Managing Complications and Revisions in Sinus Surgery
- 59 Downloads
Purpose of Review
To discuss strategies to avoid, identify and deal with both minor and major complications, as well as indications for revision sinus surgery.
Complication rates from endoscopic sinus surgery are low and have improved with increased surgical experience and new technology. Early extensive surgery in patients with complex sinonasal disease can improve long-term outcomes.
A majority of patients undergoing endoscopic sinus surgery have a positive outcome. The surgeon must be competent in recognising and dealing with potential complications, as well as approaching complex revision cases.
KeywordsFrontal sinus surgery Complications in sinus surgery Revision sinus surgery Chronic rhinosinusitis
Functional endoscopic sinus surgery (FESS) is one of the commonest procedures performed by a rhinologist. Over 250,000 FESS cases are performed annually in the USA alone, the majority for chronic rhinosinusitis with or without nasal polyposis . Complication rates have reduced as training, experience and comfort with endoscopes and powered instruments have increased. In experienced hands, minor complication rates of 5% and major complication rates below 1% are cited [2, 3, 4]. While the majority of patients undergoing FESS will require a single operation, 10–19% of patients will require revision surgery [5, 6, 7].
We discuss strategies to avoid, identify and deal with both minor and major complications, as well as indications for revision sinus surgery.
CLOSE mnemonic to assess for anatomical abnormalities during FESS
(i) Keros classification
(i) Dehiscences or orbital prolapse from previous surgeries
Onodi cells/optic nerve
(i) Identification of Onodi cells
(ii) Dehiscent optic nerve/carotid within sphenoid/Onodi
(i) The sphenoid roof gives the level of the skull base posteriorly
(ii) Note lateral sphenoid landmarks
(i) Identification of anterior ethmoid arteries hanging on a mesentery
As with all surgical skills, there is a “learning curve” associated with FESS. The FESS surgeon should be competent with undertaking emergency procedures to stabilise patients and rectify acute complications such as intra-orbital haematoma. Trainees should participate in cadaveric dissection courses and then perform diagnostic endoscopic procedures, allowing them to become comfortable with the endoscope, camera, orientation within the nasal cavity and three-dimensional interpretation of two-dimensional live images.
The first 100 procedures performed by solo inexperienced surgeons generally have a higher complication rate . Studies have shown that, when performed in a training environment under guidance of an experienced FESS surgeon, there is no increase in complication rate during the learning curve period [2, 3].
A thorough pre-operative history will alert the surgeon of potential increased bleeding risks. Anti-coagulants should be stopped with an appropriate time interval to allow clotting to normalise. Haematological advice should be sought when bridging heparinisation may be required. Patients with known bleeding disorders should be managed according to protocols agreed with the haematology team. Beware of patients using over-the-counter vitamins and herbal therapies as these can impact on the clotting time.
Careful insertion of the Hopkins rigid endoscope and instruments will minimise mucosal trauma. Localised superficial bleeding can be controlled with topical epinephrine-soaked patties, reserving bipolar cautery for refractory bleeds. Hypotensive total intravenous anaesthesia (TIVA) provides a clearer surgical field with less bleeding compared with gaseous anaesthetic agents .
The post-operative removal of nasal packing is very distressing for the patient and causes unnecessary trauma to the mucosal lining. Dissolving nasal packs show some evidence of reducing post-operative adhesions ; despite a general subjective feeling that they reduce post-operative bleeding, this is not backed up by a recent systematic review .
Anterior Ethmoidal Artery
Internal Carotid Artery
Endoscopic skull base surgery (ESBS) necessitates greater exposure of the ventral and anterior skull base, increasing the risk of ICA injury; thankfully, in experienced hands, the incidence of ICA injury in ESBS is below 1% . Pre-operative contrast CT and MRI angiography allow appreciation of variations in ICA pathways and distortion due to surrounding or invading mass lesions . The ICA can be damaged at any point along its path, although the left cavernous segment is still most at risk .
Should an ICA injury occur, the surgeon should gain immediate local control with direct pressure, utilise suction and irrigation to clear the surgical field, gain proximal and distal control (extending the dissection if required) and then assess the ICA injury to determine salvage options. Sheep model experiments have shown crushed muscle patch or use of an aneurysm clip to be effective measures for controlling acute ICA injury . It should be borne in mind that over 80% of patients will tolerate ICA sacrifice . Inability to control bleeding should be managed by balloon occlusion and immediate angiography.
Following acute management of an ICA injury, post-operative angiography is mandatory. Residual active bleeding or formation of a pseudoaneurysm is an indication for endovascular management by interventional radiology or vascular teams.
Damage to intraocular contents is thankfully incredibly rare. A large single-centre review  found the right eye to be at greater risk than the left, possibly due to the majority of surgeons being right-handed. The medial rectus muscle was found to be the most commonly injured, leading to strabismus and diplopia; should this persist, medial orbital wall reconstruction and strabismus surgery may provide benefit. If orbital contents are exposed, it is advised not to instrument the orbital contents, though gentle bipolar to the prolapsing orbital fat can allow continued access to complete the procedure. Failure to differentiate orbital fat from intranasal contents, with continued microdebrider use, can lead to irreversible damage and complete loss of vision .
The optic nerve may be dehiscent in the sphenoid sinus in 4% of cases, and sphenoethmoidal air cells may contain a dehiscent optic nerve as well as the ICA  (Fig. 4). The risk to the optic nerve can be reduced by careful study of pre-operative triplanar CT scans, looking for these anatomical variations.
In case of inadvertent exposure of orbital contents, the patient should be advised to avoid blowing their nose for 2 weeks to reduce the chance of orbital emphysema. Any damage to orbital contents should be managed in conjunction with the ophthalmology team.
Damage to Nasolacrimal Duct
The nasolacrimal duct may be dehiscent in up to 7% of patients . Aggressive removal of the uncinate bone with a back-biting instrument and anterior overenlargement of the middle meatal antrostomy may lead to excess bone removal in 3% of cases , and may damage the duct itself, leading to epiphora. In recalcitrant cases failing non-surgical ophthalmological intervention, dacrocystorhinostomy may be required.
Cerebrospinal Fluid Rhinorrhoea
Cerebrospinal fluid (CSF) rhinorrhoea can be due to defects anywhere along the anterior and lateral skull base. Lateral skull base CSF leak can present with CSF rhinorrhoea by passage via the Eustachian tube. Anterior skull base CSF leaks may be idiopathic, traumatic or iatrogenic; CSF leaks associated with standard FESS are rare, with an incidence of 0.2% , but may be due to both anatomical and technical factors . The extended skull base exposure with ESBS increases the incidence of CSF leak to 7% . Common sites for anterior skull base defects are in the ethmoid and sphenoid sinuses [30, 31]. Recognising skull base damage and subsequent CSF leak during initial FESS allows concurrent repair; missed skull base damage may require additional surgical reparative procedures, adding to the patient’s morbidity and inpatient stay .
Accurate diagnosis of the source and aetiology of a CSF leak is imperative in aiding surgical planning for repair. High-resolution CT is useful to locate bony defects in the skull base, and to rule out an otological cause. MRI and MR cisternography are useful in situations of multiple bony defects, or where the site of defect cannot be identified on CT ; CT cisternography may be reserved for cases where these have failed to identify a source. Intrathecal peri-operative fluorescein can be utilised in cases where all available imaging modalities have been exhausted .
Multiple repair methods have been described. Accepted methods involve a three-layer approach to repair dura, substitute the bony defect and then to provide mucosal cover [34, 35, 36]. While a clean operative field is preferred, CSF leak repair may be carried out in patients with acute sinus infections or meningitis without added risk of complications .
Post-FESS intracranial infections may present as meningitis, intracranial abscess or cavernous sinus thrombosis. The risk of meningitis with a persistent CSF leak is 19%, decreasing after repair of the skull base defect . Abscesses will require urgent neurosurgical drainage and therefore should be managed in the appropriate tertiary unit. All intracranial infections should be managed in a multidisciplinary environment, involving physicians, neurology and microbiology.
Pneumocephalus is an uncommon complication of FESS. Tension pneumocephalus post-FESS is incredibly rare; only a handful of isolated cases have been described in the literature [39, 40, 41, 42]. All cases of pneumocephalus must be managed in conjunction with neurosurgical teams in a tertiary unit. While very small, uncomplicated cases may be managed with bed rest and administration of 100% oxygen; the majority will require surgical repair of the underlying bony defect . Tension pneumocephalus will require urgent surgical decompression along with repair of the defect to prevent brain herniation .
Risk factors for requiring revision FESS
Allergic fungal rhinosinusitis
Frontal sinus disease
More Extensive Surgery
The inverted papilloma, a subtype of Schneiderian papilloma, is a benign but locally aggressive tumour with malignant potential , commonly affecting the nose and paranasal sinuses. Increasing Krouse staging score  will necessarily require more extensive resection. Identification of the location of attachment and adequate resection reduce risk of recurrence . The importance of sending abnormal-looking tissue and nasal polyps for histopathological analysis cannot be overemphasised. Missed inverted papilloma can continue to progress in situ, presenting with complications including frontal pyoceles . Resection of frontal sinus inverted papilloma is associated with up to 37% incidence of mucocele formation; this is higher in combined endoscopic and open techniques than endoscopic alone [58, 59].
Obstruction of the frontal sinus outflow tract (FSOT) following FESS or EDCR can lead to the formation of frontal mucocele. This may be due to adhesions or lateralisation of the middle turbinate , both of which can obstruct the FSOT. This may expand into the orbit or become infected leading to a pyocele and associated intracranial complications.
The nasalisation technique, involving giant middle meatus antrostomy, middle turbinate resection, complete sphenoethmoidectomy and dissection of the FSOT cells, is associated with reduced incidence of recurrence but increased incidence of mucoceles; this can be reduced by preserving the horizontal portion of the basal lamella and the lateral insertion to the palatine bone .
Adhesions post-FESS can cause nasal obstruction and recurrence of CRS, requiring revision FESS. Instillation of topical hyaluronic acid with hydroxyethyl starch or carboxymethylcellulose has been shown to reduce the incidence of post-operative adhesions [62, 63]. Atraumatic endoscopy and instrumentation techniques minimise the incidence of adhesions.
The use of high-quality operating equipment assists the sinus surgeon with visualisation and instrumentation during FESS . The ever-increasing variety of two- and three-dimensional endoscopes, microdebriders and drills allow the surgeon to find the instrument he or she is most comfortable with.
Image-guided navigation systems are useful adjuncts in revision FESS cases, where normal anatomical landmarks may be distorted or previously resected. The American Association of Otolaryngology–Head and Neck Surgery advocates the use of navigation systems for advanced FESS, revision cases and tumour resection . A large meta-analysis has shown reduction in overall and major complication rates with the use of image-guided navigation during FESS .
A majority of patients undergoing FESS have a positive outcome from a single operation, with no morbidity or recurrence. The FESS surgeon must be competent in recognising and dealing with potential complications, as well as approaching complex revision cases.
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no competing interests.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 1.Pynnonen MA, Davis MM. Extent of sinus surgery, 2000–2009: a population-based study. Laryngoscope. 2014:820–5.Google Scholar
- 2.Hosemann W, Draf C. Danger points, complications and medico-legal aspects in endoscopic sinus surgery. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2013;12:Doc06.Google Scholar
- 4.•• Chou T-W, Chen P-S, Lin H-C, Lee K-S, Tsai H-T, Lee J-C, et al. Multiple analyses of factors related to complications in endoscopic sinus surgery. J. Chin. Med. Assoc. 2016;79:88–92. This study shows that there is no increase in complication rates with the use of the microdebrider. CrossRefGoogle Scholar
- 5.• Stein NR, Jafari A, DeConde AS. Revision rates and time to revision following endoscopic sinus surgery: a large database analysis. Laryngoscope. 2018;128:31–6. This study shows that patients with nasal polyps are more likely to require revision surgery than those without polyps. CrossRefGoogle Scholar
- 9.•• Hopkins C, Rimmer J, Lund VJ. Does time to endoscopic sinus surgery impact outcomes in chronic rhinosinusitis? Prospective findings from the National Comparative Audit of Surgery for Nasal Polyposis and Chronic Rhinosinusitis. Rhinology. 2015;53:10–7. This study shows that patients with asthma are more likely to experience a delay in surgical intervention compared with other patients. This study also shows that delayed surgical intervention leads to reduced improvement in symptomsCrossRefGoogle Scholar
- 16.Kennedy D. Diseases of the sinuses: diagnosis and management. Hamilton: B.C. Decker; 2001.Google Scholar
- 17.Wu H, Shen T, Chen J, Yan J. Long-term therapeutic outcome of ophthalmic complications following endoscopic sinus surgery. Medicine (Baltimore). 2016;e4896:95.Google Scholar
- 24.Modica PA, Tempelhoff R, Rich KM, Grubb RLJ. Computerized electroencephalographic monitoring and selective shunting: influence on intraoperative administration of phenylephrine and myocardial infarction after general anesthesia for carotid endarterectomy. Neurosurgery. 1992;30:842–6.Google Scholar
- 25.Chang JR, Grant MP, Merbs SL. Enucleation as endoscopic sinus surgery complication. JAMA Ophthalmol. 2015:850–2.Google Scholar
- 32.Hassab MH, Eweiss AZ, Ibrahim AA. Missed skull base injury during sinonasal surgery: a dangerous scenario still existing. Ear Nose Throat J. 2015;94:E37–42.Google Scholar
- 33.Vemuri NV, Karanam LSP, Manchikanti V, Dandamudi S, Puvvada SK, Vemuri VK. Imaging review of cerebrospinal fluid leaks. Indian J Radiol Imaging. 2017;27:441–6 Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5761172/.CrossRefGoogle Scholar
- 39.Pillai P, Sharma R, MacKenzie L, Reilly EF, Beery PR 2nd, Papadimos TJ, et al. Traumatic tension pneumocephalus - two cases and comprehensive review of literature. Int J Crit Illn Inj Sci. 2017;7:58–64 Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5364769/.CrossRefGoogle Scholar
- 40.Celikoglu E, Hazneci J, Ramazanoglu AF. Tension pneumocephalus causing brain herniation after endoscopic sinus surgery. Asian J Neurosurg. 2016;11:309–10.Google Scholar
- 48.Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, et al. European position paper on rhinosinusitis and nasal polyps 2012. Rhinol Suppl. 2012;23:3 p preceding table of contents:1–298.Google Scholar
- 52.Amar YG, Frenkiel S, Sobol SE. Outcome analysis of endoscopic sinus surgery for chronic sinusitis in patients having Samter’s triad. J Otolaryngol. 2000;29:7–12.Google Scholar
- 57.Kawada M, Yokoi H, Maruyama K, Matsumoto Y, Yamanaka H, Ikeda T, et al. Rhinogenic intracranial complication with postoperative frontal sinus pyocele and inverted papilloma in the nasal cavity: a case report and literature review. SAGE Open Med Case Rep. 2016;4:2050313X16629828.Google Scholar
- 59.Sama A. Indications for the use of the osteoplastic flap, with or without obliteration, in the management of frontal sinus disease in the endoscopic era. J. Ent Mastercl. 2012;5:138.Google Scholar
- 64.Khanna A, Sama A. New instrumentations in the operating room for sinus surgery. Curr Opin Otolaryngol Head Neck Surg. 2018;26:13–20.Google Scholar
- 65.American Academy of Otolaryngology - Head and Neck Surgery. AAO HNS position statement: intra-operative use of computer aided surgery [Internet]. Available from: http://www.entnet.org/content/intra-operative-use-computer-aided-surgery.
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.