Nasal polyp removal is most commonly performed using functional endoscopic sinus surgery (FESS), a minimally invasive procedure done entirely through the nostrils with no external incisions. The surgery takes one to two hours in most cases and is considered the standard treatment when polyps don’t respond to medications like steroid sprays or oral steroids. Here’s what to expect before, during, and after the procedure.
Why Surgery Instead of Medication
Surgery isn’t usually the first option. Most ENT specialists start with nasal steroid sprays, short courses of oral steroids, or both. Surgery enters the picture when polyps keep growing despite these treatments, when they’re blocking your sinuses badly enough to cause chronic infections, or when you’ve lost your sense of smell and medications haven’t brought it back.
A newer alternative for some patients is biologic therapy, injectable medications that target the inflammation driving polyp growth. Many guidelines recommend trying surgery before biologics, but biologics may be a better fit if you have significant health conditions that make general anesthesia risky, or if you also have severe asthma or eczema that the same medication could treat. For patients who’ve already had a thorough surgery and polyps returned despite consistent steroid use afterward, a biologic is a logical next step. The choice between surgery and biologics is ultimately a shared decision between you and your doctor based on your goals and health profile.
How FESS Differs From Older Techniques
The older approach, called simple nasal polypectomy, involved grabbing and pulling polyps out without addressing the underlying sinus blockage. This had a high recurrence rate, with polyps returning in roughly three out of four patients within about four years. That approach has largely been replaced.
FESS takes a more comprehensive strategy. Rather than just removing the visible polyps, the surgeon opens up the natural drainage pathways of your sinuses. The ethmoid sinuses (the honeycomb-like cells between your eyes) are opened, the natural sinus openings are widened, and sometimes the sphenoid sinuses deeper in the skull are opened as well. Critically, the healthy lining inside your nose and sinuses is preserved as much as possible. This “mucosal sparing” philosophy helps your sinuses heal and function normally after surgery.
What Happens During the Procedure
FESS is traditionally performed in an operating room under general anesthesia, meaning you’re fully asleep. However, in-office polypectomy under local anesthesia has become more common in North America for selected patients, particularly those with large obstructive polyps who prefer to avoid general anesthesia or who’ve been deemed too high-risk for it by an anesthesiologist.
The surgeon works through your nostrils using a thin, lighted camera called an endoscope, which provides a magnified view of your nasal passages on a monitor. Polyp tissue is removed using a microdebrider, a small rotating blade with built-in suction that precisely cuts and removes tissue while minimizing damage to surrounding structures. In more complex cases, the surgeon may use image-guided navigation, essentially a GPS system that overlays your preoperative CT scan onto a real-time 3D map. This allows the surgeon to track the exact position of instruments relative to critical structures like the eye socket and skull base.
Preparing for Surgery
Before the procedure, you’ll need a CT scan or MRI to give your surgeon detailed images of your polyps’ size, location, and relationship to surrounding anatomy. These images also feed into the navigation system if one is used during surgery.
In the days and weeks before your procedure, expect these requirements:
- Blood thinners and aspirin: Stop at least 10 days before surgery, along with certain supplements that affect clotting (like fish oil and vitamin E)
- Smoking: Quit at least one month before your procedure to reduce complications and improve healing
- Food and drink: Nothing after midnight the night before if you’re having general anesthesia
Your surgeon may also prescribe a short course of oral steroids beforehand to shrink the polyps and reduce bleeding during the procedure.
Risks and Complication Rates
Endoscopic sinus surgery is generally safe, but it operates near the eyes and brain, so the potential complications are worth understanding. A large outcomes analysis found the following complication rates within 30 days of surgery:
- Bleeding complications: 3.0% of patients, the most common issue. Males had a slightly higher risk (3.2%) compared to females (2.8%)
- Eye-related complications: 0.74%, including double vision, tearing problems, or orbital bleeding
- Skull base complications: 0.21%, including cerebrospinal fluid leak or infection, the rarest but most serious category
Put differently, over 96% of patients experienced none of these complications. Minor issues like crusting, temporary congestion, and mild pain are expected parts of normal healing, not complications.
Recovery Timeline
Plan to take at least one week off work. You’ll be tired, congested, and may have mild bloody drainage from your nose during this time. If your job involves physical labor or heavy lifting, you’ll need longer.
For the first two weeks after surgery, avoid lifting anything heavier than 5 to 10 pounds. No exercise, bending, or straining during this period either, as increased blood pressure can cause bleeding at the surgical site. Light walking is fine, but hold off on anything that raises your heart rate significantly until your surgeon clears you.
Nasal saline irrigation is a cornerstone of recovery. Your surgeon will likely have you start rinsing your sinuses with a saline solution (using a squeeze bottle or neti pot) within the first few days. Regular irrigation flushes out crusts, dried blood, and mucus, helping your sinuses heal cleanly. Many patients find the rinses so helpful they continue using them long after recovery is complete. That said, follow your surgeon’s guidance on frequency, as overuse without a clear need may actually increase infection risk from residual fluid collecting in the sinuses.
Post-operative care also typically includes a course of antibiotics, pain medication, and prescription steroid sprays to control inflammation and discourage early polyp regrowth.
Polyp Recurrence After Surgery
This is the hard truth about nasal polyps: they tend to come back. FESS is far better than the old grab-and-pull method, but polyps are driven by chronic inflammation, and surgery doesn’t eliminate that underlying cause. Five-year recurrence rates sit around 30%, and by 10 years that number climbs to roughly 66%. The median time before polyps return is about 106 months, or just under nine years.
Recurrence doesn’t always mean you need another surgery. Many patients manage returning polyps with steroid sprays, occasional oral steroid courses, or biologic injections. Consistent use of nasal steroid sprays after surgery is one of the most important things you can do to extend your polyp-free period. Some patients do undergo revision surgery, and FESS can be repeated, though each subsequent procedure works with more scar tissue.
Factors that increase recurrence risk include having asthma (especially aspirin-exacerbated respiratory disease), more severe polyp disease at the time of initial surgery, and elevated markers of a specific type of inflammation called type 2 inflammation. Your surgeon can give you a better sense of your individual risk based on these factors.