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1.1.5 Sphenopalatine Artery
It is the largest terminal branch of third part of
maxillary artery and it supplies a major part of
the nasal cavity and paranasal sinuses. It originates within the pterygopalatine fossa region and
it enters into the nose via the sphenopalatine
foramen. Foramen lies just deep to the posteriormost attachment of middle turbinate. The presence of the anterior bony crest in the middle
meatus close to posterior end of middle turbinate
is the landmark for endoscopic surgery (see
Chap. 9).
1.1.6 Cribriform Plate
It is made up of the horizontal medial part (lamina cribrosa) and vertical lateral part (Fig.1.6).
Crista galli is the thick upward middle projection on the lamina cribrosa. Olfactory nerve
comes out via the perforators in the lamina
cribrosa. Flax cerebri attaches with the crista
galli and the olfactory bulb and tract lie above
lamina cribrosa. Keros classication is based on
the depth of olfactory fossa (height of vertical
lamina). Type 1 is when the depth of the olfactory fossa varies from 1 to 3mm. In this risk of
Lateral lamella cribriform plate
Crista galli
Medial lamella
cribriform plate
Fig. 1.6 Crista galli is a thick upward projection on lamina cribrosa. The olfactory fossa is bounded by lateral
lamella of cribriform plate laterally, medial lamella of
cribriform plate inferiorly, and crista galli medially
injury to the cribriform plate is less but the
height if the skull base is less so that the risk of
injury is more in fovea ethmoidalis (bone of
skull base over ethmoid air cells). Type 2 is
when the depth of olfactory fossa varies from 4
to 7 mm. It is the most common keros type.
Type 3 is when the depth of olfactory fossa is
more than 8mm and it is least common. Type 3
is more associated with skull base injury at the
cribriform plate area. The thickness of the vertical lamina is 0.2 mm. The thickness reduces
with increasing height of vertical lamina [3].
The thickness is 0.05mm at the entry point of
the anterior ethmoid artery. It is the weakest part
of the vertical lamina [4].
1.1.7 Sphenoid Sinus
Sphenoid sinus dimension is 22×20×22mm.
Sphenoid sinus ostia is present 7 cm from the
anterior nasal spine at 30° angle. Other landmarks for ostium are 1–1.5cm above choana and
5 mm from the septum. Pneumatized sphenoid
sinus can show bluish hue when the skull base is
exposed. The skull base is concave whereas it is
convex over sphenoid sinus anterior wall.
Conchal, presellar, and sellar are types of pneumatization. In the conchal type, the sphenoid
sinus is either nonpneumatized or minimally
pneumatized and it is the rarest type of pneumatization. Seller is the most common subtype. The
protrusion of the internal carotid artery (ICA) in
the lateral wall ranges from 8% to 70% in different studies (Fig. 1.7). ICA dehiscence ranges
from 3% to 30% and it is more common with the
sellar type of pneumatization. Accessory pneumatization is more commonly seen in the sellar
type. Optic canal dehiscence is documented from
4% to 30% (Fig.1.7). The presence of accessory
sphenoid septa ranges from 10% to 80% and it is
more common on the right side. It can inserts on
the carotid canal and optic canal in 6–26% of
cases [5]. Inadvertent injury to accessory septa
can lead to the internal carotid artery or optic
nerve injury so that whenever required, accessory
septum must be drilled.
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Internal carotid artery
Sphenoid sinus
Fig. 1.7 CT angiography is depicting the relationship of internal carotid artery with sphenoid sinus. The right picture is showing relationship of the internal carotid artery and optic nerve and the optic canal is dehiscent on both sides
Type 3 ON
ICA
classied into four different types. Type 1 is
when no indentation visible in the lateral wall on
SO
the sphenoid sinus. Type 2 is when indentation
visible in the lateral wall on the sphenoid sinus.
Type 3 is when the optic canal is within the
SR
sphenoid sinus. Type 4 is when the optic canal is
present adjacent to the posterior ethmoid and
sphenoid sinus.
Type 4 ON
Fig. 1.8 Optic nerve (ON) is visible in lateral relation
with the left side Onodi cell (OC). Sphenoid ostia (SO) is
demarked on the right side which communicates with a
sphenoethmoidal recess (SR)
1.1.8 Optic Nerve Relationship with
Paranasal Sinuses
The optic nerve runs in the lateral wall of the
sphenoid sinus and Onodi cell (Fig. 1.8). It is
SS
OC
1.2 Part B: Local Anesthesia
and Regional Blocks in
Nasal Surgery
The detailed preoperative evaluation is very
much important to attain the healthiest patient.
It helps in reducing perioperative morbidity and
mortality to a signicant extent. The cardiovascular and respiratory system needs more attention to overcome the possibility of complication
during surgery under local anesthesia (LA).
Routine laboratory investigations like hemogram, electrolytes, ECG, and chest X-ray are
part of the basic preoperative workup for surgery. Pre-existing acute and chronic medical illnesses needs stabilization. Cardiovascular
illnesses require detail preoperative evaluation
and intra- operative monitoring by the anesthetist. Proper consent and good preoperative medication are requiring to obtain excellent
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intraoperative patient’s cooperation. Daycare
surgery and minor operations can be performed
under local anesthesia and regional block. It is
also administered for the procedure in general
anesthesia as part of preoperative preparation to
get good local vasoconstriction and postoperative pain control. The outcome of surgery under
local anesthesia is based on detailed knowledge
of anatomy and injection techniques. Sensory
innervations of the nose are supplied by the
branches of the trigeminal nerve (V). The external nose is supplied by branches of the trigeminal nerve (supratrochlear, infratrochlear,
anterior ethmoid nerve) and maxillary nerve
(branches of the infraorbital nerve). The internal
nose is supplied by anterior and posterior ethmoid nerves, sphenopalatine, and greater palatine nerve. Local anesthetic drugs act by
reversible blocking or inhibiting conduction at
nerve endings by blocking the inow of sodium
ions via the nerve membrane. These agents are
applied at mucosa or in the neighborhood of
peripheral nerve endings. Commonly used drugs
are lidocaine, prilocaine, bupivacaine, ropivacaine, cocaine, etc. Cocaine is out of use because
of its high toxicity prole and addictive potential. The action of local anesthetic depends on
the following parameters.
1. Diffusion, water solubility, and penetration in
tissue, potency, etc.
2. Protein binding ability.
3. Ionized drugs are more diffusible at the nerve
ending and have a faster onset of action.
Inamed tissue has poor drug penetration by
decreasing local tissue pH.Sodium bicarbonate increases potency by increasing the pH at
the inamed nerve ending site.
4. Local anesthetic drugs can cause vasodilata-
tion except for cocaine and lignocaine.
Administration of adrenaline reduces drug
absorption and increases the duration of
action.
The amount of doses that need to be adminis-
tered is depending on listed parameters.
1. Smallest effective dose
2. Addition of adrenaline
3. 1cc of sodium bicarbonate in every 9ml of
LA would increase potency and reduce the
burning sensation
Lignocaine is a heat-stable and autoclavable
local anesthetic drug. The duration of action is 1
h for injectable preparation and it can extend to
2–3 h by the accumulation of adrenaline. The
inltrative form comes in 0.5–1.5% formulation.
The dose of lignocaine (0.5%) without adrenaline is 3mg/Kg body weight with maximum safe
administrative dose is 200mg in healthy adults
whereas lignocaine with adrenaline is 7 mg/kg
body weight. The maximum dose is 500mg in
healthy adult. 2% viscous, 4% solution, and 10%
spray are the lignocaine preparations for topical
anesthesia with maximum safe limit is 200mg.
Mucosal surface anesthesia is required to prepare the nose prior to the application of injection
[6]. The action lasts till 20min. Bupivacaine is
more potent than lignocaine and it comes only in
injection form [7]. The dose without adrenaline
(0.5%) is 2 mg/Kg body weight and the maximum safe limit is 175 mg/dose whereas with
adrenaline, the dose is 2.5 mg/kg body weight
and the maximum safe limit is 225mg/dose. It is
generally used for regional nerve block because
of its long duration of action. Other drugs like
prilocaine and amethocaine are less effective
than lignocaine. For adrenaline, the dose is
0.01mg/kg with maximum safe limit is 0.5 mg
in healthy adults and 1: 200,000 is required for
surgical procedure.
The toxicity prole can vary from redness at
the application site to multi-organ failure [8]. An
allergic reaction is relatively rare and the common ones are rashes, bronchospasm, etc. so preoperative sensitivity should be done for all cases
planned under LA.The cardiac effect is hypotension and circulatory collapse. The neurological
side effect can be classied into three stages.
1. Early stage—local anesthetics can cross the
blood brain barrier. It depresses inhibitory
cortical activity and presents with symptoms
of light-headedness, tinnitus, visual changes,
slurred speech, dizziness, etc.
2. Late stage—If proper resuscitative methods
are not taken than symptoms like drowsiness,
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disorientation, seizure, loss of consciousness,
etc. can develop.
3. Respiratory distress, severe hypoxia occurs if
proper resuscitative measures are not taken.
The therapeutic measures for mild to moder-
ate levels of toxicity are the administration of
100% oxygenation. Anesthetist and resuscitation
cart should be warranted if muscle twitching and
convulsion occur. The commonly used technique
for the regional block is mentioned below.
(a) Moffett’s technique—The original Moffett’s
solution was 2ml cocaine 8%, 2ml sodium
bicarbonate 1%, 1 ml 1:1000 adrenaline.
Modied Moffett’s solution is prepared by
4% xylocaine (6ml) with 1: 100,000 adrenaline. It is poured in each nostril, in drop by
drop form in a hyperextended position
(Proetz position) of the neck. The drops are
dispensing along the superior most part of
lateral wall of the vestibule to block the sphenopalatine nerve (Fig.1.9).
(b) For nasal packing—Self-prepared cotton
pledgets or commercially available nonabsorbable packs can be used. They are
soaked in 4% lignocaine solution with
adrenaline. One pack is kept along the oor
of the nasal cavity. The second is above rst
one and encroaching in the middle meatus.
Third one is at the frontal recess area for
10–20 minutes. Periodic suctioning over
the throat is required to prevent aspiration
during surgery as pharyngeal mucosa gets
anesthetized.
(c) For endoscopic surgery—First block is
applied at the uppermost part of the middle
turbinate and at the axilla of the middle
turbinate to anasthetise the anterior ethmoid
neurovascular tissue and infraorbital neurovascular tissue. It can be blocked by external
route as mentioned in nasociliary (anterior
ethmoid) block. The second injection is
applied to block the sphenopalatine neurovascular tissue (Fig. 1.10). It is performed
by administration of drug at the posteriormost part of the middle meatus just inferior to the middle turbinate and above
choana.
(d) For rhinoplasty—Local anesthetic is
applied at columella over the tip, in between
and around the dome of lower lateral cartilage, at the rim of lower lateral cartilage. The
quantity is varying from 0.1 to 0.3ml with 26
gage needle to prevent distortion of anatomy.
For intercartilaginous incision, LA is injected
at limen nasi in the subperichondrial plane.
For osteotomies, LA is injecting inside and
outside of the frontal process of the maxilla
in the sub-periosteal plane.
Fig. 1.9 The white line is showing chin and the external
auditory canal is in the same line. The needle is pointed
towards the supero-lateral part of the vestibule (Courtesy—
Dr. Hitesh Verma, Associate Professor, AIIMS, New
Delhi, India)
Nerve blocks—It is required for the therapeutic purpose only. The various kind of blocks
require for nasal surgeries are mentioned subsequently [9].
A. Frontal Nerve Block
It is required for the median forehead ap.
Supraorbital and supratrochlear divisions of
frontal nerve exit through supraorbital foramen and supply frontal scalp and forehead,
medial part of the upper eyelid, and root of
the nose. Supraorbital foramen can easily be
palpated along the medial orbital rim. It is
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MT
MT
Nasopharynx
Polypoidal
uncinate
process
Fig. 1.10 Both gures are representing the site of local
inltration for the anterior ethmoid and the sphenopalatine neurovascular structure. MT middle turbinate, IT infe-
2 cm from the midline in adults. Series of
injections from central to medial brow block
frontal nerve branches. After the injection,
rm pressure is applied for better anesthetic
spread and prevention of ecchymosis.
B. Infraorbital Nerve Block
It can be blocked by two routes: Extraoral and
intraoral
1. Extraoral route: A longitudinal line is
drawn along the pupil, another horizontal
line along the ala of the nose. At the point
of intersection, the needle is advanced in
lateral- to- medial direction, as the foramen
is directed medially and caudally.
2. Intraoral approach:-The needle is inserted
into the canine fossa and the nger is kept
over the infraorbital foramen to assess the
proper location of the needle tip. 1–3mL
of local anesthetic is injected after negative
aspiration (Fig.1.11).
C. Nasociliary Nerve (Anterior Ethmoid
Nerve) Block
It is blocked at the anterior ethmoidal foramen.
A 26G needle was inserted 1–1.5 cm above
the medial canthus halfway between the palpe-
IT
rior turbinate (Courtesy—Dr. Hitesh Verma, Associate
Professor, AIIMS, New Delhi, India)
bral fold and the eyebrow. The needle is
directed forward and medially till it reaches
the bony roof of the orbit. At a depth of
1.5–2cm, the needle is at the level of the anterior ethmoidal foramen. 1–2ml of local anesthetic solution is inltrated (Fig.1.12).
D. Greater Palatine Nerve Block
Greater palatine nerve supplies the lower part
of the septum and oor of the nasal cavity.
Greater palatine foreman is located 1 cm
medial to second/third molar or 1.4–1.5 cm
lateral to the maxillary suture line. The needle
is inserted 0.5–1cm and 1cc of local anesthetic is applied (Fig.1.13).
E. Sphenopalatine Nerve Block
Two approaches are recommended: Intraoral
and intranasal approach.
1. Intraoral approach: Palpate the greater palatine foramen intraorally just medial to the
second/third molar 5–7mm anterior to the
posterior margin of the hard palate. A needle bent 45° and advanced 2 cm in greater
palatine foreman and 1–2ml injected.
2. Intranasal approach: The nerve is blocked
by injecting anesthetic solution near the
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Fig. 1.11 Intraoral approach for infraorbital nerve block (Courtesy—Dr. Hitesh Verma, Associate Professor, AIIMS,
New Delhi, India)
H. Verma et al.
Fig. 1.12 Blue dotted line is marked from the inner canthus. 26 G needle is inserted 1 cm above the line
(Courtesy—Dr. Hitesh Verma, Associate Professor,
AIIMS, New Delhi, India)
Fig. 1.13 The site of local inltration is corresponding to
the second and third molar for greater palatine nerve block
(Courtesy—Dr. Hitesh Verma, Associate Professor,
AIIMS, New Delhi, India)
sphenopalatine foramen region, near the
posterior attachment of middle turbinate
[10] (Fig. 1.10). Alternatively, cotton
tipped soaked in the local anesthetic solution can be placed in the region and kept
for 5–10min (Sluder’s) method.
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F. Maxillary Nerve Block
The techniques for maxillary nerve block are
external approcah, high tuberosity approach
and greater palatine canal approach.
1. External approach—Needle is inserted just
below the zygomatic arch at the midway of
the coronoid and the condylar process of
the mandible. It is inserted at the right
angle to the skin till pterygoid plates are
palpable. Local anasthetic is injected after
minimal withdrawal of needle. The needle
is pushed anteriorly towards the eye to
reach the pterygopalatine fossa. 5cc of the
anesthetic drug is injected.
2. High tuberosity approach—Three centimeter insertion of the needle is done in the
upper gingivobuccal sulcus at the level of
second molar at 45° angle. 2cc of the drug
is needed to block maxillary nerve. For
posterior superior nerve block, the needle
is inserted at 2cm depth.
3. Greater palatine canal approach—The needle is inserted till 3cm depth in the greater
palatine canal and 1.5–2cc drug needs to
be injected (Fig.1.13).
Advantages of LA
1. Patient is conscious
2. Maintain airway
3. Smooth recovery
4. Less monitoring, less postoperative care, less
expensive
5. Less pain medication required
Disadvantages of LA
1. Less operable time
2. Experience required
3. Accidental intravenous administration can
induce generalized toxicity
Satisfactory application of the local anesthesia
technique is the utmost requirement for the surgical execution, patient cooperation [11].
1.3 Part C: General Anesthesia
Endoscopic sinus surgery (ESS) is the primary
approach used today for the surgical treatment of
most of the rhinological illnesses e.g. chronic
sinusitis, nasal polyposis. The surgical management of juvenile nasopharyngeal angiobroma
(JNA) has also got revolutionized with nasal
endoscopic approaches; however, the extensive
vascularity and vital structures nearby pose signicant challenges for surgery as well as anesthesia [12]. Preoperative optimization including
angioembolization of feeding vessel in highgrade JNA lessens the perioperative complications related to extensive blood loss. General
anesthesia or TIVA maintaining a lower acceptable blood pressure (hypotensive anesthesia) is
preferred. The anesthetic techniques should
address specic concerns like stable hemodynamics during surgery, effective management of
blood loss, adequate analgesia, and smooth emergence. A good perioperative multimodal analgesia is associated with better emergence.
1.3.1 Preoperative Concerns
The possibility of difcult airway should be
assessed, which might be because of the distorted
face due to swelling of the cheek, trismus, or
inferior displacement of the soft palate by the
bulk of tumor. Specically in cases of JNA of
higher grade, embolization of the terminal
branches of the internal maxillary artery should
ideally be done 24–48h before surgery. Adequate
blood and blood products should be crossmatched. Premedication is done with anxiolytic
(benzodiazepine), the night before and morning
on the day of surgery. Perioperative steroid
administration is done to decrease mucosal
edema and improve endoscopic visibility during
surgery.
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1.3.2 Anesthesia Technique
General anesthesia or Total Intravenous
Anesthesia (TIVA) with oral cuffed endotracheal
tube is preferred in such cases. In the case of
FESS laryngeal mask airways (LMA) have also
been used successfully by experienced anesthesiologists. Two large-bore (16 gauze is preferred)
IV cannulas are secured and one is preferentially
placed in the lower limb great saphenous vein, as
the site is most easily accessed after positioning
and placing the anesthesia workstation at the foot
end. Routine American Society of
Anesthesiologist (ASA) standard monitoring
(electrocardiogram, plethysmography, and noninvasive blood pressure) is done. In case of JNA,
invasive blood pressure monitoring is done by
securing radial artery, anterior tibial, or dorsalis
pedis artery so that beat to beat blood pressure
can be monitored, and also serial blood gas sampling can be done at frequent interval. Peripherally
inserted central catheter (PICC) is inserted
through the antecubital vein preferably, as the
neck is not accessible. It can be used for central
venous pressure (CVP) monitoring and vasopressor administration if needed, as there is the anticipation of signicant blood loss and hemodynamic
instability. However in cases with intracranial
extension, the subclavian vein is chosen for cannulation. Central venous access is often required
for the infusion of irritant medications (concentrated potassium chloride) or vasoactive agents,
certain diagnostic or therapeutic radiologic procedures, and in any patient for whom peripheral
access is not possible. For cases with intracranial
extension, N2O should be used cautiously or
avoided as there is the chance of increase in ICP,
although hyperventilation, barbiturates, benzodiazepines, or narcotics can attenuate the effects. In
these cases, hypotensive anesthesia is also
avoided, as it might impair the cerebral perfusion, because of swelling and rise in ICP.The airway is secured with cuffed endotracheal tube
(South Pole Ring Adair Elwin or Armored tube)
preferred over standard tube after muscle relaxant [13].
Patients with difcult airways require video
laryngoscope or beroptic bronchoscope intervention for securing the airway. These should be
explained to the patient in preoperative visit and
informed consent should be taken. Positive end
expiratory pressure (PEEP) is avoided. Throat
packing with roller gage is done to reduce the
blood contamination of the airway and at the end
of surgery, it should be removed after thorough
suctioning. Normothermia is maintained by
infusing warm uids through the hotline and also
by the use of warming blankets. The urinary
bladder is catheterized, so that hourly urine output of around 0.5–1 ml/kg can be maintained
with adequate volume resuscitation. Local anesthetic with vasoconstrictor (1:100,000 adrenaline
or phenylephrine drops) is either instilled topically or inltrated. However caution should be
applied in patients with hypertension, coronary
artery disease as systemic absorption of these
drugs causes hypertension, tachycardia, and
arrhythmias. Ideally, the dose of phenylephrine
should not exceed 4 drops of 0.25% preparation
(0.5mg) in adults or 20 mcg/kg in children upto
25kg of body weight. If hypertension is severe
after local vasoconstriction, direct vasodilator or
α2—antagonists are administered. Cough and
straining during light plane increase the bleeding,
so adequate depth of anesthesia is very essential.
Blood loss is managed with crystalloids, colloids,
packed red blood cells, fresh frozen plasma, and
platelets.
1.3.3 Hypotensive Anesthesia
Deliberate decrease of systemic blood pressure
below 20% of normal or maintenance of systolic
blood pressure 85–90mmHg with mean arterial
blood pressure (MAP) at 60±5mmHg helps to
provide a dry surgical eld by decreasing the
oozing and blood loss [9]. This can be achieved
with reverse Trendelenburg position at 30 degrees
with exed knees. For maintenance of higher
minimum alveolar concentration, (MAC) isourane or other inhalational agent is required. Total
intravenous anesthesia is possible with propofol
and fentanyl or remifentanil with the added
advantage of decrease of sympathetic response
during intubation or surgical stimulation.
α-agonists such as clonidine and dexmedetomidine infusion decreases the central sympathetic
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outow, thereby helps to induce controlled hypotension. It also decreases the requirement of
anesthetic agent. Nitroglycerine and sodium
nitroprusside infusion, by vasodilatation reduce
the peripheral vascular resistance. Beta-blockers
like esmolol, labetalol, or metoprolol, and calcium channel blockers also help to maintain
hypotension. Magnesium sulfate infusion also
helps to induce hypotension and helps to reduce
blood loss, however, it might prolong the anesthesia emergence time [14].
1.3.4 Acute Normovolemic
Hemodilution
It can be used as a technique for blood conservation strategies. After induction of anesthesia,
blood is withdrawn upto a limit of 7 g% hemoglobin, and subsequently, crystalloids and colloids are infused to maintain the blood volume.
Intraoperative red blood cell salvage is not done
as there is chance of contamination by nasal ora.
Blood loss is carefully estimated by counting the
number of gauze pieces used and from the suction bottle. End tidal CO2 is maintained to prevent any hypercarbia or hypocapnia.
Normothermia is maintained for the proper functioning of platelets and coagulation factors.
(ICP). The extensiveness of the surgery with
massive blood loss, postoperative mechanical
ventilation with intensive care unit (ICU) stay
should be explained in informed consent.
1.3.6 Emergence fromAnesthesia
Smooth recovery of anesthesia is warranted to
prevent any straining and bleeding. The throat
pack is removed after suctioning of the oral cavity
and it is better to do under either direct laryngoscope or video laryngoscope. Postnasal space
should be carefully evaluated to remove any blood
clots. Administration of esmolol or lignocaine
prevents extubation response. Decompression of
the stomach with an orogastric tube should be
performed prior to extubation to remove the blood
clots, which is a predisposing factor for postoperative nausea and vomiting. In cases with massive blood loss or high-grade JNA with intracranial
extension, patients are kept intubated and mechanically ventilated to avoid any rise of ICP by hypercarbia. Dexamethasone is administered 0.1mg/kg
to decrease airway edema by surgical trauma.
Extubation should be done in controlled environment with adequate hemostasis, stable coagulation status, and hemodynamics [16].
1.3.5 Juvenile Nasopharyngeal
Angiobroma
withIntracranial Extension
Patients with Radkowski Grade III tumors are
usually require combined approach with the neurosurgery team. Intraoperative blood loss is an
predicting factor for better Glasgow Outcome
scale, so these cases should be planned with multidisciplinary approach involving the neurosurgeon, intervention radiologist, and
anesthesiologist, so that there will be minimal
blood loss and stable hemodynamics perioperatively [12, 15]. Such cases are kept intubated and
put on mechanical ventilatory support to maintain the end tidal carbon dioxide (EtCO2), as
hypercarbia can cause cerebral vasodilatation
and subsequent rise in intracranial pressure
1.3.7 Postoperative Concerns
Patients should be kept in closed observation
with monitoring of vitals. Postoperative hemogram should be done to ensure adequate replacement of blood loss.
For Nausea and Vomiting:
• The presence of blood in the stomach, inammation of the uvula and throat and the
occasional use of opioids for pain control is
contributing factors. Intraoperatively ondansetron and dexamethasone are administrated
as a prophylactic measure.
Postoperative Pain:
• The expected postoperative pain from FESS
may range from mild to moderate and is due to
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surgical trauma as well as nasal packing. Oral
acetaminophen and an NSAID/cyclooxygenase 2 inhibitor usually provide safe and
effective analgesia. Encourage the patient to
breathe through the mouth due to the presence
of nasal packing. The patient should have
counseled in the preoperative visit.
1.3.8 Emergency Surgical
Intervention
Sometimes there is postoperative orbital hematoma or might be progressive deterioration of
vision warranting a relook for hemostasis. In
such situation airway is secured by rapid sequence
intubation with anticipation of blood in the oral
cavity and difcult mask ventilation. The wide
bored suction catheter should be kept ready during securing of airway. Invasive monitoring is
continued in the perioperative period. Arterial
blood gas analysis should be done to know the
current hematocrit, lactate levels, and electrolytes. Sometimes patients with JNA present with
epistaxis in the causality, which might be resistant to traditional compression or vasoconstrictor
drops. Such cases need emergency embolization
and subsequent diagnostic procedures, so that
excision can be planned. In such cases with epistaxis, the airway is secured by rapid sequence
induction followed by intubation with cuffed
endotracheal tube.
1.4 Part D: FESS
Chronic rhinosinusitis is dened as inammation
of the nose and paranasal sinuses which generally lasts for more than 3 months. It is characterized by two or more symptoms, one of which is
either nasal discharge or blockage/obstruction/
congestion along with the presence or absence of
either facial pain or reduction of the sense of
smell. Treatment of CRS mostly involves medical therapy with surgery reserved for those cases
where symptoms persist in spite of adequate
medical therapy. Functional Endoscopic Sinus
Surgery (FESS) aims to restore mucociliary func-
tion by restoring physiologic sinus ventilation
and drainage. A proper diagnosis of the condition
by thorough history, clinical examination,
Endoscopy, imaging is necessary. Correct knowledge of the endoscopic anatomy, its variations,
and steps of surgery aids in the successful outcome of the surgery. With advances in better
understanding of disease and the introduction of
newer antibiotics along with better endoscopes,
the treatment of CRS has greatly revolutionized.
Among the various options available for surgery
it may range from Mini FESS, i.e., middle meatal
antrostomy and anterior ethmoidectomy to full
FESS with the opening of frontal, sphenoid, and
complete ethmoidectomy. More recent advances
have come like balloon sinus dilatation to the use
of high-powered drills and computer navigation
system. The use of the appropriate surgical technique will depend on proper evaluation of disease, its extent, and the expertise available. Here
in this chapter, we would briey discuss the steps
of FESS, with emphasis on various techniques,
complications, and recent advances.
1.4.1 Diagnostic Endoscopy
A careful diagnostic endoscopy is the key for
successful diagnosis and planning for surgery. It
is of two types anterior to posterior
(Messerklinger technique) and posterior to anterior (Wigand technique). In anterior to posterior,
it consists of three passes. In rst Pass, The 0°
endoscope (or 30° endoscope) passes along the
oor of the nasal cavity between the inferior turbinate and septum. The structures studied are
nasal septum, inferior turbinate and inferior
meatus, nasal cavity anterior and inferior to the
middle turbinate, posterior choana, posterior wall
and roof of the nasopharynx, eustachian tube,
fossa of Rosenmueller, and nasolacrimal duct. In
second Pass, The scope passes medial to the middle turbinate. Structures studied are the space
medial to middle turbinate, anterior face of sphenoid sinus, sphenoid ostium, superior turbinate
and meatus, sphenoethmoidal recess. In third
Pass, it is done to examine the contents of the
middle meatus (Fig. 1.14). The scope is gently
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