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Fess complications

  1. 1. Avoiding Complications in ESS Balasubramanian Thiagarajan drtbalu's otolaryngology online
  2. 2. Intranasal ethmoidectomy is the Easiest way to kill a patient Mosher drtbalu's otolaryngology online
  3. 3. Common complications ● Injury to orbit ● Injury to optic nerve ● Injury to great vessels ● CSF leak ● Injury to nasolacrimal duct ● Synechiae drtbalu's otolaryngology online
  4. 4. Factors that help in avoiding complications ● Nasal endoscope ● True cut instruments ● Shaver system ● Imaging ● Image guidance ● Through knowledge of anatomy ● Hypotensive anesthesia drtbalu's otolaryngology online
  5. 5. Complications are common in: ● Revision FESS ● Surgery for nasal polyposis ● Type III kerio skull base ● Right handed surgeons ● Anatomical variants like asymmetrical low lying ethmoidal roof drtbalu's otolaryngology online
  6. 6. Some stable intranasal landmarks ● Middle turbinate ● Uncinate process ● Bulla ethmoidalis ● Sphenoid ostium ● Skull base ● Maxillary sinus ostium drtbalu's otolaryngology online
  7. 7. 10 Rules ● Avoid classical uncinectomy if possible (prevents synechia in the infundibular region) ● Avoid middle turbinate resection ● Don't be a destroyer of nose ● Avoid combination of septal surgery with FESS ● Retain bulla till the very end drtbalu's otolaryngology online
  8. 8. Contd ● Look out for washout sign ● Proceed from less vascular areas to more vascular ones ● Hypotensive anesthesia ● Abandon surgery when bleeding is excessive ● Avoid nasal packing drtbalu's otolaryngology online
  9. 9. Extreme Uncinate positions drtbalu's otolaryngology online
  10. 10. Training a Surgeon ● 100 diagnostic endoscopies ● Cadaver dissection ● Supervised surgery ● Staged surgery ● Dedicated work in follow up clinics drtbalu's otolaryngology online
  11. 11. Lamina papyracea ● Respect the Bulla ● Bulb press test ● Beware of lateralized uncinate ● Always use sickle knife perpendicular to lateral nasal wall drtbalu's otolaryngology online
  12. 12. Onodi cell ● Be aware of this condition ● This condition will cause difficulty in identifying sphenoid sinus ● Optic nerve is endangered drtbalu's otolaryngology online
  13. 13. Intersphenoidal septum Use true cut instruments in this scenario drtbalu's otolaryngology online
  14. 14. Kero skull base types ● Beware of type 3 skull base ● Avoid excessive medialisation of middle turbinate ● Always keep skull base in view drtbalu's otolaryngology online
  15. 15. Orbital complications ● Orbital hematoma ● Diplopia ● Nasolacrimal duct injury ● Subcutaneous emphysema ● Blindness drtbalu's otolaryngology online
  16. 16. Orbital hematoma ● Indicates breach of lamina ● Can occur despite intact periorbita ● Risk increases 4 times when periorbita is breached ● Common in post septal injuries ● Venous / arterial bleed (rate of development of symptoms vary) drtbalu's otolaryngology online
  17. 17. Ecchymosis / orbital hematoma Ecchymosis Orbital hematoma Preseptal accumulation Post septal accumulation Injury to angular vein Injury to veins around lamina/ anterior/posterior ethmoidal artery Causes more lid oedema / color is darker Lid oedema is less Conjunctiva normal /pupil normal Conjunctival chemosis /pupillary changes No proptosis Proptosis drtbalu's otolaryngology online
  18. 18. Diplopia ● Caused due to temporary / permanent injury to medial rectus / superior oblique muscles ● Powered instruments are known to cause more damage to medial rectus ● Injury due to: nerve,blood supply, direct damage ● Unintentional injection of anesthetic into lamina can cause temporary diplopia drtbalu's otolaryngology online
  19. 19. Subcutaneous emphysema ● Very common ● Immediate / delayed ● Immediate due to breach of lamina on the table ● Delayed due to forceful blowing of nose during the immediate post op period. Can be prevented by not packing the middle meatus drtbalu's otolaryngology online
  20. 20. Blindness ● Temporary ● Permanent drtbalu's otolaryngology online
  21. 21. Temporary blindness ● Increasing orbital pressure due to hematoma ● Compromises blood supply to optic nerve ● Intraocular pressure may reduce within 2 hrs ● Light perception – several hours ● Pupil – 2 days to recover drtbalu's otolaryngology online
  22. 22. Permanent blindness ● Disaster ● Retrobulbar / retro orbital hematoma ● Retina can tolerate extremes of pressures only for 2 hours. Intervention should be within this window. If it is arterial bleed then this window reduces by half an hour drtbalu's otolaryngology online
  23. 23. Prevention ● Respect landmarks ● Pre op assessment of bleeding diathesis ● Aspirin intake ● Right handed surgeons – prone to cause more damage due to anatomical illusion on the left side. Left ethmoidal sinus is actually more medial than appreciated by the surgeon drtbalu's otolaryngology online
  24. 24. Management ● Arterial hematoma – managed at war footing ● IV mannitol 20% ● Orbital massage ● Heavy dose of steroids – 1-1.5 mg /kg in divided doses of dexamethasone drtbalu's otolaryngology online
  25. 25. Nasolacrimal duct injury ● Sac & duct lie close to ethmoids ● Agger nasi cells are adjacent to sac ● Natural ostium of maxillary sinus lie close to the duct ● To avoid injury antrostomy should be performed anterior to the anterior end of middle turbinate ● Injury commonly resolves on their own drtbalu's otolaryngology online
  26. 26. drtbalu's otolaryngology online
  27. 27. Recirculation syndrome drtbalu's otolaryngology online
  28. 28. Thank you drtbalu's otolaryngology online