functional endoscopic sinus surgery

Preop antibiotic (give 60 min before incision)

Often none routinely; surgeon dependent. May use cefazolin or clindamycin if indicated.

Local anesthetic

• —Lidocaine 1% with epinephrine 1:100,000 — injected into turbinates and lateral nasal wall
• —Lidocaine 4% topical on pledgets
• —Cocaine 4% topical (some facilities) — controlled substance, requires waste documentation

Irrigation

• —Warm normal saline for scope irrigation and field rinse
• —Saline irrigation via syringe or pressurized system

Other field meds

• —Oxymetazoline (Afrin) pledgets for decongestion
• —Epinephrine 1:1000 topical pledgets (confirm concentration — NEVER inject 1:1000)
• —Floseal/Surgiflo hemostatic agents

Labeling

ALL medications on the sterile field must be labeled — syringes, basins, pledgets containers. Clearly distinguish injectable lidocaine/epi from topical epinephrine 1:1000 to prevent fatal injection errors. If cocaine used, follow controlled substance waste protocol.

Core trays

• —FESS/Sinus instrument tray
• —Nasal speculum set
• —Frazier suction tips (assorted sizes, typically 7-10 Fr)

Specialty items

• —Rigid sinus endoscopes — 0 degree, 30 degree, 45 degree, 70 degree (4mm adult, 2.7mm pediatric)
• —Through-cutting forceps (Blakesley, straight and upturned)
• —Backbiting forceps
• —Sinus curettes
• —Kerrison rongeurs
• —Microdebrider with assorted blades (straight, curved, angled)
• —Cottonoid pledgets (various sizes)
• —Image guidance/navigation system (Stryker, Medtronic, Brainlab) if used
• —Defogger / scope warmer
• —Nasal packing material (Merocel, NasoPore, Doyle splints, etc.)

Energy devices

• —Suction monopolar Bovie (insulated, fine tip) — if used
• —Suction bipolar forceps for endoscopic hemostasis
• —Coblation wand (some surgeons)

Scopes / robot

• —Rigid sinus endoscopes 0/30/45/70 degree
• —Camera, light cord, monitor tower
• —Image guidance system if navigation case

Primary position

Supine with head of bed elevated (reverse Trendelenburg 10-15 degrees) to reduce venous bleeding. Head on donut or gel headrest, slightly turned toward surgeon. Arms tucked at sides with draw sheet.

Variations

• —Some surgeons use image guidance/navigation requiring specific headset or reference frame attached to forehead
• —Head may be placed in Mayfield pins for navigation-assisted cases or skull base work

Pressure points

• —Occiput on headrest
• —Elbows and ulnar nerves when arms tucked
• —Heels — pad with foam or pillow
• —Eyes — must remain accessible and uncovered for surgeon to palpate orbit during case

Arm position

Both arms tucked at sides, padded, palms in

Pearls

• —Eyes are NOT taped or covered with eye pads — surgeon needs to palpate globe to monitor for orbital entry
• —Bed turned 90 or 180 degrees away from anesthesia; confirm direction with surgeon before positioning
• —Reverse Trendelenburg helps reduce bleeding — confirm anesthesia is ready before tilting
• —Secure ETT to opposite side of mouth from surgeon's working side; oral RAE tube common

Prep solution

• —Surgeon preference — many use no skin prep on face, or a gentle non-alcohol prep around nares/face
• —Avoid alcohol-based preps near eyes and airway
• —Some surgeons use baby shampoo or aqueous betadine swabs to nares

Prep area

Face, with focus on nares and upper lip. Eyes left exposed and visible. Avoid prep solution pooling in eyes or ear canals.

Draping

Head drape (turban) with towels around face. Split sheet or head/neck drape with opening exposing nose and eyes. Eyes left visible through drape. Clear plastic adhesive drape sometimes used.

Pearls

• —Eyes MUST remain visible to surgeon throughout case — do not cover with drape
• —Place towel or absorbent pad under chin to catch blood/irrigation runoff
• —Confirm bovie pad placement before draping — usually thigh
• —Have suction immediately available — significant bleeding/irrigation common

Typical sutures

• —Generally none — no external incisions
• —Occasional 4-0 chromic or Vicryl if septoplasty performed concurrently
• —Doyle splints may be sutured in with 3-0 nylon transseptally

Energy

• —Suction bipolar cautery
• —Suction monopolar (insulated)
• —Microdebrider for tissue removal (not energy but primary cutting tool)

Hemostatic agents

• —Afrin (oxymetazoline) pledgets
• —Epinephrine-soaked pledgets (1:1000 or 1:10,000 — confirm concentration with surgeon)
• —Lidocaine with epinephrine injection
• —Floseal or Surgiflo
• —Topical thrombin
• —Merocel, NasoPore, or other absorbable/non-absorbable packing

Wound dressings

• —Mustache dressing / drip pad under nose (folded 4x4 with tape or commercial nasal drip pad)
• —No external dressing on face

Drains

• —None typical
• —Nasal packing (Merocel, NasoPore, Doyle splints) may be placed intranasally — not a drain but document

Application notes

Mustache dressing changed PRN for drainage. Educate PACU on packing in place — patient will be mouth-breathing. Document any packing/splints with plan for removal.

Typical specimens

• —Sinus contents / polyps — to permanent pathology in formalin
• —Ethmoid tissue
• —Cultures of purulent material if infection suspected (aerobic, anaerobic, fungal)

Handling

Tissue to formalin for permanent path. Cultures to appropriate transport media — communicate STAT if surgeon wants. Separate specimens by side (right vs left) and sinus location if surgeon specifies.

Labeling notes

Label each specimen with side and anatomic location (e.g., 'Right ethmoid', 'Left maxillary polyp'). Confirm labeling with surgeon before sending. Cultures must specify aerobic/anaerobic/fungal as ordered.

Common pitfalls

• —ALWAYS verify with facility preference card — positioning, ports, sutures, packing, and energy device choice vary by surgeon
• —Confusing topical epinephrine 1:1000 with injectable can be fatal — label everything
• —Forgetting to leave eyes uncovered — surgeon must palpate globe
• —Inadequate pledget counting — high retained-item risk
• —Bovie pad placement after draping is too late — place before
• —Not having navigation registered before prep delays case
• —Failing to communicate nasal packing to PACU

Conversion risks

• —Conversion to open external approach (e.g., Caldwell-Luc, external ethmoidectomy) if uncontrolled bleeding or anatomy
• —Orbital entry requiring ophthalmology consult
• —CSF leak requiring skull base repair

Vascular structures at risk

• —Sphenopalatine artery (posterior bleeding)
• —Anterior and posterior ethmoid arteries
• —Internal carotid artery (sphenoid sinus wall)
• —Cavernous sinus
• —Ophthalmic artery

Reportable events

• —Orbital injury (hematoma, muscle injury, vision loss)
• —CSF leak / skull base breach
• —Internal carotid artery injury — catastrophic, mass transfusion protocol
• —Retained pledget or packing
• —Medication error (epinephrine concentration mix-up)
• —Fire risk if alcohol prep used near airway/oxygen

Initial count

Initial count of instruments, sharps, and cottonoid pledgets per AORN. Pledgets/cottonoids are the highest-risk retained item in this case — count meticulously.

Closing count

Final count of all pledgets, sharps, and instruments before patient leaves room. Pledgets often have radiopaque strings — ensure ALL strings accounted for and none left in nasopharynx.

Special items to count

• —Cottonoid pledgets — COUNT EVERY ONE, including small neuro pledgets
• —Strings on pledgets must be visualized exiting nares
• —Doyle splints / nasal packing if left in place — document in chart and communicate to PACU

Step-by-step

• —Patient brought to room, standard time out, SCDs applied, IV access confirmed.
• —General anesthesia induced; oral RAE ETT typically placed and secured to side opposite surgeon.
• —Bed turned 90 or 180 degrees from anesthesia; patient positioned supine with reverse Trendelenburg, head on donut, arms tucked.
• —Bovie pad placed on thigh; eyes left uncovered and visible.
• —Surgeon places pledgets soaked in topical decongestant (oxymetazoline or epinephrine) into nares for vasoconstriction — usually 5-10 minutes before incision.
• —Surgeon injects lateral nasal wall and turbinates with lidocaine with epinephrine via long needle under direct visualization.
• —Time out completed, prep/drape as above, scope and camera white-balanced and defogged.
• —Surgeon introduces rigid endoscope, identifies landmarks (middle turbinate, uncinate). Uncinectomy performed, then maxillary antrostomy, ethmoidectomy, sphenoidotomy, frontal recess as indicated.
• —Microdebrider and through-cutting instruments used to remove polyps/diseased mucosa; specimens collected and labeled by side/location.
• —Hemostasis with suction bipolar, pledgets, Floseal/Surgiflo as needed.
• —Final inspection, packing or splints placed if needed, mustache dressing applied.
• —Patient extubated, transferred to PACU with HOB elevated.

Circulator notes

• —Confirm image guidance/navigation needed and registered BEFORE prep if used
• —Have multiple sizes of pledgets opened and counted on field
• —Pre-mix and clearly label topical epinephrine vs injectable lidocaine/epi — NEVER confuse
• —If cocaine used, follow controlled substance protocol with witnessed waste
• —Keep extra microdebrider blades and suction tips available — they clog frequently
• —Communicate specimen labels (side + location) clearly with scrub and surgeon
• —Monitor for sudden hypotension or bradycardia during epinephrine pledget placement
• —Have suction set up and ready — bleeding can be brisk