Possible complications of Functional Endoscopic Sinus Surgery
- Recurrence of disease: polyps, fungus or inverted nasal papilloma.
- Intranasal adhesions and stenosis of sinus ostium.
- Crustation and the need for regular nasal toilet.
- Impaired or loss of sense of smell which could be due to disease or surgery.
- Persistent postnasal discharge: this is due to allergic or vasomotor elements, limited surgery or fungus infection. Fungus causes mucopurulent discharge which is not responding to antibiotic treatment. Antifungal agents are given once diagnosis is confirmed.
- Virus rhinitis during first two weeks postoperative is really disappointing and may predispose for complications such as bacterial infection, adhesions, stenosis and prolonged postnasal drip. If this happens a long course of antibiotics and costicosteroid is indicated.
- Squint or double vision due to injury to the eye muscles, medial rectus muscle or superior oblique muscle.
- Impaired or loss of vision due to:
- Intraorbital bleeding.
- Injury to optic nerve.
- CSF leak and meningitis due to dural tear.
- Brain abscess due to spread of infection by emissary veins.
Superior overdissection, may lead to cerebrospinal fluid leak, due to penetration of the dura through the fovea ethmoidalis or cribriform plate. If this is recognized intraoperatively, it should be repaired with fat, fascia, mucosal flap, tissue glue and packing. If recognized postoperatively, conservative treatment is recommended unless it is too large to close spontaneously. Closure is obtained by endoscopic approach or by the external approach with the help of the neurosurgeon.
Lateral overdissection, may lead to penetration of the lamina papyracea. If orbital fat is noted, do not pull or remove the fat, just leave it alone. There will be no adverse effect other than some echymosis in the medial canthus area. Deeper entry into the orbit may result in damage to the medial rectus muscle or the optic nerve. If this occurs, an immediate ophthalmic consultation should be obtained. The surgeon should always be prepared to do an orbital decompression. This is most quickly obtained by lateral canthotomy, or during the procedure by removing the lamina papyracae and medial wall of the orbit.
Fig. 15 – 6. Basic endoscopic sinus surgery: excision of uncinate process, bullous Ethmoidalis, excentration of anterior ethmoid air cells, enlargement of natural maxillary ostium and partial trimming of middle turbinate.
- can damage the nasolacrimal duct, spontaneous fistulization may occur. In case of obstruction, endoscopic intranasal dacrocystorhinostomy is indicated.
Based on the author’s experience of over 1,100 cases of Functional Endoscopic Sinus Surgery, the author recommends the following prophylactic means:
- The patient should stop aspirin or any anticoagulant a few days before the operation.
- The preoperative CT Scan should be available and positioned in front of the surgeon during the procedure.
- Immediate preoperative preparation of the nasal cavity by decongestant and local packing with Xylocaine gel and adrenaline 1:100,000 for twenty minutes.
- Do not cover the eye, observe and palpate during the procedure.
- Do not pull orbital fat, just leave it and continue your procedure.
- If any possibility of CSF leak, repair immediately with fat and fascia. Neurosurgical consultation is advised.
- Enter the sphenoid medially:
The distance to the back of the sphenoid is nearly equal to the distance to the back of the nasopharynx.
- If there is much bleeding or if there is any question of distorted anatomy due to previous surgery, stop surgery and reassess, if you are still not sure, discontinue the operation or call a senior colleague.
- A right handed surgeon should start on the right side, because it is more difficult.
- At the end of the procedure, always use intranasal splints to reduce the incidence of adhesions.
- Perioperative medication. (p. 359)
|Fig. 15 – 7. (14) Pansinusitis (15) Chronic rhino-sinusitis, with maxillary polyposis. (16) Bilateral maxillary sinusitis right side, right frontal, ethmoid and partial sphenoid sinusitis, hypertropheid nasal turbinates with nasal polyps.|