functional endoscopic sinus surgery

Preop antibiotic (give 60 min before incision)

Cefazolin 2g IV (3g if >120kg) within 60 minutes of incision; clindamycin if PCN-allergic. Often skipped for clean sinus cases per surgeon preference — check.

Local anesthetic

• —1% lidocaine with epinephrine 1:100,000 for septal/turbinate injection
• —4% topical lidocaine on pledgets
• —Oxymetazoline (Afrin) on pledgets for topical decongestion

Irrigation

• —Warm normal saline for irrigation and scope defogging — he will call it cold regardless of temperature.
• —Bottle of saline for the suction-irrigator if used

Other field meds

• —Epinephrine 1:1000 on pledgets (topical only — LABEL IT, label it again, point at the label)

Labeling

Every medication on the field gets a label. Every. Single. One. Epi 1:1000 vs lido with epi vs topical lido — they look identical, and confusing them is a sentinel event.

Core trays

• —FESS / Sinus tray
• —Nasal/septoplasty tray (open even if 'we're not doing a septum today' — we are doing a septum today)

Specialty items

• —0-degree, 30-degree, 45-degree, and 70-degree Hopkins rod endoscopes (he will ask for the 70 once, for three seconds)
• —Microdebrider with sinus blades (straight and curved/angled)
• —Through-cutting forceps (Blakesley straight and upturned)
• —Kerrison rongeurs
• —Frazier suctions (assorted sizes — he will want the 8, then the 10, then the 8)
• —Cottle elevator, Freer elevator
• —The 'angled curved sinus thingy' — the instrument that does not technically exist by that name. Hand him a Kelly. He will say 'perfect.'
• —Image guidance wand/probe (if navigation)
• —Neuropatties/cottonoids with strings (various sizes, soaked in topical decongestant)

Energy devices

• —Suction monopolar (Frazier-tip Bovie) on low setting
• —Suction bipolar forceps for posterior bleeding

Scopes / robot

• —Rigid sinus endoscopes 0/30/45/70 degree, 4mm (and 2.7mm pediatric if needed)
• —Camera, light cord, scope warmer or warm saline for defogging
• —Image guidance system if pre-op CT was loaded — and pray someone loaded it

Primary position

Supine, head of bed rotated 180 degrees away from anesthesia, slight reverse Trendelenburg, head on a foam donut or gel headrest. You will spend ten minutes positioning. He will move the bed two inches and call it 'much better.' It is the same position.

Variations

• —Image guidance headset/registration if navigation is used
• —Shoulder roll occasionally requested then declined

Pressure points

• —Heels
• —Elbows (ulnar nerve)
• —Occiput against headrest
• —Eyes — taped and protected, this is non-negotiable with a drill near the lamina papyracea

Arm position

Both arms tucked, padded, palms in. Tuck them like you mean it — once he sits down he is not getting up, and neither is that arm.

Pearls

• —Bed height has no correct value. He will raise it, lower it, and end exactly where you started.
• —Eyes must be visible to the surgeon throughout the case — corneal shields or clear tape, no goggles taped over.
• —Tape the ETT to the LEFT side of the mouth or wherever it is not in the way of the scope. He will move it anyway.

Prep solution

• —Half-strength povidone-iodine swabs to the face and inside the nares
• —Avoid alcohol-based prep near the eyes and airway

Prep area

Face from forehead to upper lip, including both nares. There is no correct prep border. Whatever you prep, he will want one inch wider or narrower.

Draping

Head drape (turban), split sheet up the body, towel across the forehead, towel under the chin to catch the blood-tinged saline that is absolutely going to run down the patient's neck and pool under the shoulder blades.

Pearls

• —Three-minute dry time is a suggestion he ignores at ninety seconds.
• —Put an extra towel under the head. Trust me. The drape will not catch everything.
• —Tape the suction tubing to the drape before he asks you to, then act surprised when he asks you to.

Typical sutures

• —4-0 chromic on small needle for septal quilting if septoplasty is done
• —Whatever you opened, he wanted the other one. Open the other one. He will use the first.

Energy

• —Suction Bovie at 15-20 cut/coag
• —Suction bipolar for sphenopalatine area bleeding

Hemostatic agents

• —Topical oxymetazoline or epinephrine 1:1000 on pledgets (LABELED, on the field)
• —Floseal or Surgiflo (he will say he doesn't need it, then need it)
• —Thrombin
• —Absorbable nasal packing (NasoPore, MeroGel, or similar)

Wound dressings

• —Absorbable nasal packing (NasoPore/MeroGel) bilaterally
• —Occasionally non-absorbable packing (Merocel with string, or Doyle splints if septoplasty)
• —Nasal drip pad ('mustache dressing') taped under the nose

Drains

• —Doyle splints (if septoplasty) — these come out in clinic, document placement

Application notes

It starts as a simple dressing. It will not end as one. The drip pad will need to be changed before the patient leaves PACU. Tape allergy will be discovered at this exact moment.

Typical specimens

• —Sinus contents / polyps / mucosa — bilateral, by sinus (maxillary, ethmoid, sphenoid, frontal)
• —Septal cartilage/bone if septoplasty performed
• —Turbinate tissue if reduction performed

Handling

Dropped onto your field in a wad of bloody mucosa with no name and no site. You know what it is. You do not know what it is. Ask before he turns away. Ask again. Write it down the second you hear it.

Labeling notes

Cultures (aerobic, anaerobic, fungal) frequently sent for CRS — confirm with surgeon before he scrubs out. Each sinus is a separate specimen container. 'Sinus contents' is not a site. Left maxillary, right ethmoid, etc.

Common pitfalls

• —The case is never as quick as scheduled.
• —No eye contact. Ever.
• —Mislabeled topical epi vs injectable lido-with-epi is a sentinel event waiting to happen — label everything.
• —Cottonoids without strings do not go in the nose. Ever.
• —Image guidance not loaded = case delayed = blame lands on the circulator.
• —Tucking arms badly will cost you twenty minutes mid-case when anesthesia needs an IV.
• —Assuming 'just sinus' means no septoplasty. It means septoplasty.

Conversion risks

• —CSF leak — recognized intraop, requires repair, possible lumbar drain. Surgeon will say: 'That wasn't there a second ago.'
• —Orbital injury / lamina papyracea breach with periorbital fat herniation. Surgeon will say: 'Did you see that?' (You did not. You are not supposed to.)
• —Major bleeding from sphenopalatine or anterior ethmoidal artery requiring packing or angio. Surgeon will say: 'Let's just pack it and see.'
• —Conversion to open frontal sinus approach (rare) — Surgeon will say: 'We may need a different tray.'

Vascular structures at risk

• —Anterior ethmoidal artery
• —Posterior ethmoidal artery
• —Sphenopalatine artery
• —Internal carotid artery (lateral sphenoid wall — dehiscent in up to 25% of patients)
• —Cavernous sinus

Reportable events

• —Suspected or confirmed CSF leak
• —Orbital injury, periorbital hematoma, or vision change
• —Internal carotid artery injury
• —Retained foreign body (cottonoid without string, broken instrument tip)
• —Medication error involving unlabeled topical epinephrine
• —Airway fire (electrocautery near oxygen-enriched airway)
• —Unintended dural breach or intracranial entry

Initial count

Initial count: correct. Sharps, instruments, neuropatties/cottonoids (count the strings — cottonoids without strings do not belong in this case).

Closing count

He will add cottonoids to the field without telling you. He will also pull some out and toss them on the drape. Final count is a personal journey for everyone in the room. Count cottonoids by string. Count them again. Count them a third time before he leaves the room.

Special items to count

• —Cottonoids/neuropatties — count by string, every single one
• —Pledgets soaked in epi/lidocaine — count separately from clean ones
• —Microdebrider blade tip (verify intact at end of case)
• —Suction tips and small Frazier tips can disappear into the drape

Step-by-step

• —Schedule says 45 minutes. Discover the correct time yourself.
• —Patient enters, time-out, sign-in. Confirm CT is loaded for navigation BEFORE induction.
• —Induction, ETT taped to the side, eyes taped/shielded.
• —Bed turned 180. Reposition. He moves it two inches. 'Perfect.'
• —Image guidance registration if used (this takes longer than anyone admits).
• —Topical decongestant pledgets placed in nares for 5-10 minutes while you're still draping.
• —Inject septum/turbinates/uncinate with lido-epi.
• —Prep, drape, dry time ignored at 90 seconds.
• —Surgeon sits down. Bed height wrong. Adjust. Wrong again. Adjust. Back to original.
• —Uncinectomy → maxillary antrostomy → anterior ethmoidectomy → posterior ethmoidectomy → sphenoidotomy → frontal recess (Draf as indicated).
• —Repeat opposite side.
• —Discover polyps were worse than the CT suggested. Add 30 minutes.
• —Septoplasty 'while we're in there.' Add 30 more.
• —Hemostasis — pledgets, Floseal, bipolar the sphenopalatine bleeder you weren't expecting.
• —Place absorbable packing bilaterally.
• —Final count (begin the journey).
• —Drip pad applied. Wake up. Extubate. Transport.
• —Total actual time: 2 to 2.5 hours.

Circulator notes

• —Confirm CT scan is loaded into navigation BEFORE the patient is asleep. No one will tell you this until it's too late.
• —Image guidance headset, drapes, and reference frame need to be opened sterile if used.
• —Have a second set of pledgets and topical decongestant ready — the first batch is already on the field by the time you turn around.
• —Eyes must remain visible — do not let anesthesia bury them under tape and tubing.
• —Suction will clog. Have a second suction setup primed.
• —Specimen containers x6 minimum, pre-labeled by sinus and side if possible.
• —PACU needs a heads-up about packing and drip pad — they will ask.