What are the pre-operative, intra-operative, and post-operative considerations for a patient undergoing Functional Endoscopic Sinus Surgery (FESS) with a history of recurrent sinus infections and potential bleeding disorders?

Functional Endoscopic Sinus Surgery (FESS): Comprehensive Perioperative Management

Pre-operative Considerations

For patients with recurrent sinus infections and potential bleeding disorders undergoing FESS, mandatory pre-operative CT scanning must be performed immediately before surgery to confirm disease extent and identify anatomical risk factors for complications. 1

Essential Pre-operative Imaging and Assessment

• CT scanning without contrast is mandatory prior to surgery to confirm the presence and extent of disease, and to identify anatomical features that may predispose to complications 1
• Multiplanar CT images are required to fully assess the anatomy, particularly the osteomeatal complex, skull base, and orbital boundaries 1
• For patients with recurrent infections, evaluate for mucosal thickening patterns: rounded thickening suggests low complication risk, while irregular or circumferential thickening >4mm requires otorhinolaryngology consultation before proceeding 1

Medical History Requirements

• Obtain detailed history of nasal obstructions, facial trauma, previous sinus infections, allergic symptoms, chronic respiratory diseases, previous nasosinusal surgeries, and atmospheric pressure-related discomfort 1
• For patients with potential bleeding disorders, document complete coagulation history including anticoagulant use, family history of bleeding disorders, and previous bleeding complications 1
• If acute rhinosinusitis symptoms are present, delay surgery for 30 days after proper treatment to obtain adequate mucosal trophism and osteomeatal complex patency 1

Pre-operative Medical Optimization

Topical corticosteroids (mometasone 200 mcg twice daily for 4 weeks preoperatively) significantly reduce intraoperative blood loss, improve surgical field quality, and decrease operation time compared to placebo. 1

• The evidence for oral corticosteroids is mixed: one study showed benefit with 60mg prednisolone tapered over 7-10 days, while two other studies showed no difference 1
• Given the bleeding disorder concern, prioritize topical corticosteroids over systemic steroids to minimize bleeding risk while still optimizing the surgical field 1

Otorhinolaryngology Consultation Criteria

• Mucosal thickening >3mm with osteomeatal complex closure requires specialist evaluation before surgery 1
• Radiologic signs of radiopacity, impaired nasal breathing, or chronic respiratory disease warrant consultation 1
• Any symptoms of active sinusitis that persist beyond 10 days of treatment require consultation and 30-day waiting period after resolution 1

Intra-operative Considerations

Bleeding Management Strategies

For patients with bleeding disorders, meticulous attention to vascular anatomy is critical, particularly the alveolo-antral artery location identified on pre-operative imaging. 1

• Use bone wax for intrabony bleeding sources 1
• Apply diathermy for extrabony bleeding 1
• Protect the sinus membrane with collagen sponges during elevation to minimize perforation and bleeding 1
• Use sharp, efficient diamond burs of proper size to minimize trauma and bleeding 1

Technical Considerations to Minimize Complications

• Ensure wider flap design and proper retraction to maintain adequate access throughout the procedure 1
• Use computed-guided antrostomy with surgical stents when available to ensure correct ostium location 1
• Maintain constant contact between detachers and bone during membrane elevation to avoid perforation 1
• Evaluate for sinus septa (present in approximately 30% of cases) on pre-operative imaging, as these increase perforation risk 1

Anatomical Pitfalls

• Incomplete uncinate process removal leads to persistent middle meatal obstruction and continued mucus collection 1
• Ensure complete visualization and resection of diseased ethmoidal cells, as residual disease in posterior ethmoids is particularly difficult to resolve 1
• Verify that middle meatal antrostomy is genuine and not mistakenly created in an ethmoid air cell 1

Post-operative Considerations

Immediate Post-operative Management

Nasal saline irrigations are mandatory after FESS to improve mucociliary clearance and maintain sinus patency. 1, 2

• High-volume nasal douching (250ml twice daily) is more effective than spray or nebulization for distributing irrigation to maxillary sinuses and frontal recess 1
• Continue nasal corticosteroid sprays for maintenance therapy 1
• Provide appropriate pain management with minimal opioid use 2

Critical Surveillance for Complications

Regular endoscopic examination is essential to detect early complications, with the first examination typically within 1-2 weeks post-operatively. 2, 3

Short-term Complications (First 3 Months)

• Synechiae formation between middle turbinate and lateral nasal wall is the most common complication requiring early detection and lysis to prevent recurrent obstruction 4, 3
• Turbinate lateralization can occur and requires repositioning 3
• Retained secretions and mucus recirculation perpetuate symptoms despite adequate surgical ostia 1, 4
• Crusting and minor bleeding are common and managed with continued saline irrigation 3

Long-term Complications (Beyond 3 Months)

• Ostial stenosis from scarring requires revision surgery if symptomatic 3
• Assess surgical ostium patency for narrowing from synechiae, edema, or thickened mucus 2
• Monitor for disease recurrence, which occurs in approximately 12% of patients despite initial improvement 5

Special Considerations for Bleeding Disorders

• More frequent post-operative visits in the first 2 weeks to monitor for delayed bleeding
• Lower threshold for intervention if crusting or retained blood clots are visualized
• Avoid aggressive debridement that might precipitate bleeding episodes
• Ensure patient has clear instructions on when to seek emergency care for post-operative hemorrhage

Expected Outcomes

• Major complications occur in less than 1% of cases 2
• Approximately 88-90% of patients report symptom improvement or resolution 5, 6
• However, 41.5% still require some ongoing medical therapy for optimal control 5
• Quality of life improvements are significant when surgery is combined with appropriate post-operative medical management 2

Long-term Follow-up Protocol

• Clinical and endoscopic follow-up for at least 3 years is appropriate for experienced surgeons 7
• CT scanning 4-6 months post-operatively may be helpful if symptoms recur, particularly for less experienced surgeons 7
• Continue medical therapy indefinitely to prevent recurrence and optimize surgical outcomes 2