niyada

Orbital hematoma

-Ophthalmologist consultation

-Orbital massage,Off packing

-Manitol 1-2 g/Kg IV

-Lateral canthotomy

-Orbital decompression

Control bleeding

-Optic nerve decompression

Observe ,Bed rest sedation F/U

success

FAIL

Observe : IOP,VA,Pupil reflex proptosisRecovery :

IOP 2-3 hrs. (10-21 mm Hg.)

Light perception within 24 hrs.

Pupillary reflex : 24-48 hrs.

Prevention

• Pre-op CT scan evaluate unusual orbit anatomy

• Both eyes should be include in surgical field

• Preferred LA due to pain response

• Identify ant. ethmoidal artery that locate on posterior to ant. wall of EB

Prevention

• Palpate and compress the orbit when suspected LP injury

Blindness

• Temporary : transient increase IOP

• Permanent : directed optic nerve injury and prolonged IOP (60-90 min.)

Blindness

• Optic nerve injury may be in – Orbit– Sphenoid sinus – Sphenoethmoidal cell (Onodi cell)

Blindness

• Optic canal– 98% at superolateral of sphenoid sinus – 4-12% bony dehiscence– 78% bony covering <0.5 mm. thickness– 65% of the optic nerve in Asians was present i

n the posterior ethmoid

Blindness

• Symptoms & signs– Severe pain– Acute VA drop– Pupil dilate and not react to light– Orbital hemorrhage

Blindness

• Treatment as orbital hemorrhage– Ophthalmologic consultation– Remove nasal packing– Systemic steroid (controversy)

• Dexamethasone 1 mg/kg then 0.5 mg/kg q 6 hr

– Optic nerve decompression if failure to conservation

Prevention

• Beware Intraoperation – Post. ethmoid sinus– Sphenoid sinus– Onodi cell

Diplopia

• Damage to ocular musculature or its nerve or vascular supply

• Temporary due to edema or local anesthesia

• Most common are medial rectus and superior oblique

• MR closed to LP within 2-3 mm.

• Break LP and pulling orbital content with a microdebrider

Diplopia

• Symptoms & Signs• Significant pain• Diplopia • Limitation of eye movement• Subconjunctival hemorrhage at medial side • Force duction test

Diplopia

Diplopia

• Urgent MRI evaluate muscle damage

• Immediate repair by ophthalmologist

• Poor prognosis

• Prevent as orbital hematoma

Nasolacrimal duct injury

• Cause– Over opening of ant. edge of the maxillary sinus ostium

• Post-op epiphora immediately or 1-2 wk. post-op• Occult injury about 15%

Nasolacrimal duct injury

• DCR in symptomatic patient

DCR : Dacryocystorhinostomy

Prevention

• Not performed anterior to ant. margin of MT

• Bone covering NLD is harder

Prevention

• Agger nasi cell is closed to lacrimal sac

Subcutaneous emphysema

• Small fracture of LP• Positive pressure via mask ventilation• Cough, vomit, or blow nose• Periorbital subcutaneous crepitation• Spontaneous resolve in 7-10 days

Intracranial complications

Intracranial complications

• CSF fistula (most common)• Meningitis • Brain abscess• ICH• Brain injury• Pneumocephalus

CSF fistula

• Incidence : 1 in every 200 to 500 cases

• Risk factors– Performed under GA

due to loss of pain at skull base

– Revision case– Extensive disease

CSF fistula

• Danger areas– Fovea ethmoidalis– Cribiform plate

CSF fistula

• Danger areas– Roof of ethmoid

and sphenoid– Area posterior to

ant. ethmoidal artery

Olfactory GrooveOlfactory Groove

Keros Classification

CSF fistula

• Onset – Intra-op leakage– Delayed post-op

leakage

• Occult CSF fistula about 2.9%

Intra-op leakage

• Diagnosis– Washout sign– Compress bilateral IJN

10-12 sec.

(Queckenstedt-stookey test)

Intra-op leakage

• IT fluorescine– Most popular– No FDA approved– 0.1 ml. of 10% fluorescine

(IV prep.) + 10 ml. of CSF– Infused slowly >30 min.– Grand Mal seizure : dose

related complication

Treatment

• Repaired immediately– Soft tissue patch : nasal mucosa, temporalis

fascia, fat, muscle, or dermal graft– Bone or cartilage bridge– Fibrin glue

Treatment

• Defect < 1 cm. – Mucosal graft or fascia

• Defect > 1 cm.– Solid graft

Delayed post-op leakage

• Diagnosis

– Days, weeks, months, or years after procedure

– Clear intermittent rhinorrhea

– Associated lean forward position

Delayed post-op leakage

• Diagnosis– Hyposmia or headache– Halo sign : clear ring , central bloody spot– Endoscopic exam

Delayed post-op leakage

• Confirmed CSF leakage– Glucose oxidase test

strip : high false +ve and false -ve

– Beta-2 transferrin : most specific

– Radionuclide cisternography : I 131, Tc 99, and In 111

Delayed post-op leakage

• Locate leakage site – Endoscopic exam– High resolution CT– IT fluorescein– CT cisternography

(metrizamide)– MR cisternography T2-

weighted with fat suppression

Treatment

• Small leakage often close spontaneously

• Conservative for 1-2 wk.

• Surgery when unresponsive

• Mostly need surgical intervention

Conservative treatment

• Strict bed rest

• Head elevation

• Stool softener

• Avoid cough, sneezing, nose blowing, and straining

• Lumbar drainage

Lumbar drainage

• Draining rate = 5-10 ml/hr

• Complication – Pneumocephalus : low ICP– Meningitis

• Prophylaxis ATB in case of sinusitis• Unwarranted prophylaxis ATB in traumatic case

• ATB prevent cellulitis at puncture site

Surgical treatment

• Transcranial approach

• Extracranial approach– Trans-sinus external approach– Endoscopic transnasal approach

Transcranial approach

• Craniotomy

• Tissue graft + fibrin glue– Fascia lata– Muscle plugs– Pedicle galeal flap

Transcranial approach

• Advantage– Multiple areas– Identify leakage site– Associated intracranial problem

• Disadvantage– Morbidity & mortality– Prolong hospital stay– Limited sphenoid sinus approach

Transcranial approach

• Morbidity– Brain compression – Hematoma– Seizure– Anosmia

Endoscopic transnasal approach

• Advantage – Excellent visualization– Well tolerated– Excellent outcome (85-90%)

Endoscopic transnasal approach

• IT fluorescine locate leakage site

• Free graft is preferable (low failure rate)

• Underlayer is ideal

A : duraB : fascial autograftC : bone/cartilageD : fascial autograftE : mucosal free autograftF : surgical sealant

Endoscopic transnasal approach

• Mucosal graft should never placed intracranially (intracranial mucocele)

• Nasal packing – Absorbable packing is placed adjacent the

graft– Non-absorbable packing support beneath

• Excellent access to ethmoid roof, cribiform plate, and sphenoid sinus

Endoscopic transnasal approach

Endoscopic transnasal approach

• Post-op care– Bed rest – Anti -staphylococcal ATB– Monitor intracranial complication in first 24 hr.– CSF drainage continued for 4-5 days– Avoid strenuous activity, sneezing, and cough

for 6 wks.

Direct brain injury

• Wide spectrum– Injury to dura– SAH– ICH– Secondary

meningoencephalitis

• Poor prognosis and high mortality

Direct brain injury

• Frontal lobe is common site

• Treatment – Immediate rhinological closure– Consult neurosurgeon

Prevention

• Preferred LA • More yellow color at

ethmoid roof• Attention at ant.

ethmoid artery enter ethmoid sinus

• Keep lateral to MT

Synechiae

• Incidence : 1.2-8%• 15-20% symptomatic

and need treatment• Location : raw surface

between middle turbinate and lateral nasal

• Treatment : lysis synechiae and silastis spacer for 4 wks.

• Prevention – Minimal injury to surrounded mucosa– Preserve mucosa of MT– Serial post-op cleanning– Silastic stent

Synechiae

Other complications

• Asthma exacerbation– Usually occur in LA

• Infection– Sinus surgery + septorhinoplasty risk to

severe infection

• Mucocele – Long term sequelae

Conclusion

• Prevention is the best

• Pre-op assessment and decision to operate

• Knowledge of anatomy relationship and its variation

• Informed about complication to the patient

Conclusion

• Adequate training

• CT-scan

• Expose the eye during surgery

• Do not blind dissection

• Early detection and treatment