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NASAL POLYPOSIS
of bilateral diuse CRS with type 2 endotype dominance.1 However, polyps can also accompany localised CRS such as allergic fungal rhinosinusitis (AFRS).
Incidence and Prevalance
e annual incidence of CRSwNP is 1–20 per 1000 population. is incidence declines aer
60 years of age. Prevalence is 1–4% in adults and 0.1% in children. NPs are more common in
males (2–4:1). ere is no racial predilection.
Clinical Presentation
Clinical presentation is variable and depends on the extent of polyp disease. Small polyps
may be asymptomatic whilst larger polyps can cause signicant nasal obstruction, congestion, hyposmia, rhinorrhoea, postnasal discharge and facial pain. Rarely, proptosis, hypertelorism and diplopia can result from alterations in the craniofacial structure.
Pathogenesis
Factors causing CRS are complex, individual to the patient and usually unknown, hence
the interest now is centred on the resulting inammation that develops in the sinus tissue.
When the mucosal barrier is breached, a self-limited immunodefensive response is generated, characterised by a cellular and cytokine repertoire targeting one of the three classes
of pathogens: type 1 immune responses target viruses; type 2 responses target parasites and
type 3 responses target extracellular bacteria and fungi, all of which resolve with elimination
of the pathogens and restoration of barrier integrity.
In cases of CRS, barrier penetration results in a chronic inammatory response that fails
to resolve, but still typically utilises the type 1, 2 or 3 pathways alone, or in combinations.
Approximately 80% of NPs in Western countries are associated with a type 2 eosinophilic
inammatory response, characterised by activation of T-helper 2 cells and innate lymphocytes to produce the key cytokines interleukin (IL)-4, IL-5 and IL-13. ese cytokines upregulate the expression of vascular cell adhesion molecule 1 (VCAM-1) on endothelial cells
allowing selective adhesion and migration of eosinophils into sinonasal tissue. Furthermore,
IL-4 facilitates B-cell maturation into IgE producing plasma cells that release specic IgE
and trigger mast cell degranulation and activation. IL-5 can stimulate synthesis and release
of eosinophils aiding in their propagation and survival in the bloodstream. e overall
eect of this type 2 inammatory response is an eosinophilic-mediated mucosal injury and
chronic inammation, which results in nasal polyposis.
Allergy
e role of allergy is unclear and varies with phenotype. NPs are found in 25.6% of patients
with allergy compared with 3.9% in a control population.
Bacteria
e link between bacterial colonisation and NPs has been postulated but remains unproven.
Staphylococcus aureus enterotoxin is thought to be the main species involved. e secreted
enterotoxins behave as super-antigens, directly activating T cells stimulating a massive cytokine response resulting in eosinophilic inammation and formation of IgE antibodies.
Histologically, NPs consists of loose connective tissue, goblet cell hyperplasia, inammatory
cells and uid and are usually covered by pseudostratied, columnar, ciliated epithelium.
Associated Diseases
Asthma
ere is a strong correlation between NPs and asthma. In 25% of patients, NPs coexist
with asthma out of which up to 45% will develop asthma within 10 years of NP diagnosis. Patients with asthma are more likely to suer treatment failure and need repeated
surgeries.
178 Rhinology and Facial Plastic Surgery
NASAL POLYPOSIS
Non-Steroidal Anti-Inammatory Drugs Exacerbated
Respiratory Disease (NERD)
NERD is a chronic eosinophilic inammatory disorder of the respiratory tract in patients
with asthma and/or CRSwNP. It has also described as aspirin exacerbated respiratory disease
(AERD) or Samter’s triad.
Its prevalence is 0.9% in normal population, 10–20% in asthmatics and 30–40% among asthmatics with NP.
It is related to cyclo-oxygenase inhibition resulting in increased leukotriene synthesis leading to mast cell instability with histamine release, causing increased vascular permeability,
oedema and eosinophilic inammation of sinonasal membranes resulting in NP formation.
NPs tend to be extensive with a h igher recurrence rate p ost-surgery (90% recur rence at 5 years).
Allergic Fungal Rhinosinusitis
AFRS is subset of CRSwNP characterised by a type I mediated hypersensitivity reaction to fungi
with the presence of eosinophilic mucin and non-invasive fungal hyphae within the sinuses.
e Bent and Kuhn diagnostic major and minor criteria is used to make the diagnosis of AFRS.
Medical therapy alone is inadequate and surgery is the mainstay treatment for AFRS. Oral
steroids have been shown to reduce recurrence. Little evidence exists for use of antifungals
in AFRS.
e ve major Bent and Kuhn criteria which must be met for diagnosis are:
1 Type 1 hypersensitivity to fungi (demonstrated by skin allergy test, fungal IgE in sinus
mucin, or PCR)
2 Positive fungal staining of an intranasal surgical specimen
3 Eosinophilic mucin
4 Nasal polyposis
5 Characteristic CT ndings – central hyperdense allergic mucin, peripheral hypodense.
Other Diseases Associated with Nasal Polyposis
Cystic brosis, primary ciliary dyskinesia (Chapter 33), and eosinophilic granulomatosis
with polyangiitis (Chapter 44) are also frequently associated with NPs.
Diagnosis
Anterior rhinoscopy and nasendoscopy are required for assessment and identication of NPs,
discharge, crusting or scarring. Blood tests including eosinophil count, specic serum IgE levels
for allergens and other serological tests aimed at underlying associated systemic causes should
be performed. Computed tomography (CT) scanning with coronal sections is used to assess the
extent of disease and detail the anatomy before surgery. In cases of extensive disease w ith attenuation of anterior skull base, magnetic resonance can be helpful to dierentiate from tumour.
Imaging Studies and Staging Systems
Endoscopic and CT-based staging systems are used to determine the extent of disease and
evaluate ecacy of therapeutic responses (Table 34.1).
Management
e primary objective is to eliminate symptoms, re-establish nasal breathing and olfaction,
prevent recurrence and improve quality of life.
Medical (Further Described in Chapter 35)
Patients should have a trial of medical therapy rst unless histology is required. Medical
management includes:
Intra-nasal corticosteroids (INCS).
•
Short courses of systemic corticosteroids in more extensive polyposis.
•
Antihistamines help only if allergy is present.
•
Leukotriene inhibitors may help patients with coexisting asthma and/or aspirin
•
sensitivity.
Rhinology and Facial Plastic Surgery 179
NASAL POLYPOSIS
Table 34.1 Endoscopic staging of nasal polyps in CRSwNP
Lund-Kennedy Endoscopic staging of nasal
polyps in CRSwNP
Polyp 0 = Absence of polyp
1 = Polyps in middle meatus only
2 = Beyond middle meatus
Oedema 0 = Absent
1 = Mild
2 = Severe
Discharge 0 = No discharge
1 = Clear, thin discharge
2 = Thick, purulent discharge
Scarring 0 = Absent
1 = Mild
2 = Severe
Crusting 0 = Absent
1 = Mild
2 = Severe
Note: The Lund-McKay Score: each side is scored separately and the total score is calculated.
Source: Lund VJ, Kennedy DW. Quantication for staging sinusitis. In: Kennedy DW. International
Conference on Sinus Disease: Terminology, Staging, Therapy. Annals of Otology Rhinology and
Laryngology. 1995;104(Suppl 167):17–21; Lund VJ, Mackay IS. Staging in rhinosinusitis. Rhinology.
1993;31(4):183–184.
0 = No abnormalities
1 = Partial opacication
2 = Complete opacication
0 = Not occluded
2 = Occluded
The Lund-McKay Score
Radiological staging CRS
Maxillary sinus
Anterior
ethmoid sinus
Posterior
ethmoid sinus
Sphenoid sinus
Frontal Sinus
Ostiomeatal
complex
Recent advances in biological treatments have resulted in availability of therapeutic monoclonal antibodies (mAbs) targeting several key mediators of NP pathogenesis that can potentially improve treatment of nasal polyposis in the setting of type 2 CRS:
1 Omalizumab binds free circulating IgE, downregulates the expression of IgE recep-
tors on mast cells/basophils and reduces release of inammatory mediators ([IL-4).
2 Dupilumab is an mAb to IL-4 receptor that inhibits the signaling of IL-4/IL-13 and
reduces 2-mediated inammation. It is the only biological therapy approved for use
in CR SwNP.
3 Mepolizumab prevents activation of IL-5 receptors by binding to IL-5, which is impor-
tant for dierentiation/maturation/survival of eosinophils in tissue.
e EPOS2020 guidelines have highlighted specic criteria for their application in NP1
(Table 34.2).
Recent trials using these biological treatments in NP and comorbid asthma as well as
CRSwNP refractory to standard therapy have shown encouraging results with decrease in
total polyp and symptoms scores.
Surgical (Further Described in Chapter 36)
Surgical management is considered for patients who have failed to respond to adequate
medical treatment. Endoscopic sinus surgery (ESS) aims to improve sinus ventilation and
drainage and facilitate topical INCS delivery. Patients with NPs derive the greatest benet
from ESS, and those whose main pre-operative symptom is nasal obstruction or headache
report higher benet.
Post-operatively, patients should be treated with nasal irrigation and intra-nasal or systemic corticosteroids. Compliance inuences the long-term ecacy of surgery. ere is
good evidence that post-operative use of topical nasal steroids reduces the rate of polyp
recurrence.
180 Rhinology and Facial Plastic Surgery
MEDICAL MANAGEMENT OF CRS
Table 34.2 EPOS2020 criteria for biological treatments in CRS
Presence of bilateral nasal polyps in a patient who has had endoscopic sinus surgery
+
Three criteria required
Criteria Cutoff points
Evidence of type 2 inammation Tissue eosinophil count ≥10/hpf, OR
Blood eosinophil count ≥250, OR
Total IgE ≥100
Need for systemic corticosteroids OR
Contraindication to systemic steroids
Signicantly impaired quality of life SNOT-22 ≥40
Signicant loss of smell Anosmic on smell test (score depending on
Diagnosis of comorbid asthma Asthma needing regular inhaled corticosteroids
Source: Adapted from Fokkens WJ, Lund VJ, Hopkins C, et al. European Position Paper on
Rhinosinusitis and Nasal Polyposis 2020. Rhinology. 2020;58(Suppl S29):1–464.
≥2 courses per year, OR
Long term (>3 months) low-dose steroids
test)
1
KEY POINTS
• Nasal polyps are the end result of chronic inammation.
• The pathophysiology remains unclear but is the result of type 2 eosinophilic
inammatory response, characterised by activation of T-helper 2 cells and innate
lymphocytes to produce the key cytokines IL-4, IL-5 and IL-13.
• Certain systemic diseases are associated with a much higher incidence of CRSwNP
with a prevalence of around 7% in patients with asthma and up to 30–60% in
patients with NERD.
• Adequate medical therapy with intranasal corticosteroids, nasal irrigations and oral
steroids are rst-line treatment for NPs.
• Surgery is indicated where there is failure to respond to adequate medical therapy.
ESS aims to improve sinus ventilation and drainage and facilitate topical intranasal
corticosteroids delivery.
Further Reading
1. Fokkens WJ, Lund VJ, Hopkins C, et al. European Position Paper on Rhinosinusitis
and Nasal Polyps 2020. Rhinology. 2020;58(Suppl S29):1–464. Published 2020 Feb 20.
doi:10.4193/Rhin20.600.
35. MEDICAL MANAGEMENT OF CRS
Introduction
Acute rhinosinusitis (ARS) is common, aecting 6–15% of the population each year. Most
cases are viral, with acute bacterial rhinosinusitis (ABRS) estimated in less than 2% of
cases. Nearly all cases of ARS resolve spontaneously within 10 days, and the incidence of
complications is very low. Medical treatment may be antimicrobial or anti-inammatory
(Figure 35.1).
Rhinology and Facial Plastic Surgery 181
MEDICAL MANAGEMENT OF CRS
CARDINAL NASAL SYMPTOMS
<10 days
SELF-CARE
PHARMACY
REFER TO/TREATMENT BY PRIMARY CARE
CHECK FOR LIKELY ABRS
>= 3 of the following
- Fever above 38
- Double sickening
- Unilateral disease
- Severe pain
CARE
PRIMARY
REFER TO SECONDARY/TERTIARY CARE
CARE
Consider and test for dierential diagnosis and treat
accordingly (e.g. odontogenic, fungal ball, bacterial
SECONDARY
TERTIARY
resistance, immundeciency, migraine)
CARE
+
+
CHECK FOR LIKELY ABRS
>= 3 of the following
- Fever above 38
- Double sickening
- Unilateral disease
- Severe pain
–
Duration >10 days, or immunocompromised or <2 or >75 yrs of age or
comorbidity
- Diabetes
- Respiratory (e.g. asthma, COPD)
- Underlying CRS
Self-education/e-Health
NaCI spray/rinses
–
INCS if available
Decongestants <10 days
NSAIDs/PCM
Avoid antibiotics
+
oedema/erythema
Ophthalmoplegia
Reduced visual acuity
No improvement after 10 days of antibiotics or
>=3 episodes of ABRS last year
PRESENCE OF ALARM SYMPTOMS
Periorbital
Displaced globe
Double vision
–
Consider antibiotics
No other investigations
+
Severe headache
Frontal swelling
Signs of sepsis
Signs of meningitis
Neurological signs
IMMEDIATE REFERRAL
Figure 35.1 ARS management chart (EPOS2020).1 ABRS, acute bacterial rhinosinusitis; COPD,
chronic obstructive pulmonary disease; CRS, chronic rhinosinusitis; INCS, intra-nasal corticosteroid;
NSAIDS, non-steroidal anti-inammatory drugs.
Reduction of Infective Load
Although the majority of ARS is viral, antibiotics are oen expected by patients. Most studies
have shown little benet from antibiotics in most patients with ARS and should be restricted
in uncomplicated ARS.
Differentiating Bacterial from Viral ARS
ABRS is suggested by the presence of three out of four symptoms including nasal purulence,
purulence in the post-nasal space, high fever (>39°C) and raised erythrocyte sedimentation
rate (ESR). A description of ‘double-sickening’, unilateral disease and severe pain may also
be helpful. In ABRS or due to the presence of complications the choice of antibiotics is preferably based on culture results. If treatment is empiric, a short course of narrow-spectrum
agents is recommended.
Reduction of Inammation
Studies of intra-nasal glucocorticoids have demonstrated benet for the relief of symptoms in both viral and ABRS; as the risk of harm is low, these can be oered to all patients.
Similarly, meta-analysis supports a role for systemic steroid treatment as adjunctive treatment to antibiotics. Patients treated with oral corticosteroids were more likely to have
short-term resolution or improvement of symptoms than those receiving antibiotics
alone. However, given the risks of systemic steroids, these should only be considered in
severe cases.
Symptomatic Improvement
Nasal decongestants may have a small symptomatic eect in reducing nasal congestion but
not overall duration of ARS. ere is little evidence that saline therapies assist in symptom
relief. Low-volume saline sprays may assist in removing mucus and crusts, but high-volume
irrigations are oen poorly tolerated during acute inammation.
Management of ARS complications is described in Chapter 37.
182 Rhinology and Facial Plastic Surgery
MEDICAL MANAGEMENT OF CRS
MEDICAL MANAGEMENT OF CHRONIC RHINOSINUSITIS
Introduction
e treatment of chronic rhinosinusitis (CRS) is primarily medical, with surgery reserved for
those who fail a trial of maximal medical therapy (Figure 35.2). However, there are important exceptions.
Overview of the Pathophysiology of CRS
As described in chapter 33, the EPOS 2020 group has chosen to look at CRS as primary and
secondary1:
Primary CRS refers to most patients with unexplained inammation of the upper
•
airway. It is common to nd lower airway disease as part of a broader respiratory
condition.
Figure 35.2 Management of Rhinosinusitis (EPOS2020).1 ATAD, aspirin treatment after desensi-
tisation; CRS, chronic rhinosinusitis; CT, computed tomography; FESS, functional endoscopic sinus
surgery; INCS, intra-nasal corticosteroid; MRI, magnetic resonance imaging; N-ERD, non-steroidal
anti-inammatory exacerbated respiratory disease; OCS, oral corticosteroids; SPT, skin prick test.
Rhinology and Facial Plastic Surgery 183
MEDICAL MANAGEMENT OF CRS
Secondary CRS refers to sinonasal disease with a manifestation of systemic disease;
•
examples include vasculitis, cystic brosis, sarcoidosis and ciliary motility disorders. CRS may also occur as a direct result of focal abnormalities including a foreign body, fungal ball, odontogenic infection or an anatomical obstruction. Medical
management plays no signicant role in rst-line management in this group.
Primary CRS may be subcategorised phenotypically by the presence or absence of polyps:
CRS with polyps (CRSwNP) or CRS sine (without) polyps (CRSsNP). It is acknowledged that
there is a move away from phenotyping the disease and increasing focus on endotyping of
the mucosal inammatory pattern to identify those with eosinophil-dominated (eCRS or
T-helper 2 cell (2) skewed) inammation.
Treatment Targeting Intrinsic Mucosal Inammation
Mucosal inammat ion is the dening feature of CRS. Glucocorticoids have formed the mainstay of medical therapy for CRS, whereas long-term macrolides, doxycycline and monoclonal
antibodies also target the inammatory pathway.
Intra-Nasal Corticosteroids
It has been shown in many studies that topical corticosteroids improve symptoms,
decrease the polyp score and size and prevent polyp recurrence aer surgery. Intra-nasal
corticosteroids have an excellent safety prole with low systemic bioavailability and are
also safe for long-term use in children. Instruction in correct delivery techniques is essential (Figure 35.3).
Systemic Corticosteroids
In contrast, there is a relative paucity of data for the ecacy of systemic corticosteroids. In
CRSsNP, there are no studies evaluating systemic steroids alone. In CRSwNP, a systematic
review showed a short-term benet of a short (2-to 4-week) course of oral steroids of variable
doses and duration when compared with placebo. ere was a reduction of polyp size and
improvement of nasal symptoms and quality of life; however, by 3 months there was no difference between groups. erefore, short courses of systemic steroids can be recommended
Figure 35.3 Correct application for nasal drops. (A) Head-back position. (B) Head-down position.
184 Rhinology and Facial Plastic Surgery
MEDICAL MANAGEMENT OF CRS
for the treatment of CRSwNP, although the risk of side eects must be considered with
repeated courses.
Immunomodulatory Antibiotics
Long-term (oen 12 weeks) macrolide antibiotics are used for their anti-inammatory
eects, especially on neutrophil-mediated inammation.
ere are two prosp ective randomised controlled trials. e rst study included only CRSsNP
and showed a signicant eect of roxithromycin on symptom scores and with greater ecacy
in patients with normal IgE levels. A subsequent study has found no eect; however, this
study included both CRSwNP and CRSsNP, and therefore it is likely that this study included
more patients with elevated IgE than the rst.
Long-term use of macrolide antibiotics is associated with macrolide resistance, and gastrointestinal side eects are relatively common. erefore, use should be directed at those
patients most likely to benet (i.e. CRSsNP, normal IgE levels). Macrolides interact with
many other drugs and may prolong the QT interval; a careful medical history should be
taken prior to usage.
A 20-day course of doxycycline has been shown to have a moderate and sustained eect on
polyp size over a 12-week period, and doxycycline may be an adjunct in patients with CRSwNP.
Novel Immunoregulation
Direct targeting of the inammatory pathway is possible using monoclonal antibodies such
as omalizumab (anti-IgE), mepolizumab (anti-IL-5) and dupilumab (anti-IL-4 and 13). ey
can signicantly reduce symptom scores and polyp size. However, high cost, risk of anaphylaxis, and need for subcutaneous injection are limiting factors that likely to restrict use to
those failing more established treatment regimens. EPOS2020 suggested criteria for biological treatment that are described in Chapter 34.
Aspirin Desensitisation
Aspirin sensitivity is usually associated with nasal poly posis and asthma (Samter’s triad). Patients
oen have exten sive polyposis, w ith high rates of recurrence aer treatment. A placebo-controlled
randomised control trial has shown a reduction in polyp recurrence when tolerance is achieved
by aspirin desensitisation and ongoing daily aspirin maintenance. is must be performed under
medical supervision, with optimum results achieved in the early post-operative period.
Treatment Aimed at Reducing Microbial Load
Treatment aimed at reducing microbial load or eradicating pathogens from the sinuses
assumes that these play a role in causing or propagating CRS. Bacteria may play a role in
acute infective exacerbations where culture-directed short-term antibiotics may be indicated, but there are no studies evaluating long-term symptom control.
Treatment Aimed to Improve Mucociliary Clearance
Saline irrigation can improve mucociliary clearance by the removal of mucus, infected crusts
and pro-inammatory agents. A Cochrane meta-analysis demonstrated benet from saline
irrigation both when used as the sole modality treatment and as an adjunct.
As irrigation is generally well tolerated, and it can be recommended for use in patients with
CRS. Again, patients should be instructed in their use (Figure 35.4).
Mucoactive Agents
Johnson & Johnson Baby Shampoo® has been shown to have both antibiolm-forming properties at 1% solution and is useful for treating crusting, thick mucus and chronic bacterial
mucosal colonisation.
Rhinology and Facial Plastic Surgery 185
MEDICAL MANAGEMENT OF CRS
Figure 35.4 Technique for nasal irrigation (A) Stand over a sink or in the shower/bath, keep your
head straight and put the nozzle of the bottle in one nostril. (B) Squirt half the bottle into one
nostril and then repeat on the other side. Following irrigation, blow your nose gently.
Delivery of Medical Therapy
Studies have documented poor penetration of topical therapies into the sinuses in the preoperative state. Consequently, systemic therapy is necessary to treat the sinus mucosa.
Endoscopic sinus surgery (ESS) can improve delivery and in the post-operative state, topical therapy is paramount in managing disease. Delivery of topical steroid by high-volume
irrigation has been shown to achieve better control of the sinus cavity on endoscopy than an
equivalent dose of steroid delivered by conventional spray.
e delivery device is important, and the most eective devices are the positive-pressure,
high-volume irrigation bottles (Figure 35.4).
Assessment of the Response to Medical Treatment
e aim of treatment for CRS is to reduce symptoms and improve quality of life. Subjective
symptoms need to be quantied using disease-specic quality-of-life measures. e
SNOT-22 questionnaire is most used but many others exists.
Response to treatment should be considered and if not achieved, the history and examination should be reviewed. It may be necessary with more aggressive medical therapy or consider combination with surgery. More than two courses of systemic corticosteroid per year
(of 2–3 weeks’ duration and less than 40 mg maximal daily dose) indicates failure.
Any patient with unilateral polypoid disease, where there is a suspicion of malignancy, the
presence of associated neurological or orbital symptoms or atypical features should not be
considered for medical therapy. ey require urgent radiological imaging, followed by surgery and histological examination where indicated.
KEY POINTS
• Medical therapy should have a three-way goal of reducing inammatory load,
normalising microbial community and restoration of mucociliary function.
• Medical therapy to the paranasal sinus is primarily via the systemic route in the
unoperated patient.
• Systemic corticosteroid is effective in CRSwNP, but use is usually limited to two courses
a year.
• Surgery, while potentially curative for some, is more commonly utilised to enable long-
term local or topical therapy to control disease.
• Intra-nasal corticosteroid irrigations are a common effective delivery mechanism in the post-
surgical patient. Their use is similar to that of a prophylactic inhaler for asthma patients.
186 Rhinology and Facial Plastic Surgery
SURGICAL MANAGEMENT OF CRS
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=× ×MAPHRstrokevolume SV SVR
Further Reading
1. Fokkens WJ, Lund VJ, Hopkins C, et al. European Position Paper on Rhinosinusitis
and Nasal Polyps 2020. Rhinology. 2020;58(Suppl S29):1–464. Published 2020 Feb 20.
doi:10.4193/Rhin20.600.
36. SURGICAL MANAGEMENT OF CRS
Introduction
e aims of functional endoscopic sinus surgery (FESS) are the restitution of physiology and
should fulll the following criteria:
Creating a sinus cavity that incorporates the natural ostium
•
Allows adequate sinus ventilation
•
Facilitates mucociliary clearance
•
Facilitates instillation of topical therapies
•
Several acronyms are used to describe the extent of FESS:
‘Mini FESS’: approach involving simple ventilation of the lower sinuses (less aggressive
•
endot y pe s)
‘Full-house FESS’: complete sinus opening including anterior and posterior ethmoid-
•
ectomy, middle meatal antrostomies, sphenoidotomy and frontal opening
Extended endoscopic surgery: Draf III and other extended frontal sinus approaches,
•
pre-lacrimal approach to maxilla and radical sphenoidotomy
Mucosal ‘reset’: includes signicant removal of inamed/dysfunctional mucosa
•
Surgical Procedures
Anaesthesia for Sinus Surgery
Usually performed under general anaesthetic with a laryngeal mask.
•
Hypotensive anaesthesia for optimal surgical eld; Desurane (at low concentration
•
only) and remifentanil combined probably provides just as good a surgical eld as
total intravenous anaesthesia (TIVA) and avoids the need for bispectral index (BIS)
monitoring.
A systolic mean arterial pressure (MAP) of approximately 90 mmHg is recommended
•
and best achieved with a heart rate (HR) ≤60 beats/min. Volatile agents, which achieve
hypotension by reducing systemic vascular resistance (SVR), can cause a deterioration
of the surgical eld from vasodilatation of the microvasculature.
Surgical Position and Intranasal Preparation
Reverse Trendelenburg position (up to 15° angle), produces a 35–40% reduction in
•
nasal blood ow.
Eyes can be le open with lubrication or taped to provide better corneal protection
•
whilst still allowing rapid access to the globe.
Rhinology and Facial Plastic Surgery 187
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