Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature.

The history of nasal endoscopy and of endoscopic sinus surgery parallels advances made in the development of instruments suitable for examining the small confines of the nose, nasopharynx and the paranasal sinuses. Bozzini is credited for the development and use of the first "light conductor.".

Subsequently, Czermak, who coined the term "rhinoscopy," popularized the use of the nasal speculum, an instrument that unknownst to him had already been in use during the first century in Pompeii. In 1879, the Nitze-Leiter cystoscope with a platinum wire light source, was modified into the first endoscope bearing any resemblance to today's modern scopes, the Storz Fiberoptic Endoscope, which was developed in the mid-1950's. These advances, along with the development of computed tomography, made it possible for clinicians to localize sinus disease and thereby redirect their therapeutic interventions.

Messerklinger is credited as the first to develop a systematic approach to diagnosing and treating sinus inflammatory disease. He noted that despite the seemingly extensive nature of the disease process in remote areas of the nose and paranasal sinuses, in most cases these observations could be explained by relating anatomical form to function. The frontal, maxillary and anterior ethmoid sinuses converge on a rather limited area known as the ethmoid infundibulum, which comprises one component of the osteomeatal unit. Other structures in this area include the uncinate process, the middle turbinate and the ethmoid bulla. Physiologically, this area is important in the etiology of inflammatory sinus disease.

Obstruction either by inflammation, polyp, tumor, or by dysfunction of the normal mucociliary clearance mechanisms in this area leads to primary disease that can progress and cause contiguous infection of the larger paranasal sinuses, or secondary disease.

Functional endoscopic sinus surgery is based on the premise that removing the obstruction to normal mucociliary clearance in the area of the OMC will lead to subsequent clearance of secondary disease and restoration of normal mucociliary clearance. This is in contrast to more extensive interventions in which nearly all accessible mucosa is debrided. Although this is sometimes necessary, as in severe nasal polyposis, such extensive procedures usually are not required and add to the overall risk of complications.

Early in this century, Mosher stated that intranasal ethmoidectomy is "the blindest and most dangerous operation in all of surgery." While this may have been true then, the endoscopic approach to intranasal surgery has afforded surgeons unparalleled illumination and clarity of the surgical field. Despite these advances, with their attendant reductions in morbidity and mortality, complications remain a real concern when performing ESS. They are divided into major complications including: death, intracranial hematoma, massive hemorrhage, blindness, orbital hematoma, and CSF leak, and minor complications including synechiae, orbital emphysema, acute asthma exacerbation, epiphora, hyposmia, anosmia and dysgeusia.

In the first U.S. study that quantified complications related to ESS, Stankiewicz, reported a 6% major and 13% minor complication rate, the most common being synechiae. In a follow-up study, Stankiewicz reported on the complication rate of a subsequent group of 90 patients, and noted a rate of 2.4%, which compared favorably with previous reports of complications as reported by Freedman and Kern in 1979 using conventional intranasal methods. This significant drop in the complication rate was attributed to greater operative experience, concurrent cadaveric dissection, and the use of limited ethmoidectomy initially, with gradual progression to more extensive procedures.

Several studies have subsequently demonstrated a further decline in the incidence of complications. Dessi noted a 1.2% complication rate for overall complications.

There are several general aspects that impact on the risk of performing ESS. First is patient selection. Multiple studies have cited an increased risk of complications associated with ESS performed on patients with polyposis, prior surgical intervention and in those who have had long-standing disease. Dessi noted that all 5 of his complications occurred in patients being operated on for significant polyposis.

The type of anesthesia utilized has been debated. Those espousing local techniques cite the patient's ability to convey painful stimuli when the skull base or peri-orbita is encroached upon as well as a significantly lower blood loss. However, this requires both a compliant patient and an optimal topicalization of the nose by the surgeon. Alternatively, other authors recommend general anesthesia in addition to topical preparation of the nose citing greater patient comfort, especially in more extensive procedures. Stankiewicz (1989) reported in a series of 180 patients that there was no difference in the rate of complications when either technique was used. He did note, however, that blood loss was greater in those procedures done under general anesthesia.

Meticulous hemostasis and atraumatic technique are essential. Several authors have emphasized the need to ensure adequate visualization. If bleeding precludes an adequate view, the procedure should be stopped until hemostasis is achieved or terminated if this is not possible.

Functional ESS, which espouses a more limited approach, can and should be used whenever the disease process dictates its appropriateness. Smith and Brindley, utilizing this approach, found comparable results when compared with studies using more extensive interventions. Experience of the surgeon, as alluded to earlier, plays a large part in determining the risk of an adverse outcome.

Finally, familiarity with endoscopic anatomy and its variations play an extremely important part in reducing complications. As in all of surgery, anatomical landmarks are critical to maintaining spatial orientation. This is also true in the nasal cavity. The close proximity of the ethmoid sinuses to the skull base and brain as well as the orbit and optic nerve mandates continuous awareness of one's location. Streitmann et al studied 50 cadaveric heads and performed several measurements from the base of the columella to various important landmarks, relating both the angle of incidence and the distance to these structures.

Ohnishi identified 5 high-risk areas that he considered to merit special attention during ESS. The lamina papyracea, given its protrusion into the field and its relative fragility, is an area that is frequently violated. Injury in this area predisposes to medial rectus entrapment or transection. Extensive manipulation in this region has resulted in blindness in some cases. The anterior ethmoid artery and roof are likewise in a susceptible location, and injury laterally can predispose to either significant hemorrhage into the field or to orbital hematoma if the vessel retracts in its bony canal. Injury more medially, with fracture of the attenuated ethmoid roof, is a common cause for CSF leak and predisposes to possible meningitis. The lateral lamella of the cribriform plate (also the lateral wall of the olfactory bulb) is an area where attempts at complete exenteration of superior ethmoid air cells can result in small dehiscences that predispose to increased risk of infection. The posterior ethmoid roof and artery, although usually not problematic, may present with a dehiscent artery lying inferior to the roof, with or without a bony canal. Finally, the area Between the posterior ethmoid and the sphenoid sinus is of critical significance because it is here where anatomical variations can predispose to inadvertent injury to the optic nerve or the carotid artery. Takedown of thick bony buttresses in this area should not be performed as fracture planes can be created that run into the carotid artery bony canal with possible pseudoaneurysm formation or fistulization to the cavernous sinus.

As important as familiarity with normal anatomy is, it is of equal importance to be aware of the anatomical variants that one might encounter in performing ESS. Bolger, in a detailed analysis of 202 consecutively-imaged patients, identified several bony anatomic variations. The most common of these, the agger nasi, which was present in 98.5% of patients, is described as being the most anterior of the anterior ethmoid cells, bounded superiorly by the frontal sinus. These can be quite large, may displace the lamina papyracea to a more lateral position. A concha bullosa (or pneumatized middle turbinate) was present in 53% of cases. No consistent relationship between the presence of this variation and the pathogenesis of OMC disease has been established. The need for resection of these should proceed on a patient-to-patient basis, as these may be the reason for primary disease at the OMC.

Haller's Cells are ethmoid cells that project into the maxillary sinus. Although it was present in 45% of scans, not all Haller cells are pathologically important. Again, case-by-case evaluation of these entities is required to assess their role in contributing to maxillary ostium blockage.

The Onodi Cell is a posterior ethmoid cell that has encroached upon the area of the sphenoid sinus. It is of considerable significance because in a large majority of these, a frankly dehiscent optic nerve, carotid artery or both may be present in variable locations. Several other variants have been described.

Among these are the uncinate bulla, which although relatively infrequent, may alter the anatomy at the OMC. Others include Bulla Gali (5.4%), pterygoid pneumatization (43.6%), and anterior clinoid pneumatization (13.3%). Preoperative recognition of these variations is useful as these at times may require special attention in order to prevent postoperative recurrent disease, and more importantly, complications by allowing the surgeon to better estimate the limits of resection.

I would now like to discuss the prevention and management three complications, that, if detected early, can be dealt with before more severe delayed sequelae evolve. These include massive hemorrhage, cerebrospinal fluid leak, and orbital hematoma. The management of synechiae and of nasolacrimal duct obstruction will also be briefly reviewed.

Massive hemorrhage, resulting from major vascular injury, is an exceedingly rare complication. Avoidance of complications in this area requires familiarity with the variations that occur with respect to the ICA. The lateral sphenoid wall usually demonstrates an inward bulge harboring the ICA occasionally associated with the optic nerve lying superior to it. Kennedy et al noted that in 22% of 188 sphenoid sinuses examined, there was dehiscence of the bony canal over the ICA. In three cases, the artery was found to be completely dehiscent in the posterior wall of the posteriormost ethmoids. Near-midline ICA's were seen in one case. It is believed that these anomalies account for the reported cases of ICA injury. These reports led to the development of the carotid drill by Sofferman.

In the event of carotid artery injury with massive hemorrhage, nasal packing should be placed immediately with manual compression of the ipsilateral cervical ICA. Controlled hypotension, blood products and neurosurgical and neuroradiological consultation should be called. Carotid angiography should then be undertaken. If this should indicate a significant carotid injury, balloon occlusion is attempted with EEG surveillance. If no changes occur on EEG, then carotid artery ligation may be performed. If there is evidence of lateralization on EEG with occlusion, then the balloon should be deflated and the packing left in place. In the ICU, Swan-Ganz catheterization and hypervolemic therapy should be implemented to optimize cerebral perfusion. Once this has been attained, occlusion should be reattempted. If evidence of adequate collateralization is present, then the carotid may be ligated. If not, then the patient should continue to be observed, and an attempt at removal of packing in the operating room should be attempted at a later time.

CSF leak resulting from penetration of the skull base near the area of the ethmoids or the sphenoids occurs in approximately 1% of cases. Preservation of the middle turbinate as a landmark is of critical importance in preventing complications. One should always operate lateral to its origin, since medial dissection can violate the thinner and lower cribriform plate. Although thicker than the cribriform, the fovea ethmoidalis is still susceptible to fracturing, especially medially. Therefore, one should try to remain as close to the lamina papyracea as possible when approaching the frontal recess. Similarly, the middle turbinate is important in locating the sphenoid sinus posteriorly, as its anterior wall lies in a plane between the superior inferior turbinate and the lower aspect of the middle turbinate. On average, the sphenoid sinus lies 7 centimeters posterior to the nasal introitus. This wall is very thin and should not require excessive force to infracture. Undue resistance implies that basilar skull bone is being impinged upon and that landmarks need to be reidentified.

CSF leaks noted intra-operatively can be repaired primarily using either temporalis fascia, septal or turbinate mucosa or fascia lata. The graft is placed over the defect and tucked under the bony edges as seen here. Muscle is then placed over this followed by Gelfoam for support. Leaks of the sphenoid sinus have been managed by plugging the defect with fibrin glue and Gelfoam followed by Gelfoam obliteration of the sphenoidotomy. Delayed fistula can be managed with bedrest with or without a lumbar drain. If this fails to resolve within 2 to 3 weeks, exploration either endoscopically with flourescein, extranasally or intranasally, or via craniotomy may be necessary. The use of antibiotics as prophylaxis against CNS infection is controversial.

Orbital complications, including blindness and diplopia, occur via two mechanisms: direct injury to the optic nerve or extraocular muscles, which is rare; and retro-orbital hematoma. Injury to either the anterior or posterior ethmoidal arteries or penetration of the lamina papyracea can lead to trace edema, periorbital and lid ecchymosis, chemosis and minimal proptosis, and may progress to massive proptosis with temporary loss of vision. If this is not rapidly addressed by the surgeon, persistent elevation of intraocular pressure with compromise of venous outflow leads to retinal ischemia with resultant permanent blindness. Use of general anesthesia increases risk as the patient is no longer able to sense pain when the lamina or ethmoid roof is injured. The eyes should remain uncovered and checked routinely by the surgeon in order to assess proptosis early. One should remember that the lamina papyracea lies superior and lateral to the natural maxillary ostium. Of note, several studies have cited a significantly greater incidence of orbital complications on the left side. This reflects an alteration in how the right-handed surgeon perceives the location of the ethmoids. On the right, they lie directly posterior as one would expect. On the left, however, scope orientation alters the view giving the surgeon the impression that the lamina papyracea is more lateral when in actuality it is more medial. Gentle palpation of the eye while dissecting in the area allows one to identify the lamina prior to entering it. Exposure of orbital fat in and of itself is usually of no consequence. However, a careful inspection of the eye should be undertaken. If signs of orbital hematoma are present, the patient should be admitted and observed as delayed blindness up to 48 hours post-op have been documented. Orbital packs should be avoided as these may increase intraorbital pressure. Management of an intraoperative orbital hematoma entails immediate ophthalmologic consultation and institution of several methods aimed at reducing intraorbital pressure. Eye massage is effective in that it helps to redistribute intraocular and extraocular fluids. This maneuver is absolutely contraindicated in patients with a prior history of ophthalmic surgery including corneal, retinal, or glaucoma filtering surgery. Acetazolamide 500 mg. IV can reduce intraorbital pressure by decreasing aqueous humor production, however its onset of action is slow. Mannitol has a much quicker onset and acts by osmotically drawing fluid out of the orbital spaces. A dose of 1-2 GRAMS per kilogram given over 20-30 minutes is usually safe and effective. Miotics should be avoided as these interfere with pupillary responses and thereby confuse the clinical picture. The use of steroids for this condition is not clear. Currently, no studies have shown a therapeutic gain associated with their use. Should medical management fail, lateral canthotomy has proven effective in reducing intraorbital hypertension. Briefly, the technique entails releasing the lateral canthal structures, including the lateral canthal tendon, by placing a straight hemostat across the area followed by sharp division of these structures down to the periorbital fascia. If this is not effective, medial canthotomy via the Lynch external ethmoidectomy approach can be performed with satisfactory results. Postoperative monitoring with diuretics in consultation with ophthalmology is usually uneventful.

Nasolacrimal duct stenosis resulting from middle meatal antrostomy is uncommon. It is presumed that the nasolacrimal duct is injured more frequently, but few cases result in frank obstruction with epiphora. Regardless, a few points are worthy of mention. First, it should be remembered that the nasolacrimal duct lies only 3-6 millimeters anterior to the natural ostium of the maxillary sinus and that the antrostomy should be made no further forward than the anterior end of the middle turbinate. If hard bone is encountered anteriorly, this likely represents a natural bony septum separating the ostium from the canal, or the lacrimal duct canal itself and should not be violated. Cases of persistent epiphora can be managed with serial lacrimal probing. Formal dacryocystorhinostomy, either endoscopically or via the external approach or both can be performed if necessary. A combined approach is currently favored in which the lacrimal sac is cannulated with a light source and endoscopically, the area of the lacrimal sac is identified, stripped of its bony and mucosal covering, and marsupialized into the frontal recess.

Finally, synechiae usually results from fibrous scar band formation between the lateral nasal wall and the middle and/or inferior turbinates. Atraumatic technique and stenting in these areas have been shown to be useful, but invariably, reduced incidence of this outcome results from meticulous debridement postoperatively in the office. Partial middle turbinectomy has been implemented by several authors with mixed results.

Major complications in endoscopic sinus surgery are rare. However, when they do occur they can be catastrophic and it behooves the surgeon to identify these problems early before permanent deficits evolve. Practical knowledge of the anatomy, both normal and variant, is requisite. Prevention of complications based on technique and implementation of limited surgery based on extent of disease are well established. Management strategies aimed at minimizing or reversing adverse events exist and these should be familiar to the endoscopic sinus surgeon.

A 54-year-old female with a long-standing history of chronic sinusitis and nasal polyposis presented with symptoms of bilateral frontal, retro-orbital, and midfacial pain, nasal obstruction, purulent post-nasal drip and halitosis. Her past medical history was significant for hypertension and arthritis. Her medications included Beconase, Seldane, Augmentin, Capoten and Premarin. She denied allergy to aspirin. On exam, she was noted to have minimal maxillary and frontal sinus tenderness. Anterior rhinoscopy showed streaking of purulent material across the middle turbinates bilaterally, large inferior turbinates, leftward septal deviation and polyps of the left osteomeatal complex. All extraocular muscle movements were intact. The remainder of her physical exam was unremarkable.

A CT scan of the nose and paranasal sinuses without contrast revealed complete opacification of the right maxillary, ethmoid, frontal and sphenoid sinuses. The left maxillary, ethmoid, frontal, and sphenoid sinuses were opacified to varying degrees. Paradoxical curvature of the right inferior turbinate was also noted.

The patient underwent endoscopic sinus surgery consisting of bilateral anterior and posterior ethmoidectomy, middle meatal antrostomy, and sphenoidotomy. Four months post-operatively, she demonstrated signs and symptoms of epiphora of the left eye. Despite conservative therapy, her symptoms persisted.

She subsequently underwent septoplasty and partial resection of her inferior turbinate for persistent nasal obstruction, at which time a dacryocystorhinostomy was performed on the left side. Six months post-operatively, she is doing well, remains asymptomatic with regard to her sinus symptoms, and has not experienced any repeat episodes of epiphora.

Bibliography

Bolger WE, Butzin CA, Parsons DS. Paranasal sinus bony anatomic variations and mucosal abnormalities: CT analysis for endoscopic sinus surgery. Laryngoscope 1991;101:56-64.

Corey JP, Bumsted R, Panje W, Namon A. Orbital complications in functional endoscopic sinus surgery. Otolaryngol Head Neck Surgery 1993;109:814-820.

Dessi P, Casto F, Triglia JM, Zanaret M, Cannoni, M. Major complications of sinus surgery: a review of 1192 procedures. J Laryngol Otol 1994;108:212-215.

Edelstein DR, Arlis HR, Bushkin S, Han JC. Posterior sinus anatomy: clinical correlations and pitfalls. In: Friedman M. Operative Techniques in Otolaryngology - Head and Neck Surgery. Philadelphia: W.B. Saunders, 1991:222-225.

Freedman HF, Kern EB. Complications of intranasal ethmoidectomy: a review of 1,000 consecutive operations. Laryngoscope 1979;89:421-432.

Gadacz T. Endoscopic sinus surgery: part II. Surg Rounds 1994;17:249-262.

Isenberg SF, Scott JA. Management of massive hemorrhage during endoscopic sinus surgery. Otolaryngol Head Neck Surg 1994;111:134-137.

Johns ME, Price JC, Mattox DE. Atlas of Head and Neck Surgery. Philadelphia: B.C. Decker, 1990:81.

Kennedy DW, Zinreich SJ, Hassab MH. The internal carotid artery as it relates to endonasal sphenoethmoidectomy. Am J Rhinol 1990;4:7-12.

Kennedy DW, Zinreich JS, Johns ME. Functional endoscopic sinus surgery. In: Goldman J, et al. The Principle and Practice of Rhinology. Philadelphia: John Wiley & Sons, 1987:879-902.

Kennedy DW, Zinreich SJ, Kuhn F, Shaalan H, Naclerio R, Loch E. Endoscopic middle meatal antrostomy: theory, technique, and patency. Laryngoscope 1987;97:(Suppl 43):1-9.

Lanza DC, Kennedy DW. Endoscopic sinus surgery. In: Bailey BJ, et al. Head and Neck Surgery - Otolaryngology. Philadelphia: J.B. Lippincott, 1993:389-401.

Lawson W. The intranasal ethmoidectomy: evolution and an assessment of procedure. Laryngoscope 1994;104:(Suppl 64):1-49.

Maniglia AJ. Fatal and other major complications of endoscopic sinus surgery. Laryngoscope 1991;101:349-354.

Mattox DE, Kennedy DW. Endoscopic management of cerebrospinal fluid leaks and cephaloceles. Laryngoscope 1990;100:857-862.

May M, Schiatkin B, Kay SL. Revision endoscopic sinus surgery: six friendly surgical landmarks. Laryngoscope 1994;104:766-767.

May M, Mester SJ, O'Daniel TG, Curtin HD. Decreasing the risks of endonasal endoscopic sinus surgery by imaging techniques. In: Friedman M. Operative Techniques in Otolaryngology - Head and Neck Surgery. Philadelphia: W.B. Saunders, 1990:89-92.

Myerson MC. The natural orifice of the maxillary sinus. Arch Otolaryngol 1932;15:80-91.

Netter FH. Atlas of Human Anatomy. Summit, NJ: CIBA-Geigy, 1989:Plates 31-44.

Ohnishi T, Tachibana T, Kaneko Y, Esaki S. High risk areas in endoscopic sinus surgery and prevention of complications. Laryngoscope 1993;103:1181-1185.

Rice DH. Endoscopic sinus surgery. Otolaryngol Head Neck Surg 1994;111:100-110.

Rice D. Endoscopic sinus surgery: anterior approach. In: Friedman M. Operative Techniques in Otolaryngology - Head and Neck Surgery. Philadelphia: W.B. Saunders, 1990:99-103.

Schaefer SD. Endoscopic sinus surgery: posterior approach. In: Friedman M. Operative Techniques in Otolaryngology - Head and Neck Surgery. Philadelphia: W.B. Saunders, 1990:104-107.

Smith LF, Brindley PC. Indications, evaluation, complications, and results of functional endoscopic sinus surgery in 200 patients. Otolaryngol Head Neck Surg 1993;108:688-696.

Sogg A, Eichel B. Ethmoid surgery complications and their avoidance. Ann Otol Rhinol Laryngol 1991;100:722-724.

Stammberger H. Functional Endoscopic Sinus Surgery. Philadelphia: Mosby, 1991:466-477.

Stankiewicz JA. Blindness and intranasal endoscopic ethmoidectomy: prevention and management. Otolaryngol Head Neck Surg 1989;101:320-329.

Stankiewicz JA. Cerebrospinal fluid fistula and endoscopic sinus surgery. Laryngoscope 1991;101:250-256.

Stankiewicz JA. Complications in endoscopic intranasal ethmoidectomy: an update. Laryngoscope 1989;99:686-690.

Stankiewicz JA. Complications of endoscopic nasal surgery: occurrence and treatment. Am J Rhinol 1987;1:45-49.

Stankiewicz JA. Complications of sinus surgery. In: Bailey BJ, et al. Head and Neck Surgery - Otolaryngology. Philadelphia: J.B. Lippincott, 1993:413-427.

Streitmann MJ, Otto RA, Sakai CS. Anatomic considerations in complications of endoscopic and intranasal sinus surgery. Ann Otol Rhinol Laryngol 1994;103:105-109.

Van Alyea OE. The ostium maxillare. Arch Otolaryngol 1936;24:553-569.3

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