Patient and Procedural Predictors of Early Recovery Quality after Endoscopic Endonasal Surgery

Clinical Question

Which patient and procedural factors influence early post-operative recovery quality and post-anesthesia care unit (PACU) outcomes after endoscopic endonasal surgery (EES)?

Bottom Line

Procedural factors such as nasal packing and anesthetic type significantly influence PACU length of stay, while neuropsychiatric comorbidities—including depression, migraine, and anxiety—are key determinants of patient-reported recovery quality. Oral acetaminophen may improve early recovery outcomes.

Background: Endoscopic endonasal surgery is commonly performed for sinonasal disease and is generally well tolerated; however, variability in early post-operative recovery—including pain, nausea, and PACU duration—can affect patient experience and healthcare efficiency. Data guiding short-term recovery expectations and optimization strategies remain limited.

Study Design: Retrospective cohort study of patients undergoing EES (January 2024 to March 2025). Demographic and procedural variables, as well as comorbidities, were reviewed, and Lasso regression was used to evaluate associations between key outcomes: PACU length of stay (PACU-LoS), morphine equivalents (PACU-ME), and 15-item Quality of Recovery (QoR-15) scores.

Setting: Single academic tertiary-care center (University of Washington)

SYNOPSIS: The cohort included 110 patients (69% female; median age 41 years). Common comorbidities included anxiety (40%), depression (37%), migraine (25%), and chronic pain disorders (20%). Mean PACU length of stay was 59 minutes, average PACU-ME was 38.13 mg, and mean QoR-15 score was 112.25, reflecting overall good recovery.

Procedural factors strongly influenced PACU outcomes. Nasal packing increased PACU-LoS by approximately 12.5 minutes, while total intravenous anesthesia (TIVA) reduced PACU-LoS by about 6.7 minutes. Infraorbital nerve block was associated with a modest increase in PACU duration. Opioid use and operative factors such as blood loss and procedure duration had moderate effects on PACU time.

In contrast, patient comorbidities were the primary determinants of recovery quality. Depression had the largest negative impact on QoR-15 scores (−8.38), exceeding the minimal clinically important difference, followed by migraine (−5.80) and anxiety (−3.31). Doyle splint placement also modestly reduced recovery scores.

Importantly, oral acetaminophen administered in the PACU improved QoR-15 scores (+2.07), suggesting benefits extending beyond its pharmacologic half-life into early recovery. No strong independent predictors of opioid requirements were identified in multivariable analysis.

Limitations include retrospective design, single-center setting, and potential influence of nonclinical factors such as institutional workflow. Nevertheless, the study highlights actionable perioperative factors that can optimize early recovery and patient counseling.

Citation: Fernández-Penny FE, et al. Patient and procedural predictors of early recovery quality after endoscopic endonasal surgery. Int Forum Allergy Rhinol. 2025;15:1412-1415. doi:10.1002/alr.70037.

Comment: This manuscript explores factors related to the quality of the immediate recovery following bread-and-butter nasal and sinus surgery. Given that these interventions are performed for quality of life, it’s important to consider the patient’s experience and ease of recovery. Patient selection, intra-operative, and post-operative factors were all found to be influential in a satisfying outcome. From a patient standpoint, comorbid diagnoses of anxiety, depression, and migraine were all associated with worse recovery quality. Operatively, TIVA reduced PACU stay (while nasal packing understandably increased duration), and acetaminophen given in the PACU provided benefits that outlasted the half-life of the medication. Given the frequency with which these surgeries are performed, it is important to counsel patients on expectations, incorporating their past history, and some relatively easy interventions (TIVA, immediate post-op acetaminophen) can enhance the recovery experience. —Ashoke Khanwalkar, MD