1. Dip. Diab.DCA, Dip. Software statistics- Phd
Anaesthesia for FESS
Dr. S. Parthasarathy
MD., DA., DNB, MD (Acu),
Dip. Diab.DCA, Dip. Software statistics- Phd
Mahatma Gandhi Medical college and research institute , puducherry , India

2. FESS is a nasal endoscopic technique that allows visualization of the paranasal sinuses and nasal cavity without a skin incision

4. History
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
Almost 350 cases / year in MGMC

5. Indications surgical treatment of sinusitis; nasal polyps; epistaxis;
bacterial, fungal, recurrent, acute, and chronic sinus problems.
Extended
skull base surgery, trans sphenoidal pituitary tumor resection, and treatment of vascular malformations.

6. Complications- nose, orbit and brain

7. Intraoperative bleeding
Intra operative 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.

8. Preoperative look out

9. Samter’s triad
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.

10. Preoperative preparation
NSAIDs ??
Bronchial asthma but beta blockers
Local adrenaline
Long term steroids
Planning deliberate hypotension
Ask h/o CVS CNS diseases

11. Helpful preoperative studies include prothrombin time, activated thromboplastin time, platelet count, and complete blood count.
ECG, ECHO, Xray, PFT

12. 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

13. Combined with local anesthetics, vasoconstrictors are frequently employed.
Topical agents are also used in combination with infiltration techniques.
Oxymetazoline, phenylephrine, cocaine, and epinephrine are the vasoactive agents most commonly used in FESS.
ENT surgeons pack ??

14. GA children, developmentally disabled adults,
potentially difficult airways
have a risk of aspiration
require longer operative times
Concepts ??
Motionless, bloodless field and a secure airway

15. Anaesthetic technique
Controlled GA – ETT routine tube or RAE
LMA - throat pack !!
In patients with a history of significant gastro esophageal reflux disease, obesity, hiatal hernia, or prior gastric surgery, use of LMAs should be discouraged.
LMAs do not protect against aspiration as well as cuffed ETTs -- but ?? Studies

16. Intraoperative Dexa and propofol Steroids – wheezing and PONV
Propofol - hypotension and PONV
Glyco, fentanyl, isoflurane, vec –
No halo , no atracs

17. Deliberate hypotension
“Controlled” hypotension is an anesthetic technique aimed at “deliberately” significantly decreasing the MAP
Advocated to aid in the reduction of blood loss and improve visualization in sinus surgery.

18. Deliberate hypotension
one can safely achieve a 30% decrease from baseline MAP or an absolute value of 50 mm Hg in healthy patients with ASA class I status
But the definition is
Reduction of the systolic blood pressure to 80-90mmHg
Reduction of mean arterial pressure (MAP) to mmHg
30% reduction of baseline MAP

19. Routine drugs Remifentanil- 1 µg.kg-1.min-1 and
µg.kg-1.min-1 infusion
One and one is OK
Propofol mg.kg-1
& 200 µg.kg-1.min-1
Sevoflurane %
Clonidine IV sos

20. How to give controlled hypotension
the answer is -- VIAGRA
V – Vasodilators (SNP, NTG, Adenosine)
I - Inh. Agents , IV anaesthetics
A - Adrenergic blockers(labetolol,esmolol)
G – Ganglion blockers
R – Regional
A – Anaesthesia

21. Saudi Journal of Anaesthesia Vol. 7, Issue 2, April-June 2013
Both dexmedetomidine or esmolol with sevoflurane are safe agents for controlled hypotension and are effective in providing ideal surgical field during FESS.
Compared with esmolol, dexmedetomidine offers the advantage of inherent analgesic, sedative and anesthetic sparing effect.

22. Reduce BP
better fields
Reduce complications

23. Other techniques
Vasoactive medications are injected and infiltrated into the nasal sinuses to decrease mucosal congestion, reduce blood loss, and help achieve hemostasis

24. Maintenance of Anesthesia
Remifentanyl propofol TIVA
Remi + isoflurane
Fentanyl + isoflurane
nitrous oxide (50%–75%) with remifentanil (0.1–0.5 mg/kg/min)/propofol (25–50 mg/kg/min) infusions can be used.

25. Maintenance of Anesthesia
mild degree of hypocapnia or hyperventilation has long been advocated to induce vasoconstriction in the nasal sinuses and minimize bleeding
Hypercapnia and oozing is well known
Controlled ventilation – must
PEEP increased incidence of bleeds

26. What we use here – better field
Propofol
Dexmed , clonidine
Fentanyl + iso
Local vasoconstrictors
Head up
Preop beta blockers , captopril ??

27. Emergence Smooth No cough Neostigmine and spasms So LMA is better !!
NO NSAIDs for pain relief
Remove pack

28. Nasociliary nerve block + infra orbital nerve block --- OK
Acta Anaesthesiologica Scandinavica Volume 49, Issue 10, pages 1471–1476, November 2005
Local anesthesia for functional endoscopic sinus surgery employing small volumes of epinephrine-containing solutions of lidocaine produces profound hypotension
Nasociliary nerve block + infra orbital nerve block --- OK

29. The infraorbital nerve is located 1
The infraorbital nerve is located 1.5 cm lateral to the nasal bone and 1 cm below the orbital rim

30. Infraorbital nerve block

31. Maxillary nerve block

32. Nasociliary nerve blockade
Posteroinferior 1.5 cm- 2.5 cm depth 1.5 ml

33. Technique
To perform blockade of the nasociliary nerve, the medial canthus is identified and a line is drawn superiorly to a point just below the eyebrow.
The skin overlying this area is prepared with antiseptic solution, with care being taken to avoid spillage into the eye.
A 22-gauge, 1½-inch needle is inserted at this point, and, with close contact kept with the bony surface of the orbit, the needle is carefully advanced posteroinferiorly approximately 35 degrees off the perpendicular to a depth of approximately 1¼ inches.

34. Srilankan journal of anaesthesiology

35. Coroner's Clot
Any clot left behind can be inhaled after removal of a tracheal tube and lead to total airway obstruction and death—hence the term “coroner's clot.”
Be more careful in OSA patients
IV cannula – be there till pack removal (nasal)
Post op pain relief - RA, narcotics , para ( oral !!)

36. Regional anaesthesia for FESS
Maxillary nerve block + nasociliary nerve block
Infraorbital nerve block + nasociliary nerve block

37. summary Definition Indications Preop Anaesthetic technique
Deliberate hypo
Post op pain + PONV

38. Thank you all