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

20th century “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 %)

• Stankiewicz suggested that the

complication rate decreases with

increasing experience, reporting a rate of

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 ESS

A-Preoperative assessment (history, examination and imaging studies)

B-Intraoperative precautions (general recommendations , specific precautions)

C-Postoperative follow up

A- Preoperative assessment

1- 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 ofi. Scar of previous surgery or traumaii. 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 examination (DNS, HIT, FS, 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

3-Imaging studies

•CT scan•MRI• X-ray ( of little value)

CT scan of PNS

•Should 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 base2- Medial orbital wall & its relation of UP3-Anterior ethmoidal artery4-Vertical height of posterior ethmoids5- Maxillary sinus – Haller’s cells, accessory ostia6- Sphenoid sinus7- Frontal sinus8- Nasal turbinates

Importance of Axial View

• Onodi’s 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 recommendations1. Keep the eye uncovered during the whole time of

the surgery2. Ask for hypotensive anaethesia3. Elevate the head of the patient about 30 degrees4. Check the tissue you remove to know if it sinks of

floats5. Don't hesitate to stop the surgery at any time if

there is a profuse bleeding6. Recurrent cases------ for seniors

Important Landmarks

1- Uncinate Process2- Middle Turbinate

B- Intraoperative precautions

Important LandmarksUncinate Process

B- Intraoperative precautions

Important Landmarks

Middle Turbinate

Its 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 surgery

Step of the surgery

I. Difficulties to see the Middle Meatus

• Deviated nasal septum• Concha bullosa

Management

• Septoplasty• Remove the outer half of

the middle turbinate

B- Intraoperative precautions

Precautions during steps of the surgery

Step of the surgery

II-Difficulties on removing the Uncinate process

• Adherent uncinate to the lamina papyracea

• Pneumatized uncinate

• Management

• use a curette to dissect the uncinate off the medial orbital wall, do retrograde uncinectomy

• May be mistaken for ST

B- Intraoperative precautions

Precautions during steps of the surgery

Step of the surgery

III-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 surgery

Step of the surgery

IV-Opening of Maxillary sinus

1- Can’t reach the natural opening

2- Atelectatic sinus or Silent sinus syndrome

3- Haller’s cells

Management

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-Haller’s cells may be a misleading for opening the antrum

B- Intraoperative precautions

Precautions during steps of the surgery Step of the surgery

V-Difficulties on removing ethmoids

1-Small bulla (Torus lateralis)

2- Removing the basal lamella on removing the anterior ethmoids

3- Onodi’s cells4- (true or relatively)bulging of

medial orbital wall

Management

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

2- if you complete this step the next partition is the skull base (don’t remove otherwise CSF leak may occur

3&4- Check CT scan (Optic nerve injury-susceptible to orbital fat prolapse)

B- Intraoperative precautions

Precautions during steps of the surgery

Step of the surgery

VI-Removal of polyps on the skull base

VII-Orbital fat prolapse

Management

• You should work from posterior to anterior and from medial to lateral

• Don’t pull or push and leave it in place ,you can cauterize if it is obscuring on the field

B- Intraoperative precautions

Precautions during steps of the surgery

Step of the surgery

VIII- Frontal sinus1-Opening of the frontal sinus

2-Cutting of the anterior ethmoidal artery

Management

1-Don’t work circumferentially on the opening .

• External frontal sinus puncture

2-Orbital decompression (lateral canthotomy& inferior cantholysis)

B- Intraoperative precautions

Precautions during steps of the surgery

Step of the surgery

IX- opening of Sphenoid sinus

Management

• Don’t manipulate the sphenoid septae

B- Intraoperative precautions

Precautions during steps of the surgery

Step of the surgery

X- Fungal sinusitis

Management

• If unilateral, don’t use the endoscope in the other side.

• Be aggressive to eradicate it• Canine fossa approach • Long term nasal wash

&follow up

B- Intraoperative precautions

Precautions during steps of the surgery

Step of the surgery

XI- Unstable middle turbinate from excessive manipulation

Management

• Middle turbinate resection

• Bolgerization• Middle meatal spacers• Conchopexy sutures

B- Intraoperative precautions

3-Postoperative follow up

•The first visit usually in the first two days

postoperatively 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, remove

crusts…etc.

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

ESS Acute& Chronic Rhinosinusitis

disorders

 Blindness, Diplopia , Nasolacrimal duct and sac injury

Orbital hematoma Subcutaneous emphysema ,

Ecchymosis Lid edema and Anisocoria

I- Orbital

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

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

ESS Acute & Chronic Rhinosinusitis

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

Death

II- Brain

MeningitisBrain abscess

‘‘‘

Death

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

ESS Acute & Chronic Rhinosinusitis

 III- Packing related   

- Displaced packs -Aspiration

-Increased orbital pressure

-Myospherulosis-   Toxic shock syndrome 

  

III- Septicemia & Septic shock syndrome

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

ESS Acute &Chronic Rhinosinusitis

IV- Vascular injury  Bleeding from branches of sphenoplalatine

  Internal carotid artery Anterior and Posterior

ethmoidal artery

V- Synechiae

 

IV- Mucoceles & Mucopyoceles

V- Pott’s puffy tumour

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

2-Byron J. Bailey &Tonas T. Johnson Head & Neck Surgery- Otolaryngology, 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 suture to

secure middle meatus spacers”. Ear, Nose and Throat journal,

Jan,2006.

8- Bhalla R K, Kaushik, V and deCarpentier J :- “ Conchopexy Suture

to prevent middle turbinate lateralization and septal Hematoma

after endoscopic sinus surgery”. Rhinology,43,14305,2005.

Thank You