Clinical Rhinology
Volume 14 | Issue 1-3 | Year 2023

Evaluation of Surgical Conditions during Elective Endoscopic Sinus Surgery with Total Intravenous Anesthesia and Monitored Anesthesia Care

Sanjeev Kumar Singla1, Ankush Singla2

1Department of Anaesthesiology and Intensive Care, Adesh Institute of Medical Sciences and Research, Batinda, Punjab, India

2Department of Anaesthesiology, Adesh Medical College, Batinda, Punjab, India

Corresponding Author: Sanjeev Kumar Singla, Department of Anaesthesiology and Intensive Care, Adesh Institute of Medical Sciences and Research, Batinda, Punjab, India, Phone: +91 9592261611,

How to cite this article: Singla SK, Singla A. Evaluation of Surgical Conditions during Elective Endoscopic Sinus Surgery with Total Intravenous Anesthesia and Monitored Anesthesia Care. Clin Rhinol 2023;14(1–3):1–4.

Source of support: Nil

Conflict of interest: None

Received on: 10 June 2020; Accepted on: 06 June 2023; Published on: 21 March 2024


Background: The diseases of sinuses are commonly seen in all age groups. Currently, endoscopic sinus surgery (ESS) is commonly performed as a daycare procedure. The anesthetic technique should also be selected on this basis. Keeping these considerations in view, ESS has been performed under total intravenous anesthesia (TIVA) using or monitored anesthesia care (MAC).

Materials and methods: This prospective randomized open-level study was conducted in 40 ASA I–II adult patients of either sex, undergoing elective ESS. All the patients were divided into two groups according to the randomized table: Group A: TIVA and group B: local anesthesia and conscious sedation. In group B, patients who did not tolerate the procedure were converted to the TIVA group.

Results: The duration of surgical procedure was 69.00 ± 9.63 minutes in group A patients and 55.00 ± 10.34 minutes in group B patients. This result was statistically significant. But in group A, 55% of patients had a score of 2, and 45% had a score of 3. In group B, 90% had a score of 2 and 10% had a score of 3. This was statistically significant (p < 0.05).

Conclusion: The time taken for ESS is reduced, the surgical field is better despite of higher mean blood pressure done with MAC care in comparison to TIVA. However, this needs the cooperative patient.

Keywords: Endoscopic sinus surgery, Monitored anesthesia care, Total intravenous anesthesia.


The diseases of sinuses are commonly seen in all age groups. The endoscopic procedures for sinuses are commonly used to treat various diseases. This procedure increases the ability of surgeons to manage both limited and widespread disease through better visualization of the surgical field.1 The common procedures done with endoscopic sinus surgery (ESS) are infundibulotomy, turbinectomy, rhinoplasty, septoplasty, etc. The chronic sinusitis is commonly treated with this technique through transnasal route.2 Nowadays, ESS is usually done as a day care surgery.3 The anesthetic agents should have a short duration of action for early recovery and discharge. The other consideration is a bloodless field during surgery for better visibility in the confined area. The tissue in nasal cavities is inflamed with greater vascularity. This leads to increased bleeding and decreased visibility in the surgical space during ESS.2 So, the anesthetic technique adopted should provide optimal surgical conditions and patient comfort.4 Endoscopic sinus surgery can be performed under total intravenous anesthesia (TIVA) or local anesthesia and conscious sedation.5,6 The advantages of TIVA are analgesia, patient cooperation is not an issue, and decreased risk of aspiration of blood and irrigation fluids. However, the risk of complications like orbital penetration increases as the patient is not awake with TIVA. The experience of a surgeon can detect and prevent such complications. There are limited studies comparing these two techniques of anesthesia for ESS. The choice of anesthesia depends on subjective preference of surgeon and patient. Hence, we compared the surgical condition and hemodynamic changes under TIVA with local anesthesia and conscious sedation during elective ESS.


This was a prospective randomized open-level study conducted in 40 American Society of Anesthesiologists (ASA) status-I or -II adult patients of either sex having elective ESS for 2 years after permission from the Institutional Ethics Committee. The exclusion criteria included bleeding disorders, receiving anticoagulants, and a history of allergy to local anesthetics. All patients had preoperative anesthetic checkups in the PAC room. In the operative room, monitoring included electrocardiogram, mean blood pressure, and pulse oximeter (SpO2). All the patients were randomized into two groups with randomized table.

Group A: Included 20 patients who had total intravenous anesthesia (TIVA) with propofol, fentanyl, vecuronium, and maintenance with continuous propofol infusion. About 50% oxygen in air was used with intermittent positive-pressure ventilation. The infusion rate of propofol was titrated to hemodynamic parameters. However, maximum 8 mg/kg/hour of propofol was given. Neuromuscular blockade was reversed with neostigmine 0.05 mg/kg and atropine 0.02 mg/kg.

Group B: Included 20 patients who had monitored anesthesia care (MAC). The area was infiltrated with 2% lignocaine with 1:2,00,000, maximum dose used was 7 mg/kg. Fentanyl 1–2 µg/kg and midazolam 0.02–0.04 mg/kg intravenously were given for conscious sedation. The patients in which this technique failed were given TIVA as in group A. In both the groups, heart rate, SpO2, and mean blood pressure were monitored at an interval of 5 minutes intraoperatively and hourly, thereafter in the postop period, along with any complications or side effects.

The surgical field was assessed by the surgeon as per Fromme et al.7

Best score was considered as 2 or 3.

Statistical Analysis

Data were expressed as mean ± SD. Student’s t-test and Chi-square test were used for comparison of demographic data. Chi-square test was used for the comparison of the surgical field, and the Student’s t-test for comparison of hemodynamic changes. p < 0.05 is significant.


Demographic data are as per Table 1. Surgical field, heart rate, and mean arterial pressure are shown in Tables 2 to 4 respectively.

Table 1: Demographic data
Parameter Group A Group B p-value
Age (years) (mean ± SD) 39.38 ± 12.16 37.54 ± 9.58 0.666
Weight (kg) (mean ± SD) 59.30 ± 11.22 60.10 ± 9.26 0.892
Sex (M/F) 12/8 14/6 0.125
ASA (I/II) 14/6 13/7 1.000
Table 2: Comparison between two groups
  Group A(mean ± SD) Group B(mean ± SD) p-value
Duration of surgery (min) 69.00 ± 9.63 55.00 ± 10.34 0.000*
Surgical field grading (n = 20) (n = 20)  
2 11 (55%) 18 (90%) 0.035*
3 9 (50%) 2 (10%)  
*p < 0.05, statistically significant
Table 3: Comparison of heart rate between two groups
Time (min) Group A (mean ± SD) Group B (mean ± SD) p-value
0 82.56 ± 8.34 (n = 20) 76.23 ± 8.52 (n = 20) 0.062
10 85.20 ± 10.40 (n = 20) 76.32 ± 8.86 (n = 20) 0.010*
20 78.23 ± 7.46 (n = 20) 77.22 ± 7.32 (n = 20) 0.742
30 76.67 ± 6.58 (n = 20) 77.52 ± 7.32 (n = 20) 0.264
40 78.60 ± 7.28 (n = 20) 81.11 ± 7.19 (n = 20) 0.393
50 76.82 ± 5.76 (n = 20) 78.00 ± 7.42 (n = 12) 0.686
60 81.84 ± 6.97 (n = 17) 79.67 ± 8.08 (n = 6) 0.277
70 85.66 ± 6.80 (n = 12) 86.20 ± 1.10 (n = 2) 0.286
75 82.20 ± 9.50 (n = 2) 86.00 ± 0.00 (n = 1) 0.745
*p < 0.05, statistically significant
Table 4: Comparison of mean blood pressure between two groups
Time (min) Group A (mean ± SD) Group B (mean ± SD) p-value
0 94.50 ± 7.34 (n = 20) 90.22 ± 6.21 (n = 20) 0.080
10 96.70 ± 10.54 (n = 20) 89.40 ± 6.68 (n = 20) 0.047*
20 82.22 ± 9.52 (n = 20) 88.16 ± 5.64 (n = 20) 0.029*
30 80.65 ± 7.76 (n = 20) 90.12 ± 7.62 (n = 20) 0.003*
40 82.20 ± 7.30 (n = 20) 92.24 ± 7.14 (n = 20) 0.002*
50 83.46 ± 7.64 (n = 20) 94.28 ± 8.62 (n = 12) 0.003*
60 89.34 ± 8.14 (n = 17) 97.14 ± 6.44 (n = 6) 0.205
70 97.34 ± 7.42 (n = 12) 94.00 ± 0.00 (n = 2) 0.697
75 97.00 ± 8.00 (n = 2) 90.00 ± 0.00 (n = 1) 0.582
*p < 0.05, statistically significant

Hemodynamic Parameters

The intraoperative hemodynamic changes including heart rate and mean blood pressure were as follows:

Group A (TIVA) included 12 male and 8 female patients, with mean age 39.38 ± 12.16 years and mean weight 59.30 ± 11.22 kg. About 14 patients were ASA-I and 6 patients of ASA-II status. ASA II had hypertension.

Group B (MAC) included 14 male and 6 female patients with mean age 37.54 ± 9.58 years and mean weight 60.10 ± 9.26. Thirteen ASA-I and seven ASA-II status. ASA-II had hypertension. No patient had oversedation. One patient was rescued with TIVA in this group, and another patient was included for statistical analysis.

The duration of surgery was 69.00 ± 9.63 minutes in group A and 55.00 ± 10.34 minutes in group B and was statistically significant. The surgical field score in both groups was 2 or 3.

Group A: 55% had a score of 2 and 45% a score of 3. Group B: 90% had a score of 2 and 10% a score of 3 (p < 0.05).


Heart rate was more in group A at 5 and 10 minutes. This can be as a result of intubation. Mean BP was higher in group A at 10 minutes, and after 20 minutes of the surgery, this was higher in group B till 55 minutes with (p < 0.05). This difference could be a result of the maintenance of the depth of anesthesia in TIVA as compared with group B. Despite of high mean BP in group B, the surgical condition was better (p = 0.035).


Endoscopic sinus surgery is a common procedure for management of sinus disease and results in better visualization of nasal structures.8,9 Endoscopic sinus surgery is commonly done for sphenoethmoidectomy, sinusitis, polyposis, repair of cerebrospinal fluid leaks, and orbital decompression.1013 Excessive bleeding from inflamed tissue with increased vascularity increases the procedure time and complications like orbital penetration, dural puncture, injury to blood vessels, and injury to medial rectus muscle.1418 To overcome this, a number of agents, including beta-blockers, inhalational agents, nitroglycerine, nitroprusside, etc., have been used to provide hypotensive anesthesia with varying results and side effects.1922 The side effects of hypotensive agents include tachyphylaxis and cyanide intoxication after administration of sodium nitroprusside, bradycardia with beta-blockers, and delayed recovery with inhalational agents. Reverse trendelenburg position is tried to decrease venous engorgement.

General anesthesia is preferred in noncooperative, anxious patients and advanced disease.18 The surgical condition was assessed by the same surgeon to reduce the subjective error.

Both groups were comparable in their demographic data. The surgery lasted longer in group A due to the time taken for preparation before general anesthesia, bleeding, and prolonged recovery after anesthesia. In both the groups, surgical field score was within ideal limits. But, in group B, 90% patients had a score of 2 as compared with 55% in group A. This difference in surgical score may be as a result of vasodilatation induced by TIVA.

Despite higher mean BP in group B, surgical condition was better in group B as a result of local use of vasoconstrictors. After completion of surgery, the nasal cavity is packed, making the patient to breathe through his mouth. Extubation should be done in a fully awake patient to prevent aspiration of blood or secretions. The ESS was done using local anesthesia and conscious sedation had less operative time, less blood loss, low surgical cost, and no endotracheal intubation.2326 The patient is conscious throughout the surgery and can complain of pain if any adjacent orbital structure is approached by the surgeon to prevent any complications.


The time taken for ESS is reduced, the surgical field is better despite of higher mean blood pressure done with MAC care in comparison to TIVA. However, this needs the cooperative patient.


Sanjeev Kumar Singla


1. Gittleman PD, Jacobs JB. Skorina J. Comparison of functional endoscopic sinus surgery under local and general anaesthesia. Ann Otol Rhinol Laryngol 1993;102(4 Pt 1):283–293. DOI: 10.1177/000348949310200408.

2. Ebehart LH, Folz BJ, Wolf H, et al. Intravenous anaesthesia provides optimal surgical condition during microscopic and endoscopic sinus surgery. Laryngoscope 2003;113(8):1369–1373. DOI: 10.1097/00005537-200308000-00019.

3. Danielsen A. Functional endoscopic sinus surgery as a day care out-patient basis. Clin Otolaryngol Allied Sci 1992;17(6):473–477. DOI: 10.1111/j.1365-2273.1992.tb01699.x.

4. Nair S, Collins M, Hung P, et al. Effect of β-Blockers premedication on the surgical field during endoscopic sinus surgery. Laryngoscope 2004;114(6):1042–1046. DOI: 10.1097/00005537-200406000-00016.

5. Blackwell KE, Ross DA, Kapur P, et al. Propofol for maintenance of general anaesthesia a technique to limit blood loss during endoscopic sinus surgery. Am J Otolaryngol 1993;14(4):262–266. DOI: 10.1016/0196-0709(93)90072-f.

6. Fedok FG, Ferraro RE, Kingsley CP, et al. Operative times postanaesthesia recovery times and complications during sinonasal surgery using general anaesthesia and local anaesthesia with sedation. Otolaryngol Head Neck Surg 2000;122(4):560–566. DOI: 10.1067/mhn.2000.100495.

7. Fromme GA, Mackenzie RA, Gould AB, et al. Controlled hypotension for orthognathic surgery. Anesth Analag 1986;65(6):683–686. PMID: 3706806.

8. Mackay IS, Lon VJ. Surgical management of sinusitis. In: Makay IS, Bull TR, editors. Scott Browns Otolaryngology, 6th edition. Butterworth Heinmann 1997. pp. 5–26.

9. Stammberger H. Functional endoscopic sinus surgery. In: The Messerklinger Technique Edition. Philadelphia: BC Decker 1999. pp. 283–318.

10. Jakobsen J, Vendstrip S. Functional endoscopic sinus surgery in chronic sinusitis: A series of 237 consecutively operated patients. Acta Otolaryngol Suppl 2000;543:158–161. DOI: 10.1080/000164800454279.

11. Keleş N, Ilicali OC, Değer K. Objective and subjective assessment of nasal obstruction in patients undergoing endoscopic sinus surgery. Am J Rhinol 1998;12(5):307–309. DOI: 10.2500/105065898780182408.

12. Sun H, Tan G, Xiao J. Endoscopic sinus surgery, clinical expect with 69 cases. Zhonghue Er Bi Yan Hou Ke Za Zhi 1996;31(1):18–19. PMID: 9275396.

13. Sipila J, Antila J, Suonpaa J. Pre and postoperative evaluation of patients with nasal obstruction undergoing endoscopic sinus surgery. Eur Arch Otorhinolaryngol 1996;253(4–5):237–239. DOI: 10.1007/BF00171134.

14. Wang L, Kim J, Heilman CB. Intracranial mucocele as a complication of endoscopic repair of cerebrospinal fluid rhinorrhea: Case report. Neurosurgery 1999;45(5):1243–1245. DOI: 10.1097/00006123-199911000-00052.

15. Jones GW. Anaesthesia for ENT surgery. In: Aitkentre AR Rowbotham DJ, Smith G, editors. Textbook of Anaesthesia. 4th edition. London: Churchill Living Stone; 2001. pp. 590–593.

16. Stammberger H, Hawke M. Essentials of Endoscopic Sinus Surgery. 2nd edition. Mosby; 2000. pp. 143–144.

17. Ronald D Miller. Miller’s Anesthesia. 6th edition, vol. 1. Elsevier, Churchill Livingstone; 2004. pp. 335–344.

18. Stoelting RK. Pharmacology and Physiology in Anesthetic Practice. 3rd edition. Lippincott-Raven 1999. pp. 93–96.

19. Degoute CS, Dubreuil E, Ray MJ, et al. Effects of posture, hypotension and locally applied vasoconstrictors on the middle ear microcirculation in anaesthetized humans. Eur J Appl Physol Occup Physiol 1994;69(5):414–420. DOI: 10.1007/BF00865405.

20. Degoute CS, Ray MJ, Manchon M, et al. Remifentanil controlled hypotension, comparison with nitroprusside or esmolol during tympanoplasty. Can J Anesth 2001;48(1):20–27. DOI: 10.1007/BF03019809.

21. Boezart AP, Vander MJ, Coetzee AR. Comparison of sodium nitroprusside and esmolol controlled hypotension for functional endoscopic sinus surgery. Can J Anesth 1995;42(5 Pt 1):373–376. DOI: 10.1007/BF03015479.

22. Ankichetty SP, Ponniah M, Cherian V, et al. Comparison of total intravenous anesthesia using propofol and inhalational anesthesia using isoflurane for controlled hypotension in functional endoscopic sinus surgery. J Anaesthesiol Clin Pharmacol 2011;27(3):328–332. DOI: 10.4103/0970-9185.83675.

23. Vleming M, Middel Weerd RJ, Devries N. Complications of endoscopic sinus surgery. Arch Otolaryngol Head Neck Surg 1992;118(6):617–623. DOI: 10.1001/archotol.1992.01880060067015.

24. Maier W, Laszig R. Complication of endonasal paranasal sinus surgery – Diagnostic and therapeutic consequences. Laryngorhinootolgie 1998;77(7):402–409. DOI: 10.1055/s-2007-996998.

25. Unlu NH, Goktan C, Astan A, et al. Injury to lacrimal apparatus after endoscopic sinus surgery, surgical implications from active transport dacryocystography. J Otolaryngol Head Neck Surg 2001;124(3):308–312. DOI: 10.1067/mhn.2001.112433.

26. Holden JP, Vaughan WC, Brock Utne JG. Airway complications following FESS. J Clin Anesth 2002;14(2):154–157. DOI: 10.1016/s0952-8180(01)00376-2.

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