What is the Boezaart grading system for intra‑operative bleeding during functional endoscopic sinus surgery and how is it applied?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Educational purpose only • Exercise caution as content is pending human review
Article Review Status
Submitted
Under Review
Approved

Last updated: March 4, 2026 • View editorial policy

Personalize

Help us tailor your experience

Which best describes you? Your choice helps us use language that's most understandable for you.

Boezaart Grading System for Intraoperative Bleeding in Sinus Surgery

The Boezaart grading system is a 6-point scale (0-5) used to assess the quality of the surgical field during functional endoscopic sinus surgery (FESS), where lower scores indicate less bleeding and better visualization. 1

Scale Description and Application

The Boezaart scale evaluates the endoscopic field of view during FESS based on the degree of bleeding present:

  • Grade 0-2: Represents a "clean surgical field" with minimal to moderate bleeding that allows adequate visualization 2
  • Higher scores (3-5): Indicate progressively worse bleeding that impairs surgical visualization and may compromise safety 1

The scale is applied by the surgeon or observer during the procedure to document intraoperative bleeding conditions in real-time. 1

Clinical Utility and Limitations

The Boezaart scale has been widely used in research evaluating hemostatic interventions during FESS, including studies on tranexamic acid, desmopressin, and patient positioning. 3, 2, 4, 5

Key Applications:

  • Outcome measurement: Used as a primary endpoint in clinical trials assessing bleeding reduction strategies 3, 2
  • Surgical field assessment: Helps quantify the impact of interventions like reverse Trendelenburg positioning (15-20 degrees), which significantly improves Boezaart scores (mean scores of 1.4-1.66 vs 2.33 in horizontal position) 4, 5
  • Standardization: When combined with standardized video-endoscopy techniques, inter-rater reliability improves to 0.74 1

Important Limitations:

A newer 11-point Wormald grading scale has demonstrated superior performance compared to the Boezaart scale, with significantly higher inter-rater (0.80 vs 0.74) and intra-rater (0.89 vs 0.83) reliability. 1 The Wormald scale also shows greater sensitivity to changes in the most common surgical field conditions encountered during FESS. 1

Practical Considerations

For optimal use of any bleeding grading system during FESS, standardized video-endoscopy documentation is essential as it significantly improves both reliability and reproducibility of assessments. 1

The scale is most meaningful when:

  • Applied consistently throughout the procedure 1
  • Used in conjunction with other bleeding metrics (total blood loss, blood loss per minute) 4, 5
  • Documented with standardized video recording techniques 1

References

5
Research

Comparing the reverse Trendelenburg and horizontal position for endoscopic sinus surgery: a randomized controlled trial.

Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery, 2013

Related Questions

What is the Boezaart grading system in functional endoscopic sinus surgery?
How is the Boezaart surgical field grading scale scored?
What is the likely cause and appropriate management of breakthrough bleeding occurring one week after the end of a normal menstrual period?
Is it safe to perform a living donor kidney transplant in a recipient who recently received a blood transfusion, and what immunologic evaluation is required?
In a minor with a life‑threatening condition and a 50 percent chance of survival whose mother refuses all intravenous (IV) and oral medications and the child is unvaccinated, what is the next appropriate step in management?
What is the appropriate next diagnostic and therapeutic management for a 23‑year‑old male with left flank pain for 5 days, high‑grade fever (up to 104 °F, now 100 °F), tachycardia (120 bpm), blood pressure 117/76 mmHg, mild transaminitis, CRP 68 mg/L, discordant platelet count (automated 90 ×10³/µL vs manual 148 ×10³/µL), normal renal function, urine showing few pus cells and red blood cells, who has not improved after two doses of ceftriaxone (1 g IV) and metronidazole, and is currently receiving ceftriaxone 1 g IV twice daily plus amikacin 500 mg IV once daily?
What are the current treatment guidelines for stress urinary incontinence?
What is the body mass index (BMI) for a person who is 165 cm tall and weighs 84 kg?
What are the indications, dosing regimen, contraindications, and monitoring recommendations for potassium citrate syrup?
What is the Boezaart grading system in functional endoscopic sinus surgery?
What are the brief clinical features of left-sided heart failure and right-sided heart failure?

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

Have a follow-up question?

Our Medical A.I. is used by practicing medical doctors at top research institutions around the world. Ask any follow up question and get world-class guideline-backed answers instantly.

Ask Question