Fess complications

Avoiding Complications in ESS

Balasubramanian Thiagarajan

drtbalu's otolaryngology online

Intranasal ethmoidectomy is the
Easiest way to kill a patient

Mosher


Common complications
● Injury to orbit
● Injury to optic nerve
● Injury to great vessels
● CSF leak
● Injury to nasolacrimal duct
● Synechiae


Factors that help in avoiding
complications
● Nasal endoscope
● True cut instruments
● Shaver system
● Imaging
● Image guidance
● Through knowledge of anatomy
● Hypotensive anesthesia

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


Some stable intranasal landmarks
● Middle turbinate
● Uncinate process
● Bulla ethmoidalis
● Sphenoid ostium
● Skull base
● Maxillary sinus ostium


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

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

Extreme Uncinate positions


Training a Surgeon
● 100 diagnostic endoscopies
● Cadaver dissection
● Supervised surgery
● Staged surgery
● Dedicated work in follow up clinics


Lamina papyracea
● Respect the Bulla
● Bulb press test
● Beware of
lateralized uncinate
● Always use sickle
knife perpendicular
to lateral nasal wall


Onodi cell
● Be aware of this
condition
● This condition will
cause difficulty in
identifying sphenoid
sinus
● Optic nerve is
endangered

Intersphenoidal septum
Use true cut instruments in this scenario


Kero skull base types
● Beware of type 3
skull base
● Avoid excessive
medialisation of
middle turbinate
● Always keep skull
base in view


Orbital complications
● Orbital hematoma
● Diplopia
● Nasolacrimal duct injury
● Subcutaneous emphysema
● Blindness


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)

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


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

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

Blindness
● Temporary
● Permanent


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

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


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

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


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

Recirculation syndrome


Thank you


Fess complications

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