Major complications during endoscopic sinus surgery are rare and occur in 0.36% to 3.1% of patients. Postoperative hemorrhage accounts for 23% to 39% of complications. Despite being rare, major hemorrhage can be serious for the patient. This article discusses hemorrhagic complications during and following endoscopic sinus surgery, focusing on a review of the surgical anatomy, common pitfalls to avoid, preventative measures, and management of certain catastrophic complications for which preparedness can mean the difference between life and death.
Key points
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Vascular anatomy of the nose and paranasal sinuses is well defined and avoiding certain pitfalls during endoscopic sinus surgery can prevent intraoperative and postoperative hemorrhage and associated complications.
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Internal carotid artery injury can be prevented by a thorough understanding of the surgical anatomy. Having a plan of action in place before such injuries can save valuable time and improve outcomes.
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Preoperative steps, including thorough history and physical, review of medications/vitamins, and preoperative steroid courses can decrease the risk of bleeding.
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Intraoperatively, total intravenous anesthesia, controlled hypotension, and positioning of the patient can reduce blood loss and improve visibility.
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Postoperatively, any patient with epistaxis should be evaluated with nasal endoscopy. Special attention should be directed to the most common sites of postoperative bleeding.
Introduction
Major complications during endoscopic sinus surgery (ESS) are rare, occurring in 0.36% to 3.1% of patients, and include severe bleeding, orbital injury, cerebral spinal fluid leak, and intracranial damage. Of this subset of patients, postoperative hemorrhage accounts for 23% to 39% of those complications. Major hemorrhage with the need for transfusion occurs rarely and occurred in only 0.76% of patients in one large review. Although rare, major hemorrhage can be serious for the patient, resulting in increased morbidity and mortality if appropriate action is not taken immediately.
This article focuses on those hemorrhagic complications during and following ESS, with attention to relevant surgical anatomy, common pitfalls leading to bleeding from major intranasal vessels, preventative measures, and management of certain catastrophic hemorrhagic complications for which preparedness can mean the difference between life and death.
Introduction
Major complications during endoscopic sinus surgery (ESS) are rare, occurring in 0.36% to 3.1% of patients, and include severe bleeding, orbital injury, cerebral spinal fluid leak, and intracranial damage. Of this subset of patients, postoperative hemorrhage accounts for 23% to 39% of those complications. Major hemorrhage with the need for transfusion occurs rarely and occurred in only 0.76% of patients in one large review. Although rare, major hemorrhage can be serious for the patient, resulting in increased morbidity and mortality if appropriate action is not taken immediately.
This article focuses on those hemorrhagic complications during and following ESS, with attention to relevant surgical anatomy, common pitfalls leading to bleeding from major intranasal vessels, preventative measures, and management of certain catastrophic hemorrhagic complications for which preparedness can mean the difference between life and death.
Vascular anatomy of the nose and sinuses
The nose and paranasal sinuses have a robust vascular supply. Much of this blood supply is derived from the external carotid system via the sphenopalatine artery (SPA). This artery exits through the sphenopalatine foramen (SPF) within the lateral nasal wall and lies within the superior meatus between the basal lamella of both the middle and superior turbinates. The SPF sits at a distance of 6 cm from the nasal sill in most patients. The artery often divides into multiple branches and can enter the nasal cavity through multiple accessory foramina. The posterior septal branch, a branch of the SPA, is most notable for its cause of post-ESS hemorrhage and is discussed in greater detail later.
Several commonly used techniques in ESS (middle turbinate resection and the creation of wide maxillary antrostomies) place the SPA and its branches at risk of injury. When performing these techniques it is best to leave a stump of the resected middle turbinate attached to the lateral nasal wall and use cautery to seal any exposed vessels. In addition, clinicians should avoid enlarging the maxillary antrostomy too far posteriorly, because the SPA exits in close proximity to the posterior maxillary sinus wall.
Endoscopic control of the SPA for epistaxis management includes performing SPA ligation/cautery, a procedure first described by Budrovich and Saetti. An incision is made in the mucosa of the lateral nasal wall roughly 1 cm anterior to the lateral insertion point of the middle turbinate. This area may also be easily accessed after creating a maxillary antrostomy. A mucoperiosteal flap is then elevated posteriorly toward the SPF with a freer elevator. One anatomic landmark that has been shown to have a fairly consistent relationship with the SPF is the crista ethmoidalis. Locating this bony eminence in the perpendicular plate of the palatine bone is helpful in aiding the surgeon locate the SPF, which lies posterior to the crista ethmoidalis in 95% of cases. In addition, Bolger and colleagues performed 22 cadaver dissections and found that the SPA exited the SPF posterior to the crista ethmoidalis in 21 of 22 cadavers. Once identified, the SPA is then clipped or cauterized with bipolar cautery. As previously stated, the anatomy of the SPA can vary and it is important to inspect the area for additional branches of the SPA exiting the lateral nasal wall via alternative foramina. Failure to find additional accessory foramina, if present, could result in inadequate control of bleeding from the region of the SPA.
The posterior septal artery is a branch of the SPA that supplies blood to the posterior nasal septum and nasal cavity. It is also the vascular pedicle on which the nasoseptal flap used for skull base reconstruction is based. The posterior septal artery runs along the inferior face of the sphenoid sinus and may be injured while creating a sphenoidotomy or when providing exposure for pituitary hypophysectomy. Bleeding from the posterior septal branch can be brisk, but is easily controlled with monopolar or bipolar cautery. Note that, with increasing performance of endoscopic skull base surgery and use of the nasoseptal flap for reconstruction, the incidence of significant epistaxis requiring intervention in the operating room is around 1.3% to 1.5% following transnasal transsphenoidal pituitary surgery.
The internal carotid artery (ICA) is intimately associated with the lateral portion of the sphenoid sinus. It is divided into the following segments: parapharyngeal, petrous, paraclival, cavernous, and supraclinoid. The intersinus septations of the sphenoid sinus often insert directly onto the carotid canal and put the ICA at risk of injury during the removal of these septations. In a well-pneumatized sphenoid sinus, the cavernous and paraclival segments of the ICA are at the greatest risk for traumatic injury. The cavernous portion of the ICA abuts the posterior lateral roof of the sphenoid sinus and is covered by a thin layer of bone. It can be dehiscent in up to 20% of people ( Fig. 1 ). Laterally in the sphenoid sinus, pneumatization of the anterior clinoid gives rise to the opticocarotid recess ( Fig. 2 ). The paraclival segment of the ICA courses along the lateral aspect of the clival recess.
Avoiding injury to the ICA when operating within the sphenoid sinus is of paramount importance. Careful review of preoperative computed tomography (CT) scans to identify when the bone overlying the ICA is either thin or dehiscent can help with surgical planning. Second, excellent knowledge of the surgical anatomy and use of known anatomic landmarks throughout the surgical procedure can help to stay safe and out of the skull base and carotid arteries. The sphenoid os can be found medial to the inferior third of the superior turbinate. It can also be located approximately 7 cm posterior to the nasal spine at a 30° angle or roughly 1.5 cm above the choana. The os also lies in the same plane as the roof of the maxillary sinus. Once identified, avoidance of ICA is performed by using a through cutting device to enlarge the os in a medial and slightly inferior direction. In addition, intraoperative navigation can be used as an adjunct to anatomic knowledge to confirm the location within the paranasal sinuses.
Injury to the ICA occurs in between 0.1% and 0.3% of ESS. The best way of preventing injury is to have a clear idea of the anatomy from thorough review of the axial CT scan, carefully localizing the true sphenoid os using reliable landmarks or surgical navigation, and opening the os in a controlled medial and inferior manner. The best preparation for this type of injury is to develop a clear plan of action. Any brisk bleeding or massive hemorrhage that develops during surgery in the sphenoid sinus should be treated as an injury to the ICA until proved otherwise. The sphenoid sinus, nose, and nasopharynx are immediately packed. Clear communication to the anesthesia team is of the utmost importance because aggressive fluid resuscitation must be instituted immediately to maintain cerebral perfusion. In general, normotension is recommended. Blood transfusion is likely to be necessary as well. The patient should be transferred to interventional radiology emergently for angiography and treatment of the injury site with balloons, coils, or stents. If balloon occlusion shows adequate cross circulation, the affected ICA can be occluded without subsequent neurologic deficit. If cross circulation provides inadequate cerebral perfusion, extraintracranial or cross-cranial vascular bypass may be warranted and neurosurgery consulted. Note that the initial packing, being performed under duress, is sometimes too tight and can compress the ICA, leading to an inability to identify the vessel on angiography. Therefore, the otolaryngologist should be present during this procedure in case the nasal packing needs to be adjusted.
In some cases, injury to the ICA is small and can easily be controlled while the patient remains hemodynamically stable. In situations such as these, the surgeon can address the injury directly with an autologous muscle patch (eg, taken from the thigh), clips, bipolar cautery, or allogenic material. In one study on a sheep model of ICA injury, autologous muscle patch and aneurysm clips outperformed other materials in survival, blood loss, and vessel patency. However, in such repairs, pseudoaneurysm may develop within a matter of weeks and therefore postoperative angiography is recommended. Despite many advances in management, the mortality of major ICA injuries remains around 17% and, with balloon occlusion, the overall complication rate is between 8% and 20%.
The anterior ethmoid artery (AEA) is a branch of the ophthalmic artery, which branches from the ICA. It provides blood to the ethmoid and frontal sinuses, anterior nasal septum, and meninges. The AEA runs along the skull base in a posterior-lateral to anterior-medial direction. It is most often attached to the skull base, but in a small number of people can be 2 to 3 mm below the skull base in its own separate mesentery, which is dehiscent in between 11.4% and 40% of individuals ( Figs. 3 and 4 ). The artery is most often found between the second and third lamellae and less often is intralamellar. Given the anatomic location, this artery is most likely to be injured during an anterior ethmoidectomy or frontal sinusotomy. Certain characteristics, including greater distance from the skull base, intralamellar location, and bony dehiscence, make the AEA more prone to injury than if it is fully covered by bone and immediately adjacent to the skull base.
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