Complications in endoscopic sinus surgery

Process Steps

Good preparation

Study CT

Be conservative

Deal with it

Assistant professor Ahmed Al-ZubiadiFIBMS.FEBORL.DOHNS

The shrine of Imam Ali Bin Abi Talib

College of medicine Kufa university

“To avoid injuring your patient” Hippocrates(460BC)

• Orbit • Skull base • Anterior ethmoidal artery

Know your enemy

• Anatomical considerations of orbit:A. Dehiscencent in cranial quarter of lamina papyracea in 5.6%B. you may penetrate lamina papyracea in tow sites

• Anatomical consideration of skull baseA. Low skull baseB. Curved posterior skull base.C. Sphenoethmoidal cell.

Grab the bars tightlydo not cross the limits

• Anatomical consideration of anterior ethmoidal artery:A. This is the superior limit of ethmoidectomyB. When see it mean we reached the SB.C. Try to preserve upper part of bulla ethmoidalis to the last of ethmodectomy.

Prevention of complications

• Start even before you see your patientA. Cadaveric dissectionB. Diagnostic endoscopy (100)C. Familial with imaging( CLOSE)D. Use the proper instrument in proper place

CLOSE

CCRIBRFORM PLATE

OONODI

SSKULL BASE

LLAMINA

PAPYRACEA

EETHMOIDAL

ARTERY

What you should consider When see your patient for the first time ?

• Extent of disease• Revision surgery• Time for medical treatment

When you see your patient in theater

• Fixed anatomical landmarks1. Middle turbinate.2. Uncinate process.3. Natural ostium of maxillary sinus.4. Bulla ethmoidalis.5. Upper border of inferior turbinate.

Middle turbinate

It is mandatory for endoscopic surgeon to work strictly in plane lateral to lateral part of

MT and medial to lamina papyracea

Uncinate process

1. 2 areas at risk in uncinectomy(orbit &NLD)

2. Be aware of atelactetic UP3. Swing door technique

Natural ostium of maxillary sinus

• Should be identified early in surgery.• Never work in plane superolateral to it to avoid orbit entery.• Very helpful as landmark if middle turbinate not present.

Bulla ethmoidalis

• Never remove bulla before identification of maxillary sinus ostium• Intact bulla technique for frontal recess

Upper border of inferior turbinate

• Useful when middle turbinate is lost or distorted by previous surgery.

Classification of complications

• Minor 1. Orbital haematoma2. Orbital surgical emphysema.3. NLD injury4. SynechiaeMajor 5. Haemorrhage.6. Blindness7. Injury to internal carotid artery.8. CSF rhinorrhea9. Pneumocephalus10. Brain abscess11. Death

Situations and solutions

• Clinical scenario: a 37 years old patient is undergoing FESS for CRS that have failed to respond to maximum medical therapy . Ct scan confirms wide spread mucosal changes and absence of anatomical variation that might increase the risk of complications. During dissection in the posterior ethmoids, there is unexpected bleeding and the operative visualization is difficult . A stream of clear fluid , highly suggestive of CSF, is observed in the field.

What do I do now ?

What to do if I cannot find the leak?

If I I find the site of injury, how do I repair it?

Do I need fluorescein?

Do I need lumber drain?

Do I need to give antibiotics ?

Can I manage the leak conservatively ?

What do I do post operatively ?

Do I need CT scan ?

What do I tell the patient ?

Clinical scenario

• 45 yeard old smoker man had been undergo endoscopic sinus surgery for chronic rhinosinusitis with nasal polyposis .

• Ct scan shows extensive polyposis on righ side and lesser changes on left side • Surgery done after 2 wks treatment with (doxidar 100mg/day , mometasone

nasal spry once/day and isonic irrigation of nasal cavity

What are the risk factor for this man for orbital complication ?

What are the measures that should be taken preoperatively and perioperativly to decrease the risk of complication

How you detect orbital haematoma

What you should do if you expose orbital fat ?

How you mange this situation