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Complications of endoscopic sinus surgery
Am J otolqngol 12:32632&X1991
Complications of Endoscopic Sinus Surgery SALAH D. SALMAN, MD teen patients had remarkable bleeding: in two patients the bleeding was bilateral, mucosal, and severe enough to stop the surgery before all its aims were achieved. Both patients had nonsymptomatic septal deviations that made endoscopic access difficult. At present consent for septal surgery is usually obtained and a more extensive submucous resection (SMR) is done to facilitate surgery. An SMR also facilitates postoperative cleaning. In one patient a branch of the sphenopalatine artery bled and a suction cautery was successfully used. No sensory deficit along the distribution of the corresponding nerve was observed postoperatively. The 10 patients who bled 350 to 700 mL were analyzed separately: all had polyps and bilateral surgery under general anesthesia. Three had a concomitant submucous resection. Bleeding was mucosal, diffuse, and constant, necessitating packing one side and working on the other several times during the procedure. Seven of the 10 had recurrent polyps (four had one previous operation, two had two operations, and one had three operations). There were five men and five women, with an age range of 29 to 61 years. Two were smokers and two were previous smokers. Three were hypertensives under control. Four were asthmatics and one was a diabetic. None gave a history suggestive of a bleeding tendency and all bleeding studies were normal (platelet count, prothrombin time (PT), partial thromboplastin time (PTT), and bleeding time). The operative time for these 10 patients was 30 minutes to 1 hour longer than the others. This was considered a result of greater bleeding rather than its cause.
With the increasing popularity of functional endoscopic sinus surgery (FESS) attention has been directed more toward its possible serious complications. It is still appropriate to quote Masher,’ who in 1929 wrote, “in practice the ethmoid operation has proved to be one of the easiest operations with which to kill a patient.” In 1979 Freedman and Kern’ reported a 2.8% complication rate in 1,000 cases of intranasal ethmoidectomy. With the advent of the endoscopic technique, the literature on complications is increasing, illustrating the variety and seriousness of the possible complications.3-g Maniglial’ reported fatal and major complications. Buus et al” reported a case of bilateral optic nerve transection. Wigandl’ had six cases of cerebrospinal fluid (CSF) rhinorrhea that he ascribed to tears of the olfactory mucosa and leaks around the olfactory filaments. Kainz and Stammberger13 reported three cases of CSF leaks secondary to dural injury at the roof of the ethmoid labyrinth where the anterior ethmoidal artery enters the anterior cranial fossa. Kloppers4 reported three cases of orbital emphysema. The aim of this paper is to present the author’s experience with complications associated with endoscopic sinus surgery.
Significant Scarring. Adhesions that do not seem to interfere with breathing and sinus drainage are no longer treated aggressively. They may be divided in the office a few months later. Earlier treatment is unnecessary, time consuming, and may have to be repeated. Two patients had adhesions of the anterior 1 cm of one middle turbinate and the lateral wall. Both had a flaccid middle turbinate that tended to lateralize at the end of surgery. They were revised successfully when symptoms recurred. Three patients who had bilateral surgery ended up with a unilateral symptomatic stenosis of the middle meatal antrostomy. They underwent revision surgery: one of them twice. The unilaterality of the stenosis in cases of bilateral surgery suggests that the causes of scarring are local rather than systemic or constitutional.
COMPLICATIONS Table 1 lists 28 complications that occurred in 25 of the 118 patients operated on by the author between April 1988 and November 1990, an incidence of 21%. Twenty-two patients had one complication and three had two. All of them may be considered minor except, of course, the CSF leak. Bleeding during surgery averaged 95 to on the anesthesia used and the unilaterality or bilaterality of the operation [Table 2). Thir-
Bleeding.
168 mL depending
Received June 27, 1991, from the Harvard Medical School, Massachusetts Eve and Ear Infirmarv, Boston, MA. Accepted _ for publication October 9, 1991. Presented at the Triological Society, Eastern Section Meetina. Philadelphia, PA, January 31, February 2, 1990. xddress ckespondkce and reprint requests to Salah D. Salman. MD, Harvard Medical School, Massachusetts Eye and Ear Infirmary, 243 Charles St, Boston, MA 02114. Copyright 0 1991 by W.B. Saunders Company 0196-0709/91/1206-0003$5.0010
Incomplete Surgery. Surgery was stopped before all its aims were achieved in five cases: because of the absence of recognizable landmarks in two, profuse mucosal bleeding in two, and the occurrence of chest pain in the other. Patients with coronary artery disease require consultation with a cardiologist and must be eval326
327
SALAH D. SALMAN TABLE 1.
Complications
Bleeding Significant scarring Incomplete surgery Lid ecchymosis and emphysema Epiphora ? Exophthalmos CSF leak Note.
13 cases
5 cases 5 cases 2 cases 1 case 1 case
1 case
Twenty-eight complications in 25 of the 118 patients.
uated carefully to determine appropriate anesthesia. Generally, local anesthesia is less risky, and is therefore preferred, unless the patient is very anxious. Lid Ecchymosis and Emphysema. One patient who sneezed a few hours postoperatively in spite of the presence of bilateral nasal packs developed lid ecchymosis and emphysema on the right side. Both lasted for only a few days. Another patient with a bony dehiscence of the lamina papyracea and/or the lacrimal plate recognized at surgery, developed a lower lid ecchymosis soon after surgery. A few days later, she blew her nose and upper and lower lid emphysema occurred with worsening of the ecchymosis. Both conditions resolved in several days but left her with a darker colored lower lid skin that finally resolved 3 months later.
Epiphora. One patient had a revision of a unilateral ethmoidectomy and middle meatal antrostomy because of recurrent infection. She developed a recurring epiphora that is still under investigation. The cause or obstruction of the tear system has yet to be determined. ? Exophthalmos. A unilateral exophthalmos was suspected on careful examination in one case immediately postoperative in the recovery room. A full investigation by the neuro-ophthalmologist proved to be negative. This patient had asymmetric palpebral fissures that were not appreciated preoperatively and of which she was not aware. A careful preoperative examination of the palpebral fissures is now done to avoid a false alarm and resultant anxiety. Cerebrospinal Fluid Leak. One patient who had a polyp in the frontal recess and secondary frontal sinusitis developed a profuse CSF leak 48 hours after surgery. The 4-mm coronal computed tomography (CT) cuts had not shown evidence of dehiscence and surgery was uneventful. Packing for 24 hours did not stop the leak. The roof of the ethmoid was then explored endoscopically under local anesthesia. No leak site could be identified in spite of the patient’s cooperation and head lowering, and although he was leaking on bending up to 1 hour prior to surgery when he demonstrated the leak to the anesthesiologist who visited him preoperatively. TABLE 2.
Unilateral Range Average
Bilateral Range Average
Bleeding
LOCAL ANESTHESIA
GENERAL ANESTHESIA
20-200 mL 95 mL
40-200 mL 110 mL
20-325 mL 104 mL
20-700 mL 168 mL
At surgery all the previously exposed fovea was lined with postauricular periosteum that was covered with surgicel then with a tight pack that was left for 7 days. The patient recovered. In retrospect, a fluorescein injection as described by Montgomery14 should have been done to facilitate the identification of the leak site. The most vulnerable area for dural injury and CSF leak is the medial part of the anterior fovea that constitutes the lateral wall of the olfactory groove, where the anterior ethmoidal neurovascular bundle enters the anterior cranial fossa.13
DISCUSSION Preoperative meticulous study of the coronal and axial computed tomography scan by the surgeon is vital. It reveals the relations of the fovea ethmoidalis, orbit, posterior ethmoidal cells, sphenoid sinus, carotid artery, and optic nerve. The sphenoid septum is almost always midline anteriorly; posteriorly, however, it usually is not midline, and may be attached to the carotid bulge. Axial computed tomography cuts will demonstrate this possible dangerous relation. Maniglial’ wrote that complications are more common on the right side and in cases of previous sinonasal surgery. He stressed the importance of avoiding assisted ventilation with a face-mask postoperatively and of trying to avoid sneezing for a few days. It is necessary to observe patients for several hours postoperatively. The author keeps all patients hospitalized overnight. An observation unit has been created at the Massachusetts Eye and Ear Infirmary for patients whose insurance allows only ambulatory surgery. The nurses, the patients, and their companions need to be very well educated about the possible danger signs and symptoms and what to do if any appears. The surgeon should have a clear strategy in mind for immediate implementation when problems or the potential for problems arise. The preoperative appreciation of any discrete asymmetry in the palpebral fissures, which may be seen in normal people, will help eliminate distressing false alarms. One important way to reduce the risks of some complications is to ensure adequate training in this relatively new surgical approach. Attending one course is not enough preparation for a surgeon to begin doing this kind of surgery. The teaching of FESS in residency programs is easier, but teaching it to practicing surgeons is more challenging. The author proposes the creation of structured mini-fellowships for this purpose. The literature on complications in increasing. Those interested in FESS are urged to study these reports.
328
References 1. Mosher HP: The surgical anatomy of the ethmoid labyrinth. Trans Am Acad Oph Otol 1929: 34:376-407 2. Freedman HM, Kern EB: Complications of intranasal ethmoidectomy. Laryngoscope 1979; 89:421-434 3. Kennedy DW: Surgery of the sinuses, in Johns ME (ed): Complications in Otolaryngology-Head and Neck Surgery, vol 2. Head and Neck. Toronto, Canada, Decker, 1986, pp 71-82 4. Kloppers SP: Endoscopic examination of the nose and results of functional endoscopic sinus surgery in 50 patients. S Afr Med J 1987; 72:622-624 5. Stankiewicz JA: Complications of endoscopic intranasal ethmoidectomy. Laryngoscope 1987; 97:1270-1273 6. Stankiewicz JA: Complications of endoscopic sinus surgery. Otolaryngol Clin North Am 1989; 22:749-758 7. Stankiewicz JA: Blindness and intranasal endoscopic ethmoidectomy: Prevention and management. Otolaryngol Head Neck Surg 1989; 101:320-329
SINUS SURGERY COMPLICATIONS 8. Schaefer SD, Manning S, Close LG: Endoscopic paranasal sinus surgery: Indications and considerations. Laryngoscope 1989; 99:1-5 9. Toffel PH, Weinmann RH: Secure endoscopic sinus surgery as an adjunct to functional nasal surgery. Arch Otolaryngo1 1989; 115:822-825 10. Maniglia AJ: Fatal and major complications secondary to nasal and sinus surgery. Laryngoscope 1989; 99:276-283 11. Buus DR, Tse DT, Farris BK: Ophthalmic complications of sinus surgery. Ophthalmology 1990; 97:612-619 12. Wigand ME: Transnasal ethmoidectomy under endoscopic control. Rhinology 1981; 19:7-15 13. Kainz J, Stammberger H: The roof of the anterior ethmoid: A place of least resistance in the skull base. Am J Rhino1 1989; 3:191-199 14. Montgomery WW: Surgery of the Upper Respiratory System, vol 1, ed 2,Philadelphia, PA, Lea and Febiger, 1979, p 207
Complications of Endoscopic Sinus Surgery SALAH D. SALMAN, MD teen patients had remarkable bleeding: in two patients the bleeding was bilateral, mucosal, and severe enough to stop the surgery before all its aims were achieved. Both patients had nonsymptomatic septal deviations that made endoscopic access difficult. At present consent for septal surgery is usually obtained and a more extensive submucous resection (SMR) is done to facilitate surgery. An SMR also facilitates postoperative cleaning. In one patient a branch of the sphenopalatine artery bled and a suction cautery was successfully used. No sensory deficit along the distribution of the corresponding nerve was observed postoperatively. The 10 patients who bled 350 to 700 mL were analyzed separately: all had polyps and bilateral surgery under general anesthesia. Three had a concomitant submucous resection. Bleeding was mucosal, diffuse, and constant, necessitating packing one side and working on the other several times during the procedure. Seven of the 10 had recurrent polyps (four had one previous operation, two had two operations, and one had three operations). There were five men and five women, with an age range of 29 to 61 years. Two were smokers and two were previous smokers. Three were hypertensives under control. Four were asthmatics and one was a diabetic. None gave a history suggestive of a bleeding tendency and all bleeding studies were normal (platelet count, prothrombin time (PT), partial thromboplastin time (PTT), and bleeding time). The operative time for these 10 patients was 30 minutes to 1 hour longer than the others. This was considered a result of greater bleeding rather than its cause.
With the increasing popularity of functional endoscopic sinus surgery (FESS) attention has been directed more toward its possible serious complications. It is still appropriate to quote Masher,’ who in 1929 wrote, “in practice the ethmoid operation has proved to be one of the easiest operations with which to kill a patient.” In 1979 Freedman and Kern’ reported a 2.8% complication rate in 1,000 cases of intranasal ethmoidectomy. With the advent of the endoscopic technique, the literature on complications is increasing, illustrating the variety and seriousness of the possible complications.3-g Maniglial’ reported fatal and major complications. Buus et al” reported a case of bilateral optic nerve transection. Wigandl’ had six cases of cerebrospinal fluid (CSF) rhinorrhea that he ascribed to tears of the olfactory mucosa and leaks around the olfactory filaments. Kainz and Stammberger13 reported three cases of CSF leaks secondary to dural injury at the roof of the ethmoid labyrinth where the anterior ethmoidal artery enters the anterior cranial fossa. Kloppers4 reported three cases of orbital emphysema. The aim of this paper is to present the author’s experience with complications associated with endoscopic sinus surgery.
Significant Scarring. Adhesions that do not seem to interfere with breathing and sinus drainage are no longer treated aggressively. They may be divided in the office a few months later. Earlier treatment is unnecessary, time consuming, and may have to be repeated. Two patients had adhesions of the anterior 1 cm of one middle turbinate and the lateral wall. Both had a flaccid middle turbinate that tended to lateralize at the end of surgery. They were revised successfully when symptoms recurred. Three patients who had bilateral surgery ended up with a unilateral symptomatic stenosis of the middle meatal antrostomy. They underwent revision surgery: one of them twice. The unilaterality of the stenosis in cases of bilateral surgery suggests that the causes of scarring are local rather than systemic or constitutional.
COMPLICATIONS Table 1 lists 28 complications that occurred in 25 of the 118 patients operated on by the author between April 1988 and November 1990, an incidence of 21%. Twenty-two patients had one complication and three had two. All of them may be considered minor except, of course, the CSF leak. Bleeding during surgery averaged 95 to on the anesthesia used and the unilaterality or bilaterality of the operation [Table 2). Thir-
Bleeding.
168 mL depending
Received June 27, 1991, from the Harvard Medical School, Massachusetts Eve and Ear Infirmarv, Boston, MA. Accepted _ for publication October 9, 1991. Presented at the Triological Society, Eastern Section Meetina. Philadelphia, PA, January 31, February 2, 1990. xddress ckespondkce and reprint requests to Salah D. Salman. MD, Harvard Medical School, Massachusetts Eye and Ear Infirmary, 243 Charles St, Boston, MA 02114. Copyright 0 1991 by W.B. Saunders Company 0196-0709/91/1206-0003$5.0010
Incomplete Surgery. Surgery was stopped before all its aims were achieved in five cases: because of the absence of recognizable landmarks in two, profuse mucosal bleeding in two, and the occurrence of chest pain in the other. Patients with coronary artery disease require consultation with a cardiologist and must be eval326
327
SALAH D. SALMAN TABLE 1.
Complications
Bleeding Significant scarring Incomplete surgery Lid ecchymosis and emphysema Epiphora ? Exophthalmos CSF leak Note.
13 cases
5 cases 5 cases 2 cases 1 case 1 case
1 case
Twenty-eight complications in 25 of the 118 patients.
uated carefully to determine appropriate anesthesia. Generally, local anesthesia is less risky, and is therefore preferred, unless the patient is very anxious. Lid Ecchymosis and Emphysema. One patient who sneezed a few hours postoperatively in spite of the presence of bilateral nasal packs developed lid ecchymosis and emphysema on the right side. Both lasted for only a few days. Another patient with a bony dehiscence of the lamina papyracea and/or the lacrimal plate recognized at surgery, developed a lower lid ecchymosis soon after surgery. A few days later, she blew her nose and upper and lower lid emphysema occurred with worsening of the ecchymosis. Both conditions resolved in several days but left her with a darker colored lower lid skin that finally resolved 3 months later.
Epiphora. One patient had a revision of a unilateral ethmoidectomy and middle meatal antrostomy because of recurrent infection. She developed a recurring epiphora that is still under investigation. The cause or obstruction of the tear system has yet to be determined. ? Exophthalmos. A unilateral exophthalmos was suspected on careful examination in one case immediately postoperative in the recovery room. A full investigation by the neuro-ophthalmologist proved to be negative. This patient had asymmetric palpebral fissures that were not appreciated preoperatively and of which she was not aware. A careful preoperative examination of the palpebral fissures is now done to avoid a false alarm and resultant anxiety. Cerebrospinal Fluid Leak. One patient who had a polyp in the frontal recess and secondary frontal sinusitis developed a profuse CSF leak 48 hours after surgery. The 4-mm coronal computed tomography (CT) cuts had not shown evidence of dehiscence and surgery was uneventful. Packing for 24 hours did not stop the leak. The roof of the ethmoid was then explored endoscopically under local anesthesia. No leak site could be identified in spite of the patient’s cooperation and head lowering, and although he was leaking on bending up to 1 hour prior to surgery when he demonstrated the leak to the anesthesiologist who visited him preoperatively. TABLE 2.
Unilateral Range Average
Bilateral Range Average
Bleeding
LOCAL ANESTHESIA
GENERAL ANESTHESIA
20-200 mL 95 mL
40-200 mL 110 mL
20-325 mL 104 mL
20-700 mL 168 mL
At surgery all the previously exposed fovea was lined with postauricular periosteum that was covered with surgicel then with a tight pack that was left for 7 days. The patient recovered. In retrospect, a fluorescein injection as described by Montgomery14 should have been done to facilitate the identification of the leak site. The most vulnerable area for dural injury and CSF leak is the medial part of the anterior fovea that constitutes the lateral wall of the olfactory groove, where the anterior ethmoidal neurovascular bundle enters the anterior cranial fossa.13
DISCUSSION Preoperative meticulous study of the coronal and axial computed tomography scan by the surgeon is vital. It reveals the relations of the fovea ethmoidalis, orbit, posterior ethmoidal cells, sphenoid sinus, carotid artery, and optic nerve. The sphenoid septum is almost always midline anteriorly; posteriorly, however, it usually is not midline, and may be attached to the carotid bulge. Axial computed tomography cuts will demonstrate this possible dangerous relation. Maniglial’ wrote that complications are more common on the right side and in cases of previous sinonasal surgery. He stressed the importance of avoiding assisted ventilation with a face-mask postoperatively and of trying to avoid sneezing for a few days. It is necessary to observe patients for several hours postoperatively. The author keeps all patients hospitalized overnight. An observation unit has been created at the Massachusetts Eye and Ear Infirmary for patients whose insurance allows only ambulatory surgery. The nurses, the patients, and their companions need to be very well educated about the possible danger signs and symptoms and what to do if any appears. The surgeon should have a clear strategy in mind for immediate implementation when problems or the potential for problems arise. The preoperative appreciation of any discrete asymmetry in the palpebral fissures, which may be seen in normal people, will help eliminate distressing false alarms. One important way to reduce the risks of some complications is to ensure adequate training in this relatively new surgical approach. Attending one course is not enough preparation for a surgeon to begin doing this kind of surgery. The teaching of FESS in residency programs is easier, but teaching it to practicing surgeons is more challenging. The author proposes the creation of structured mini-fellowships for this purpose. The literature on complications in increasing. Those interested in FESS are urged to study these reports.
328
References 1. Mosher HP: The surgical anatomy of the ethmoid labyrinth. Trans Am Acad Oph Otol 1929: 34:376-407 2. Freedman HM, Kern EB: Complications of intranasal ethmoidectomy. Laryngoscope 1979; 89:421-434 3. Kennedy DW: Surgery of the sinuses, in Johns ME (ed): Complications in Otolaryngology-Head and Neck Surgery, vol 2. Head and Neck. Toronto, Canada, Decker, 1986, pp 71-82 4. Kloppers SP: Endoscopic examination of the nose and results of functional endoscopic sinus surgery in 50 patients. S Afr Med J 1987; 72:622-624 5. Stankiewicz JA: Complications of endoscopic intranasal ethmoidectomy. Laryngoscope 1987; 97:1270-1273 6. Stankiewicz JA: Complications of endoscopic sinus surgery. Otolaryngol Clin North Am 1989; 22:749-758 7. Stankiewicz JA: Blindness and intranasal endoscopic ethmoidectomy: Prevention and management. Otolaryngol Head Neck Surg 1989; 101:320-329
SINUS SURGERY COMPLICATIONS 8. Schaefer SD, Manning S, Close LG: Endoscopic paranasal sinus surgery: Indications and considerations. Laryngoscope 1989; 99:1-5 9. Toffel PH, Weinmann RH: Secure endoscopic sinus surgery as an adjunct to functional nasal surgery. Arch Otolaryngo1 1989; 115:822-825 10. Maniglia AJ: Fatal and major complications secondary to nasal and sinus surgery. Laryngoscope 1989; 99:276-283 11. Buus DR, Tse DT, Farris BK: Ophthalmic complications of sinus surgery. Ophthalmology 1990; 97:612-619 12. Wigand ME: Transnasal ethmoidectomy under endoscopic control. Rhinology 1981; 19:7-15 13. Kainz J, Stammberger H: The roof of the anterior ethmoid: A place of least resistance in the skull base. Am J Rhino1 1989; 3:191-199 14. Montgomery WW: Surgery of the Upper Respiratory System, vol 1, ed 2,Philadelphia, PA, Lea and Febiger, 1979, p 207