What is debridement and how should recovery after FESS be managed?

The AAO-HNS recommends a comprehensive approach to care after FESS that includes nasal irrigation, topical corticosteroids, debridement (removal of crusts, blood and secretions) and long-term follow-up. Key points of the guideline (2025): ^[1][2]

• Nasal irrigation: high-volume saline irrigation (240 ml) is recommended both after surgery and for long-term management of CRS. Irrigation improves mucociliary clearance, softens crusts and supports healing of the mucosa. Hypertonic solution may be superior to isotonic. Patients should be taught to use distilled or boiled water and to clean the devices regularly
• Topical corticosteroids: intranasal corticosteroids (spray, budesonide irrigation, steroid-eluting stents) are the basis of postoperative medical therapy. In patients after FESS with moderate to severe disease not controlled by spray, intranasal budesonide irrigation showed an advantage in symptom control. High-volume corticosteroid irrigation is more effective than a spray of equivalent dose in operated patients
• Debridement: postoperative debridement (removal of blood clots, crusts and fibrin deposits) is important for healing after FESS. The procedure is performed in an outpatient setting under topical anesthesia; the frequency and need for visits depend on the type of operation and the endoscopic findings
• Long-term follow-up: a routine follow-up examination is recommended 3 to 12 months after surgery, with assessment of symptoms (SNOT-22), nasal endoscopy and adherence to therapy. CT is not routinely required. Long-term follow-up is especially important for patients with nasal polyps, given the chronic nature of the disease and the risk of recurrence

I. Debridement: timing, frequency, evidence

Technique. Debridement is performed in an outpatient setting with a rigid endoscope after applying a topical anesthetic (lidocaine) and a vasoconstrictor. Blood clots, crusts and secretions are carefully removed with suction and forceps; firmly attached crusts are left in place. The procedure may cause discomfort and minor bleeding. ^[3]

Optimal timing and frequency. There is no single standardized protocol. The Cochrane systematic review by Tzelnick et al. (2018, 4 RCTs) found considerable variation in regimens: ^[3]

The prospective RCT by Lee & Byun (2008, n=30) compared three debridement frequencies during the first 4 weeks: twice a week, once a week and once every 2 weeks. Once a week proved optimal: with less frequent debridement (once every 2 weeks), patients had significantly more discomfort between visits, while with more frequent debridement (twice a week) their daily activities were significantly more disrupted. Surgical outcomes at 6 months (SNOT-20, endoscopic findings) did not differ. ^[4]

Debridement vs. no debridement. The Cochrane review (2018) found no convincing evidence that debridement is better than no debridement in terms of endoscopic scores and synechiae formation, although the quality of the evidence was low. The critical review by Eloy et al. (2017) confirmed that the effectiveness of debridement remains debatable, and most surgeons perform it based on personal experience, the extent of the operation and the severity of postoperative inflammation. ^[3][5]

Practical recommendation: the first debridement 5–10 days after surgery (removal of packing/stents, if placed, and initial cleaning), then once every 1–2 weeks for the first 4–6 weeks, and after that as needed. The frequency is individualized according to the extent of the operation, the speed of healing and the presence of polyps. ^[1][4][5]

II. Nasal irrigation: protocols

• Volume — 240 ml per side (high-volume irrigation, squeeze bottle or neti pot)
• Solution — isotonic (0.9% NaCl) or hypertonic (1.5–3%) saline
• Frequency — 2–3 times a day in the early postoperative period, then 1–2 times a day long term
• Start — usually 24–48 hours after surgery (or after packing is removed)
• Water — only distilled, bottled or boiled (to prevent Naegleria fowleri infection)

The systematic review by Gnanasekaran et al. (2024, 14 RCTs) confirmed that irrigation with various additives (budesonide, hyaluronic acid, honey) outperforms plain saline on SNOT-22 and endoscopic scores, with budesonide showing the greatest effect in a subgroup analysis. ^[6]

Budesonide irrigation is the best-studied and increasingly used strategy of topical steroid therapy after FESS. A typical dose is 0.25–0.5 mg of budesonide (1 respule of 0.5 mg/2 ml) per 240 ml of saline, 1–2 times a day; studies used doses from 0.25 to 1 mg per irrigation. The RCT by Huang et al. (2019, n=60) showed that budesonide irrigation was significantly better than plain saline on all Lund-Kennedy components (polyps, edema, discharge, scarring) 3 months after FESS, with no difference in side effects. The meta-analysis by Magboul et al. (2025, 26 studies, n=1,464) confirmed improvement in SNOT-22 and LKES with normal cortisol levels and IOP after treatment. Mitchell & Bhattacharyya (2024, n=8,157) showed that budesonide prescribing after FESS rose from ~12% in 2016 to 24.9% in 2022, while prescriptions of oral corticosteroids fell. ^{[7][9][10][11]}

As Claire Hopkins notes (NEJM, 2019), delivering glucocorticoids by high-volume (240 ml) nasal irrigation was more effective at reducing endoscopic signs of recurrence than delivering an equivalent dose by nasal spray in patients after sinus surgery. ^[12]

III. Topical corticosteroids: delivery options

Steroid-eluting stents (PROPEL). The systematic review by Alsaedi et al. (2026, 6 studies, n=412) showed that stents reduce inflammation and frontal sinus restenosis compared with surgery without a stent, but are not superior to high-volume steroid irrigation; the rate of frontal ostium occlusion/restenosis was 15.6% and the need for repeat surgery 6.9%. The review by Calvo-Henriquez et al. (2024, 29 studies) confirmed that several questions about the effectiveness of stents remain unanswered, including cost-effectiveness. ^[13][14]

Safety of topical corticosteroids. The systematic review by Bertazzoni et al. (2025, 20 studies) and the meta-analysis by Magboul et al. (2025) found no significant suppression of the hypothalamic-pituitary-adrenal axis or increase in intraocular pressure with high-volume steroid irrigation. The meta-analysis by Donaldson et al. (2020, 60 studies) confirmed no lasting changes in cortisol levels or IOP with any form of intranasal corticosteroids; the only significant side effect was a higher risk of nosebleeds (RR 1.56; 95% CI 1.13–2.14). ^[10][16][17]

IV. Antibiotics: postoperative use

Routine antibiotics after FESS are not supported by the available evidence. The systematic review and meta-analysis by Swords et al. (2021, 5 RCTs) found no significant differences between antibiotics and placebo on SNOT-22 (SMD −0.215) and endoscopic scores. The systematic review by Patel et al. (2018) also did not support routine antibiotic prophylaxis in FESS. A survey of the British Rhinological Society (Hayois et al., 2024, n=96) showed considerable variation in practice: only 17.7% of surgeons routinely prescribe antibiotics after FESS, 26% never do, and the rest prescribe them when indicated. ^[18][19][20]

Antibiotics may be justified for purulent discharge during surgery, extensive surgery with packing, immunodeficiency and cystic fibrosis. ^[21]

V. Pain relief

Pain after FESS is usually moderate and peaks in the first 3 days. The median use of combined acetaminophen/opioid tablets is only 3 tablets. NSAIDs (ibuprofen) do not increase the risk of bleeding after FESS and reduce the need for opioids. The recommended strategy is paracetamol ± ibuprofen as first line, with a limited number of opioid tablets when individually indicated. ^[1]

VI. Long-term follow-up and prevention of recurrence

The AAO-HNS (2025) recommends a follow-up examination between 3 and 12 months after FESS, with assessment of symptoms (SNOT-22), nasal endoscopy and assessment of adherence to therapy. Endoscopic findings in this period are more predictive of the need for revision surgery than pre-operative measures. The study by Riva et al. (2022, n=60) showed how critical adherence to follow-up is: patients with regular endoscopic examinations and timely treatment of minor recurrences had a recurrence rate of 7.7% versus 38.2% in patients without regular follow-up (p<0.001). Yet adherence to regular check-ups and nasal corticosteroids was only 25%. ^[1][22]

Summary table: postoperative protocol after FESS