Complications of Sinus Surgery Sari
Complications of Sinus Surgery Sari
Complications of Sinus Surgery Sari
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.
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
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
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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
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
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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
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
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COMPLICATIONS
SINUS SURGERY
Vascular
injury
Nerve
injury
Facial
dissorder
s
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
Stankiewics JA. Complications of Sinus Surgery in Bailey, BJ.; Johnson JT.; Newlands SD.; Head and
Neck Surgery Otolaryngology 5th edition 2014.
During Operation
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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
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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
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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
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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
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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
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25
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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
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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
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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
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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
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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
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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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
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