complications of sinus surgery

1. Complications in FESSComplications in FESS
Dr Satish JainDr Satish Jain
Jain ENT HospitalJain ENT Hospital
JaipurJaipur
Prevention, Identification & management

3. Orbital ComplicationsOrbital Complications
• Minor
-Damage to LP & Periorbita
-Periorbital emphysema
• Major
-Intraorbital Haematoma
-Damage to NLD
-Damage to Medial Rectus
-Injury to Optic Nerve

4. Predisposing factorsPredisposing factors
• Dehiscense of LP
• Revision surgery
• Extensive disease
• Distorted anatomy
• Excessive bleeding
• Hypoplastic max. sinus
• General anaesthesia

5. Rhinocon 2009Rhinocon 2009

7. ManagementManagement
• Leave it
• Do not pull or push the fat
• Watch for proptosis
• Do not pack
• Do not blow nose postoperatively
• Antibiotics to avoid orbital cellulitis

8. EmphysemaEmphysema

10. Medial rectus muscleMedial rectus muscle

11. Risk factors

15. ManagementManagement
• If contusion only-
Observe,antibiotics,steroids
• If entrapped-
Release entrapped muscle,repair medial
wall (gelfilm/medpore)
• If transected-Ophthalmologist,
s call
hang-back suture,botulinum toxin in
LR,transposition of other muscles etc.

16. Damage to NLDDamage to NLD

20. ManagementManagement
•If diagnosed intraop.If diagnosed intraop.
-Observe-Observe
-Stenting-Stenting
•If postop.epiphoraIf postop.epiphora
-Endoscopic DCR-Endoscopic DCR

21. Anterior ethmoidal arteryAnterior ethmoidal artery

26. Intraorbital haematomaIntraorbital haematoma

27. Complete transection &
retraction.

29. Pathophysiology of visual lossPathophysiology of visual loss
•Normal IOP 10-20 mmNormal IOP 10-20 mm
•Normal Orbital volume 30 mlNormal Orbital volume 30 ml
• in orbital volumein orbital volume
•Compression of Optic n.Compression of Optic n.
•Compression of centralCompression of central
retinal arteryretinal artery
•Compression of post. CiliaryCompression of post. Ciliary
arteriesarteries

30. DiagnosisDiagnosis
• Rapid proptosis
• Chemosis
• Tension in globe
• Optic nerve pallor
• Retinal vascular shutdown
• Afferent pupillary reflex

31. Afferent pupillary reflexAfferent pupillary reflex

32. ManagementManagement
Volume of Orbit
• Lateral Canthotomy
• Cantholysis
• Medial (Endoscopic)
decompression
• Inferior
decompression
Blood volume in Orbit
• IV Mannitol
• Cortocosteroids
• ?Orbital massage
• ?Orbital torniquet
Catching Bleeder
CauterizationX

33. Lateral CanthotomyLateral Canthotomy
Reduces IOP by 17 mm Hg

34. CantholysisCantholysis
Reduces IOP by 14 mm Hg

35. ManagementManagement
Volume of Orbit
• Lateral Canthotomy
• Cantholysis
• Medial (Endoscopic)
decompression
• Inferior
decompression
Blood volume in Orbit
• IV Mannitol
• Cortocosteroids
• ?orbital massage
• ?Orbital torniquet
Catching Bleeder
CauterizationX

36. Optic nerve injuryOptic nerve injury
Optic
Sphenoid

39. • Direct -Physical insult
• Indirect -Transmitted
Optic nerve injuryOptic nerve injury
Oedema in optic canal
Nerve compression

40. ManagementManagement
• 1 gm. IV Bolus dose of Methylprednisolone
250 mg.IV Methylprednisolone/6 hrly 48 hrs.
Optic nerve decompression
• If bony spicule impinging-
Optic n. decompression
If does not improve

41. Risk factors for ICA ruptureRisk factors for ICA rupture
• Anatomic relationships
– Carotid dehiscence
– Sphenoid septal attachment to ICA
– Midline ICA
• Revision surgery
• Prior radiotherapy

46. So what’s the plan?So what’s the plan?
• Packing
– Gauze
– Teflon and methyl methacrylate patch
– Syvek marine polymer
– Muscle patch
– Fibrin glue
– Gel foam and oxidized cellulose packing
– Thrombin-gelatin matrix
– Oxygel and glue
– Muslin gauze

47. Best optionsBest options
• Endovascular cover stent
• Muscle patch with tissue glue
Pseudoaneurysm

48. Prevention of complicationsPrevention of complications
• Study preOp. 3D CT carefully
• Preoperative management for optimal surgical field
• Prepare the intraoperative field
• Identify landmarks properly
• Avoid operating on patients with extensive /recurrent
disease,unless experienced
• Be meticulous in your surgery
• Never Cover Patient,
s eyes
• Place all surgically removed tissues in saline
• Learn from your mistakes