Endoscopic sinus surgery – procedures

What the Anesthesiologist Should Know before the Operative Procedure

Endoscopic sinus surgery remains one of the most effective management options for patients with chronic sinusitis. It offers symptomatic relief for 90% of patients and entails a low-risk ambulatory anesthetic for most patients.

What are the indications for functional endoscopic sinus surgery?

• Chronic, recurrent, acute complications of rhinosinusitis

• Sinonasal polyposis, mucoceles

• Intractable epistaxis

• Cerebrospinal fluid (CSF) leaks and anterior meningoencephaloceles

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• Foreign body removal

• Choanal atresia repair

• Tumors

• Headaches and facial pain

• Expanded transnasal approaches to the skull base and orbit

1. What is the urgency of the surgery?

What is the risk of delay in order to obtain additional preoperative information?

Surgical indications are generally elective with a few important exceptions.

Emergent: Foreign bodies must be removed upon diagnosis if they pose an airway threat. Infectious processes with threat to intracranial extension, cerebral fluid leaks, acute diplopia, or epistaxis refractory to tamponade warrants immediate surgical intervention without significant delay for preoperative risk stratification.

Urgent:Foreign bodies, trauma, epistaxis currently managed with packing, or infectious processes responsive to intravenous antibiotic therapy may warrant appropriate preoperative risk stratification, especially with identifiable morbidities such as cardiac or pulmonary disease. Delay of surgery may be appropriate in patients with significant comorbidities or risks. Some neoplastic processes may warrant expedited preoperative planning.

Elective: A vast majority of functional endoscopic sinus surgeries are intended to improve patient symptoms and quality of life and therefore, adherence to recommended guidelines for disease-specific preoperative risk stratification is indicated. Current recommendations from the American Heart Association/American College of Cardiology should be followed. Chronic medical conditions should be stable and adequate documentation from primary sources should be available to establish suitable preparation for planned surgery.

2. Preoperative evaluation

A majority of patients are young and generally healthy with an average age of approximately 40 years. For most of these patients, preoperative diagnostic studies are not indicated according to current guidelines. The vast majority of patients are discharged home the same day. Major complication rates are low with approximately 1% postoperative nausea vomiting rates.

3. What are the implications of co-existing disease on perioperative care?

Medically unstable conditions warranting further evaluation include: Patients exhibiting recent or current cardiac symptoms, exacerbation of chronic or acute pulmonary disease, poorly controlled diabetes with multi-systemic comorbidities, patients in shock, or other clinical manifestations of significant multisystem disease.

For patients in the emergent category above, the role of preoperative diagnostic testing must be balanced against delay in therapy. Patients with significant epistaxis will likely warrant hemograms and perhaps coagulation assay. Patients with an acute infectious process may warrant complete blood count, blood cultures, and infectious disease consultation before surgical intervention.

Delaying surgery may be indicated if:

• significant cardiac symptoms suggest increased risk for perioperative myocardial infarction (MI) or if patient tracks to American Heart Association/American College of Cardiology (AHA/ACC) recommendations for invasive cardiac testing.

• evidence of significant systemic disease but surgical indication permits delay.

• the coagulation status is unclear or requires reversal of anticoagulant therapy.

b. Cardiovascular system

Acute/unstable conditions

Any patient with a significant cardiac condition requires review of acute changes and consideration for immediate consultant input prior to surgery. Signs and symptoms of coronary ischemia must be thoroughly elucidated. Acute dyspnea may indicate heart failure, myocardial infarction, or other cardiac disease. Patients at low risk for cardiac events with acute chest pain may have acute coronary events excluded and surgery completed.

Chronic/stable conditions

Males most commonly present for functional endoscopic sinus surgery (FESS) procedures and therefore the epidemiology of chronic cardiac diseases affecting men will prevail for this cadre of patients. Well controlled hypertension, asymptomatic atherosclerotic coronary disease, or generally poor functional status should be noted but is not considered to increase perioperative risks.

c. Pulmonary

Asthma

The triad of asthma, allergic atopy, and nasal polyposis affects many patients. Stable asthma should be noted, but symptomatic wheezing, dyspnea, or hypoxia needs additional evaluation and treatment. While mixed evidence exists for the prophylactic treatment of chronic asthma with inhaled medications prior to general endotracheal anesthesia such treatment might decrease perioperative respiratory symptoms. Patients with moderate persistent or severe persistent asthma have limitation in functional status and impaired pulmonary function, and therefore should be optimized before elective surgery.

Cystic fibrosis

FESS procedures are often necessary to treat sinusitis in patients with cystic fibrosis (CF). This disease of impaired mucociliary transport results in thick viscous secretions, 90% to 100% opacification of sinus cavities, and polypoid disease in up to 33% of affected patients. FESS improves patient satisfaction though radiological improvement of sinus aeration is poorly achieved. Refractory patients may require a combined approach of FESS, medial maxillectomy and Caldwell-Luc surgery. The exact therapeutic role of sinus surgery in CF remains controversial.

Ideally, CF patients are evaluated by their pulmonologist prior to elective anesthesia to establish optimum health. General anesthesia may exacerbate pulmonary health and careful attention to humidification of inhaled gases, minimized respiratory depression, and early tracheal extubation. Use of a supraglottic airway may be considered.

d. Renal-GI:

N/A

e. Neurologic:

Neurologic disease generally effects anesthesia management relative to the risks of intraoperative hypoperfusion or iatrogenic injury to the brain.

The patient with neurologic diseases such as prior cerebral infarction should have a well-documented neurologic exam preoperatively to assist postoperative neurologic events become suspected. While direct injury to the orbit, cribriform plate, or sphenoid bone is the most common neurologic injury, cerebral injury from relative hypotension, vasopressor arterial constriction, or hemorrhage may also occur. Acute symptoms suggestive of meningitis can accompany a CSF leak.

f. Endocrine:

Rarely, FESS is indicated for treatment for a paranasal neuroendocrine tumor such as paraganglioma. Such a tumor may elaborate catcholamines or other vasoactive substances during manipulation and appropriate counter-therapy may be needed to stabilize the patient’s vital signs during surgery.

g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)

Hematology

Patients with blood dyscrasias and coagulopathy require thorough evaluation and documentation to plan a safe anesthetic. Considerable risks of hemorrhage from noncompressible mucosal tissues can complicate minor sinus procedures. Routine coagulation panels are not indicated unless a history of bleeding diathesis is offered. Epistaxis may suggest a coagulation abnormality.

von Willebrand’s disease

The most common coagulopathy, von Willebrand’s disease (vWD) requires classification prior to elective surgery as desmopressin (DDAVP) responsive (Type 1&2A) and unresponsive (Type2B, 2M, 2N, 3). Humate-P or Factor VIII concentrate is needed for DDAVP unresponsive vWD.

Therapy is needed for at 1 to 5 days following all but the most minor sinus surgery according to the National Heart, Lung, and Blood Institute (http://www.nhlbi.nih.gov/guidelines/vwd/4_managementofvwd.htm).

Anemia

The risk of significant blood loss during sinus surgery requires caution with anemic patients. Intraoperative strategies to decrease blood loss include deliberate hypotension, elevation of head, elective beta-blockade, and ventilation strategies intended to reduce intrathoracic pressures (e.g., high frequency jet ventilation). Anemia increases the potential risks of cerebral or coronary ischemia and therefore may necessitate transfusion for significant drop in hemoglobin.

Oncologic

Tumors may be friable, leading to bleeding into the airway or chronic blood loss. Previous irradiation of the head and neck may affect airway management. Functional decline due to chronic systemic disease may increase risk of postoperative complications. Document neurologic and ophthalmic status preoperatively to assess for acute complications. Seek consultant input as needed.

4. What are the patient's medications and how should they be managed in the perioperative period?

Many patients are treated with systemic steroids for the immediate preoperative period (10-14 days) and therefore may require be at risk for perioperative adrenal suppression. Topical steroids and vasoconstrictors are often prescribed and should be continued up to the day of surgery.

h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

Intranasal topical application of cocaine remains a common practice despite surgical literature validating the effective substitution of other topical agents such as oxymetazoline or phenylephrine. While systemic cocaine uptake is much more likely to incite adverse events (hypertension, dysrhythmias) all vasoactive agents have the potential to lead to adverse physiologic response.

i. What should be recommended with regard to continuation of medications taken chronically?

Cardiac: All medications should be continued up to and including the day of surgery. May consider holding ACE inhibitors.

Pulmonary: All medications should be continued up to and including the day of surgery. Prophylactic bronchodilators may be warranted in the wheezing patient.

Renal: Standard recommendations regarding fluid management and perioperative renal replacement therapy apply.

Neurologic: Neurologic agents should be continued.

Antiplatelet: Perioperative antiplatelet therapy is usually suspended prior to FESS, although cardiac patients with intra-coronary stents may require specific guidance from specialists.

Psychiatric: Psychiatric medicines are typically continued, although monoamine oxidase inhibitors should be discontinued if cocaine is to be used.

j. How To modify care for patients with known allergies –

Patient with known allergies to specific antibiotics must be handled appropriately: penicillin, since the patient may receive clindamycin for antimicrobial prophylaxis.

k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.

Latex-sensitive patients should be treated accordingly. Sinus surgery does not increased likelihood for exposure to latex products.

l. Does the patient have any antibiotic allergies- [Tier 2- Common antibiotic allergies and alternative antibiotics]

N/A

m. Does the patient have a history of allergy to anesthesia?

Malignant hyperthermia

Sinus surgeries amenable to alternative anesthetic techniques. Succinylcholine can be avoided and alternative neuromuscular blocking drugs substituted if needed. Total intravenous anesthesia is a reasonable technique for the MH-susceptible patient, with appropriate attention to the maintenance of adequate anesthetic depth and patient immobility to ensure the patient’s safety.

5. What laboratory tests should be obtained and has everything been reviewed?

Few laboratory tests are absolutely necessary. As most patients are young and generally healthy, preoperative tests should be considered on the basis of specific patient history. Patients with polyp disease may be at increased risk for significant blood loss and, therefore, may warrant preoperative hemoglobin level. Patients with bleeding history including epistaxis may warrant laboratory assessment of coagulation status.

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

Numerous options exist and certain benefits to all render a “best” technique impossible to describe. Each anesthetic should strive for optimum patient safety with consideration for coexisting disease and the proposed surgery, ideal surgical conditions to manifest the greatest opportunity for a therapeutic success, elimination of perioperative complications, and assurance of an efficient and expedient transition from preoperative evaluation through discharge-readiness.

General anesthesia

General endotracheal anesthesia is most often used for FESS in the United States.

Advantages

Endotracheal intubation protects the lower airways from blood and secretions. While this seems obvious, there are conflicting data whether an endotracheal tube (ETT) truly prevents aspiration of hypopharyngeal fluids more than other devices such as supraglottic airways (e.g., laryngeal mask airway [LMA]). Allows paralysis, thereby reducing risk of patient movement with possible injury to skull base or orbit. While supraglottic airways (SGA) allow positive pressure ventilation and potentially the same use of relaxants, it remains an infrequently used or recommended technique. ETT dislodgement is less likely with repositioning of patient head.

Disadvantages

Increases anesthesia time, longer emergence time to recovery room, and increases total doses of anesthetic drugs necessary to moderate the increased sympathetic tone elicited by a tracheal tube. It may increase blood loss compared to local/MAC or supraglottic airway (SGA). Emergence may be associated with increased coughing, bucking or straining, possibly contributing to increased post-operative bleeding.

General anesthesia with supraglottic airway

The SGA is often substituted for an endotracheal tube to mitigate adverse effects of tracheal tubes. It does not mechanically prevent penetration of fluids from the lower respiratory tree although many reports document no increased adverse event rates with its use in properly selected patients. Frequently cited exclusion criteria for SGA use include significant gastroesophageal reflux, obesity, or hiatal hernia.

Advantages

Lower mean intraoperative blood pressures and decreased blood loss (versus ETT with remifentanil/propofol). Decreased risks of injury to the teeth and larynx compared to ETT. Decreased doses of anesthetic (intravenous or inhaled) necessary to establish an equivalent depth of anesthesia. Large series data demonstrate no increased risks in selected FESS patients. Even in pediatric patients, there seems to be no increased risks of aspiration compared to ETT.

Disadvantages

Heterogeneous and incomplete data available on the true safety and risks of SGA versus ETT. Evidence that blood and secretions penetrate to the lower airway more frequently than ETT may suggest higher risk of aspiration despite current outcomes data. Patients are less frequently paralyzed with SGA devices; therefore, there is a potentially higher risk of patient movement during surgery leading to possible injury.

Monitored anesthesia care with local anesthetic infiltration

Local anesthesia/sedation

While local infiltration, topical anesthesia, and moderate sedation was commonly employed for sinus surgery in the past, this technique requires a cooperative patient, an expedient surgeon, and a “talented, interested, and experienced anesthesiologist” and is likely suitable only for minor endoscopic procedures.

Advantages

• Faster recovery and discharge times

• Obviates risks associated with general anesthesia

• Patient can report symptoms associated with injury to the eye or brain

Disadvantages

• Requires cooperative, calm patient with minimal risks for sedation relatedcomplications such as apnea, agitation, and bleeding, Intraoperativeevents such as bleeding, coughing, significant respiratorydepression/apnea will require immediate airway interventions and generalanesthesia, with accompanying risks of complications such as aspirationpneumonitis, negative pressure pulmonary edema, or unexpected difficult airway/difficultintubation.

6. What is the author's preferred method of anesthesia technique and why?

Given the currently available literature and our high-volume practice, which includes high-risk patients (American Society of Anesthesiologists Physician Classification Status 3-4) and low-risk ambulatory patients, we consider most patients for general anesthesia with a balanced technique of low-dose inhaled anesthetic and remifentanil infusion. Local infiltration with sedation is reserved for septoplasty and possible coblation of middle turbinate only.

SGA is the device of choice for suitable patients. Careful attention to cuff seal pressures (>15-18 cm H2O) and confidence in the positioning of the device before initiation of surgery is imperative. We find this decreases induction times, improves surgical conditions with less interventions needed to maintain close blood pressure control. Tracheal tubes are the default airway device in patients with difficult airways, gastroesophageal reflux disease (GERD), severe obesity, or other risks. Long-duration analgesia includes preoperative oral acetaminophen, low-dose morphine (0.05 mg/kg), and intravenous nonsteroidal analgesics in appropriately screened patients (e.g., Ketorolac 15 mg IV [intravenously] in recovery room).

Intraoperative blood pressure management is discussed with the attending surgeon to establish a reasonable goal with review of risks associated with comorbidities and specific focus on myocardial and cerebrovascular disease. Routine mean arterial pressures are permitted to 80% of preoperative values with beta blockade initiated after local infiltration if systemic blood pressures remain elevated. Antiemetic regimen includes 5-HT3 antagonist, low dose dexamethasone, avoidance of nitrous oxide, minimal opiate dosing, careful evacuation of blood from the hypopharynx, and propofol administration either as an infusion or intermittent low-dose bolus. High-risk patients are offered a scopolamine patch and low-dose haloperidol (1 mg) is considered.

Extubation of the larynx or trachea is routinely performed at a deep plane of anesthesia to mitigate coughing and valsalva. This technique is not suitable for all patients, especially children with current upper respiratory illness, adult smokers or patients with chronic pulmonary obstructive disease, or patients with known difficult airways.

Intraoperative medications

Antiemetics: Most patients will be at increased risk of postoperative nausea and vomiting due to the presence of blood in the pharynx, the duration of surgery, and the need for systemic opiates for pain control. Nitrous oxide should be avoided. Prophylactic antiemetics may include 5-HT3 antagonists and dexamethasone.

Prophylactic antibiotic therapy: Inconsistent data exist for the administration of antibiotics. A 2008 survey data demonstrated a 57% rate of antibiotic therapy. Cefazolin (1 g) is the most routine drug requested. Clindamycin 600 mg IV for penicillin-sensitive patients.

What do I need to know about the surgical technique to optimize my anesthetic care?

FESS involves a range of surgical procedures with specific therapeutic goals and techniques. Communication with the surgical team is the first step to optimized intraoperative care. The basic techniques were described by Messerklinger and Wigand and involve thorough nasal endoscopic examination, removal of the uncinate process, removal of the ethmoid bulla, exposure of the frontal sinus opening and identification of the skull base. Clinical indications direct extent of surgery and may include maxillary antrostomy, anterior, posterior, or complete ethmoidectomy. sphenoid sinusotomy, or frontal sinusotomy.

Guidance systems use high-resolution computed tomography to establish instrument position in the nasopharyngeal cavity. A variety of systems exist that interface a three-dimensional detection array incorporated in the endoscopic instruments and projected in real time onto the patient’s computed tomography (CT) images in three planes. More recent systems employ an intraoperative CT acquisition system to enhance the fidelity of the CT data as the surgical procedure progresses and alters the patient’s anatomy.

Any movement of the patient while the instruments reside at or near the skull base of orbit will increase the risk of traumatic penetration into the cranium or orbit. Minimally invasive techniques include balloon sinuplasty. This may employ fluoroscopy guidance though recent high-intensity light transillumination catheters have largely replaced this practice.

What can I do intraoperatively to assist and optimize patient care?

Blood pressure control decreases bleeding on the field and improves efficiency. While some patients cannot tolerate extreme decrements in perfusion pressure, most FESS patients have few comorbidities and can tolerate MAP 20% to 30% less than preoperative levels. Anesthetic depth will prevent patient movement and decrease blood pressure.

Access to the eyes is needed to permit intraoperative examination of the eye and orbits. Ophthalmic ointment with or without a small strip of tape to approximate the lateral eyelids may suffice for protection against corneal abrasion.

What are the most common intraoperative complications and how can they be avoided?

Hemorrhage:

• May be minor (venous) or major (arterial).

• Significant polyposis associated with greater blood loss.

• Hemorrhage can be caused by surgical injury to mucosal beds or arterial structures, specifically branches of the internal carotid artery including the posterior septal artery below the sphenoid sinus or branches of the internal maxillary artery at the middle turbinate.

• Expert blood pressure control may decrease bleeding in the field and improve surgical visualization of anatomy.

Intracranial injury: Patient movement must be prevented to avoid penetration of instruments through the relatively thin skull base in the medial nasopharyngeal roof. CSF leak or other evidence of trauma into the cranial vault may require immediate repair and possible neurosurgical intervention. Minimize risk by use of paralytics or vigilant monitoring of adequate anesthetic depth.

Orbital injury: Accounts for 0.12% of FESS procedures. The lamina papryracea is a thin bony partition between the lateral nasopharynx and the medial orbit. Injury is most often related to surgical error. Other ophthalmic complications include injury to the optic nerve, extrocular muscles, nasolacrimal drainage system, and orbital bleeding.

a. Neurologic:

N/A

b. If the patient is intubated, are there any special criteria for extubation?

Removal of an endotracheal tube or supraglottic airway requires careful attention to avoid pulmonary aspiration of blood or saliva. The low-risk patient may be considered for airway device removal while anesthetized only if the patient is adequately breathing, maintaining appropriate tidal volumes, exhibits reasonable and tidal carbon dioxide levels, and does not demonstrate signs of a reactive airway (breath-holding, wheezing, coughing). In these patients, extubation may proceed following careful suctioning of the hypopharynx, placement of an oral airway device, and careful attention to airway management during subsequent emergence. Benefits to “deep extubation” may include decreased coughing, straining, systemic hypertension, and resultant nasal bleeding. Risks include laryngospasm, pulmonary aspiration, negative pressure pulmonary edema, apnea,

Patients at risk for aspiration should be considered for awake extubation following return of laryngeal reflexes.

Vigilance is necessary to prevent upper airway obstruction precipitated by an obstructed nasal aperture. This may precipitate a sense of suffocation and elicit a panic response.

c. Postoperative management

• Most patients are suitable for ambulatory care and postoperative management should minimize risk for unplanned admission. Pain management is often achieved with titration of low-dose opiates and non-opioid analgesics. Intraoperative infiltration of short acting anesthetics offers limited benefit.

• PONV may require treatment based on clinical guidelines. PONV rates are approximately 1%.

• Uncontrolled bleeding in the recovery room may signal surgical hemorrhage and require emergent return to the operative suite.

• Hypertension in the recovery room may be related to pain, infiltration of epinephrine, systemic cocaine or oxymetolazine uptake, poor perioperative management of essential hypertension, or the perioperative administration of vasoactive medications such as ephedrine. Rarely, hypertension may require a search for other causes such as intracranial hypertension.

• Overnight observation is usually not necessary without specific complications or clinical events such as intractable PONV, poorly controlled pain, or post-operative bleeding.

• Oral analgesics often suffice for most patients with a first dose often administered in the recovery suite. Significant agitation, however, may accompany nasal packing and an appropriate antianxiolytic may be offered.

What's the Evidence?

Lal, D, Stankiewicz, J. “Cumings Otolaryngology: Head and Neck Surgery”. vol. 19. 2010. (The current standard text for otolaryngology that describes the surgical indications, techniques, and complications related to sinus surgery in adult patients.)

Robertson, JM, Friedman, EM, Rubin, BK. “Nasal and sinus disease in cystic fibrosis”. Paediatr Respir Rev. vol. 9. 2008. pp. 213-9. (Review article on the nature and treatment of sinonasal disease associated with cystic fibrosis.)

Danielsen, A, Gravningsbraten, R, Olofsson, J. “Anaesthesia in endoscopic sinus surgery”. Eur Arch Otorhinolaryngol. vol. 260. 2003. pp. 481-6. (Retrospective analysis of 1,460 patients, consecutively operated on by one surgeon from 1987 to 2001, of ages 4 to 79 years, with a comparison of three anesthetic techniques and concluding that total intravenous anesthesia (TIVA) with a supraglottic airway is the author's preferred technique.)

Atef, A, Fawaz, A. “Comparison of laryngeal mask with endotracheal tube for anesthesia in endoscopic sinus surgery”. Am J Rhinol. vol. 22. 2008. pp. 653-7. (The authors conclude that use of a flexible reinforced supraglottic airway with controlled hypotension resulted in decreased blood loss compared to an endotracheal tube under TIVA.)

Danielsen, A, Olofsson, J. “Endoscopic endonasal sinus surgery: a review of 18 years of practice and long-term follow-up”. Eur Arch Otorhinolaryngol. vol. 263. 2006. pp. 1087-98. (Single-institution retrospective analysis of 1915 patients having 4285 FESS procedures with discussion of indications, complications, and anesthetic management.)

Al-Mazrou, KA, Abdullah, KM, ElGammal, MS, Ansari, RA, Turkistani, A, Abdelmeguid, ME. “Laryngeal mask airway vs. uncuffed endotracheal tube for nasal and paranasal sinus surgery: paediatric airway protection”. Eur J Anaesthesiol. vol. 27. 2010. pp. 16-9. (Randomized trial of 60 children 1 to 12 years to ETT versus SGA management during sinus surgery. Evidence of blood staining in the trachea with an ETT was significantly higher than with an SGA.)

Kaplan, A, Crosby, GJ, Bhattacharyya, N. “Airway protection and the laryngeal mask airway in sinus and nasal surgery”. Laryngoscope. vol. 114. 2004. pp. 652-5. (Prospective nonrandomized trial of 74 patients with comparison of ETT to SGA. SGA provided better protection from blood staining in the glottis or pharynx thought the ETT group had significantly less blood staining in the distal trachea.)

Chandra, RK, Conley, DB, Kern, RC. “Prophylactic i.v. antibiotics in functional endoscopic sinus surgery: trends and attitudes of the American Rhinologic Society membership”. Am J Rhinol Allergy. vol. 23. 2009. pp. 448-50. (Survey data from 49 attendees at the 2008 annual meeting of the American Rhinologic Society suggesting that systemic antibiotics where used by 57% of respondents, although 93% documented doing so despite no solid evidence to support this practice.)

Bhatti, MT, Stankiewicz, JA. “Ophthalmic complications of endoscopic sinus surgery”. Surv Ophthalmol. vol. 48. 2003. pp. 389-402. (Important guidance for generally iatrogenic injury to the eye and orbit during FESS. Major review on the anatomical, technical and surgical aspects of orbital and ophthalmic complications during FESS.)

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