinoscopy Instrument Basket
      8. Neuro patties, ½ x ½, ½ x 1½, ½ x 3
      9. Storz fiberoptic light cable, 3.5 mm x 230 cm
3. Medications (specific to nursing)
   1. 1% lidocaine with 1:100,000 epinephrine. Alternatively, 4% cocaine (no more than 4 ml) may be used for pre-surgical vasoconstriction and to assist with hemostasis. (see below)
   2. Oxymetazoline HCL nasal spray, 0.05%
   3. Hydrogen peroxide solution, topical, 3%
   4. FRED (fog reduction elimination device)
4. Prep and Drape
   1. Standard prep, 5% providone iodine
   2. Drape
      1. Head drape
      2. A throat pack may be placed if concern exist for excessive bleeding is anticipated
      3. Square off with towels at neck and forehead
      4. Split sheet
      5. The patient's eyes should be left accessible for assessment during the case in the event of orbital injury or concern for intraorbital bleeding.
5. Drains and Dressings
   1. Merocel nasal packs
   2. Nasopore or Surgicel (or other absorbable packing) may be used
   3. A "drip dressing" may be fashioned using a 2x2 cm gauze or oval eye pad
   4. Special Considerations
   5. Place FRED and hydrogen peroxide solution on surgeon's instrument table in medicine glass with cotton.
   6. Specimens should be in saline. If specimen floats, notify surgeon (regarding periorbital fat).

ANESTHETIC CONSIDERATIONS

1. Intranasal anesthesia
   1. Cocaine: Only local anesthetic (blocks sodium channels) with vasoconstrictive properties (blocks sympathetic norepinephrine re-uptake leading to increased constriction)
      1. 4% topical solution (40 mg/ml); We use 4 ml  =  160 mg
      2. Safe maximum dose = 200 mg or 2-3 mg/kg (This is not based upon a controlled study)
2. Intravenous Conscious Sedation
   1. Local anesthesia with sedation or general anesthesia can be employed
3. Preoperative Systemic Medications
   1. Intravenous antibiotics at induction of anesthesia
4. Positioning
   1. Head of table oriented to position anesthesia equipment at the patient's side opposite the surgeon
   2. Television monitor offset from the head of the patient
   3. Instrument trays positioned so that instruments can be placed in the surgeon's hand away from the uncovered eyes of the patient
   4. Head of bed elevated (to decrease intraoperative bleeding)
   5. The oral endotracheal tube is traditionally secured to the corner of the mouth on the patient's LEFT side to allow ample access to the airway by the anesthesia provider and to prevent interference with the operative surgeon's hands during instrumentation.

OPERATIVE PROCEDURE

1. The nose is preliminarily packed under endoscopic control, using 0.5 x 0.5 in cottonoids soaked in oxymetazoline HCL, 0.05%, if the procedure is performed under general anesthesia. If the procedure is performed under local anesthesia, the pledgets are soaked in a solution of 8 cc of tetracaine HCL, 1%, and 2 cc of epinephrine nasal solution, 1:1,000. A lateral wall injection is performed at the root of the middle turbinate using 1% xylocaine and epinephrine, 1:100,000. The sphenopalatine may be injected at this time as well.  This injection site is located posterior and superior to the posterior root of the middle turbinate. This can be reached using a slightly bent 27 gauge spinal needle.
2. A full 10 minutes are allowed after injection and packing for decongestion to take effect. The CT scans are reinspected at this time. The packing is then removed on the side to be operated on first. In the case of severe septal deformity, the most open side is operated on first. The septoplasty is performed, and the second side is then subjected to surgery.
3. The surgical description is for a primary ethmoidectomy and maxillary antrostomy, using the Messerklinger technique. The eyes should be protected, but accessible to the surgeon, and checked periodically for evidence of increase in pressure due to intraorbital hemorrhage.
   1. The uncinate process is removed, using an infundibulotomy incision performed with a sharp sickle knife. The most posterior and inferior portion of the uncinate must be specifically removed to allow for early positive identification of the natural ostium of the maxillary sinus. Nasal polyps, when present, are removed using power-assisted suction dissection. Not every case of ESS requires maxillary antrostomy. If a decision is made to perform maxillary antrostomy, the antrostomy is made in the posterior fontanelle. The anterior lip of the ostium is left undisturbed to prevent circumferential scarring and to prevent damage to the lacrimal drainage system. It is crucial to identify accessory ostia and connect these with the natrual ostia of the maxillary sinus to avoid recirculation phenomena (as the cilia of the paranasal sinuses will only beat in the direction of natural ostia).
   2. The bulla ethmoidalis is entered in its inferomedial quadrant. Dissection is carried posteriorly through the basal lamina into the posterior ethmoids. Care is taken to maintain an inferior strut of basal lamina to help maintain support the middle turbinate. The skull base is identified in the posterior ethmoid where the ethmoid cells are larger and fewer in number. Dissection is then carried out from posterior to anterior along the previously identified skull base. If indicated, the frontal recess can be explored at this stage. Alternatively, in cases of isolated frontal disease, an intact bulla approach may be utilized.
   3. The sphenoid sinus can be entered, where indicated, using a variety of techniques. The sphenoid may be entered medial to the middle turbinate, using the arch of the posterior choana as a guide. The natural ostium can be enlarged inferomedially, or a fresh sphenoidotomy created. In dissections via the posterior ethmoid, the inferior portion of the superior turbinate can be resected to facilitate sphenoid ostial identification and entry. In almost every case, the sphenoid is more inferior and medial than initially thought. The sphenoid sinus is not a direct posterior relation of the last posterior ethmoidal air cell.
4. After completion of surgery, hemostasis is checked. The untaped eyes are again checked at the completion of the operation, as they have been on a regular basis throughout the surgery. If septal surgery is performed, the incision is closed and a quilting suture is used for flap approximation. Small Merocel stents may be placed in each middle meatus. Their use is not routine and depends on hemostasis and integrity of middle turbinate support.

POSTOPERATIVE CARE

1. Surgery is performed either as a day case or an overnight hospital observation (23-hour observation).
2. Begin oral feedings when the patient is alert.
3. Begin oral antibiotics covering staphylococcus when the nasal packs are in place. The antibiotics may be subsequently changed on the basis of intraoperative culture and sensitivity results.
4. Packs, if placed, are removed on postoperative day 3. Their removal is helped by having them preliminarily soaked with saline. Pack removal may produce brief bleeding. Under endoscopic control, the nose is suctioned free of clots. Gentle saline irrigations are started, when indicated, on postoperative day 1. Steroid nasal sprays are generally not started again for 3-4 weeks.
5. Endoscopically directed cleaning of the surgical cavity is performed at approximately weekly intervals for one month, depending upon the patient's progress. A copy of the operative pathology report is given to the patient at postoperative day 7.

SAMPLE DICTATION

1. Initial preparation and examination:

   • Informed consent was reviewed with the patient in the preoperative evaluation area. The patient was brought to the operating room, placed on the operating table in the supine position and transorally intubated. The patient was then draped in a clean fashion and placed in a reverse Trendelenburg position. Rigid nasal endoscopy was performed on both sides. 1% lidocaine and epinephrine 1:100,000 was injected in the lateral nasal wall and the axilla of the middle turbinate on both sides and the middle meatus on both sides packed with oxymetazoline-soaked cottonoid pledgets.

2. Documenting use of image guidance:

   • The Stealth image guidance system was then configured according to the manufacturer's instructions and the patient registered with the system. Image guidance was necessary due to the absence of normal anatomical landmarks. It was utilized throughout the procedure to confirm the location of the skull base, lamina papyracea, and other structures.

3. Concha bullosa takedown:

   • The concha bullosa of the middle turbinate was removed by making an incision in the anterior edge of the middle turbinate and removing the lateral portion of the middle turbinate. There was a large air cell within the middle turbinate that was exposed in this way. This opened up the middle meatus, so the lateral nasal wall was visible.

4. Uncinectomy and maxillary antrostomy:

   • The middle meatus was visualized and the uncinate was removed with a sickle blade and back biting forceps. The natural ostium of the maxillary sinus identified with a ball-tip prove and opened in a posterior and inferior direction to create a large antrostomy. The polyps and mucus within the maxillary sinus were removed and sent for culture and pathological analysis.

5. Ethmoidectomy:

   • Ethmoidectomy was then performed by proceeding through the ethmoid bulla, anterior ethmoid cells and into the posterior ethmoid air cells. The basal lamella and skull base were identified and the ethmoid air cells and their contents dissected off the skull base in a posterior to anterior direction. The frontal recess was then identified and cleared out, removing polyps and the suprabullar ethmoid air cells. The lamina papyracea was intact without evidence of violation of the orbit.

6. Sphenoidotomy:

   • The sphenoid rostrum was identified and a sphenoidotomy was created medial and inferior to the attachment of the superior turbinate. The sphenoidotomy was created in a medial and inferior direction. The sphenoid sinus was then explored with a 30-degree telescope and any polyps and inspissated secretions removed. The sinus was then copiously irrigated and suctioned gently to clear any remaining secretions and biofilm.

7. Balloon sinuplasty:

   • Balloon sinuplasty was performed. A Lumiere guidewire was utilized and confirmed to be within the frontal sinus. The balloon was inflated several times so the frontal recess was opened.

8. Wrap up:
   • The contralateral side was then addressed in a similar fashion performing a concha bullosa takedown, maxillary antrostomy, total ethmoidectomy, sphenoidotomy and balloon sinuplasty. Hemostasis was obtained with oxymetazoline-soaked cottonoid pledgets. Nasopore was placed on both sides of the middle meatus to help stop bleeding and also medialize the turbinates. The nose was then re-examined and hemostasis verified. Throughout the procedure, the eyes were intermittently examined. There was no evidence of violation to the lamina papyracea, and the eyes were soft to palpation on both sides. The patient tolerated the procedure well, was extubated in the operating room, and transferred uneventfully to the post anesthesia care unit.

REFERENCES

Bolger WE, Keyes AS, Lanza DC. Use of the superior meatus and superior turbinate in the endoscopic approach to the sphenoid sinus. Otolaryngol Head Neck Surg. 1999;120:308-13.

Graham SM, Carter KD. Combined-approach decompression for thyroid-related orbitopathy. Clin Otolaryngol. 1999;24:109-113.

Stammberger H. Functional Endoscopic Sinus Surgery. Philadelphia, Pa: BC Decker. 1991.