TABLE 24–1. Anatomical Variations Associated with Higher Risk of Complications from ESS
Note. AEA: anterior ethmoid artery; ESS: endoscopic sinus surgery; ICA: internal carotid artery; PEA: posterior ethmoid artery
• Absence of computed tomography (CT) scan in operating room at time of surgery; considered grounds for malpractice
• Calibration errors with image guidance
• Loss of visualization and poor surgical field
• Failure to identify complications in a timely manner
History and Physical Examination
• Appropriate patient selection for surgery after optimal medical management has failed
• Evaluation for extent of disease, prior craniofacial trauma, surgical history including previous ESS, ocular history, and bleeding risk
Imaging Studies
• Review triplanar (axial, coronal, sagittal) CT images for degree and distribution of disease, sinus development, key surgical landmarks, and high-risk anatomical variations
Counseling
• Provide informed consent to all patients undergoing ESS; discuss complication rates of orbital, neurological, and vascular injuries.
• Review potential complications of ancillary procedures, which may be performed to gain better endoscopic access to diseased sinonasal structures.
1. Septoplasty: septal perforation, septal abscess, septal deformities
2. Inferior turbinate resection: crusting, bleeding, empty nose syndrome
Image Guidance
• Indications for image-guided ESS
1. Revision sinus surgery
2. Distorted anatomy
3. Frontal, posterior ethmoid, or sphenoid sinus disease
4. Disease involving skull base, orbit, optic nerve, or carotid artery
5. Presence of CSF rhinorrhea, encephalocele, or other skull base defects
6. Benign or malignant tumors
• Confirm accurate image guidance calibration using known bony anatomic landmarks.
Surgical Technique
• Optimal visualization with adequate exposure
• Meticulous dissection and tissue handling
• Lamina papyracea and skull base are key anatomic landmarks to prevent orbital and neurological injuries, respectively.
• Careful use of powered instruments, such as the tissue shaver, with full visualization of the cutting edge away from key skull base and orbital structures
• Minimal routine use of nasal packing
Observation
• If there is concern about orbital or skull base injury, monitor patient in hospital with serial ocular and neurological examinations.
• Educate patient, family, and nursing staff about clinical presentation of ESS-related complications.
Postoperative Care
• Nasal hygiene (nasal saline spray and irrigation) and in-office endoscopic sinonasal debridement to prevent obstruction from adhesions and to decrease clot/crust burden
• Long-term medical treatment of chronic sinusitis +/− nasal polyposis to prevent disease recurrence after ESS
ORBITAL COMPLICATIONS OF ENDOSCOPIC SINUS SURGERY
Etiology
• Topical or injectable local anesthesia causes nasociliary ganglion block
• Loss of corneal reflex with unequal pupillary sizes
• Loss of accommodation
• Loss of sensation over tip of nose
• No associated conjunctival chemosis, proptosis, or globe firmness
Management
• Self-limited; resolves in several hours
• Monitor with serial ocular examinations until resolution of symptoms
Etiology
• May occur during maxillary antrostomy, ethmoidectomy, and/or frontal sinus surgery
Presentation
• Ranges from no symptoms to mild periorbital ecchymosis, orbital emphysema, or retrobulbar hematoma
Prevention
• Preoperative review of CT scan for:
1. Dehiscent lamina papyracea from previous surgery, polypoid disease, fungal rhinosinusitis, or sinus mucocele
2. Hypoplastic maxillary sinus or silent sinus syndrome where the uncinate process is lateralized and tightly adherent to the orbit with a thin/absent lamina papyracea
• Intermittent intraoperative evaluation for lamina papyracea injury
1. Bulb press test: simultaneous external eye palpation and endoscopic visualization of lamina papyracea to assess for periorbita and/or orbital fat exposure
2. “Fat float” test: historically described; if positive, be aware of risk of extraocular muscle injury and intraorbital bleeding as well
Management
• Avoid further manipulation of exposed tissues if lamina papyracea is penetrated.
• Do not remove any exposed periorbita and/or orbital fat.
1. Nasal packing may push through a dehiscent lamina papyracea into the orbit and cause increased intraocular pressure.
2. If bleeding occurs, nasal packing prevents drainage of blood with subsequent intraorbital accumulation.
• Perform serial ocular examinations postoperatively to monitor for evolution of lid edema, ecchymosis, chemosis, visual changes, pupillary changes, and/or proptosis.
• Prevent sudden increase in intraocular pressure (IOP), which occurs with straining, vomiting, coughing, and nose blowing.
Retrobulbar (Postseptal) Hematoma
Etiology
• Venous (slow) hematoma: entrance through the lamina papyracea +/− periorbita/orbital fat with injury to orbital veins supplying these structures
• Arterial (fast) hematoma: injury to anterior ethmoid artery adjacent to the lamina papyracea with subsequent vessel retraction into orbit; very rarely occurs with posterior ethmoid artery injury
• Blood accumulation into retrobulbar space causes increased IOP in range of 30 to 40 mmHg.
• Increased IOP compromises optic nerve perfusion within minutes.
• Must differentiate from a periorbital (preseptal) hematoma.
1. Often due to injury of angular vessels from needle injection
2. Presents with more diffuse eyelid edema, darker ecchymosis, and more significant orbital emphysema
3. No conjunctival chemosis, proptosis, pupillary changes, and visual changes
4. Will resolve spontaneously; monitor with serial ocular examinations
Presentation
• Eyelid ecchymosis and edema
• Conjunctival chemosis, proptosis, globe firmness, pupillary changes including mydriasis and non-reactive pupil with afferent pupillary defect (APD)
• Blindness that can occur within:.
1. 60 to 90 minutes after venous injury
2. 15 to 30 minutes after arterial injury
• Venous retrobulbar hematoma may not develop for 24 to 48 hours after surgery.
• Drape eyes into operative field and cover with transparent tape to allow for regular inspection and palpation throughout surgery.
• Perform intermittent bulb press test (see previous).
• Proceed with immediate management if there is sudden proptosis, globe firmness, and/or pupillary changes.
Management
Conservative Management
• Elevate head of bed
• Remove nasal packing
• Initiate gentle orbital massage to redistribute intraocular blood and allow for hematoma evacuation through the nose
• Measure IOP using a tonometer
1. Normal: 10 to 20 mm Hg
2. Elevated: 30 to 40 mmHg
3. Have a low threshold for investigating borderline reading since general anesthesia decreases IOP, thus masking presence of elevated pressure
• If a tonometer is not immediately available in operating room, obtain urgent intraoperative ophthalmology evaluation while proceeding with further management.
• Do not delay further management while awaiting IOP measurements and/or ophthalmology consultation; these interventions are not necessary when clinical examination is concerning for an expanding retrobulbar hematoma
• If there is persistent proptosis, globe firmness, APD, and/or IOP is greater than 40 mmHg despite conservative measures, proceed with immediate surgical intervention and ancillary medical management
Surgical Management
• Perform a lateral canthotomy-cantholysis
1. Lateral canthotomy: make a 1 to 1.5 cm horizontal incision through the lateral canthus followed by dissection through the canthal soft tissue down to the lateral orbital rim
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