How to avoid complications in ESS?How to avoid complications in ESS?

Codrut Codrut SarafoleanuSarafoleanu

Bucharest, RomaniaBucharest, Romania

How to How to avoidavoid ComplicationsComplications

�� Preoperative measuresPreoperative measures� Know your-self:

� Surgical skills

� Appropriate instruments, including optical aids

� Explicit knowledge of the surgical anatomy

� Know your patient�� Appropriate history (Appropriate history (““bleedingbleeding”” risk factorsrisk factors, antiplatelet medication), antiplatelet medication)

�� Preop. treatmentPreop. treatment

� Adequate preoperative imaging

�� Intraoperative measuresIntraoperative measures�� AnesthesiaAnesthesia

� Adjusting the operative strategy to the specific goal

� Hemostatic measures

� Intraoperative image guidance systems

� Closure of the surgical defect

�� Postoperative measuresPostoperative measures�� Antiinfectious treatmentAntiinfectious treatment

�� Lumbar drainLumbar drain (when needed)(when needed)

�� Nasal lavage, ointments, crusts removalNasal lavage, ointments, crusts removal

Complications of endoscopic sinus surgeryComplications of endoscopic sinus surgery

Site Site ComplicationComplicationOrbit Orbit Nasolacrimal duct damagNasolacrimal duct damagee

Extraocular muscle injurExtraocular muscle injuryy

IntraorbitalIntraorbital haemorrhage/emphysemahaemorrhage/emphysema

Optic nerve damageOptic nerve damage

Intracranial Intracranial HaemorrhageHaemorrhage

Cerebrospinal fluid leakCerebrospinal fluid leak+/+/-- meningitismeningitis

Nasal HaemorrhageNasal Haemorrhage

Minor complications Minor complications –– synechia, crusting, adhesionssynechia, crusting, adhesions, epistaxis, epistaxis

J R Soc Med 1997;90:422J R Soc Med 1997;90:422--428428

Complications of endoscopic sinus surgery

Group Group PatientsPatients (n)(n) CSF leak CSF leak I/CI/C Orbit Orbit Haem Haem DeathDeath

Schaefer Schaefer &&al. al. 100100 -- -- -- -- --Levine'Levine'°° 250 250 -- 33 -- -- --

WigandWigand&&

HosemannHosemann 1000+1000+ 10 10 22 -- 1 1 11

Stammberger' Stammberger' 6000+ 6000+ 3 3 1 1 2 2 -- --

KennedyKennedy 120 120 -- -- -- -- --

Vleming et al. Vleming et al. 593 593 2 2 -- 2 2 15 15 --

MackayMackay 600600 -- -- 1 1 3 3 --

Dessi et al.Dessi et al. 386 386 2 2 -- 3 3 -- --

Lund Lund 730 730 -- -- -- 44 --

Optimize Medical TreatmentOptimize Medical Treatment

Medical treatmentMedical treatment

1.1. Will complement surgery Will complement surgery

in making the mucosa as in making the mucosa as

healthy as possiblehealthy as possible

2.2. Can be a useful predictor Can be a useful predictor

of what can be achieved by of what can be achieved by

surgerysurgery

Preoperative considerationsPreoperative considerations

�� Appropriate history (Appropriate history (““bleedingbleeding”” risk factorsrisk factors, antiplatelet , antiplatelet

medication)medication)

�� Preop. treatment with antibiotics and steroids Preop. treatment with antibiotics and steroids ((even if not effectiveeven if not effective, ,

this will optimize the condition of the nasalthis will optimize the condition of the nasal mucosa before surgerymucosa before surgery))

�� Review of pertinent imaging studies (defects in lamina Review of pertinent imaging studies (defects in lamina

papyracea, lowpapyracea, low--lying cribriform plate, dehiscence of carotid or lying cribriform plate, dehiscence of carotid or

optic nerve canal)optic nerve canal)

StepsSteps…….approaching the patient.approaching the patient

�� Anatomic variants (silent sinus, Onodi cell undeveloped frontal Anatomic variants (silent sinus, Onodi cell undeveloped frontal

sinus)sinus)

�� ImageImage--guidance technology reduce the complications riskguidance technology reduce the complications risk

�� Check tCheck the visual status of the patienthe visual status of the patient before surgerybefore surgery

�� DiscussionDiscussion regarding possible results and outcomes regarding possible results and outcomes ((should be should be formallyformally notednoted))

Imaging of the sphenoid areaImaging of the sphenoid area

Distance between the floor of theDistance between the floor of the

sphenoid sinus and sphenopalatinesphenoid sinus and sphenopalatine

foramenforamen

Sphenopalatine foramen close to the anterior andSphenopalatine foramen close to the anterior and

inferior edges of the sphenoid sinusinferior edges of the sphenoid sinus

Imaging of the sphenoid areaImaging of the sphenoid area

Relationship between the posterior ethmoidalRelationship between the posterior ethmoidal

cells and sphenoid sinusescells and sphenoid sinuses

The posterior wall of the ethmoid is not always flat or entirelyThe posterior wall of the ethmoid is not always flat or entirely

in contact with the sphenoidin contact with the sphenoid

The extension of the ethmoid above, beside or below the The extension of the ethmoid above, beside or below the

sphenoid sphenoid –– OnodiOnodi’’s cells cell

Most common extention is aboveMost common extention is above

Sometimes direct relationship between OnodiSometimes direct relationship between Onodi’’s cell and the s cell and the

optic nerve or ICAoptic nerve or ICA

Agger nasi cellAgger nasi cell

Excessive pneumatisation Excessive pneumatisation

frontal recess blockingfrontal recess blocking

HallerHaller’’s s

infraorbital cellsinfraorbital cells

Excessive pneumatisation - drainage

impairment

Sometimes difficult to identify –

risk of orbital penetration

Excessive pneumatisation Excessive pneumatisation

of the bullaof the bullaMaxillary sinus hipoplasia

Orbital penetration risk

Often associated with uncinate process hipoplasia

Ethmoidal transverse diameter narrowingEthmoidal transverse diameter narrowing

�� High risk of orbital penetrationHigh risk of orbital penetration

�� ””MedialisationMedialisation”” of the orbital wallof the orbital wall

Ethmoidal roofEthmoidal roof

NormalNormalNormal DescendedDescendedDescended Incline and

asymmetric

Incline and Incline and

asymmetricasymmetric

fovea fovea etmoidalisetmoidalis

olfactiveolfactivefossafossa

lateral lamella

�� Lateral Lateral –– fovea ethmoidalis of the frontal bonefovea ethmoidalis of the frontal bone

�� Medial Medial –– olfactive fosseolfactive fosse

Keros clasification* - Olfactive fosseOlfactive fosse

* Keros, 1965 / Stammberger et al. 1995* Keros, 1965 / Stammberger et al. 1995

Type 1

< 4 mm

Type 2

4 -7 mmType 3

8-16 mm

Type 3

8-16 mm

Dehiscent carotid canal

Axial CT

Vulnerability of the carotid canalVulnerability of the carotid canal

Vulnerability of the carotid canalVulnerability of the carotid canal

Internal carotid artery bulges into sphenoid sinus

Vulnerability of the optic nerve (I)Vulnerability of the optic nerve (I)

1 Onodi cell (bulging of the optic canal into the posterior ethmoid)

2 Pneumatization of the lesser wing of the sphenoid bone

3 Pneumatization of the anterior clinoid process of the sphenoid bone

1

23

Encasement of the optic nerveWithin the sphenoid sinus

PosteriorPosterior

ethmoid ethmoid

surgerysurgery

SphenoidSphenoid

sinus sinus

surgerysurgery

SphenoidSphenoid

sinus sinus

surgerysurgery

Vulnerability of the optic nerve (II)Vulnerability of the optic nerve (II)

Axial CT

11 22

22

1. Bulging of the optic nerveinto the sphenoid sinus

2. Dehiscent optic canal

LLocal versus generalocal versus general anaesthesia anaesthesia

�� GGeneral anaesthesia continues toeneral anaesthesia continues to prevail because surgeons have not been persuaded of prevail because surgeons have not been persuaded of thethe 'safety' of local anaesthesia. 'safety' of local anaesthesia.

�� Stankiewicz Stankiewicz -- no differenceno difference between the two in incidence of complicationsbetween the two in incidence of complications

““MMinimize bleedinginimize bleeding”” measuresmeasures

�� decongestants (cottons) 30 minutes before the operationdecongestants (cottons) 30 minutes before the operation

�� patient in a reverse Trendelenburg positionpatient in a reverse Trendelenburg position

�� decongestants during the operationdecongestants during the operation

�� inducing mild hypotension if appropriate.inducing mild hypotension if appropriate.

�� iinstrumentsnstruments that incorporate suction devices can be helpfulthat incorporate suction devices can be helpful

but but !!!!!! !!!!!! are onlyare only……....

complementary to a knowledge of the anatomycomplementary to a knowledge of the anatomy

and and

………………. . scrupulous surgical techniquescrupulous surgical technique

Risk areas in ESSRisk areas in ESS

�� Vascular structures Vascular structures �� Ant.Eth. ArteryAnt.Eth. Artery

�� Post.Eth. ArteryPost.Eth. Artery

�� Sphenopalatine ArterySphenopalatine Artery

�� ICAICA

�� NervesNerves�� Optic nerveOptic nerve

�� Skull baseSkull base

�� OrbitOrbit

�� Naso Naso -- lachrymal ductlachrymal duct

Normal Anatomy/Anatomic Variants

EEthmoidal thmoidal

arterarteriesies

Anterior Ethmoidal ArteryAnterior Ethmoidal Artery

�� In cases of accidents:In cases of accidents:

�� Intranasal hemorrhageIntranasal hemorrhage

�� Retrobulbar hematomaRetrobulbar hematoma

�� proptosis, proptosis,

�� mydriasis, mydriasis,

�� edema of the lid, edema of the lid,

�� chemosis, chemosis,

�� massive increase of bulb massive increase of bulb

pressure, pressure,

�� loss of visionloss of vision

Intraorbital HematomaIntraorbital Hematoma

N.B. The retina can tolerate 30N.B. The retina can tolerate 30--90 min of ischemia90 min of ischemia

Medical management (slowly expanding hematomas)Medical management (slowly expanding hematomas)::pack removal, pack removal,

Systemic steroids (0,2 mg/kg), Systemic steroids (0,2 mg/kg),

manitol (1manitol (1--2mg/kg) and2mg/kg) and

acetazolamide (10acetazolamide (10--15 mg/kg)15 mg/kg)

Rapid expanding hematomasRapid expanding hematomas

Lateral cantotomy and cantholysisLateral cantotomy and cantholysis

Orbital decompressionOrbital decompression

Sphenopalatine artery and branchesSphenopalatine artery and branches

26 yrs old patient26 yrs old patient

�� Operated on several times for nasopharyngeal angiofibroma Operated on several times for nasopharyngeal angiofibroma

(according to the medical documents)(according to the medical documents)

�� In fact In fact –– septoplasty, biopsy of the tumor, and failed septoplasty, biopsy of the tumor, and failed

tentative of tumor removal (just major bleeding followed by tentative of tumor removal (just major bleeding followed by

nasal packing 7 days!!!!!)nasal packing 7 days!!!!!)

�� Patient informed about external carotid artery ligationPatient informed about external carotid artery ligation

�� No carotid ligation (angiography showed this and allowed No carotid ligation (angiography showed this and allowed

selective embolisation of the internal maxillary arteryselective embolisation of the internal maxillary artery

�� No tumor removalNo tumor removal

Orbital fat exposureOrbital fat exposure

�� Lamina papyracea disruption Lamina papyracea disruption –– aggressive ethmoidectomy, aggressive ethmoidectomy,

silent sinus syndromesilent sinus syndrome

�� Exposure of the periorbit Exposure of the periorbit –– no treatment, no consequencesno treatment, no consequences

�� Injury of the periorbit Injury of the periorbit –– let the fat into the ethmoid; no let the fat into the ethmoid; no

manipulation of the fatmanipulation of the fat

�� Avoid nasal packingAvoid nasal packing

�� Packing Packing –– one way valve, air or blood trap within the orbital one way valve, air or blood trap within the orbital

tissues tissues –– periorbital edema, ecchymosis, subcutaneos periorbital edema, ecchymosis, subcutaneos

emphysema or proptosisemphysema or proptosis

Orbital injuryOrbital injury

Injury of the medial rectus the most frequent – diplopia

Sometimes – inferior rectus or superior oblique

Increased risk with shavers

Management: ophtalmology evaluation, exploration and repair

Strabism surgery – not always succesfull

Optic nerve injuryOptic nerve injury

�� Papyracea injury not Papyracea injury not

recognized (especially in the recognized (especially in the

posterior ethmoid)posterior ethmoid)

�� Unrecognized Onodi cellUnrecognized Onodi cell

�� Partial loss of vision or Partial loss of vision or

blindnessblindness

�� Sphenoidotomy and optic Sphenoidotomy and optic

nerve decompressionnerve decompression

Suspected ON injury:Suspected ON injury:

Systemic steroidsSystemic steroids

Ophthalmology assessmentOphthalmology assessment

CT scan evaluationCT scan evaluation

CSF CSF -- leakleak

Conditions:Conditions: excessive intraop. bleeding, revision cases, massive polyposisexcessive intraop. bleeding, revision cases, massive polyposis

ManagementManagement::

�� Single layer repair Single layer repair –– free intranasal mucosal graft harvested from thefree intranasal mucosal graft harvested from the

septum or turbinateseptum or turbinate

�� Sometimes Sometimes –– 2 layers procedure using septal bone or cartilage2 layers procedure using septal bone or cartilage

+ absorbable packing material + nonabsorbable packing (7 days)+ absorbable packing material + nonabsorbable packing (7 days)

Immediately after the procedure Immediately after the procedure -- CT scan to asses pneumocephalus orCT scan to asses pneumocephalus or

brain injurybrain injury

�� 62 yrs old women62 yrs old women

�� left nasal fossa watery discharge (last 2 yrs)left nasal fossa watery discharge (last 2 yrs)

�� 2 episodes of bacterial meningitis (Pneumococcal)2 episodes of bacterial meningitis (Pneumococcal)

�� No trauma, no prior surgeryNo trauma, no prior surgery

�� Several negative ENT examinations (including endoscopy)Several negative ENT examinations (including endoscopy)

�� CT CT –– scan interpreted as normal( but a mild assymetric scan interpreted as normal( but a mild assymetric

olfactory cleft can be observed)olfactory cleft can be observed)

�� What would you like to do next?What would you like to do next?

Carotid Artery InjuryCarotid Artery Injury

ConditionsConditions

Sphenoid sinus entered too far laterallySphenoid sinus entered too far laterally

Disection performed along the lateral sphenoid wallDisection performed along the lateral sphenoid wall

Intersphenoid bony septum manipulated aggressive Intersphenoid bony septum manipulated aggressive

ManagementManagement

Packing the sphenoidPacking the sphenoid

Aggressive fluid resuscitation Aggressive fluid resuscitation –– hemodynamic controlhemodynamic control

Interventional radiology Interventional radiology –– coils or baloons to oclude the holecoils or baloons to oclude the hole

Stent of the ICAStent of the ICA

CrossCross--cranial vascular bycranial vascular by--passpass

ICA ICA �� As with conventional As with conventional cranial base surgery, the risk of vascular injury, and thecranial base surgery, the risk of vascular injury, and the

ability to treat it effectively, are related to the ability to treat it effectively, are related to the experienceexperience of the operating of the operating team.team.

�� A A neurosurgeonneurosurgeon ((who has cerebrovascularwho has cerebrovascular expertiseexpertise)) is a valuable addition is a valuable addition to the skull baseto the skull base surgery team and may be a critical component for thesurgery team and may be a critical component for themanagement of cases with complexity Levels IV and V.management of cases with complexity Levels IV and V.

�� TThe surgical team should he surgical team should acquire experienceacquire experience incrementally with surgeries of incrementally with surgeries of lower levels of complexitylower levels of complexity prior to undertaking procedures with complexity prior to undertaking procedures with complexity LevelsLevels IV and V. IV and V.

�� IIncreasencreasedd incidence incidence of vascular events is directly proportionalof vascular events is directly proportional to the to the increase in the increase in the level of surgical complexitylevel of surgical complexity..

Intra op or pIntra op or postopostop. minor . minor complicationscomplications

EpistaxisEpistaxis

During the operation During the operation –– coagulation or packingcoagulation or packing

Immediate after surgery or at 5Immediate after surgery or at 5--7 days when intranasal crusts dislodge7 days when intranasal crusts dislodge

ManagementManagement

Vasoconstrictors and aspiration of the clots and secretionsVasoconstrictors and aspiration of the clots and secretions

Packing materials Packing materials –– the best waythe best way

Silver Silver ––nitrate cauterizationnitrate cauterization

Electro cauterizationElectro cauterization

Extremely rare Extremely rare –– selective embolisationselective embolisation

SynechiaeSynechiae

Dense synechiae – source of anosmia, recurrent sinusitis and

mucocele formation

Place spacer or a packing material during surgery when the middle

turbinate mucosa is injured

Office procedures during the first weeks to divide the adhesions

LASER procedures under GA once healing completed

Orbital complicationsOrbital complications

Corneal abrasionCorneal abrasion

due to inadequate protection during surgerydue to inadequate protection during surgery

ophthalmology assessment, eye drops or ointments or eye patchingophthalmology assessment, eye drops or ointments or eye patching

EpiphoraEpiphora

Injury of the nasoInjury of the naso--lacrimal duct during antrostomylacrimal duct during antrostomy

Back biting forceps for too far in an anterior directionBack biting forceps for too far in an anterior direction

Probing, irrigation and intubation of the duct. If persists: EnProbing, irrigation and intubation of the duct. If persists: Endoscopic DCRdoscopic DCR

Orbital infectionOrbital infection

Conditions: Conditions: direct spread through bony dehiscence, retrograde thrombophlebitdirect spread through bony dehiscence, retrograde thrombophlebitisis

Periorbital celuluitis, erythema, oedema, eye pain,etcPeriorbital celuluitis, erythema, oedema, eye pain,etc

I.V. Antibiotics, packing removal and close monitoringI.V. Antibiotics, packing removal and close monitoring

Worsening of symptoms Worsening of symptoms –– CT scanCT scan

KnowKnow youryour--selfself -- TrainTrain youryour--selfself

1.1. Intensive theoretical studiesIntensive theoretical studies

2.2. Cadaver dissectionsCadaver dissections

3.3. Visiting surgical coursesVisiting surgical courses

4.4. Assist more experienced surgeonsAssist more experienced surgeons

5.5. Multimedia teaching (network of surgical Multimedia teaching (network of surgical

sites, CT interpretationsites, CT interpretation repair repair

complications)complications)

6.6. The novice surgeon: first 50 operations The novice surgeon: first 50 operations

with the help of an experienced surgeon with the help of an experienced surgeon

and the next 50 with help readily available and the next 50 with help readily available

(according to Draf)(according to Draf)

KnowKnow youryour--selfself -- EquipEquip youryour--selfself

1.1. Appropriate Appropriate instrumentationinstrumentation

2.2. High quality endoscopic equipmentHigh quality endoscopic equipment

1.1. Visualization (Visualization (High DefinitionHigh Definition))

2.2. Optics (0, 30, 45, 70 degree Optics (0, 30, 45, 70 degree telescopestelescopes))

3.3. ImageImage--guidance technology reduce guidance technology reduce

the complications riskthe complications risk

1.1. AnatomyAnatomy

2.2. ImagingImaging

3.3. Diagnostic endoscopyDiagnostic endoscopy

4.4. Surgery Surgery

5.5. Tips and tricksTips and tricks

Learning curve

Keep in mind!Keep in mind!

Surgical goal may not be achievedSurgical goal may not be achieved

Complications may be frequent during the first operationsComplications may be frequent during the first operations

RRecommendationsecommendations

�� Extended surgery (Skull base )Extended surgery (Skull base )

undertaken only after performingundertaken only after performing

> 1000 level I procedures (ESS)> 1000 level I procedures (ESS)

�� Cadaver dissectionCadaver dissection

�� Supervised surgerySupervised surgery

�� Staged surgeryStaged surgery

�� Dedicated followDedicated follow--up clinicsup clinics

The concept of The concept of staged surgerystaged surgery

Take home messagesTake home messages

�� Do as little as possible and as much as necessary (Wigand 1990)Do as little as possible and as much as necessary (Wigand 1990)

�� What we need: minimally invasive surgery or radical surgery What we need: minimally invasive surgery or radical surgery –– judge the judge the disease and itdisease and it’’s treatment optionss treatment options……

�� Staging is mandatory Staging is mandatory –– symptomes score, CT score , endoscopic score, symptomes score, CT score , endoscopic score, histopathologic scorehistopathologic score

�� Operate patients to relief symptoms, do not operate CT scans! Operate patients to relief symptoms, do not operate CT scans!

�� If complications occur you have to be able to manage them (aloneIf complications occur you have to be able to manage them (alone or team)or team)

�� The most serious complications belong to the most experienced suThe most serious complications belong to the most experienced surgeons rgeons (Draf)!(Draf)!