Complications of Endoscopic Sinus Surgery (ESS)

Dr. Ausaf Ahmed Khan
Professor of ENT/Head & Neck Surgery
Hamdard College of Medicine & Dentistry
Hamdard University, Karachi
Pakistan

Introduction
• Endoscopic Sinus Surgery (ESS) is effective in
improving the symptoms of chronic rhinosinusitis.
• It helps improving the quality of life in these pts.
• An important drawback is the potential for serious
complications.
• Proximity of critical anatomic structures :
orbit, skull base, the internal carotid arteries,
dura, and brain.

Introduction
• Complications are both minor and major
• Most common – hemorrhage, synechia, orbital
complications, CSF leak . . .
• Population at increased risk ; revision surgery, polyps
and extensive disease, anatomic variation
• Their avoidance depends on preoperative awareness
of potential surgical pitfalls, proper knowledge of
sinonasal anatomy, meticulous surgical technique,
and adequate intraoperative hemostasis.
• When complications do occur, prompt recognition and
appropriate management usually result in good outcomes.

C o m p l i c a t i o n s
MAJOR (1%)
• CSF leak / Meningitis
• Orbital hematoma
• Internal carotid injury
• Blindness or ed vision
• Major epistaxis
• Diplopia
• Anosmia
• Nasolacrimal duct trauma
• Intracranial hemorrhage
MINOR (7%)
• Minor epistaxis
• Adhesions (synechiae)
• Hyposmia
• Periorbital ecchymosis
• Periorbital hematoma
• Headache
• Dental / facial pain

I - Preoperative considerations
II - Intraoperative complications
III - Postoperative complications

C o m p l i c a t i o n s
Intraoperative
Intranasal complications
Diffuse hemorrhage
Arterial injury
Intra-orbital complications
Orbital fat exposure
Intraorbital hematoma
Extraocular muscles injury
Optic nerve injury
Intra-cranial complications
CSF leak
Carotid Artery injury
Postoperative
Intranasal complications
Epistaxis
Sinusitis
Olfactory dysfunction
Synechia formation
Orbital complications
Corneal abrasions
Diplopia
Epiphora
Orbital infections
Intracranial Complications
CSF leak
Parenchymal brain injury
CNS infections

By failing to prepare,
you are preparing to
fail.
Benjamin Franklin
Preoperative considerations

WORK-UP
• Appropriate pre-op. workup:
– History, bleeding disorders, risk factors for bleeding :
antiplatelet medicines, family history of bleeding disorders
and excessive bleeding with prior surgery
– Labs, Consultations – control asthma, allergies, HTN.
– Documented “failed medical management”?
– Documented informed consent
– Explain the risks, benefits, alternatives and complications.
• Preoperative medical treatment with antibiotics and
steroids  decreased mucosal inflammation & edema 
reduced intra-op. bleeding & allows better visualization.

IMAGING
• Review of pertinent Radiologic imaging studies
– Can alert the sinus surgeon to potential surgical pitfalls
– Defect in the lamina papyracea, low-lying cribriform plate
(Keros type 3) or dehiscence of a carotid canal.
– Anterior and Posterior Ethmoidal arteries : especially
important in revision surgery, where protective bone in
these regions may have been removed
– Preoperative recognition of anatomic variants:
• hypoplastic maxillary sinus,
• sphenoethmoidal (Onodi) cell,
• undeveloped frontal sinus

A defect in the right lamina papyracea with
herniation of orbital fat (arrow) into the
ethmoid sinus is evident on this
preoperative computed tomography scan.
Intraoperative view of Onodi cell at
the time of sphenoethmoidectomy.
- Preoperative CT scan shows the presence of an
Onodi cell ( OC) above the left sphenoid sinus (SS).
- The optic nerve (arrowhead) and carotid artery
(arrow), which run along the lateral wall of this
cell, are at increased risk for injury during a
posterior ethmoidectomy

Hypotensive anesthesia
DEFINITION
– Reduction of systolic blood pressure to 80-90 mm Hg
– Reduction of mean arterial pressure (MAP) to mmHg
– 30% reduction of baseline MAP
• Propofol
• Remifentanil
 30% reduction in blood loss using IV Propofol
infusion versus inhaled anaesthetics.
 Topical decongestant/vasoconstrictor…..
 Head-up position 10-15

REMEMBER !!
The 3-D Anatomy of Paranasal Sinuses
should be in your head

Intraoperative complications
1. Intranasal complications
a. Diffuse hemorrhage
b. Arterial injury
2. Intra-orbital complications
a. Orbital fat exposure
b. Intraorbital hematoma
c. Extraocular muscles injury
d. Optic nerve injury
3. Intra-cranial complications
a. CSF leak
b. Carotid Artery injury

Intranasal Complications
Diffuse Hemorrhage
• Diffuse bleeding typically occurs in presence of
extensive mucosal inflammation or large nasal polyps.
• Adequate hemostasis  proper pre-op. preparation
(Use of topical decongestants (e.g., oxymetazoline 0.5% or cocaine 4%) /
submucosal injection of vasoconstrictive agents (lidocaine with adrenaline)
• Communication with the anesthesia to maintain
hypotensive anesthesia
• Put intermittent nasal packs soaked in a topical
decongestant ; xylo/oxymetazoline with adrenaline
(be careful in Cardiovascular conditions).

Diffuse Hemorrhage
• Microdebrider instrumentation is helpful in such
cases because of its ability to simultaneously suction
blood from the surgical field and remove tissue.
• When bleeding cannot be sufficiently controlled to
see anatomic landmarks, surgery may be halted
 A staged second procedure to remove residual
disease when bleeding is no longer an issue.

Arterial Injury
• Various causes;
– Resection of the middle turbinate near its
posterior insertion site along the lateral nasal wall
(pulsatile bleeding from the sphenopalatine artery
or one of its branches).
• How to avoid : Preserve the posterior third of MT.
– Overly aggressive enlargement of the maxillary
ostium in a posterior direction (bleeding from the
region of the sphenopalatine foramen).

Arterial Injury
• How to control such bleeding;
– Use either monopolar or bipolar cautery
– If bleeding is brisk  use suction cautery
– Avoid excessive cauterization : delayed healing
and postoperative discomfort from crust
formation and osteitis.
• For more definitive control of arterial bleeding
 apply a clip on the sphenopalatine artery where it
exits from the pterygopalatine fossa

Endoscopic image of two clips placed on the left
sphenopalatine artery (SPA) for control of severe
epistaxis following endoscopic sinus surgery.
The SPA is located between the posterior wall of
the maxillary sinus (MS) and the horizontal
insertion of the middle turbinate (MT). FS, Frazier
suction tip.

Arterial Injury
• Avoid damaging Posterior septal branch of SPA during
enlargement of natural ostium of sphenoid sinus in
inferior direction
• Pulsatile bleeding may occur because
the vessel runs transversely in the soft
tissue located below the natural
sphenoid ostium and above to the
choanal arch.
• Use Monopolar or bipolar cautery,
with or without suction.
• Consider Prophylactic cauterization
and transaction of this vessel.

Endoscopic visualization and anatomical scheme of the posterior septal branch
of the SPA, arrow head is pointing out the same bleeding artery

Arterial Injury
• Injury to the anterior or posterior ethmoid artery along the
ethmoid roof can result in significant intraoperative bleeding.
• The posterior ethmoid artery : runs @ 5 mm anterior to the
sphenoethmoid angle.
• The anterior ethmoid artery : traverses the skull base @12
mm anterior to the posterior ethmoid artery.

Arterial Injury
• Why injury occurs
– there is bony dehiscence of their canals or
– when they are mistaken for an ethmoid septation.
• In the extensively pneumatized ethmoid labyrinth, the AEA
(and, rarely, the PE Artery) may lie below the level of the
skull base, traversing the ethmoid along a mesentery.
• In such cases, the artery may be particularly
susceptible to injury, but this anatomic variant can be
anticipated by a careful preoperative review of CT
images.

Arterial Injury
• Blood flow through the ethmoid arteries occurs
from lateral to medial direction (via ophthalmic
artery)  their disruption must be meticulously
managed to avoid retraction of the arterial stump
into the orbit could lead to intraorbital
hemorrhage.
• If electrocautery is used : use Bipolar cautery
(to avoid transmitting current to skull base and orbit)
• Consider external or endoscopic ligation of AEA in
complicated cases.

Intraorbital Complications
• REASONS
– during uncinectomy near the start of sinus surgery 
Incision of the UP that is directed too far lateral or posterior
– Hypoplastic or atelectatic maxillary sinus
– Aggressive lateral dissection during ethmoidectomy
• Inadvertent penetration or removal of the lamina with
exposure of the periorbita usually does not have
adverse consequences if it is recognized promptly and
the periorbita has not been violated.
• Avoid powered instrumentation to minimize risk of
inadvertent damage to orbital contents

• WHAT TO DO?
– If the periorbita has been violated & orbital fat seen 
avoid further manipulation of exposed fat within the ethmoid.
– No repair of this defect is needed.
– If vision is not obscured  surgery be continued as planned.
– Perform serial examinations of eye during the remainder of
surgery to ensure that I/Orbital hemorrhage has not developed.
– Avoid Nasal packing  Placement of packing over the orbital
defect can create a one-way valve and trap air or blood within
the orbit  periorbital edema, ecchymosis, subcutaneous
emphysema, or proptosis may develop
– Continue close monitoring of the eye, including vision testing

Intraorbital Hematoma
• Synonyms : Retro-orbital or Retrobulbar hemorrhage
• A potentially devastating complication of ESS
• Favourable outcome if recognized promptly and treated
appropriately
• Reasons of Bleeding into the orbit
– injury to vessels within the orbit
– retraction of a bleeding anterior or posterior ethmoid artery
• Consequence
– increased intraorbital pressure with retinal ischemia.
** The retina can tolerate 30 to 90 minutes of ischemia before
irreversible damage.

   Medical management of a slowly expanding
Orbital Hematoma without visual loss ;
– Immediate Ophthalmology consultation,
– Serial examination of visual acuity and IOP.,
– Removal of nasal packing and eye massage,
– I/V Dexamethasone (0.2 mg/kg),
– Mannitol (1 to 2 g/kg IV),
– Acetazolamide (10 to 15 mg/kg IV).
Signs
&
Symptoms
Tense globe , increased Intraocular pressure,
loss of pupillary reflex, eye pain,
limited eye mobility & decreased vision.


• For rapidly expanding hematomas
 Perform Lateral canthotomy and cantholysis
without delay
A simple and effective procedure that can be done in
the OR, Recovery or bedside
LATERAL CANTHOTOMY
Incision of the lateral canthal tendon
CANTHOLYSIS
Canthotomy combined with disinsertion of at least the inferior
crus of the lateral canthal tendon

lateral canthotomy and cantholysis
healed without the need for repair
Lateral canthotomy performed by advancing a
scissor to the bone of the lateral orbital rim
and incising full thickness of skin and
underlying canthal tendon
Additional reduction in intraorbital
pressure can be achieved with an
inferior cantholysis
Right eye of a patient who underwent a
lateral canthotomy with cantholysis

If these measures do not bring clinical improvement
 perform Medial orbital decompression
done either by an endoscopic or external approach
removal of the lamina papyracea
Exploration of the orbit for ligation of a specific bleeding vessel
 generally not recommended.

(a)-completed ethmoidectomy with
extirpation of the ethmoid (E) and
maxillary sinuses (M) and removal of
medial and part of inferior orbital walls to
expose the orbital periosteum (OP). The
middle turbinate (MT) is seen in the
medial part of the surgical field.
(b)-Slitting of the orbital periosteum with
resultant prolapse of the orbital fat (OF)
left endoscopic orbital decompression

Extraocular muscle injury
• Occurs if violation of the lamina papyracea is not recognized at
the time of surgery and dissection continues through periorbita
• Muscles injured ; Med. Rectus > Inf. Rectus > Sup. Oblique.
• Use of microdebrider poses greater risks of injury
• Range of Injuries : muscle contusion  complete transection
• If an EOM injury recognized at the time of surgery :
 urgent intraoperative consultation with ophthalmologist
 determine the extent of injury and the need for immediate
orbital exploration with muscle repair.
• Consider strabismus surgery later on to treat diplopia

Postoperative computed tomography scan of a patient
who suffered orbital injury during sinus surgery. Passage
of a motorized instrument through the lamina papyracea
resulted in transection of the medial rectus muscle
(arrow). Preoperative recognition of the atelectatic right
maxillary sinus with an unusually low right orbital floor
(arrowhead) might have prevented the injury.

Axial CT of a patient who underwent ESS.
Pt. complained of postoperative diplopia.
The CT reveals a large dehiscence of bone along the
right orbit and evacuation of the orbital contents.
This Injury was sustained when the surgeon violated
the LP with a microdebrider. In this situation, the
suction power of the microdebrider drew orbital fat as
well as extraocular muscle.

Optic Nerve injury
 Prevention of optic nerve injury during ESS is critical
 Severe morbidity (blindness or partial loss of vision)
 Lack of treatment options
• When it occurs;
– If Lamina papyracea is violated, accidental instrumentation
within the orbital apex can result in optic nerve injury
– During manipulation within the superolateral sphenoid sinus
if the optic canal is dehiscent.
– An unrecognized Onodi cell can place patients at risk for optic
nerve injury during a posterior ethmoidectomy.

Optic Nerve injury
• How to prevent
– Perform Sphenoidotomy by careful enlargement of the
natural sphenoid ostium, (anteromedial aspect of the
sphenoid), so that bone removal begins as far away from the
optic nerve as possible.
– Identify Onodi cell on the preoperative CT scan. If present,
care should be taken during dissection in this region
• If injury to the optic nerve is suspected during surgery
– Give high-dose systemic corticosteroids
– Ophthalmologic consultation should be obtained
– Patient awakened in a timely fashion to assess visual acuity.
• A postoperative CT scan is necessary

Fig. 29.2 (A) Preoperative computed tomography scan demonstrates the presence
of an Onodi cell ( OC) located above the left sphenoid sinus (SS). The optic nerve
(arrowhead) and carotid artery (arrow), which run along the lateral wall of this
cell, are at increased risk for injury during a posterior ethmoidectomy. (B)
Intraoperative view of the Onodi cell at the time of a sphenoethmoidectomy.

CSF leak
• Incidence of CSF leak ; around 0.5%
• When it occurs;
– violation of the skull base during surgery,
– Excessive intraoperative bleeding  obscured
landmarks  surgical disorientation.
• What to do when surgery becomes technically
difficult and anatomic landmarks are obscured
 better to leave the disease along the skull base
and terminate the procedure.
• Image guidance technology can help to confirm the
location of skull base : BUT can not be solely relied upon !!

CSF leak
• Where it occurs most :
 Anywhere along skull base
► junction of the AEA and MT along
the anterior ethmoid roof (thinnest
and most susceptible to injury area)
► posterior ethmoid roof,
► cribriform plate,
► posterior wall of the frontal sinus,
► roof of the sphenoid sinus.

CSF leak
• How it appears;
– Stream of clear fluid OR
– A dark stream coursing running through blood.
 If only minimal bleeding is present, alternating
streams of clear CSF and red blood are seen.
Oh my God Its CSF !  step back and collect you thoughts
and act accordingly : seek help if u want . . . .
 Likelihood of success if recognized per-operatively
and managed correctly : > 90%

CSF leak
Intraoperative leaks during ESS are usually small <1 cm
• Mostly repair with a single layer consisting of a free
intranasal mucosal graft from septum or turbinate.
• Occasional larger defects require additional layer :
septal bone or cartilage placed on the intracranial side
• The mucosal graft is stabilized and protected with
SURGICEL or GELFOAM.
• Additional layer of nonabsorbable packing, such as
strip gauze or MEROCEL.

CSF leak
• The nonabsorbable packing is removed after 1 week
• Absorbable packing is left & allowed to dissolve.
• Obtain CT Scan once the patient is awake and out of
the operating room : pneumocephalus or intracranial
injury.
• Antibiotics (I/V with CSF Penetration/Oral antistaphylococcal
antibiotics) : Controversial
• Lumbar drain +/-
• CT scan 3 to 6 mo post-op. for surveillance of repair

One of the most catastrophic complications that can occur during ESS
 INCIDENCE is less than 0.1%. Devastating Consequences with stroke
WHEN DOES IT OCCURS ?
• When the sphenoid sinus is entered too far laterally
• When surgical dissection is performed along the lateral sphenoid wall
and the carotid canal is penetrated.
• Microdebrider used within the SS
HOW TO AVOID ?
• Enter the sphenoid sinus medially through natural sphenoid ostium
• Enlarge this opening in an inferio-medial direction
• Avoid instrumentation within the sphenoid sinus : If required,
approached with extreme caution.
• Avoid removing the intersphenoid septum

Bolger's Box: boundaries:
lateral – Lamina Papyracea,
Superior – Skull base,
Inferior – Ground lamella
Medial – Septum & Superior turbinate.

WHAT WILL HAPPEN
• Profuse bleeding will rapidly fill the nasal cavity.
WHAT TO DO IMMEDIATELY
• Pack the sphenoid sinus.
• Aggressive fluid resuscitation
• Hemodynamic control to maintain cerebral perfusion.
• Arrange blood and blood products
• Call Neurosurgeon and interventional Neuroradiologist
• Shift to a tertiary care canter

Treatment of Carotid Artery Injury
THE CAROTID DRILL
Tertiary care center
1. For every sinus operation, have available, on momentary notice, two long polyvinyl
acetate (Merocel) sponges, petroleum-impregnated gauze, two 18F Foley
catheters and umbilical damps for nasal packing.
2. Pack nose immediately at the first sign of severe hemorrhage.
3. Compress the carotid artery in the neck on the affected side.
4. Begin anesthesia to induce controlled hypotension.
5. Ready blood for transfusion.
6. Call neurosurgeon immediately.
7. If patient's condition is unstable, the neuroradiologist should perform intraoperative
arteriography. If patient's condition is stable, transfer the patient to
neuroradiology suite.
8. Perform balloon occlusion under EEG surveillance.
a. If there is no evidence of a change in perfusion or lateralization, ligate the carotid A.
b. If changes are present on the EEG (dangerous recording), deflate the balloon, maintain
packing, and observe.
9. Insert Swan-Ganz catheter. Put the patient in a hyperdynamic state by using high
molecular weight starch to increase cerebral perfusion.
10. After cerebral perfusion has been increased, reinflate the balloon and check the EEG.
a. If lateralization occurs, try carotid bypass.
b. If bypass is possible, reinflate the balloon and ligate the carotid artery.

Nontertiary hospital
1. Call neurosurgeon.
2. Expose the carotid artery in the neck.
3. Temporarily occlude the carotid artery with a clamp or tape.
4. Ligate the carotid artery.
5. Perform a trapping procedure: Clip the carotid artery below the
anterior communicating artery to isolate this segment from blood
flow
Treatment of Carotid Artery Injury
THE CAROTID DRILL

Postoperative complications
1) Intranasal complications
1. Epistaxis
2. Sinusitis
3. Olfactory dysfunction
4. Synechia formation
2) Orbital complications
1. Corneal abrasions
2. Diplopia
3. Epiphora
4. Orbital infections
3) Intracranial Complications
1. CSF leak
2. Parenchymal brain injury
3. CNS infections

Post-operative complications
Epistaxis
• Incidence ; 2%
• When occurs;
– immediately following surgery from inadequate hemostasis
– 5 to 7 days after surgery when intranasal scabs dislodge
• Most common sites : turbinates and septum
• How to prevent ;
– placement of packing material/absorbable hemostatic agents
NB: If excessive bleeding is not present at the conclusion of surgery,
studies have suggested that nasal packing need not be placed
at the conclusion of routine endoscopic sinus surgery

Epistaxis
• Management
– Mild bleeding  topical decongestant sprays
– Severe bleeding  check vitals, control hypertension, draw
blood sample: Hb., Crossmatch, IV , fluid volume replacement.
– identify the site of bleeding with an endoscope
– silver nitrate cauterization under direct visualization.
– absorbable or nonabsorbable nasal packing
– tamponade balloons
– operative exploration with electrocauterization
– SPA, AEA, PEA ligation (endoscopic/open approach)
– embolization of bleeding vessel interventional radiologist

Sinusitis
• Incidence; up to 16% of patients
• Reason
– Raw mucosal surfaces
– intranasal bacterial colonization
– decreased mucociliary clearance of nasal secretions
• How to reduce incidence
– Prophylactic use of antistaphylococcal antibiotics
– frequent nasal saline irrigations
– postoperative sinus debridement
• If sinusitis develops in the postoperative period
– endoscopically directed cultures
– appropriate antibiotic

Olfactory dysfunction
• May present during healing period for 1 to 2 weeks.
• If abnormal olfaction persists after the healing of the sinus
cavities  do nasal endoscopy and a sinus CT scan
• If symptoms persist after topical or oral corticosteroids 
olfactory testing
• Avoid mucosal trauma along the olfactory cleft or cribriform
plate during surgery.
 Postoperative adhesions b/w MT and septum

Synechiae
• Mostly small, asymptomatic and noted as incidental findings
at the time of nasal endoscopy following sinus surgery.
• Dense adhesions and synechiae  postoperative anosmia,
recurrent sinusitis, and mucocele formation
• One study showed its incidence was 56%
• Contributing factor for failure in up to 31% of patients
• If the middle turbinate mucosa is traumatized  adhesion
may form between MT and lateral nasal wall  obstruction of
sinus drainage pathways.
• Adhesion between the medial surface of the middle turbinate
and septum  postoperative airway obstruction & anosmia.

Synechiae
• How to prevent ;
– insert a spacer or packing material
• How to treat;
– If adhesions noted at the time of office endoscopy in early
post-op. period  can be divided with minimal discomfort.
– Once healing is completed  divide under local or general
anesthesia  splints

Orbital Complications
Corneal abrasions
• Reason
– inadvertent contact with the surgeon’s hands or instruments.
• Symptom
– eye pain and foreign body sensation
• Refer to ophthalmologist :
– fluorescence staining and slit-lamp examination.
• Treatment
– Topical antibiotic ointment and patching.
• How to prevent
– ophthalmic ointment and taping of the eyelids
– scleral shell or a large contact lens

Diplopia
• Indicative of injury to an EOM or its motor nerve
• Medial rectus muscle most commonly injured
• Reason ; Violation of lamina papyracea and periorbita with
the passage of an instrument into the orbital cavity
• Complete rectus muscle transection with microdebrider
• If superficial muscle injury or intraorbital inflammation :
Spontaneous resolution of diplopia
• What to do
– ophthalmic consultation to document visual acuity and globe status
– CT scan to localize the site and extent of injury
– eye patch or an eyeglass prism
– Strabismus surgery to correct persistent double vision

Epiphora
Injury to the nasolacrimal duct during maxillary antrostomy.
• Reason; Use of back-biting
forceps or a microdebrider
is used to enlarge maxillary
ostium too far in an anterior
direction

Epiphora
Injury to the nasolacrimal duct during maxillary antrostomy.
• How to avoid; avoiding removal of the bone anterior to
the maxillary line when enlarging the ostium.
• Symptoms; epiphora or dacryocystitis
• Treatment;
– probing, irrigation, or intubation of the lacrimal system.
– endoscopic dacryocystorhinostomy (DCR)

Orbital infection
• Reasons;
– Direct spread of bacteria through bony dehiscence in LP
– Retrograde thrombophlebitis from valveless veins.
• Signs ; eye pain, periorbital edema, and erythema
• Treatment
– Broad-spectrum oral or intravenous antibiotics
– Removal of any intranasal packing
– close monitoring for an extension of the infection into the
orbital compartment
• If symptoms worsens  CT imaging to rule out orbital
cellulitis, abscess, or cavernous sinus thrombosis.

Parenchymal brain injury
• Parenchymal brain injury and intracranial bleeding
may occur if an instrument is passed through an
unrecognized skull base defect.
• Mental status change or neurologic deficits in the
immediate postoperative period are suggestive of
such neurologic injury.
• Do an urgent CT scan or MRI
• Neurosurgical consultation to determine the site and
extent of brain tissue injury.

CNS infections
Rare nowadays
1- Meningitis
– Usually the result of an unidentified CSF leak,
– There is direct bacterial spread from the sinonasal cavity
through a skull base defect.
– Severe Headache, high fever, photophobia, and nuchal
rigidity after sinus surgery
– Emergent evaluation with CT scan, lumbar puncture, and
neurologic consultation
– Intravenous antibiotics.

CNS infections
2- Intracranial abscesses
– Can develop in the epidural, subdural, or intraparenchymal
spaces
– Need Neurosurgical drainage.
3- Cavernous sinus thrombosis
– Occurs from venous extension of sinus or orbital infection
– Signs : Proptosis, chemosis, and ophthalmoplegia
– MRI/Magnetic resonance venography
– Neurology and Infectious disease consultation
– Intravenous antibiotics and anticoagulation

Conclusion
• Complications of both minor and major consequence
are associated with the performance of endoscopic
sinus surgery.
• Their avoidance depends on preoperative awareness
of potential surgical pitfalls, proper knowledge of
sinonasal anatomy, meticulous surgical technique,
and adequate intraoperative hemostasis.
• When complications do occur, prompt recognition
and appropriate management usually result in good
patient outcomes

Complications of Endoscopic Sinus Surgery (ESS)

Complications of Endoscopic Sinus Surgery (ESS)

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