COMPLICATIONS OF

ENDOSCOPIC SINUS SURGERY

Literature Reading
Rhinology
Febryanti P.Sari

Supervisor : dr. Arif Dermawan, Sp.THT-KL, M.Kes.

Dept of Otorhinolaryngology - Head and Neck Surgery

Faculty of Medicine University Padjadjaran / Hasan
Sadikin General Hospital
Bandung
2016
1

Introduction
Surgical is an art of working with the hands
Endoscopic Sinus Surgery
Intimate relationship of the sinuses to the orbit and
anterior cranial fossa
Potential source of sinus surgery complications
Mosher, a pioneer of this surgical technique in the United States, wrote
in 1929 Theoretically the operation is easy. In practice, however, it was
proved to be one of the easiest operations with which to kill a patient.

Kaluskar SK. Complications in Endoscopic Sinus Surgery. Jaypee

Brothers.2002

Introduction
Risk is inherent with any surgical
procedure
most surgeries performed to relieve
sinus disorders are uncomplicated and
result in high patient satisfaction
Intense preparation and experience
With early recognition, many
complications can be controlled early
and reversed
Stankiewics JA. Complications of Sinus Surgery in Bailey, BJ.; Johnson JT.; Newlands SD.; Head and
Neck Surgery Otolaryngology 5th edition 2014.

Introduction
intraoperati
ve
complicatio
ns
postoperati
ve
complicatio
ns

vascular and neurologic

injury
catastrophic bleeding
visual loss
cerebrospinal fluid ( CSF)
leaks
poor long-term surgical
outcomes
patient dissatisfaction
revision sinus surgery

Stankiewics JA. Complications of Sinus Surgery in Bailey, BJ.; Johnson JT.; Newlands SD.; Head and
Neck Surgery Otolaryngology 5th edition 2014.

Introduction
In 1000 intranasal ethmoidectomies, Freedman and Kern (1979)
reported an incidence of complications (2,8%), most of them of a
minor type.
Wigand ME (1981) described 2 cases of cerebral spinal fluid leak
in 1000 cases of extensive functional endoscopic sinus surgery.
Levine HL (1990) had 8,3% minor and 0,7% major complications.
Most major complications reported are CSF leaks.
Serdahl CL et al (1990) discussed 8 patients with epiphora following
endoscopic sinus surgery.
Goal of this presentation :
To prevent and minimize complication of endoscopic sinus surgery
Kaluskar SK. Complications in Endoscopic Sinus Surgery. Jaypee Brothers. 2002
6

RELEVANT ANATOMY

7
Adapted from : Miller, A.J. Sinus Anatomy and Funstion In : Bailey, B.J. Head & Neck Surgery-Otolaryngology.4 Edition. 2006
th

DANGER AREA
Skull Base Keros
3
Lamina papyracea
onodi
Ethmoid artery
Optic nerve
Carotid artery

Stankiewics JA. Complications of Sinus Surgery in Bailey, BJ.; Johnson JT.; Newlands SD.; Head and
Neck Surgery Otolaryngology 5th edition 2014.

MIDDLE TURBINATE
Acts as an important
landmark.
It separates the cribriform plate
from the fovea ethmoidalis,
its anterior tip marks the limits of
anterior dissection of the
maxillary antrostomy,
the basal lamella identifies the
entrance into the posterior
ethmoids,
lower half and insertion into the
choana help identify the entrance
into the sphenoid sinus.

Stankiewics JA. Complications of Sinus Surgery in Bailey, BJ.; Johnson JT.; Newlands SD.; Head
and Neck Surgery Otolaryngology 4th edition 2006.

10

Ductus Nasolacrimal

The Nasolacrimal duct lies 6 6.5 cm

from the nasal opening
It ostium enters the nose within 1 cm
from the end of inferior turbinate.
The anterior ethmoidal cells
encroach on the nasolacrimal sac at
the level of the middle turbinate and
duct at the level of the middle
meatus in 86% of patients
It can be injured in antrostomy

Stankiewics JA. Complications of Sinus Surgery in Bailey, BJ.; Johnson JT.; Newlands SD.; Head
and Neck Surgery Otolaryngology 4th edition 2006.

11

MEASUREMENTS

Stankiewics JA. Complications of Sinus Surgery in Bailey, BJ.; Johnson JT.; Newlands SD.; Head and
Neck Surgery Otolaryngology 5th edition 2014.
12

Stankiewics JA. Complications of Sinus Surgery in Bailey, BJ.; Johnson JT.; Newlands SD.; Head
and Neck Surgery Otolaryngology 4th edition 2006.

Prevention of Complication
Basic understanding of the pathophysiology of chronic
inflammatory diseases of the sinuses.
Proper diagnosis by means of detailed history taking, an
orderly and attentive nasoendoscopy and CT scan of the
sinuses.
A thorough knowledge of surgical anatomy of
paranasal sinuses especially in relation to the
intracranial stuctures.

the
orbital and

Feeling comfortable with handling the instrumens first in

the outpatients department for diagnosis.
A thorough preoperative preparation of the nose.
Assess systemic medical conditions that may affect nose
and sinuses.
Kaluskar SK. Complications in Endoscopic Sinus Surgery.Jaypee Brothers.2002

13

Complication of FESS
Major complication
Complications that
require further surgical
intervention, or blood
transfusion, or that result
in a new patient deficit or
death

Minor complication

cerebrospinal fluid (CSF) leak

optic nerve injury
ocular motility deficits
injury to the nasolacrimal duct
permanent anosmia
major intraoperative or perioperative
hemorrhage.

periorbital swelling
orbital emphysema
small orbital hematomas
temporary olfactory dysfunction
bleeding that does not require reoperation or
blood transfusion (minor epistaxis)
tooth pain
Synechiae
scar formation
recurrent inflamatory disease

Kaluskar SK. Complications in Endoscopic Sinus Surgery.Jaypee Brothers.2002

14

COMPLICATIONS
SINUS SURGERY

Vascular
injury

Carotid artery,Anterior communicating

artery, Carotid cavemous fistula, Ethmoidal
arterie$ (anterior and po5terior},
Sphenopalatine artery, Septal branch of the
sphenopalatine artery

Nerve
injury
Facial
dissorder
s

Infraorbital hypesdlesia, Infraorbital pare

sdlasia, Supraorbital and supratrochlear
hypesthesia, Supraorbital and supratrochlear
paresthesia, Inferior alveolar hype5thasia,
Inferior alveolar pare5thasia

Facial edema
Subcutaneous emphysema

Stankiewics JA. Complications of Sinus Surgery in Bailey, BJ.; Johnson JT.; Newlands SD.; Head and
Neck Surgery Otolaryngology 5th edition 2014.

COMPLICATIONS
SINUS SURGERY

Orbital
dissorder
s
Brain
and
neurologi
c
Packing
related

Blindness, Diplopia, Nasolacrimal duct injury,

Nasolacrimal sac injury, Injury to Hasner
valve, Orbital hematoma, Orbital
emphysema, Periorbital ecchymosis, Lid
edema, Anisocoria
Cerebrospinal fistula, Meningitis, Frontal lobe
injury, Hyposmia, dysosmia, anosmia,
Pneumocephalus, Anterior carebral artery
injury, Subarachnoid hemormage, Brain
abscess, Death
Displaced packing, Aspiration, Infection,
Increased orbital pressure, Toxic shock
syndrome, Myospherulosis, Scar tissue
formation

Stankiewics JA. Complications of Sinus Surgery in Bailey, BJ.; Johnson JT.; Newlands SD.; Head and
Neck Surgery Otolaryngology 5th edition 2014.

Bleeding During Operation

There are two types of bleeding during endoscopic
sinus surgery :
Mucosal Bleeding
Arterial Bleeding

Key to minimise bleeding during Endoscopic Sinus

Surgery
Prepare nasal cavity under direct vision with suitable
vasoconstrictor agent
Use gently, non traumatizing material for packing
Thorough preparation takes time

During Operation

Develop a meticulous and gentle operative technique,

Always use good quality sharp instruments
If possible use non tearing instruments
Avoid tearing mucosa as this will only result in mucosal bleed

Kaluskar SK. Complications in Endoscopic Sinus Surgery.Jaypee Brothers.2002

17

Mucosal Bleeding
Essentially due to the operative trauma with the surgeons
instruments
Patients on long term local steroid sprays have a tendency to bleed
more than others.
Extra care packing the nasal cavity repeatedly with vasoconstrictor
agents

Kaluskar SK. Complications in Endoscopic Sinus Surgery.Jaypee Brothers.2002

18

Arterial Bleeding
Anterior Ethmoidal Artery
A branch of ophthalmic artery traverses from the
orbit, through the roof of the nasal cavity to the
anterior cranial fossa
A bleeding vessel may retract into the orbit with
consequent intra orbital bleeding and possible
blindness
Sphenopalatine
Artery
A continuation of the internal maxillary artery, enters the nasal cavity through
the sphenopalatine foramina on the lateral wall of the nose near the
posterior end of the middle turbinate
Important surgical landmark upper stump of the middle turbinate
If bleed, can be cauterized with mono or bipolar diathermy

Posterior Branch of the Sphenopalatine Artery

Runs above the anterior surface of the sphenoid sinus

Usually damaged while trying to perform sphenoidotomy
To avoid injury enter into the anterior wall of the sphenoid sinus at about 1,5
cm from the upper border of the choana

Kaluskar SK. Complications in Endoscopic Sinus Surgery.Jaypee Brothers.2002

19

Arterial Bleeding
Anterior Branch of Sphenopalatine Artery
This artery is related to the maxillary sinus and could be damaged while
working in the middle meatus

Internal Carotid Artery

The artery is related to the lateral wall of the sphenoid sinus
To avoid injury is not to advance any instruments into the
sphenoid sinus
ICA four parts : cervical, intratemporal, cavernous and
supra cavernous.
Cavernous part is more likely to be damaged

Initial emergency measure after

carotid bleed
Pack the sphenoid sinus and replace blood
(transfusion)
Heparinised saline infusion to perfuse the
ophthalmic artery
(If rapid saline infusion ocular ischemia and
visual loss)
Kaluskar
SK. Complications
in Endoscopic and
Sinus Surgery.Jaypee Brothers.2002
Urgent
consult
to neurosurgeon

20

Orbital Complications
Minor Complication
Damage to the lamina papyracea and
periorbita ecchymosis
Periorbital surgical emphysema
Major Complication
Damage to the medial rectus muscle
diplopia
Damage to the Nasolacrimal duct
Intraorbital haemorrhage
Injury to the optic nerve

Kaluskar SK. Complications in Endoscopic

Sinus Surgery.Jaypee Brothers.2002
21

Prevention of Intraorbital Complications :

Avoid operating on patients with extensive polyposis, revision
surgery, hypertensive until the surgeon is well experienced in
endoscopic techniques.
Study preoperative CT-Scan to detect any likehood of dehiscence
of the lamina papyracea.
NEVER cover patients eyes with drapes during operation.
Instruct the assistant to inform the surgeon immediately if undue
eye movements occur during instrumentation inside the nose or if
there is a sudden proptosis.
If in doubt check the transmitted movements of the orbit
through the endoscope from time to time.
Place all the surgically removed tissues in saline to observe if it
sinks or floats. (fats and brain tissue floats.

Kaluskar SK. Complications in Endoscopic Sinus Surgery.Jaypee

Brothers.2002

22

Minor Complications
Damage to the Periorbita ecchymosis
If the lamina papyracea is cracked or a segment is removed during
the procedure, may cause a minor ecchymosis this will settled
spontaneously in 34 days.
Patient should be advised note to blow the nose within a few days.
If the orbital periosteum is traversed, then orbital fat prolapses into
the nasal airway.
Although fat has a yellow hue, it can look remarkably like nasal
polyps.
If it is fat:
Periorbital
Emphysema
Not to Surgical
push it back
into the orbit (this will fail), not to pull it out
(this will
makewhen
the damage
to the
worse), notof
to the
cauterize
Usually
occurs
the patient
hasorbit
a dehiscence
laminait.
papyracea and the patient blows the nose very hard in the
postoperative period.
If emphysema occurs, it will resorb, provided the patient does not
blow any more air into the area. Prophylactic antibiotics are given
to avoid periorbital cellulitis.
Kaluskar SK. Complications in
Endoscopic Sinus
Surgery.Jaypee Brothers.2002

23

Major Complications
Damage to the Medial Rectus Muscle
Medial rectus is closely related to the ethmoid
labyrinth.
Complains of diplopia
CT/MRI scan to see the damage. Consult to
ophthalmologist
Damage
to the Nasolacrimal Duct epiphora

Damage to the Nasolacrimal Duct epiphora

Nasolacrimal apparatus is in close proximity to the
middle meatus.
Injury to the duct occurs more commonly while
performing middle meatal antrostomy, when surgeon
works anteriorly.
Damage to the sac may occur during surgery of the
frontal recess, if works more laterally.
Referral to Opthalmologist (dacryorhinostomy)

Kaluskar SK. Complications in Endoscopic Sinus Surgery.Jaypee Brothers.2002

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Optic Nerve Injury

Optic nerve is more closely related to the posterior ethmoid than
sphenoid sinus.
Most vulnerable when there is a presence of a sphenoethmoidal
cell (Onodi Cell).
Intraorbital
Haemorrhage
Management
: High doses of methylprednisolone 250 mg IV every
6 hours.
High potential to cause visual loss.
Blindness can be prevented if managed immediately.
The intraoperative risk can be minimised, by stopping surgery
immediately when bleeding obscures vision, by observing
transmitted eye movement during surgery and awareness of
the development of proptosis.

Kaluskar SK. Complications in Endoscopic Sinus Surgery.Jaypee

Brothers.2002

25

Management of Intraorbital Haemorrhage

relieve pressure on artery supply of the optic
nerve
General measure : semi sitting position, normalisation
blood pressure
Increasing orbital space : nasal packing removed
immediately, if bleed, cauterized it. Lateral canthotomy
and cantholysis.
Decreased volume : Mannitol IV, acetazolamide,
corticosteroid

Kaluskar SK. Complications in Endoscopic Sinus Surgery.Jaypee

Brothers.2002

26

Stankiewics JA. Complications of Sinus Surgery in Bailey, BJ.; Johnson JT.; Newlands SD.; Head and
Neck Surgery Otolaryngology 5th edition 2014.

Intracranial Complications
Intraoperative
Complications

CSF leak
Intracranial haemorrhage
Injury to the Internal
Carotid Artery/Cavernous
sinus

Postoperative
Intracranial
Complications

Pneumoencephalus
Meningitis, epidural,
subdural and brain
abscess

Kaluskar SK. Complications in Endoscopic Sinus Surgery.Jaypee Brothers.2002

28

CSF Rhinorrhea
Occur intra or postoperatively. Nasal endoscopic examination appear
normal. Target sign (+)
Symptom such as nasal obstruction, catarrh, sneezing.
Complications of CSF fistulas, such as recurrent meningitis, or an air fluid
level (pneumocephalus) suggest a persistent leak.
90% closed spontaneously

Operative Technique to Prevent CSF Leak

Co-ordinated radiological and anatomical background

Working should be lateral rather than medial, as medially the base of skull
is lower than the roof of ethmoid.

Kaluskar SK. Complications in Endoscopic Sinus Surgery.Jaypee Brothers.2002

29

Meningitis
Pathogen enter the CNS the physical barrier of mucosa-bone & dura
matter is broken
Common organisms : S. Pneumonia, H. Influenza, S. Aureus
Management : Dexamethasone 0,6 mg/kg/day for 2-4 days, high dose
antibiotic 10-14 days, monitoring of electrolytes

Brain Abscess, subdural emphyema, epidural abscess

Most common pathogen : staphylococcal infection

Diagnosis : clinically and imaging (CT-Scan & MRI)
Management : medical and surgical (referral to neurosurgeon)

Kaluskar SK. Complications in Endoscopic Sinus Surgery.Jaypee Brothers.2002

30

Perioperative and Delayed

Postoperative Complications
Haemorrhage
Adhesions
Infection
Osteitis
Crusting
Recirculation of mucus
Mucus cysts
Epiphora
Kaluskar SK. Complications in Endoscopic Sinus Surgery.Jaypee Brothers.2002

31

Haemorrhage
Reactionary haemorrhage first 24 hours of the operation
Secondary haemorrhage after five to six days following the
operation
Must have proper nasal packing or with Merocel pack

Adhesions or synaechia

Develop when two opposing raw mucosal surfaces remain in

contact for some time in the postoperative period.

Predisposing factors for the formation of adhesions :

Extensive surgery with tearing of the mucous membrane.
Unnecessary trauma to the mucous membrane during operation.
Inability to remove crusts, blood clots, thick secretions in the
postopperative period
Patient neglects postoperative attendance.
High deviated septum not corrected at the time of operation.
Kaluskar SK. Complications in Endoscopic Sinus Surgery.Jaypee Brothers.2002

32

Infection
Infection may develop after an upper respiratory tract infection.
Prolonged packing in the nose is known to harbour Staphylococcus
Aureus Toxic Shock Syndrome (high fever, rash, hypotension, GI tract
symptoms, muscular & renal symptoms
Management removal of packs, antibiotics, fluids, vasopressor.

Osteitis

If the excessive mucous membrane is removed at the time of operation

and the underlying bone is exposed, this may result in chronic osteitis.
Should not leave any loose bone in the nasal cavity or in the sinuses.
Management removal of infected sequstrated bones, antibiotics,

Crusting
Frequent cavity care is important to so that patient does not develop
secondary infection in the cavity. remove these crusts

Recirculation of Mucus
The natural and accessory ostium has not been connected
The mucus drains out of the natural ostium but reenters through the
accessory ostium into the sinus
Kaluskar SK. Complications in Endoscopic Sinus Surgery.Jaypee Brothers.2002

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Revision Endoscopic Sinus Surgery

Success rate of ESS 76-98%. BUT failure rate
2-24% and Revision Endoscopic Sinus Surgery
(RESS) is needed
Performed by experienced surgeons
The problems in RESS :
Distorted surgical anatomy
Excessive scar tissue
Chronically congested and edematous mucous membrane
further resulting excessive bleeding
Higher incidence of complication due to poor visualization
of surgical landmark

Kaluskar SK. Complications in Endoscopic Sinus Surgery.Jaypee Brothers.2002

35

HINTS for Endoscopic Sinus Surgery

In the Operating Room Before starting the operation:
Never be tempted to operate without the CT scans.
Do not operate without the patients records.
Take your time. Being in a hurry may mean that you forget
something on your checklist, that you do not give enough time for the
topical decongestant to work,
It is worth taking time to show that you appreciate the anesthetist
and the nursing and supporting staff.
Optimize your operating conditions by maximizing preoperative
medical treatment.
Anesthetists
Goals. Hints to reduce bleeding:
A smooth induction and anesthetic
Maintain blood pressure (MAP 70-75), Bradycardia lowers cardiac
output and bleeding.
Avoid other methods of lowering the blood pressure, such as volatile
agents, as this will result in peripheral vasodilatation and more
bleeding.

Kaluskar SK. Complications in

Endoscopic Sinus Surgery.Jaypee
Brothers.2002

36

Hightlight
There are no easy sinus operations.
Practical knowledge of surgical anatomy correlated with CTScan is most important in avoiding complications.
All sinus procedures have common minor complications that
resolve in most cases.
Major complications in sinus surgery are rare; however, when
they occur they often are catastrophic.
Revision Endoscopic Sinus Surgery is performed by
experienced surgeons

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THANK YOU

38