Controlled hypotension is frequently employed during Functional Endoscopic Sinus Surgery (FESS) to improve surgical field visibility. Intranasal (IN) administration of dexmedetomidine provides a noninvasive alternative with lower peak plasma concentrations and milder pharmacodynamic effects, including reduced hypotension, bradycardia, and sedation, compared to intravenous (IV) delivery. This study compared IN and IV dexmedetomidine in the context of hypotensive anesthesia for FESS.In a randomized, triple-blind, controlled trial, 60 patients scheduled for FESS were randomly allocated into two equal groups. The IN group received 1 μg/kg dexmedetomidine in 10 mL of 0.9% saline intranasally 45–60 minutes before anesthesia, whereas the IV group received the same dose in 10 mL of 0.9% saline infused over 10 minutes. The primary endpoint was total atropine usage, while secondary endpoints included hemodynamic changes preoperatively, intraoperatively, and postoperatively at defined intervals. Operative field quality, sedation levels, adverse events, and post-surgical hemostatic requirements were also evaluated. Findings revealed a significant reduction in atropine consumption in the IN group. Ramsay Sedation scores were similar at baseline (T0), T5, T50, and T60, but were lower in the IN group between T10 and T40. Mean arterial pressure showed no difference at T0, T5, and T60, yet was lower in the IV group from T10 to T45. Both groups demonstrated comparable satisfaction, postoperative sedation, operative field quality, hemostatic needs, and incidence of complications. In conclusion, intranasal dexmedetomidine is an easy-to-administer and effective option that avoids first-pass metabolism. Its slower onset relative to IV administration necessitates preoperative administration about one hour before surgery, making it suitable for adult patients who require mild sedation prior to FESS.
