’ Review Article

Anesthetic considerations for functional

endoscopic sinus surgery: a narrative review
Amit Saxena, MD*, Vladimir Nekhendzy, MD, FASA

Abstract
This review article discusses state-of-the-art perioperative anesthesia care for patients presenting for functional endoscopic sinus
surgery (FESS). A comprehensive literature review (years 2000–2019) was performed with a focus on FESS topics related to
preoperative patient evaluation and preparation, airway management, and optimization of the major anesthetic and surgical goals.
The authors identify and elaborate in detail on essential intraoperative considerations, such as the use of controlled hypotension and
total intravenous anesthesia, discuss their advantages and disadvantages and provide practical recommendations for manage-
ment. Lastly, the postoperative period for patients undergoing FESS is discussed with an emphasis on approaches that facilitate
prompt hospital discharge with high patient satisfaction.
Keywords: Endoscopic sinus surgery, Functional endoscopic sinus surgery, Anesthesia, General anesthesia, Laryngeal mask
airway, Controlled hypotension, Deliberate hypotension, Total intravenous anesthesia, Remifentanil

E
ndoscopic sinus surgery is one of the most commonly
performed surgical procedures in the United States[1,2].
The increased use of precision, image-guided surgery has
led to improved patient safety and to a rise in functional endo-
scopic sinus surgery (FESS) cases performed for treatment of
chronic rhinosinusitis (CRS).
The anesthesiologist should act as a knowledgeable consultant
for appropriate patient selection and preparation, understand
some of the unique anesthetic goals for FESS (Table 1) and be
comfortable with total intravenous anesthesia (TIVA).[3,4] Most
of the FESS procedures are performed in a free-standing ambu-
latory surgical centers, which presents additional challenges due
to a combination of limited anesthesia back-up, variability of
monitoring modalities and anesthesia equipment, and the pres-
sure to produce cost-effective, efficient, and quality care.
This review aims to address possible existing gaps in knowl-
edge and summarizes the best practices for perioperative anes-
thesia management of adult patients presenting for FESS.
Sponsorships or competing interests that may be relevant to content are disclosed
at the end of this article.
Departments of Anesthesiology, Perioperative and Pain Medicine, Stanford
University Medical Center, Stanford, CA
*Corresponding author. Address: Department of Anesthesiology, Perioperative and
Pain Medicine, Stanford University Medical Center, Rm H3580 300 Pasteur Drive
Stanford, CA 94305-5640. Tel.: + 650-723-6412; fax: + 650-725-8544. E-mail
address: arsaxena@stanford.edu (A. Saxena).
Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of
The Society for Head and Neck Anesthesia. This is an open access article distributed
under the Creative Commons Attribution License 4.0 (CCBY), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original
work is properly cited.
Journal of Head & Neck Anesthesia (2020) 4:e25
Received 22 November 2019; Accepted 11 March 2020
Published online 21 April 2020
http://dx.doi.org/10.1097/HN9.0000000000000025
Methods
A main and additional specific literature searches using MeSH
terms, title words, and text words were performed in PubMed for
the years January 1, 2000 to October 27, 2019 (Appendix 1). A
total of 1564 articles were identified and 1454 were analyzed
after removing 200 duplicate papers. Upon review, 260 refer-
ences were identified as pertinent and 164 articles were selected
for this publication.
Preoperative patient assessment and preparation
The adult patients presenting for FESS are diverse and could be
either completely healthy (American Society of Anesthesiologists
[ASA] physical status I) or have controlled systemic diseases of
varying severity (ASA physical status II–III). Patients of both
sexes are approximately equally affected, and the surgical
procedure spans across all age groups[5]. The debilitating symp-
toms of CRS and frequent revision surgeries may leave a long-
standing negative psychological impact, and result in chronic
depression and/or pain in up to 20% of patients[6,7].
Outpatient FESS can be considered a low-risk surgical procedure,
with similar rate of major complications (cerebrospinal fluid leak,
meningitis, hemorrhage, orbital injuries) recorded for both primary
and revision cases (0.36% vs. 0.46%, odds ratio = 1.26; 95%
confidence interval: 0.79–2.00)[8]. Suzuki et al[9] found an overall
incidence of surgical complications after FESS at 0.5%, with
the corresponding rates for cerebrospinal fluid leak 0.09%, orbital
injury 0.09%, and hemorrhage requiring surgery 0.1%.
Nevertheless, the anesthesiologist should be aware that the surgery
itself presents an independent risk factor for an unanticipated
overnight hospital admission, and for early hospital readmission
due to nasal bleeding, pain, or intolerance of nasal packing or
dressing[10,11].
Major perioperative considerations should center around
general anesthetic requirements for head and neck surgery[3], and
those specific for FESS (Table 1). Focused patient assessment and

1
Saxena and Nekhendzy. JOHNA (2020) 4:e25
Table 1
Major anesthetic objectives and strategies for functional
endoscopic sinus surgery.
Objectives Strategies
Airway management Facilitate surgical access
Shared airway precautions
Preference for the flexible laryngeal mask airway
(FLMA) as a primary ventilatory device
Provision of a clear surgical field Superior hemodynamic stability
A stable, adequate plane of anesthesia
Preference for total intravenous anesthesia (TIVA)
with propofol and remifentanil
Moderate controlled hypotension
Relative bradycardia
Preference for FLMA as a primary ventilator device
Hypnotic monitoring
Effective surgical hemostasis
Elevating patient’s head 15–20 degrees
Minimizing mean inspiratory pressure during
controlled ventilation
Immobility of the surgical field for Absence of patient’s movement
precision surgery Hypnotic monitoring
Avoidance of iatrogenic motion interference:
Placement of blood pressure cuff away from
the surgeon
Situational awareness
Smooth and rapid emergence from Preference for TIVA with propofol and
anesthesia, without associated remifentanil
bucking, coughing, or straining Avoidance of deep extubation
Rapid return of consciousness and protective
airway reflexes
Smooth extubation strategies:
Remifentanil emergence
Bailey maneuver
FLMA as a primary ventilatory device
Fast-tracking patients for discharge Stratified use of intravenous opioids
Multimodal analgesia
Adjuvant techniques
Aggressive prevention of postoperative nausea
and vomiting
preparation shall be aimed at optimizing intraoperative surgical
exposure and minimizing factors that may promote bleeding in
the perioperative period.
Maintaining superior hemodynamic stability during FESS is
required intraoperatively, and special attention should be direc-
ted to patients with preexisting coronary artery disease and sys-
temic hypertension (HTN). Poorly controlled HTN carries
increased risk of microvascular bleeding or postoperative hema-
toma formation[12]. Controlled hypotension (CH) should be
avoided in patients with advanced cardiac disease, history of
cerebrovascular abnormalities, and those with chronic kidney
and liver disease. Patient’s suitability for controlled hypotensive
anesthesia (discussed below) should be carefully evaluated.
Evaluation of the patient’s cardiac status should follow the
American College of Cardiology (ACC) and American Heart
Association (AHA) guidelines on perioperative evaluation and
care for noncardiac surgery[13]. If the patient’s baseline functional
capacity is moderate-to-excellent then additional cardiac testing
should not be required. Patients with significant cardiac disease
need to be evaluated by the cardiologist preoperatively.
2
Journal of Head & Neck Anesthesia
Cardiac and anti-HTN medications should usually be continued
in the perioperative period. It is common for surgeons to inject local
anesthetic with epinephrine into the nasal mucosa, but it should be
noted that preoperative pharmacologic β-blockade could lead to an
exaggerated intraoperative hypertensive response to intranasally
injected epinephrine-containing solutions[14]. Both the anesthesiol-
ogist and surgeon should be aware of this potential occurrence and
the risks and benefits should be discussed. Minimizing the rise in
blood pressure could be accomplished by administering additional
anti-hypertensive agents besides β-blockade at the time of local
anesthetic injection or by decreasing the concentration of epi-
nephrine in the local anesthetic mixture if possible[4,14,15].
It is common for patients to be on a variety of oral antic-
oagulants prior to elective FESS, and plans for cessation of
anticoagulants and antiplatelet agents for high risk patients
should be formulated in consultation with patient’s cardiologist
or primary care physician[15,16]. The nonsteroidal anti-inflam-
matory medications (NSAIDs) and herbal supplements such as
the 4 Gs (garlic, ginkgo biloba, ginseng, ginger) and certain
vitamins (eg, vitamin E), may provoke microvascular bleeding
and should ideally be discontinued at least 1 week before surgery
when possible[17,18].
Optimization of the pulmonary status of patients with cystic
fibrosis will decrease the possibility of postoperative pulmonary
complications. It will also minimize the risk of excessive coughing
on emergence from anesthesia and in the immediate postoperative
period, which may provoke postoperative bleeding. Nearly 50% of
patients with CRS and nasal polyposis develop comorbid asthma,
which is thought to impact disease severity and deteriorate intrao-
perative conditions[19,20]. At least 16%–26% of these patients also
have concomitant hypersensitivity to aspirin and cyclooxygenase 1
(COX-1) inhibitors, and a high incidence of reactive airway
disease[19,21]. Perioperative use of inhaled bronchodilators is indi-
cated in these patients[16], and intraoperative use of NSAIDs
including IV ketorolac, should be avoided[21].
Preoperative administration of systemic antibiotics or steroids to
counteract active infection and decrease tissue swelling will vary
depending on surgeon’s preference[22]. Nevertheless, many of the
patients with nasal polypoid disease will have received a pre-
operative course of oral steroid therapy in an attempt to reduce
intraoperative bleeding and improve surgical visibility[23–28]. Simple
sinus surgery may only require a small dose such as 4 mg IV dex-
amethasone; however, more extensive polyposis may require a dose
up to 12 mg to further decrease postoperative edema. Routine
intraoperative administration of IV dexamethasone also makes
additional stress-dose steroids unnecessary[21].
Patients with diabetes mellitus and those with rheumatologic
diseases may be particularly prone to bruising and delayed healing,
and will require careful intraoperative positioning. The positioning
considerations equally apply to the elderly patients[29]. Healthy
elderly patients can undergo outpatient surgery safely[30,31], but the
anesthesiologist should be aware of pathophysiological implications
of advanced age on organ function and pharmacokinetics of anes-
thetic drugs. A steadfast maintenance of intraoperative nor-
mothermia is also important for the elderly[29].
Routine and comprehensive preoperative airway evaluation
should include a careful history and an 11-point ASA bedside air-
way examination[32]. Special attention should be directed to iden-
tifying the predictors of difficult and/or impossible mask ventilation
and their association with difficult direct laryngoscopy[33–36]. The
patients with the history of difficult airway, obesity, and obstructive
Saxena and Nekhendzy. JOHNA (2020) 4:e25
sleep apnea (OSA) should be approached with particular caution[4].
Obese patients have a higher incidence of adverse airway events on
induction and emergence from anesthesia[37]. The possibility of
difficult mask ventilation and difficult tracheal intubation shall
always be considered in OSA patients[33–35].
Patients with known or suspected OSA should be carefully
screened for suitability for the same day ambulatory surgery,
as they demonstrate the increased risk for perioperative
complications[38]. The enhanced sensitivity of OSA patients to
opioids and benzodiazepines[39,40] may lead to rapidly developing
respiratory depression and airway obstruction. The nature of FESS
also makes institution of effective postoperative continuous positive
airway pressure treatment problematic for these patients. The
patients with either known or presumed OSA should undergo
outpatient surgery only if their cardiovascular and pulmonary
comorbidities are optimized and will especially benefit from mul-
timodal approach to perioperative analgesia[38,41,42]. For practical
purposes, the patients with severe OSA should not routinely
undergo outpatient FESS surgery under general anesthesia or
sedation[4].
Anesthetic management
The essential anesthesia requirements for FESS include airway
management considerations for facilitating surgical access, pro-
vision of a clear and still surgical field for precision surgery,
assuring quick and nonstimulating emergence from anesthesia,
and fast-tracking patients for discharge (Table 1). The strategies
to achieve these objectives are discussed below.
Premedication and monitoring
The IV placement on the patient’s side next to the surgeon (usually,
on patient’s right), and the noninvasive blood pressure cuff on the
opposite side may be recommended for FESS cases to avoid
iatrogenic noninvasive blood pressure–induced tremor interference
with precision surgery[3]. A 20 g IV is usually sufficient for FESS.
Routine ASA monitoring is usually sufficient, even if CH is used
intraoperatively. The forehead sensors for electroencephalogram-
based assessment of the depth of anesthesia usually do not interfere
with intraoperative use of stereotactic navigation system by the
surgeon and can be particularly beneficial when TIVA is used.
Conscious sedation
In highly motivated patients, selected FESS cases can be per-
formed under local anesthesia with sedation (monitored anesthe-
sia care, MAC). Local anesthesia removes the need for airway
management, may shorten the operating time and reduce blood
loss, eliminates the general anesthesia emergence phenomena,
reduces the incidence of postoperative nausea and vomiting
(PONV), and facilitates patient’s discharge[4,43,44].
Administering a successful MAC without immediate access to the
patient’s airway (the OR table is usually turned away from the
anesthesiologist) is frequently more challenging than conducting a
general anesthetic[4]. Effective administration of supplemental
oxygen (O2) during FESS is problematic, and blunting fluctuating
levels of noxious stimulation may be difficult due to the highly
variable patient’s responses. Oral O2 administration makes capno-
graphy monitoring unreliable, and placement of the precordial
stethoscope over the patient’s trachea to monitor breath sounds may
be recommended.
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If MAC is chosen, the desired level of sedation should be clearly
defined and discussed with the surgeon preoperatively. Once the
consensus is reached, the choice for safe and rationale use of IV
sedating, analgesic, and hypnotic agents will largely depend on
the preference and experience of the anesthesiologist[4]. Sedation
of OSA and morbidly obese patients should either be avoided or
performed with extreme caution[45,46].
Local and regional anesthesia (eg, sphenopalatine ganglion
block) facilitates MAC cases, and its use is widespread to supple-
ment general anesthesia, which is performed far more frequently.
General anesthesia
Compared with MAC, general anesthesia provides adequate
amnesia, protects patient’s airway, assures adequate gas exchange,
and abolishes patient’s movement[4].
Airway management
Under general anesthesia, either an oral tracheal intubation
(endotracheal tube, ETT), or a flexible laryngeal mask airway
(FLMA, Teleflex Inc., Wayne, PA) can be used to secure and
maintain patient’s airway. A wire-reinforced flexible ETT or RAE
ETT may be recommended to facilitate surgical access and are
usually taped midline; FLMA is secured in a similar manner.
Intraoperative access to the patient’s airway is highly restricted,
as the OR table is usually turned 90 or 180 degrees away from the
anesthesiologist. Therefore, the dedicated airway and all the
anesthesia circuit connections must be properly secured.
Although tracheal intubation is performed more frequently,
absent contraindications (eg, poorly controlled gastroesophageal
reflux disease, history of upper gastrointestinal surgery, stage II–
III obesity, etc.) the use of FLMA may offer significant advan-
tages, including decreased incidence of the upper airway trauma
and adverse respiratory events, facilitation of maintenance of
anesthesia and quality of surgical field, and smoother and faster
emergence from anesthesia[4,47–54]. The properly placed FLMA
creates a reliable oropharyngeal seal, adequately protecting the
lower airway from blood, secretions, irrigation fluid and surgical
debris[48,55–57]. Furthermore, with the use of FLMA neuromus-
cular blockade can be avoided and the resumption of adequate
spontaneous ventilation is greatly facilitated[58].
If FLMA is chosen, meticulous attention must be directed to the
confirmation tests for its placement, to assure adequate ventilation
and airway protection[58]. Using 3 strict criteria for proper FLMA
placement and function during administration of the positive pres-
sure ventilation (PPV), such as the ability to achieve and/or maintain
adequate ventilation (tidal volume, ≥ 6 mL/kg), airway protection
from above the cuff (airway sealing pressure, > 12 cm H2O), and
adequate separation of the respiratory and gastrointestinal tracts
(absent gastric insufflation during PPV), Nekhendzy et al[58] have
demonstrated a nearly 93% overall success rate of intraoperative
FLMA use by experienced operators.
Anesthesia induction and maintenance
Standard IV induction with propofol and opioid is used most often,
and propofol’s beneficial antiemetic effect is facilitated if TIVA is used
for maintenance[59,60]. Most prospective studies demonstrate that,
compared with balanced inhalational technique, TIVA provides
superior intraoperative hemodynamic stability, quicker recovery
times, faster return of cognitive function, decreased incidence of
Saxena and Nekhendzy. JOHNA (2020) 4:e25
PONV, and improved patient satisfaction[4,61,62]. If inhalational
anesthetic is chosen for maintenance, sevoflurane may be preferred,
as it reduces the incidence of coughing and postoperative agitation
compared with desflurane, and produces less somnolence and PONV
compared with isoflurane[63–66].
Provision of a clear and quiet surgical field
Achieving effective surgical hemostasis is critical for FESS, as even a
small amount of bleeding can have a significant impact on intrao-
perative exposure. The conventional interventions, such as elevating
the patient’s head 15–20 degrees[67,68] (reverse Trendelenburg posi-
tion should be avoided to prevent intraoperative fluid shifts), topical
decongestion of the nasal mucosa, and the use of injectable
vasoconstrictors by the surgeon play an important role in optimizing
the view of the operative field. A recent meta-analysis by Kim et al[69]
has shown that intraoperative administration of tranexamic acid IV
10–15 mg/kg (not to exceed 1 g total dose), decreases intraoperative
bleeding, operative time and improves surgical visibility without side
effects. The clinical significance of these findings may apply mostly to
cases where larger than usual intraoperative bleeding is anticipated.
Compared with inhalational or balanced inhalational anesthesia,
best surgical visibility may be afforded by TIVA with propofol
(90–150 mcg/kg/min) and remifentanil (0.1–0.3 mcg/kg/min),
which facilitates induction and maintenance of moderate CH (mean
arterial pressure, MAP, 60–70 mm Hg)[4,15,21,22,70–76]. Maintaining
intraoperative MAP within 60–70 mm Hg range in otherwise
healthy patients is safe during FESS, and no biomarkers of the
associated cerebral ischemia could be detected[77].
Under moderate CH, synergistic interactions of IV propofol
and remifentanil optimize surgical field through a combination of
cardiac negative chronotropic and inotropic effects[70,71,73,78–85].
In contrast, when the vapor-based or balanced FESS anesthesia
techniques are selected, especially in conjunction with the use of
direct-acting peripheral vasodilators (eg, sodium nitroprusside),
heart rate (HR) increases, and a lower quality of surgical field and
a clear trend toward increased blood loss is observed[78,81–84,86].
Some controversy exists regarding the effect size of TIVA-
induced CH on intraoperative blood loss and the quality of sur-
gical field during FESS[87,88]. In some studies, no clear direct
correlation between intraoperative MAP and blood loss could be
demonstrated[78,79,89–92]. Gomez-Rivera and colleagues showed
that TIVA compared with a sevoflurane-remifentanil anesthetic
actually increased sinonasal mucosal blood flow as measured by
optical rhinometry but found no difference in blood loss or sur-
gical field visualization[93]. This may be related to the complexity
of nasal vascular structure and to the predominantly capillary
nature of the bleeding[80,89]. As a result, while the intensity of
arterial bleeding during FESS will be mainly influenced by MAP
and HR[80–82], other factors, such as local mechanisms regulating
functional capillary networks and venous pressure may play a
significant role in regulating overall nasal capillary perfusion[94].
A prospective, randomized trial of 180 patients conducted under
TIVA and CH demonstrated that the blood loss during FESS may be
best predicted by the severity of preexisting sinus disease
and duration of surgery[94]. This suggests that factors such as
adherence to meticulous surgical technique, and judicious use of
epinephrine-containing local anesthetic solution to decongest nasal
mucosa may be more important in reducing intraoperative bleeding
than any single anesthesia-related intervention[94]. Proper anesthetic
management, however, can indirectly decrease blood loss during
4
Journal of Head & Neck Anesthesia
FESS by improving the operating conditions and allowing for a
more rapid surgery[94].
Aside from remifentanil, a range of other medications have been
successfully tried for improving operating conditions during FESS,
but perioperative use of the α2-adrenoreceptor agonists and β-
blockers deserve a special discussion. The use of the centrally acting
α2-adrenoreceptor agonists, such as clonidine or dexmedetomidine,
produces a dose-dependent reduction of the central sympathetic
outflow, with resultant decrease in blood pressure and HR. In small
prospective trials, the use of both oral and IV clonidine effectively
improved the surgical field for different anesthetic techniques during
FESS, compared favorably with IV remifentanil, but results in
undesired carry-over patient sedation[95–101]. Dexmedetomidine has
been extensively studied due to its dose-dependent sedation and
anxiolysis, potentiation of the opioid analgesia, absent or minimal
respiratory depression, and additional antisialagogue, antitussive
and sympatholytic properties[102–110]. As opposed to clonidine,
which possesses partial α1-adrenoreceptor agonist properties and
may produce variable hemodynamic responses, dexmedetomidine is
not only more α2-adrenoreceptor selective, but has an affinity to
α2-adrenoreceptors 8 times that of clonidine[111]. Even preoperative
topical administration of atomized dexmedetomidine may result in
improved surgical conditions and decreased bleeding during FESS,
despite the severity of preoperative surgical pathology[112]. Some
small randomized trials have shown that compared with IV remi-
fentanil or esmolol, IV dexmedetomidine produced comparable
decreases in HR and MAP[113,114], but similar to clonidine caused
more somnolence and prolonged recovery room stay in the
immediate postoperative period[115].
The perioperative use of an oral (eg, metoprolol) and IV
β-blockers (eg, esmolol, labetalol) desirably elicits negative chron-
otropic and inotropic effects, resulting in improved operating
conditions[89,116–121]. The additional advantage of IV esmolol may
be related to its ability to potentiate opioid-induced analgesia,
decrease the incidence of postoperative nausea and vomiting, and
improve the overall patient’s recovery room profile[118–120,122–131].
Besides medications, the influence of intraoperative factors,
such as carbon dioxide (CO2) level and mechanical ventilation
modalities on intraoperative bleeding and quality of surgical field
has been investigated in a number of ESS trials[94,132,133]. No
effect of adjusting the CO2 levels to either hypocapnia or
hypercapnia[94], choosing pressure-controlled versus volume-
controlled ventilation[133], with or without positive end-expira-
tory pressure (PEEP)[132] could be demonstrated, but lowering
mean inspiratory pressure below 15 cm H2O was found to be
beneficial if PEEP was used concomitantly[132]. The latter finding
may favor the use of pressure-controlled ventilation intraopera-
tively, especially if PPV through FLMA is used[58].
Smooth and rapid emergence from anesthesia
A quick emergence from anesthesia, without associated bucking,
straining, or coughing and with full return of patient’s protective
airway reflexes is required to help prevent profuse microvascular
bleeding and laryngospasm, and also minimizes postextubation
hypertensive responses.
The use of FLMA in lieu of ETT will enable smooth patient
awakening and allow for safe reduction of the level of anesthesia
near the end of the surgery[4,58]. With ETT, smooth emergence
constitutes a particularly challenging task. True deep extubation has
associated risks after FESS because of the increased risk of
Saxena and Nekhendzy. JOHNA (2020) 4:e25
postextubation laryngospasm and increased need for airway sup-
port on the part of the anesthesiologist[4,21]. A few strategies can be
tried. One, is the Bailey maneuver[134], which involves insertion of
the LMA behind the existing ETT at a sufficiently deep plane of
anesthesia, removal of the ETT, and administration of the ventila-
tory support through the LMA until the return of spontaneous
ventilation and awakening from anesthesia. Another approach to
extubation is ventilation through an extraglottic tracheal tube[135].
This is referred to as an asleep-staged extubation and involves
withdrawal of the tracheal tube until the tip rests above vocal cords
in the supralaryngeal space. This technique requires practice but
when performed appropriately can be well tolerated by the patient
to avoid bucking while still providing adequate oxygenation and
ventilation. The last approach relies on a low-dose remifentanil
infusion during emergence to dull the tracheal responses and pro-
mote smooth extubation. Current data indicate that EC95 of the
effect site concentration of remifentanil for blunting tracheal reflexes
ranges between 1.5 and 2.9 ng/mL (corresponding manual infusion
rate 0.05–1.0 mcg/kg/min)[136–145].
Fast-tracking patients for discharge
FESS is characterized by low postoperative pain scores[146], and
remifentanil represents a nearly ideal intraoperative opioid due to
its context-insensitive half-life, superior potency and titratability,
and demonstrated improvement of respiratory and general
patient recovery after outpatient surgery (Nekhendzy and
colleagues)[4]. Furthermore, the intraoperative use of IV fentanyl
can either be completely avoided, or safely limited to a total dose
1–2 mcg/kg for the majority of patients.
While postoperative analgesia in the recovery room after FESS is
easily facilitated by IV fentanyl, 25–50 mcg prn, and early transition
to oral pain medications, there is also a role for multimodal
analgesia to help keep opioid use to a minimum. Studies have shown
that scheduled oral acetaminophen can provide effective pain con-
trol and reduced opioid requirements in the days after surgery[146],
and the initial investigations into the value of perioperative IV
acetaminophen use for pain control after FESS seem encouraging
although no definitive conclusions can be made[147].
The immediate recovery room period after FESS is usually
uncomplicated. A retrospective study by Gengler et al[10] of over
900 patients after sinonasal surgery demonstrated that the
patient’s age (older than 50), duration of surgery (longer than 80
min), and the requirement for nasal packing carried a statistically
higher risk for unanticipated hospital admission. Early BP control
is essential for preventing occult postoperative bleeding, and is
usually achieved by administration of IV labetalol, 0.1–0.2 mg/
kg, in repeated doses.
The incidence of PONV is reduced with TIVA and remifentanil
use, as the emetogenic effect of inhalational anesthetics is
avoided[148]. Patient’s discharge can be further facilitated by
aggressive PONV prophylaxis, usually with IV 5-HT3 antagonist
(eg, ondansetron 4–8 mg) and IV dexamethasone (8–12 mg),
which is routine for FESS. Multimodal PONV prophylaxis (eg,
the addition of transdermal scopolamine patch) is warranted in
high risk patients[148,149].
Several small prospective randomized trials attempted to further
improve postoperative analgesia and patient’s recovery profile
through the use of the regional nerve blocks, most commonly sphe-
nopalatine ganglion block[150–157]. While infiltrative submucosal
local anesthesia is used commonly by the surgeon intraoperatively,
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adequate analgesia may be difficult to attain secondary to preexisting
mucosal inflammation, extensive polyposis, bleeding and other
technical difficulties[158]. The results of the sphenopalatine ganglion
block investigations are largely equivocal, with some studies
demonstrating lower pain scores, reduced analgesic consumption, less
nausea and vomiting, and faster recovery room discharge
times[151–153,155–157], and others[150] failing to show significant ben-
eficial effects. Other intraoperative techniques for postoperative pain
control that show early promise include topical fentanyl application
to nasal packs and intraoperative infusion of magnesium[159,160].
Although current evidence supports the postdischarge use of
NSAIDs and gabapentin for the control of pain after FESS[161,162],
the prescription of postoperative opioids after FESS continues to
predominate among the members of the surgical community[146,163].
In a retrospective study of 136 FESS patients, Raikundalia et al[164]
identified concurrent septoplasty and younger patient’s age as the
factors predisposing to increased postoperative opioid usage. These
findings provide additional insight for pain management in the
immediate postoperative period and can guide surgeons to counsel
their patients on expectations for postdischarge pain better[164].
Conclusions
Anesthetic management for FESS presents some unique anesthesia-
related considerations. Provision of a clear and still surgical field and
assuring smooth, nonstimulating emergence of anesthesia should
constitute some of the top priorities for the anesthesiologist.
The anesthesiologist caring for FESS patients should become
familiar with the proper patient selection and preparation,
understand the critical parts of the precision surgery, and com-
municate closely with the surgical team during the perioperative
period. Thorough appreciation of the fundamental principles of
the anesthetic management for FESS and meticulous execution of
the properly selected anesthetic and airway management strate-
gies will facilitate surgical access and may contribute to improved
patient outcomes.
Conflicts of interest disclosures
The authors declare that they have no financial conflict of interest
with regard to the content of this report.
Appendix 1. Literature searches performed in
PubMed database using MeSH terms, title words and
text words for the years January 1, 2000 to October
27, 2019. The searches were limited to PubMed
filters, such as “Languages” (English), “Humans” and
“Ages” (Adult: 19 + years).
1. Main literature search (the numbers represent the specific anesthe-
sia journals indexed in PubMed)
(“anesthesia” [mesh] OR “anesthesia, general” [mesh] OR
Anesthesia and Analgesia [mesh] OR sedat* [ti] OR anesthes*
[tw] OR “positive pressure”[tw] OR Airway Management [mesh]
OR “positive airway” [tw] OR ventilation [tw] OR “Signs and
Symptoms, Respiratory” [mesh] OR hypercapn* [tw] OR hypo-
capn* [tw] OR hypox* [tw] OR “Anesthetics, Intravenous”
[Pharmacological Action] OR “Anesthetics”[Mesh] OR
“Anesthetics” [Pharmacological Action] OR “Hypnotics and
Saxena and Nekhendzy. JOHNA (2020) 4:e25
Sedatives”[Mesh] OR “Hypnotics and Sedatives”
[Pharmacological Action] OR dexmedetomidine [tw] OR remifen-
tanil [tw] OR 101637720 [jour] OR 0431420 [jour] OR 0340732
[jour] OR 0421022 [jour] OR 0370270 [jour] OR 0370271 [jour]
OR 9432542 [jour] OR 101214918 [jour] OR 8409340 [jour] OR
9504685 [jour] OR 101652401 [jour] OR 0342017 [jour] OR
0371112 [jour] OR 0370524 [jour] OR 101472620 [jour] OR
7611455 [jour] OR 0370525 [jour] OR 8005775 [jour] OR
9109478 [jour] OR 0436571 [jour] OR 7705399 [jour] OR
9424972 [jour] OR 1310650 [jour] OR 0404017 [jour] OR
9207842 [jour] OR 0043533 [jour] OR 101273663 [jour] OR
8810131 [jour] OR 0414774 [jour] OR 1300217 [jour]
OR 0372332 [jour] OR 9815987 [jour] OR 8213275 [jour] OR
101121446 [jour] OR 100968535 [jour] OR 0372541 [jour] OR
101624623 [jour] OR 100891616 [jour] OR 0370650 [jour]
OR 0371163 [jour] OR 8701709 [jour] OR 7909277 [jour] OR
0317206 [jour] OR 7900421 [jour] OR 9109511 [jour] OR
8813436 [jour] OR 7806536 [jour] OR 0373214 [jour]
OR 8411711 [jour] OR 8804068 [jour] OR 0370760 [jour] OR
9200430 [jour] OR 8009540 [jour] OR 0431453 [jour] OR
8905667 [jour] OR 101651624 [jour] OR 8709732 [jour] OR
9110208 [jour] OR 8812166 [jour] OR 0330010 [jour] OR
8910749 [jour] OR 9610507 [jour] OR 8609069 [jour] OR
7503104 [jour] OR 7605042 [jour] OR 8200948 [jour] OR
0413707 [jour] OR 8604187 [jour] OR 0375272 [jour] OR
9009407 [jour] OR 9206575 [jour] OR 0417656 [jour] OR
8309693 [jour] OR 7707549 [jour] OR 9804508 [jour] OR
0401316 [jour] OR 0135226 [jour] OR 0134516 [jour] OR
9807630 [jour] OR 100956422 [jour] OR 0332052 [jour] OR
0417700 [jour]) AND (fess [tw] OR (“paranasal sinuses/surgery”
[mesh] OR “sinusitis/surgery” [mesh] OR (sinus* [tw] AND surg*
[ti])) AND (Endoscopy [mesh] OR endoscop* [tw])) AND
English [lang]
2. Additional literature searches.
a. Preoperative assessment
(“paranasal sinuses/surgery” [mesh] OR “sinusitis/sur-
gery” [mesh] OR (sinus* [tw] AND surg* [ti])) AND
(Endoscopy [mesh] OR endoscop* [tw]) AND English
[lang] AND (Preoperative Care[mesh] OR “preoperative
assessment” [tw] OR preoperat* [ti] OR (anesth* [ti]
AND (evaluat* [ti] AND assess* [ti])))
b. Monitored anesthesia care (MAC)
(MAC [tw] OR “monitored anesthesia” [tw]) AND (“para-
nasal sinuses/surgery” [mesh] OR “sinusitis/surgery”
[mesh] OR (sinus* [tw] AND surg* [ti]) AND (Endoscopy
[mesh] OR endoscop* [tw])) AND English [lang]
c. Regional anesthesia/Nerve block
(“Nerve Block” [mesh] OR “nerve block” [tw] OR
“Anesthesia, Conduction” [mesh] OR “regional anesthe-
sia” [tw] OR “sphenopalatine ganglion block” [tw] OR
block [ti]) AND (“paranasal sinuses/surgery” [mesh] OR
“sinusitis/surgery” [mesh] OR (sinus* [tw] AND surg*
[ti]) AND (Endoscopy [mesh] OR endoscop* [tw])) AND
English [lang]
d. Inhalation anesthesia versus total intravenous anesthesia
(TIVA)
((“Anesthetics, Inhalation” [mesh] AND “Anesthetics,
Intravenous” [mesh]) OR (inhal* [ti] AND intravenous
[ti]) OR (TIVA [ti] AND inhal* [ti])) AND ((“paranasal
sinuses/surgery” [mesh] OR “sinusitis/surgery” [mesh]
6
Journal of Head & Neck Anesthesia
OR (sinus* [tw] AND surg* [ti])) AND (Endoscopy
[mesh] OR endoscop* [tw])) AND English [lang]
e. Blood loss and Controlled hypotension
(hypotension [ti] OR “blood Pressure” [mesh] OR “con-
trolled hypotension” [tw] OR “hypotension, controlled”
[mesh] OR “blood loss” [tw] OR “Blood Loss, Surgical”
[mesh]) AND ((“paranasal sinuses/surgery” [mesh] OR
“sinusitis/surgery” [mesh] OR (sinus* [tw] AND surg*
[ti])) AND (Endoscopy [mesh] OR endoscop* [tw])) AND
English [lang]
f. Airway management: endotracheal tube versus laryngeal
mask airway (LMA)
(“laryngeal mask airway” [tw] OR “laryngeal airway”
[tw] OR “endotracheal tube” [tw] OR lma [ti] OR lma [ti]
OR endotracheal [ti] OR “airway management” [mesh]
OR (airway [ti] AND manage* [ti])) AND ((“paranasal
sinuses/surgery” [mesh] OR “sinusitis/surgery” [mesh]
OR (sinus* [tw] AND surg* [ti])) AND (Endoscopy
[mesh] OR endoscop* [tw])) AND English [lang]
g. Pain control (limited to articles where it was a significant
part of the article)
(“Pain Management” [mesh] OR “pain measurement”
[mesh] OR “Pain, Postoperative” [mesh] OR “pain”
[mesh] OR pain [ti]) AND (“paranasal sinuses/surgery”
[mesh] OR “sinusitis/surgery” [mesh] OR (sinus* [tw]
AND surg* [ti])) AND (Endoscopy [mesh] OR endoscop*
[tw]) AND English [lang]
h. Inpatients, Outpatients
(inpatient [ti] OR outpatient [ti] OR “inpatients” [mesh]
OR “outpatients” [mesh] OR “patient admission” [mesh]
OR admission [ti] OR admitted [ti]) AND ((“paranasal
sinuses/surgery” [mesh] OR “sinusitis/surgery” [mesh]
OR (sinus* [tw] AND surg* [ti])) AND (Endoscopy
[mesh] OR endoscop* [tw])) AND English [lang]
i. Postopeartive issues and complications
(“paranasal sinuses/surgery” [mesh] OR “sinusitis/sur-
gery” [mesh] OR (sinus* [tw] AND surg* [ti])) AND
(“endoscopy” [mesh] OR endoscop* [tw]) AND (post-
operat* [tw] OR “Postoperative Complications” [mesh]
OR “postoperative period”[mesh] OR complication* [ti])
AND English [lang]
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