Managing Complications of Endoscopic Sinus Surgery in Children and Adults

Abstract

The overall major complication rate of FESS surgery is 1 % with haemorrhage requiring transfusion the commonest event followed by CSF leak and orbital injury. Arterial bleeding arises most commonly from the sphenopalatine artery and its branches. Anterior ethmoidal artery bleeding should be treated by packing and/or bipolar diathermy of the vessel and possibly aborting the procedure if an adequate field cannot be attained. Orbital haematoma can evolve slowly from venous ooze from traumatised periorbita or evolve rapidly from a retracted, bleeding anterior ethmoidal artery. Significant orbital haematoma should be treated by decompression either with lateral canthotomy and cantholysis or medial orbital wall decompression. Internal carotid artery bleeding during endoscopic sinus surgery is usually associated with only limited exposure of the vessel. A muscle graft, followed by a pedicled septal flap and ribbon gauze packing, is the only practical means of achieving haemostasis. The haemostasis should be immediately assessed with angiography. Optic nerve transection is irreparable. Lesser injuries should be treated by decompression of the optic nerve and removal of any impinging bone fragments and intravenous steroids. Medial rectus injuries vary from transection to haematoma and entrapment. Transection with powered instruments usually removes too much tissue to permit direct anastomosis. Post injury achievement of binocular vision in primary gaze is considered a successful outcome. CSF leaks through defects 10 mm or less in diameter can be repaired with a fat graft using the bath plug technique. Larger defects require an underlay of fascia and an overlay free or pedicled mucosal flap. Frontal trephines can be associated with CSF leaks if malpositioned or extrusion of material into the orbit or cranium if excessive force is applied on irrigation in the presence of a bony dehiscence of the frontal sinus. Canine fossa trephines give excellent access to the maxillary sinus but are associated with 3 % incidence of discomfort or numbness in the region of the cheek and upper lip. Adhesions are the commonest complication of endoscopic sinus surgery ranging in incidence from 1 to 36 %. Nasal packing materials vary in their ability to promote haemostasis and prevent adhesions. Suturing the middle turbinate to the septum is an effective means of preventing middle turbinate lateralisation. Recurrent symptoms may be attributed to insufficient surgery, surgical failure, disease recurrence or the effects of comorbid conditions. Olfaction usually improves following endoscopic sinus surgery but olfactory changes cannot be predicted on an individual patient basis. Children have more orbital but fewer skull base complications. Surgery in those under 6 years of age and particularly in those under 3 years of age is associated with less successful outcomes. The impact of a significant surgical complication on both the patient and the surgeon should be recognised.