OT notes · ENT

Functional endoscopic sinus surgery (FESS)

Usual anaesthesia
General anaesthesia with controlled hypotension; local anaesthesia for limited surgery
Position
Supine with slight head-end elevation, eyes left uncovered
Setting
elective

Operative note template for functional endoscopic sinus surgery, with a filled example for bilateral FESS done for chronic rhinosinusitis with nasal polyps under general anaesthesia.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • bleeding during or after surgery, may need nasal packing or return to theatre
  • orbital injury: eyelid bruising, orbital haematoma, damage to eye muscle
  • loss of vision from optic nerve injury (rare)
  • cerebrospinal fluid leak needing repair
  • adhesions (synechiae) inside the nose
  • watering of the eye from tear duct injury
  • loss of sense of smell
  • infection
  • persistent or recurrent disease needing revision surgery

Pre-operative details for this operation

  1. Side(s) to be operatedRightLeftBilateralwrite the side in full, not R/L only, and match it with the consent and the list
  2. IndicationChronic rhinosinusitis without polypsChronic rhinosinusitis with polypsAllergic fungal sinusitisInvasive fungal sinusitisMucoceleComplicated sinusitis (orbital / intracranial)Otherduration, and the medical treatment that failed
  3. Diagnostic nasal endoscopy findingspolyps, discharge, septal deviation, side
  4. CT paranasal sinuses revieweddate of scan; sinuses involved; anatomical variants such as Onodi cell, Haller cell, low or asymmetric skull base (Keros type), dehiscent lamina papyracea
  5. MRI (if fungal disease or tumour suspected)DoneNot needed
  6. Pre-op course of antibiotic and oral steroidGiven (drug, dose, days)Not given
  7. Allergies, smoking, antiplatelets / anticoagulants and when stopped
  8. Image guidance / microdebrider bookedYesNo

Anaesthesia and position

  1. AnaesthesiaGeneral with controlled hypotensionLocal with sedationif local, reason
  2. PositionSupine, slight head-end elevationeyes kept uncovered so orbital injury can be seen
  3. Nasal decongestionMoffett's solution or lignocaine with adrenaline 1:100,000 on pledgets; where placed and for how long
  4. Local infiltrationsaline-adrenaline under GA, or lignocaine with adrenaline 1:200,000 under local; volume; sites (uncinate process, sphenopalatine area)
  5. Endoscopes used0 degree30 degree45 degree70 degree

Operative findings

  1. SeptumCentralDeviated (side)Spur (side)
  2. Middle meatus and uncinate processpolyps, pus, anatomy of uncinate attachment
  3. Maxillary sinusnatural ostium found / accessory ostium; contents: pus, mucin, fungal debris, polyps
  4. Frontal recess and frontal sinusagger nasi and frontal cells, ostium patency
  5. Anterior and posterior ethmoidsdisease extent, skull base and lamina papyracea intact
  6. Sphenoid sinuscontents; optic nerve and carotid bulges seen
  7. Any dehiscence (lamina papyracea, skull base) or CSF leakNone seenPresent (site, size)

Procedure (steps)

  1. Middle turbinate medialised and middle meatus inspectedside; instrument (Freer's elevator)
  2. Septoplasty (if needed for access)Not neededEndoscopic limited septoplastyFormal septoplasty
  3. Polypectomy / removal of polypoidal tissueinstrument: Blakesley forceps / microdebrider
  4. UncinectomyCompletePartialinstrument: backbiter, sickle knife, Blakesley, microdebrider
  5. Middle meatal antrostomynatural ostium widened; accessory ostium joined to natural ostium; contents removed
  6. Anterior ethmoidectomybulla ethmoidalis opened; cells cleared up to skull base
  7. Posterior ethmoidectomyDoneNot doneground lamella entered low and medial; superior turbinate identified
  8. SphenoidotomyNot doneTransethmoidDirect parasagittal (medial to superior turbinate)
  9. Frontal recess clearance / frontal sinusotomyNot doneFrontal recess cleared, ostium widenedagger nasi removed; angled scope used
  10. Haemostasispledgets, bipolar to named vessel (sphenopalatine / anterior ethmoid)
  11. Eye checked at endno proptosis, no eyelid swelling, pupils equal
  12. Repeat all steps for the other side (if bilateral)record each side separately

Closure, drains and dressing

  1. Nasal packingNoneAbsorbable (e.g. Nasopore)Non-absorbableside(s), number of packs, where placed
  2. Planned date and time of pack removalwrite it even for absorbable packs (clinic suction clearance date)
  3. Splints (if septoplasty or raw mucosal surfaces facing each other)NonePlaced (side, fixed with suture)
  4. Throat pack removedYesNot used

Specimens and implants

  1. Polyps / sinus mucosa for HPElabel each container with side and sinus (e.g. 'left maxillary')
  2. Fungal debris / pus for microbiologySentNot applicable

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Pulse, BP and nasal bleedingfrequency; call if fresh bleeding soaks the drip pad; keep BP controlled
  2. Eye checkeyelid swelling, proptosis, eye movements, pupil reaction and vision; inform at once if any change
  3. Nasal packtype, side, planned removal date
  4. No nose blowingfor the period advised; sneeze with the mouth open
  5. Nasal douchingalkaline saline douche twice a day for 6 weeks, start date
  6. Nasal steroiddrug, dose, duration, if prescribed
  7. Antibioticonly if active infection was found; drug, dose, duration
  8. Analgesiadrug, dose, frequency
  9. Follow-upclinic endoscopic toilet (clots, crusts, adhesions) date; HPE review

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. S.K., 34 years, 2 years of bilateral nasal block and loss of smell. Bilateral nasal polyps on endoscopy. CT shows bilateral maxillary and ethmoid disease. No relief after 3 weeks of medical treatment.

Case details

Date: 18/04/2026. Elective. ENT OT 1.

In OT 09:05. Induction 09:15. Surgery started 09:40. Surgery ended 11:20.

Surgeon: Dr A. (3rd-year resident, ENT). Assistant: Dr B. (1st-year resident). Consultant: Dr C., present in OT.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Pre-op diagnosis: bilateral chronic rhinosinusitis with nasal polyps, not responding to medical treatment.

Procedure planned and performed: bilateral FESS (uncinectomy, middle meatal antrostomy, anterior and posterior ethmoidectomy) with polypectomy.

CT PNS (02/04/2026) reviewed in OT: both maxillary and ethmoid sinuses opacified. Frontal and sphenoid sinuses clear. Keros type 2 both sides. No Onodi cell. Lamina papyracea intact.

Pre-op oral steroid and antibiotic course for 1 week completed. No antiplatelets. Non-smoker.

Consent: general, procedure-specific and anaesthesia consent taken in Marathi. Risks of bleeding, eye injury, CSF leak, adhesions and recurrence explained.

WHO checklist sign in and time out done. Side confirmed as bilateral. No prophylactic antibiotic (FESS excluded from routine prophylaxis, ASHP 2013).

Anaesthesia and position

GA with oral cuffed tube and controlled hypotension. Throat pack placed.

Supine with head end raised about 15 degrees. Eyes taped shut but left uncovered in the field.

Both nasal cavities decongested with Moffett's solution on neuro patties for 10 minutes. Uncinate process and sphenopalatine area infiltrated with saline-adrenaline, 2 ml each side.

Findings

Septum central. Polyps filling both middle meatuses.

Right maxillary sinus: thick mucopus and polypoidal mucosa. Left maxillary sinus: mucin, no fungal debris.

Anterior and posterior ethmoids diseased both sides. Frontal recess and sphenoid ostium clear.

No dehiscence of lamina papyracea or skull base. No CSF leak.

Procedure

Right side first, 0 degree scope. Polyps removed with microdebrider. Middle turbinate medialised with Freer's elevator.

Complete uncinectomy with backbiter and upturned Blakesley forceps.

Natural maxillary ostium found and widened posteriorly with through-cutting forceps using the 30 degree scope. Pus suctioned and sent for culture.

Bulla ethmoidalis opened with Blakesley forceps. Anterior ethmoid cells cleared up to the skull base.

Ground lamella entered low and medially. Posterior ethmoid cells cleared. Superior turbinate identified. Sphenoid not opened.

Same steps on the left side.

Haemostasis with adrenaline patties. No bipolar needed. Both eyes checked: soft, no proptosis, pupils equal.

Closure

One absorbable Nasopore pack in each middle meatus. No splints. Throat pack removed and counted.

Pack clearance by suction in ENT OPD on 25/04/2026.

Specimens and implants

Polyps and ethmoid mucosa sent for HPE in formalin: two containers labelled 'right nasal polyps and ethmoid mucosa' and 'left nasal polyps and ethmoid mucosa'.

Right maxillary pus sent for culture and sensitivity. No implants.

End of procedure

Estimated blood loss 150 ml. No transfusion.

Patty, needle and instrument count correct, confirmed by scrub nurse.

No intra-operative complications.

Patient extubated and shifted to recovery in stable condition. Pulse 82/min, BP 124/78 mmHg.

Post-op orders

Pulse, BP and nasal ooze every 30 min for 2 hours, then 4-hourly.

Check both eyes 2-hourly for 12 hours: eyelid swelling, proptosis, eye movements, vision. Inform on call ENT at once if any change.

No nose blowing. Sneeze with mouth open.

Alkaline saline nasal douching twice a day for 6 weeks, from the day after the pack clearance.

Analgesic as per drug chart. Antibiotic to be decided on culture report.

Review in ENT OPD on 25/04/2026 for endoscopic clearance, and HPE review.

Signature

Dr A., JR-3, ENT. Reg. no. ________. 18/04/2026, 11:40.

Must document for this operation

  • The side operated and the exact sinuses opened on each side. The next surgeon plans any revision surgery from this record, and a claim or a complaint is judged against it.
  • Anatomical variants seen on the CT scan and at surgery (Onodi cell, low skull base, dehiscent lamina papyracea). These explain a complication if one happens, and they warn the next surgeon.
  • Any breach of the lamina papyracea, orbital fat seen, or skull base defect, and what was done. Nursing staff then watch the eye or the CSF leak closely, and a missed breach is hard to defend later.
  • Eye status at the end of surgery. It gives a baseline, so any later proptosis or loss of vision can be timed.
  • Pack type, side and planned removal date. A forgotten non-absorbable pack causes infection and is a common complaint.
  • Specimen labelling by side and by sinus. A fungal or tumour report must be linked to the correct side for further treatment.

Common mistakes in these notes

  • Writing 'FESS done' without the side or the list of sinuses opened.
  • Not recording the eye check at the end of surgery.
  • Leaving out the pack type and the removal date.
  • Sending polyps from both sides in one container with no side label.
  • Not recording a lamina papyracea breach or a small cerebrospinal fluid (CSF) leak that was repaired.

Indian practice and paperwork

  • NABH expects the operative note to be written before the patient leaves recovery, and post-op care to follow a written plan. (NABH 5th ed., COP.14(e) and (f))
  • Consent must explain the procedure, risks, benefits, alternatives and who will operate, in a language the patient understands. (NABH 5th ed., PRE.4(c))
  • Polyps and tissue not sent for HPE are human anatomical waste (yellow bag). Discarded formalin from specimen jars is yellow (f) chemical waste. (Bio-Medical Waste Management Rules 2016, CPCB guidelines)
  • Name every anaesthetist who gave anaesthesia. A consumer forum held a hospital negligent when the op note left out an anaesthetist's name. (Thomas J. Indian J Urol 2009;25:384-8)

Sources

  • Hathiram BT, Khattar VS, eds. Atlas of Operative Otorhinolaryngology and Head and Neck Surgery. Jaypee Brothers, Ch 57, Endoscopic sinus surgery (Kirtane M), pp. 460-464.
  • Hathiram BT, Khattar VS, eds. Atlas of Operative Otorhinolaryngology and Head and Neck Surgery. Jaypee Brothers, Ch 58, The technique of functional endoscopic sinus surgery (Manickavasagam J, Raghavan U), pp. 465-530.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Table 2, head and neck: clean-contaminated procedures other than cancer surgery get cefazolin or cefuroxime plus metronidazole, or ampicillin-sulbactam, with tonsillectomy and functional endoscopic sinus procedures excepted. academic.oup.com/ajhp/article/70/3/195/5112717

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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