Functional Endoscopic Sinus Surgery (FESS)
[Chronic rhinosinusitis with / Chronic rhinosinusitis without] nasal polyps involving the [right / left / bilateral] [maxillary / anterior ethmoid / posterior ethmoid / frontal / sphenoid] sinus(es) [and ***]
Same
Functional endoscopic sinus surgery
Right: [Maxillary antrostomy / Anterior ethmoidectomy / Total ethmoidectomy / Frontal sinusotomy / Sphenoidotomy / Polypectomy / None]
Left: [Maxillary antrostomy / Anterior ethmoidectomy / Total ethmoidectomy / Frontal sinusotomy / Sphenoidotomy / Polypectomy / None]
[Stereotactic image-guided navigation]
[***, MD/DO]
[Resident/Fellow/PA name]
General endotracheal
The patient is a [age]-year-old [male / female] with [chronic rhinosinusitis with nasal polyps / chronic rhinosinusitis without nasal polyps / recurrent acute rhinosinusitis / fungal ball / mucocele / other] associated with [nasal obstruction / drainage / facial pressure / impaired smell / recurrent infections / other]. Nasal endoscopy demonstrated [right-sided findings] and [left-sided findings]. Fine-cut CT imaging demonstrated [right-sided disease and anatomic considerations] and [left-sided disease and anatomic considerations]. Symptoms persisted despite appropriate medical management including [saline irrigation / topical corticosteroid / antibiotic when indicated / systemic corticosteroid / biologic therapy / other]. Treatment options, the anticipated extent of surgery, the likelihood of continued medical management, and the possibility of recurrent disease or revision surgery were discussed. The risks, benefits, and alternatives were reviewed, and informed consent was obtained.
Right: The nasal cavity demonstrated [no polyps / polyps graded *** / mucosal edema / purulence / eosinophilic or allergic mucin / fungal debris / scar or osteitic partitions] involving the [middle meatus / sphenoethmoidal recess / maxillary / anterior ethmoid / posterior ethmoid / frontal / sphenoid] region(s). The [natural ostia / prior surgical openings / uncinate process / middle turbinate / lamina papyracea / skull base] were [findings].
Left: The nasal cavity demonstrated [no polyps / polyps graded *** / mucosal edema / purulence / eosinophilic or allergic mucin / fungal debris / scar or osteitic partitions] involving the [middle meatus / sphenoethmoidal recess / maxillary / anterior ethmoid / posterior ethmoid / frontal / sphenoid] region(s). The [natural ostia / prior surgical openings / uncinate process / middle turbinate / lamina papyracea / skull base] were [findings].
[Cultures were obtained from the [right / left] [sinus or site].] [Anatomic variants relevant to the dissection included ***.] [No orbital or skull-base dehiscence was identified / Dehiscence or other altered anatomy was present at ***.]
The patient was placed supine with the head elevated. General anesthesia was induced, the endotracheal tube was secured, and a surgical timeout was completed. The eyes were protected while remaining accessible for examination. The face was prepared and draped for endoscopic sinus surgery.
Diagnostic nasal endoscopy was performed bilaterally. The nasal cavities were decongested with [oxymetazoline / epinephrine / other]-soaked pledgets. Local anesthetic containing [concentration] epinephrine was injected at the [lateral nasal wall / middle turbinate attachment / other] as performed. The pledgets were removed after adequate mucosal decongestion.
The right nasal cavity was addressed with a [0 / 30 / 45 / 70]-degree endoscope. The right-sided procedures were [maxillary antrostomy / anterior ethmoidectomy / total ethmoidectomy / frontal sinusotomy / sphenoidotomy / polypectomy], performed using the corresponding selected modules below. Tissue removal, cultures, navigation, and middle-turbinate management are documented only when performed.
The left nasal cavity was addressed with a [0 / 30 / 45 / 70]-degree endoscope. The left-sided procedures were [maxillary antrostomy / anterior ethmoidectomy / total ethmoidectomy / frontal sinusotomy / sphenoidotomy / polypectomy / none], performed using the corresponding selected modules below. Tissue removal, cultures, navigation, and middle-turbinate management are documented only when performed.
The operative cavities were irrigated and reinspected. Hemostasis was achieved with [topical vasoconstrictor pledgets / focal electrocautery / hemostatic material / other]. The right middle turbinate was [preserved in stable position / medialized / secured as described / partially resected as described], and the left middle turbinate was [preserved in stable position / medialized / secured as described / partially resected as described]. [No packing or implant was placed / [Material or implant] was placed in the [right / left / bilateral] [middle meatus / frontal recess / other].] Final endoscopy demonstrated [patent operated sinus openings / expected postoperative appearance] and satisfactory hemostasis. The eyes were [soft and symmetric / otherwise assessed as ***] at completion. All counts were correct.
None
[Right [sinus/site] contents, sent to pathology]
[Left [sinus/site] contents, sent to pathology]
[Right / Left] [sinus/site] culture
[X] mL
[None / Absorbable packing at *** / Nonabsorbable packing at *** / Steroid-eluting implant at ***]
The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [CRS with / CRS without] nasal polyps involving [right / left / bilateral] *** sinus(es)
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Functional endoscopic sinus surgery
RIGHT: [Maxillary antrostomy / Anterior ethmoidectomy / Total ethmoidectomy / Frontal sinusotomy / Sphenoidotomy / Polypectomy / None]
LEFT: [Maxillary antrostomy / Anterior ethmoidectomy / Total ethmoidectomy / Frontal sinusotomy / Sphenoidotomy / Polypectomy / None]
[Stereotactic image-guided navigation]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with [CRSwNP / CRSsNP / recurrent acute rhinosinusitis / fungal ball / mucocele / other] and *** symptoms. Endoscopy demonstrated RIGHT: ***; LEFT: ***. Fine-cut CT demonstrated RIGHT: ***; LEFT: ***. Symptoms persisted despite appropriate treatment including ***. The operative plan, alternatives, continued medical management, and potential recurrence were discussed. Consent was obtained.
FINDINGS:
RIGHT: [No polyps / Polyps grade *** / Edema / Purulence / Mucin / Fungal debris / Scar or osteitis] involving ***. Landmarks and prior openings: ***.
LEFT: [No polyps / Polyps grade *** / Edema / Purulence / Mucin / Fungal debris / Scar or osteitis] involving ***. Landmarks and prior openings: ***.
[Culture from ***.] [Relevant anatomic variants or dehiscence: ***.]
DESCRIPTION OF PROCEDURE:
The patient was positioned supine with the head elevated. General anesthesia was induced, and a timeout was completed. The eyes were protected but accessible. The face was prepared and draped. Bilateral nasal endoscopy was performed. The nose was decongested with *** pledgets, and local anesthetic with epinephrine was injected at ***.
RIGHT-SIDED PROCEDURES: *** [Insert selected maxillary, anterior ethmoid, total ethmoid, frontal, sphenoid, polyp/tissue-removal, navigation, and middle-turbinate modules as performed.]
LEFT-SIDED PROCEDURES: *** [Insert selected modules as performed; enter NONE if no left-sided surgery.]
The cavities were irrigated and reinspected. Hemostasis was obtained with ***. RIGHT middle turbinate: ***. LEFT middle turbinate: ***. [No packing or implant / *** placed at ***.] Final openings were patent as documented, and hemostasis was satisfactory. Eyes were [soft and symmetric / ***]. Counts were correct.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: RIGHT ***; LEFT ***; CULTURES ***
COMPLICATIONS: None
DRAINS/IMPLANTS: [None / ***]
DISPOSITION: Stable to PACU
Signed: .ME, .MYDEGREE
.TODAYVariants
Maxillary Antrostomy Module
[Right / Left / Bilateral]: The middle meatus was exposed, and the free edge of the uncinate process was identified. The uncinate was removed with [instrumentation], exposing the natural maxillary ostium. The natural ostium was incorporated into the antrostomy and enlarged [posteriorly / inferiorly / as dictated by the disease and anatomy]. [No accessory ostium was present / An accessory or prior posterior opening was connected to the natural ostium.] Angled endoscopy confirmed the final opening and permitted inspection of the sinus. [No tissue was removed from within the maxillary sinus / [Polypoid tissue / fungal debris / other] was removed from within the [right / left / bilateral] maxillary sinus.] The orbit and nasolacrimal region remained protected.
Anterior Ethmoidectomy Module
[Right / Left / Bilateral]: The ethmoid bulla and surrounding anterior ethmoid cells were identified. The bulla was opened, and the diseased anterior ethmoid partitions were removed with mucosa-preserving [through-cutting instruments / curettes / microdebrider as appropriate]. Dissection stopped anterior to the basal lamella; the posterior ethmoid cells were not entered. The lamina papyracea and superior boundary of the dissection were identified and preserved as encountered. The anterior ethmoid cavity was patent at completion.
Total Ethmoidectomy Module
[Right / Left / Bilateral]: After completion of the anterior ethmoidectomy, the basal lamella was entered at a known safe location while preserving its inferior supporting portion. The posterior ethmoid cells were opened to the sphenoid face. The posterior skull base was identified, and remaining partitions were removed in a controlled posterior-to-anterior dissection along the skull base and medial orbital wall. Diseased cells, osteitic partitions, and polypoid tissue were removed as documented while preserving uninvolved mucosa where feasible. The lamina papyracea, skull base, and middle-turbinate support remained intact. Do not combine this module with the anterior-only module on the same side.
Frontal Sinusotomy Module
[Right / Left / Bilateral]: Using angled endoscopy, the frontal recess anatomy was defined. The [agger nasi / suprabullar / supraorbital ethmoid / frontal / other] cell(s) obstructing the drainage pathway were identified and removed with [instrumentation]. The natural frontal drainage pathway was opened and enlarged to the planned extent while preserving mucosa where feasible. The final procedure corresponded to [frontal recess clearance / Draf I / Draf IIa / other], and the opening was [dimensions or description] at completion. [No tissue was removed from within the frontal sinus / [tissue or material] was removed.] [No stent was placed / [type] stent or implant was placed at ***.]
Sphenoidotomy Module
[Right / Left / Bilateral]: The sphenoethmoidal recess, superior turbinate, and anterior sphenoid face were identified. The natural sphenoid ostium was located and enlarged with [instrumentation], beginning at the known opening and proceeding according to the surrounding anatomy. Angled endoscopy demonstrated the [sphenoid cavity / relevant septations / Onodi cell relationship / other]. [No tissue was removed from within the sphenoid sinus / [Polypoid tissue / fungal debris / other] was removed from within the [right / left / bilateral] sphenoid sinus.] The skull base, optic canal region, and carotid prominence were protected.
Sinus Tissue, Polyp, or Debris Removal Module
[Right / Left / Bilateral]: [Polyps / diseased mucosa / eosinophilic or allergic mucin / fungal debris / other] were removed from the [nasal cavity / maxillary sinus / ethmoid cavity / frontal sinus / sphenoid sinus] with [instrumentation]. Material from the [exact side and site] was [sent to pathology / sent for aerobic, anaerobic, or fungal culture / discarded as appropriate]. The note distinguishes material removed from within a sinus from material removed only from the nasal cavity or outflow tract.
Image-Guided Navigation Module
Navigation was selected because of [revision surgery / altered or distorted anatomy / extensive polyposis / frontal, posterior ethmoid, or sphenoid disease / disease near the skull base, orbit, optic nerve, or carotid artery / other]. The system was registered to the patient's fine-cut preoperative CT dataset. Accuracy was verified against [multiple fixed surface and intranasal landmarks] before dissection and rechecked [periodically / before work near ***]. Navigation was used as an adjunct to confirm the location of [skull base / lamina papyracea / frontal drainage pathway / sphenoid / optic canal / carotid artery / other]. Registration accuracy remained satisfactory throughout use.
Middle-Turbinate Management Module
Right middle turbinate: [Preserved without manipulation / Gently medialized / Secured to the septum with *** / Supported with *** spacer or implant / Lateral lamella of concha bullosa resected / Partially resected because ***]. Left middle turbinate: [Preserved without manipulation / Gently medialized / Secured to the septum with *** / Supported with *** spacer or implant / Lateral lamella of concha bullosa resected / Partially resected because ***]. The remaining turbinate attachment and final position were [stable / otherwise described].
Revision FESS Module
Prior imaging and endoscopy demonstrated altered landmarks from [prior procedures]. On the [right / left / bilateral] side, the operative cavity contained [scar bands / lateralized middle turbinate / residual uncinate / separate natural and surgical maxillary openings / residual ethmoid partitions / osteitic bone / stenosed frontal or sphenoid opening / polyps]. Scar and polyps were reduced sufficiently to identify reliable landmarks. The [natural maxillary ostium / medial orbital wall / skull base / sphenoid face / posterior choana / other] was identified before further bony dissection. The prior opening was revised by [specific work], and residual diseased partitions or tissue were removed from [exact sites]. [Navigation was used as documented in the separate module.] Final landmarks and openings were [***].
Charting Tips
- List the exact operation performed for the right and left sides separately; do not use “bilateral FESS” as a substitute for naming each sinus.
- For ethmoidectomy, state whether dissection was confined to the anterior cells or crossed the basal lamella to include the posterior cells. Do not select both modules for the same side.
- For maxillary antrostomy, document identification and incorporation of the natural ostium, the direction and extent of enlargement, and whether an accessory or prior opening was connected.
- For maxillary and sphenoid surgery, clearly state whether tissue was removed from within the sinus and identify the tissue, side, and location.
- For frontal surgery, name the cells or partitions removed, the resulting drainage pathway, and the Draf classification only when the actual extent supports it.
- Record polyps, edema, purulence, mucin, fungal debris, osteitis, scarring, and cultures separately by side and site.
- If navigation was used, record the indication, CT dataset, registration method, initial and repeat 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 preservation, medialization, fixation, partial resection, spacer, packing, or implant placement.
- In revision surgery, identify altered or absent landmarks, residual partitions, stenosed openings, scarring, and the reliable landmarks established before dissection.
- Document septoplasty, turbinate reduction, concha bullosa resection, CSF-leak repair, or orbital procedures separately when performed rather than embedding them in a generic FESS statement.
Documentation & Reimbursement Considerations
- 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.