This document discusses complications of functional endoscopic sinus surgery (FESS). It begins with an introduction stating the aim of FESS is to restore sinus function. It then discusses classifications of complications as minor or major. Minor complications include things like epistaxis while major includes blindness. Pre-operative evaluation and tips for surgery are provided such as using CT scans and taking time. Specific complications covered include hemorrhage from vessels. Overall it provides an overview of complications that can occur with FESS and tips to help avoid them.

1. COMPLICATIONS OF FUNCTIONAL ENDOSCOPIC
SINUS SURGERY
• Presenter: Dr Hameedullah Bakhtiary
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2. Layout
o INTRODUCTION
o CLASSIFICATION OF COMPLICATIONS
o PRE OP EVALUATION
o TIPS
o COMPLICATIONS OF FESS
o AVOIDANCE OF COMPLICATIONS
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3. INTRODUCTION
AIM OF FESS :
Functional endoscopic sinus surgery (FESS) aims to restore
mucociliary function by re-establishing physiologic sinus
ventilation and drainage
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4. INDICATIONS FOR PRIMARY SINONASAL
SURGERY
o Chronic Rhinosinusitis
o Acute Recurrent Rhinosinusitis
o Nasal Polyposis
o Mucocoeles
o Allergic Fungal Sinusitis
o Repair of Cerebrospinal Fluid (CSF) leaks
o Orbital and Optic Nerve Decompression
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5. INDICATIONS FOR PRIMARY SINONASAL
SURGERY
o Repair of Blow-out Fractures
o Dacryocystorhinostomy
o Hypophysectomy
o Septal and Turbinate Surgery
o Management of Epistaxis
o Drainage of Periorbital Abscess
o Some benign and Malignant Tumours
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6. CONTRAINDICATIONS FOR PRIMARY SINONASAL
SURGERY
o Intracranial Complication of acute Infection
o Meningitis
o Epidural Abscess
o Cavernous Sinus Thrombosis
o Subperiosteal Abscess
o Visual loss
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7. Classification of Complications
*Devyani Lal | James A. Stankiewicz , Cummings Otolaryngology Head&neck Surgery 6th Edition
Chapter 49
Minor complications :
 Minor epistaxis
 Hyposmia
 Adhesion
 Headache
 Periorbital Ecchymosis
or Emphysema
 Dental or Facial pain
Major complications :
 Major epistaxis
 Anosmia
 NLD trauma
 Carotid injury
 Intracranial hemorrhage
 Orbital hematoma, Diplopia
 Decreased visual acuity,
 Blindness
 CSF leak ,Pneumoencephalus
 Meningitis
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8. Classification of Complications
Major
SINUS SURGERY , Endoscopic and micoscopic appraoches by Howard
L.levine &M.Pais Clemente
SINUS SURGERY , Endoscopic and micoscopic appraoches by Howard L.levine
&M.Pais Clemente ENT dept
8
Temporary corrected with
treatment
 Orbital hematoma
 Diplopia
 NLD injury
 Massive hemorrhage
 CSF leak and Dural tear
 Pneumocephalus
 Meningitis and brain
abscess
 Focal brain damage
Permanent despite
treatment
 Blindness
 Olfactory impairment
 Stroke
 Residual CNS deficit
 Death

9. Classification of Complications
Temporary Minor , corrected with treatment
o Adhesions (symptomatic)
o Epistaxis requiring packing
o Infection
o Permanent Minor and not correctable (present beyond 1yr)
o Anosmia
o Dental/lip pain and numbness
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9

10. Classifications of complications
Manual of Endoscopic sinus and skull base surgery by Daniel simmen & Nick
Jones 2th edition
10
2-Post-operative
Bleeding
Adhesion
Epiphora
Periorbital emphysema
Anosmia
Frontal recess stenosis
Crusting
Infection
Osteitis
Neuropathic pain
1-Intra-operative
Bleeding
Fat herniation
CSF Leak
Retro- Orbital hemorrhage
Medial rectus damage
Optic Nerve damage
ENT dept

11. How common are the Complications
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11

12. Complications of Surgery for Nasal Polyposis and Chronic
Rhinosinusitis The Results of a National Audit in England and Wales
Claire Hopkins et al..
o Prospective ,multicenter study
o 3128 ,underwent FESS during 2000-2001 in 87center
o 11 Patients (0.4%) major(orbital , intracranial, bleeding)
o 207 patients (6.6%) minor comp
o Complications was Link (extend of disease and co-morbidity)
o Not correlate with surgical characteristics(extent of surgery, use of
microdebrider, grade of surgeon, and adjunctive turbinate surgery)
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13. Nationwide incidence of major complications in
endoscopic sinus surgery Vijay R. Ramakrishnan et al
o A total of 62,823 patients in a Retrospective review of a
nationwide database of patients who underwent ESS between
2003 and 2007
o The overall major complication rate was 1.00%
o CSF leak 0.17%;
o Orbital injury 0.07%;
o Hemorrhage requiring transfusion 0.76%
o CSF leak was less likely to occur in the pediatric population,
whereas orbital injury was more likely to occur in children
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14. 10/11/2017 ENT dept 14

15. Preoperative Assessment
• Scott Brown 7TH Edition Chapter 238 b
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o Detailed history whether the patient need surgery or not
o The factors with poorer outcome
(smoking,asthma,aspirin sensitivity, allergies and
immunodeficiency)
o Previous surgery
o Extend of the disease
ENT dept

16. Radiographic Examination
o Coronal views shows OMC and relationship of brain and orbit
with the PNS
o Axial views is complement of coronal view and for severe
disease In post Ethmoidal and sphenoid
o Saggital views useful for evaluation of FR anatomy and the
slope of Skull base
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17. When viewing the coronal images
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1. Start from fovea ethmoidalis to determine its slope and height

18. When viewing the coronal images
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2. Follow the lamina papyracea to rule out any
interruptions, defects, or medial displacements.

19. 3. Determine the maxillary sinus dimensions to rule
out hypoplasia
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20. 4. Observe variation of sphenoid wall and presence of
horizontal septum that may indicate Onodi cells
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Coronal CT image shows horizontal and obliquely oriented sphenoid sinus septae
(arrows) with Onodi cells (black arrowheads) into which the optic nerves are seen
dehiscent (white arrowheads).

21. 4. Observe variation of sphenoid wall and presence of
horizontal septum that may indicate Onodi cells
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22. Axial images:
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5. Follow lamina papyracea from anterior to posterior,
observing for defects
6. Finally, note the general dimensions of the sphenoid,
including its anterior-posterior depth and observe any
variation in its wall

23. Meyers and Valvassori reviewed a 400 pre
OP CT (1998)
1- Lamina papyracea lying medial to the maxillary ostium 10%
2- Maxillary sinus hypoplasia 4%
3- Fovea ethmoidalis abnormality like low or sloping fovea 2%
4- Lamina papyracea dehiscence 1%
5- Sphenoid sinus wall variations like septa attaches with Carotid
or dehiscence of carotid or Optic Nerve about 15%
6- Sphenoethmoid cell 3.4-14%
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24. TIPS
Preparation:
o Operate with the body 20◦ head up
o Have the head flexed on to the neck
o Don’t tape the eyes , regularly examine the eyes
o Never be tempted to operate without CT Scan
o Take your time . The saying “more haste ,less speed”
o Optimize your operating condition by maximizing preoperative
medical treatment
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25. Preoperative Medical Therapy
o Antibiotics and Steroid 7-10 days
o A national survey shows that in US 88.2% of Rhinologists use
pre op oral steroid 30-40 mg for 4-7 days
o Benefits
o Improves surgical field
o reduces inflammation
o reduces surgical time
o reduces bleeding
o reduces recurrence of the disease
o reduces need for revision
o improves symptoms
o Our dept policy
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26. Impact of Perioperative Systemic Steroids on Surgical
Outcomes in Patients With Chronic Rhinosinusitis With
Polyposis Erin D. Wright, MDCM, MEd; Sumit Agrawal, MD
o Double blind placebo –controlled RCT in 26 patients in 2007
o Group 1 Placebo
o Group 2 Prednisolone 30 mg daily for 5 days pre op and 9 days
o Reduced inflammation ,surgical difficulties during surgery
o No significant difference for operative duration or blood loss
o Post op olfaction was significantly better in 2 GP after 2 weeks
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27. Anesthesia
Local Anesthesia :
o LA With Sedation
o Calms Patients
o Stabilize Blood Pressure
o Minimizes Bleeding
o Improves Safety
o Young patients undergoing primary ESS for less than
2hrs
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28. Anesthesia
GA:
It is useful for anxious patients and children, and for
long procedures
Retrospective review of 177
Total operative and recovery times were shorter
The frequency of emesis, epistaxis, and
nausea was less in the LA group
Fedok FG, Ferraro RE, Kingsley CP, et al: Operative times, postanesthesia recovery
times, and complications during sinonasal surgery using general anesthesia and local
anesthesia with sedation.Otolaryngol Head Neck Surg 122:560–566,2000
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29. Anesthesia
Another study found no appreciable difference between LA
with sedation and GA
in terms of postoperative pain, nausea, vomiting, and overall
tolerance
Dept Policy: GA (hypotensive)
Thaler ER, Gottschalk A, Samaranayake R, et al: Anesthesia in ESS. Am J Rhinol
11:409–413, 1997
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30. A working party of The Royal College of
Surgeons of Edinburgh
o The operator should have experience of at least a 100
diagnostic endoscopic procedures before attempting
surgery.
o The surgeon should attend and participate in a course or
workshop that allows hands-on experience.
o Where possible a proctor system should be encouraged
with an experienced surgeon attending initial operations.
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31. A working party of The Royal College of
Surgeons of Edinburgh
o Follow-up and assessment clinics should, wherever possible,
be separate from the general clinics
o CT scan facilities should be available
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32. Hemorrhage
• bleeding can be minimize by maximizing pre op med therapy
03 forms recognized
o Bothersome mucosal ooze
o Significant bleeding from a named vessel
o Life threatening hemorrhage from ICA
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33. Mucosal ooze
o May limit visualization,
o disorient the surgeon
o Increase operative time
o Termination of procedure
1. Prevention starts form
a. Maximal pre-op medication
b. Avoidance of NSAIDs
c. Adequate mucosal decongestion
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34. Bleeding from named vessel
o The Sphenopalatine Artery
o Ant Branches
o Septal branch
o The anterior Ethmoidal artery
o 85% in suprabullar recess
o Extensive pneumatization of Ethmoidal air cell with large
supraorbital cell
o 8 mm below the skull base
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35. Bleeding from named vessel
o Avoidance by Pre op assessment
o Look for large supraorbital cell
o The main reason is poor visibility
o Never , pobe remove or grasp
o Check the position if 20 degree up
o Keep mean arterial pressure around 75mmhg
o Use ribbon gauze soaked with adrenaline
o Topical vasoconstriction ,working in the app
o Electrocautery, Bipolar
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36. ICA Injury
o The normal position of the ICA
o Extensive pneumatization of the sphenoid sinus
o Existence or incomplete bony septum in SS
o Anomalies and aneurysms of the artery
o ICA dehiscence
o Avoidance : pre op assessment
o Strict under vision work, no pulling/avulsion
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37. Management
o Firm pack
o Resuscitation and help of intervention radiologist
o If enough blood avail- remove the pack gently
o If no bleeding -then the best to packed with fascia and fat
followed by oxidized cellulose, and antibiotic ,pack for a
week
o If bleeding continues, the radiologist to be asked to do an
occlusion study under electroencephalographic control
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38. Lid Hematoma
o Cause– unintentional opening of orbit in its anterior part either
during uncinectomy or maxillary sinus ostia widening
o Manifests shortly as black eye
Heals without residuum, repositioning of prolapsed orbital fat
not recommended.
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39. Optic Nerve Injury
o Optic Nerve has a close relation with PE
o Damage can occur by penetration of LP
o Indirectly by compromising the blood supply
o Presence of sphenoethmoid cell (Onodi cells)
o Dehiscence of optic nerve
o Additional septum of the sphenoid sinus
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40. prevention
o Adequate pre-op assessment
o Look for anatomic variations like :
o Onodi cells
o Sphenoid sinus septum
o Optic nerve dehiscence
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41. Management
o Ophthalmology consultation
o Large doses of IV steroids Methylprednisolone initial
o loading dose 1gm iv followed by 250 mgxiv every six
hours
o If suspicion of bony spicule impinging on optic N
o If retrorbital hematoma -decompression
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42. EOM Injury
o Medial rectus muscle most endangered
Causes:
o Direct injury with instruments
o Indirectly injury to blood or nerve supply
o Misinterpreting fat herniation for polyps
o Symptoms :Pain ,Diplopia
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43. EOM injury
o Ophthalmologic consultation
o Urgent CT/MRI
o Repair in case of severe damage
o If no severe damage , observed
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44. Injury to Lacrimal Duct and Sac
o Leads to spontaneous fistulation(asymptomatic)
o Cause– following uncinectomy, enlargement of natural
maxillary sinus Ostia
o Epiphora occur in two to three days
o Epiphora occurs after two to three weeks
o Injury to lacrimal Sac
o DCR performed if obstruction occurs with epiphora
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45. Retro Orbital Hematoma
o One of the most severe complications
o Incidence ranges from 0.05% to 0.5% across various studies
o Ophthalmologic emergency, can lead to permanent blindness
o Slow venous type—injury to intraorbital veins
o Fast arterial type—retraction of transected AEA
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46. Presentation
o Significant proptosis
o Retrobulbar pain
o Mydriasis
o Pupillary defect
o Lid edema
o Chemosis
o Raised intrabulbar pressure
o Loss of vision
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47. Management
Aim to acutely decompress the orbit within 90 min
Intra op ophthalmology consultation
If the artery has retracted into the orbit
Lateral canthotomy and inferior cantholysis
Or endoscopic orbital decompression with cautery or clipping
If not possible, an external ethmoidectomy can be performed
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48. Management
o Other therapies include :
o Iv mannitol @ 1-2g/kg over 30 min.
o 10mg iv Dexamethasone
If the patient is in the ward :
- Sit the patient up in bed
- Remove any nasal packing
lateral canthotomy and cantholysis
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49. •Lateral canthotomy and cantholysis in retrobulbar postseptal hematoma 4
9

50. CSF Fistula
o Incidence varies from 0.2 to 2.5% across literature
o Dehiscence in skull base (recurrent polyposis, continued
Osteitis, mucocoel , fungal infection or tumor
o Critical to identify and localize in time
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51. While Uncinectomy
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52. Reasons for skull base danger
o Excessive manipulation of middle turbinate
o It is safe to open the posterior Ethmoidal air cell once
you have found the height of the roof of the Sphenoid
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53. Reasons for skull base danger
• According to keros the danger of an injury is
extremely high in type III case because the lateral
lamella is very long( up to 16mm)
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54. Diagnosis
o Recognition of skull base trauma paramount
o Confirm CSF--- B2 transferrin, CT/T2W MR
o Fluorescein nasal endoscopy( 5% sodium fluorescein 0.25-
0.5 ml diluted in 10 ml CSF)
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55. Surgical Management
Definitive management includes transnasal endoscopic repair
Homologus tissue like fascia lata or lyodura
Underlay and overlay technique
fixed by fibrin glue ,Gelfoam
Ethmoid filled with oxidized cellulose
Large defect ,bone and cartilage is used to bridge the gap
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56. Medical Management
o Small defect
o IV antibiotics( aminoglycoside)10-14 days
o Oral acetazolamide
o Stool softeners,
o Propped up position
o Reduce intracranial pressure
o Inflammatory complications(20-50%)
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57. Endoscopic view of anterior skull base defect repair, underlay and overlay graft
5
7

58. Meningitis
The common intracranial complication & varies up to 2%
o Spread Along perivascular and vascular
o Through lymphatics leading to the perineural spaces of the
olfactory fibers
o Direct dural tears,
o Cranial penetration
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59. Presentation
o Headache, Fever, Nuchal Rigidity, Vomiting
o CN Palsy, Behavioral Changes, and Seizures
o Confusion, Lethargy
o Imaging: CT Scan/ MRI
o Treatment includes targeted broad spectrum antibiotics
o Closure of the defect
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60. Pneumocephalus
o Rare complication of FESS
o The exact mechanism not know
o It is believed to be due to “ ball valve “ mechanism
o Alternatively “ inverted bottle” mechanism
o Symptoms :include dizziness, visual alterations, confusion,
and behavioral and personality change
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61. Pneumocephalus
o Signs: include CSF rhinorrhea, seizures, altered mental state,
and hemiparesis
o CT diagnostic imaging
o neurosurgical consultation
o Tension Pneumocephalus requires prompt treatment,
decompression of the aerocele followed by closure of the
defect.
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62. Pneumocephalus
• Management Options:
1-Inhalation of 100% oxygen
2-Needle aspiration of the space
3 -Ventriculostomy
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63. Olfactory impairment
o Results from over resection of ST
o Avulsion of Olfactory neuroepithelium from olfactory cleft
o Can be prevented by using sharp cutting instruments
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64. Adhesions
o Develop when two opposing raw mucosal surfaces
remain in contact
o Initially mucofibrinous bands created
o shortly matures & forms a scar tissue
Prevention :
o Alkaline nasal douching many times /day for 4-6 weeks
o Steroid nasal spray for 4- 6 weeks
o Follow up nasal endoscopy
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65. Adhesions
o No release required
o Unless symptomatic or obstruct the drainage and ventilation
o Our dept policy :
o After removing nasal packs on POD 1 , Gelfoam
o Review after one week – one month
COMPLICATIONSIN ENDOSCOPIC SINUS ,SK Kaluskar MS FRCS DLO (Eng)
Consultant Otorhinolaryngologist Tyrone County Hospital Northern Ireland, UK
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66. Avoidance of Complications
o Preparation is the key
o Taking history, physical examination, diagnostic nasal
endoscopy,
o Explicit knowledge of surgical anatomy
o Adequate preoperative imaging
o Appropriate instruments
o optical aids
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67. Pearls of sinus surgery
o Carefully examine the anatomy in more than one CT plane
o Identify the ant Ethmoidal artery
o Plan the least invasive approach possible
o Preserve the healthy mucosa
o Maintain sinus visualization and opening postoperatively
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68. Use Microdebrider form Postero Superior to
Antero Inferior direction
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69. cont
o Complications are better avoided than managed
o Adequate preoperative preparation essential
o Successful management requires early recognition and
aggressive treatment
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70. References
1-Devyani Lal James A. Stankiewicz , Cummings Otolaryngology
Head&neck Surgery 6th Edition Chapter 49
2-Scott Brown 7TH Edition Chapter 117
3-SINUS SURGERY,Endoscopic and micoscopic appraoches by Howard
L.levine &M.Pais Clemente
4-Manual of Endoscopic sinus and skull base surgery by Daniel simmen &
Nick Jones 2th edition
5- Functional Endoscopic Sinus Surgery(stammberger)
6-COMPLICATIONSIN ENDOSCOPIC SINUS ,SK Kaluskar MS FRCS DLO
(Eng) Consultant Otorhinolaryngologist Tyrone County Hospital Northern
Ireland, UK
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71. 10/11/2017 ENT dept 71
Thank you