Preoperative and Intraoperative Management of Functional Endoscopic Sinus Surgery (FESS)

Pre-operative Considerations

The American Academy of Otolaryngology recommends mandatory pre-operative CT scanning to confirm disease extent and identify anatomical risk factors for complications in patients with recurrent sinus infections and potential bleeding disorders undergoing FESS 1
CT scanning without contrast is necessary prior to surgery to confirm the presence and extent of disease, and to identify anatomical features that may predispose to complications 1
For patients with recurrent infections, evaluation of mucosal thickening patterns is crucial, with rounded thickening suggesting low complication risk, while irregular or circumferential thickening >4mm requires otorhinolaryngology consultation before proceeding 2
A detailed medical history, including nasal obstructions, facial trauma, previous sinus infections, allergic symptoms, chronic respiratory diseases, previous nasosinusal surgeries, and atmospheric pressure-related discomfort, is essential for pre-operative assessment 3, 4, 5
For patients with potential bleeding disorders, documenting complete coagulation history, including anticoagulant use, family history of bleeding disorders, and previous bleeding complications, is vital 6

Meticulous attention to vascular anatomy is critical for patients with bleeding disorders, particularly the alveolo-antral artery location identified on pre-operative imaging 6
The use of bone wax for intrabony bleeding sources, diathermy for extrabony bleeding, and protection of the sinus membrane with collagen sponges during elevation can minimize perforation and bleeding 6
Ensuring wider flap design and proper retraction to maintain adequate access throughout the procedure, and using computed-guided antrostomy with surgical stents when available, can help minimize complications 6

Nasal saline irrigations are mandatory after FESS to improve mucociliary clearance and maintain sinus patency, with high-volume nasal douching (250ml twice daily) being more effective than spray or nebulization 10
Continuing nasal corticosteroid sprays for maintenance therapy and providing appropriate pain management with minimal opioid use are essential for post-operative care 1, 7, 11
Regular endoscopic examination is necessary to detect early complications, with the first examination typically within 1-2 weeks post-operatively 11
Monitoring for disease recurrence, which occurs in approximately 12% of patients despite initial improvement, and assessing surgical ostium patency for narrowing from synechiae, edema, or thickened mucus, are crucial for long-term follow-up 11