Preoperative Phase

Risk mitigation begins with appropriate selection of patients for surgery. It is incumbent on the surgeon to establish a definitive diagnosis of chronic rhinosinusitis (CRS) and to ensure that patients have exhausted nonsurgical options before surgery is offered. Diagnostic criteria and evidence-based treatment guidelines for CRS have been established by American, Canadian, and European Otolaryngology societies, among others.

There are strong data supporting the benefits of ESS as compared with continued medical therapy in patients with CRS. However, some symptoms may be less responsive to surgery than others, and preoperative counseling should establish realistic expectations for the potential benefits in any given patient. For example, headache or sinus pressure may be less responsive to surgery than other symptoms of CRS. Approximately 50% of patients with migraines are misdiagnosed as having sinus headaches, and thus, sinus surgery performed for headache may be less effective because the underlying cause of the headache has not been correctly diagnosed. Further, in those patients without migraine, improvement in sinus pressure after ESS is difficult to predict. Other predictors of a less robust response to surgery may include a history of previous surgery, peripheral eosinophilia, eosinophilic mucin, advanced age, or aspirin-exacerbated respiratory disease.

A detailed preoperative discussion regarding potential complications, expected benefits, alternatives, and details of the postoperative recovery is prudent. The informed consent process legally mandates the surgeon to discuss the limitations and benefits of all medically reasonable alternatives, as well as to counsel the patient on the life-threatening and commonly encountered risks (those that occur with a frequency >1%). This discussion should be held during a detailed, unhurried preoperative session; it has been reported that 3 physician attributes increase patients’ likelihood to seek litigation: (1) poor communication and interpersonal skills, (2) withholding of information, and (3) perceptions that the surgeon is rushed or uninterested.

Next, a careful review of the patient’s surgical anatomy is a critical component of preoperative planning. The sinonasal anatomy is complex, encompassing critically important neurologic, vascular, and special sensory structures. Anatomic landmarks may be altered by the disease process itself or from previous surgery and are often highly variable from patient to patient ( Fig. 1 ). Anatomic variations and spatial relationships are patient-specific and mandate a comprehensive preoperative assessment. Computed tomographic (CT) scans provide an essential roadmap for surgical dissection and are preferentially obtained without contrast using a multidetector protocol in an axial plane at 0.625- to 1.25-mm slice thickness, with sagittal and coronal reformatting. As cone beam imaging technology becomes more refined and commonplace, satisfactory triplanar point-of-care imaging can be achieved in the office setting using upright, seated cone beam CT scanners.

Endoscopic view of right-sided meningocele ( star ) of ethmoid skull base, which if unrecognized could be inadvertently opened causing a CSF leak.

Preoperative review of the CT scan is best done in a systematic fashion, taking care to note not only the distribution of mucosal disease but also anatomic variations that could increase the risk of intraoperative complications. Tewfik and Wormald proposed a useful standardized preoperative radiographic checklist, which can be easily and efficiently incorporated into the routine preoperative assessment ( Box 2 ). Critical findings may include an atelectatic uncinate process, low-lying ethmoid skull base, deep olfactory groove, frontal cells, sphenoethmoid cells, bony dehiscences of the lamina papyracea or skull base, or exposed ethmoid arteries. Examples of notable CT findings are highlighted in Figs. 2 and 3 . In Fig. 4 , a large Onodi cell places the left optic nerve at elevated risk of iatrogenic injury. By identifying areas of potential risk preoperatively, one can develop a surgical plan to anticipate and safely manage these high-risk areas without compromising the surgical result.

CT of the paranasal sinuses triplanar view demonstrating deep lateral lamella with an asymmetric slope ( crosshairs ). A deeper lateral lamella increases the risk for iatrogenic CSF leak along the medial ethmoid skull base.

CT sinuses demonstrating a left posterior superior ethmoid cell (Onodi) containing a dehiscent optic nerve ( arrow ). If unrecognized preoperatively, this cell could be entered with consequent injury to the the optic canal resulting in a devastating ophthalmologic complication.

Endoscopic view left sphenoid (S) and large posterior superior ethmoid cell (Onodi, O) with dehiscent optic nerve ( arrow ) traversing toward chiasm.

Another critical step in preoperative preparation is a self-assessment of one’s surgical experience and abilities relative to the case at hand. Keerl and colleagues demonstrated that the incidence of complications was inversely proportional to surgeon experience, with a significant drop-off of surgical complications after a surgeon had performed 180 endoscopic sinus surgeries. Familiarity with surgical technique and endoscopic sinus anatomy can be enhanced by participation in cadaveric dissection courses, study of surgical demonstration videos, and attendance at educational conferences.

Finally, careful management of a patient’s medical comorbidities is essential to ensuring a smooth surgery. For example, uncontrolled hypertension, unrecognized use of nonsteroidal anti-inflammatory drugs or anticoagulants, or poorly controlled asthma could affect a patient’s suitability for surgery or anesthesia. Consultation with a patient’s primary care physician or medical specialists may be necessary to optimize a patient’s medical condition in preparation for surgery.

Intraoperative Phase

During sinus surgery, the surgeon should maintain a constant vigilance of the broader surgical environment and should engage all members of the operating room staff in open, direct communication and participation in creating a safe environment. Surgical timeouts at the beginning of the case help to set the tone for a collaborative team approach. Nurses and surgical assistants should be encouraged to raise concerns if unusual findings are observed, and close communication between the surgeon and anesthesiologist is essential.

Intraoperative avoidance of complications depends first and foremost on excellent visualization during ESS. Complications occur with greater frequency when visualization is compromised, and inadequate hemostasis is the most common reason for poor visualization. Strategies for improving the surgical field begin with positioning the patient with the head elevated. Reverse Trendelenberg or beach chair positioning with the head of bed elevated up to 30° can significantly reduce venous congestion in the nose without compromising cerebral perfusion. In a randomized blinded trial, operating with the head of bed elevated at 20° offered optimized endoscopic visualization and lower blood loss than lesser degrees of head elevation.

Mucosal injections of the lateral nasal wall and middle turbinate with lidocaine-epinephrine have long been endorsed as beneficial for reducing intraoperative bleeding. Although such injections are effective as a regional anesthetic block for endoscopic procedures performed under local anesthesia, their efficacy in reducing bleeding is less certain. A randomized study comparing lateral nasal wall injections of lidocaine-epinephrine versus saline showed no difference in blood loss between the 2 groups.

Topical epinephrine (concentration of 1:1000) applied on pledgets can provide effective mucosal decongestion and hemostasis, both at the start of surgery and throughout the procedure. The use of topical epinephrine has been supported by a systematic review, but extreme caution must be taken to avoid inadvertent injection of epinephrine, which can have disastrous adverse effects if delivered systemically. Staining the epinephrine with fluorescein or methylene blue can help to distinguish topical epinephrine from injectable medications, and explicit communication with operating room staff is essential regarding its careful handling.

Warm saline irrigations have been advocated as a hemostatic measure for endoscopic sinus and skull base surgery. Saline delivered at a temperature of 49°C demonstrated a beneficial impact on surgical field for cases lasting longer than 2 hours.

The types of anesthetic and degree of hemodynamic control have also been suggested to influence intraoperative blood loss and visualization. Several studies have suggested that total intravenous anesthesia reduces peripheral vasodilation and improves the quality of the surgical field, whereas other reports have found no improvement; therefore, further investigation is warranted. Active maintenance of relative hypotension (mean arterial pressure <70 mm Hg) and bradycardia (<60 beats per minute) as tolerated by the patient can also minimize excessive bleeding. Close communication between the surgeon and the anesthesiologist is critical to achieve these goals.

Careful use of surgical instrumentation during dissection of the sinuses is essential in prevention of intraoperative complications. Right-handed surgeons tend to have a higher rate of complications when operating in the right nasal cavity compared with the left, owing to inherent biomechanics and angulations. The use of through-cutting forceps allows removal of bony partitions without undue traction on delicate areas of the bony skull base or orbital wall. In addition, through-cutting instruments facilitate mucosal preservation, which can minimize the risk of neo-osteogenesis and cicatricial scarring, especially in narrow areas such as the frontal recess. Powered instrumentation such as the shaver can greatly facilitate the speed of surgical dissection but if used improperly can quickly violate vital structures. In particular, care must be taken during shaver dissection along the skull base and medial orbital wall. The shaver has a windowed double-barreled rotating surface that uses high-powered suction to bring tissue within its reach. The oscillating cutting surfaces coapt at a high rate and tissue is quickly removed. Thus, over the course of mere seconds, a small unrecognized dural violation can quickly escalate to brain injury, and a periorbital transgression can instantaneously result in extraocular muscle transection (most typically the medial rectus). To prevent shaver complications, it is imperative for the surgeon to position the working window of the blade tip within direct endoscopic view during tissue removal rather than plunging the tip blindly into the surgical field. The strength of the wall suction should also be carefully monitored and an appropriate level of suction should be regulated. Lower oscillating speeds (1000–1500 rpm) theoretically have longer open window times for tissue removal than higher speeds (5000 rpm), and appropriate considerations should thus be given to the impact of oscillation speed on aggressiveness of tissue removal.

Image-guided navigation (IGN) is now a commonplace technology that provides precise intraoperative positioning information (±2 mm) within the complex sinonasal anatomy. More surgeons and centers have adopted this technology into routine surgical practice, whereas others selectively use it in revision or complex cases. Initially, several studies suggested that IGN did not reduce overall complication rates or major life-threatening events (mostly attributed to inadequate powering of such studies to detect a significant change in incidence of an otherwise rare event). However, a recent systematic review revealed statistically significant reduced complication rates when IGN was used. It is important to appreciate that IGN offers localization based solely on a static set of preoperative images. As surgery proceeds and anatomy is altered, the gap between the IGN data set and actual patient anatomy widens. Furthermore, as with any technology, unforeseen technical glitches may affect the usability or accuracy of the IGN. Thus, the surgeon should not rely heavily on IGN or use IGN to compensate for a less-than-optimal knowledge of endoscopic anatomy. It may be best to consider IGN as an adjunctive tool that confirms judgments about anatomy and supplements intraoperative decision making, as opposed to guiding the surgeon. The surgeon, not the technology, steers the course of the surgical procedure. Further discernment must be used when using powered instruments as navigating probes, which are now available with the most recent generation of IGN. There may be a tendency for the operating surgeon to shift their visual attention away from the endoscopic field to the navigating radiographic monitor during active removal of tissue; the potential perils of errant shaver use have already been covered.

An exhaustive review of strategies regarding the nuances of surgical dissection is beyond the scope of this publication; however, a few technical points are worth mentioning. First, instruments and scopes must always be placed meticulously in the nose to avoid inadvertent collateral mucosal injury. Lacerations of mucosa that occur proximally in the nose can bleed down to the area of surgical dissection and obscure the field with oozing blood. Traumatic injury to the middle turbinate mucosa by indiscriminate passage of scopes and instruments in and out of the middle meatus can predispose to adhesion formation between the middle turbinate and the lateral nasal wall. Lateralization of the middle turbinate (or its remnant) can result in frontal outflow obstruction with consequent frontal sinusitis or suboptimal views of the ethmoid and maxillary sinuses. When a traumatized or floppy middle turbinate is recognized, turbinate lateralization can be prevented by suturing or scarifying the turbinate to the nasal septum, placing a middle meatal spacer or stent (eg, bioabsorbable implant, foam, packing), or even partially resecting the middle turbinate.

If the surgeon reaches a point at which the surgical field becomes inscrutable due to bleeding, scarring, or edema, or if the surgeon becomes disoriented to surgical landmarks, the best course of action may be to terminate the procedure. The surgeon can return another day after bleeding and edema have subsided, or it may be appropriate to refer to a colleague with advanced training or more experience.

Lastly, at the conclusion of surgery, a careful reinspection of all surgical sites should occur to confirm hemostasis. Bipolar cautery can be used to selectively control any bleeding arterial vessel. Although packing is not necessary to prevent postoperative hemorrhage, biomaterials such as chitosan and microporous polysaccharide hemospheres (potato starch) can be placed electively to promote hemostasis. Postoperative instructions to avoid nose blowing and nasal manipulation are provided in written format. The patient is encouraged to perform open mouth sneezing and refrain from vigorous activity or lifting greater than 10 lb (∼5 kg) until the first postoperative office visit.

Postoperative Phase

The postoperative phase of care is important to recognize any late-manifesting surgical complications and to anticipate and prevent future potential complications related to suboptimal wound healing. At the first visit, a routine series of questions should be asked of the patient to rule out occult CSF leak, orbital injury, or arterial bleeding that may not have been recognized in the immediate perioperative period. After ascertaining that no acute complications have occurred, the surgeon can focus on interventions to promote satisfactory healing.

Although postoperative debridement is widely performed and generally thought to be beneficial, the literature regarding postoperative debridement has shown conflicting outcomes. Early studies suggested there was no benefit in endoscopic or symptom scores with early postoperative debridement; however, these studies were criticized for being underpowered and poorly designed. An evidence-based review by Rudmik and colleagues reported level I evidence that early (1 week) postoperative debridement resulted in reduced crusting and scarring within the middle meatuses. However, the benefit of routine subsequent debridement is unknown. When early adhesions are identified, division of scar bands in the office setting is an appropriate intervention to prevent progression of scarring. On occasion, placement of spacers at the time of scar division may be necessary to prevent synechia recurrence.

The optimal postoperative medical regimen after ESS has not been conclusively determined. Grade B evidence exists for the use of postoperative oral antibiotics to improve symptom and endoscopic scores in the first few weeks after ESS; however, these findings are temporary, and in controlled studies, there was no difference in outcome between treated and nontreated cohorts after 6 months. Likewise, postoperative oral corticosteroids have been shown to improve endoscopic outcomes but only in the early postoperative period. In an evidence-based review by Rudmik and Smith, a recommendation was made for early saline irrigations, topical steroid sprays, and debridement, whereas oral antibiotics and steroids, steroid-impregnated saline irrigations, and drug-eluting stents were considered optional.