A 25-year-old woman with chronic sinusitis presents for functional endoscopic sinus surgery (FESS). She has a history of asthma, nasal polyps, and recurrent sinus infections that are unresponsive to multiple treatments with steroids and antibiotics. She reports a severe allergy to aspirin and is anxious about postoperative pain. After induction of general anesthesia, her blood pressure monitor reads 70/40 mm Hg. The surgeon complains of increased bleeding in the field and asks to decrease the blood pressure further to improve visualization.
What is functional endoscopic sinus surgery?
FESS is a nasal endoscopic technique that allows visualization of the paranasal sinuses and nasal cavity without a skin incision. Described in the late 1970s by Messerklinger and Stamberger, FESS has become increasingly popular in the last 30 years and is now one of the most commonly performed ambulatory surgical procedures in otolaryngology. Combined with its low risk of major complications and high success rate, it is the mainstay in the surgical treatment of sinusitis; nasal polyps; epistaxis; and bacterial, fungal, recurrent, acute, and chronic sinus problems. Across gender, ethnicity, and age groups, chronic sinusitis affects approximately 35 million Americans annually and accounts for 11.6 million physician visits each year. Chronic sinusitis has been shown to have a dramatic effect on quality of life, comparable with that seen in conditions such as coronary artery disease and asthma. More recently, functional sinus endoscopy has expanded to provide a relatively low-morbidity approach to various other surgical procedures, including skull base surgery, transsphenoidal pituitary tumor resection, and treatment of vascular malformations.
To what are complications associated with functional endoscopic sinus surgery attributed?
FESS generally is a low-risk procedure and carries with it a large safety profile. However, many catastrophic complications, including death, have been reported in patients undergoing FESS. These complications include massive hemorrhage, direct brain injury, blindness from ocular and optic nerve damage, anosmia (impaired sense of smell), cerebrospinal fluid leak, and intracranial infection. These complications are listed in Table 45-1 , and they are categorized into three major groups: orbital, intracranial, and nasal. These complications have been attributed to the location of the paranasal sinuses and nasal cavity within the skull and their close proximity to numerous major and significant anatomic structures, such as the internal carotid arteries, orbits, optic nerves, and intracranial cavity ( Figure 45-1 ).
|Orbital hemorrhage |
Blindness (damage to optic nerve)
|Cerebrospinal fluid leak |
Injury to lacrimal duct
Because of the limited field of view through endoscopes, the risk of major complications is thought to increase when uncontrolled or excessive intraoperative bleeding into the surgical field impairs visualization of important anatomic structures. Intraoperative bleeding and poor surgical conditions not only increase complications but also can prolong total surgical time and lead to incomplete resection of tissue or tumors, which may require reoperations. Numerous factors related to the patient’s comorbidities and medications, the type of procedure performed, and the anesthetic technique can contribute to a poorly visualized surgical field secondary to excessive intraoperative bleeding.
List anesthetic considerations and goals.
In highly motivated patients with minimal or limited sinonasal disease, simple sinus surgery can be performed with infiltration of local anesthetic, nerve blocks, and vasoconstrictors alone or with monitored anesthesia care. In such instances, excellent communication between all parties involved (i.e., surgeon, anesthesiologist, and patient) is necessary to create optimal surgical conditions. However, monitored anesthesia care should be used with caution in patients who may be uncooperative (e.g., children, developmentally disabled adults), possess potentially difficult airways (e.g., patients with obstructive sleep apnea, obesity, airway pathology), have a risk of aspiration (e.g., patients with gastroesophageal reflux disease), or require longer operative times. Active infections, extensive sinusitis, and large tumors may be associated with increased blood loss. In addition, the applications of FESS as a surgical technique are constantly broadening, including skull base surgery. Providing a secure airway and motionless surgical field via general anesthesia is likely to be preferred for most procedures.
For reasons stated earlier, facilitation of a “bloodless” surgical field should be a principal concern. Other important anesthetic considerations and goals for FESS are listed in Table 45-2 . These include airway protection and prevention of aspiration of blood and tissue, patient immobility, and emergence from anesthesia without bucking on extubation. Coughing or straining can increase postoperative bleeding. In addition, because FESS is often performed as an outpatient ambulatory procedure, a rapid recovery profile is highly desired. Avoiding postoperative nausea and vomiting (PONV) (postoperative retching can also promote postoperative bleeding) while providing sufficient postoperative analgesia is also desirable.
|Increased visualization |
Access to nasal passages
|Secure airway and prevent aspiration |
Safely achieve hypotension
Smooth emergence from anesthesia
|Good pain control |
Decreased nausea and vomiting
Early discharge from PACU
What information should be obtained during the preoperative assessment?
Anesthesiologists caring for patients undergoing FESS must constantly negotiate between the patient’s various comorbidities and the risks incurred by optimizing the surgical field (i.e., reduced intraoperative bleeding) via induced physiologic derangements (i.e., reduction in cardiac output [CO] and hypotension). A thorough yet directed evaluation done in accordance with current American Society of Anesthesiologists (ASA) practice advisory guidelines on preanesthetic evaluation should be performed in all patients undergoing FESS.
“Controlled hypotension” is not without risk, and patients with significant cardiac or vascular disease, including valvular pathology, congestive heart failure, and atherosclerotic disease may not tolerate significant decreases in mean arterial pressure (MAP). Significant end-organ damage can result. Assessment of physiologic reserve and tolerance of “deliberate hypotension” can be obtained with a history focusing on exercise tolerance and symptoms with physical exertion. Complaints of dyspnea, chest pain, palpitations, or dizziness with climbing two or more flights of stairs (i.e., >4 metabolic equivalents or METS) or occasionally during rest may indicate the need for further cardiovascular testing, such as an electrocardiogram (ECG), echocardiogram, stress test, or coronary angiography.
Local vasoconstrictors such as cocaine or epinephrine are commonly applied in FESS. Patients with significant coronary artery disease or cardiac arrhythmias may not tolerate the tachycardia and hypertension associated with increased circulating catecholamines. Cocaine and epinephrine should be used with caution in these patients. Antiplatelet or anticoagulation therapy should be discontinued before surgery in concordance with current practice guidelines, particularly in the setting of coronary stents. As of 2010, patients with drug-eluting stents taking clopidogrel and aspirin should avoid elective surgery and cessation of antiplatelet therapy until at least 1 year after placement of the stent, and resumption of these medications should be coordinated carefully with the patient’s cardiologist. The American College of Cardiology/American Heart Association (ACC/AHA) further recommended that, if possible, aspirin should be continued into the perioperative period even after 1 year has passed since placement of a drug-eluting stent. It is important that the perioperative management of anticoagulation therapy in these patients is discussed between the surgeon, the anesthesiologist, and the patient’s cardiologist before the day of surgery. Helpful preoperative studies include prothrombin time, activated thromboplastin time, platelet count, and complete blood count.
Describe samter’s triad and the anesthetic implications.
Patients undergoing FESS tend to share certain comorbidities that may be of particular concern to anesthesiologists ( Table 45-3 ). Preoperative diagnoses and indications for FESS include nasal polyps, chronic sinusitis, recurrent sinus infections, benign and malignant tumors, and management of previous surgical procedures (e.g., cerebrospinal fluid leak, scar tissue formation). The coexistence of asthma or reactive airways disease and nasal polyposis in patients is roughly 20%–30%. Samter’s triad, or aspirin-exacerbated respiratory disease, is the combination of reactive airways disease, chronic rhinitis and nasal polyps, and sensitivity to aspirin. The disease is produced by an abnormality in the arachidonic acid cascade resulting in overproduction of leukotrienes. Aspirin blocks the production of prostaglandins and shifts the cascade toward the production of leukotrienes, precipitating allergylike effects, such as bronchospasm, urticaria, or anaphylaxis. Other nonsteroidal antiinflammatory drugs (NSAIDs), such as ketorolac or ibuprofen, similarly block prostaglandin formation and should be avoided in these patients, although acetaminophen is generally considered safe.
|Coronary artery disease |
Atrial fibrillation (on long-term anticoagulation)
Valvular disorders (e.g., aortic stenosis)
|Chronic sinusitis |
Nasal polyposis and atopy
Asthma or reactive airways disease
Obstructive sleep apnea
|Long-term steroid use |
Pituitary lesions (skull base surgery)