Functional Endoscopic Sinus Surgery (FESS)
Chronic rhinosinusitis [with / without] nasal polyps, [bilateral / right / left]
Same
[Bilateral / Right / Left] functional endoscopic sinus surgery: maxillary antrostomy and total (anterior and posterior) ethmoidectomy[, frontal sinusotomy][, sphenoidotomy]
[Computer-assisted image-guided navigation]
[***, MD/DO]
[Resident/Fellow/PA name]
General endotracheal
The patient is a [age]-year-old [male / female] with chronic rhinosinusitis [with / without] nasal polyps causing [nasal obstruction, drainage, facial pressure, and decreased sense of smell]. Symptoms persisted despite medical therapy including [saline irrigations, intranasal corticosteroids, and oral corticosteroids]. CT of the sinuses demonstrated [findings]. The risks, including bleeding, cerebrospinal fluid leak, orbital injury and vision loss, change in sense of smell, synechiae, recurrent disease, and need for revision surgery, as well as the benefits and alternatives, including continued medical therapy, were discussed. Informed consent was obtained.
Right: [Polypoid disease / Mucosal thickening / Purulence] involving the [maxillary and ethmoid sinuses / maxillary, ethmoid, frontal, and sphenoid sinuses].
Left: [Polypoid disease / Mucosal thickening / Purulence] involving the [maxillary and ethmoid sinuses / maxillary, ethmoid, frontal, and sphenoid sinuses].
The lamina papyracea and skull base were intact bilaterally.
The patient was placed supine with the head elevated. General endotracheal anesthesia was induced, and a surgical time-out was completed. The eyes were lubricated, taped, and left exposed within the field. Oxymetazoline-soaked pledgets were placed in both nasal cavities. [Image guidance was used because of [extensive polyposis / frontal or sphenoid disease / revision surgery]. The navigation system was registered to the preoperative CT, and accuracy was confirmed at known anatomic landmarks.]
Diagnostic nasal endoscopy was performed with 0- and 30-degree endoscopes, with the findings noted above. The lateral nasal walls and the axillae of the middle turbinates were injected with 1% lidocaine with 1:100,000 epinephrine.
Attention was turned to the right side. [Polyps obstructing the middle meatus were debulked with the microdebrider.] The middle turbinate was gently medialized. An uncinectomy was performed with a [backbiter / sickle knife and through-cutting forceps]. The natural maxillary ostium was identified and widened posteriorly and inferiorly with a backbiter and the microdebrider. The maxillary sinus was inspected with the 30-degree endoscope. [Polypoid tissue / Mucin / No tissue] was removed from within the maxillary sinus.
The ethmoid bulla was opened, and the anterior ethmoid cells were removed with the microdebrider and through-cutting forceps. The basal lamella was entered inferomedially, and the posterior ethmoid cells were opened to the face of the sphenoid. The skull base was identified posteriorly and followed anteriorly, and the remaining ethmoid partitions were removed along the skull base and lamina papyracea. The lamina papyracea and skull base were preserved.
[The natural sphenoid ostium was identified medial to the superior turbinate and enlarged inferiorly and medially with a Kerrison rongeur and mushroom punch. [Polypoid tissue / Mucin / No tissue] was removed from within the sphenoid sinus. The skull base, optic nerve, and carotid artery were protected.]
[With an angled endoscope, the agger nasi and frontal recess cells were removed with frontal sinus curettes and giraffe forceps, and the frontal sinus outflow tract was opened and confirmed patent.]
Hemostasis was obtained with oxymetazoline-soaked pledgets[ and suction electrocautery].
[The same procedure was then performed on the left side.]
The cavities were irrigated and inspected, and hemostasis was confirmed. Both middle turbinates were stable in a medial position. [Absorbable packing was placed in the middle meatus bilaterally / No packing was placed / A steroid-eluting implant was placed in each ethmoid cavity]. [Sinus contents from each side were sent separately to pathology.] The nasopharynx and oropharynx were suctioned. The orbits were soft and symmetric at the conclusion of the procedure. Pledget counts were correct.
None
[Right and left sinus contents, sent separately to pathology / None]
[Culture from the *** sinus]
[X] mL
[Absorbable packing in the middle meatus bilaterally / None / Steroid-eluting implant in each ethmoid cavity]
The patient was awakened, extubated, and taken to the post-anesthesia care unit in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Chronic rhinosinusitis [with / without] nasal polyps, [bilateral / right / left]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: [Bilateral / Right / Left] functional endoscopic sinus surgery: maxillary antrostomy and total ethmoidectomy[, frontal sinusotomy][, sphenoidotomy][, image-guided navigation]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with chronic rhinosinusitis [with / without] nasal polyps causing *** despite medical therapy including saline irrigations, intranasal corticosteroids, and ***. CT demonstrated ***. Risks including bleeding, CSF leak, orbital injury and vision loss, change in smell, recurrence, and revision surgery, along with benefits and alternatives, were discussed. Informed consent was obtained.
FINDINGS:
RIGHT: [Polypoid disease / Mucosal thickening / Purulence] involving the [maxillary and ethmoid sinuses / maxillary, ethmoid, frontal, and sphenoid sinuses].
LEFT: [Polypoid disease / Mucosal thickening / Purulence] involving the [maxillary and ethmoid sinuses / maxillary, ethmoid, frontal, and sphenoid sinuses].
Lamina papyracea and skull base intact bilaterally.
DESCRIPTION OF PROCEDURE:
Supine, head elevated. General endotracheal anesthesia induced; time-out completed. Eyes lubricated, taped, and left in the field. Oxymetazoline pledgets placed bilaterally. [Image guidance used for ***; registered to preoperative CT, accuracy confirmed at known landmarks.] Diagnostic endoscopy with 0- and 30-degree endoscopes. Lateral nasal walls and middle turbinate axillae injected with 1% lidocaine with 1:100,000 epinephrine.
RIGHT: [Middle meatal polyps debulked with the microdebrider.] Middle turbinate medialized. Uncinectomy performed. Natural maxillary ostium identified and widened posteriorly and inferiorly with backbiter and microdebrider. [Polypoid tissue / Mucin / No tissue] removed from within the maxillary sinus. Ethmoid bulla opened, anterior ethmoid cells removed, basal lamella entered inferomedially, and posterior ethmoid cells opened to the sphenoid face. Skull base followed posterior to anterior; remaining partitions removed. Lamina papyracea and skull base preserved. [Sphenoid: natural ostium enlarged inferiorly and medially; [polypoid tissue / mucin / no tissue] removed from within the sinus.] [Frontal: agger nasi and frontal recess cells removed; frontal outflow tract opened and patent.] Hemostasis with pledgets[ and suction cautery].
[LEFT: Same procedure performed.]
Cavities irrigated; hemostasis confirmed. Middle turbinates stable and medial. [Absorbable packing in the middle meatus bilaterally / No packing / Steroid-eluting implant in each ethmoid cavity]. Oropharynx suctioned. Orbits soft and symmetric. Pledget counts correct.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: [Right and left sinus contents to pathology / None][; culture from ***]
COMPLICATIONS: None
DRAINS/IMPLANTS: [Absorbable packing bilaterally / None / Steroid-eluting implants bilaterally]
DISPOSITION: Extubated, stable to PACU
Signed: .ME, .MYDEGREE
.TODAYVariants
Maxillary Antrostomy
On the [right / left] side, the middle turbinate was gently medialized, and the uncinate process was removed with a [backbiter / sickle knife and through-cutting forceps]. The natural maxillary ostium was identified and enlarged posteriorly and inferiorly with through-cutting forceps and the microdebrider. [An accessory ostium was connected to the natural ostium.] The maxillary sinus was inspected with an angled endoscope. [Polypoid tissue / Mucin / No tissue] was removed from within the maxillary sinus. The orbit and nasolacrimal duct were protected.
Anterior (Partial) Ethmoidectomy
On the [right / left] side, the ethmoid bulla was opened, and the anterior ethmoid cells were removed with the microdebrider and through-cutting forceps, preserving mucosa where feasible. Dissection stopped at the basal lamella, which was left intact, and the posterior ethmoid cells were not entered. The lamina papyracea and skull base were preserved.
Total (Anterior and Posterior) Ethmoidectomy
On the [right / left] side, the ethmoid bulla was opened, and the anterior ethmoid cells were removed with the microdebrider and through-cutting forceps. The basal lamella was entered inferomedially, preserving its inferior attachment, and the posterior ethmoid cells were opened to the face of the sphenoid. The skull base was identified posteriorly and followed anteriorly, and the remaining partitions were removed along the skull base and lamina papyracea. The lamina papyracea and skull base were preserved, and the middle turbinate remained stable.
Frontal Sinusotomy
On the [right / left] side, the frontal recess was visualized with a [70 / 45]-degree endoscope. The [agger nasi / agger nasi and suprabullar] cells obstructing the frontal drainage pathway were removed with frontal sinus curettes and giraffe forceps. The frontal sinus outflow tract was opened, corresponding to a [Draf I / Draf IIa] frontal sinusotomy, and was patent at completion. [Polypoid tissue / Mucin / No tissue] was removed from within the frontal sinus. [A stent was placed in the frontal sinus outflow tract.]
Sphenoidotomy
On the [right / left] side, the natural sphenoid ostium was identified [medial to the superior turbinate in the sphenoethmoidal recess / through the posterior ethmoid cavity]. The ostium was enlarged inferiorly and medially with a Kerrison rongeur and mushroom punch, and the sphenoid sinus was inspected with an angled endoscope. [Polypoid tissue / Mucin / No tissue] was removed from within the sphenoid sinus. The skull base, optic nerve, and carotid artery were protected.
Image-Guided Navigation
Image guidance was used because of [extensive polyposis / revision surgery with altered landmarks / frontal or sphenoid disease / disease adjacent to the skull base or orbit]. The navigation system was registered to the preoperative fine-cut CT, and accuracy was confirmed at fixed external and intranasal landmarks before dissection and rechecked during the case. Navigation was used to confirm the position of the [skull base / lamina papyracea / frontal sinus outflow tract / sphenoid sinus]. Accuracy remained satisfactory throughout.
Middle Turbinate Management
The right middle turbinate was [medialized / preserved without manipulation / secured to the septum with a suture / partially resected]. The left middle turbinate was [medialized / preserved without manipulation / secured to the septum with a suture / partially resected]. [The lateral lamella of the [right / left] concha bullosa was resected.] Both middle turbinates were stable at the conclusion of the procedure.
Revision FESS
On the [right / left] side, the cavity contained [scar bands / a lateralized middle turbinate / residual uncinate process / residual ethmoid partitions / recurrent polyps] from prior surgery. Scar and polyps were cleared until reliable landmarks were identified, including the medial orbital wall, skull base, and natural maxillary ostium. Residual partitions and scar were removed, and the prior [maxillary antrostomy / sphenoidotomy / frontal sinusotomy] was revised to a widely patent opening. [Separate natural and surgical maxillary openings were connected into a single antrostomy.] [Image guidance was used to confirm the position of the skull base and lamina papyracea.] The lamina papyracea and skull base were preserved.
Charting Tips
- The default note covers bilateral maxillary antrostomy with total ethmoidectomy. For unilateral, anterior-only, or revision surgery, replace the side paragraph with the matching variant and dictate each side separately.
- Use either the anterior ethmoidectomy or the total ethmoidectomy wording for a given side, never both. State whether dissection stopped at the basal lamella or crossed it into the posterior cells.
- For maxillary, sphenoid, and frontal surgery, state whether tissue was removed from within the sinus and name the tissue, side, and location. Distinguish material removed from within a sinus from material removed only from the nasal cavity or outflow tract.
- For maxillary antrostomy, document identification and incorporation of the natural ostium, the direction of enlargement, and whether an accessory or prior opening was connected.
- For frontal surgery, name the cells removed and use a Draf classification only when the actual extent supports it.
- If navigation was used, record the indication, CT dataset, registration, accuracy checks, and the anatomy it helped localize. Do not imply that navigation replaced direct identification of surgical landmarks.
- Document each middle turbinate separately, including medialization, suture fixation, concha bullosa resection, or partial resection with its reason.
- Record polyps, purulence, mucin, fungal debris, osteitis, and cultures by side and site.
- In revision surgery, identify altered or absent landmarks, residual partitions, stenosed openings, and the reliable landmarks established before further dissection.
- For payer medical necessity, record the duration of medical therapy, symptom burden, and objective CT findings (for example, Lund-Mackay score) in the indications or the preoperative note.
- Document septoplasty, turbinate reduction, CSF leak repair, or orbital procedures separately rather than embedding them in a generic FESS statement.
Documentation & Reimbursement Considerations
- Primary service: Report Functional Endoscopic Sinus Surgery (FESS) as the primary service when it is the definitive operation performed.
- Medicare assigns the listed endoscopic sinus services a 0-day global period. Related evaluation on the procedure date is generally included; later postoperative work is not automatically part of a 10- or 90-day package.
- Report the operated side and each sinus addressed. For ethmoid surgery, state whether the operation stopped after the anterior cells or included both anterior and posterior cells.
- Total ethmoid surgery performed with frontal or sphenoid surgery on the same side may follow combined reporting conventions. The note should accurately describe the component work without presenting an included component as a separate additional service.
- For maxillary and sphenoid procedures, distinguish opening or enlargement of the ostium from removal of tissue within the sinus. Name the tissue removed and its side and location.
- When navigation is used, document the clinical reason, imaging dataset, registration, accuracy verification, and how it assisted the operation.
- If postoperative endoscopic debridement is performed, document its indication, laterality, findings, material removed, and work performed rather than relying on the original operative note.