Minimize FESS Complication

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How can we minimize complications of ESS in patient with Chronic Rhinosinusitis By Dr. Rabie Rady

Introduction ESS has been increased popularity in the last two decades Success rate 76-98% Revision surgery 12-18% Medical treatment still the first line in recurrent acute and chronic rhinosinusitis.

All otolaryngologists should be familiar

with Mosher's writings from the early 20thcentury intranasal ethmoidectomy is one of the quickest ways to kill a patient

Most of the catastrophic complications are related to ethmoidectomy and

frontal sinus surgery

Complications of ESS still occur even with the best hands.e.g.

CSF leak (0.9 %) and an orbital haematoma (0.5 %)

Stankiewiczcomplication

suggestedrate

that

thewith

decreases

increasing experience, reporting a rateof

29 % in the first 90 cases which he

performed compared with only

2.2 %

in the subsequent 90 cases

Steps needed to minimize complications of ESSA-Preoperative assessment(history, examination and imaging studies)

B-Intraoperative precautions(general recommendations , specific precautions)

C-Postoperative follow up

A- Preoperative assessment1- History Onset, course and duration DM, Hypertension, Anticoagulants, Aspirin, NSAID. Recent infection smoking Allergic rhinitis, (68%), Bronchial asthma (80%) Previous nasal surgery (54-58%)

2-Clinical ExaminationInspection & Palpation Check the face for presence of i. Scar of previous surgery or trauma ii. Swelling in the cheek, at the nasal root, frontal , frontoethmoidal areas or oedema of the orbit iii. Presence of nasal saddling

Check the oral cavity & oropharynx dental caries, oroantral fistula, swelling descending from the nasopharynx as antrochoanal polyp Nasal polyposis ..etc) If there is a recent infection starts antibiotic& topical treatment. If there is nasal polyposis one could start a small dose of Prednisolone

Nasal examination (DNS, HIT, FS,

3-Imaging studiesCT scan MRI X-ray ( of little value)

CT scan of PNSShould be obtained at least 4 to 6 weeks following

aggressive medical therapy .

Remember that approximately 30% of asymptomatic population also have some mucosal changes on CT scan. At least , we should have an Axial and Coronal views

Check list of CT scan (Coronal View)1. Skull base 2- Medial orbital wall & its relation of UP 3-Anterior ethmoidal artery 4-Vertical height of posterior ethmoids 5- Maxillary sinus Hallers cells, accessory ostia 6- Sphenoid sinus 7- Frontal sinus 8- Nasal turbinates

Importance of Axial View Onodis cells Anterior -posterior tables of frontal sinus ( for frontal minitrephination)

MRI of PNS Better than CT scan to evaluate soft tissue. In presence of intracranial or intraorbital complication .

B- Intraoperative precautions General recommendations 1. Keep the eye uncovered during the whole time of the surgery 2. Ask for hypotensive anaethesia 3. Elevate the head of the patient about 30 degrees 4. Check the tissue you remove to know if it sinks of floats 5. Don't hesitate to stop the surgery at any time if there is a profuse bleeding 6. Recurrent cases------ for seniors

B- Intraoperative precautions

Important Landmarks1- Uncinate Process 2- Middle Turbinate

B- Intraoperative precautions

Important LandmarksUncinate Process

B- Intraoperative precautions

Important LandmarksMiddle TurbinateIts superior attachment separates the cribriform plate from the fovea ethmoidalis

B- Intraoperative precautions

Important Landmarks its anterior tip marks the limits of anterior dissection of maxillary antrostomy, the basal lamella identifies the entrance into the posterior ethmoidal sinuses

B- Intraoperative precautions

Precautions during steps of the surgeryStep of the surgeryManagement

I. Difficulties to see the Middle Meatus Deviated nasal septum Concha bullosa Septoplasty Remove the outer half of the middle turbinate

B- Intraoperative precautions

Precautions during steps of the surgeryStep of the surgery II-Difficulties on removing the Uncinate process Adherent uncinate to the lamina papyracea

Management

use a curette to dissect the uncinate off the medial orbital wall, do retrograde uncinectomy May be mistaken for ST

Pneumatized uncinate

B- Intraoperative precautions

Precautions during steps of the surgeryStep of the surgeryIII-Accessory sinus ostium( usually the natural ostium is hidden by the uncinate so, if you can see an ostium before removing the uncinate it is an accessory ostium)

Management

You should connect it to the natural ostium to avoid recirculation (usually in the posterior fontanelle but may be in the anterior or even on the uncinate)

B- Intraoperative precautions

Precautions during steps of the surgeryStep of the surgery Management

IV-Opening of Maxillary sinus1- Cant reach the natural opening 2- Atelectatic sinus or Silent sinus syndrome 1&2-Insert trocar and cannula in the inferior meatus then remove the trochar to irrigate the sinus with saline to identify the natural ostium

3- Hallers cells

3-Hallers cells may be a misleading for opening the antrum

B- Intraoperative precautions

Precautions during steps of the surgeryStep of the surgery Management

V-Difficulties on removing ethmoids1-Small bulla (Torus lateralis)

1- Enter the bulla inferomedial then remove it ( we may enter the orbit if the bulla is small)

2- Removing the basal lamella 2- if you complete this step the on removing the anterior next partition is the skull base ethmoids (dont remove otherwise CSFleak may occur 3&4- Check CT scan (Optic nerve injury-susceptible to orbital fat 4- (true or relatively)bulging of prolapse) 3- Onodis cells

medial orbital wall

B- Intraoperative precautions

Precautions during steps of the surgeryStep of the surgery VI-Removal of polyps on the skull base Management You should work from posterior to anterior and from medial to lateral Dont pull or push and leave it in place ,you can cauterize if it is obscuring on the field

VII-Orbital fat prolapse

B- Intraoperative precautions

Precautions during steps of the surgeryStep of the surgery Management

VIII- Frontal sinus1-Opening of the frontal sinus 1-Dont work circumferentially on the opening . External frontal sinus puncture 2-Cutting of the anterior ethmoidal artery 2-Orbital decompression (lateral canthotomy& inferior cantholysis)

B- Intraoperative precautions

Precautions during steps of the surgeryStep of the surgery Management

IX- opening of Sphenoid sinus

Dont manipulate the sphenoid septae

B- Intraoperative precautions

Precautions during steps of the surgeryStep of the surgery Management If unilateral, dont use the endoscope in the other side. Be aggressive to eradicate it Canine fossa approach Long term nasal wash &follow up

X- Fungal sinusitis

B- Intraoperative precautions

Precautions during steps of the surgeryStep of the surgery Management Middle turbinate resection Bolgerization Middle meatal spacers Conchopexy sutures

XI- Unstable middle turbinate from excessive manipulation

3-Postoperative follow upThe first visit usually in the first two dayspostoperatively to remove the nasal packs topical treatment (Alkaline nasal douche, normal saline, physiotherm, topical corticosteroids) long term follow up is important to increase the

success rate to detect early adhesions, removecrustsetc.

Comparison of complications of both Acute& Chronic RS with ESS complications

Acute& Chronic ESS Rhinosinusitis I- Orbital disorders

Orbital cellulitis StagesPre &post -septal cellulitis, Subperiosteal abscess, orbital abscess, Cavernous sinus thrombosis

Blindness, Diplopia,Nasolacrimal duct and sac injury Orbital hematoma Subcutaneous emphysema, Ecchymosis Lid edema and Anisocoria

Comparison of complications of both Acute& Chronic RS with ESS complications

Acute & Chronic ESS Rhinosinusitis II- Brain disorders

Meningitis Brain abscess

Death

Cerebrospinal fistula Meningitis, Frontal lobe injury Anosmia, Pneumocephalus Brain abscess

Death

Comparison of complications of both Acute& Chronic RS with ESS complications

Acute & Chronic Rhinosinusitis III- Septicemia & Septic shock syndrome

ESS III- Packing related

-Displaced packs -Aspiration -Increased orbital pressure -Myospherulosis -Toxic shock syndrome

Comparison of complications of both Acute & Chronic RS with ESS complications

Acute &Chronic Rhinosinusitis IV- Mucoceles & Mucopyoceles

ESS IV- Vascular injury Bleeding from branches of sphenoplalatine Internal carotid artery Anterior and Posterior ethmoidal artery

V- Potts puffy tumour

V- Synechiae

REFERENCES1-Otolaryngology Head and Neck Surgery, Toronto Notes,2010

2-Byron J. Bailey &Tonas T. Johnson Head & Neck SurgeryOtolaryngology, 4th ed,2006.3-European Manual of Medicine, Otolaryngology Head and Neck Surgery, 2009. 4-ENT &HN Radiology Course,Prof. Mamdouh Mahfouz, Cairo University , 2011. 5- Scott Brown, Otorhinolaryngology, Head and Neck Surgery, 7th ed, 2008.

6- Soraia A. S., Marcia M . A., Luis C G and Sergio A.:- Anterior ethmoidal artery evaluation on coronal CT scans, Brez J Otolaryngol, 2009; 75(1):101-6.

7- Neil G H, Christina B B , and James N P:- Transseptal sutureto secure middle meatu