Sinus Surgery (FESS) in India and UAE | Complete Patient Guide

• IDEAL CANDIDATES:

• Adults and adolescents (typically ≥16 years) with chronic rhinosinusitis (CRS) — with or without nasal polyposis — lasting >12 weeks confirmed by PNS CT (Lund-Mackay score ≥4)

• Patients who have failed an adequate trial of maximal medical therapy: ≥12 weeks of intranasal corticosteroids plus at least one course of culture-directed antibiotics and/or systemic steroids

• Recurrent acute rhinosinusitis (≥4 documented episodes per year with interim symptom-free intervals)

• Sinonasal anatomy variants causing recurrent obstruction: concha bullosa, paradoxical middle turbinate, Haller (infraorbital ethmoid) cells, prominent agger nasi cells

• Symptomatic nasal polyps causing anosmia, mouth-breathing, sleep-disordered breathing, or refractory headache

• Acute complications of sinusitis: subperiosteal or orbital abscess, intracranial extension (necessitating urgent/emergency FESS)

• Allergic fungal rhinosinusitis (AFRS) or fungal balls (mycetoma) within sinus cavities

• Benign sinonasal tumours (inverted papilloma, osteoma) amenable to endoscopic resection

• Patients with aspirin-exacerbated respiratory disease (AERD / Samter's Triad) who have failed medical optimisation

• REQUIRED PRE-OPERATIVE DIAGNOSTICS:

• High-resolution CT PNS (coronal + axial views, ideally 1 mm cuts; Lund-Mackay scoring)

• Nasal endoscopy with photodocumentation (in-clinic or telescopic)

• Full blood count, coagulation profile (PT/INR, aPTT), renal and liver function tests

• Allergy workup: total IgE, specific IgE panel (RAST or ImmunoCAP), and skin-prick testing where indicated

• Swab for bacteriology + culture and sensitivity (nasal and sinus) to guide perioperative antibiotic selection

• MRI paranasal sinuses: reserved for suspicion of intracranial extension, skull-base erosion, malignancy, or AFRS (to differentiate signal characteristics)

• Olfactory testing (Sniffin' Sticks or UPSIT) to document pre-operative baseline

• Spirometry / pulmonary function test if concurrent asthma or samter's triad is suspected

• COVID-19 PCR or equivalent infection screen as per local hospital protocol

• RELATIVE AND ABSOLUTE CONTRAINDICATIONS:

• Uncorrected coagulopathy or therapeutic anticoagulation not safely bridged (absolute; bridging must be coordinated with prescribing physician)

• Uncontrolled diabetes mellitus (HbA1c >9%) — increased infection and wound-healing risk; optimisation required pre-operatively

• Active acute sinusitis with systemic sepsis — surgery deferred until medically stabilised (except for urgent drainage of complications)

• Severe obstructive sleep apnoea without CPAP optimisation — anaesthetic risk

• Pregnancy (elective cases deferred; urgent cases managed conservatively where possible)

• Malignant sinonasal neoplasm extending to critical skull-base structures where open craniofacial resection is required (open surgery preferred over pure FESS)

• Known severe allergy to general anaesthetic agents without feasible alternative (rare; managed with allergy/anaesthetics board)

• Paediatric patients under 6 years with uncomplicated CRS (medical therapy preferred; surgery reserved for complications or cystic fibrosis-related disease)

FESS encompasses a spectrum of procedures tailored to disease extent, anatomy, and aetiology. The following outlines the principal techniques available at GAF Healthcare's partner institutions:

1. STANDARD FESS (Uncinectomy + Middle Meatal Antrostomy):

The foundational FESS procedure involves resection of the uncinate process to expose the ethmoidal infundibulum, followed by widening of the maxillary sinus natural ostium into the middle meatus. A powered microdebrider (e.g., Medtronic Straightshot M4 or Stryker IPC) enables precise tissue removal with minimal mucosal trauma compared to through-cutting forceps alone. Anterior ethmoidectomy and frontal recess dissection are added as disease extent dictates. This approach resolves isolated maxillary or anterior ethmoid CRS with high efficacy.

2. EXTENDED / TOTAL ETHMOIDECTOMY + SPHENOETHMOIDECTOMY:

In pan-sinusitis or posterior disease, complete anterior and posterior ethmoidectomy is combined with wide sphenoidotomy. The surgeon works in close proximity to the optic nerve (lateral sphenoid wall) and internal carotid artery, making pre-operative CT navigation planning critical. At high-volume GAF partner centres, intraoperative IGS (Stryker Nav or Medtronic StealthStation) is used for all revision cases and anterior skull-base dissections, reducing the risk of inadvertent orbital or intracranial entry.

3. DRAF PROCEDURES (FRONTAL SINUS DRAINAGE):

• Draf I: Removal of agger nasi cells and superior uncinate to open the frontal recess

• Draf IIa/IIb: Partial or complete floor-of-frontal-sinus resection to widen the frontal ostium

• Draf III (Endoscopic Modified Lothrop Procedure / 'Frontal Drillout'): Creation of a common neo-ostium by removing the intersinus septum and superior nasal septum; reserved for severe frontal sinusitis, tumours, or CSF rhinorrhoea repair. Requires high-speed angled drilling systems and skull-base expertise.

4. BALLOON SINUPLASTY (BSP):

A catheter-based technology (NovaBay/Entellus/Acclarent) that dilates sinus ostia using a high-pressure balloon over a lighted guidewire without tissue removal. FDA-cleared for maxillary, frontal, and sphenoid ostia. Ideal for: patients without polyposis, those unsuitable for general anaesthesia (office-based local anaesthesia possible), or as a hybrid adjunct alongside conventional FESS. Not appropriate for CRS with significant polyposis, fungal disease, or anatomical variants requiring structural resection.

5. POWERED ENDOSCOPIC POLYPECTOMY WITH STEROID-ELUTING IMPLANTS:

In CRSwNP, microdebrider polypectomy is the standard. Following FESS, biodegradable steroid-eluting sinus stents (e.g., Propel — mometasone furoate-releasing implant) can be placed directly into the ethmoid cavity or frontal sinus, delivering sustained local corticosteroid over 30–45 days to suppress mucosal inflammation, reduce scarring, and improve long-term patency — a technology adopted at flagship centres in both India and the UAE.

6. ENDOSCOPIC SKULL-BASE AND ORBITAL DECOMPRESSION (ADVANCED):

Extension of FESS principles to manage complications: endoscopic orbital decompression for Graves' ophthalmopathy or subperiosteal abscess, endoscopic DCR (dacryocystorhinostomy) for epiphora, and endoscopic CSF leak repair using multilayer techniques (fat, fascia, mucosal flap, fibrin glue). These procedures are performed by surgeons with combined rhinology and skull-base fellowship training.

7. BIOLOGIC ADJUNCT THERAPY (PERI-OPERATIVE):

For CRSwNP patients with high type-2 inflammation (elevated blood eosinophil count, tissue eosinophilia >10/hpf, elevated IgE), biologics are increasingly integrated:

• Dupilumab (Dupixent): anti-IL-4Rα; approved for CRSwNP; significantly reduces polyp recurrence post-FESS

• Mepolizumab (Nucala): anti-IL-5; approved for CRSwNP with severe eosinophilia

• Omalizumab (Xolair): anti-IgE; effective in comorbid allergic asthma + CRSwNP

GAF Healthcare's partner hospitals offer rhinology–allergy joint clinics to determine biologic eligibility and coordinate prescription and administration for international patients.

8. COMPUTER-ASSISTED NAVIGATION (IGS):

Mandatory standard at partner hospitals for: revision FESS, frontal sinus surgery, sphenoid work near the optic nerve/ICA, and suspected skull-base involvement. Accuracy within 1.5–2 mm of actual anatomical position. Significantly reduces the risk of the most serious FESS complications (orbital injury, CSF leak, major vascular injury).

PRE-OPERATIVE PHASE (4–8 weeks before travel, or accelerated for GAF coordinated fast-track):

• Step 1 — Remote Case Review: Patient submits existing PNS CT (DICOM files preferred), nasal endoscopy reports, SNOT-22 score, and medical history to GAF Healthcare's clinical team. A GAF-affiliated consultant rhinologist reviews records within 48–72 hours and issues a written surgical opinion and estimated procedure plan.

• Step 2 — Medical Optimisation: If indicated, patient is advised to complete a pre-operative course of oral corticosteroids (e.g., prednisolone 0.5 mg/kg/day × 10 days) to reduce polyp volume and intraoperative bleeding; anticoagulants/antiplatelets are bridged or discontinued per protocol (aspirin held 5–7 days, warfarin bridged to LMWH, DOACs held 24–48 hours pre-operatively based on CrCl).

• Step 3 — Travel Arrangements & Visa: GAF Healthcare initiates e-Medical Visa for India (processed in 2–5 business days) or UAE entry formalities. Flight and airport transfer logistics are coordinated.

• Step 4 — Arrival & Pre-Admission Workup (Day –1): Patient is received at the airport and transferred to partnered hotel or hospital guest house. Pre-admission blood work, ECG, anaesthesia review, and repeat nasal endoscopy by the operating surgeon are completed. Informed consent is obtained with interpreter present if required.

INTRA-OPERATIVE PHASE (Day 0 — Surgery Day):

• Step 5 — Anaesthesia: FESS is performed under general anaesthesia with hypotensive technique (MAP 60–70 mmHg) to minimise intraoperative bleeding. Total intravenous anaesthesia (TIVA) with propofol/remifentanil is preferred over volatile agents due to superior haemostasis. Local anaesthetic (1% lidocaine with 1:100,000 adrenaline) is infiltrated into the middle turbinate and uncinate process prior to dissection.

• Step 6 — Procedure: Surgical duration is typically 45–90 minutes for standard FESS; extended/revision cases or Draf III may require 2–3 hours. The surgeon uses a 0°, 30°, and 70° Hopkins rod endoscope system. If IGS is in use, the patient's pre-operative CT is loaded into the navigation platform and registered at the start of the case. Tissue specimens are sent for histopathology and fungal culture. Haemostasis is achieved with bipolar cautery and/or resorbable haemostatic agents (e.g., Surgicel, FloSeal).

• Step 7 — Packing / Stenting: Non-absorbable nasal packing (e.g., Merocel) is used selectively; many surgeons prefer dissolvable packing (e.g., NasoPore, Surgifoam) or steroid-eluting stents (Propel) to avoid the discomfort of formal packing removal.

IMMEDIATE POST-OPERATIVE PHASE (Days 1–3):

• Step 8 — Recovery and Discharge: Patient is monitored in the recovery room for 2–4 hours, then in the ward. For uncomplicated unilateral or bilateral FESS, same-day or next-morning discharge is standard. Vital signs, oxygen saturation, and bleeding monitoring are performed at 4-hour intervals.

• Step 9 — Discharge Medications: High-volume saline nasal irrigation (NeilMed or dedicated nasal douche, 240 mL twice daily), intranasal mometasone spray (200 mcg/nostril twice daily), prophylactic oral antibiotics (amoxicillin-clavulanate 875/125 mg twice daily for 7–14 days), analgesics (paracetamol ± tramadol; NSAIDs generally avoided for 1 week if haemostasis concerns), and short course of oral prednisolone in polyposis cases.

EARLY RECOVERY PHASE (Days 3–10 — In Country):

• Step 10 — First Post-Op Clinic Visit (Day 3–5): Nasal endoscopy performed by the operating surgeon. If non-absorbable packing was used, it is removed at this visit. Clots and crusts are gently suctioned under endoscopic guidance. Irrigation technique is reviewed and reinforced.

• Step 11 — Second Post-Op Review (Day 7–10): Critical visit. Surgeon assesses cavity healing, removes residual crusting and adhesions under endoscopy, confirms haemostasis, and evaluates the patency of surgically opened ostia. This is the gatekeeping appointment for fit-to-fly clearance.

• Step 12 — Fit-to-Fly Assessment: International air travel is generally cleared at the Day 7–10 review if: no active bleeding, no CSF leak, adequate nasal crusting reduction, patient able to perform nasal saline irrigation independently, and no signs of post-operative infection. Patients with Draf III, skull-base repair, or complex revision FESS may require a 2-week stay before clearance.

LATE RECOVERY / HOME PHASE (Weeks 2–12):

• Step 13 — Ongoing Irrigation: High-volume saline irrigation is continued for a minimum of 12 weeks post-operatively; evidence shows this is the single most impactful patient-modifiable factor in long-term FESS outcomes.

• Step 14 — Steroid Irrigation: Topical budesonide irrigation (0.5 mg in 240 mL saline) is prescribed in polyposis cases and continued long-term.

• Step 15 — Remote Follow-Up with GAF: GAF Healthcare arranges teleconsultation review at Week 4, Week 8, and Week 12 post-operatively via video with the operating surgeon. Imaging (repeat CT PNS at 3–6 months) is coordinated with the patient's local radiologist using a standardised request letter provided by the operating centre.

• Step 16 — Biologic Initiation (if applicable): Patients eligible for dupilumab or other biologics receive a detailed treatment plan and prescription letter to continue therapy in their home country.