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Skull Base
Sphenoid sinus ostium
Basal Lamella
Lamina Papyracea
26 Functional Endoscopic Sinus Surgery
293
Posterior septal branch of the sphenopalatine
artery [49]: This artery serves as the vascular pedicle for nasoseptal reconstructive aps. The vessel
runs 2–6 mm inferior to the sphenoid ostium,
within the mucosa superior to the choana.
Bolger’s parallelogram [50]: parallelogram
which is traditionally used for identication of
sphenoid osteum; it is dened by following
landmarks.
Surgical steps:
Endoscopic transethmoid approach:
1. Complete ethmoidectomy is done.
2. The basal lamellae of middle turbinate is
identied.
3. A window is made through the basal lamella
to expose the superior turbinate.
4. The sphenoid osteum is located after lateral-
izing the superior turbinate.
5. The oor of the orbit when maxillary antros-
tomy is done can be used as marker as the
superior limit when searching for the sphe-
noid ostium, as the sphenoid ostium lies below
the level of the oor of the orbit.
6. The inferior part of ST can be removed for
further widening of the sphenoid osteum
using true cutting instrument.
7. When enlarging the sphenoid osteum, the
nasoseptal branch of sphenopalatine artery
may get injured and can cause troublesome
hemorrhage.
Endoscopic transnasal approach:
2. Lateralization of ST to expose the sphenoid
osteum.
3. Sphenoid osteum is widened medially and
inferiorly.
4. This approach is used in isolated sphenoid
sinus diseases or for transsphenoid approach
for sellar or parasellar lesions [44, 49–52].
Frontal sinus:
Excellent understanding of frontal sinus anat-
omy is imperative to achieve optimal surgical
outcomes. There are many endoscopic approaches
and surgeries for sinus depending upon the anatomy, relationship of the frontal osteum to the surrounding structures, and extent of frontal sinus
disease.
Arrow superior turbinate
1. Lateralization of the middle turbinate is carefully performed with a Freer elevator placed
onto the inferior aspect of the turbinate is
done till inferior part of ST is visible.
Superior Turbinate
Superior Turbinate
Bolger’s parallelogram
White arrow (natural sphenoid ostium), blue arrow (superior turbinate)
294
Orbit
Uncinate
IT : Inferior turbmate
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E. Al Duhirat et al.
Fovea
White arrow (carotid artery), blue arrow (optic nerve)
CT scan coronal section showing the relation of the optic
nerve (white arrow) and the carotid artery (red arrow) to
the lateral wall of the sphenoid sinus
Frontal sinus anatomy [53]:
1. Following are the relation of frontoethmoidal
recess:
• Anterior: uncinate, agger nasi, and Kuhn-
type frontal cells
• Posterior: ethmoid bulla, suprabullar, and
supraorbital ethmoid cells
• Lateral: uncinate, agger nasi, lamina
papyracea
• Medial: attachment of the middle turbinate
and lateral lamellae of the cribriform plate
The frontal sinus outow tract is dependent on the anatomic relationships of various
structures, including the uncinate process,
middle turbinate, agger nasi, and frontoethmoid cells. Most commonly, the uncinate process ascends from its inferior and anterior
attachments to the inferior turbinate and lacrimal bone, respectively, to blend in with the
2
CP
3
1
Septum
MT : Middle turbmate
Attachments of the uncinate
MT
IT
FS
Maxillary
sinus
medial wall of the agger nasi cell (1in Figure
above) In such cases—85% of the time—the
frontal sinus will drain between the uncinate
process and the middle turbinate. In the
remaining cases (no 2 and 3in Figure above),
the uncinate attaches to the middle turbinate
or the skull base, resulting in the frontal sinus
draining directly into the infundibulum.
2. The axilla of the middle turbinate as it attaches
to the lateral nasal wall marks the anteroinferior limit of the agger nasi region.
3. The slope of the posterior table of the frontal
sinus as it joins the ethmoid skull base determines the anterior-to-posterior dimension of
the frontal.
4. The anterior ethmoid artery is often at the posterior margin of the frontal recess.
5. Type of Frontal Cells (Kuhn’s Classication):
Bent and Kuhn divided the frontal infundibulum
cells into four categories, according to their relationship to the agger nasi cell and the orbital roof.
•
Type 1 was dened as a single anterior eth-
moid cell within the frontal recess above the
agger cell.
• Type 2 was dened as a strand of two or more
anterior ethmoid cells above the agger nasi cells.
AL GRAWANY
26 Functional Endoscopic Sinus Surgery
• Type 3 represented a single cell located above
the agger nasi and extending superiorly from the
recess, through the ostium, up into the frontal
sinus with occupation of nearly 50% of the sinus.
• Type 4 described as a single, but isolated cell
existing completely within the frontal sinus
and has no connection to the frontal recess.
Surgical approach [53–55]:
1. The approach to the frontal sinus starts with
uncinectomy.
2. The frontal recess is approached from a posteriorto-anterior and a medial-to-lateral direction.
3. 45°/30° endoscope is used for precise
visualization.
4. The anterior ethmoid artery is often identied
at the posterior border of the supraorbital ethmoid cell or at the posterior aspect of the frontal recess.
5. The frontal sinus most commonly drains
between the middle turbinate and the agger
nasi-uncinate complex; the drainage pathway
is most frequently medial and posterior to the
posterior wall of the agger nasi.
6. After the agger nasi and any Kuhn frontal
cells are removed, the opening to the frontal
sinus may be enlarged anteriorly and laterally
using a Hosemann frontal sinus punch.
7. Endoscopic frontal procedures can be
described by the following classication,
based on Wolfgang Draf’s initial work in 1991
for endonasal frontal recess dissections:
• Draf I: Removal of the superior uncinate
with preservation of the agger nasi.
• Draf IIa: Removal of all cells within the
frontal recess.
• Draf IIb: Draf IIa dissection plus removal
of the ipsilateral oor of the frontal recess,
i.e., from septum to lamina papyracea.
• Draf III: Bilateral Draf IIb dissection plus
removal of the intersinus septum and the
superior nasal septum to create a single common opening, i.e., from lamina papyracea of
one side to other side.
295
Frontoethmoidal recess
Frontal sinus
Take Home Messages
• Anatomical orientation of the nose and
paranasal sinuses is the most important
step before performing an endoscopic
sinus surgery.
• It is important to review the CT scan
before the surgery thoroughly assessing
the CLOSE mnemonic.
• Different approaches and extent of surgery should be kept in mind for successful surgical outcome and to be able to
manage any anatomical variation during
the surgery.
296
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E. Al Duhirat et al.
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Complications ofFunctional
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Endoscopic Sinus Surgery
ShanmugamGanesan, EmadAl Duhirat,
HamadAl Saey, MansourAl Sulaiti,
MaryamAbdulraheem, RaaZahid,
andAhmedShaikh
27
27.1 Introduction
Functional endoscopic sinus surgery (FESS) is
an effective treatment modality for sinus diseases, especially for patients who fail appropriate
medical therapy. The outcomes of FESS have
improved over time because of multiple factors
like technologic advances, improved surgical
training, and a better understanding of the disease’s pathophysiology. The outcome and complications of surgery are affected by multiple
factors, including patient-related factors, pathology, and surgeon-related factors.
The reported complications of FESS are not
uncommon. A literature review reveals a range of
signicant complications between 0.3% and
S. Ganesan (*) · H. Al Saey · M. Al Sulaiti
Otolaryngology-Head and Neck Surgery Division,
Department of Surgery, Hamad Medical Corporation,
Doha, Qatar
Department of Otolaryngology-Head and Neck
Surgery Division, Weill Cornell Medicine-Qatar,
Doha, Qatar
e-mail: sganesan@hamad.qa; Halsaey@hamad.qa;
Malsulaiti1@hamad.qa
E. Al Duhirat · M. Abdulraheem · R. Zahid · A. Shaikh
Otolaryngology-Head and Neck Surgery Division,
Department of Surgery, Hamad Medical Corporation,
Doha, Qatar
e-mail: EAlDuhirat@hamad.qa;
mabdulraheem1@hamad.qa;
rzahid1@hamad.qa; ashaikh4@hamad.qa
22.4% (median 7.0%) [1]. The bloody surgical
eld decreases the visualization and is associated
with higher complication rates. It is always safer to
abort the procedure and plan elective second surgery if proper hemostasis cannot be achieved.
Using image guidance during the surgery decreases
the incidence of complications signicantly [2].
The global relative ratio of complications on the
right side is reported to be 55–86% and found to be
more common than the left side [3, 4].
Proper preoperative preparation, including
thorough history taking, physical examination,
and detailed interpretation of the CT scans, will
alert the surgeon to the presence of any anatomical variations, which might increase the chance
of damage to any vital structures including the
orbit and skull base.
27.2 Increased Risk
ofComplications
• Revision surgery
• Anatomic variations
• Advanced sinus disease
• Severe comorbidities
• Increased intraoperative bleeding
• Inexperienced surgeon
• Increased risk on the right side (right handed
surgeon)
• Extended endoscopic sino-neurosurgery
© Springer Nature Switzerland AG 2021
A. Al-Qahtani et al. (eds.), Textbook of Clinical Otolaryngology,
https://doi.org/10.1007/978-3-030-54088-3_27
AL GRAWANY
299
300
S. Ganesan et al.
27.3 Prevention ofComplications
• Knowledge, skill, and experience of the
surgeon
• Patient checklist prior to surgery, which
includes:
– Sinus-skull base anatomy imaging
– Maxillary-to-ethmoid sinus ratio
– Slope of the skull base
– Cribriform plate/Olfactory cleft
– Anterior and posterior ethmoidal arteries
location
– Lamina papyracea
– Optic nerve and carotid artery positions in
the sphenoid sinus
– Presence of Onodi cell
– Anatomic variations/Asymmetric skull
base
Multiple ways were used to categorize the
complications of FESS, either to the severity or
to location (Table27.1).
Table 27.1 FESS complications
Localization/
overall type of
injury
Orbital
complicaton
Intracranial
complication
Bleeding • Minor bleeding
“Minor
complication”
• Orbital
emphysema
• Ecchymosis of
the eylid
• Uncomplicated
CSF stula
(stopped with
nasal packing,
no need for
blood
transfusion)
“Major
complication”
• Orbital hematoma
• Reduced visual
acuity/blindness
• Enophthalmos
• Injury of the
nasolacrimal duct
• CSF leak
• (Tension-)
pneumocephalus
• Encephalocele
• Brain abscess
• Meningitis
• Intracranial
(subarachnoid)
hemorrhage
• Direct injury of
brain tissue
• Injury of the ant.
ethmoidal artery
• Injury of the
sphenopalatine
artery
• Injury of internal
carotid artery
• Bleeding in need
of transfusion
Table 27.1 (continued)
Localization/
overall type of
injury
Other • Synechiae
Courtesy of Hosemann et al.: Danger points, complications, and medicolegal aspects in endoscopic sinus surgery [5]
“Minor
complication”
• Slight
exacerbation of
preexisting
bronchial asthma
• Hyposmia
• Local infection
(osteitis)
• Postoperative
MRSA-Infection
• Atrophic rhinitis
• Parafnoma
• Myospherulosis
• Temporal
irritation of the
infraorbital
nerve
• Hypoesthesia of
the lip or teeth
“Major
complication”
• “Toxic shock
syndrome”
• Anosmia
• Severe
exacerbation of a
preexisting
bronchial asthma
or bronchospasm
• Death
27.4 Intraoperative
Complications
27.4.1 Intranasal Complications
Diffuse mucosal bleeding, which affects the
operation ow and its safety, occurs mainly in
the setting of active inamed mucosa and nasal
polyposis in the absence of proper preoperative
and intraoperative preparation. About 5% of the
endoscopic sinus surgery is affected by diffuse
bleeding, and about 1.4% of the procedures are
canceled [6, 7]. The rate of peri- or postoperative bleeding is supposed to be around 2% altogether; transfusion was needed in about 0.2% of
cases [8, 9].
• A preoperative systemic steroid (e.g., 30mg/
day prednisone for 5 days) and possibly adding topical cortisone treatment can lead to
less bleeding, which reduces the duration of
surgery [5].
• Lifting the head and the upper part of the
patient’s body for about 10–20°.
27 Complications ofFunctional Endoscopic Sinus Surgery
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301
• Applying local, drug-induced vasoconstriction [10–13].
• Topical vasoconstriction by epinephrine (usually 1:1000) [14]. Optic nerve damage and
blindness after the application of pads of
adrenaline have been reported [15]. The risk
of side effects is 0.05%, and it was concluded
that the topical application of epinephrine
1:1000 is safe in adults who have no prior cardiac damage. 0.05% oxymetazoline is used,
with subsequent use of 0.1% oxymetazoline
for children; in selected cases, epinephrine
1:2000 can be used [16, 17].
• Controlled hypotension by anesthesia.
• 50–60 or 80 mmHg for elderly individuals,
and a decrease of the systolic blood pressure
less than 100mmHg [3, 18]. Note, the mean
arterial blood pressure must not be decreased
to less than 85% of the initial. Also, note that
dangerous complications like organ ischemia
have been seen in 0.02–0.06% of cases [19,
20, 22].
• Heart rate and blood loss have been shown to
have a relationship, and there is a recommendation for a pulse rate of 60 per minute [5].
• The insertion of 3% H
using saturated cot-
2O2
ton wool strips is recommended to suppress
capillary bleeding [23].
• Use of tranexamic acid.
– Tranexamic acid is applied: perioperative
administration (3 ×1 g daily for 5 days,
starting 2h before the operation) is recommended [24].
– Tranexamic acid (10 mg/kg) is adminis-
tered intravenously at the beginning of the
sinus surgery, leading to a signicant
improvement of the hemostasis in the surgical area [25].
• Rinsing the surgical eld with 40° hot water is
also helpful [26].
Sphenopalatine artery: In 80%, the sphenopalatine foramen is located in the superior nasal
meatus or the transition area between the middle
nasal meatus and the superior nasal meatus,
directly behind or below the ethmoidal crest of
the palatine bone. Several ostia are found in about
13% of cases [
27, 28]. In 97% of cases, the SPA
is divided into two or more branches. In 64% of
cases, 3–10 branches may enter the lateral nasal
wall [29, 30]. The nasoseptal branch of the sphenopalatine artery traverses through the lower
third of the anterior wall of the sphenoid sinus
and the surgeons entering the sphenoid sinus
should avoid injury to the vessel. In approximately 3% of pituitary surgery, postoperative
bleeding occurs from this vessel [
5].
Resection of the middle turbinate near its posterior insertion site along the lateral nasal wall,
aggressive enlargement of the maxillary ostium
in a posterior direction, and enlargement of the
sphenoid ostium in an inferior direction all may
cause bleeding from the sphenopalatine artery or
one of its branches. Generally bleeding from the
sphenopalatine artery is managed by identication of the vessel and its branches and controlled
by clipping or electrocautery methods (Fig.27.1).
The anterior ethmoid artery: Cadaveric studies showed variability of the location of the anterior ethmoid artery. The distance from nostrils to
the anterior ethmoid artery at the skull base is
approximately 6–7 cm, and the distance to the
27.4.2 Arterial Injury
Arterial bleeding sources are the sphenopalatine
artery, anterior ethmoid artery, and the posterior
ethmoid artery. Knowing their anatomy will help
to avoid their injury.
Fig. 27.1 Sphenopalatine artery
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302
S. Ganesan et al.
posterior ethmoid artery is approximately 7–8cm
[31–33].
The artery could be identied endoscopically
within the posterior wall of the most superior
suprabullar ethmoidal cell and approximately
11mm posterior to the common wall between the
posterior wall of the frontal infundibulum and
this superior-most suprabullar cell [31–35].
According to anatomical studies, arteries are
missing in about 5–10% of cases. The anterior
ethmoid artery traverses the skull base around
12 mm anterior to the posterior ethmoid artery
(Figs.27.2, 27.3, and 27.4).
Since the blood ows through the anterior ethmoid artery from a postero-lateral to an anteromedial direction, the angle between the lamina
papyracea to the artery is 60° and its disruption
must be managed to avoid retraction of the artery
into the orbit. Bipolar cautery is preferred to control the bleeding, to avoid transmitting the electrical current to the skull base and orbit. The
external approach can also be used for control.
The posterior ethmoid artery: It runs 5 mm
anterior to the sphenoethmoid angle, which is
formed by the junction of the anterior sphenoid
wall and the posterior ethmoid roof. It is smaller
than the anterior ethmoidal arteries, runs symmetrical and linear in most cases with bony
dehiscences noted in approximately 60% of
cases. The distance to the optic nerve is 8–9mm.
According to literature, absence of arteries is
noted in 2–34% of cases. The artery is most commonly injured during sphenoid sinus entry or
during manipulations of the posterior ethmoid
bone [5]. Bipolar cautery is preferred to control
the bleeding, to avoid transmitting the electrical
current to the skull base and orbit (Fig.27.5).
Fig. 27.2 Anterior ethmoid artery
Fig. 27.3 Anatomical dissection of the anterior ethmoid
artery
27.4.3 Intraorbital Complications
The most common orbital complication of the
endoscopic sinus surgery is a trauma of the lamina papyracea [36]. The incidence of a periorbital
injury is around 2% [6, 8].
27.4.4 Orbital Emphysema
Postoperative emphysema of the eyelid may
occur following nose-blowing, sneezing, or after
anesthesia with mask ventilation. In several
cases, there have been two likely observations—
either a surgical defect or a history of fracture in
lamina papyracea.
Mainly, in the upper eyelid, the emphysema
develops. Orbital emphysema usually managed
conservatively and resorbed within a week. Noseblowing and sneezing are advised to the patient
to be avoided (Fig.27.6) [38, 39].
27 Complications ofFunctional Endoscopic Sinus Surgery
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Fig. 27.4 Navigation assisted localization of the anterior ethmoid artery
27.4.5 Orbital Fat Exposure
Injury to the lamina papyracea may occur during
uncinectomy, or aggressive lateral dissection during ethmoidectomy. The injury most likely occurs
due to aggressive debrider powered instrumentation or in the presence of hypoplastic-atelectatic
maxillary sinus.
Routine palpation of the globe is vital while
operating in this region, watching for any
Fig. 27.5 Posterior ethmoid artery
movement by performing intraoperative pressure
test described by Draf and Stankiewicz [5]. In
case orbital fat is seen, manipulation of the fat
within the ethmoid sinus should be avoided to
prevent further injury. Uses of suction manipulation and powered instrumentation should be
avoided. No repair of this defect is needed. If
needed, a silicon sheet can be placed temporarily
on the area of the defect. Serial examinations of
the eye should be performed during the remainder of surgery to ensure that intraorbital hemorrhage has not developed. Nasal packing should
usually be avoided in such cases (Fig.27.7).
303
27.4.6 Intraorbital Hematoma
Fig. 27.6 Orbital emphysema due to injury to lamina
papyracea. (Courtesy of Kevin C. Welch, MD, James
N. Palmer, MD Department of Otorhinolaryngology,
Division of Rhinology, University of Pennsylvania [37])
The incidence of orbital hematoma is around
0.1% [40, 41]. The average orbital volume in a
conned cavity is 26cc and an increase in vol-
AL GRAWANY
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