Complications of controlled hypotension during functional endoscopic sinus surgery - a systematic review

Although functional endoscopic sinus surgery (FESS) constitutes a standard treatment for the management of chronic rhinosinusitis, intraoperative bleeding poses a considerable challenge by impairing visibility and increasing complication risks. Controlled hypotension is a widely employed technique to mitigate bleeding; however, excessive blood pressure reduction may compromise systemic perfusion and predispose to organ ischemia.

Due to the scarcity of literature evaluating the safety of controlled hypotension in FESS, we aimed to systematically review current evidence on the risks and potential complications of this technique, with an emphasis on systemic adverse events (hemodynamic instability, neurological impairment, and renal dysfunction).

The PubMed, Embase, and Cochrane databases were searched for English-language original articles published until October 1, 2025. Studies were considered eligible if they reported mean arterial pressure (MAP) values achieved and evaluated systemic complications associated with controlled hypotension during FESS.

A total of 32 articles were found eligible and included in the further analysis. Most protocols aimed for a MAP of 50-70 mmHg, primarily using dexmedetomidine, propofol, and remifentanil. Only 8 of the 32 studies utilized advanced intraoperative monitoring (e.g., near-infrared spectroscopy [NIRS], transcranial Doppler [TCD], and non-invasive cardiac output monitoring [NICOM]). The most frequent minor complication was postoperative nausea and vomiting (in 2-62% of cases). Significant hemodynamic disturbances included intraoperative bradycardia and severe hypotension (MAP < 50 mmHg), requiring pharmacological intervention. While no permanent neurological deficits were reported, intraoperative cerebral desaturation was observed in 2 studies. The follow-up observation rarely extended beyond the post-anesthesia care unit and did not include a structured assessment of cerebral and renal function.

Subclinical complications of controlled hypotension during FESS may be overlooked without advanced intraoperative monitoring, postoperative biomarker surveillance, and a long-term follow-up period. The application of a uniform MAP target of 50-70 mmHg may be insufficient in high-risk patients. The development of personalized hemodynamic management strategies and enhanced perfusion-monitoring protocols is required to reduce the risk of occult organ ischemia and to define safe limits for controlled hypotension in FESS.