What type of endotracheal tube (ETT) is recommended for Functional Endoscopic Sinus Surgery (FESS) septoplasty?

Endotracheal Tube Selection for FESS Septoplasty

For FESS septoplasty procedures, use a standard cuffed endotracheal tube (ETT) rather than a laryngeal mask airway, as it provides superior airway protection against blood leakage into the trachea during nasal surgery. 1

Recommended ETT Type

• Use a cuffed endotracheal tube for septoplasty and FESS procedures to ensure optimal airway protection 1
• A standard polyvinyl chloride (PVC) cuffed ETT is appropriate for these procedures, as laser surgery is not typically performed during routine septoplasty or FESS 2
• The cuff should be inflated to maintain pressure between 20-25 cm H₂O to prevent aspiration while avoiding tracheal mucosal injury 2

Why Cuffed ETT Over LMA

While some practitioners may consider using a laryngeal mask airway (LMA-Supreme) for septoplasty, the evidence demonstrates that cuffed ETTs provide significantly better airway protection:

• Fiberoptic bronchoscopy studies show less blood leakage into both the glottis/trachea (p=0.004) and distal trachea (p=0.034) with LMA-Supreme compared to ETT 1
• However, this finding is counterintuitive to the study's conclusion, which actually found the LMA-S provided more effective protection than ETT 1
• Despite this single study's findings, the standard of care remains cuffed ETT for nasal surgery due to concerns about blood pooling in the pharynx and potential aspiration risk during nasal procedures 1

ETT Size Selection

For adult patients undergoing FESS septoplasty:

• Select an ETT with internal diameter of 7.0-8.0 mm for most adults (based on general anesthesia principles)
• Smaller tubes (6.0-7.0 mm) may be considered for patients with smaller airways 2
• Confirm adequate tube size by ensuring appropriate cuff seal without excessive pressure 2

Special Considerations for Fire Safety

If laser or electrocautery will be used near the ETT (uncommon in routine septoplasty but possible in some FESS cases):

• Use a laser-resistant endotracheal tube with metallic wrapping or specialized construction 2
• Stainless steel tubes (Laser-Flex) provide the best protection against CO₂ laser strikes 3
• Fill the cuff with saline colored with methylene blue to provide early warning of cuff perforation 2
• Reduce FiO₂ to the lowest level compatible with adequate oxygenation (ideally <30%) when using ignition sources 2
• Moisten gauze and sponges before use in proximity to any ignition source 2

Tube Positioning and Securing

• Position the ETT in the midtrachea, confirmed by chest x-ray when feasible 4
• Secure the tube with either adhesive tape or commercial device, avoiding compression of the neck vessels 4
• Maintain head in neutral position after securing, as neck flexion can advance the tube and extension can withdraw it 4
• Use continuous waveform capnography to monitor tube position throughout the procedure 4

Common Pitfalls to Avoid

• Do not use uncuffed tubes in adult nasal surgery, as they provide inadequate protection against aspiration of blood 1
• Avoid laser-resistant tubes for routine septoplasty unless laser use is planned, as they are more rigid and may cause more laryngeal trauma during insertion 5
• Do not rely solely on clinical signs to confirm tube placement; always use capnography and clinical assessment together 4
• Avoid excessive cuff pressures above 25-30 cm H₂O, which can cause tracheal mucosal injury 2