Perioperative Management of Endoscopic Sinus Surgery

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  • Diseases of the Nasal Chambers and Nasopharynx-1st edition Copyright 2005 The American Academy of Otolaryngology—Head and Neck Surgery Foundation Slide 7—Anatomy of the Nasal Chamber Structures (Anterior Rhinoscopy) The slide contains two pictures of the nasal chamber of the right side as seen during an anterior rhinoscopy. The picture on the left demonstrates the inferior and middle turbinates as well as the nasal septum (N.S.). The middle and the inferior meatus are partially visible. The picture on the right side is also a picture of the right nasal chamber. It is a closeup view of the middle turbinate (M.T.) at the level of its insertion. The agger nasi (A.N.) is noticed as a small prominence. The bulla ethmoidalis (B) is seen as a protrusion noticed lateral to the middle turbinate.
  • Diseases of the Nasal Chambers and Nasopharynx-1st edition Copyright 2005 The American Academy of Otolaryngology—Head and Neck Surgery Foundation Slide 8—Anatomy of the Nasal Chamber Structures (Anterior Rhinoscopy)   The slide shows two pictures of the nasal chamber of the left side. The picture on the left shows structures associated with the middle meatus such as the middle turbinate (M.T.), the bulla ethmoidalis (B. Et.), and the uncinate process (U.P.). A small high deviation of the nasal septum (S) is noticed.
  • Diseases of the Nasal Chambers and Nasopharynx-1st edition Copyright 2005 The American Academy of Otolaryngology—Head and Neck Surgery Foundation Slide 9—The Nasopharynx This is an anterior view of the nasopharynx as seen through a rigid telescope. The torus tubarium (T.T) is seen forming the posterior and superior aspect of the eustachian tube (E.T.). The Rosenmuller’s fossa (R.F.) is seen as a slit posterior to the torus tubarium. The umbilications seen in the central portion of the nasopharynx correspond to the embryonic indentations left by Rathke’s pouch.
  • Diseases of the Nasal Chambers and Nasopharynx-1st edition Copyright 2005 The American Academy of Otolaryngology—Head and Neck Surgery Foundation Slide 11—CAT Scan of the Sinus (Normal) The picture shows two coronal views of the sinuses. The picture on the right shows the most anterior portion of the frontal sinus and the nasofrontal duct opening into the middle meatus. The computerized axial tomography (CAT) scan on the left shows normal ethmoid structures and patent osteomeatal ducts.
  • Diseases of the Nasal Chambers and Nasopharynx-1st edition Copyright 2005 The American Academy of Otolaryngology—Head and Neck Surgery Foundation INFECTIOUS PROCESSES Slide 17—Rhinosinusitis Purulent rhinosinusitis is an acute or chronic inflammatory process characterized by the bacterial infection of the lining of the sinuses. Purulent rhinitis refers to the bacterial infectious process of the mucosa of the nasal chambers only, seen often during the process of viral infections. Rhinosinusitis is usually preceded by a cold, excessive dryness, an allergic process, or exposure to pollutants. Excessive dryness of the nasal chambers due to environmental factors such as excessive use of air conditioning or furnace may also be a predominant factor. Symptoms such as morning headache, or dull pain over the frontal, maxillary, or ethmoid (nasal pyramid) are common. Periorbital swelling, loss of smell, and stuffy nose are often observed. Also dental pain and maxillary pressure sensation may be noticed. Sphenoid sinuses may induce retro-orbital (top of the head) pain and earache. Rhinosinusitis may cause fever, cough, runny nose, and generalized weakness. The etiology has been attributed to the compromise of the drainage system of the sinus involved (frontal sinus duct and frontal recess for the frontal sinus, the osteomeatal complex for the maxillary sinus, the sphenoid sinus ostium for the sphenoid sinus, and the ethmoid cell complex for the ethmoid sinuses). Clinically acute rhinosinusitis is characterized by sensation of pain or pressure in the maxillary area, nasal pyramid, or base of frontal area. In sphenoid rhinosinusitis retro-ocular pain is frequently found. Pain to pressure of affected sinus is a common finding. Rhinosinusitis is usually accompanied by the presence of greenish purulent material, bloody secretions, and foul odor. S. pneumonia and H. influenzae and M. catarrhalis are the most commonly found pathogens in acute rhinosinusitis. The process usually responds to a broad aspect oral antibiotic but if the disease process fails to improve a more appropriate antibiotic should be instituted to cover a penicillin-resistant bacteria. Cultures or drainage of the sinus may be necessary. A chronic rhinosinusitis is an acute rhinosinusitis that has failed to resolve after a considerable (usually 12 weeks) period of time and treatment. Usually in these cases the bacteriological characteristics of the process change and cultures are necessary in order to establish a proper treatment. Multiple bacteria are the rule, including some not commonly associated with the production of sinus disease. Surgical treatment, open or endoscopic, is aimed primarily at the re-establishment of proper drainage of the affected sinus.
  • Diseases of the Nasal Chambers and Nasopharynx-1st edition Copyright 2005 The American Academy of Otolaryngology—Head and Neck Surgery Foundation Slide 18—Rhinosinusitis (Maxillary-Ethmoid) In acute maxillary rhinosinusitis bulging of the middle meatus and hypertrophy of the bulla ethmoidalis are frequently seen due to increased intramaxillary pressure after obstruction of the osteomeatal complex. The picture on the right side shows a bulging middle meatus; the picture on the left is a coronal CAT scan view of an acute maxillary rhinosinusitis with deforming bulging of the middle meatus.
  • Diseases of the Nasal Chambers and Nasopharynx-1st edition Copyright 2005 The American Academy of Otolaryngology—Head and Neck Surgery Foundation Slide 19—Rhinosinusitis (Maxillary-Ethmoid) The picture shows two coronal CAT scans of the sinuses. The CAT scan on the right side shows a rhinosinusitis of the right maxillary sinus with obstruction of the osteomeatal complex. In the left maxillary sinus there is mucoperiosteal thickening as well as obstruction of the osteomeatal complex. There is also thickening of the mucosa of the ethmoid sinuses. Bilateral bullous middle turbinates can be seen. The CAT scan on the left demonstrates mucoperiosteal thickening of the left ethmoid cells as seen in chronic and acute ethmoiditis.
  • Diseases of the Nasal Chambers and Nasopharynx-1st edition Copyright 2005 The American Academy of Otolaryngology—Head and Neck Surgery Foundation Slide 20—Rhinosinusitis (Sphenoid) This coronal CAT scan shows an opacified left sphenoid sinus.
  • Diseases of the Nasal Chambers and Nasopharynx-1st edition Copyright 2005 The American Academy of Otolaryngology—Head and Neck Surgery Foundation PART II INFLAMMATORY DISEASES OF THE NASAL CHAMBERS AND NASOPHARYNX Nasal polyps are masses developed in the nasal mucosa in response to a chronic inflammatory condition. Histopathologically, they simply demonstrate mild inflammatory changes with slight eosinophilia in a severely edematous stroma. Slide 12—Nasal Polyps The slide shows two different manifestations of polypoid disease. The polyp on the left side of the slide is large and obstructing most of the airway. The mass is fleshy, soft to palpation, glistening, and associated with superficial small vessel enlargement. The polyps seen on the right side of the picture are located in the middle meatus and have the same morphologic characteristics as the other.
  • Diseases of the Nasal Chambers and Nasopharynx-1st edition Copyright 2005 The American Academy of Otolaryngology—Head and Neck Surgery Foundation Slide 13—Nasal Polyps (Antrochoanal) Occasionally an antral polyp arising from the mucosa of the maxillary sinus may protrude through one of the natural or accessory ostiums and become present in the nasal chamber stretching posteriorly into the nasopharynx as a hanging mass.
  • Diseases of the Nasal Chambers and Nasopharynx-1st edition Copyright 2005 The American Academy of Otolaryngology—Head and Neck Surgery Foundation Slide 14—Nasal Polyps The slide shows a CAT scan demonstrating a coronal view of the ethmoid and maxillary sinuses. There is extensive homogeneous opacification of the ethmoid cells with decreased density of the bony structures as seen in extensive polyposis. There is evidence of bilateral air fluid levels of both maxillary sinuses.
  • Diseases of the Nasal Chambers and Nasopharynx-1st edition Copyright 2005 The American Academy of Otolaryngology—Head and Neck Surgery Foundation Slide 35—Septum Deviation – Adhesion The slide on the left side shows a septum deviation with almost total obstruction of the nasal airway. The slide on the left side shows an adhesion of the middle turbinate to the septum. These adhesions are usually of iatrogenic origin after endonasal surgery or nasal packing in the treatment of epistaxis. These adhesions induce respiratory obstruction and may promote crusting.
  • Diseases of the Nasal Chambers and Nasopharynx-1st edition Copyright 2005 The American Academy of Otolaryngology—Head and Neck Surgery Foundation Slide 56—Cavernous Sinus Thrombosis Cavernous sinus thrombosis is usually found subsequent to ethmoiditis and/or sphenoiditis. The disease is potentially fatal and requires immediate and adequate treatment. Classical signs of cavernous sinus thrombosis include proptosis, chemosis and ophthalmoplegia, fever, and general toxicity. The treatment includes antibiotics, surgical drainage of the affected sinus, and anticoagulants. The disease has a high index of morbidity and mortality. The slide on the right side demonstrates a transverse MRI view at the level of the sphenoid sinus and the cavernous sinus. There is evidence of right-sided sphenoiditis. At the same time there is diffuse opacification of the cavernous sinus as demonstrated around the lower portion of the white lines (circles). On the left side of the picture in the upper part we can see pre-septal and post-septal edema manifested by eyelid edema and proptosis. In the same picture small skin ulcerative lesions are seen in the nasal pyramid. These lesions were disturbed by the patient causing skin cellulitis and subsequent cavernous sinus thrombosis. The small picture in the lower left shows proptosis and chemosis.
  • Diseases of the Nasal Chambers and Nasopharynx-1st edition Copyright 2005 The American Academy of Otolaryngology—Head and Neck Surgery Foundation Slide 55—Squamous Cell Carcinoma - Rhinophyma The slide on the right side shows a rhinophyma. A rhinophyma is a hypertrophy of the sebaceous glands usually due to longstanding rosacea. The lesion can induce severe deformity of the nasal pyramid. Treatment when early may be focused as a treatment for the rosacea. Surgery may be necessary when the disfigurement is severe. The slide on the left side shows an extensive squamous cell carcinoma of the skin with destruction of the nasal pyramid.
  • Diseases of the Nasal Chambers and Nasopharynx-1st edition Copyright 2005 The American Academy of Otolaryngology—Head and Neck Surgery Foundation Slide 42—Estesioneuroblastoma   The estesioneuroblastoma is a rare embryonic tumor associated with the neuroblasts of the olfactory epithelium (neuroectodermic). This tumor is locally aggressive, invading adjacent structures such as the orbit, paranasal sinus, cranial fossa, and cavernous sinus. It has the potential to produce local and distant metastases. Usual symptoms include nasal obstruction of long duration, anosmia, and bleeding. However, the tumor may remain silent for a prolonged period of time, and symptoms of intracranial invasion may be its first manifestation. At examination a polypoidal easily bleeding mass is usually found. The slide on the right side shows an estesioneuroblastoma presenting as a polypoid mass arising from the medial aspect of the insertion of the middle turbinate (cribriform plate). The left side of the slide demonstrates an estesioneuroblastoma of the cribriform plate with extensive extension to the anterior cranial fossa.
  • Perioperative Management of Endoscopic Sinus Surgery

    1. 1. Perioperative Management of Endoscopic Sinus Surgery Chad McCormick, MD, FAAOA
    2. 2. Sinus Anatomy Review
    3. 3. Paranasal Sinuses
    4. 4. Paranasal Sinuses
    5. 5. Sinus CT scan (coronal cut)
    6. 6. Sinus CT scan (axial cut)
    7. 7. Objectives <ul><li>Define chronic rhinosinusitis (CRS) </li></ul><ul><li>Review anatomy of paranasal sinuses </li></ul><ul><li>Describe medical management of CRS </li></ul><ul><li>Describe surgical management of CRS </li></ul><ul><ul><li>Preoperative, intraoperative, and postoperative care </li></ul></ul><ul><li>Discuss expected results and possible complications of sinus surgery </li></ul>
    8. 8. Definitions <ul><li>Sinusitis affects 1 in 7 adults in the United States each year </li></ul><ul><ul><li>31 million individuals diagnosed each year </li></ul></ul><ul><li>Direct annual healthcare cost of $5.8 B </li></ul><ul><ul><li>500,000 surgical procedures performed each ear </li></ul></ul><ul><ul><ul><ul><li>Executive summary (AAO/HNS). Clinical practice guideline on adult sinusitis. Rosenfeld RM. Otolaryngology-Head and Neck Surgery (2007) 137, 365-377 </li></ul></ul></ul></ul>
    9. 9. Definition of rhinosinusitis <ul><li>Rhinosinusitis </li></ul><ul><ul><li>The term rhinosinusitis is preferred because sinusitis is almost always accompanied by inflammation of the contiguous nasal mucosa </li></ul></ul><ul><ul><li>Symptomatic inflammation of the paranasal sinuses and nasal cavity </li></ul></ul><ul><ul><li>Duration of symptoms </li></ul></ul><ul><ul><ul><li>Acute, recurrent acute, subacute, chronic </li></ul></ul></ul>
    10. 10. Definition of rhinosinusitis <ul><ul><li>Acute </li></ul></ul><ul><ul><ul><li>Affected < 4 weeks </li></ul></ul></ul><ul><ul><li>Recurrent acute </li></ul></ul><ul><ul><ul><li>4 or more acute episodes per year without persistent symptoms between episodes </li></ul></ul></ul><ul><ul><li>Subacute </li></ul></ul><ul><ul><ul><li>Affected 4-12 weeks </li></ul></ul></ul><ul><ul><li>Chronic </li></ul></ul><ul><ul><ul><li>Affected > 12 weeks, with or without acute exacerbations </li></ul></ul></ul>
    11. 11. Chronic rhinosinusitis (CRS) <ul><ul><ul><li>12 weeks or longer of 2 or more of the following signs and symptoms: </li></ul></ul></ul><ul><ul><ul><ul><li>Mucopurulent drainage (anterior, posterior, or both) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Nasal obstruction (congestion) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Facial pain-pressure-fullness, or </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Decreased sense of smell </li></ul></ul></ul></ul><ul><ul><ul><li>AND inflammation is documented by 1 or more of the following findings: </li></ul></ul></ul><ul><ul><ul><ul><li>Purulent mucus or edema in the middle meatus or ethmoid region </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Polyps in nasal cavity or middle meatus, and/or </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Radiographic imaging showing inflammation of the paranasal sinuses </li></ul></ul></ul></ul>
    12. 12. Acute Bacterial Sinusitis
    13. 13. Chronic rhinosinusitis
    14. 14. Anatomy
    15. 18. Anatomy of the Nasal Chamber Structures (Anterior Rhinoscopy)
    16. 19. Anatomy of the Nasal Chamber Structures (Anterior Rhinoscopy)
    17. 20. The Nasopharynx
    18. 21. CAT Scan of the Sinus (Normal)
    19. 23. Rhinosinusitis
    20. 24. Rhinosinusitis (Maxillary-Ethmoid)
    21. 26. Rhinosinusitis (Sphenoid)
    22. 27. Nasal Polyps
    23. 28. Nasal Polyps (Antrochoanal)
    24. 29. Nasal Polyps
    25. 30. Medical management of chronic rhinosinusitis <ul><li>Oral antibiotics </li></ul><ul><li>Nasal decongestants </li></ul><ul><li>Nasal saline spray/irrigation </li></ul><ul><li>Intranasal steroid spray </li></ul><ul><li>Oral mucolytics </li></ul><ul><li>Oral steroids </li></ul>
    26. 31. Medical management <ul><li>Confirmatory diagnosis </li></ul><ul><ul><li>Nasal endoscopy </li></ul></ul><ul><ul><ul><li>Culture if indicated </li></ul></ul></ul><ul><ul><li>Limited sinus CT scan </li></ul></ul><ul><ul><ul><li>“ Gold standard” </li></ul></ul></ul>
    27. 32. Medical management <ul><li>Consider allergy and immune testing </li></ul><ul><ul><li>Allergic rhinitis </li></ul></ul><ul><ul><ul><li>Most patients with extensive sinus disease on CT scan have evidence of environmental allergy </li></ul></ul></ul><ul><ul><li>Immunodeficiency </li></ul></ul><ul><li>Other possible contributing etiologies </li></ul><ul><ul><li>Cystic fibrosis </li></ul></ul><ul><ul><li>Ciliary dyskinesia </li></ul></ul>
    28. 33. Medical management <ul><li>Prevention </li></ul><ul><ul><li>Practice of good hand hygiene, especially when in contact with ill individuals </li></ul></ul><ul><ul><li>Smoking cessation </li></ul></ul><ul><ul><li>Use of nasal saline spray/irrigation </li></ul></ul><ul><ul><li>Consider allergy shots/drops (immunotherapy) for allergic patient </li></ul></ul>
    29. 34. Surgical management of chronic rhinosinusitis <ul><li>If medical management fails, </li></ul><ul><ul><li>And, clear evidence of bacterial infection or anatomic obstruction, </li></ul></ul><ul><ul><li>And, significant symptoms and/or significant loss of times at work, school etc., </li></ul></ul><ul><ul><li>Then, consider surgery </li></ul></ul><ul><ul><ul><li>No official guideline for frequency of infections </li></ul></ul></ul><ul><ul><ul><ul><li>Consider 4 or more episodes of infection during the past year </li></ul></ul></ul></ul>
    30. 35. Surgical management <ul><li>Open approaches are now relatively rare </li></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><li>Complications (subperiosteal abscess, etc.) </li></ul></ul><ul><ul><li>Complex frontal sinus disease (frontal mucocele, etc.) </li></ul></ul>
    31. 36. Intraorbital Abcess Secondary to Acute Sinusitis
    32. 37. Frontal Mucocele
    33. 38. Surgical management <ul><li>Functional endoscopic sinus surgery (FESS) </li></ul><ul><ul><li>Vast majority of sinus surgery </li></ul></ul><ul><ul><li>Surgical treatment is aimed primarily at re-establishment of proper drainage of the affected sinus </li></ul></ul><ul><ul><ul><li>Intraoperative image guidance may be used </li></ul></ul></ul><ul><ul><ul><ul><li>revision sinus surgery </li></ul></ul></ul></ul><ul><ul><ul><ul><li>diffuse nasal polyposis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>abnormal anatomy </li></ul></ul></ul></ul>
    34. 39. Surgical management <ul><li>Minimally invasive sinus surgery </li></ul><ul><ul><li>ie, balloon sinuplasty </li></ul></ul>
    35. 40. Steps in using these devices are:                                                        
    36. 41. Surgical management - preoperative <ul><li>Review Anatomy </li></ul><ul><li>Limit blood loss/reduce inflammation </li></ul><ul><ul><li>Avoid aspirin, ibuprofen for 7-10 days prior to surgery </li></ul></ul><ul><ul><li>Preoperative oral steroids utilized by some surgeons </li></ul></ul>
    37. 42. General preventive strategies <ul><ul><ul><ul><li>Thorough preoperative evaluation of patient </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>hx bleeding diathesis, ASA/ibuprofen usage, prolonged steroid use, poorly-controlled hypertension </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>history previous sinus surgery </li></ul></ul></ul></ul><ul><ul><ul><ul><li>detailed review of preoperative CT scan </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>evaluate frontals, maxillary/OMC, ethmoids/cribiform plate, sphenoid </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>localize key landmarks to prevent disorientation </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>anterior ethmoid artery, anterior face sphenoid, fovea ethmoidalis, lamina papyracea, middle turbinate </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Skull base slopes downwardly from anterior to posterior </li></ul></ul></ul></ul></ul>
    38. 43. General preventive strategies <ul><ul><ul><ul><li>excellent knowledge of anatomy and clear view of the field are mandatory </li></ul></ul></ul></ul><ul><ul><ul><ul><li>medial skull base roof associated with anterior ethmoidal artery medially is 10X thinner than other regions </li></ul></ul></ul></ul><ul><ul><ul><ul><li>excessive intraoperative bleeding or disorientation is indication for termination of procedure </li></ul></ul></ul></ul>
    39. 44. Surgical management - intraoperative <ul><li>Intraoperative </li></ul><ul><ul><li>Excellent knowledge of anatomy/CT scan up </li></ul></ul><ul><ul><li>Turn table 90 or 180 degrees </li></ul></ul><ul><ul><li>Endotracheal tube to left side of mouth if right handed surgeon </li></ul></ul><ul><ul><li>Leave eyes untaped </li></ul></ul><ul><ul><li>Local injection/topical decongestant use </li></ul></ul><ul><ul><li>Reverse Trendelenburg position/controlled hypotension </li></ul></ul>
    40. 45. Surgical management - postoperative <ul><li>Pain control </li></ul><ul><li>Antibiotics/steroids debatable </li></ul><ul><li>Nasal saline spray/irrigation </li></ul><ul><li>Oxymetazoline x 3 days </li></ul><ul><li>Elevate head of bed x 2-3 days </li></ul><ul><li>Plan for 4-7 days off of work </li></ul><ul><li>Approximately 1 month until fully healed </li></ul>
    41. 46. Surgical management - postoperative <ul><li>Removable versus absorbable nasal dressings </li></ul><ul><ul><li>Trend away from removable nasal dressings </li></ul></ul><ul><ul><li>No conclusive evidence that absorbable nasal dressings show any advantage over no dressing at all </li></ul></ul><ul><li>Postoperative debridement to prevent scarring </li></ul>
    42. 47. Possible complications of FESS <ul><li>Surgery “under the brain and between the eyes” leaves little margin for error </li></ul><ul><li>“ Surgery of the ethmoid has proved to be one of the easiest operations with which to kill a patient.” </li></ul><ul><ul><ul><li>Mosher, 1929 </li></ul></ul></ul>
    43. 48. Complications <ul><ul><li>Complications specific to endoscopic sinus surgery (ESS) may be categorized as: </li></ul></ul><ul><ul><ul><li>intranasal </li></ul></ul></ul><ul><ul><ul><li>periorbital/orbital </li></ul></ul></ul><ul><ul><ul><li>intracranial </li></ul></ul></ul><ul><ul><ul><li>vascular </li></ul></ul></ul><ul><ul><ul><li>systemic </li></ul></ul></ul><ul><ul><ul><li>potential need for revision surgery </li></ul></ul></ul>
    44. 49. Major vs. minor complications <ul><ul><li>Major </li></ul></ul><ul><ul><ul><li>those complications that caused permanent damage to the patient or those that might have caused permanent damage if they had not been treated </li></ul></ul></ul><ul><ul><ul><ul><li>most commonly CSF leak </li></ul></ul></ul></ul><ul><ul><li>Minor </li></ul></ul><ul><ul><ul><li>all other complications </li></ul></ul></ul><ul><ul><ul><ul><li>most commonly synechiae formation, periorbital eccymosis/emphysema, hemorrhage </li></ul></ul></ul></ul>
    45. 50. Possible complications of FESS - minor <ul><li>Anesthesia risks </li></ul><ul><li>Bleeding </li></ul><ul><li>Synechiae (scar formation) </li></ul><ul><li>Nasolacrimal duct injury </li></ul><ul><li>Diminished sense of smell </li></ul><ul><li>Surgical failure (failure to improve) </li></ul><ul><ul><li>5-15% </li></ul></ul>
    46. 51. Complications <ul><ul><ul><li>Intranasal </li></ul></ul></ul><ul><ul><ul><ul><li>synechiae (~8%) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>stenosis or closure of surgically enlarged maxillary sinus ostium (~2%) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>nasolacrimal duct injury (variable incidence) </li></ul></ul></ul></ul>
    47. 52. Ant. ethmoid artery
    48. 53. Septum Deviation – Adhesion
    49. 54. Terris MH, et al. Review of published results for ESS. Ear Nose Throat J. 1994. (UCSD) <ul><ul><li>Reviewed 10 large series of reports on ESS (1713 patients) </li></ul></ul><ul><ul><ul><li>major complication rate - 1.56% </li></ul></ul></ul><ul><ul><ul><ul><li>most commonly bleeding </li></ul></ul></ul></ul><ul><ul><ul><li>minor complication rate - 2% </li></ul></ul></ul><ul><ul><ul><ul><li>most commonly temporary epiphora, periorbital ecchymosis or emphysema </li></ul></ul></ul></ul><ul><ul><ul><li>need for revision surgery - 12% </li></ul></ul></ul><ul><ul><ul><ul><li>as patients are followed for longer periods, revision rate likely to increase </li></ul></ul></ul></ul>
    50. 55. Terris MH, et al. Review of published results for ESS. Ear Nose Throat J. 1994. (UCSD) <ul><ul><li>Patients subjectively rated own results </li></ul></ul><ul><ul><ul><li>very good result (63%) : either complete resolution of symptoms or rare episodes of sinusitis (<2/year) which respond to antibiotics </li></ul></ul></ul><ul><ul><ul><li>good result (28%): improvement but no resolution of symptoms (2-5 episodes of sinusitis per year with good response to antibiotics) </li></ul></ul></ul><ul><ul><ul><li>poor result (9%): no resolution or worsening of symptoms </li></ul></ul></ul><ul><ul><li>Objective results are more difficult to assess </li></ul></ul>
    51. 56. Possible complications of FESS - major <ul><li>Intracranial injury </li></ul><ul><li>Orbital injury </li></ul><ul><li>Carotid artery injury </li></ul>
    52. 57. Complications <ul><ul><ul><li>Intracranial injury </li></ul></ul></ul><ul><ul><ul><ul><li>most commonly secondary to cribiform plate damage or penetration of medial ethmoid wall </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>CSF leak (0.05-0.9%) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>pneumocephalus </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>meningitis </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>intracranial abscess </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>intracranial hemorrhage </li></ul></ul></ul></ul></ul>
    53. 58. Complications <ul><ul><ul><li>Periorbital/orbital </li></ul></ul></ul><ul><ul><ul><ul><li>periorbital ecchymosis/edema/emphysema </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>disruption of lamina papyracea (0.5-1.5%) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>diplopia </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>medial rectus or superior oblique muscle/nerve injury </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>optic nerve injury or blindness </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>intraorbital or retrobulbar hemorrhage </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>direct optic nerve injury </li></ul></ul></ul></ul></ul>
    54. 59. Complications <ul><ul><ul><li>Vascular </li></ul></ul></ul><ul><ul><ul><ul><li>anterior or posterior ethmoid artery </li></ul></ul></ul></ul><ul><ul><ul><ul><li>sphenopalatine artery </li></ul></ul></ul></ul><ul><ul><ul><ul><li>internal carotid artery </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>10-20% ICA’s dehiscent in sphenoid and only mucosally protected </li></ul></ul></ul></ul></ul>
    55. 60. Maniglia AJ. Fatal and other major complications of ESS. Laryngoscope. 1991. (Case Western) <ul><ul><li>Emphasized that informed consent is necessary </li></ul></ul><ul><ul><ul><li>patients should be aware of potential devastating problems and alternative forms of medical treatment </li></ul></ul></ul>
    56. 61. Low cribiform plate
    57. 62. Intracranial injury
    58. 63. Dehiscent lamina papyracea
    59. 64. Orbital injury
    60. 65. Optic nerve
    61. 66. Optic nerve
    62. 67. Dehiscent optic nerve
    63. 68. Optic nerve injury
    64. 69. Pneumatization
    65. 70. Carotid artery
    66. 71. Carotid artery
    67. 72. Cavernous Sinus Thrombosis
    68. 73. Squamous Cell Carcinoma - Rhinophyma
    69. 74. Estesioneuroblastoma
    70. 75. Review <ul><li>Define chronic rhinosinusitis (CRS) </li></ul><ul><li>Review anatomy of paranasal sinuses </li></ul><ul><li>Describe medical management of CRS </li></ul><ul><li>Describe surgical management of CRS </li></ul><ul><ul><li>Preoperative, intraoperative, and postoperative care </li></ul></ul><ul><li>Discuss expected results and possible complications of sinus surgery </li></ul>
    71. 76. <ul><li>Questions </li></ul>

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