OPERATIVE
CARE
IN FESS
PATIENTS
DR. ASHISH CHANDRA AGARWAL
The primary objective of functional endoscopic sinus surgery (FESS)
is to restore paranasal sinus function by reestablishing the
physiologic pattern of ventilation and mucociliary clearance.
The goal of ESS is to remove irreversibly diseased mucosa and bone,
preserve normal tissue, and judiciously widen the true natural ostia of
the sinuses.
PREOPERATIVE
WORKUP
PREOPERATIVE WORKUP
1. History taking
2. Examination
3. Radiographic Assessment
4. Preoperative Medical Therapy
◦ Oral Corticosteroids
◦ Antibiotics
◦ Intranasal corticosteroid sprays
◦ Anti-histaminics
1. History taking
• History taking is the first and most important step in preparation and planning of FESS patients.
• Factors that have been associated with poorer outcomes from surgery must be assessed preoperatively.
• Drugs such as anticoagulants must be noted and stopped 5 days prior to surgery.
• Any history of nasal surgery (open/endoscopic) must be noted.
2. Examination
• Complete head and neck examination
• Basic ocular examination
• Anterior rhinoscopy - septal deviation, nasal valve collapse
• Posterior rhinoscopy – any presence of nasopharyngeal mass, status of ET opening, posterior
pharyngeal wall, nasal polyp extending into oropharynx
• Nasal endoscopy - should be conducted in a systematic fashion (three passes) with a rigid or flexible
endoscope. The character of the mucosa, appearance of the sinus drainage pathways, and the presence
of anatomic variations, structural abnormalities, purulent drainage, and polyps are noted.
PREOPERATIVE WORKUP
Tips for preoperative preparation include: For cases with chronic
rhinosinusitis, there are six main
use of short-term oral corticosteroids to help categories for the approach to
stabilize the mucosa and decrease blood loss. antibiotic use:
• no prior surgeries,
Oral antibiotics can help decrease • perioperative use,
inflammation. • antibiotics that are used
immediately post surgery,
Blood loss should be considered ahead of • cases where remote surgery is
performed (such as for acute
time -what is the total amount of loss that’s exacerbations),
acceptable and should the surgery be staged? • inflammatory basis for disease
Consider too the use of pledgets and whether (presence of polyps), and
• infectious-based cases
injections are intranasal or intraoral.
PREOPERATIVE WORKUP
• Biopsy of the nasal mass might be indicated in cases where the diagnosis is in doubt prior to
consideration for FESS.
• Serum Total IgE is indicated in patients with allergic etiology.
For cases with chronic rhinosinusitis, there are six main categories for the approach
to antibiotic use:
• no prior surgeries,
• perioperative use,
• antibiotics that are used immediately post surgery,
• cases where remote surgery is performed (such as for acute exacerbations),
• inflammatory basis for disease (presence of polyps), and
• infectious-based cases
3. Radiographic Assessment
• CT remains the gold standard imaging modality for preoperative diagnosis in FESS.
• Axial, Coronal and Sagittal views (atleast 5mm slices) should be obtained for each patient to assess the
anatomy, variations and disease extent in all the sinuses.
• CT scans are performed to assess sinonasal anatomy and disease pattern to guide surgery. Noncontrast
CT scans ordered for diagnostic purposes are useful for preoperative planning and can also be used for
image guidance if they are protocoled for use in navigation systems.
• If bony dehiscence or erosion of the skull base or lamina papyracea is present, magnetic resonance
imaging may be indicated for differentiating inflammatory sinus pathology from tumors and possible
encephaloceles.
• A mental or formal checklist is useful for preoperative planning.
CT Scan
Preoperative
Checklist
CT Scan Preoperative Checklist :
Axial View Coronal View Saggital View
A CT scan of a 35-year old male with findings suggestive of
Chronic Rhinosinusitis
CT Scan Preoperative Checklist :
Lamina papyracea
dehiscence
Radiographic anatomy of skull base
(Coronal View)
CT Scan Preoperative Checklist :
An acute angle of attachment between the
uncinate process and the lamina papyracea is
of significance as it increases the chances of
orbital penetration during FESS
Keros classification : Type 1 (1-3 mm)
Type 2 (4-7 mm)
Type 3 (8-16 mm)
CT Scan Preoperative Checklist :
Variations in attachment of Uncinate process
CT Scan Preoperative Checklist :
Coronal unenhanced CT scan shows right-
sided sphenoethmoidal (Onodi) cell (O) in
upper lateral sphenoid sinus (S). Projection
The anterior ethmoidal artery - branch of the of optic nerve canal into sphenoethmoidal
ophtalmic artery - exits the orbit through the (Onodi) cell (arrow) is evident.
anterior ethmoidal foramen and enters the
olfactory fossa at the point of attachment of the
CT Scan Preoperative Checklist :
CT Scan Preoperative Checklist :
A laterally draining FSDP into the
ethmoidal infundibulum (EE) when
the uncinate process attaches to
middle turbinate
CT Scan Preoperative Checklist :
CT scan showing Right Concha bullosa Coronal unenhanced CT scan of sinuses shows bilateral
paradoxically bent middle turbinates.
4. Preoperative Medical Therapy
• Patients should generally be treated with optimal medical therapy and fail adequate disease
control to be considered candidates for surgery.
• Factors that have been associated with poorer outcomes from surgery must be assessed
preoperatively.
• Stop Aspirin, Ibuprofen and Coumadin 5 days before and after surgery.
POST-OPERATIVE
CARE
1. Removal of nasal packs : Nasal packs, if kept, are removed at the time of discharge 24 h after the
operation.
2. Antibiotics : An intraoperative intravenous antibiotic (amoxiclav, cephalosporin or quinolone) is
administered and then continued for 7-10 days by oral route.
3. Anti-histaminics
1. Analgesics. For relief of postoperative pain.
2. Nasal irrigations. Saline irrigations are started after 1 week postoperatively to remove blood clots, crusts
and secretions and continued once or twice a day for 1 week.
3. Steroid nasal sprays. Required in cases of nasal allergy or those operated for nasal polyps.
POSTOPERATIVE CARE
• Surgical outcomes may be optimized through meticulous mucosal preservation and with removal of all
bony partitions within the sinuses addressed.
• Comprehensive postsurgical care with directed debridement, sinonasal irrigations, and appropriate
medical therapy is critical to achieving high success rates in surgery.
In-Hospital Care Ambulatory Care
POSTOPERATIVE CARE
The postoperative period is almost as critical to the success of surgery as the surgery
itself.
It is individualized for each patient in accordance to the extent of surgery done.
Two most important aim in follow up:
To ensure that crusting and scarring are not obstructing the sinus ostia;
To ensure that the middle turbinate is not lateralized.
Nasal packs, if kept, are removed in 3 to 5 days based on hemostasis and intraoperative mucosal
injury.
Patients with hypertension are advised to continue medications for the same with strict control
of blood pressure.
Patients on anticoagulants must omit their drugs for another 7 days postoperatively.
Oral Antibiotics are added till the nasal packs are in-situ.
Anti histaminics to be continued
After removal of the pack, endoscopic examination of the nasal cavity is done to ensure no
points of active bleed, crusts,major blood clots are present.
Intranasal corticosteroids are started in patients with allergic etiology.
POSTOPERATIVE CARE
1. Removal of nasal packs
2. Antibiotics
3. Anti-histaminics
POSTOPERATIVE CARE
4. Nasal saline irrigations
Saline nasal irrigation is encouraged in the postoperative period as it leads to
improved nasal and general symptoms and may help with postoperative
debridement.
5. Steroid nasal sprays
6. Analgesics
7. Endoscopic toilet
POSTOPERATIVE CARE
•Post-operative care for endoscopic sinus surgery includes 12:
•Arrange for transportation to take you home from the hospital.
•Fill prescription 1-2 days prior to surgery.
•Stop Aspirin, Ibuprofen and Coumadin 5 days before and after surgery.
•Gently apply ice packs over the nose and affected sinuses for initial 24 hours after surgery (15
minutes on/30 minutes off).
•Do not blow your nose for 1 week following surgery.
•You may be given prescriptions for antibiotic as oral steroids for several weeks to treat infection
and swelling.
•Activity should be limited for the first week after surgery.
7. Endoscopic toilet.
Blood clots, crusts and debris are removed by suction and forceps from the ethmoid are lateral
to middle turbinate. Any adhesion formation in the nose is divided with suction. Healthy mucosa
should not be disturbed. Suction can be done from within the maxillary sinus with a curved
cannula. Since the endoscopic clearance is a painful process, topical nasal anaesthetic with a
decongestant is sprayed before the procedure.
Patient pays weekly visits for inspection of the cavity for 4 weeks and thereafter as required till
mucosalization of the cavity is complete.
References
O’Brien, William T.; Hamelin, Stefan; Weitzel, Erik K. (2016). The Preoperative Sinus CT:
Avoiding a “CLOSE” Call with Surgical Complications. Radiology, 281(1), 10–
21. doi:10.1148/radiol.2016152230
Shpilberg, Katya A.; Daniel, Simon C.; Doshi, Amish H.; Lawson, William; Som, Peter M.
(2015). CT of Anatomic Variants of the Paranasal Sinuses and Nasal Cavity: Poor Correlation
With Radiologically Significant Rhinosinusitis but Importance in Surgical Planning. American
Journal of Roentgenology, 204(6), 1255–1260. doi:10.2214/AJR.14.13762
THANK YOU
Antibiotics are not routinely prescribed
o Instruct not to blow nose hard for at least 48 hours0
Commence topical decongestants for 5 days & saline spray for6weeks.o Suction toilet of the
nose•
Recommence long-term nasal steroids after 1 wk in nasal polyposis• Decrust the nose with a
rigid endoscope it necessary
