COMPLICATIONS

IN
ENDOSCOPIC
SINUS SURGERY
Diagnosis, Prevention and Management
COMPLICATIONS
IN
ENDOSCOPIC
SINUS SURGERY
Diagnosis, Prevention and Management

Second Edition

SK Kaluskar MS FRCS DLO (Eng)

Consultant Otorhinolaryngologist
Tyrone County Hospital
Northern Ireland, UK

Sanjay Sachdeva MS (ENT) DCH

Consultant Otorhinolaryngologist
Indraprastha Apollo Hospitals
New Delhi, India

Foreword by
Prof. W. Draf

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Complications in Endoscopic Sinus Surgery: Diagnosis, Prevention and Management

© 2006, SK Kaluskar, Sanjay Sachdeva

All rights reserved. No part of this publication should be reproduced, stored in a retrieval system,
or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or
otherwise, without the prior written permission of the authors and the publisher.
This book has been published in good faith that the material provided by authors is original.
Every effort is made to ensure accuracy of material, but the publisher, printer and authors will
not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters to
be settled under Delhi jurisdiction only.
First Edition: 2002
Second Edition: 2006
ISBN 81-8061-705-X

Typeset at JPBMP typesetting unit

Printed at Gopsons Papers Ltd., Sector 60, Noida
 To
Our Patients Who have
Placed Their
Faith in Us
Foreword

The number of books dealing with endonasal surgery using microscope and endoscope increases after
the start in the late seventies (Buiter, Draf, Messerklinger) from year to year. It is much more popular to
discuss surgical success rather than complications being caused by the surgeon or occurring after surgery.
Therefore, it can be appreciated enough, that experienced surgeons like Dr Kaluskar and his co-
worker Dr Sachdeva have worked out a monograph dealing with diagnosis, prevention and management
of complications in endoscopic sinus surgery.
It has to be emphasized that the most important factor for avoiding complications is the prevention
by detailed understanding of pathophysiology, proper diagnosis, a thorough knowledge of surgical
anatomy, feeling comfortable with handling the instruments, the thorough preoperative preparation
of the nose and a systematic assessment of medical conditions, that may affect nose and sinuses.
Consequently the authors are giving in a stepwise manner important recommendations for the beginner
in this very special type of surgery.
The authors touch all groups of complications as haemorrhage during operation, orbital complications,
intracranial complications, perioperative and delayed postoperative complications, complications in
revision surgery, and complications of more advanced endonasal techniques. They give tips and quips
for the beginners and excellent recommendations for the documentation and instruments. As an annexa
the reader will find a reasonable selection of literature. The text is written in a most didactic manner and
well understandable for beginners as well as for more advanced surgeons. Most important is the excellent
documentation of anatomy, radiology, and intraoperative findings.
In conclusion this book includes not only diagnostic pieces of advice but also clear recommendations
how to deal with complications in a very concentrated but also detailed way. I am sure, it has been
expected by many general ENT surgeons and more specialized rhinologists for a long time and will find
a wide distribution.

Prof Dr Med Wolfgang Draf MD PhD FRCS

Director
Department of ENT Diseases
Head & Neck and Facial Plastic Surgery
Klinikum, Fulda
Teaching Hospital of Warburg University
Germany
Preface to the Second Edition
It is with great pleasure that we now write a preface for the second edition for this book. This is not
because we have encountered more or varied complications. However, as the medicine is an ever
evolving science and we owe to our readers recent advances in the same. Therefore we decided to add
on more of our clinical and surgical experiences of the last four years.
The spectrum of para sinus infection is changing globally. There is an increasing awareness of the
fungal infections of the para nasal sinuses due to better investigative facilities, imaging modalities and
mycological identification. Resistance to the present antifungal drugs is becoming a reality and newer
antifungal drugs are being added to control the disease process. Unfortunately fungal infection, even
apparently showing a benign course such as fungal balls and allergic fungal sinusitis may produce
serious complications due to local destruction of the tissues and distorted surgical anatomy. Depending
upon the host response the fungus can be invasive in nature to produce serious intracranial and
intraorbital complications. The surgery in this situation demands an extra care and meticulous handling
of the tissues during surgery to prevent serious complications.
We have also taken this opportunity to discuss several common challenges in the routine work of
endoscopic sinus surgery which requires special consideration and decision making process during
surgery. We have tried to outline our method of approach to the solution of these types of problems.

SK Kaluskar
Sanjay Sachdeva
Preface to the First Edition

Among many aphorisms of Hippocrates (460 BC), perhaps the most important one is “to avoid injuring
your patient”. Regarding surgery he wrote “surgery is concerned with the patient, operator, assistants,
instruments, the light, what sort and where, for the individual patient.” A surgeon must learn to use his
fingers through regular use and practice. The fingers of the surgeon must train in all kinds of work,
individually as well as together they should function well, rapidly, easily, cleanly and immediately.
Sushurta, a notable Indian surgeon of his time and a pioneer in ancient Indian medicine around 800 BC
emphasized the importance of learning surgery on cucumbers, watermelons and wax murals. Sushurta
also placed great emphasis on preparation of the patient prior to surgery. Interestingly these principles
also apply today in endoscopic sinus surgery.
An eminent rhinologist Maurice Cottle of Chicago described five letters to be kept in mind during
surgery, i.e. P.Q.R.S.T. The P stands for pain, the Q for querulousness, R is for restlessness, S for swelling
and T for temperature. When any of these symptoms appear in the postoperative period, he advised that
all dressings are removed and the tissues of the nose examined. This may prevent a minor complication
developing into one of major proportions.
With the advent of multiangled endoscopes, better imaging facilities such as CT scanning and better
understanding of the pathogenesis of chronic sinusitis, the scope of endoscopic sinus surgery has enhanced
all over the world in the last 15 years. Unfortunately at the same time some of the dreadful complications
have also been reported in the literature. Complications associated with endoscopic sinus surgery have
increased due to the large number of procedures being performed. Working with the variable intricate
anatomy of the nose and sinuses under the “brain and between the orbits” leaves little margin for error.
Two constant themes appear in the literature while discussing complications of endoscopic sinus surgery,
i.e. disorientation and the learning curve. Disorientation of the surgeon is usually secondary to the lack of
knowledge of precise sinus anatomy. This is combined with poor exposure of the operative area secondary
to bleeding during surgery. To proceed with the operation under these circumstances, can lead to the
disastrous complications and this is where the learning curve comes into play.
In this book we have humbly tried to explain minor to major complications that have occurred or
likely to occur in endoscopic sinus surgery, and more importantly discussed in details how to prevent
and manage them. The book is aided by profuse illustrations of anatomy and surgical photographs to
give to the reader as clear understanding of the problems as possible. We strongly emphasize on adequate
training in surgical principles and technique.
There are two kinds of working with the “hands”, i.e. one in which when surgery is accompanied by
safety and one in which surgery ends in a disaster. We have drawn reader’s attention in this book to the
kind of work that can be performed safely. A surgeon should seek greater degree of excellence and diligence
for himself and safety for his patients
SK Kaluskar
S Sachdeva
Acknowledgements

I sincerely wish to express my thanks to my son Anup who has helped me tirelessly, in my endeavour to
all my publications including this book. I specially appreciate his expert help in preparation of photographs.
I wish to take this opportunity to express my sincere thanks to Prof. Wolfgang Draf, Head and Director
of Otorhinolaryngology, Fulda University, Germany from whom I have learned many aspects from his
vast experience in this field especially Frontal Sinus Surgery.
I wish to thank Mrs Hugh Mills, Chief Executive, Mrs Bernie McCrory, General Services Manager and
Mrs Martina Corrigan, Asst. General Services Manager of Sperrin Lakeland Health Trust for their
unyielding support in my work. I also wish to thank medical and nursing staff at Tyrone County Hospital,
Omagh, N. Ireland, for their support for the last twenty years. Last but not least, I wish to thank my wife
Hema, and children Komal, Anup and Soniya for their understanding throughout protracted process of
publications and my work.
Finally on behalf of my co-author I wish to thank sincerely Jaypee Brothers Medical Publishers for
their expertise in the publication of this book.

SK Kaluskar

I am indebted to my parents who educated me with right values in life. I am grateful to my teachers who
taught me during my educational career.
I would like to express my thanks to Prof. Wolfgang Draf, Head and Director of Otorhinolaryngology,
Fulda University, Germany from whom I have learned many aspects of Endoscopic Sinus Surgery,
including Skull Base Surgery.
I also wish to express my sincere thanks to Dr SK Kaluskar, who has always been a source of inspiration
and made me understand the importance of hard work.
I would like to take this opportunity to express my sincere thanks to my wife Sonia, and children
Sukriti, Smriti and Stuti who have borne my absence with grace and patience so as to let me complete this
work.
Sanjay Sachdeva
Contents

1. Overview ........................................................................................................................................ 1
Prevention of Complications
2. Review of Literature ..................................................................................................................... 7
3. Intraoperative Anatomical Landmarks of Surgical Importance ........................................ 13
4. Haemorrhage During Operation .............................................................................................. 53
Causes, Prevention and Management
5. Orbital Complications ............................................................................................................... 63
Injury to Lamina Papyracea, Medial Rectus Muscle, Nasolacrimal Duct,
Retrobulbar Haemorrhage, Injury to Optic Nerve, Periorbital Emphysema
6. Intracranial Complications ....................................................................................................... 79
CSF Leak, Pneumocephalus, Meningitis, Brain Abscess
7. Perioperative and Delayed Postoperative Complications ................................................ 101
Adhesions, Osteitis, Infection, Crusting
8. Complications in Revision Surgery ...................................................................................... 115
Role of Laser, Microdebrider
9. Fungal Infections of the Nose and Paranasal Sinuses ....................................................... 135

10. New Horizons ............................................................................................................................ 143

Complications of Endoscopic Transsphenoidal Pituitary Surgery,
Endoscopic DCR, Mucoceles, Tumours, Fungal Infections, Orbital Abscess, etc.
11. Situations and Solutions ......................................................................................................... 175
12. Tips and Quips for the Beginners ......................................................................................... 183
13. Documentation and Instruments ........................................................................................... 225

Bibliography .................................................................................................................................. 229

Index ............................................................................................................................................. 233
Abbreviations

A Adhesions
AN Agger nasi
BE Bulla ethmoidalis
CG Crista galli
ET Eustachian tube
Eth Ethmoids
FE Fovea ethmoidalis
FR Frontal recess
HS Hiatus semilunaris
IC Internal carotid
IM Inferior meatus
IMA Inferior meatal antrostomy
IT Inferior turbinate
LP Lamina papyracea
LW Lateral wall
MM Middle meatus
MMA Middle meatal antrostomy
MT Middle turbinate
Mx Maxillary sinus
ON Optic nerve
OS Ostium
P Pus
PNS Post nasal space
PO Polyp
S Septum
SM Superior meatus
SP Sphenoid
ST Superior turbinate
UP Uncinate process
A
surgical complication can be defined
as a development, which is
generally to the detriment of the
patient, arising either at the time of
operation, or during postoperative
period. Surgery is an art of working with the
hands. Its name derives from the Latin word
chirurgia, which in turn comes from the Greek
cheiros (hand) and ergon (work).
The intimate relationship of the sinuses to the
orbit and anterior cranial fossa have rendered
sinus surgery a potent source of complications and
thus in recent years medico-legal litigation. In 1929
Mosher regarded intranasal ethmoidectomy which
he described as the “easiest way to kill a patient”.
The use of multi angled endoscopes and imaging
techniques of the sinuses might have reasonably
been expected to diminish these problems, but
instead has resulted in a number of serious
complications all over the world. Sometimes the
endoscopic technique is aggressively adapted by
the surgeon without undue regard to the important
structures around the sinuses and hence the
development of disastrous complications. At the
same time it is true to say that although serious
complications have been reported in the literature
i.e. orbital and intracranial, in experienced hands,
these complications are extremely low, constituting
less than one percent. Stankiewitz in 1989 reported
28 percent of complications in his first 100 patients,
which ultimately dropped to nine percent
following the learning curve in the subsequent 100
cases.
Albucasis, (Haeger K, 1988) a physician and a
skilled surgeon of his time in middle ages (936 -
1013 AD) stated “those who lack a good grasp of
anatomy are prone to commit serious and even
fatal mistakes.”
A thorough understanding of the surgical ana-
tomy of the paranasal sinuses is of utmost impor-
tance and its variations properly understood by
the endoscopic surgeon. Preoperative CT scanning
should be regarded as mandatory prior to endo-
scopic sinus surgery. Regarding instruments it is
important that the surgeon understands that a
straight 0 degree endoscope points to exactly the
area in which one is looking. With angled
endoscopes such as 30° and 70°, one is not looking
where one is pointing, and as a result, distortion
of the operative field occurs leading to excessive
tissue trauma, bleeding and higher risk of
complications.
In the early stages of the learning curve, it is
imperative that the surgeon should keep checking
from outside the nose to see where the endoscope
is entering into the nose. This can only be done
with a 0° endoscope. The angled endoscopes such
as 30° and 70° are more useful for looking around
the corners and crevices of the nose and paranasal
sinuses, e.g. working in the maxillary sinus, frontal
recess etc. In vast majority of the patients a 0°
endoscope is strongly recommended for routine
surgery, as it does not cause any distortion or
foreshortening of the operating view. This results
in a better orientation of the anatomical structures
compared to angled endoscopes.
It takes a few years of experience in endoscopic
sinus surgery to handle successfully 30° and 70°
endoscopes with ease. It is also important for the
endoscopic surgeon to realise that the deeper the
penetration and the operative procedure, the
greater the importance of the 0° endoscope. In
these circumstances, the surgeon must know
precisely where he is and where the instruments
are pointing. The surgical orientation becomes
more difficult in the posterior ethmoids than in
the sphenoid sinuses due to the anatomical
location of the posterior ethmoid cells. The 0°
endoscope also avoids trauma, which
unfortunately occurs with angled endoscopes due
to distortion of the operative field. Trauma during
operative procedure causes bleeding which makes
surgery potentially dangerous as anatomical land-
marks become unclear. Ideally one should have
0 and 30 degree endoscopes in the outpatient for
diagnosis. A 0° endoscope may not be adequate
for diagnosis for the diseases in the lateral wall of
the nose, yet the 0° endoscope is the instrument of
choice for the majority of the patients during
surgery. In authors’ experience 2.7 mm 30 degree
endoscope is most ideal for diagnosis as it can be
negotiated through narrow areas of the nose
 4 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY
especially in the presence of septal spurs,
deflections and in children with ease. A flexible
endoscope have been used for diagnostic purpose,
however its relatively smaller diameter and the
optical distortion should be taken into
consideration prior to interpretation of the findings
A potential endoscopic surgeon should practice
endoscopic sinus surgery dissection preferably on
fresh cadavers. Preserved cadavers in anatomy
department are not the ideal situation as usually
it contains considerable amount of debris. The
tissues in the preserved cadavers peel off easily
unlike normal mucous membrane. At the same
time quite often the position of the cadaver is
hyperextended making surgical orientation more
difficult. In some cadavers there remains a strong
and highly irritating smell of either formalin or any
other preservative making dissection very
unpleasant.
Carefully selected patients with minimal disease
should be operated in the initial stages preferably
under local anaesthesia. The patient himself warns
the surgeon if the surgeon is near the orbit and/or
skull base inspite of thorough local anaesthesia and
adequate sedation. After some experience the
surgeon should undertake surgery under general
anaesthesia. The surgeon should only tackle revision
surgery and advanced procedures, such as muco-
celes, tumors and frontal sinus surgery after consi-
derable experience with endoscopic techniques.
Begin with simple procedures such as uncinec-
tomy, ethmoidectomy and middle meatal antro-
stomy in the early stages, then gradually going
through the ground lamella into the posterior
ethmoids, opening the anterior wall of the
sphenoid and finally tackling the frontal recess
pathology.
Prevention of complications in endoscopic sinus
surgery begins when the patient is first seen in the
outpatient’s clinic rather than in an operating
theatre. The following scheme should help the
surgeon to avoid complications:
1. Basic understanding of the pathophysiology of
chronic inflammatory diseases of the sinuses.
2. Proper diagnosis by means of detailed history
taking, an orderly and attentive nasal
endoscopy and CT scanning of the sinuses. The
interpretation of the CT scan and diagnostic
endoscopic evaluation should be done in
conjunction with the patient’s history.
3. A thorough knowledge of surgical anatomy of
the paranasal sinuses especially in relation to
the orbital and intra cranial structures.
4. Feeling comfortable with handling the instru-
ments first in the outpatients department for
diagnosis.
5. A thorough preoperative preparation of the
nose.
6. Assess systemic medical conditions that may
affect nose and sinuses.
Prevention of complications begins with ade-
quate history and careful and complete nasal and
sinus examination. A complete physical examina-
tion is essential to make sure the patient is in good
health generally. This should be done regardless
of age. Patients are again examined the day before
surgery to rule out any upper respiratory tract
infection. If there is any question whatsoever about
feasibility of the sinus surgery, the operation should
be postponed. The surgical procedure is performed
as carefully and as skillfully as is possible within
the capabilities of the surgeon. Under these
conditions, the possibility of a serious complication
is markedly reduced. However, under most ideal
conditions, complications do occur and one must
be prepared to handle them promptly and comple-
tely.
PREOPERATIVE PREPARATION
Certain preoperative preparations are mandatory
so as to prevent operative and postoperative
complications.
General Precautions
If the patient has or just recovering from acute
upper respiratory tract infection, the operation
should not be carried as it will only result in
excessive bleeding due to mucous membrane
congestion, oedema and vasodilatation. Patients
suffering from hypertension should be well under
control before embarking upon surgery. Patients
suffering from bleeding diathesis should be
 OVERVIEW: PREVENTION OF COMPLICATIONS
properly investigated and only after joint
consultation with the expert haematologist,
procedure should be considered. Similarly patients
on aspirin, warfarin etc. should have appropriate
investigations before considering surgery.
Preoperative Steroids
Patients suffering from gross polyposis would
benefit from a short course of systemic steroids in
an attempt to reduce the size of the polyps and
allowing surgical landmarks to be identified easily.
Steroids may also help patients suffering from
chest symptoms as a result of naso bronchial
syndromes.
CT Scans
CT scan of the patients should be available at all
times in the theatre during surgery. This is not only
to plan an individual procedure but also to refer
the scan during the operation to appreciate the
pneumatisation of the various air cells and identify
the level of the skull base to the nasal cavity.
LOCAL ANAESTHESIA FOR FESS
Endoscopic sinus surgery under local anaesthesia
offers a great deal of advantage over general
anaesthesia. This is mainly due to the fact that
inspite of sedation and thorough preparation of
the nasal cavity, if the surgeon approaches skull
5
base and or orbit, the patient inevitably will feel
the pain which would warn the surgeon. The
surgeon should be familiar with the nerve supply
of the nose to anaesthetize the nose and inject at
the appropriate sites to “ block” the sensory nerves.
It is important to remember that the local
anaesthesia will not control the pain of cautery.
Aspiration before injection of local anaesthetic
should be performed to avoid direct entry into the
vessel. Blindness has been reported by accidentally
injecting into the vessel, causing retrograde flow
through ophthalmic artery, leading to vasospasm
and ischaemia of the optic nerve and retina. The
surgeon should be well aware of the toxicity and
over dosage of the various anaesthetic agents.
Preoperative consultation with the anaesthetist is
advisable.
Important Preoperative Evaluation
1. Detail systemic history and physical examina-
tion to exclude systemic diseases affecting nose
and sinuses.
2. Detail drug history such as aspirin, warfarin,
antihypertensive medications, etc.
3. Relevant investigations from anaesthetic point
of view such as X- ray chest, ECG etc. along
with haematological investigations.
4. Specific investigations such as immunological
status, if systemic disease affecting sinuses is
suspected.
E
thmoidectomy either conventional or
endoscopic carries a risk of both major
and minor complications. In 1,000 intra-
nasal ethmoidectomies, Freedman and
Kern (1979) reported an incidence of
complications (2.8%), most of them of a minor type.
Friedman and Katsantonis (1990) also reported an
incidence of complications secondary to intranasal
ethmoidectomy (2.06% minor and 0.94% major).
However, other workers have reported serious
intracranial and intraorbital complications.
Stankiewicz (1987) reported his experience with
endoscopic sinus surgery and indicated a comp-
lication rate of 29% in 90 patients. Following a
“learning curve” Stankiewicz (1989) again discussed
the complications in 300 ethmoidectomies perfor-
med in 180 patients. His overall complication rate
had dropped to 9.3 percent. Most complications
were minor. However, two cases of cerebrospinal
fluid (CSF) leak and one case of temporary blindness
occurred. The author credited the lower incidence
of complications in the latter group of patients to
experience.
Schaefer SD et al (1989) reported an incidence of
14 percent minor complications and zero percent
major. In 458 procedures, Levine HL (1990) had 8.3%
minor and 0.7 percent major complications. Most
major complications reported are CSF leaks. On the
other hand, Stammberger H,(1986) one of the
pioneers to popularise the Messerklinger technique
of endoscopic endonasal sinus surgery, states, “to
date, more than 2,500 endoscopic ethmoid opera-
tions have been carried out on the basis of
aforementioned concept at Graz University ENT-
Clinic without any serious complications. Blood
losses were always negligible and never required
administration of blood. None of the patients has
suffered injury to the roof of the ethmoid sinus or
even dura.” Stammberger reported complications
consisting of emphysema around the orbit, and
synaechia between the middle turbinate and lateral
nasal wall. Stenosis of the newly reconstructed
maxillary ostium was very rare.
Several outcome studies for endoscopic sinus
surgery have been published in the otorhinolaryn-
gologic literature. Levine (1990) reported a series
of 250 patients undergoing endoscopic sinus
surgery in which there were 42 unilateral and 208
bilateral procedures. In his series there was a 8.3
percent minor and a 0.7 percent major complication
rate. Matthews BL et al (1991)reported outcome on
155 cases with a 1.5 percent complication rate.
Wigand ME(1981)described two cases of cerebral
spinal fluid leak in 1000 cases of extensive functional
endoscopic sinus surgery. Among the most
commonly reported complications were reactionary
haemorrhage in the postoperative period, periorbi-
tal emphysema, and unilateral eye echymosis.
Maniglia AJ (1991) reported two cases of intraorbital
complications one of which was a case of intraorbital
invasion and damage to the medial rectus muscle.
The second case was of a very serious nature of
bilateral, complete blindness due to optic nerve
injury. He further reported catastrophic complica-
tions of three cases of intracranial complications of
which two cases were damage to the cribriform
plate with brain injury and intracerebral haema-
toma, and one case of damage to the cribriform plate
with extensive intracranial haemorrhage and death.
One of the latter patients suffered extensive
intracerebral haemorrhage due to laceration of the
anterior cerebral artery and required emergency
craniotomy but died two days later.
Epiphora following Endoscopic sinus surgery
have been reported by experienced surgeons
between 0.3 to 1.7 percent of cases. This occurred
while performing middle meatus antrostomy.
Serdahl CL et al (1990) discusses eight patients with
epiphora following endoscopic sinus surgery. An
inclusive knowledge of anatomy of the nasolacrimal
system is essential to prevent this complication as
the nasolacrimal apparatus is closely related (3 to 6
mm.) to the natural ostium of the maxillary sinus.
The eight cases reported here were all referred
for evaluation of epiphora over a course of 18
months. Six of the eight patients complained of epi-
phora immediately following the initial procedure
suggesting operative damage to the Nasolacrimal
sac. The other two patients noted onset of epiphora
from one to two weeks after surgery.
Two hundred patients with chronic sinusitis were
operated by Davis WE et al(1991) with functional
 10 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY
endoscopic sinus surgery (FESS) techniques. These
patients were followed closely over 3 years. Patency
of the endoscopic middle meatal antrostomy was
recorded. The overall patency rate of the endoscopic
middle meatotomy was 93.55 percent, and the
patency rate at 36 months was 87.47 percent. The
presence of seasonal allergy with nasal polyps was
the most important variable in predicting closure.
Neuhaus RW (1990) reported eight cases of signi-
ficant orbital complications associated with endo-
scopic sinus surgery. The anatomic problems
generally fell into four categories;
1. Nasolacrimal sac or duct injury,
2. Extraocular muscle injury,
4. Intraorbital haemorrhage /emphysema, and
5. Optic nerve injury.
He added that successful management of each
complication depends on a thorough knowledge of
the anatomy and pathophysiology of the orbital
injury. Return to normal function of the traumatised
orbital structures after medical and/or surgical
intervention is anticipated. However, direct optic
nerve injury with immediate visual field and /or
acuity deficit is usually irreversible.
Corey JP et al (1993) indicated that orbital
complications-including retrovulver haematoma is
among the most feared complication of endoscopic
sinus surgery. Injuries can be direct or indirect from
pulling on diseased structures. A retrospective chart
review of 616 endoscopic sinus procedures revealed
serious orbital complications in seven patients.
These included two medial rectus injuries, five
orbital haemorrhages, and one nasolacrimal duct
injury. Predisposing factors included hypertension,
lamina papyracia dehiscences, extensive polypoid
disease, previous surgery, inability to visualise the
maxillary ostia, violent coughing or sneezing, and
chronic steroid use.
As can be seen, severe complications from
functional endoscopic sinus surgery have been
reported; however, it is unclear as to how the rate
compares with that of the more traditional forms of
intranasal surgery. To ascertain this, Kane K.(1993)
circulated a questionnaire to 100 otolaryngologists
in Australia known to have an interest in endoscopic
nasal surgery and analysed the results. The results
of this survey showed that complications are
infrequent and that the incidence for functional
endoscopic sinus surgery compared favourably
with those of the traditional techniques.
Stankiewicz JA (1991)) reported seven cases of
cerebrospinal fluid fistulae occurring as a result of
endoscopic sinus surgery in a total of 800 ethmoi-
dectomies. One cerebrospinal fluid fistula was
intrasphenoid, four were posterior ethmoid/base
of skull, two were anterior ethmoid. Six of seven
fistulae were closed endoscopically.
Endoscopic sinus surgeons encounter the same
risks as traditional intranasal or external sinus
surgeons. New technology demands added training
and increased vigilance so that complications rates
remain as low as possible. Synaechia formation, are
the most common complications. CSF leak with
meningitis, double vision, and blindness is the most
devastating. Reduction of complication rates begins
with prevention, which is achieved through diligent
preparation of the patient. Careful surgical techni-
que based on both old and new principles combined
with compulsive postoperative care are the neces-
sary ingredients needed for safe sinus surgery.
From the foregoing review of literature it is obvious
that the incidence of endoscopic sinus surgery has
a wide range from very low to significantly high
rate of complications. It probably identifies the
difference between the experienced and the inexpe-
rienced endoscopic surgeon. It is also important to
emphasise that the complications, both minor and
major have been reported in conventional, either
internal or external sinus operations. It is therefore
prudent that the endoscopic surgeon should be well
trained in this new, minimally invasive technique,
has a sound knowledge of surgical anatomy of
paranasal sinuses. It is most imperative that he/she
selects the appropriate cases, following a skilful
diagnostic work up, practice on cadavers and last
but not the least understands own limitations.
Inflammatory disease of the paranasal sinus is not
a “killer” disease as compared to cancer and there-
fore, benefit and the risk of operation have to be
carefully balanced by the endoscopic surgeon.
In author’s (SKK) own series of endoscopic sinus
surgery for chronic inflammatory diseases in more
than 3000 operations, serious complications
 REVIEW OF LITERATURE
occurred in two patients who developed CSF leaks
on the operating table. Both these leaks occurred in
revision cases while working in the frontal recess
for chronic frontal sinusitis. Both leaks were reco-
gnised on the table and were repaired endoscopi-
cally with successful outcome. Other serious
complications included in the author’s series were
four cases of nasolacrimal duct injury of which two
settled down with cannulation but other two requi-
red dacryocystorhinostomy. One case (See Figs 5.8
to 5.11) had a significant orbital echymosis in the
early post operative period. This was a case of
revision bilateral nasal polyposis with complete
dehiscence of lamina papyracea. There was no
threat to her vision at any time and no surgical
treatment was required. Other less serious compli-
cations were primary haemorrhage, which occurred
in two cases, very early in the series which needed
insertion of postnasal pack. Minor complications
included small number of patients with reactionary
and rarely secondary haemorrhage, which required
insertion of small merocel pack for a day or two.
Synaechia between middle turbinate and the lateral
wall was a problem in the early part of the series
which was reduced significantly with diligent post-
11
operative care and minimal wedge resection of the
anterior part of the middle turbinate (See Fig. 7.7
and 7.8).In other author’s series (SS) minor
complications such as adhesions and postoperative
haemorrhage both reactionary and secondary
occured in a small number of cases in dealing with
the chronic inflammatary diseases of the sinuses.
All post operative haemorrhages were controlled
by the nasal packs for a day and none needed blood
transfusion. However in a series of 55 patients who
underwent transnasal endoscopic hypophysectomy
CSF leak occured in four cases. Three of these
occured intraoperatively and one in the post-
operative period. All these were repaired with fascia
lata graft and had lumbar drain inserted to reduce
CSF pressure. In addition to these one patient had
a intercavernous bleed which needed packing. One
interesting but equally alarming complication
occured when a piece of gelform which was used
to cover the bleeding surface of the tumour slipped
on the optic nerve complex. During recovery from
anaesthesia it swelled in the tumour cavity and as a
result patient complained of diminished vision on
one side. The gelform piece was removed out of sella
and the vision was restored.
A
natomical landmarks during endo-
scopic sinus surgery could be con-
veniently divided into three different
surgical areas while performing sur-
gery.
A. Anterior ethmoidectomy and middle meatal
antrostomy
B. Posterior ethmoidectomy and sphenoidotomy
C. Frontal recess and frontal sinus surgery
The Middle Turbinate is THE MOST IMPORTANT
surgical landmark throughout endoscopic sinus
surgery.
ANTERIOR ETHMOIDECTOMY AND
MIDDLE MEATAL ANTROSTOMY
The important surgical landmarks are:
1. Middle turbinate
2. Uncinate process
3. Natural ostium of the maxillary sinus
4. Bulla ethmoidalis
5. Upper border of the inferior turbinate
Middle Turbinate
The middle turbinate forms the medial boundary
of the ethmoid labyrinth.
FIGURE 3.1: Lateral view of the nasal cavity in cadaver showing middle meatus following
retraction of the middle turbinate. Note direction of the uncinate process (UP)
The anterior ethmoidal cells, bulla ethmoidales
(and Haller cell when present) are all contained
between the lateral surface of the middle turbinate
and the medial wall of the orbit ie, lamina
papyracea (Fig s 3.1 to 3.4).
The space between the middle turbinate and the
nasal septum leads to the floor of the anterior cranial
fossa ie, cribriform plate.
It is therefore mandatory that the endoscopic
surgeon during surgery must work strictly lateral
to the lateral surface of the middle turbinate and
medial to the lamina papyracea. It is vitally
important that the surgeon should not excise middle
turbinate in such a way, so as to cause distortion of
the surgical field which might lead to accidental
entry into the cranium. Any manipulations of the
middle turbinate should be as gentle as possible as
the superior attachment of the middle turbinate is
quite flimsy and aggressive traumatic manipula-
tions may result in a distance crack fracture at the
cribriform plate with resultant CSF leak (Figs 3. 5to
3.7).
The main attachment of the middle turbinate is
the ground lamella (Syn. Basal lamella) (Fig. 3.8)
which essentially has three planes i.e., medial to
lateral, anterior to posterior and inferior to superior.
As far as possible these three parts of the ground
lamella should be identified during the operation,
 16 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 3.2: Lateral view of the middle meatus in cadaver. Note

upward extension of the bulla ethmoidales towards the skull base.

FIGURE 3.3: Coronal view of the cadaver at the level of ostiomeatal

complex. Uncinate process (UP) and bulla ethmoidalis (BE) forming
anteromedial and posterolateral boundary of the ethmoidal
infundibulum respectively. Supero lateral is the orbit, thus forming
a three dimensional channel

FIGURE 3.4: Coronal CT scan showing

Haller cell, when present, narrows the
infundibulum.
 INTRAOPERATIVE ANATOMICAL LANDMARKS OF SURGICAL IMPORTANCE 17

FIGURE 3.5: Left nasal cavity in a dry skull. Note cribriform plate (CP) superiorly between the septum and middle
turbinate (MT). Note uncinate process extending much more posteriorly parellel to the middle turbinate.

FIGURE 3.6: Laterally placed uncinate process (UP) in close contact with the lamina papyracea (LP). Initial incision
on the uncinate process may lead the surgeon accidently into the orbit.
 18 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

Whenever the surgeon need to clear the posterior

FIGURE 3.7: Linear skull base fracture as a result of forceful
and traumatic manipulation of the middle turbinate.
this may not be easy in the presence of pathology
and bleeding (Fig. 3.9). Quite often the disease such
as thickened mucosa and polyp may remain behind
these parts of the ground lamella, and subsequently
would be responsible for the residual disease, and
continued symptoms.
ethmoids, it is important that entry into the posterior
ethmoids should be made at the junction of the
horizontal and the vertical part of the ground
lamella medially close to the lateral surface of the
middle turbinate (Figs 3.10 and 3.11).
At times the thickened mucosa and/or polyps
cover the ground lamella. In this situation it may
be difficult to identify the ground lamella in which
case one should pass instruments close to the lateral
surface of the middle turbinate and advance
posteriorly until the junction of the horizontal and
the vertical part of the ground lamella is palpated.
Occasionally there may be one or more ethmoid cells
which may encroach upon ground lamella and may
make identification of the ground lamella more
difficult. Once again palpation close to the lateral
surface of the middle turbinate would be an
important step during the operation. When large
part of the ground lamella is removed in an attempt
to clear posterior ethmoid cells, any manipulations
of the middle turbinate should be done extremely

FIGURE 3.8: Lateral wall of the nasal cavity in a dry skull. Note upward extension of the uncinate
process ( UP) , bulla ethmoidalis and ground lamella (GL)
INTRAOPERATIVE ANATOMICAL LANDMARKS OF SURGICAL IMPORTANCE 19

FIGURE 3.9: Endoscopic view of the right side of the

nasal cavity, showing oedematous ground lamella. In
this situation the surgeon may enter the posterior
ethmoid through ground lamella without knowing,
while removing diseased mucous membrane.

FIGURE 3.10: Endoscopic view of the left nasal cavity in a dry skull. Note horizontal
and vertical parts of the ground lamella (GL). The surgeon should enter the posterior
ethmoids at the junction of these two parts nearer to the middle turbinate medially.
 20 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 3.11: Endoscopic view (4 mm. 0 degree) of the right nasal cavity clearly showing horizontal
and vertical parts of the ground lamella and the site to enter the posterior ethmoids

gently else it may become floppy and adhere

laterally and obstruct drainage and ventilation of
either ethmoid cavity and /or maxillary sinus.
Therefore, it is important that the small part of the
horizontal part of the ground lamella be preserved
which will help to stabilise the middle turbinate
more medially (Fig. 3.12).
In many situations a paradoxical middle
turbinate (Figs 3.13 and 3.14) and concha bullosa
(pneumatisation of middle turbinate) will restrict
adequate access to the uncinate process and the
entire ostio meatal complex. In this circumstance
some form of either turbinoplasty, lateral excision
of the middle turbinate or wedge resection of the
anterior end of the middle turbinate should be
performed. Following wedge resection of the FIGURE 3.12: Operative view of the left nasal cavity,
anterior end of the middle turbinate sufficient length illustrating preservation of the lower part of the horizontal
of the upper and lower stump of the middle segment of ground lamella (GL). This technique stabilises
turbinate should be preserved, so that there is no the middle turbinate (MT) and does not allow lateralisation
distortion of the surgical field. postoperatively.
 INTRAOPERATIVE ANATOMICAL LANDMARKS OF SURGICAL IMPORTANCE
FIGURE 3.13: Right nasal cavity showing paradoxical
middle turbinate (PT) which is concave medially and
convex laterally. The paradoxical turbinate in conjunction
with high deviated nasal septum and laterally placed
uncinate process (UP) make access to the osteomeatal
complex extremely difficult.Correction of the high DNS
and some form of turbinoplasty is called for prior to
removal of uncinate process. (LW-lateral wall)
FIGURE 3.14: Coronal CT scan showing lateral lamella of
the concha bullosa (CB) restricting access to the osti-
meatal complex.
21
Uncinate Process
Although it is commonly named as process it is in
fact a thin bony plate attached to the lateral wall of
the nose (Figs 3.15 to 3.18). The uncinate process is
like a “hook” as the name implies. The process is
related to the lacrimal bone anteriorly and to the
bulla ethmoidales posteriorly .
The two dimensional space between the two
structures is the hiatus semilunaris (Fig. 3.17).
The uncinate process passes superior to inferior
in its most part parallel to the lateral surface of the
middle turbinate and anterior to posterior in its
lower part close to the upper surface of the inferior
turbinate (Fig. 3.18).
In a significant number of patients the uncinate
process is laterally placed close to the lamina
papyracea (Figs 3.19 and 3.20).
In a small number of patients it is medially
placed with its original embryological “lamella”
attached to the lateral wall of the nose (Fig. 3.21).
The superior attachment of the uncinate process
is of utmost importance to the endoscopic surgeon,
as it will determine the frontal recess drainage either
into the maxillary sinus or into the middle meatus.
In majority of patients (80%) the upper part of the
uncinate process turns laterally and attaches to the
lamina papyracia to form the sinus terminalis (Fig.
3.22). In a small number of patients the upper part
of the uncinate process turns medially and attaches
to the lateral surface of the middle turbinate (Fig.
3.23). Equally in a smaller number of patients it
continues superiorly to attach to the anterior skull
base (Fig. 3.24). In these last two situations the
frontal recess is draining directly into the maxillary
sinus. Very occasionally it can extend well into the
frontal sinus (Fig. 3.25).
The surgeon must very carefully dissect the
upper part (the “dome”) of the uncinate process
close to the lateral surface of the middle turbinate).
This is preferably performed with a 70-degree
endoscope as to delineate the operative field. Under
no circumstances “blind” instrumentation is
performed without adequate exposure while
dissecting upper part of the uncinate process,
otherwise accidental entry into the skull base is a
real possibility.
 22 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 3.15: Cadaver showing lateral wall of the nasal cavity. The middle turbinate (MT) has been partly excised to
reveal middle meatus.. Note the attachment, and direction of the uncinate process (UP), bulla and the superior
turbinate and its relation to the anterior wall of the sphenoid sinus.

FIGURE 3.16: 4mm, 0 degree endoscopic view of the left nasal cavity showing line of incision (yellow line) for the
excision of the uncinate process.Note posterior extension of the incision in the lower part.
 INTRAOPERATIVE ANATOMICAL LANDMARKS OF SURGICAL IMPORTANCE
FIGURE 3.18: Endoscopic view 4 mm, 0 degree,
of right nasal cavity showing thick, short
uncinate process (UP).
As the uncinate process forms the antero-medial
boundary of the ethmoidal infundibulum, it must
be recognised that the complete excision of the
uncinate process should be performed in an attempt
to exteriorise the ethmoidal infundibulum (Figs 3.26
and 3.27).
23
FIGURE 3.17: Lateral wall of the nose on cadaver showing
two dimensional space of hiatus semilunaris between
uncinate process and bulla ethmoidalis.
Only in a very small number of cases where the
disease process is very limited, a partial uncinec-
tomy may be appropriate in its lower part to
establish free pathway of the mucociliary mecha-
nism from the maxillary sinus. In a vast majority of
the common inflammatory diseases affecting ante-
 24 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 3.19: Left nasal cavity with laterally placed

uncinate process (UP).

FIGURE 3.20: Coronal CT scan showing

uncinate process (UP) in close contact with
lamina papyracea. Incision for uncinectomy
in this case should be made very carefully
otherwise surgeon’s knife may slip into the
orbit and damage medial rectus muscle.

rior group of sinuses, the upper and lower part of 1. In the upper part the surgeon will have difficulty
the uncinate process must be excised meticulously. in identifying the frontal recess, which need to
Inadequate removal of these parts will result in the be cleared when there is a disease in the frontal
following problems: sinus (Fig. 3.28).
INTRAOPERATIVE ANATOMICAL LANDMARKS OF SURGICAL IMPORTANCE 25

FIGURE 3.21: Endoscopic display of left nasal cavity with

uncinate process (UP) which is detached from the lateral
wall of the nose and showing extention posteriorly.

FIGURE 3.22
 26 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY
FIGURE 3.24
2. Undue trauma in the upper part may also lead
to the formation of scar tissue which in turn will
lead to the development frontal sinusitis.
3. Inadequate removal of the uncinate process in
its lower part will lead to difficulty in identifying
the natural ostium of the maxillary sinus and
subsequently performing middle meatal antro-
stomy (Figs 3.29 amd 3.30).
With a sharp sickle knife the mucosa and the
FIGURE 3.23
bone of the uncinate process is cut sharply. Exces-
sive trauma in this area also produces adhesions
which may later impair drainage of agger nasi cells
or compromise on the drainage of the frontal recess
and subsequently frontal sinus infection.
During uncinectomy an incision with a sickle
knife for the removal of the uncinate process should
be made into the mucous membrane at an oblique
angle at its upper attachment to the lateral wall.
 INTRAOPERATIVE ANATOMICAL LANDMARKS OF SURGICAL IMPORTANCE 27

FIGURE 3.25

FIGURES 3.22 to 3.25: Coronal CT scan of the sinuses illustrates various attachments of the upper part of the uncinate
process towards the lamina papyracea, lateral surface of the middle turbinate and the skull base. Occasionally it can
also extend upto the frontal sinus. Careful examination of these anatomical variations is important in order to enter
into the frontal recess and sinus.

FIGURE 3.26: Coronal cadaver section with three

dimentional space of ethmoidal infundibulum between
uncinate process, bulla ethmoidalis and the orbit.
Following this the sickle knife should be made
vertical and parallel to the lamina papyracia in the
most part. As the incision is carried in its lower and
posterior part, the sickle knife should be made
horizontal, taking care that the surgeon should not
FIGURE 3.27: Right nasal cavity in a dry skull showing
infundibulum as a channel with yellow arrow.
cut into the vascular mucous membrane of the
inferior turbinate. If the upper part of the inferior
turbinate is cut, it will result in bleeding which in
 28 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 3.28: CT scan of diseased left frontal sinus. Usually due to blokage of the
frontal recess and frontal mucociliary outflow tract.

FIGURES 3.29 and 3.30: Operative view with 4mm, 0 degree endoscope of the left and right nasal cavity displaying
relative positions of the accessory and natural ostium of the maxillary sinus. Note natural ostium is anterolateral to
the bulla ethmoidalis.
 INTRAOPERATIVE ANATOMICAL LANDMARKS OF SURGICAL IMPORTANCE 29

FIGURES 3.31 to 3.34: Steps of left uncinectomy with 4mm, 0 degree endoscope. Note the position of the sickle knife
beginning at an angle and making vertical in its middle part.
Following incision on the uncinate process, upper part is grasped by the angled forceps turning medially but not
removing uncinate process at this stage otherwise tearing of the mucous membrane will result in bleeding. The
lower part of the uncinate process is grasped, turned medially and then entire process is removed.

turn will stain the end of the endoscope every time
the ‘scope is inserted in to the nose (Figs 3.31 to
3.34).
It is important that the direction of the uncinate
process either medial or lateral, and its superior
attachment be carefully studied on the coronal CT
scan prior to surgery being undertaken. The CT scan
should also be available at all time in the operating
theatre for ready reference during surgery. Inability
to remove the upper and lower segment of the
uncinate process is a major cause of residual disease
in the infundibulum affecting ethmoids and
maxillary sinuses and continued cause of recurrent
symptoms.
Natural Ostium of the Maxillary Sinus
The mucociliary mechanism of the maxillary sinus
works towards the natural ostium hence it is vitally
important that the natural ostium should be iden-
tified accurately and widened if required to perform
middle meatal antrostomy. Very commonly the
accessory ostium is mistaken for the natural ostium,
and simple widening of the accessory os results in
a “Pseudo middle meatal antrostomy” which does
not allow normal physiological mucociliary mecha-
nism to take place. The middle meatal antrostomy
is essentially through the natural ostium and NOT
through the accessory ostium. Unfortunately signi-
ficant number of accessory ostia lie in the vicinity
 30 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 3.35: Schematic diagram showing relative positions of the natural ostium of the maxillary sinus in hiatus
semilunaris.

of the natural ostium and hence the difference

between the two ostia should be clearly understood
to avoid “Pseudo antrostomy” and persistence of
symptoms (Figs 3.35 and 3.36).
The difference between the natural and accessory
ostia are as follows inTable 3.1.

TABLE 3.1: Difference between the natural and

accessory ostia
Natural Os Accessory Os
1. Always present Present in about 10-40
percent
2. Very difficult to see Easily seen on endoscopy
clinically
3. Lies deep in the Lies in the sagittal plane
infundibulum in fontanella
4. Usually oval shaped Usually round and
“punched out” appearance
5. Always single Could be multiple
6. Lies at the level of Lies anywhere in the
MT or upper border middle meatus
of IT FIGURE 3.36: Right nasal cavity with accessory ostium
on the lateral wall of the nose in the fontanella. Note its
7. Usually quite small in Could be large up to half
position in saggital plane and punched out appearance.
diameter to one centimeter
It is also easily identifiable on routine nasal endoscopy.
 INTRAOPERATIVE ANATOMICAL LANDMARKS OF SURGICAL IMPORTANCE
Once the natural ostium of the maxillary sinus
has been identified the surgeon should not work
laterally and superiorly in relation to the natural
ostium. It is important that the natural ostium be
identified at an early stage of the operation so that
inadvertent entry is not made into the orbit. This is
highly recommended especially in revision cases
where the normal anatomy is often distorted. The
middle meatal antrostomy should not be unduly
large one, as the functional size of the antrostomy
rather than physical size is important for the
successful mucociliary drainage. In fact a very large
antrostomy will allow inspiratory air current to pass
into the maxillary sinus directly giving rise to
uncomfortable symptoms on the face, even to the
extent of facial pain in few patients.
Bulla Ethmoidalis
From the anatomical point of view, the bulla
ethmoidalis is a middle ethmoid cell, however
surgically it is usually referred to as part of the
anterior ethmoid cell system. It develops from the
embryonic anterior group of the cells and drain into
FIGURE 3.37
31
the hiatus semilunaris. Bulla is related laterally to
the lamina papyracia and posteriorly to the ground
lamella (Figs 3.37 to 3.40).
At times there is a space between the bulla and
the ground lamella known as sinus lateralis which
must not be mistaken for the posterior ethmoid cell.
Bulla ethmoidales is not just one globular cell as it
appears to be on the coronal CT scan, but often
extends up towards the skull base (Fig. 3.41).
Sometimes it even extends anteriorly towards
the frontal recess and blocks the drainage of the
frontal recess into the middle meatus. Occasionally
there is more than one bullar cell (Fig. 3.42).
Once again careful evaluation of the bulla exten-
sion should be made on the coronal CT scan prior
to the operation. Bulla ethmoidalis forms the postero
lateral boundary of the ethmoidal infundibulum
and should be removed when diseased (Fig. 3.43).
The natural ostium of the maxillary sinus is
always anterior to the bulla hence it is recommen-
ded that bulla should not be removed until natural
ostium have been identified. In difficult cases of
revision surgery bulla can also be used as a guide
 32 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 3.38
FIGURES 3.37 and 3.38: Lateral wall of the nose on a dry skull and cadaver showing various anatomical structures
and the site of main blood vessels in the nose and sinuses i.e, sphenopalatine artery entering the nose through
sphenopalatine foramen (SPF) and anterior and posterior ethmoidal arteries (AEA & PEA) at the skull base.

FIGURE 3.39: Right nasal cavity

showing bifid middle turbinate
(MT) and bulla ethmoidalis.
INTRAOPERATIVE ANATOMICAL LANDMARKS OF SURGICAL IMPORTANCE 33

FIGURE 3.40: Coronal CT scan showing bulla ethmoidalis (BE)

forming posterolateral boundary of the infundibulum.

FIGURE 3.41: Endoscopic view of left nasal cavity showing upward extension of the
bulla ethmoidalis towards skull base.
 34 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 3.42: Coronal CT scan with two bullar cells on the right side.

FIGURE 3.43: 4mm, 0 degree endoscopic view during
surgery showing excision of the medial half of the bulla.
to identify frontal recess sometimes known as
“intact bulla technique“ for the frontal recess
surgery.
Upper Border of Inferior Turbinate
When middle turbinate has been excised ,distorted
from the previous surgery or destroyed by the
FIGURE 3.44: Coronal CT scan illustrates complete
destruction of the lateral wall of the nose. This can cause
considerable dificulty in identifying the natural ostium of
the maxillary sinus. In this situation upper border of the
inferior turbinate is an important surgical landmark.
disease and the inferior turbinate is intact, the upper
border of the inferior turbinate is an important
surgical landmark for the identification of the
natural ostium of the maxillary sinus (Fig. 3.44).
INTRAOPERATIVE ANATOMICAL LANDMARKS OF SURGICAL IMPORTANCE 35

FIGURE 3.45: Right nasal cavity in cadaver showing relation of the posterior
ethmoid cells and posterior ethmoidal artery (PEA) and skull base.

FIGURE 3.46: Coronal CT scan displaying ground lamella (GL) and

the site of entry into the posterior ethmoid cells
 36 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 3.47: Left nasal cavity showing remnants of ground lamella (GL), skull base and
olfactory filaments. The sphenoid sinus is inferomedial to the posterior ethmoids

POSTERIOR ETHMOIDECTOMY AND

SPHENOIDOTOMY
The posterior ethmoid cells are usually two or three
in numbers and could be accessed once the ground
lamella is taken down in its medial aspect at the
junction of the horizontal and vertical part (Figs 3.45
to 3.47).
The most important structure in relation to the
posterior ethmoid cells is the optic nerve in its
course to the optic chiasma (Fig. 3.48). It is therefore
imperative that the surgeon once entered into the
posterior ethmoids should work more medially
close to the middle turbinate. The skull base in this
area is thicker than the anterior part and must be
identified at all time (Figs 3.49 and 3.50). It can then FIGURE 3.48: Endoscopic view of left nasal cavity with
be taken as a guide coming anteriorly forward to Onodi cell and the exposed optic nerve laterally. It is
extremely important that the surgeon once in the posterior
the dissection of the frontal recess.
ethmoids should work more medially than laterally.
Sometimes there is a lateral pneumatisation of
the posterior cell known as Onodi cell which
surrounds the optic nerve and if there is any disease Entry into the sphenoid sinus is usually thought
in this cell utmost care should be taken to avoid to be difficult especially in the presence of bleed-
any injury to the optic nerve. ing and other pathology in the region. However
INTRAOPERATIVE ANATOMICAL LANDMARKS OF SURGICAL IMPORTANCE 37

FIGURE 3.49: Left nasal cavity showing posterior ethmoids and its roof (fovea)
which is thick in this region. Note olfactory filaments medially warning the
surgeon that he/she is at the skull base.

FIGURE 3.50: Coronal CT scan displaying thick skull base

forming the roof of the posterior ethmoids
 38 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 3.51: Lateral wall of the nose in a dry skull with relations of the superior
and the middle turbinate to the anterior wall of the sphenoid sinus.

FIGURE 3.52: 4mm, 0 degree endo-

scopic view of the sphenoethmoidal
recess of the right side showing
superior turbinate (ST) and supreme
turbinate in relation to the anterior wall
of the sphenoid sinus and its ostium.

there are four important surgical landmarks which 2. Lower most border of the superior turbinate
should guide the surgeon safely into the sphenoid 3. Upper border of the posterior choana
sinus 4. Posterior part of the nasal septum (Figs 3.51 and
1. Posterior end of the middle turbinate 3.52).
 INTRAOPERATIVE ANATOMICAL LANDMARKS OF SURGICAL IMPORTANCE 39
During surgery into the sphenoid sinus it is useful pathology i.e., a polyp, the distance from the anterior
to remember that the anterior wall of the sphenoid nasal spine is an important guide. Similarly thin
sinus is approximately five to six centimeter from anterior bony wall of the sphenoid sinus is appro-
the anterior nasal spine at an angle of 30 degree. In ximately 1 to 1.5 centimeter from the upper border
the presence of bleeding and poor view due to of the posterior choana (Figs 3.53 and 3.54).

FIGURE 3.53: Dry skull showing distance

from the anterior nasal spine to the
anterior wall of the sphenoid sinus at
an 30 degree angle which is usually 5
to 6 cm. in a caucasian nose.
Surgeon should be constantly
aware of the distance from the nasal
spine to the inside of the nose and
sinuses.

FIGURE 3.54: The distance from the upper border of the posterior choana and
the anterior wall of the sphenoid sinus is about 1 to 1.5 cm. This is an important
landmark for entering into the sphenoid sinus.
 40 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY
It must be remembered that the sphenoid sinus
is NOT a continuation of posterior ethmoid but it
is infero medial to the posterior ethmoid. Once the
dissection of the posterior ethmoid cell is completed,
it is obligatory that the surgeon should stay close to
FIGURE 3.55: Nasal endoscopy with 4mm, 0 degree ‘scope
on the left side reveals sphenoid ostium which in majority
of cases is nearer to the skull base. Great care should
be excercised while working in or around the ostium.
FIGURE 3.56: Endoscopic view of right sphenoid sinus
where anterior wall is obscured by the polypoidal superior
turbinate (ST).
the posterior end of the middle turbinate in an infero
medial direction.
The anterior wall of the sphenoid sinus has two
parts ie, a lower one which is quite thick and an
upper part which is thin. It is through this thin part
of the anterior wall that the entry should be made
in to the sphenoid sinus. The sphenoid sinus ostium
is in the upper part in about 90 percent of the time,
nearer to the roof of the sphenoid sinus, which forms
the floor of the anterior cranial fossa. It is extremely
important that entry into the sphenoid should not
be made in its upper part near the roof, as there is a
possibility that the surgeon would accidentally enter
into the cranium (Figs 3.55 and 3.56).
Once into the sphenoid sinus, the surgeon should
be careful not “pulling out” any thickened mucosa
or polyps as the internal carotid artery is closely
related to the postero lateral wall of the sphenoid
sinus. In as many as 23 percent of the cases the
internal carotid artery is dehiscent and any trauma
is likely to end in the disastrous complication of
carotid bleed (Fig. 3.57 to 3.59).
At the same time when the sphenoid sinus is
divided by its septum, it may be attached to the
lateral wall of the sphenoid sinus near to the carotid
dehiscence (Fig. 3.60).
Unnecessary and traumatic manipulations of the
sphenoid sinus septum also might result in carotid
artery injury. Sometimes sphenoid sinus is asym-
metrical as the intersinus septa are not strictly in
the midline. This situation may disorient the
surgeon while entering in to the sphenoid sinus.
Extensive pneumatisation can occur in the sphenoid
bone exposing vital structures, which the surgeon
should be aware of during operation in the sphenoid
sinus. Proper evaluation of the size of the sphenoid
sinus should be made on the CT scan prior to the
operation and appropriate care should be taken to
avoid any injury to the internal carotid artery or any
other important structures in the sphenoid sinus
(Figs 3.62 and 3.62)
FRONTAL RECESS AND FRONTAL
SINUS SURGERY
Due to its anatomical position and relation to the skull
base and orbit, frontal recess and frontal sinus
surgery presents a challenging problem to the
 INTRAOPERATIVE ANATOMICAL LANDMARKS OF SURGICAL IMPORTANCE 41

FIGURE 3.57: Lateral view of the sphenoid sinus in a dry skull shows the relation of the internal
carotid artery (ICA) to the lateral wall of the sphenoid sinus.

FIGURE 3.58: Postoperative cavity seen with an 0 degree endoscope on the left side
clearly shows dehiscent internal carotid artery in the lateral wall of the sphenoid sinus.No
instrumentation should be performed inside the sphenoid sinus during operation.
 42 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 3.59: Axial view of the posterior ethmoids and the sphenoid
sinuses displays dehiscent internal carotid artery which should be noted
prior to undertaking sphenoid sinus surgery.

FIGURE 3.60: Coronal CT scan of the sphenoid sinus showing intersphenoid septum
attached to the lateral wall nearer to the dehiscent internal carotid artery. Note the
mucosal disease in the sphenoid sinus. Indiscriminate attempt at removal of this
disease may result in a carotid bleed and a major catastrophy.

endoscopic surgeon. Only after some experience one
should embark upon endoscopic approach to the
frontal recess and sinus. The specific problems in
dealing with the frontal recess and sinus are as
follows:
1. It is a difficult area to visualise on the operation
table
2. Frontal recess surgery is essentially a careful dis-
section of the agger nasi cells, which are variable
in number and in position (Figs 3.63 to 3.66).
 INTRAOPERATIVE ANATOMICAL LANDMARKS OF SURGICAL IMPORTANCE 43

FIGURE 3.61

FIGURE 3.62
FIGURES 3.61 and 3.62: In a well pneumatised sphenoid sinus optic nerve is
related to the lateral wall along with the pneumatisation of the clinoid process,
pterygoid plates and maxillary nerve as seen in a coronal CT scan.

The surgeon should be looking for thin “egg
shell” roof of the agger nasi cells, which then are
removed to enter into the frontal recess.
3. A careful evaluation of the agger nasi cells is
mandatory on the CT scan with thin, at least
2 mm cuts.
4. The surgeon must use angled endoscopes either
30 or preferably 70 degree, which gives an
excellent view of the cribriform plate and the
orbit at the same time (Fig. 3.67).
5. The angled endoscope causes distortion and
foreshortening of the operative field. With these
 44 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 3.63: Endoscopic view of the right nasal cavity

showing agger nasi cells which are anterior to the
attachment of the middle turbinate (MT)

FIGURES 3.64 and 3.65: Coronal CT scan shows agger

nasi cells obstructing frontal recess and mucociliary
outflow tract from the frontal sinus.
 INTRAOPERATIVE ANATOMICAL LANDMARKS OF SURGICAL IMPORTANCE 45

FIGURE 3.66: 4 mm 70 degree endoscope showing right nasal cavity and

agger nasi cell (AN) during surgery of the frontal recess.

FIGURE 3.67: Excellent view obtained with 4mm,70 degree endoscope which
shows upper part of the middle turbinate (MT) and cribriform plate (CP)
with agger nasi cells well exposed.

endoscopes, one is not “pointing the endoscope
and the instruments where one is looking”.
Frequent instrumentation either with the forceps
or even with the suction can cause more trauma
and bleeding which enhances the risk of serious
complications. This can lead to the surgeon
“going” further than the operative field of frontal
recess and sinus, which can result in serious
intracranial and intra orbital complications (Figs
3.68 and 3.69).
6. The roof of the ethmoid sinuses or the fovea
ethmoidalis is essentially formed by the medial
thin wall (lateral lamella of the cribriform plate)
of the ethmoid bone whereas the lateral part of
the roof is formed by the relatively thick frontal
bone (Figs 3.70 to 3.72).
The medial part of the roof of the ethmoid is
somewhat nine times thinner than the corres-
ponding lateral part. The skull base at lateral
lamella of the cribriform plate, the thinnest part
46 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURES 3.68 and 3.69: These two photographs illustrates the optical distortion that
can occur from a straight endoscope ( 0 degree) to an angled ‘scope (70 degree).
Both photographs have been taken at the same distance and central and peripheral
dark dots are same diameter in both illustrations.
 INTRAOPERATIVE ANATOMICAL LANDMARKS OF SURGICAL IMPORTANCE 47

FIGURE 3.70: Skull base of a fresh cadaver shining light from the
nasal cavity clearly displays extremely thin fovea ethmoidalis
near cribriform plate of the ethmoid bone.

of the anterior skull base and the medial wall of
the orbit are very close to the frontal recess
dissection (Figs 3.73 and 3.74). Therefore great
care must be taken to avoid injury to these
structures
Sometimes these two important anatomical
areas have natural dehiscences and even the
slightest trauma with the suction or the
instruments can result in serious complications
(Figs 3.75 and 3.76).
In addition the dura mater is also very closely
applied to this part of the skull base and slightest
trauma in this region may injure dura mater
resulting in CSF leak (Fig. 3.77).
7. The anterior ethmoid artery from the orbit
courses through the nasal cavity to the cranium
at the skull base level posterior to the frontal
recess (Figs 3.78 to 3.79A). Utmost care must be
taken to avoid injury to the vessel.
8. In majority of the patients the frontal sinus
ostium is situated behind the postero medial roof
of the agger nasi cells, more medial, nearer to
the thin lateral lamella of the cribriform plate and
injury in this area can result in CSF leak.
9. Last but not the least, special frontal sinus
instruments are required for dissection in this
area, as routinely used ethmoid instruments are
not long enough to work in this region.
The only way to perform safe frontal recess and
sinus surgery is to learn on cadaver first, and
understand the anatomy of agger nasi cells both on
the cadaver and in relation to the CT scan. There
are four different ways in which the surgeon would
know that he is at the skull base.
1. Identification of anterior ethmoid artery
2. Sometimes short and thick posterior ethmoid
artery
 48 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 3.71

FIGURE 3.72

3. If the bleeding is not excessive one can identify will inevitably cause pain inspite of sedation and
olfactory fibres analgesia given to the patient, which obviously
4. If the patient is operated under local anaes- is an important indication for the surgeon to be
thesia, touching this extremely sensitive area careful .
 INTRAOPERATIVE ANATOMICAL LANDMARKS OF SURGICAL IMPORTANCE 49

FIGURE 3.73
FIGURES 3.71 to 3.73: Coronal CT scans and cadaver dissection shows very thin lateral
lamella of the cribriform plate which forms the fovea ethmoidalis medially. This part is
nine times thinner than the lateral fovea formed by the frontal bone.

FIGURE 3.74: Cadaver dissection on left side demonstrates how easy it

is to go into the cranium with a slightest pressure in this region of the
lateral lamella of the cribriform plate.
50 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURES 3.75 and 3.76: Dry skull seen from above and coronal CT scan
shows the dehiscent skull base which surgeon must in keep in mind at
all times during sinus surgery.
INTRAOPERATIVE ANATOMICAL LANDMARKS OF SURGICAL IMPORTANCE 51

FIGURE 3.77: operative view of a patient on the left side

who developed CSF leak following endoscopic sinus
surgery at the level of the fovea ethmoidalis.

FIGURE 3.78
52 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 3.79

FIGURE 3.79A

FIGURES 3.78 to 3.79A: Coronal CT scan and the operative

photographs showing position of anterior ethmoidal artery (AEA)
at the skull base. This point is also the weakest point at the skull
base and great care should be taken during surgery in this area.
N
ose and sinuses are extremely vas-
cular structures and therefore any
trauma will result in a continuous
oozing from the mucous membrane
or a significant arterial bleeding
depending upon the severity of the trauma. This
will inevitably obscure the important surgical
landmarks leading to complications. Nose bleed
can be life-threatening if patient is on the blood
thinning agents. Warfarin loses its effect in five
days and can be reversed by vitamin K. Heparin
can be discontinued immediately five hours before
surgery and can be recommended again five hours
following surgery. The prothrombin time measures
factors two and seven. When Warfarin is stopped
factor seven returns to normal faster than factor
two, therefore a normal prothrombin time does not
necessarily mean that all factors have returned to
normal.
There are two types of bleeding that usually
occur during endoscopic sinus surgery.
1. Mucosal bleeding
2. Arterial bleeding.
MUCOSAL BLEEDING
Mucosal bleeding is essentially due to the operative
trauma with the surgeon’s instruments i.e., forceps,
suction, diathermy etc. and is usually avoided by
employing a meticulous technique of handling the
various instruments and “respecting” the tissues
at all times during operation. Patients on long term
local steroid sprays have a tendency to bleed more
than others. In this situation extra care should be
taken to avoid mucosal trauma. Unnecessary
tearing of the tissue should be avoided at any cost
especially in cases of nasal polyposis. One definite
way of minimising the mucosal bleeding is to
prepare the nose thoroughly prior to the operation
under direct vision with a 0 degree endoscope.
Preparation of the nose is done by packing the
nasal cavity repeatedly with vaso constrictor agents
such as four percent cocaine with 1: 1000 adrenaline
or four percent zylocaine with adrenaline (half and
half). Prepare nasal cavity gently from anterior to
posterior upto the area of middle turbinate, then
inferior to superior, which will anaesthetise
branches of anterior ethmoidal nerve. Once this is
achieved, start preparing nasal cavity again from
anterior to posterior from middle turbinate to the
post nasal space so as to anaesthetise the branches
of sphenopalatine ganglion. Finally prepare
sphenoethmoid recess to achieve complete surface
anaesthesia and vasoconstriction of the nasal cavity.
A preferred material for nasal packing is a soft
merocel in small strips or cotton wool or unstarched
ribbon gauze. A merocel pack with a attached thread
can be placed nearer to the post nasal space. Rapid
traumatic packing of the nose should be avoided at
any cost. It usually takes at least half an hour to a
fourty minutes to prepare the nasal cavity
thoroughly for an operation. For patients for surgery
under local anaesthetic, gently apply first local
anaesthetic “block” with pledget of cotton wool on
a orange stick to the sphenopalatine nerves at the
posterior end of the middle turbinate. Insert second
block to the roof of the nasal cavity to anaesthetise
the anterior ethmoidal nerves. Finally third block
should be applied to the middle meatus. Just prior
to the operation injection of a local anesthetic
solution of one percent lidocaine with I: 200.000
adrenaline should be made at the attachment of
the middle turbinate to the lateral wall of the nose
and one at the posterior end of the middle turbinate
(Figs 4.1 and 4.2).
FIGURE 4.1: Operative photograph illustrates site of
injection of local anaesthetic with adrenaline to block
branches of the anterior ethmoidal nerve.
 56 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY
FIGURE 4.2: Cadaver specimen shows the site of injection
for the sphenopalatine nerves. This is at the posterior
end of the middle turbinate (MT) towards the lateral wall
of the nose.
During operation if there is excessive amount
of oozing or bleeding, then the nasal cavity should
be packed on that side with wet ribbon gauze
which has been squeezed and the surgeon can
continue operating on the other side. This alternate
method of packing on one side and working on
the other side works extremely well when
operating on both sides.
Key to Minimise Bleeding during Endoscopic
Sinus Surgery
1. Prepare nasal cavity under direct vision with
suitable vasoconstrictor agent
2. Use gently, non traumatising material for
packing
3. Thorough preparation takes time.
During Operation
1. Develop a meticulous and gentle operative
technique, respecting the tissues at all time.
2. Always use good quality sharp instruments ie,
sickle knife, grasping forceps etc. otherwise
unnecessary mechanical force may be applied
to the tissues causing more trauma and
bleeding.
3. If possible use non-tearing instruments such as
thru cut forceps, Microdebrider and laser for
precise removal of disease.
4. Avoid tearing mucosa as this will only result in
mucosal bleed.
ARTERIAL BLEEDING
Anterior Ethmoidal Artery
This artery, a branch of ophthalmic artery
traverses from the orbit, through the roof of the
nasal cavity to the anterior cranial fossa (Figs 4.3
to 4.5). It is usually in a bony canal but in a
significant number of cases it is without any bony
cover with small mucosal mesentery attached. If
artery is damaged during operation, it is likely to
bleed significantly. In a rare case a bleeding vessel
may retract into
the orbit with consequent intra orbital bleeding
and possible blindness. Haemorrhage from the
anterior ethmoidal artery at the skull base can be
cauterised with bipolar diathermy and failing this
packing for a short while usually would stop the
bleeding.
Similarly posterior ethmoidal artery, a smaller
but a thicker vessel, runs along the skull base about
2.5 cm. posterior to the anterior ethmoidal artery.
This artery, if it bleeds, can be cauterised with
bipolar diathermy or alternatively bleeding can be
stopped with pressure packing (Fig. 4.6).
Sphenopalatine Artery
This artery, a continuation of the internal maxillary
artery, enters the nasal cavity through the spheno-
palatine foramina on the lateral wall of the nose
near the posterior end of the middle turbinate. Due
to significantly high pressure in the vessel, when
damaged it bleeds quite furiously. It can be
cauterised with either mono or bipolar diathermy.
An endoscopic ligation of the artery, following
dissection and identification at or near spheno-
palatine foramen is an ideal solution (Figs 4.7 and
4.8).
If this is not possible and the bleeding continues,
then post nasal and anterior packing is indicated.
While performing wedge resection of anterior part
of middle turbinate the upper stump of the middle
turbinate should always be preserved as an
important surgical landmark during surgery. The
 HAEMORRHAGE DURING OPERATION 57

FIGURE 4.3 FIGURE 4.4

FIGURE 4.5
FIGURE 4.3 to 4.5: Cadaver, endoscopic and CT scan view shows the
location of the anterior ethmoid artery (AEA) at the skull base. Note the
position of the artery is always posterior to the frontal recess.

lower cut on the anteroinferior turbinate should
not be taken further posteriorly. If this is done
branches of the sphenopalatine artery could be
damaged with the resultant haemorrhage (Fig.
4.9).
Posterior Branch of the Sphenopalatine Artery
This, small but significant artery runs above the
anterior surface of the sphenoid sinus. It is usually
damaged while trying to perform sphenoidotomy.
If damaged, it could be cauterised with bipolar/
suction monopolar diathermy or packing the area
for a short time. Only occasionally, if the bleeding
continues then, a post nasal pack and an anterior
nasal pack may be necessary. Once again the best
 58 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 4.6: Occasionally there is a middle ethmoid artery FIGURE 4.7

just anterior to the posterior ethmoid artery but posterior
to the anterior ethmoid artery at the skull base as seen
on the right side of the cadaver dissection.

way to avoid injury to this vessel is to enter into

the anterior wall of the sphenoid sinus at about
1.5 cm. from the upper border of the choana.

Anterior Branch of Sphenopalatine Artery

This is a small branch of the sphenopalatine artery,
which runs anteriorly. This artery is related to the
maxillary sinus and could be damaged while
working in the middle meatus.

Internal Carotid Artery

Damage to the internal carotid artery is obviously
a catastrophic complication of endoscopic sinus
surgery. The artery is related to the lateral wall of
the sphenoid sinus and is dehiscent in about 23
percent of the cases or the covering bone is extre-
mely thin. In some cases the intersphenoid septum
is attached to the carotid canal and any rough
manipulations with these septa can damage the
artery (Figs 4.10 to 4.12). The best way of avoiding
injury to the internal carotid artery is not to
FIGURE 4.7 and 4.8: Operative views of the exposed
advance any instruments either forceps, suction sphenopalatine artery (SPA) following elevation of the
etc. into the sphenoid sinus. The aim of the mucoperiosteal (MP) flap from the lateral wall of the nose
sphenoid surgery for chronic inflammatory disease formed here by the perpendicular plate of the palatine
is simply to perform sphenoidotomy and thus bone (PPP). Sometimes a thick specule of bone can
exteriorising the disease. obscure the proper exposure of the artery.
 HAEMORRHAGE DURING OPERATION 59

FIGURE 4.9: Anterior wedge resection of the middle turbinate on the left
side during operation occasionally results in a brisk bleeding usually
controlled by a temporary pack for a few minutes.

FIGURE 4.10 FIGURE 4.11

FIGURE 4.10 and 4.11: Cadaver dissection shows the dehiscent

internal carotid artery in the lateral wall of the sphenoid sinus

Internal Carotid Artery Injury to be damaged during endoscopic sinus surgery

Anatomy The course of ICA can be divided into of the sphenoid sinus.
four parts. Cervical, intratemporal, cavernous and Physiology of cerebral blood flow The average
supra cavernous. The cavernous part is more likely normal cerebral blood flow is 50 to 55 ml per 100
 60 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 4.12: A case of transitional cell papilloma (TCP) in the right

sphenoid sinus. Any aggressive and rough manipulations of the
tumour in the sphenoid sinus may result in damage to the internal
carotid artery in the lateral wall of the sphenoid sinus.

gms brain tissue per minute. Irreversible cellular
damage occurs when flow decreases below 6 to 8
ml/100gm/min. The depth and duration of
ischaemia profoundly affects resultant brain injury.
The brain may tolerate reduced flow 12to15ml/
100gm/min for two hours before infarction occurs,
h o w e v e r lateral direction. It is imperative that the CT scan
2to 3 ml/100gm/min may be tolerated for only a
few minutes before irreversible damage occurs.
Prevention of Injury to ICA
From the endoscopic point of view ICA would
come in relation of the lateral wall of the sphenoid
sinus where it may have very variable course.In
as many as 23 percent of the cases ICA has been
found to be dehiscent and so liable to the direct
trauma. The intersphenoid septum also often
attaches to the ICA. Any trauma to this septum
may result in injury to the internal carotid artery.
This injured artery can spill arterial blood in to the
parasellar veins. If one of the parasellar veins get
avulsed, no amount of trapping or embolisation
of the ICA would control the distal blood flow and
this injury can lead to carotid cavernous fistula.
With this anatomical facts sphenoidotomy should
be performed in the inferomedial rather than
of the sphenoid should be studied carefully to
assess the thickness of the bone between the ICA
and the sphenoid sinus. It
is clear therefore, that NO instrumentation or
“plucking“ of a polyp or thickened mucosa from
the sphenoid sinus should be performed.
In most unfortunate circumstance, if the
internal carotid artery is traumatised, it is
important to pack the sphenoid sinus and replace
blood. Cervical exposure of artery is time
consuming and also proximal liagtion of bleeding
artery will steal blood from the cranial cavity,
which can lead to serious neurological deficits.
 HAEMORRHAGE DURING OPERATION
Following initial emergency measures after a
carotid bleed, neuroradiologist and a
neurosurgeon is urgently consulted to occlude the
bleeding artery with a baloon passed through
double lumen Swan- Ganz catheter. Heparinised
saline must be infused slowly to allow retrograde
flow of blood to perfuse the ophthalmic artery.
Rapid saline infusion can produce ocular ischemia
and uniocular visual loss. Occlusion of the bleeding
artery is not without grave risk. Complications of
the procedure includes, stroke, cranial nerve
palsies, and blindness.
In the perioperative period if there is a change
in the level of consciousness in the absence of
temperature or obvious CSF leak, this must alert
the surgeon to the possibility of intracranial
haemorrhage. An emergency CT scan is imperative
to exclude intracranial accumulation of blood.In
this event an immediate craniotomy is
recommended.
Postoperative Haemorrhage
Due to the immense vascularity of the nose and
sinuses, and some degree of trauma during
operation, a small amount of oozing is normal and
this does not call for any “routine” packing in the
nasal cavity at the end of the operation. At the
end of the operation, if there is still some bleeding,
then endoscope should be used in an attempt to
localise the bleeding point so that it can be
cauterised. If there is a continuous ooze, an anterior
61
nasal packing may be carried out.
Postoperative haemorrhage could be:
1. Reactionary
2. Secondary
Reactionary haemorrhage This occurs in first 24
hours and is usually due to constant mucosal ooze
or at times due to the bleeding from one of the
larger branches of the sphenopalatine artery
especially following middle turbinate surgery. If
the bleeding persists, then a non-traumatising
Merocel pack may be inserted in the nasal cavity
to be removed on the following day. However, the
surgeon should be extremely careful in packing
the nasal cavity if there is any dehiscence of the
lamina papyracia, as the bleeding may trickle into
the orbit. In this situation patient may need to be
taken back to the theatre and bleeding stopped
under direct vision and packing avoided.
Secondary haemorrhage Secondary haemorrhage
occurs five to six days following the operation. It
may occur in the form of a slight oozing from the
nose or it may be quite a significant bleed. In this
situation slight oozing can be arrested by non-
traumatising pack such as Merocel. If the bleeding
continues then packing of the nose may need to
be performed. In all cases endoscope should be
used to identify the bleeding point and endoscopic
cauterisation should be performed. Systemic anti-
biotics should be given.
I
ntraorbital complications can arise during
and after endoscopic sinus surgery.
These are:
A. Minor complications
1. Damage to the lamina papyracea and
periorbita—resulting into postoperative
ecchymosis
2. Periorbital surgical emphysema
B. Major complications:
1. Damage to the medial rectus muscle—resul-
ting in diplopia
2. Damage to the Nasolacrimal duct
3. Intraorbital haemorrhage
4. Injury to the optic nerve
Predisposing Factors for Orbital
Complications
1. Dehiscence of the lamina papyracea
2. Revision surgery
3. Distorted surgical anatomy
4. Sphenoethmoidal cell( Onodi cell)
5. Extensive nasal polyposis
6. Fungal infections, mucoceles etc. with bony
destruction
7. Excessive bleeding during surgery
8. Hypoplastic maxillary sinuses
9. Hypertension, bleeding diatheses
10. Forceful blowing of the nose in the post-
operative period.
11. General anaesthesia - In this situation patient
is unable to respond if the surgeon violates the
boundaries of the sinuses.
Prevention of Intraorbital Complications
1. Avoid operating on patients with extensive
polyposis, revision surgery, hypertensive
patients until the surgeon is well experienced in
endoscopic techniques.
2. Study preoperative CT scan to detect any likeli-
hood of dehiscence of the lamina papyracea. This
may be due to previous surgery or orbital blow
out fractures, which may cause prolapse of the
ocular contents and the muscles into the ethmoid
sinuses (Figs 5.1 to 5.4).
3. NEVER cover patient’s eyes with drapes during
operation.
4. Instruct the assistant or the scrubbed nurse to
inform the surgeon immediately if undue eye
movements occur during instrumentation inside
the nose or if there is a sudden proptosis.
5. If in doubt check the transmitted movements of
the orbit through the endoscope from time to
time.
6. Place all the surgically removed tissues in saline
to observe if it sinks or floats?—as fat and brain
tissue floats whereas other tissues sinks.
A. MINOR COMPLICATIONS
1. Damage to the Periorbita
This usually occurs while performing uncinectomy
especially when uncinate process is closely related
to the lamina papyracea (Fig. 5.5),during excision
of the bulla and while performing middle meatal
antrostomy. If the important surgical landmark, the
middle turbinate, is missing from the operative field
or is distorted, this will result in considerable risk
to the intraorbital contents.
If the surgeon has violated the periorbita or is in
doubt, then immediately he should confirm this, by
gently pressing the side (NOT the cornea) of the
eyeball covered by upper eye lid skin and watching
the transmitted movements of the eyeball through
the endoscope (Figs 5.6 and 5.7).
The surgeon should be able to see the transmitted
movements of the periorbita or the protruding
orbital fat through the endoscope. No specific
treatment is necessary, as far as the surgeon do not
traumatise the periorbita any more. No attempt
should be made to place the fat in the orbit, as this
will only cause unnecessary trauma. Nasal packing
should be avoided in this situation as further
bleeding in the postoperative period may allow the
blood to enter in to the orbit. Postoperatively the
patient will develop some degree of ecchymosis
around the eye, which will subside over a period of
next few days. Patient should be advised not to blow
the nose for a few days (Figs 5.8 to 5.11).
66 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURES 5.1 and 5.2: Dehiscent left and right lamina papyracea
showing prolapse of the orbital contents into the ethmoid cavity as
seen on coronal CT scans. It is obligatory for the surgeon to study
the CT scans of all patients prior to surgery.
 ORBITAL COMPLICATIONS 67

FIGURES 5.3 and 5.4: Coronal CT scan showing destruction of lamina

papyracea due to fungus and transitional cell papilloma.
 68 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 5.5: Excision of the laterally placed uncinate process in

contact with the lamina papyracea may damage the orbital
periosteum and probably orbital contents.

2. Periorbital Surgical Emphysema
Periorbital surgical emphysema usually occurs
when the patient has a dehiscence of the lamina
papyracea and the patient blows the nose very hard
in the postoperative period. This results in
periorbital emphysema (Fig. 5.12). This does not
warrant any specific treatment and it usually settles
down over a period of one-week depending upon
the severity of the emphysema.
A. MAJOR COMPLICATIONS
1. Damage to the Medial Rectus Muscle
Medial rectus is closely related to the ethmoid
labyrinth (Fig. 5.13).
Injury to the medial rectus muscle could be vari-
able from a minimal damage to a complete seve-
rance of the muscle. This is a serious complication
where patient will develop diplopia. If the muscle
is damaged, the injury would be noticeable in the
immediate postoperative period. The patient will
complain of significant pain in the affected eye, there
will be bruising and ecchymosis around the eye.
Patient should be examined immediately for the
mobility of the eyeball. Patient usually complains
of diplopia. If there is any concomitant intraorbital
bleeding threatening the eyesight, then appropriate
steps for decompressing the orbit should be taken
immediately. An ophthalmic consultation must be
sought and the advice taken so as to plan the further
treatment. An urgent CT/MRI scan should be
performed to see the damage, and in a case of severe
injury to the muscle, immediate repair should be
undertaken by the ophthalmologist. In case of
minimal injury without intraorbital bleeding or
diplopia patient may be observed carefully.
However, ophthalmic opinion should be sought to
manage the damage to the medial rectus muscle.
2. Damage to the Nasolacrimal Duct
The Nasolacrimal apparatus is in close proximity
to the middle meatus. Injury to the nasolacrimal
 ORBITAL COMPLICATIONS 69

FIGURE 5.6

FIGURE 5.6A

FIGURES 5.6, 5.6A and 5.7: Right nasal cavity - Operative

4mm 0 degree endoscopic views of the damaged lamina
papyracea with the protrusion of the orbital fat. If in doubt
during operation a gental pressure should be applied to
the ipsilateral eyeball to see through the endoscope any
transmitted movements of the orbital periosteum. FIGURE 5.7

duct occurs more commonly while performing ostium, in an attempt to enlarge the ostium. In this
middle meatal antrostomy. The nasolacrimal duct situation of working anteriorly, the surgeon should
is liable to be injured when surgeon works more stop as soon as thick bone is encountered. It is safer
anteriorly following identification of the natural to perform antrostomy in an antero inferior direc-
 70 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 5.8

FIGURE 5.9

tion, away from the direction of the nasolacrimal Clinical Features

duct. Damage to the sac may occur during surgery Damage to the nasolacrimal duct will manifest in
of the frontal recess, if the surgeon is working more the symptom of epiphora (Figs 5.14 and 5.15). If the
laterally. symptom occurs within first two to three days, it
 ORBITAL COMPLICATIONS 71

FIGURE 5.10

FIGURE 5.11
FIGURES 5.8 to 5.11: Postoperative photographs of a patient who had complete dehiscence
of both lamina papyracea and developed ecchymosis. Note this is not an intraorbital
haemorrhage but simply a subperiosteal extravasation of blood. Note normal movements
of the eye ball. However, with this development in the postoperative period, the patient
should be kept under close observation till the ecchymosis resolves.
72 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 5.12: Patient with bilateral dehiscent lamina papyracea developed

surgical emphysema in the delayed postoperative period due forceful blowing
of the nose.This is usually self limiting and does not require active treament.

FIGURE 5.13: Axial CT scan showing close relation of the medial rectus to the
ethmoid sinuses especially posteriorly. This anatomical fact must be kept in
mind by the surgeon at all times while working in the posterior etmoids.
 ORBITAL COMPLICATIONS 73

FIGURE 5.14: Patient having undergone FESS and septorhinoplasty developed right epiphora following
operation. This symptom spontaneously setteled as the blokage of the nasolacrimal duct appeared
to be due to postoperative oedema rather than direct injury to the duct.

may be due to injury to the duct at the time of opera-
tion alternatively it may be related to the oedema at
the operating site, in which case this is likely to settle
down after a few days. If the patient complains of
epiphora after several weeks of the operation, this is
likely to be due to the scar tissue and subsequent
obstruction of the duct. These situations usually
require referral to the ophthalmologist/ENT sur-
geon, further investigations and probably dacryo-
cystorhinostomy. It is important to bear in mind that
this complication of epiphora may appear insigni-
ficant to the surgeon, but it is quite troublesome and
most annoying to the patient, not only in day to day
work but especially while driving and reading.
3. Intraorbital Haemorrhage
This is one of the most serious complications that
can occur during endoscopic sinus surgery. It has a
high potential to cause visual loss. It is essentially
an ophthalmic emergency as the vision may be lost
rapidly and permanently. The endoscopic surgeon
should have a definite plan to tackle such an
emergency. All precautions should be taken to avoid
complication taking place in the first place as
described earlier. The intraoperative risk can be
minimised, by stopping surgery immediately when
bleeding obscures vision, by observing transmitted
eye movements during surgery and awarness of the
development of proptosis. One must be aware of
the differences between the orbital contents i.e. fat
as opposed to the nose/sinus tissue.
Pathology of Visual Loss
Whenever there is haemorrhage in the central space
of the globe, the orbital pressure exceeds the filling
pressure of the central retinal artery. This inevitably
results in the ischaemia of the retina. Irreversible
damage occurs if the hypoxia persists more than 90
minutes. Similarly optic nerve is damaged when the
blood flow from the posterior ciliary arteries is
interrupted. Compressive optic neuropathy can also
result in visual loss.
 74 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY
Other possible mechanisms include, stretching
of nutrient vessels leading to optic nerve ischaemia,
and axonal stretch secondary to the proptosis, which
accompanies orbital haemorrhage, Sharma S et al
(2000).
Diagnosis of Acute Orbital Haemorrhage
Intraoperative haemorrhage If this occurs during
surgery patient will develop a:
1. Rapid proptosis
2. Chemosis
3. Increased tension in the globe
4. Vascular engorgement of the conjunctiva
5. Retinal vascular shutdown or absence of arterial
pulsation
6. Optic nerve pallor
7. Restricted movements of the eyeball
8. Loss of direct and consensual light reflex.
These signs should immediately alarm the sur-
geon to take immediate steps to relieve pressure on
the optic nerve by decompression as described
below.
If the patient returns to the ward and the intra
orbital haemorrhage occurs, the diagnosis should
be made on following clinical features.
Symptoms
1. Pain One of the first symptom with intraorbital
haemorrhage will be pain in the affected eye.
Any patient following endoscopic sinus surgery
complaining of pain should be immediately
attended to and investigated.
2. Colour blindness The first colour to be affected
in the involved eye would be red. Immediate
examination with red object should be perfor-
med in the ward.
3. Orbital signs Eight orbital signs as described
earlier should be sought and immediate arrange-
ments should be made to take patient to the
theatre for definitive treatment of orbital decom-
pression.
The surgeon should keep in mind “4 Ps” in a
suspected orbital haemorrhage patient.
1. Perception of light
2. Pupils—loss of direct or consensual reflex
3. Pallor of the optic nerve
4. Pulsatility of the central retinal artery
Management of Orbital Haematoma
Aim To relieve pressure on arterial supply of the
optic nerve.
The orbital contents are encased within five rigid
boundaries. Four of these, medial, lateral, superior
and inferior are bony. The fifth, anterior wall is
fibrous and is formed by the tarsoligamentous dia-
phragm and orbital septum. The intraconal space,
is separated from the extarconal space by the
extraocular muscles. There is a firm attachment of
each muscle and its fascia around the annulus of
Zinn at the orbital apex as well as to the globe. Any
increase in the volume of the orbital contents may
result in rise of orbital pressure. Therefore, the
principles in managing orbital haemorrhage is either
to increase the size of the orbital space or to decrease
the blood volume in the orbit.
The orbital contents are distributed within five
orbital spaces.
1. Subperiosteal space
2. Extraconal space
3. Intraconal space
4. Subarachnoid space of intraorbital optic nerve
5. Subtenon’s space - deep to Tenon’s capsule i.e.,
a thin fibrous layer that surrounds the globe.
Due to the rigidity of the orbital walls, orbital
pressure will increase with an increase in the
volume of any one of the orbital spaces. Any
increase in pressure causes compression of the
arterial supply to the vital structures within the orbit
and may result in optic nerve or retinal infarction.
Therefore, the objective of the treatment is to
decompress the orbit and its contents so that arterial
flow is restored. Three types of procedures can
achieve this:
1. General measures
2. Increasing the orbital space
3. Decreasing the volume in any one or more of
the orbital spaces.
General Measures
Patient should be nursed in semi sitting position
and normalisation of the blood pressure should be
maintained.
 ORBITAL COMPLICATIONS
Increasing the Orbital Space
a. If the nasal cavity is packed, this should be
removed immediately. If a bleeding point is seen
then, this should be cauterised.
b. Lateral canthotomy and cantholysis
This is a useful procedure for early or immediate
decompression if the proptosis is rapidly pro-
gressing. This is a short procedure which can be
performed in the recovery room or in the ward
using local anaesthesia. If the incision is made
in the skin crease, there is virtually no cosmetic
deformity.
Lateral canthotomy This technique involves
making a horizontal incision commencing at the
lateral canthus extending approximately 1 cm.
The lateral end of the lid is pulled anteriorly and
inferiorly away from the globe. This allows
stretching of the lower limb of the lateral canthal
tendon and orbital septum, making fibrous
structures easily identifiable. Lower cantholysis
75
involves dividing these structures, thus allowing
globe and orbital contents pushed anteriorly
(Figs 5.15 and 5.16). The cantholysis combined
with canthotomy is significantly better than
canthotomy alone. Adding superior cantholysis
can enhance the effect of canthotomy.
c. Orbital decompression Orbital decompression
into the ethmoid sinuses with incisions on the
periorbita. This can be done by either external
or endoscopic approach. If the surgeon is not
comfortable or experienced, it is recommended
that a standard external ethmoidectomy app-
roach should be used to access the medial
wall of the orbit. However, if the surgeon is
experienced to use endoscopic technique,
decompression should be performed by multiple
incisions on the orbital periostium following
removal of entire lamina papyracea. With this
technique, the orbital fat herniates into the
ethmoid sinuses and thus relives the pressure
on the retinal artery.

FIGURE 5.15: This patient developed bilateral epiphora after several months following
endoscopic sinus surgery. Repeated attempts to clear the obstruction of the
nasolacrimal duct failed. Patient was subjected for bilateral dacrycystorhinostomy.
This case appeared to be due to injury to the nasolacrimal duct and subsequent
developments of scar tissue obstructing nasolacrimal duct.
 76 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 5.16: In case of intraorbital ( retrobulbar )haemorrhage a lateral

canthotomy should be performed under local anaesthetic if the
haematoma is rapidly increasing before patient could be subjected to a
definitive orbital decompression under general anaesthetic.

d. Methods of decreasing the volume of the orbital
contents
Intravenous mannitol, Acetazolamide, and
corticosteroids. Mannitol is a hyperosmotic agent
and when given intravenously it largely confines
to the extracellular and vascular spaces. This
agent reduces intraocular pressure as fluid
passes down the osmotic gradient from the intra-
cellular to the extracellular space. Acetazolamide
is not only a diuretic but also decreases the
production of aqueous by the ciliary bodies. This
further reduces the aqueous volume within the
eye. Corticosteroids, (usually dexamethasone)
reduces any associated orbital inflammation. It
also stops vascular leakage by mechanism of
stabilising, vascular endothelium. Topical B-
blocker also reduces intraocular pressure.
Once the raised orbital pressure has been
successfully treated, the orbit usually remains stable
along with the successful orbital decompression.
The tests for the visual acuity and perimetry should
be performed before the patient is allowed home.
OPTIC NERVE INJURY
Optic nerve is more closely related to the posterior
ethmoid than sphenoid sinus. It is most vulnerable
when there is a presence of a sphenoethmoidal cell
(Onodi cell) (Figs 5.17 and 5.17A).
Optic nerve injury can be divided into:
1. Direct By physical insult, which penetrates the
optic nerve.
2. Indirect Indirect injury occurs when forces are
imparted or transmitted to the optic nerve
through the skull.
Direct injury affecting the proximal portion of
the optic nerve within 10 mm of the globe, anterior
to the central retinal artery produces a variety of
 ORBITAL COMPLICATIONS 77

FIGURES 5.17 and 17A: Endoscopic view of the right posterior ethmoid showing
dehiscent optic nerve with Onodi cell. The surgeon must always work more
medially once entered into the posterior ethmoid cells.
 78 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY
disturbances that are immediately apparent in the
ocular fundus. In contrast, injuries to the optic nerve
posterior to the entrance of the central retinal artery
produce no immediate changes in the appearance
of the ocular fundus. The second situation is true
for iatrogenic optic nerve injury during endoscopic
sinus surgery. The optic disc remains normal in
appearance for at least three to five weeks.
Clinical Assessment of the Optic Nerve Injury
1. Visual acuity Whenever possible visual acuity
should be first determined
2. Colour vision This is an excellent test of optic
nerve function. The simplest method of checking
of colour is with the red test object. An eye with
the an optic nerve injury may see red object as
black, brown or orange. The colour may be
described as faded. In some cases the colour may
not be identified at all.
3. Since the optic canal is surrounded anteriorly by
the annulus of Zinn, injury in this area can
disrupt the function of the muscles originating
from the annulus. These patients may complain
of diplopia
4. Visual field examination can provide limited
information regarding possible location of optic
nerve damage. Within the optic canal the pial
penetrating vessels that provide blood to the
optic nerve are subject to shearing forces at the
time of injury.
5. If the optic nerve has been injured, a Marcus
Gunn ( pupil reacts poorly to light on the affected
side while consensual light reflex is preserved)
pupil would be expected.
6. Visual evoked potential may be diminished or
absent.
Although CT scan is clearly superior to magnetic
resonance imaging in delineating fractures of bone,
MR imaging is superior to CT scanning in its ability
to image soft tissues. Both the scans may need to be
performed in an individual case.
Pathogenesis of Blindness
The optic nerve is closest to the paranasal sinuses
in posterior ethmoidal cells. It is here that the lateral
wall of the sinuses is very thin formed by the lamina
papyracea. The presence of Onodi cell i.e. the
sphenoethmoidal cell makes the optic nerve more
vulnerable to the injury. As the optic nerve traverses
in to its intracanalicular portion, it is covered by a
thick bone, which is hard to penetrate, and this part
is well protected. Direct optic nerve injury causes
permanent damage to the optic nerve axons.
In optic nerve injury immediate and appropriate
intervention has the potential to stop secondary
injury. This situation is seen in cases of intraorbital
haematoma where a quick and rapid decompres-
sion can preserve the vision. Secondary damage is
caused by vasoconstriction and swelling of the
nerve which is maximum within the confines of the
non expansible optic canal. This leads to worsening
ischaemia and irreversible damage to the axons that
may have been spared at the time of initial injury.
The cell membrane of axons is composed of high
concentration of polyunsaturated lipids. The release
of oxygen free radicals that follows ischaemia is
thought to result in peroxidation of these lipids, thus
damaging the neural membrane. Oxygen free
radicals and lipid peroxydation may play a central
role in cell death following ischaemia.
Management
Following an acute insult to the optic nerve in the
initial stages it is difficult to assess whether is it a
direct or an indirect injury and since the time is a
crucial factor, it is valid to treat all patients on a
similar line. High doses of methyl prednisolone are
given with the initial loading dose of one gram
intravenously, followed by methyl prednisolone
250 mg. I/V every six hours. If there is a suspicion
of a bony spicule impinging on the optic nerve, as
seen with imaging this should be removed by an
endoscopic approach.
T
he close proximity of the paranasal
sinuses to the skull base carries a higher
risk of violating skull base during endo-
scopic sinus surgery. This can result in
serious intra and postoperative intra-
cranial complications (Figs 6.1 and 6.2).
Certain anatomical factors such as extremely thin
lateral lamella of the cribriform plate, the medial
part of the fovea ethmoidales, is nine times thinner
than the corresponding fovea laterally, which is
formed by the frontal bone and is usually thick (Figs
6.3 and 6.4).
Even the simplest manipulations with the suc-
tion, instruments such as forceps or Microdebrider
can result in the damage of the fovea and sub-
sequent cerebrospinal fluid leak.
The serious intracranial complications could be
divided into the following.
Intraoperative Complications
1. CSF leak.
2. Intracranial haemorrhage
3. Injury to the Internal Carotid Artery / Cavernous
sinus
Postoperative Intracranial Complications
1 Pneumoencephalus
2 Meningitis, epidural, subdural and brain abscess
FIGURES 6.1 and 6.2: Lateral view of the cadaver showing relation
of the skull base to the roof (fovea) of the ethmoid and sphenoid
sinuses
CSF LEAK: COMMONEST MAJOR
COMPLICATION
Historical View
Traumatic CSF leak have been recognised since the
17th-century.
A Dutch surgeon, Elder described a case in which
intra cranial fluid flowed from the nose like a
clear fountain (Morgagni G.1762) In 1884, the
phenomena of air within the cranial cavity, from
an ethmoid defect, was reported at autopsy by
Chiari H. The incidence of meningitis in patients
with untreated CSF leak’s was shown to be 50
percent by Calvert CA et al (1942) in the pre
antibiotic era. Following discovery of antibiotics,
however, meningitis was not eliminated. The
mortality rate was still found to be 20 percent
by Levins S et al (1972). During the 1920s, Dandy
WD, described the first successful intra cranial
repair, and this was the principal method of
approach until Dohlman G (1948), reported a case
of an extra cranial repair of a spontaneous CSF
rhinorrhea. Hirsh O (1952) first described the
endonasal repair of sphenoid sinus CSF rhinorrhea
using septal mucosal flap. Montgomery W (1973)
described his experience with treatment of
ethmoidal/cribriform plate and sphenoid sinus
spontaneous CSF rhinorrhea through an external
nasal approach with septal flaps. Papay F et al (1989)
 82 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 6.3

FIGURES 6.3 and 6.4: Coronal CT scan and cadaver

section displaying two parts of the roof of the ethmoid
FIGURE 6.4 sinuses and crbriform plate (CP).

published two papers describing endoscopic
management of spontaneous and traumatic CSF
rhinorrhea in the sphenoid and ethmoid sinuses
using fascia lata muscle and fat.
Physiology of CSF Fluid
CSF is produced at a rate of 20ml/hr. by the choroid
and lateral ventricular plaxus in adults.. It is a clear,
watery fluid. This amounts to nearly 500 ml. per
day, or roughly four times the normal volume of
the CSF compartment, which is 90 to 150 ml. The
normal pressure of the CSF is 70 to 180 mm of water.
The glucose content in CSF is around two-thirds of
that in blood; it is rarely below 50 mg/ml. It is
devoid of platelets, leukocytes, or fibrin precursors.
It is lacking in elements of self repair. Even small
defects of the CSF leaks can be so agonisingly
recurrent and persistent.
Clinical Features
On nasal endoscopic examination the nasal cavity
may appear completely normal. In a patient who
 INTRACRANIAL COMPLICATIONS
had a fresh leak, one may be able to see unnaturally
wet mucous membrane usually on one side.
Positions of the head in relation to the neck may
aggravate the leak, as also straining or the Valsalva
manoeuvre. Antihistamines, local nasal sprays have
no effect on the leak. Symptom such as nasal
obstruction, catarrh, sneezing is usually absent.
Complications of CSF fistulas, such as recurrent
meningitis, or an air-fluid level (pneumocephalus)
suggest a persistent leak.
Diagnosis of CSF Rhinorrhea
CSF rhinorrhea can occur either intra or post-
operatively.
Intraoperative Diagnosis
If a CSF leak is suspected during operation, it is most
important that the surgeon should obtain a good
haemostasis as it can be quite difficult to see a clear
fluid in the field of blood. Following haemostasis
suspected area is observed carefully. If in doubt, a
simple test in the theatre can help to point towards
the diagnosis of a possible CSF leak. Several drops
of suspected fluid mixed with blood is smeared on
a filter paper, and observed after few minutes. Due
to different osmolarity of the CSF and blood, there
appears a halo on a filter paper which has been
described as a “Target Sign.”
If the surgeon is suspicious of a leak but is unable
to localise, the anaesthetist should be asked to raise
the intracranial pressure by positive Valsalva
manoeuvre. This will result in a sudden gush of CSF
from the leak in a suspected area. If this manoeuvre
fails, a lumbar drain can be inserted to inject 10 ml
of normal saline into the intra-thecal space to raise
intra cranial pressure, which may then help to
identify the leak.
Intrathecal freshly made sodium fluorescein
without preservatives have been used as described
by Charles DA et al (1979). In this test, 0.5 ml of sterile
five percent fluorescein dye is injected intrathecally,
slowly (over five minutes) after being diluted in
10ml of CSF. Following some interval the nasal
cavity is examined with the help of a blue filter
attached to an endoscope. A coloured CSF leak may
83
be demonstrated in the nasal cavity and with careful
examination, precise location of the leak can be
documented. Serious complications as a result of
sodium fluorescein injection, such as transverse
myelitis have been described hence every pre-
caution should be taken to inject sodium fluorescein
very slowly and in a proper strength intrathecally.
Fluorescein solution used by ophthalmologist for
checking lacrimal drainage must not be used as it
may lead to convulsions.
Diagnosis of Perioperative and
Delayed CSF Leak
CSF leak may be missed during operation or may
manifest following surgery. A meticulous exami-
nation of the nasal cavity with zero degree and
angled endoscope is mandatory. Postoperative leak
may be treated conservatively with patient being
nursed in a supine position, lumbar drain and
Mannitol for three days. However, if the leak
persists, patients should be taken for surgical repair.
The CSF leak in peri or postoperative period should
be diagnosed by a history of clear fluid dripping
out of the nose from one or other side. Sometimes
the patient may complain of intermittent salty taste
in the mouth. Every effort should be made to collect
this clear fluid for biochemical examination to
confirm the diagnosis.
Laboratory Diagnosis of CSF Rhinorrhea
The collected CSF is sent for sugar estimation, the
sugar in the CSF will be around two-thirds of that
in the blood. The most specific method of identifi-
cation of CSF is to test for presence of beta trans-
ferrin. A venous sample of blood is also recom-
mended to be taken at the same time as the specimen
for CSF, as certain rare conditions such as chronic
liver diseases and altered glycoprotein metabolism
may give false positive results.
Chloride in CSF fluid is about 120 mEq/L, which
is higher than serum range of 98-112mEq/ L. thus
an elevated chloride value in an unknown sample
of dripping from the nose is highly suggestive of
CSF.
 84 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 6.5

FIGURES 6.5 and 6.6: Plain X-ray and CT scan of the

patients following CSF leak where air has entered the
FIGURE 6.6 intracranial cavity giving rise to pneumoencephalocele.

Radiological Localisation of the In recent years, computed tomographic and

Source of CSF Rhinorrhea
Plain X-ray of the skull does not delineate the site
of leak but may show presence of intracranial air
This constitutes a proof of a fistula and more
importantly, a clinical emergency. Intracranial air
may act as an expanding intracranial mass with the
danger of permanent neurological deficits or even
death (Figs 6.5 and 6.6).
magnetic resonance imaging cisternography is the
radiological study most likely to be used to localise
the CSF leak (Figs 6.7 and 6.9).The combination of
fine cut (0.5 to 1mm.) CT and non-ionic aqueous
contrast cisternography with iohexol (OMNIPAQE)
is commonly used.
Unfortunately, in 20 to 40 percent of cases, even
with provocative measures like intrathecal saline
infusion, coughing and decubitus positioning, dye
 INTRACRANIAL COMPLICATIONS 85

FIGURE 6.7 FIGURE 6.8

FIGURE 6.9
FIGURES 6.7 to 6.9: MRI cisternography showing CSF leak
through the skull base in all three patients.

fails to show the site of leak (Manelfe C et al, 1982) specific for a fistula with pooling of CSF in the
As commonly known in medicine, absence of proof sphenoid sinus
does not constitute proof of absence.
The reservoir sign—the ability of a patient to Anatomical Considerations
voluntarily produce CSF at will by correct The roof of the ethmoid sinuses is formed by the
positioning of the head, is generally taken to be quite following two parts:
 86 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

1. A medial—formed by the lateral lamella of
cribriform plate of the ethmoid bone and is of
variable length in relation to the nasal cavity.
This part of the fovea is nine times thinner than
the lateral part of the fovea (Fig. 6.10).
2. The lateral—formed by the frontal bone and is
usually thick but not necessarily in every case
(Figs 6.11 and 6.12).
The anterior ethmoidal artery leaves the orbit to
enter into the olfactory fossa, which further weakens
this area adding further danger for the damage to
the skull base. This site is medial to the middle
turbinate. The middle turbinate separates the
cribriform plate from fovea ethmoidalis (Fig. 6.13).
The dura mater in this area is also quite adherent to
the cribriform plate and the fovea.

FIGURE 6.10

FIGURE 6.11
 INTRACRANIAL COMPLICATIONS 87

FIGURE 6.12

FIGURE 6.13
FIGURES 6.10 to 6.13: Coronal CT scans showing variations in
the roof of the ethmoid sinuses from anterior to posterior

The fovea is occasionally dehiscent in this area
and the surgeon is then directly looking at the dura
mater (Figs 6.14 and 6.20).
It is clearly seen that a slightest trauma in this
area could results in a CSF leak. In view of these
various anatomical facts the surgeon must not
operate medially in the region of the fovea ethmoi-
dalis or against and into the middle turbinate. The
angled endoscope preferably 70 degree must be
used so that entire area could be visualised and
blind instrumentation is avoided.
A thin “cuts” CT scan will delineate the precise
anatomy in this region and should be referred to
during the operation (Fig. 6.21).
88 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 6.14 FIGURE 6.15

FIGURE 6.16
FIGURES 6.14 to 16: Coronal CT scans of the foveae ethmoidales showing
dehiscence. In this situation the dura mater is directly exposed to the surgeon’s
instrumentation and utmost care should be taken during operation in this area. Fig.
6.15 shows a tumour (transitional cell papilloma (TCP) of the right nasal cavity
extending into posterior ethmoid and destroying skull base.
 INTRACRANIAL COMPLICATIONS 89

FIGURE 6.17

FIGURE 6.19

FIGURE 6.18
FIGURES 6.17 and 6.18: Endoscopic operative views of
the skull base clearly showing exposed dura and CSF
leak as a result of post head injury.

The identification of important surgical land-

marks such as anterior ethmoidal artery, lateral
lamella and orbit in this region is further complica-
ted by the presence of disease, bleeding, scar tissue
and in revision cases by distorted anatomy. Only
when the surgeon has gained adequate experience
in endoscopic sinus surgery, diseases in this region
should be tackled. It is important to note that the
frontal recess leading to frontal sinus is always
anterior to the anterior ethmoidal artery (Fig. 6.22).
In cases of extensive disease, especially with loss
of landmarks, it is helpful to find sphenoid sinus,
identify the skull base and the roof of the ethmoids
ie, working from posterior to anterior.
FIGURE 6.20
FIGURES 6.19 and 6.20: Endoscopic operative views of
the skull base showing exposed dura due to dehiscence
of the skull base.
Operative Technique to Prevent CSF Leak
There is no doubt that meticulous and careful sur-
gery with co-ordinated radiological and anatomical
background will avoid this complication.
While attempting uncinectomy, in cases where
uncinate process is attached to base of skull or
 90 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 6.21: A thin cut of the anterior ethmoids delineates precise anatomy of
the cells and helps the surgeon to remove these cells during endoscopic
sinus surgery when there is disease in the frontal recess/sinus

than the roof of ethmoid. Working in this area the

FIGURE 6.22: A 4mm, 70 degree endoscope offers
excellent view of the operative area for the surgeon while
working in the region of the frontal recess. The frontal
recess is always anterior to the anterior ethmoidal artery
(AEA). Note simultaneous appearance of the middle
turbinate (MT) and orbit.
middle turbinate, it is important to stay lateral rather
than medial, as medially the base of skull is lower
direction of the forceps should be lateral rather than
medial. It is important to appreciate that this area
has the narrowest axial dimension of the ethmoidal
labyrinth. The size of the forceps, has to be
judiciously selected. A very large forceps if turned
medially, will bite into the mucosa of middle turbi-
nate on one side, tearing the mucous membrane or
worse, it may damage the lateral lamella of the
cribriform plate with resultant CSF leak. A large
forceps would also obscure the vision and blind
manipulation may damage the very thin roof of the
ethmoid sinus.
Sometimes the base of the skull is thinned out
by disease process like recurrent polyposis, conti-
nued osteitis, mucocele, fungal infection or tumor
(Figs 6.23 to 6.25).
If the tissues are not handled carefully in this
area even a slight trauma can leave the dura mater
exposed. The dura mater of anterior base skull is
densely adherent to the underlying bone and it is
 INTRACRANIAL COMPLICATIONS
FIGURE 6.23
FIGURE 6.24
FIGURES 6.23 and 6.24: Coronal CT scans of the patients
with extensive fungal disease shows destruction of the
skull base.The surgeon should take great care working
in this area to avoid CSF leak.
easier to open the subarachnoid space with CSF
leak. Olfactory fibres are tough, and if pulled with
the mucosa would bring down the dura resulting
in CSF leak (Fig. 6.26).
No traumatic or rough manipulations are to be
performed on the middle turbinate at any stage
during endoscopic sinus surgery. Whenever a
wedge resection of the anterior part of the middle
91
turbinate is to be performed on a paradoxical or a
pneumatised middle turbinate (concha bullosa) a
curved sharp scissors specifically designed for the
purpose, should be used. A sweep and a clean cut
should be made without trauma to the middle
turbinate. A upper stump of the anterior part of the
middle turbinate should always be preserved as an
important surgical landmark during surgery (Fig.
6.27).
Ethmoid bulla often extends upto the base of
skull, and exenteration of the bulla towards the skull
base should be done very carefully (Fig. 6.28).
It is also important to remember that the presence
of most postero lateral cell of the posterior ethmoid,
the Onodi cell, is superior and lateral to the sphenoid
sinus, which is in close proximity to the optic nerve
laterally and to the Subarachnoid space above. The
presence of Onodi cell should be studied on CT scan
and if present, great care should be taken to enter
ground lamella medially and inferiorly. The presence
of a large Onodi cells sometimes can make the
identification of the sphenoid difficult.
It is important to recognise that the sphenoid
sinus is not a continuation of ethmoid but it lies
inferior and medial to the posterior ethmoidal cells
(Fig. 6.29).
92 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 6.25: Coronal CT scan of a patients with encephalocele showing

destruction of the skull base. This patient also had concomitent ethmoidal
and maxillary disease on both sides.The surgeon should take great care
in dealing with this type of cases to avoid intracranial complications.

FIGURE 6.26: Endoscopic cadaver photograph showing olfactory fibres

at the skull base which carry delicate pia mater with it. Forceful and
rough instrumentation in this area could damage these fibres and result
in CSF leak.
 INTRACRANIAL COMPLICATIONS
FIGURE 6.27: Right ethmoid cavity showing preservation
of the upper stump of the middle turbinate as an important
surgical landmark and also keeping anterior attachment
of the middle turbinate to the skull base intact.
Excessive manipulation of middle turbinate is
to be avoided specially in its vertical insertion, as
anteriorly the middle turbinate is attached to the
93
thin skull base. Posteriorly middle turbinate is
attached to the lamina papyracea and sometimes
to the skull base by means of ground lamella in its
vertical and horizontal direction. To preserve the
stability of the middle turbinate a variable part of
the horizontal part of the ground lamella should be
kept intact. With this technique the turbinate will
not become floppy and displace laterally towards
the ethmoid cavity. Forcible movements of the
middle turbinate anteriorly can fracture the base of
skull leading to CSF leak. Similarly posterior eth-
moidal cells open into the superior meatus under-
neath the superior turbinate, which is an important
surgical landmark while opening posterior ethmoi-
dal cells (Fig. 6.30).
The superior turbinate is attached to the skull
base and great care should be taken not to trau-
matize the turbinate. Avulsion of the olfactory fibres
can cause a dural fistula even without a fracture.
Planum sphenoidale is a strong bone and diffi-
cult to damage unless disease has thinned the bone
or great force is applied in this area.

FIGURE 6.28: Dry skull showing bulla ethmoidalis extending upwards

towards the skull base and care should be taken during surgery while
removing disease in the upper part of the bulla.
 94 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 6.29: Dry skull showing relative position of the sphenoid sinus to the
posterior ethmoid sinuses. Note that the sphenoid sinus is not a continuation
of the posterior ethmoid but is inferomedial to the posterior ethmoids.

with fat or muscle, to stop the leak. A local muco-

FIGURE 6.30: Endoscopic view of the right superior
turbinate which is an important landmark for entering in
to the sphenoid sinus.
Operative Technique of CSF Leak Repair
If a leak is identified during surgery then it should
be repaired immediately. Since the injury is fresh,
the flaps of dura can be repositioned or plugged
periosteal flap can be placed to support the site of
injury. This can be supported by a BIPP pack, to be
taken out after four to five days. The chances of
healing are maximal at this stage as there is no
scarring at the site of injury, and the margins of
leptomeninges are still fresh (Figs 6.31 to 6.37).
If the CSF leak remains undiagnosed during sur-
gery, the initial management should be based upon
spontaneous cessation of CSF leak. Conservative
management includes nursing the patient in a semi
sitting position, avoiding strenuous activities and
constipation.Patient be advised not to blow the nose.
Surgical intervention is required if there is a
persistent or recurrent active leak. Immediate repair
is also called for if there is an enlarging Pneumo-
encephalous or an attack of meningitis. There are
times when leak heals spontaneously after a bout
of meningitis. Antibiotics have not proved effective
in changing the incidence of meningitis in post-
operative CSF leaks.
 INTRACRANIAL COMPLICATIONS 95

FIGURES 6.31 and 6.32: Operative demonstration of a CSF leak. This was
repaired with muscle and a posteriorly based mucoperichondrial flap.

FIGURE 6.33

FIGURE 6.34 FIGURE 6.35

 96 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY
FIGURE 6.36
FIGURE 6.37
FIGURES 6.33 to 6.37: Spontaneous left sided CSF leak
seen just prior to the repair. Subsequent steps include
precise location of the leak which was quite large in this
case. Small amount of bone is removed surrounding the
leak to prepare for the graft. A temporalis muscle and a
contralateral perichondrial flap was used to seal off the
leak along with the gelform and final nasal packing.
External Drainage of CSF
Drainage when recommended, should be continued
for three to five days to allow healing after stoppage
of CSF leak. If the leak recurs, operative repair is
indicated. External drainage has its own inherent
complications like risks of convulsions, haematoma
formation, abscess, and ventriculitis. Infection with
indwelling catheters, which in most cases is by
Staphylococcal needs prophylactic antibiotics.
Nursing position The head up position reduces
intracranial CSF pressure and raises the pressure
on the spinal theca. For this reason, patients with
cranial leaks should be nursed at 45 degrees or more.
Endoscopic visualisation of the leak is of primary
importance. Once an obvious fistula is seen,
insertion of a plug of either fat or muscle is done to
stop the leak. Muscle when used may fibrose and
shrink but fat remains viable by recruiting a blood
supply from adjacent tissues. Intrathecally dye
injected in the beginning of the procedure helps to
visualise the leak intra operatively. Saline can be
injected to distend the subarachnoid space and
provoke a leak. A flap rotated from the middle
turbinate or the septum is used to cover the ethmoid
roof from below. This is layered with fibrin glue.
The three major operative approaches are
currently in use, either singly or in combination.
1. Craniotomy, including intradural and extradural
technique
2. The extra cranial extradural approach(external
ethmoidectomy)
3. Endonasal endoscopic approach.
The intracranial extradural approach has several
limitations. The dural tears are virtually inevitable
in the course of the dissection, and cerebral hernia-
tion may be missed.
Endonasal Endoscopic Approach to Repair
CSF Leak
Endoscopic repair of the fistula is done under gene-
ral anaesthesia. During operation following care-
ful observations are useful to identify the CSF
leak.
1. Pulsation transmitted from the cranial cavity.
2. A flow of thin fluid spurting out into the blood,
which is slowly welling up in the operative field.
3. A small meningocele may be seen.
 INTRACRANIAL COMPLICATIONS
4. A black hole, in contrast to the white denuded
bone.
5. A definitive CSF stained with fluroscien seen
with a blue filter attached to the endoscope.
6. To enhance the identification of an intermittent
leak, the anaesthetist can raise the CSF pressure
either by positive Valsalva’s manoeuvre or by
injecting 10ml.saline through the lumbar punc-
ture
Following complete haemostasis, a definite leak
may be identified. The adjoining bone is carefully
removed, so that an underlay graft can be placed.
The surrounding mucosa of the fistula need to be
denuded to which the mucosal flap can be applied.
Materials Used for the Repair
Over a period of time various materials have been
used to repair a CSF leak such as septal perichon-
drium, middle turbinate either as a free or a pedicled
graft, temporalis fascia and muscle, fat and fascia
lata. It is important to realise that it is not the type
of material but how it is used, i.e. the technique,
which is important for the successful closure of the
leak.
A three-layered repair is recommended:
1. A “sealing plug” of a living tissue, i.e. fat, muscle
or fascia should be used to plug the leak, this
stops the leak and permits surgeon to operate in
a dry field. Muscle has an advantage of swelling
and thus facilitating the seal. However, it will
shrink with the passage of time. Fat does not
shrink but is cumbersome to place and if the plug
is small, it can be lost in the cranial cavity. For
larger leaks fascia is recommended. The plug is
to be inserted through the defect in a dumb-bell
shaped manner. The living tissue supplies fibrin,
fibroblasts and capillaries to aid final closure of
the leak.
2. Structural support of septal bone or cartilage may
be used. Fascia lata also forms a good support
to the bony defect.
3. A third layer of pedicled mucoperiosteal flap
either from the septum or middle turbinate is
placed to give vitality to this assembly.
4. Tissue glue has an added advantage to keep the
grafting material in place.
97
5. Gelform should be used with final BIPP packing,
as when the BIPP pack is removed, it will not
disturb the underlying graft material.
Key Points to the Technique of Endoscopic
Repair
1. It is important to define both bony and dural
defect clearly.
2. The size of dural defect determines the type
of free graft tissue to be used.
3. For a small dural defect a fat graft is preferred,
for larger leaks muscle and / or fascia grafts
are required.
4. For large bony defect some scaffolding of
either bone or cartilage is required to prevent
sagging of dura and recurrence of the leak .
5. The bone around the defect should be
denuded of the mucous membrane.
6. Vascularised pedicled muco periosteal flap
gives vitality to the repair.
7. Fibrin tissue glue helps to retain this assembly
8. If the middle turbinate obstructs the view to
the skull base, it may be removed partially
with endoscopic scissors to improve the view
of the operative field.
9. Muscle has an advantage as it will swell with
CSF and acts as a plug in an actively leaking
patient.
10. It is sometimes difficult to work around the
dura mater from the area of the leak where
dura is well adherent to the anterior cranial
fossa. This may be a problem in leaks occur-
ring from lateral lamella of the cribriform plate
especially in Keros Type III skull base.
11. The bone of the anterior cranial fossa is
extremely thin. A lager piece of bone may be
inadvertently removed while preparing “bed”
for the graft. Great care should be taken to
avoid this and all dissection should be perfor-
med very meticulously.
12. Post operatively patient is nursed in a semi
seating position. Lumbar drain if inserted is
removed after 72 hours. Nasal pack is remo-
ved after 4-5 days. Patient is instructed to
refrain from blowing the nose and from
strenuous activities for a few weeks.
 98 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY
MENINGITIS
Pathogens may enter the CNS from paranasal sinu-
ses once the physical barrier of mucosa-bone and
dura mater is broken. Acute infections may result
in meningitis or cerebral abscess formation, whereas
a chronic infection is more likely to produce an
abscess. Common infecting organisms are S. pneu-
moniae H. influenzae or staph. aureus causing
meningitis, and anaerobes, causing brain abscess.
Pathological changes in meningitis have two
stages of development. The first is pus in the subara-
chnoid space, which then accumulates on the brain
surface, in the sulci, around the cranial nerves at
the base of the brain. This may lead to edema in the
cortex, which may produce uncal or tonsillar
herniation and subsequent death.
In chronic stage, fibrin is deposited in the subara-
chnoid space leading to blockage of CSF channels
and subsequent hydrocephalus. Inflammatory
vasculitis or endarteritis obliterans leads to throm-
bosis in the vessels and subsequent infarction. Extra
axial fluid collection (subdural hygroma) may occur,
and less frequently, there is formation of intra-
cerebral abscesses.
Clinical features
• Headache, painful eye movements, photophobia
and vomiting.
• Limitation of flexion of neck (Neck stiffness),
which can be measured as nurnber of finger
breadths between chin and chest on maximum
flexion. (present in 80% of patients)
• Brudzinski’s sign - reflex flexion of legs on
flexion of neck (positive in 50% of patients).
• Kernig’s sign - pain on passively extending knee
joint with hip joint in flexed position (positive
in 50% of patients).
• The head can usually be rotated without pain,
which distinguishes meningeal irritation from
neck stiffness in disorders of cervical spine.
• Papilledema is rare, as a matter of fact its
presence may suggest another diagnosis such as
space occupying lesions.
• CSF rhinorrhoea may be actively present.
Diagnosis
Prior to lumbar puncture it is important to rule out
raised intracranial pressure.
Examination of CSF shows elevated opening
pressure, cloudy fluid, neutrophilia and elevated
proteins and reduced sugar content.
Gram’s staining of CSF can be confirmatory.
Smears and cultures should be done even when CSF
chemistry is normal.
Imaging: CT Scan/ MRI
MRI is difficult to perform in critically ill patients.
It is superior to CT scanning in identifying cerebral
oedema, cerebritis, cavernous sinus lesions, and
brain abscess particularly when gadolinium DTPA
is used. It is useful to detect the site of CSF leak in
cases of recurrent meningitis.
Management
1. This involves monitoring of electrolytes to
prevent hyponatremia because of inappropriate
ADH secretion, and preventing fluid over load.
2. Dexamethasone in doses of 0.6 mg/kg/day for
2-4 days have shown to reduce neurological and
audiological sequelae.
Principles of Antibiotic Treatment
1. Drugs with high lipid solubility e.g. aminoglyco-
sides, which will cross blood brain barrier and
lead to adequate drug levels in CSF.
2. High drug concentration, approximately 10
times the minimum inhibitory concentration are
needed to kill bacteria.
3. Patients who have gross CSF leak need anti-
biotics—as part of definitive treatment.
4. Commonly used antibiotics in meningitis are
based on bacteriology.
The duration of antibiotics to be given is for 10 -
14 days.
BRAIN ABSCESS
Postoperative brain abscesses are usually staphylo-
coccal infections.
Clinical Features
1. Raised intracranial pressures, fever, headache,
nausea vomiting and altered sensorium. Signifi-
cant number of patients (25%) will have
papilledema.
2. Focal neurological deficit disturbance of higher
function, inattention, dysphasia, or visual field
disturbances may be seen.
Lumbar puncture is contraindicated in brain
abscess because of risk of brain herniation.
 INTRACRANIAL COMPLICATIONS
MRI is preferred (Figs 6.38 to 6.40) over CT as a
diagnostic tool because of:
1. Lack of ionising radiations
2. Lack of bony artifacts.
FIGURES 6.38 to 6.40: Coronal, axial CT scans and MRI
of the patients with extradural and intracranial abscesses.
These cases need to be treated in conjunction with the
neurosurgeons.
99
3. Better tissue definition
4. Less toxic contrast agent (gadolinium—DTPA).
Management
This is medical and surgical.
Since staphylococcal infection is suspected, the
drugs to be given are according to the culture sen-
sitivity keeping in account of methicillin resistant
staphyococcus aureus (MRSA).
Duration of medication should be 4-10 weeks
depending on the response. At the stage of cere-
britis, only antibiotics will suffice. If pus is suspec-
ted, CT guided aspiration should be performed. In
case there is a need for repeated aspiration surgical
excision via craniotomy is preferred and is safer.
Subdural Empyema
Subdural empyema is a collection of pus in the space
between duramater and arachnoid membrane. The
pathogenesis involves thrombophlebitis and spread
of infection to the subdural space, via valveless
emissary veins or an osteomyelitis of the skull with
accompanying epidural abscess.
Clinical Manifestations
1. Signs and symptoms related to increased
intracranial pressure.
2. Meningeal irritation.
3. Focal cortical inflammation—leading to hemi-
paresis, hemiplegia, ocular palsies, dysphasia,
seizures etc.
4. Lumbar puncture is contraindicated because of
risk of cerebral herniation.
5. On the basis of signal intensity it is easy to diffe-
rentiate between sterile effusion, haematoma and
empyema, more readily by MRI than CT scan.
6. MRI is also preferred to differentiate between
subdural empyema and epidural abscess.
Subdural empyema is a surgical emergency and
immediate exploration should be performed.
Epidural Abscess
This is defined as suppurative infection in space
located between the dura and the overlying bone.
The aetiology, pathogenesis and bacteriology is
similar, to subdural empyema. An epidural abscess
100 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY
is a slow growing lesion, which explains its insidous
clinical presentation.
Headache is a usual complaint but the patient
may otherwise be asymptomatic unless complicated
by subdural empyema or deeper intracranial inva-
sion. MRI is preferred than CT scan as small
collections are better defined. It can also differentiate
between sterile effusions, haematomas and pus.
Treatment
Medical-Surgical combined as in brain abscess.
Cavernous Sinus Thrombosis
Cavernous sinus lies in a space between periosteum
of sphenoid bone and a fold of dura mater. Two
cavernous sinuses, left and right lie along sphenoid
bone in the middle cranial fossa. Internal carotid
artery and 6th cranial nerve pass through the sinus.
3rd, 4th, and 5th.cranial nerves are found in the
lateral wall. The cavernous sinus is different from
all other venous sinuses of the dura as they have
numerous septa, dividing blood into spaces, hence
the name of cavernous sinus. Sphenoid air sinus lies
in front of the pituitary fossa which forms the medial
wall of the cavernous sinus.
Cavernous sinus thrombosis may be caused by
thrombophlebitis ascending via veins following
infection of the paranasal sinuses or during post-
operative period. Patients present with headache,
proptosis, eyelid swelling, nausea, vomiting, ocular
pain, papilledema, venous stasis and haemorrhage
in the optic fundus. A late symptom is total opthal-
moplegia caused by damage to the third, fourth and
sixth cranial nerves in the cavernous sinus. A few
patients manifest with high fever, septic tempera-
tures, and chills. Treatment includes high doses of
antiobitics, anticoagulants and fibrinolytic agents.
Pneumocephalous
The term pneumocephalous, a collection of air
within the skull was first described by Wolf in 1914.
However, it was Chiari (1884) who first reported a
case of intracranial pneumocephalous in a patient
with severe ethmoiditis. The air is trapped in the
subarachnoid space to cause tension pneumo-
cephalous. The exact cause of the occurence of
pneumocephalous is not known but it is believed
to be due to “ ball valve “ mechanism whereby air
enters the intracranial space by coughing, sneezing,
or forceful nose blowing through the cranial defect.
Alternatively it is said to be due to “ inverted bottle”
mechanism whereby in the presence of CSF leak,
negative pressure within the cranium causes air to
be sucked in. The air is then trapped by the menin-
ges or the brain which increases the intracranial
pressure. The most common symptoms are head-
ache, nausea and vomiting. In the early postopera-
tive period a change in consciousness is apparent,
seizures, meningismus may also be present.
Management
This is direceted to relieving the pressure by needle
aspiration after burr hole. Attention is then turned
to sealing of the CSF leak.
T
hese include: and cauterise the bleeding point with the help of
1. Haemorrhage—Reactionary and an endoscope. Systemic antibiotics should be given
Secondary (for details see chapter on Haemorrhage).
2. Adhesions
3. Infection 2. ADHESIONS
4. Osteitis Adhesions or scar tissue (synaechia) is a common
5. Crusting occurrence following any nasal surgery. Adhesions
6. Recirculation of mucus develop when two opposing raw mucosal surfaces
7. Mucus cysts remain in contact for some time in the post-
8. Epiphora operative period. In the initial stages there are
mucofibrinous bands between the two opposing
surfaces in the nasal cavity, which shortly matures
1. HAEMORRHAGE
and forms a scar tissue. Adhesions are inevitable
Reactionary haemorrhage can occur within first following any surgery in the nose and sinuses. The
24 hours of the operation. If it is significant then a surgeon can only minimise this, so that it does not
Merocel pack is usually sufficient. It is extremely become symptomatic. Simple presence of adhesions
rare in authors’ experience that the patient needs is no indication for its removal, unless these are
to return to the theatre for the control of the symptomatic, to the extent that they obstruct the
haemorrhage. Secondary haemorrhage can occur drainage and ventilation of the sinuses or the
after five to six days following the operation. This patency of the nasal airway (Figs 7.1 to 7.3).
may be due to infection in the ethmoid cavity and
usually is controlled by simple Merocel pack or in Predisposing Factors for the
a severe case may need packing under general Formation of Adhesions
anaesthesia, which is also very rare. Before packing A. Extensive surgery with tearing of the mucous
the nose every effort should be made to localise membrane

FIGURE 7.1
104 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 7.2

FIGURE 7.3
FIGURES 7.1 to 7.3: Postoperative dense adhesions between the nasal
septum and the lateral wall of the nose obstructing drainage and
ventilation of the ethmoid sinuses and maxillary sinus.
 PREOPERATIVE AND DELAYED POSTOPERATIVE COMPLICATIONS 105

FIGURE 7.4: Appearance of the left postoperative ethmoid cavity with an 4mm
0 degree endoscope following FESS in 48 hours. Note the cavity contains
blood clots and thick mucus which need to be gently sucked out.

B. Unnecessary trauma to the mucous membrane
during operation by instruments, suction,
improper use of microdebrider, or aggressive
use of laser resulting in ulceration of the mucous
membrane
C. Inability to remove crusts, blood clots, thick
secretions in the postoperative period, i.e.
inadequate postoperative care (Fig. 7.4).
D. Patient neglects postoperative attendance
E. High deviated septum not corrected at the time
of operation. This results in unnecessary
mucosal trauma to middle turbinate and the
lateral wall of the nose as it restricts the access
to the ostiomeatal complex during surgery and
in postoperative period. This mucosal trauma
to the two opposing surfaces lead to formation
of adhesions (Figs 7.5 and 7.6).
Prevention of Post-operative Adhesions
The endoscopic surgeon should develop skilled and
meticulous operative technique and take diligent
care not to damage unnecessarily the mucous mem-
brane during the operation. If meticulous preope-
rative preparation is done, bleeding should be
minimal and unnecessary trauma with suction and
other instruments is avoided. Nasal packing when
performed at the end of the operation, adds to the
problem of mucosal trauma especially to the oppo-
sing raw surfaces and contributes to the post-
operative adhesions. Surgeons insert various types
of nasal packing either Merocel, fingerstalls packed
with ribbon gauze or various types of splints avai-
lable commercially in the ethmoid cavity. Author’s
preferred technique is not to use any packing at
the end of the operation unless the bleeding is signi-
ficant, in which case Kelsostat ™ (calcium
alginate) pack is inserted and removed after 24
hours. A small anterior wedge resection of the
middle turbinate has been found very successful
in keeping the middle turbinate away from the
lateral wall of the nose. It also facilitates excellent
approach to the ethmoid cavity for a postoperative
cavity care, thus preventing adhesions (Figs 7.7 to
7.8B). If there is a significant trauma to the mucous
106 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURES 7.5 and 7.6: Same patient—Left nasal cavity showing high deviated
nasal septum restricting access to the middle meatus. In this situation a limited
excision of the septum with the endoscope helps significantly to allow surgeon
to get easy access to the osteomeatal complex and also facilitates the surgeon
to work in the area of frontal recess.
 PREOPERATIVE AND DELAYED POSTOPERATIVE COMPLICATIONS 107

FIGURES 7.7 and 7.8: 4 mm. 0 degree, endoscopic views of the postoperative
ethmoid cavities showing well exteriorised and easily accessible cavity with
minimal adhesions. This results from careful anterior wedge resection of the
middle turbinate.

membrane, then appropriate postoperative regime
should be instituted to prevent formation of
adhesions. This involves following measures to be
taken by the patient and the surgeon.
By the patient It is authors’ routine practice to
hand over written instructions to the patients when
they are discharged following endoscopic sinus
surgery.
Patients are instructed to use alkaline nasal
douche several times a day. This involves taking a
small jug of lukewarm water, which is boiled and
cooled, to which two teaspoonfuls of sodabicarb
(baking soda) is added. This solution is then taken
into 20-ml. syringe and the nasal cavity is syringed
with the head down position in front of a wash
basin. The alkaline solution is a mucolytic one,
which dissolves the excessive mucus secretions,
that occurs in the postoperative period. The
manual cleansing also removes blood clots and
crusts which form in the ethmoid cavity in the
postoperative period. Patients are advised to
perform nasal douche for at least four to six weeks
following the operation. By this time the ethmoid
cavity is gradually epithelialised. Patients are also
given steroid nasal spray for four to six weeks.
Patients are instructed to attend the postoperative
follow up examination regularly .
By the surgeon The surgeon should take diligent
care of the ethmoid cavity in the postoperative
period. This involves the following:
a. Use of local anaesthetic such as four percent
cocaine with 1.1000 adrenaline, or four percent
lignocaine on a piece of Merocel or a cotton
wool pledget to anaesthetise the nose may be
necessary in some cases.
b. With 0-degree endoscope and sterile suction
remove mucus, blood clots and crusts from the
nasal and ethmoid cavity. In doing so, divide
small fibrinous bands that form between the
two adjoining surfaces. Antibiotic and steroid
cream may be applied to the raw mucous
membrane (Figs 7.9 and 7.9A)
It is extremely important that the surgeon should
not use excessive force in removing the crusts and
the blood clots in the early postoperative period. If
undue force is used, it will not only be painful for
the patient but will result in removing the thin
delicate epithelium that forms under these crusts.
Once the new epithelium develops in the ethmoid
cavity, these crusts will become loose, and then can
be gently removed under direct vision with the use
of endoscope. Depending upon the extent of surgery
and the original disease, the ethmoid cavity will
heal over a period of several weeks, until then the
patient should be followed up in the clinic at varying
108 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURES 7.8A and 7.8B: Endoscopic views of the operative ethmoid cavities
showing careful anterior wedge resection of about 1 to 1.5 cm. of the middle
turbinate. It is important to keep upper stump of the middle turbinate to keep
orientation of the surgeon especially while working in the frontal recess. The
lower cut for the wedge resection should not extend more posteriorly otherwise
excessive bleeding may result form the branches of the sphenopalatine artery.
 PREOPERATIVE AND DELAYED POSTOPERATIVE COMPLICATIONS 109

FIGURES 7.9A and 7.9B: Removal of crusts

and blood clots from the postoperative
ethmoid cavity as part of the cavity care in
the outpatient clinic.

intervals which should be “tailor made (Fig. 7.10). INFECTION

Diligent cavity care will only minimise postoperative
Infection of the ethmoid cavity in the postoperative
adhesions. Inspite of meticulous cavity care some
period is rare, it may develop after an upper respi-
adhesions may form in the ethmoid cavity, however,
ratory tract infection. Depending upon the severity
these are minor and asymptomatic and do not
of the infection, this might require a course of
require any surgical treatment.
antibiotics following a culture and sensitivity swab
The aim of the cavity care is to keep the natural
(Figs 7.13 and 7.14).
ostia of the sinuses patent to restore physiological
drainage and ventilation (Figs 7.11 to 7.12A).
Toxic Shock Syndrome
Prolonged packing in the nose is known to harbour
Staphylococci Aureus, which may induce toxic
shock syndrome. This potentially serious condition
is characterised by high grade fever, rash, hypo-
tension, involvement of GI tract, muscular and
renal symptoms. Hepatic, hematological and CNS
involvement soon follows.
Treament consists of removal of packs, fluids,
vasopressores, and antibiotics. Clindamycin with
or without Vancomycin are given intravenously
for fourteen days.

OSTEITIS
If the excessive mucous membrane is removed at
the time of operation and the underlying bone is
FIGURE 7.10 exposed, this may result in chronic osteitis. This
110 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 7.11

FIGURE 7.12A
PREOPERATIVE AND DELAYED POSTOPERATIVE COMPLICATIONS 111

FIGURE 7.12B
FIGURES 7.10, 7.11, 7.12A and 7.12B: A well epithelialised cavity
several years following FESS with natural ostia of the maxillary
and frontal sinus draining into the nasal cavity

FIGURE 7.13
112 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 7.14
FIGURES 7.13 and 7.14: Excessive amount of mucus is within normal
limits in many patients following FESS. Unless there is some bacterial
infection, patients do not need any active treatment. Frequent nasal
douche and regular follow up usually suffice.

may also act as a permanent source of infection in

the cavity. If significant and troublesome then this
would require removal of the infected sequestrated
bone, antibiotics and assiduous cavity care until
epithelialisation takes place in the cavity. It is
highly recommended that the surgeon should not
leave any loose bone in the nasal cavity or in the
sinuses, as this would eventually form sequestrum
and a constant source of infection in the cavity.

CRUSTING (Fig 7.15)

This could be a significant problem in the operated
cavity and more likely to occur in a dry and hot
climate. The cilia needs moisture for its physiolo-
gical functioning and drying of the mucous FIGURE 7.15: Occasionally ethmoid cavity produces
membrane will affect the cilia adversely. This is excessive crusting which requires frequent nasal douche
turn will result in more stagnation of secretions, and it usually settles down over a period of time. This
may result from excessive removal of the mucous
and more crusting. The crusts in the early
membrane of the nasal cavity during opeartion.
 PREOPERATIVE AND DELAYED POSTOPERATIVE COMPLICATIONS 113

FIGURE 7.16: Rarely mucus retention cysts can form in the ethmoid cavity. These are usually symptomless but if in large
numbers as shown obstructing drainage and ventilation of the sinuses then it can be removed under local anaesthesia.

postoperative period is due to temporary cessation
of the ciliary activity as a result of use of
vasoconstrictor agents, instrumentation and
packing. Frequent cavity care is important to
remove these crusts so that patient does not develop
secondary infection in the cavity.
RECIRCULATION OF MUCUS
Traditionally it has been thought that this compli-
cation arises mainly due to the fact that the surgeon
has not connected the natural and accessory
ostium during the operation. In this situation the
mucus drains out of the natural ostium but reenters
through the accessory ostium into the sinus. This
may lead to the patients complaining of some post
nasal drip. However, authors believe that the
recirculation of the mucus in the postoperative
period may be occurring as a result of excessive
trauma and scarring of the natural ostium and
natural mucus pathways which probably leads to
stagnation of mucus. This mucus is then driven
towards the accessory ostium as the final common
pathway is scarred.
MUCOUS CYST (Fig 7.16)
Occasionally, a mucous retention cyst may form
in the operated ethmoid cavity or in the maxillary
sinus. These are usually symptomless and do not
require treatment. However, if large and sympto-
matic may be removed under local anaesthesia.
EPIPHORA
Epiphora as a late complication occurs due to the
damage to the nasolacrimal duct during the
operation. This is due to formation of fibrous tissue
around the nasolacrimal duct resulting in obs-
truction. The obstructed duct can be probed initially
to assess the degree of blockage. If significant and
symptoms continues, then dacryocystorhinostomy
would be necessary.
F
unctional Endoscopic Sinus Surgery is
now a well-established procedure
through out the world. Many studies in
the literature have demonstrated the
clinical effectiveness of the technique.
Successful outcome in the region of 76-98 percent
are common (Moses et al 1998) with great majority
of studies suggesting improvements in more than
85 percent of patients. At the same time there is a
failure rate of 2-24 percent of primary surgery and a
Revision Endoscopic Sinus Surgery (RESS) is needed.
The surgeon’s knowledge of surgical anatomy
is critical and revision surgery challenges surgeon’s
skill and experience as usual anatomic landmarks
are distorted or absent by previous surgery and scar
tissue. This chapter discusses the role of laser, most
common anatomical sites of residual and/or recur-
rence of disease and how to tackle these difficult
areas without risking serious complications, which
are more likely to occur in revision cases. It describes
preoperative evaluation and important surgical
landmarks in patients undergoing revision surgery.
The problems in revision endoscopic sinus surgery
are:
1. Distorted surgical anatomy (Figs 8.1 to 8.3)
2. Excessive scar tissues (Figs 8.4 and 8.5)
3. Inadequate local anaesthesia and hence requiring
general anaesthesia, resulting in excessive
bleeding
4. Chronically congested and oedematous mucous
membrane further resulting quite often in
excessive bleeding (Figs 8.6 and 8.7)
5. Higher incidence of serious complications due
to poor visualisation of surgical landmarks.
THE COMMON ANATOMICAL SITES OF
RESIDUAL DISEASE
1. Upper and lower one third of Uncinate process
(Figs 8.8 to 8.10)
2. Upper segment of Bulla Ethmoidalis
3. Agger nasi cells (Figs 8.11 and 8.12)
4. Anterior extension of ground lamella
5. Posterior ethmoid and Sphenoid (Figs 8.13 to
8.14)
6. Frontal Recess and Sinus (Figs 8.15 and 8.16)
The anatomical landmarks usually found in
revision cases are as follows.
1. Arch of the middle turbinate: In revision cases
even if a large part of the middle turbinate is
missing, upper attachment of the middle
turbinate to the lateral wall of the nose is a very
useful landmark during revisoion surgery. The

FIGURES 8.1 and 8.2: Right nasal cavity—4 mm, 0 degree enodoscopic view in a case of
revision surgery showing abscence of middle turbinate. A small ethmoidal cell (eth.),
cribriform plate (CP) and lamina papyracea (LP) are the only surgical landmarks available
to the surgeon. A collection of pus is seen emerging from the agger nasi (AN) cells.
118 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 8.3: Same patient as Fig. 8.1 and 8.2 coronal CT scans showing diseased
right frontal sinus due to obstruction by the agger nasi cells. As seen patient had
previous inferior meatal antrostomy and Caldwell Luc procedure.

FIGURE 8.4
 COMPLICATIONS IN REVISION SURGERY 119

FIGURE 8.4 and 8.5: Endoscopic view of the densely adherant left middle
turbinate to the lateral wall of the nose obstructing completely ethmoid
cavity and the middle meatal antrostomy. Note KTP/532 laser being used
to divide these adhesions very precisely without any bleeding.

FIGURE 8.6: Endoscopic view of the right nasal

cavity in a case of revision suregry. Note
persistent mucosal disease in the ethmoids and
actively infected maxillary sinus.
120 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY
FIGURE 8.8
surgeon must not work medial to this arch as it
will lead to the cribriform plate.
2. Middle Meatal Antrostomy and /or lamina
papyracea: If there is a middle meatal antro-
stomy and the maxillary sinus can be viewed
with a 0 degree or an angled endoscope, this
forms another important surgical landmark for
the surgeon.In this situation surgeon should not
work superior and lateral to the antrostomy.
3. Posterior choana: The posterior choana is always
present. The anterior wall of the sphenoid can
be judged which is 1 to 1.5 cm from its upper
FIGURE 8.7: Left side of the nasal cavity showing
inferior meatal antrostomy (IMA) actively
discharging mucopus from the maxillary sinus.
Note polypoidal disease in the middle meatus.
FIGURE 8.9
border. Sphenoidotomy is then performed.
Following this skull base can be identified
and surgeon can work its way anteriorly to
remove the disease from the ethmoids and
frontal recess.
4. Posterior part of the nasal septum: In relation
to the posterior choana and the posterior part of
the septum, surgeon can identify anterior wall
of the sphenoid sinus.
5. Superior turbinate: If this is present, posterior
ethmoids, skull base and sphenoid can be
worked out.
 COMPLICATIONS IN REVISION SURGERY 121

FIGURE 8.10
FIGURES 8.8 to 8.10: KTP/532 laser excision of the remnants of the lower and
upper part of the uncinate process. Complete excision of the uncinate process
is important to exteriorise the infundibulum and to gain access to the natural
ostium of the maxillary sinus below and to the frontal recess superiorly.

FIGURE 8.11 FIGURE 8.12

FIGURES 8.11 and 8.12: Endoscopic views with the 4mm, 70 degree endoscope showing
vaporisation of the diseased agger nasi cells. Note complete abscence of bleeding and
draining of mucopus from the agger nasi cells.Lateral thermal damage to the surrounding
vital structures such as cribriform plate (CP) is nonexistent with laser parameters used for
this ablation of the agger nasi cells.
122 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 8.13: KTP/532 laser being used to vaporise ground

lamella on the left side of the ethmoid cavity. Note once
again blanching of the blood vessels and bloodless field
with use of non contact mode of the laser. Middle meatal
antrostomy at 4 o’clock position.

FIGURES 8.15 and 8.16: Endoscopic view with 4mm, 70

FIGURE 8.14: Right nasal cavity displaying vaporisation of
the anterior wall of the sphenoid sinus. A microstat with
6oo micron laser fibre along with the suction attached is
in the spheno ethmoidal recess. KTP/532 laser power is
at 6 watts continuous.
6. Inferior turbinate: If this is present, natural
ostium of the maxillary sinus can be worked out
at its superior border in an infero lateral direction
and antrostomy performed and subsequently
lamina papyracea identified
During revision surgery surgeon should conti-
nuously feel for the bony septa of the ethmoid cells
and should work in a forward direction and NOT
posteriorly towards the skull base.If in doubt
surgeon should not pull any tissue especially in a
degree endoscope showing further removal of agger nasi
cells in an attempt to identify frontal recess (FR) and the
frontal sinus ostium.
case where there is a dehiscence of the orbit and /
or skull base.
USE OF LASER IN REVISION SURGERY
Why Use a Laser ?
Advantages of Lasers
By virtue of the characteristic of the laser to be a
precise tool with the ability to cut, coagulate and
vaporise the tissues with minimal trauma, bleeding
and low postoperative oedema and morbidity, is
well suited to be used in nose and sinus surgery
(Figs 8.17 to 8.20). Minimal bleeding during endo-
scopic sinus surgery allows better identification of
 COMPLICATIONS IN REVISION SURGERY 123

FIGURE 8.17: Operative view of the right nasal cavity showing medially displaced uncinate process
being excised with the use of KTP/532 laser. In this situation lamina papyracea would be close
to the laser energy but the laser parameters ( 6 watts, continuous with 0.6 mm. spot size ) used
would not result in any thermal damage to the vital surrounding structures.

uncinectomy, dividing adhesions with minimal

FIGURE 8.18: KTP/532 laser uncinectomy on the right side
of the nasal cavity. Note precise excision without any
trauma or bleeding.
surgical landmarks and therefore reduces chances
of complications. Laser, system which is truly fibre
transmissible such as KTP/ 532 Lasers, can cut the
tissues in a contact mode for example performing
trauma. In a near contact mode it can simply
vaporise the nasal polyps or thickened mucosa, thin
bulla ethmoidalis, anterior thin bony wall of the
sphenoid sinus, or “egg shell “ of the ager nasi cells
in the region of the frontal recess without any
bleeding. This bloodless field gives access to the area
which are obscured by the disease. In a non contact
or coagulation mode, laser can coagulate bleeding
vessels or oozing from the mucous membrane. This
obviously keeps the operative field as clear as
possible and thereby reduces the incidence of
complications. Due to the very precise nature of
surgery with the laser and minimal trauma, the
postoperative morbidity and scaring is also
reduced. At the same time, as there is no tearing of
the mucous membrane, the healing appears to be
quicker than conventional technique.
Over a period of time various lasers such as CO2,
Neodymium-Yag, and Argon have been used in the
nasal cavity to achieve cutting, vaporisation and
coagulation especially to the inferior turbinate.
124 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURES 8.19 and 8.20: Same patient—Coronal CT scan and intraoperative photograph
show diseased right hypoplastic maxillary sinus with dehiscent lamina papyracea exposing
orbital periosteum.A pseudo middle meatal antrostomy has not alleviated patient’s
symptoms and maxillary drainage has to be established through the natural ostium. In
this circumstance laser with its precise tissue interaction is extremely useful for vaporising
small part of the anterior fontanelle to enlarge natural ostium of the maxillary sinus.
 COMPLICATIONS IN REVISION SURGERY
Further applications of these lasers for example CO2
in the nose have been restricted firstly due to the
fact that it could not be delivered deep into the nasal
cavities.. Secondly the tissue penetration was such
in case of Nd-Yag, that it would result in thermal
damage to the important vital structures such as
medial rectus, optic nerve, thin skull base etc.
However, since the introduction of Holmium-Yag
and KTP/532, which is transmitted through a quartz
fibre, it has been possible to apply the laser energy
anywhere into the nasal cavity and paranasal
sinuses.
Which Laser ?
CO2, Neodymium -Yag, Holmium-Yag, and KTP/
532 lasers have been used for various indications in
nose and sinuses. Holmium Yag laser was used by
Metson R (1996) on one side of the nose with
conventional endoscopic instrumentation on the
other in a prospective, randomised controlled single
blinded study of 32 patients. The study concluded
that the laser offers a very precise tissue interaction
in terms of ablations and much less bleeding than
the conventional methods.
Shapsay SM et al (1991) showed that Holmium-
Yag laser provides a good haemostasis, controlled
soft tissue ablation and bone removal. The access
to all sinuses was very good due to fibre optic
delivery system. He concluded that the use of laser
is warranted to increase the precision and safety of
endoscopic sinus surgery. Ikeda K et al (1996) used
KTP/532 laser in 80 patients and performed
endoscopic sinus surgery in patients suffering from
chronic sinusitis and mucoceles. He demonstrated
excellent results showing reduction of post-
operative polyps and granulation tissues around
enlarged maxillary sinus ostium. In addition,
patients with chronic sinusitis showed enhanced
healing of the polypoid degeneration of the
maxillary sinus. It was concluded from their
experience that the KTP/532 laser is a promising
tool in endoscopic sinus surgery.
Disadvantages of Lasers
Laser is an expensive tool and the cost has to be
justified in any given situation. However, a laser
125
system such as KTP/532 which is versatile and can
be used by all surgeons in their specialty is
obviously more attractive. It is extremely important
that the surgeon and all the support staff working
in the theatre has to undergo specific training before
laser can be used safely on the patient. The laser
training consists of understanding specific laser
tissue interactions as all lasers do not have similar
tissue effects. Laser safety for both patients and
theatre staff have to be strictly observed. The
surgeon must have specific “hands on” laser
training using preferably anaesthetised laboratory
animals. If this is not possible, alternatively “hands
on” should be on various fresh animal tissues to
understand laser tissue interactions.
KTP/532 LASER
The author (SKK) has now used routinely KTP/532
laser for endoscopic sinus surgery especially in
revision cases for more than 10 years with gratifying
results (Fig. 8.21).
The Potassium Titanyl Phosphate (KTP) is a solid
crystal laser produced by passing Neodymium-Yag
laser through a KTP crystal resulting in the emission
of half its wavelength (532), the process known as
frequency doubling. The KTP / 532 laser dwells in
the visible range of the electromagnetic spectrum
and hence it does not need an aiming beam as with
CO2 and Nd -Yag laser. This ensures high surgical
accuracy to the tissues in the nasal cavity when the
laser energy is applied especially working on the
lamina papyracea, frontal recess, near the thin
lateral lamella of the cribriform plate and the roof
of the sphenoid sinus. At the same time the tissue
penetration of this laser into the pigmented tissue
is less than Nd.-Yag which also enables the laser to
be used near the orbit and the skull base.
Hand in hand, the development of the newer
instruments has made it possible for the laser fibre
to be passed through a channel along with the nasal
endoscope. Alternatively, a quartz flexible fibre can
be passed through a hand held instrument making
it “feel” a conventional instrument in the surgeon’s
hand. The quartz fibres tips are unsharpened and
remain cool which prevents accidental trauma and
126 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 8.21: Operative view of KTP/532 laser in use in the theatre.

Note visible and truly fibre transmittable laser.

thermal burns, both to the patients and the surgeon.
Above all, what surgeons need during an operation
is a relatively bloodless field particularly in vascular
tissues of the nose and sinuses. The wavelength of
the KTP laser, 532 nm is selectively and highly
absorbed in the blood pigments such as haemo-
globin and melanin, making it an excellent
coagulator resulting in minimal bleeding during
sinus surgery
The vapourisation mode of the KTP is particularly
useful in the presence of polyps in the nasal cavity
obscuring the important surgical landmarks such as
middle turbinate and uncinate process. These polyps
can be simply vaporized to gain access to the middle
meatus and uncinate process.
thickened mucosa, and fibrous tissue of anterior and
posterior fontanelle encountered in the nose. In
addition there is a thin bone of the ethmoid cells,
ground lamella, anterior wall of the sphenoid and
thin “eggshell” of agger nasi cells. The quartz optical
fibre is always calibrated in excess of 80 percent. If
the char is formed on the surface of the tissues then
this is removed either with the suction or with the
forceps. This is important, as lasing on the charred
surface will result in further secondary thermal
damage to the surrounding tissues and thereby
possible injury to the deeper vital structures.
Simply changing the distance between the tissue
and the laser fibre surgeon can vary the amount of
laser energy at the tissue interface.

Laser Parameters for KTP/532 Wavelength Uncinate Process (Fig. 8.22)

The author recommends various power settings at
different stages of the endoscopic sinus surgery
(usually between 6 to 12 watts in a continuous mode
with a 6oo micron fibre for FESS). This is mainly
due to different soft tissue structures i.e., polyps,
Inadequate excision of the uncinate process in the
upper part will result in obstruction of the frontal
recess whereas a remnant of lower part of uncinate
process will cause difficulty in identifying the
natural ostium of the maxillary sinus. The remnants
 COMPLICATIONS IN REVISION SURGERY 127

FIGURE 8.22 FIGURE 8.25

FIGURE 8.23 FIGURE 8.26

FIGURE 8.24 FIGURE 8.27

128 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 8.28 FIGURE 8.29

FIGURES 8.22 to 8.29: These intraoperative photographs show various stages of the endoscopic
sinus surgery with KTP/532 laser in revision cases. As can be seen excision of the remnants of
the uncinate process, vaporisation of bulla, agger nasi cells, ground lamella and anterior wall of
the sphenoid could be performed almost bloodlessly with the laser.

of the uncinate process along with the scar tissue
can be removed in contact, continuous mode with
the power of 6 watts of KTP laser with a 600 micron
fibre.
Bulla Ethmoidalis (Fig. 8.23)
It is important to note that quite often bulla extends
upwards towards the skull base and in some cases
even anteriorly up to the frontal recess. The residual
disease usually remains in the upper part of the
bulla. Using KTP laser the residual bulla can be
removed and the disease exteriorized (power 8
watts continuous, 600 micron fibre).
Agger Nasi Cells (Figs 8.24 and 8.25)
These are the most anterior ethmoidal cells of the
ethmoid labyrinth and the most common site for the
residual disease. These cells are removed with conti-
nuous laser energy combined with vapourisation of
polyps in this area to identify frontal sinus Os.
Posterior Ethmoids and Sphenoid
(Figs 8.26 and 8.29)
In some cases there are polyps and /or thickened
scarred mucosa in this region which can be
vapourised in a bloodless manner to exenterate the
posterior ethmoid and sphenoid safely.
Frontal Recess (Figs 8.30 to 8.34)
Anterior ethmoidal cells obstructing frontal recess
can be effectively vaporised with the laser para-
meter of six watts in a continuous mode with 6oo
micron fibre to establish free drainage from the
frontal sinus.However, any instrumental trauma
either with suction or forceps or excessive lasing is
to be avoided in the area of the frontal sinus ostium.
As stripping of the mucosa or destroying the
mucosa with laser in this area will inevitably result
in new bone formation and further obstruction of
the frontal sinus drainage with consequent frontal
sinusitis.
Middle Meatal Antrostomy (Figs 8.35 and 8.36)
This is essentially an enlargement of the natural
ostium of the maxillary sinus usually in its antero
inferior direction at the expense of the anterior
fontanelle. A common error is to make a simple “
hole” in the middle meatus without identifying the
natural ostium .The natural ostium of the maxillary
sinus is lateral to the lower one third of the uncinate
 COMPLICATIONS IN REVISION SURGERY 129

FIGURE 8.30 FIGURE 8.33

FIGURE 8.31 FIGURE 8.34

FIGURES 8.30 to 8.34: Right revision FESS—Following
identification of the frontal recess with 4mm, 70 degree
endoscope lasing can be performed to remove obstructing
agger nasi cells and identify frontal sinus, thick mucopus
evacuated and final outflow tract from the frontal sinus
can be established.
process in hiatus semilunaris in vast majority of
patients. A very large antrostomy is neither
necessary nor it is physiological. Every effort should
be made to preserve the mucous membrane around
the antrostomy especially in its posterior part for
normal mucociliary mechanism to be established.
An antrostomy with an exposed bone will result in
excessive granulations tissue, osteitis, scar tissue
FIGURE 8.32 and poor mucocialiary drainage.
130 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 8.35 FIGURE 8.36

FIGURES 8.35 and 8.36: Vapourisation of the fontanelle following identification of the
natural ostium can be easily performed with the use of laser and middle meatal
antrostomy (MMA) can be fashioned almost bloodlessly.

FIGURE 8.37 FIGURE 8.38

FIGURES 8.37 and 8.38: Right nasal view with 4mm, 0 degree endoscope showing
bloodless separation of a plastered middle turbinate to the lateral wall of the nose.
The laser parameters used are 6oo micron fibre with 8 watt in a continuous mode.

ADHESIONS (Figs 8.37 and 8.38)

Adhesions or scar tissue after any surgery is
common but in case of nose and sinuses it should
be minimal and not interfering with the physio-
logical function of the mucociliary clearance.
Authors’ preferred method is to remove a small
(about 1cm.) wedge of anterior part of the middle
turbinate with KTP laser in a continuous mode. This
not only prevents laterlisation of the turbinate but
also gives excellent access to the ethmoid cavity in
post-operative period for cavity care (Kaluskar SK
1998). Authors firmly believe that atraumatic
technique without undue trauma to the mucous
membrane and diligent post operative care of the
ethmoid cavity is all that is needed to prevent or
minimise postoperative adhesions.
 COMPLICATIONS IN REVISION SURGERY
PREOPERATIVE EVALUATION
A thorough history with analysis of patient’s symp-
toms including differential diagnosis is absolutely
mandatory. Systemic diseases such as primary or
secondary ciliary dyskinesia, cystic fibrosis, ASA
triad, involving sinuses should be excluded and an
aggressive medical line of treatment should be
employed before embarking upon revision surgery.
Surgeon must find out why the first operation failed
by detailed analysis on nasal endoscopy (Kaluskar
et al 1992). CT images using “thin cuts” should be
studied carefully in relation to the patient’s symp-
toms and only then revision surgery should be
undertaken.
In the presence of distorted anatomy and scar
tissue in revision cases author finds KTP/532 laser
extremely valuable with its main advantage as a
good coagulator. This makes revision surgery much
safer as the remaining anatomical landmarks are
easily identified with minimal bleeding. Image
guided surgery in three different planes i.e., coronal,
axial and sagittal has an advantage in revision cases
but the cost of the equipment and time taken for
preoperative preparation of the patients prevents
its wider use in common inflammatory diseases of
the sinuses at the moment.
Postoperative Care
The postoperative care following laser FESS is no
different than the operation being performed by a
conventional method.
CONCLUSIONS
Revision FESS accounts for a small number of cases
but the incidence is slowly increasing as more
surgeons are undertaking endoscopic sinus surgery.
These cases could be avoided by understanding a
clear basic concept of the recurrent sinusitis. A
comprehensive knowledge of the complex and
variable surgical anatomy of the nose and sinuses
is of paramount importance. The surgeon should
be able to read and interpret CT scan in relation to
the patient’s symptoms and nasal endoscopy
findings (Kaluskar SK 1997). The importance of the
cadaver dissection before undertaking revision
surgery cannot be over emphasized to learn the
131
difficult areas of the agger nasi, frontal recess and
posterior group of sinuses. As elsewhere in
medicine prevention is better than cure. Lastly it
must be remembered that laser is a tool with its
specific advantages and has to be used following
thorough understanding of its tissue interactions.
ROLE OF MICRODEBRIDER
Functional endoscopic sinus surgery is essentially
a mucosa preserving surgery. This can be achieved
by means of developing a skilled and meticulous
surgical technique and secondly by devices such as
microdebrider and “thru cut “ instruments. Power
driven suction based rotating surgical system was
first developed by Dr. Jack Urban, (Krouse JH et al
(1997) at House Ear Institute in United States for
removal of acoustic neuroma. Afterwards it was
then used by the orthopaedic surgeons in knee,
shoulder and temporomandibular joints. Setliff RC
et al (1994) used it in nose and sinuses and named it
as “hummer”.
The basic principle of powered instruments or
microdebrider is a “blade in a blade”, in which a
hollow suction blade oscillates inside a metal tube
which is open at the tip with a atraumatic rounded
“head”. The tissues get sucked in and get cut
without stripping the mucous membrane. There is
a built in suction irrigation mechnism to keep the
operative field clear. The microdebrider can be used
in the following situations (Fig. 8.39).
1. Polyposis
2. Thickened diseased mucosa
3. Excision of the uncinate process with curved
blade
4. Middle meatal antrostomy - by removing part
of the fontanelle
5. Removal of thin bony “egg shell” of the ager nasi
cells with curved blades, posterior ethmoid and
anterior wall of the sphenoid sinus.
6. Cysts of the maxillary sinus through the middle
meatal antrostomy.
7. Base of the A.C. polyp either through the middle
meatal antrostomy or through the canine fossa
approach.
8. Turbinoplasty of concha bullosa or paradoxical
middle turbinate.
132 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURES 8.39: Microdebrider showing straight shot to remove

polypi from the left side of the nasal cavity.

FIGURES 8.40: Left nasal view with the straight shot of the microdebrider showing
excision of the lateral wall of the middle turbinate. Being a mucosa preserving
technique the bleeding and tearing of the mucous membrane is minimal.
 COMPLICATIONS IN REVISION SURGERY 133

FIGURES 8.41: Left side of the nasal cavity. Ethmoidal polypi have been removed
with the use of straight shot of the microdebrider. A curved blade is being used
to fashion middle meatal antrostomy.

Advantages everything that is sucked into the metal window.

The following are the main advantages of
microdebrider:
1. It preserves mucosa leading to:
a. Minimal adhesions formation
b. Minimal bleeding as the tissues are not
striped or removed
c. Less exposure of bare bone and thereby redu-
ced chances of osteitis in the ethmoid cavity.
d. Only aspirated tissues are removed as a result
damage to the vital structure is avoided if
correctly used.
2. It also avoids frequent change of instruments. A
large part of the operation can be accomplished
by the microdebrider rapidly.
Disadvantages
1. The equipment is by no means cheap and initial
cost has to be justified. An occasional use of the
equipment may not be cost effective
2. The surgeon needs to be properly trained in the
use of this instrument. Microdebrider removes
If the surgeon is not familiar with the anatomy ,
he/she is likely to inflict serious damage to the
surrounding vital structures.
3. Frequent blockage of the suction with pieces of
bony fragments, thickened mucosa etc. can occur.
4. A powerful suction in the theatre is absolutely
essential at least to the extent of 180 mmHg.
pressure. A weak suction will not aspirate the
tissues properly, it will allow the pooling of
irrigation fluid and more importantly blood in
the operative field thereby obscuring the vision
and increasing the chances of complications.
5. The various types are blades, which are
available, are disposable ones and are quite
expensive, thus increasing the cost. A reusable
blade is more cost effective.
It is an adjunct to the traditional FESS instru-
ments and not to be considered as an alternative to
the conventional or throughcut instruments. It is
certainly NOT a substitute for not knowing the
surgical anatomy.
H
ISTORY
It was Millar et al (1981) who
recognized histologic resemblance
between chronic fungal sinusitis
and allergic bronchopulmonary
asperigillosis. Later on in 1983 Katzenstein et al
described seven cases of chronic sinusitis asso-
ciated with fungal hyphae.
The first case of concurrent Acute Bron-
chopulmonary Asperigillosis and allergic fungal
sinusitis was reported by Sher and Schwartz in
1988.
Further research lead by Allphin et al and
Manning et al in 1991 showed that the fungi of
the Dematiaceae family, not Aspergillus species,
were the primary etiological agents were respon-
sible for allergic fungal sinusitis.
FIGURE 9.1: Structure of the fungus
In 1995- Rassekh et al described allergic fungal
sinus disease affecting skull base.
Fungal infection of the nose and sinuses is a
common condition which is now recognized, both
in normal and immuno-compromised individuals.

WHAT IS A FUNGUS?
Fungi are plant-like organisms but lack chloro-
phyll. Since they do not have chlorophyll, fungi
must absorb food from dead organic matter. Fungi,
as with bacteria share the important ability to
break down complex organic substances of almost
every type (cellulose) and are essential to the
recycling of carbon and other elements in the cycle
of life. Fungi are supposed to “eat” only dead
things, but sometimes they start eating when the
organisms are still alive. This is the cause of fungal FIGURE 9.2: Histology showing fungus in the tissue
infections and the treatment is directed to the
eradicating the fungus (Figs 9.1 to 9.3).
In the past three decades, there has been a
significant increase in the number of recorded
fungal infections. This is likely to be due to increased
public awareness, recent immunosuppressive
medications such as cyclosporine that “fool” the
body’s immune system to prevent organ rejection
in transplanted patients and indiscriminate use of
FIGURE 9.3: Aspergillus
antibiotics.
138 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

When the body’s immune system is suppressed,

fungi find an opportunity to invade the body and
produce number of symptoms. These organisms
do not require light for food production, they can
live in a damp and dark environment. The sinuses,
consisting of moist, dark cavities, are a natural
“home” to the invading fungi. When this invasion
takes place, fungal sinusitis results.
Aspergillus species are the most common
causative agents of fungal sinusitis. Aspergillus is
a spore forming filamentous fungus which occurs
as a saprophyte in soil and decaying matter. It is
spread by airborne transmission. Human to human
transmission is unknown.
Histologically Aspergillus shows septate FIGURE 9.4: CT scan showing fungus in sphenoid sinus.
hyphae, and spores are produced asexually. Note concretions in the fungal ball
The species most commonly implicated in
nosed with AFS usually have a history of
human pathogenicity are A. fumigatus, A . flavus
allergic rhinitis, but the onset of AFS develop-
and A. niger. In most parts of the world, the
ment is not certain. Thick fungal debris and
organism usually isolated is A. fumigatus.
mucin which contains glycoproteins are
developed in the sinus cavities and must be
TYPES OF FUNGAL SINUSITIS surgically removed so that the inciting allergen
1. Mycetoma (Asperigilloma)—An old nomen- is no longer present. Recurrence occurs in some
clature, in this situation Fungal Sinusitis patients but meticulous clearance of the polyps,
produces clumps of spores, a “fungal ball,” diseased mucosa and adequate drainage of the
within a sinus cavity, most frequently the sinuses through their natural ostia remains the
maxillary sinuses.The correct name should be mainstay of the treatment. Sometimes steroids
Asprigilloma. The patient usually maintains an are prescribed to prevent AFS recurrence
effective immune system. Generally, the fungus (Fig. 9.5).
does not cause a significant inflammatory res-
ponse, unless in a long standing case sinus
discomfort occurs. The noninvasive nature of
this disorder requires treatment consisting of
simple but very thorough removal of the
infected sinus with adequate irrigation. An anti-
fungal treatment is generally not necessary.
Mycetoma form is considered as the least
troublesome and simplest to handle (Fig. 9.4).
Sinus mycetoma may occur in any paranasal
sinus and is often unilateral. Patient may
present with symptoms of chronic sinusitis.
2. Allergic Fungal Sinusitis (AFS) is now believed
to be an allergic reaction to environmental fungi
that is finely dispersed into the air. This
condition usually occurs in patients with a FIGURE 9.5: CT scan showing unilateral
normal immunocompetence. Patients diag- fungal allergic sinusitis
 FUNGAL INFECTIONS OF THE NOSE AND PARANASAL SINUSES
FIGURE 9.6: Intracranial fungal spread
3. Chronic Indolent Sinusitis is an invasive form
of fungal sinusitis in patients without an
identifiable immune deficiency. This form is
generally found most commonly in the Sudan
and northern India. The disease progresses from
months to years and presents symptoms that
include chronic headache and sometimes facial
swelling. Microscopically, chronic indolent
sinusitis is characterized by a granulomatous
inflammatory reaction. A decreased immune
system can place patients at risk for the disease
to become invasive.
4. Fulminant Sinusitis is usually seen in the
immunocompromised patients. The disease
leads to progressive destruction of the sinuses
and can invade the bony cavities containing the
eyeball and brain (Fig. 9.6).
The recommended therapies for both chronic
indolent and fulminant sinusitis are aggressive
surgical removal of the fungal material and
intravenous anti-fungal therapy.
According to the new classification system
Fungal sinusitis can be divided into –
Invasive Chronic indolent sinusitis
Acute fulminant sinusitis
Non-invasive Allergic fungal sinusitis
Aspergilloma.
139
ETIOPATHOGENESIS
There are various factors considered in the
pathogenesis of fungal sinus infection such as:
1. Previous surgery
2. Long-term antibiotic therapy
3. Obstruction to sinus ostia
Aspergillus fumigatus is the most commonly
involved fungus. It does not actually invade the
sinus mucosa and tends to be on the mucosal
surface and create problems by its local effects such
as tissue destruction. Hyphae stimulates a primary
inflammatory reaction by the host as a first non-
specific immune defence response. Further growth
of inflammatory products makes a tangle of
mycelia with entrapped mucus and exudates. This
produces the so called ‘mycetoma’ or Asprigilloma
which is pathognomonic of this form of the disease.
The fungal ball lies in the sinus, enlarging slowly
and over a period of time it can result in expansion
and ultimate erosion of the bone of the sinus walls.
Obstruction of the sinus then produces secondary
bacterial infection of the involved sinus.
CLINICAL FEATURES
Clinical features of fungal sinusitis are those of
acute or subacute rhinitis or sinusitis. A black or
greyish membrane is seen in nasal mucosa, which
are associated with A. niger and A. fumigatus
respectively. Exploration of maxillary sinus reveals
a fungal ball containing semisolid cheesy white or
blackish material. Allergic mucin is very tenacious,
thick, pasty and resembles peanut butter. When
exposed to air, the color changes from light green
to dark brown.
Histology shows layers of mucus mixed with
sheets of eosinophils, Charcot-Leyden crystals
which represents necrotic eosinophils are seen in
high power.
DIAGNOSIS
Fungal infection, both invasive and non-invasive
forms, can prove difficult to diagnose. Symptoms
mimic chronic rhinosinusitis. Clinical examination
by means of thorough nasal endoscopy is manda-
140 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY
tory and it may reveal pus or even traces of fungal
material in the middle meatus or other parts of
the nasal cavity depending upon the extent of the
disease.
Imaging Studies
CT is the primary imaging modality and is prob-
ably more accurate than MRI in diagnosing
specificities and determining the extent of the bone
erosion. On a CT scan examination the Asprigil-
loma appears as an opacification of the sinus that
is dense with the surrounding soft tissue. It lacks
homogenicity and may appear to have an ‘onion
skin’ type of conformation interspersed with areas
of radio-opacity that have a similar density to the
bone. In the center of the Asprigilloma quite often
a dense opacity is found characteristic of fungal
sinusitis as it represents inorganic deposits of iron,
calcium, magnesium and manganese.
On MRI imaging the T1 images shows increased
density of irregular nature suggestive of inflam-
mation, whereas on T2 images the center of the
fungal ball shows significantly diminished signal
to almost no signal due to lack of hydrogen ions in
the center of the fungal sinusitis.
Diagnosis is best made by staining of the
specimen followed by microscopic examination
and culture in Sabouraud’s agar medium. A smear
may be stained and examined (potassium
hydroxide stain), thereby precluding the need for
biopsy. Fugal specific stains such as Grocott’s
Methenamine Silver (GMS), Gridley, or Periodic
Acid-Schiff (PAS) are most often necessary for
definitive diagnosis of the organisms.
Identifying these organisms is difficult as they
closely resemble numerous other types of fungi as
fungi are omnipresent. Furthermore mycology
laboratories vary in capability and specimen
handling, which significantly influences the rate
of positive fungal cultures in a clinical setting.
Some of the reagents used in the diagnosis are
extremely expensive as well.
COMPLICATIONS
There are no specific complications in relation to
the fungal sinusitis per se but the surgeon must be
aware of the fact that even in a non-invasive type
of a common fungal ball, there could be a local
tissue destruction and bone erosion of the skull base
or lamina papyracea which can predispose to
intracranial and intraorbital complications respec-
tively. Rate of serious complications are seen more
often in fungal sinusitis due to distorted anatomy
and other systemic disorders.
Perhaps the most important aspect in treating
fungal sinusitis in terms of surgical technique
is NOT to strip or damage the mucous membrane
which is a barrier for fungal invasion into the
deeper tissues. At the same time a meticulous
removal of fungus though, time consuming during
surgery is mandatory with frequent irrigations and
removal of fungal material.
MUCORMYCOSIS
Mucormycosis is a serious and aggressive invasive
fungal disease which is mostly seen in immuno-
compromised patients like hematological
malignancies or patients who have uncontrolled
diabetes mellitus. Diabetic ketoacidosis predisposes
to this type of fungus as fungus grows more
rapidly in a acidic media full of sugar. It is becom-
ing a serious problem as many patients of tissue
transplant are on immunomodulators. Patients
with HIV also are prone to this fungal infection.
Rhizopus and Rhizomucor species are ubiqui-
tous, commonly found on decaying vegetation,
dung and foods of high sugar content. The infec-
tion is acquired from nature with no contact
spread. In all forms of Mucormycosis, vascular
invasion by hyphae is a prominent feature.
Ischemic or hemorrhagic necrosis is commonly
found with vasa nervosa invasion producing nerve
palsies. Mortality increases with intracranial
spread.
Clinical suspicion warrants immediate action
as this is essentially an endoscopic emergency even
before the laboratory tests show any positive
results. In an emergency situation with the threat
of intracranial complications, debridement must
be done at bed side, the procedure is not painful
as the nerve endings are destroyed. The aim of
the treatment is to prevent further spread of the
 FUNGAL INFECTIONS OF THE NOSE AND PARANASAL SINUSES
fungus and to institute aggressive intravenous
antifungal therapy as the mortality is consider-
ably high with intracranial spread.
Mucormycosis affecting nose and paranasal
sinuses produces a characteristic clinical
manifestations, however early symptoms may
mimic bacterial sinusitis. Low grade pyrexia, dull
sinus headaches associated with nasal congestion
are common early symptoms. At times there is a
history of bloody nasal discharge followed by
diplopia, increasing pyrexia and severe headache.
Endoscopic examination shows dusky red to
blue blackish necrotic nasal mucosa with areas of
gangrene and crusting. The depth of invasion can
be assessed by mucosa turning black and the
adjoining healthy mucosa which is seen as pink to
red. The facial skin may be inflamed and exami-
nation of the orbit reveals generalized reduction
in the movements of the ocular muscles, chemosis
and proptosis suggestive of orbital apex or
cavernous sinus involvement. Involvement of
ophthalmic artery may lead to blindness. Hard
palate may be affected. Intracranial invasion of
the brain leads to coma and unless immediate
treatment is instituted patient may die over a
period of few days.
Mucormycosis is a fulminant invasive disease
affecting paranasal sinuses. Early diagnosis should
be established on clinical suspicion with the
141
endoscope, where characteristic appearance can
be seen in deep areas which would otherwise be
missed on simple anterior rhinoscopy. Necrotic
tissue is ischemic and insensitive, hence can be
removed endoscopically with minimal blood loss
and practically no local anesthesia. Oozing and
pain starts when healthy tissue is approached
which will act as a margin for the endoscopic
debridement. As the disease has a tendency to
grow rapidly into the orbit and/or brain, it may
be too late to wait for the fungal studies which are
difficult to grow in the laboratory.
BIBLIOGRAPHY
1. Allphin, Manning et al: Fungi of the Dematia-
ceae family, not Aspergillus species, were the
primary etiologic agent in AFS, 1991.
2. American Journal of the Medical Sciences.
Sinusitis 316(1):39-45,1998.
3. Millar et al: Recognize histologic resemblance
between chronic fungal sinusitis and allergic
bronchopulmonary aspergillosis, 1981.
4. Paul J Donald: The Sinuses, Chapter 21, 271,
1994.
5. Rassekh et al: Skull base allergic fungal sinus
disease, 1995.
6. Sher, Schwartz: Report the first case of
concurrent ABPA and AFS, 1988.
C
OMPLICATIONS OF
ENDOSCOPIC DCR
(DACRYOCYSTORHINOSTOMY)
DCR is an operation performed for
the obstructions within the nasolacri-
mal sac and the duct. This surgery is also indicated
to relieve lacrimal sac infection before an intraocular
surgery. The direct route to approach the lacrimal
sac was described by Toti (Jones LT,et al 1976). Later
his technique was refined by Dutmps Bourget (Jones
LT et al 1976) and it continues to give satisfactory
results. The outcome of the lacrimal surgery
depends on the cause of the disease process, the
technical skill of the surgeon, a clear understanding
of the physiological processes involved in tear
production and drainage, and above all a compre-
hensive knowledge of the regional anatomy and its
many variations.Technical developments in the use
of endoscopes, fibre optics, lasers and video cameras
for functional sinus surgery have rekindled the
interest of both nasal and ophthalmic surgeons in
the endonasal approach to operations on the
lacrimal apparatus.
ANATOMICAL CONSIDERATION OF
NASOLACRIMAL APPARATUS
The nasolacrimal sac This varies in size and
configuration, with a large and more vertical sac
being present frequently in the male. Generally, the
sac measures 12 to 15 mm vertically, four to eight
mm anteroposteriorly, and three to five mm in
width. Approximately one-third of the lacrimal sac
lies above the level of medial canthal tendon. The
lacrimal sac is housed in lacrimal fossa, formed by
frontal process of the maxillary bone antertiorly
and lacrimal bone posteriorly. Superiorly these
bones are attached to nasal process of the frontal
bone. The anterior and posterior lacrimal crests are
the location for bony attachments of the superficial
and deep components of the medial canthal tendon.
The posterior and superior extensions of the medial
canthal tendon should be respected as these are
primary supportive structures of the medial canthal
tendon, loss of this support can result in telecanthus.
This anatomical relation is more important
while performing external approach to the sac, but
still it must be remembered during endoscopic
approach. Extensive pneumatisation of the lacrimal
bone may result in intervening air cells between the
lacrimal fossa and nasal bone and mucosa. Aware-
ness of this variation is critical in surgical considera-
tions. Studies by Whitnall SE (1911) demonstrated
that in approximately 50 percent of individuals
studied, the air cells extend at least to the lacrimal
crest and the surgeon may encounter these cells
medial to the lacrimal sac. The sac lies anterior to
the anterior end of the middle turbinate and the duct
runs into the inferior meatus. Hasner’s valve is the
terminal soft tissue component of the lacrimal
passage which opens into the inferior meatus (Figs
10.1 to 10.6).
Physiology
During blinking the orbicularis muscle contracts,
the palpeberal fissure closes from the lateral to
medial propelling tears towords the lacrimal lake.
The puncta are two mounds that sit on the upper
and lower lids just above the tear lake. As blinking
begins,the puncta strike each opposing eyelids and
as the closure increases the tears are squeezed into
the canaliculi through the puncta. Tears enter the
sac through the common internal punctum either
by means of pumping mechanism, or by siphoning
(principle of Bernouli) and a gravitational effect as
postulated by Sisler HA (1990) and Murube del
Castillo J (1978). It has become clear that canalicular
arm is probably more important than sac pump as
following DCR when the sac ceases to exist, tears
still drain into the nose because of functioning
canalicular pump.
Specific Conditions
Prior to DCR surgery certain conditions should be
excluded such as sarcoidosis, Wegners granuloma-
tosis, rhinoscleroma, tuberculosis , leprosy, nasal
allergy and polyposis.These conditions can affect
the sac and drainage into the nose and may present
with epiphora.
146 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 10.1 FIGURE 10.4

FIGURE 10.2 FIGURE 10.5

FIGURE 10.3 FIGURE 10.6

FIGURES 10.1 to 10.3: Right nasal cavity showing location FIGURES 10.4 to 10.6: 4mm 0 degree endoscopic view of
of the lacrimal bone and sac on cadaver and in a patient the right DCR operation in progress. Note exposed
with 4mm. 0 degree endoscope. lacrimal sac following removal of bone.
 NEW HORIZONS
Preoperative Assessment
Patients complaining of epiphora need a detailed
history followed by local and systemic examination.
Face, eyelids, medial canthus, conjunctiva and the
globe are inspected. Any eyelid laxity or punctal
disease should be ruled out. The physiological tests
of lacrimal excretion should include flouroscein
dye and its inspection into the nose. Even if the
syringing is satisfactory or flouroscein dye injected
in the lacrimal sac appears in the nose, there is a
possibility that a physiological blockage or small
stenosis exists. This stenosis can be diagnosed by
dacryocystography, which is also useful in cases
of trauma, suspected tumour, stone and revision
DCR. CT dacryocystography is also useful. Lacrimal
scanning can be used in suspected stenosis if
anatomy is totally normal. Nasal endoscopy should
be performed in all cases to exclude ethmoidal
disease.
Important Points in DCR Surgery
1. In cases of lid lag or when the blink reflex is
sluggish, as in case of facial nerve palsy, the tears
cannot be pumped into the puncta.These cases
are not suitable for sac surgery.
2. The condition of the punctum is also an
important factor to be assessed before surgery.
An ectropion needs to be corrected for epiphora
prior to DCR.
3. Cases of pump failure should be diagnosed prior
to taking up surgical intervention.With lacrimal
syringing if there is any regurgitation of fluid
from the same puntum, this would indicate a
blockage in the canaliculi. In this circumstance
opening the sac will not help the symptom of
epiphora. In cases where the fluid can be seen
coming out of the other puncta indicating a
stenosis at the sac level or below, surgery of sac
would be beneficial.
4. While attempting syringing, if the needle stops
in the soft tissue, there is a possibility that the
blokage is in the canaliculi. If the needle can be
passed on further, it may indicate that the
blockage is beyond the sac probably at the
nasolcrimal duct level.
147
5. A simple test of “snapping back” of the eyelid
to assess the tone of the orbicularis oculi should
be performed in the clinic prior to sac surgery.
6. An optical fibre carrying light from a fibre-optic
light source can be passed into the canaliculus
to illuminate the sac, which is then observed
intranasally through the endoscope.
Complications of the DCR Surgery
Haemorrhage
Immediate bleeding following surgery can be due
to blood pressure rising up suddenly especially
when hypotensive anaesthesia have been used
during operation. Surgery performed under local
anaesthesia with adequate preparation of the nose
bleeds considerably less. Intraoperative haemor-
rhage can occur if the nose is not adequately
prepared. If the patient is taking aspirin or any other
blood thinning agent, this should be stopped prior
to surgery. Use of lasers have reduced bleeding and
overall morbidity, especially with super and ultra
pulse mode of the lasers. Micro debriders have been
used to achieve the same end. During exposure of
the lacrimal fossa, if the bone is removed far too
anteriorly it may injure the angular vein, which can
cause significant bleed. Delayed bleeding may be
due to infection or excessive crusting. This can be
managed by suitable packs and antibiotics.
In order to prevent closure, a large bony stoma
is required. The sac should not be opened into an
ethmoidal cell, as this would impair free drainage
of tears into the nose.
Orbital Emphysema
This complication can occur if the patient blows the
nose forcibly in the immediate postoperative period
If it occurs, it usually resolves spontaneously.
Orbital Haemorrhage
This is discussed in Chapter 5.
Problems with Silastic Tubes
The indwelling tube may migrate inwards and cause
trauma to the canaliculi. Silastic tubes are known
to promote granulation tissue and subsequent
148 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY
scarring. However, if the stoma in the nasal cavity
is patent this does not seem to cause problem.
Infection
This can occur around the tube, leading to exces-
sive crusting and foul smelling discharge. The
surgical site should be douched clean and kept moist.
Problem of Stenosis
Factors predisposing are:
1. Small bony opening
2. Opening into ethmoid cells instead of lacrimal
sac
3. Removal of lateral wall of the lacrimal sac
To avoid stenosis
• Regular ‘tailor made’ follow up
• Strict syringing schedule to wash away crusting
till epithelisation occurs
• Prevent adhesions between middle turbinate
and septum
• Avoid excessive granulations and silastic tube
care if inserted
• Regular endoscopic examination avoids crus-
ting, adhesions scarring and ensures patency
COMPLICATIONS OF ENDOSCOPIC
TRANSSPHENOIDAL PITUITARY SURGERY
Surgical Anatomy of the Sphenoid Sinus
Developmentally, sphenoid sinus is an outgrowth
of the sphenoid bone in the postero superior part of
the sphenoid recess. It is situated deep in the nasal
cavity, behind the posterior choana and is not
readily accessible to clinical examination. Pneumati-
sation of the sphenoid sinus varies in degree and
can involve a part or the entire body of the sphenoid
bone. In 86 percent of the cases the sinus is very
well developed (sellar), 24 percent partially develo-
ped (presellar), and two to three percent poorly
developed (conchal). The natural ostium of the
sphenoid sinus is near the upper and medial part
of the nasal septum. It could be circular, ovoid, or
merely a narrow slit. In approximately 90 percent
the ostium is situated in the upper part of the
anterior wall about 5mm lateral to the septum.
The anterior wall of the sinus is a sloping vertical
plate of bone related to the rostrum of the sphenoid.
The thickness of the wall varies from 0.1 to 0.7 mm
in sellar type and 0.3 to 1.5 mm in presellar type.
The distance between the anterior wall and the sella
is about 1.7 cm and the distance from the anterior
nasal spine to the anterior wall of the sphenoid sinus
is about five to seven cm at an angle of 30 degree to
the horizontal plane. The lateral wall of the sinus is
intimately related to the internal carotid artery,
which is dehiscent in 23 percent of cases, and to the
optic nerve. The sinus is asymmetrical due to verti-
cal and angled septa in 76 percent and symmetrical
in 24 percent of the cases.
The all important surgical landmarks for sphe-
noid surgery are:
1. Superior turbinate
2. Posterior end of the middle turbinate
3. Septum
4. Posterior choana
At least fourteen important vascular and neuro-
logical structures are closely related to the sphenoid
sinus as follows.
Vascular Cavernous sinus, internal carotid artery,
ophthalmic artery, sphenopalatine artery.
Neurological Optic nerve and chiasma, Maxillary
nerve, 3rd, 4th, and 6th nerves, vidian nerve,
sphenopalatine ganglion.
Cerebral Duramater and pituitary gland.
FIGURE 10.7: Intraoperative view with 4mm 0 degree
endoscope showing removal of the posterior part of the
nasal septum before entering the sphenoid sinus to
access pituitary.
 NEW HORIZONS 149

FIGURE 10.8: MRI scan showing pituitary tumour bulging

into the sphenoid sinus

FIGURE 10.9: Use of C-arm or any other device of navigation system in a

case of pituitary surgery is very useful
150 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 10.10 FIGURE 10.13

FIGURE 10.11 FIGURE 10.14

FIGURE 10.12 FIGURE 10.15

 NEW HORIZONS 151
The Trans-sphenoid Approach for
Pituitary Surgery
Advent of multiangled telescopes has advanced the
scope of pituitary surgery. The trans-sphenoidal
approach is commonly used for the operative
treatment of pituitary adenomas., it is also highly
suitable for the management of certain other
tumours of the sellar area, such as craniopharyngeo-
mas, mucoceles, cysts, carcinomas and secondaries.
The technique employed is essentially that used by
Cushing H (1909) and Hirsch O, (1910) with the
technical advances introduced by Hardy (1969)
FIGURE 10.16 (Figs 10.7 to 10.23).

FIGURE 10.17
FIGURES 10.10 to 10.17: 4 mm 0 degree intraoperative
endoscopic views of the transphenoidal pituitary surgery
in progress. The bulging anterior sellar wall is removed to FIGURE 10.18: A carotid angiogram sometimes is necessary
expose the dura of the sella turcica which is then incised to exclude any other intracranial pathology.
to remove the pituitary tumour. The dural vessels are cau-
terised to achieve haemostasis. At the end of the removal
of the main mass of the tumour a 4mm 30 degree
endoscope offers an excellent view of the surrounding area
to locate any residual tumour which can then be removed.
During the entire procedure the surgeon must keep in the
mid line of the sphenoid sinus.

The sphenoid sinus is usually paired and asym-

metrically developed. The sinus is in the geometric
centre of the head and it is absent only in 1 to 1.5
percent of cases (Grunwald, 1925). In seller pneu-
matisation the bone between the brain stem and the
sinus can be extremely thin. The inter sinus septum
is usually off the midline and at times may be FIGURE 10.19: Axial MRI scan showing pituitary tumour
attached to the carotid canal laterally. with an incidential CP angle tumour.
152 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 10.20 FIGURE 10.22

FIGURE 10.21 FIGURE 10.23

FIGURES 10.20 to 10.23: A coronal MRI scan with T2 images displays clearly a large CSF leak on the right side through
the skull base which is repaired with muscle graft as seen in Figure 10.21. The muscle graft is then reinforced with
fascia lata graft and covered with final packing with surgicel as shown in Figures 10.22 and 10.23

Diagnosis and Preoperative Assessment to
Prevent Complications
Endocrine function studies provide an accurate
assessment of the nature and degree of hormonal
status. The most common lesions are prolactinomas,
growth hormone producing adenomas causing
acromegaly, and cortisol secreting adenomas
producing Cushing syndrome. MRI not only
demonstrates the size and the shape of the tumour
but also defines its relationship to the neighbouring
structures like optic nerve and carotid artery.
Visual symptoms do not develop until tumour
has expanded 1.5 cm outside the sella to impinge
on the optic chiasm. Thus the visual testing and field
examination are only appropriate when suprasellar
extension is seen. Cranial nerves palsies involving
third, fourth and sixth nerves with double vision
results from parasellar extension, usually into the
cavernous sinus. This occurs with adenomas
following acute haemorrhage or infarction.
In terms of tumour extent, approximately 90
percent of adenomas are amenable to removal by
trans-sphenoidal approach. This approach is contra-
indicated in patients with infections of the nose and
sinuses or an invasive tumour showing nonencap-
sulation in its intracranial portion. In these cases
both transcranial and trans-sphenoidal approaches
may be required. These can be carried out at an
 NEW HORIZONS
interval of two to three weeks, transsphenoidal
operation being scheduled first.
Key Points to Prevent Complications
1. If the mucosa of the sphenoid sinus is resected,
it will decrease the risk of postoperative
mucocele formation.
2. The mucosa in cases of acromegaly is quite
tough as compared to the mucosa of Cushings
syndrome which is delicate, fragile and bleeds
easily.
3. The opening of the sinus should be adequate
for exposure of the sella, far too lateral expo-
sure lends optic nerve and internal carotid
artery at risk.
4. If the antero inferior wall of the sphenoid is
exposed this might damage a branch of spheno-
ethmoidal artery which can cause troublesome
bleeding.
5. The anterior wall of the sella is removed as
widely as possible between the blue transverse
intercavernous sinuses.
6. A plane of dissection between the two layers
of dura should be avoided to prevent damage
to the cavernous sinus and subsequent massive
haemorrhage.
7. Great care should be taken not to tear the
diaphragmatic sellae superiorly and thus
create a CSF leak. This is more likely in cases
of supra sellar extension of the tumour or
dumbbell type of lesion.
8. The chances of CSF leak also increases if the
patient has had radiotherapy which results in
fibrosis and adherence of tumour and also in a
situation where arachnoid mater descends into
the pituitary fossa. This can be evaluated by
preoperative MRI scan.
9. If CSF leak occur at the time of operation it is
best repaired immediately.
10. It is important to leave the pituitary stalk in
situ to keep the hypothalmic connection.
11. Angled endoscope i.e., 30 and/or 70 degree
should be used during operation to ensure
complete excision of the tumour.
12. Following removal of a sellar tumour, there
remains a free space within the pituitary fossa,
the walls of which are potentially haemor-
153
rhagic. This space should be obliterated other-
wise intra sellar haematoma and abscess can
develop.
13. Separation of the pituitary fossa from the
sphenoid sinus following tumour excision is
important to prevent meningitis especially
when there is a suspicion of CSF leak.
14. If the pituitary fossa is not separated from
brain, there is a potential risk of herniation of
arachnoid and chiasmal cistern. Over a period
of time pulsations of the brain can cause secon-
dary atrophy of the diaphragma sellae.
15. The tumour cavity should be optimally packed
with fat or muscle. Excessive packing in the
supra sellar region may lead to optic nerve
compression or press into cavernous sinus.
This may cause cranial nerve palsies or spasm
of carotid artery in its intercavernous segment.
16. “Ghost sella” can result when excessive
anterior and inferior wall of bony sella turcica
is removed. An attempt should be made to
reconstruct sella turcica with muscle, fat and
cartilage fragments.
17. Empty sella syndrome can result postopera-
tively as a consequence of diminished support
of the diaphragm and arachnoid mater
following removal of the tumour. If this is not
supported by suitable graft, prolapse of the
chiasmatic cistern and optic apparatus may
occur in the sellar cavity.
18. Incidents of about one percent serious compli-
cations of pituitary surgery have been reported
(Hardy J, Mohrg 1981). This includes mortality,
CSF leak and meningitis. The complications
like carotid artery damage, cavernous sinus
and cranial nerve involvement, and optic nerve
injury are rare. Other complications include
mucocele, epistaxis, secondary empty sella
syndrome, sellar abscess, diabetes insipidus
and anterior pituitary insufficiency.
MUCOCELES
These are most commonly expanding lesions of the
paranasal sinuses.The walls of the mucoceles are
lined by cuboidal epithelium surrounding the thick
mucoid secretions. The exact aetiology is not known
154 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY
but are believed to be developed as a result of
obstruction of the sinus ostium, from a compartment
of a septated sinus, or as an entrapment within a
frontal sinus fracture line, Rice D.(1994). The sinus
walls may be normal, thinned or eroded depending
on the duration of its existence. Pressure effects
to neighbouring structures beyond sinus wall may
occur and may give rise to obvious clinical symp-
toms. These may be proptosis in case of fronto
ethmoidal mucoceles and neurological symptoms
in case of sphenoidal mucoceles.
Mucoceles commonly occur in fronto ethmoid
region, followed by sphenoid and maxillary sinuses.
On CT scan these appear to be expanding lesions
with homogeneous material of mucoid attennua-
tion. In frontal mucoceles one of the first sign may
be disappearence of scalloping of the sinus on CT
scan. Infection can lead to mucopyocele which can
be seen on CT scan, as a thin zone of enhancement
just inside the bony sinus wall. MRI should be
performed to differentiate from benign and
malignant tumours. The fluid filled mucoceles give
a high signal on both T1 and T2 images on MRI scan.
Prior to surgery, both coronal and axial thin cuts
CT scans should be obtained, to evaluate the
FIGURE 10.24
destruction of the surrounding bony walls and care
should be taken during surgery to avoid injury to
the orbit and skull base which are often dehiscent
in long standing mucoceles (Figs 10.24 to 10.36).
FUNGAL INFECTIONS
With the help of better investigative laboratory
facilities, CT scans and nasal endoscopy increasing
cases of fungal sinus disease are being recognised.
Fungal diseases of the sinuses are classified as
follows.
1. Allergic—Characterised by Type I hypersensi-
tivity, nasal polyposis, eosinophilic mucus with-
out fungal invasion.
2. Non invasive—Also known as “fungal ball”.
Usually confined to single sinus.
3. Invasive—Insiduous extention across the
mucosa and bone into the adjoining soft tissue.
4. Fulminant (e.g. Mucormycosis)—This type
occurs in immunocompromised patients and pro-
gressively causes gangrenous mucoperiosteitis
affecting orbit and skull base. Frequently it is fatal.
This is a “sinus” emergency and should be treated
as such with urgent debridment .
 NEW HORIZONS 155

FIGURES 10.25 FIGURES 10.26

FIGURES 10.24 to 10.26: Same patient—A large fronto right ethmoid mucocele with proptosis.
Endoscopic views show large fronto ethmoid cavity with complete exposure of the orbital
periosteum and skull base. Also note the extension of mucocele to right maxillary sinus.

The mucosa in fungal disease is hyperemic TUMOURS

and tends to bleed excessively obscuring the
operative field.This with frequent bony erosions
makes surgery difficult and can lead to serious
intraorbital and/or intracranial complications. A
careful evaluation on both CT and MRI images
should be performed and studied prior to under-
taking surgery (Figs 10.37 to 10.51).
During surgery in a patient with fungal diasese,
following exteriorisation of the disease, thorough
irrigation of the involved sinuses should be perfor-
med. Postoperatively depending upon the clinical
features and laboratory isolation of fungi, appro-
priate medical line of treatment i.e., antifungal,
immunotherapy should be instituted.
Both benign and malignant tumours of the
paranasal sinuses are rare. In benign tumours such
as osteoma, a powered drill should be used with
care to avoid damage to the adjoining thinner bone
of skull base and orbit. A distance fracture of skull
base can occur while drilling if the surgeon is not
careful(Figs 10.52 to 10.54).
INTRA ORBITAL COMPLICATIONS OF
ACUTE SINUSITIS
Inspite of increasing number of antibiotics available,
intraorbital complications do occur from time to
time. These are as follows:
156 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURES 10.27

FIGURES 10.28 FIGURES 10.29

1. Inflammatory oedema the intimate relationship of the orbit to the para-

2. Orbital cellulitis nasal sinuses still allows bacterial invasion by direct
3. Subperiosteal abscess spread along the suture lines, direct invasion of
4. Orbital abscess the bone and through thrombophlebitis. Treatment
5. Cavernous sinus thrombosis consists of surgery, if antibiotics treatment fails.
The advent of antibiotics has significantly The predominant presenting symptoms are:
changed the management of acute sinusitis and its 1. Swelling of the involved eye
complications both in children and adults. However 2. Pain in and around the eye
 NEW HORIZONS 157

FIGURE 10.30 FIGURE 10.31

FIGURES 10.27 to 10.30: Coronal CT and MRI scans
showing ethmoidal mucocele and mucopyocele extending
into orbit and skull base. A thorough examination of the
pre-op scans both in coronal and axial images should be
performed prior to undertaking any endoscopic surgery.
Great care should be taken during endoscopic procedure
not to damage dura mater or the orbital periosteum

3. Pyrexia
4. Proptosis
Depending upon the experience of the surgeon
these complications should be surgically mana-
ged either externally or through the endoscopic
approach which is preferred by the authors FIGURE 10.32
(Kaluskar 1998). Both approaches are not without
further complications and hence individual surgeon
must decide which approach to choose.We believe
if the surgeon is well acquainted with surgical ana-
tomy of the sinuses and feels confident and
comfortable then an endoscopic approach is
preferable. It is important to note that the nose
and sinus anatomy is distorted with mucosal
oedema and congesion resulting in excessive
bleeding. However, if meticulous technique is
adopted then these cases can be treated success-
fully with minimal morbidity, minimally invasive
technique and without any external incision in the
oedematous tissues and subsequent scar formation FIGURE 10.33
on the face.If the surgeon is not comfortable with
FIGURES 10.31 to 10.33: Coronal and axial MRI T2 images
the endoscopic techniques then an exteral drainage
with contrast shows sphenoid mucocele giving rise to
should be performed (Figs 10.55 to 10.59). third nerve palsy.
158 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 10.34

FIGURE 10.35

FIGURES 10.34 to 10.36: Same patient—Coronal CT scan

of the sphenoid mucopyocele and intraoperative photo-
graphs showing its removal. In this particular case the
anterior wall of the sphenoid was extremely thick and
had to be removed with drill before removal of the cyst
wall from the sphenoid sinus. Note superior turbinate as
an important surgical landmark for the sphenoid sinus. FIGURE 10.36
 NEW HORIZONS 159

FIGURE 10.37 FIGURE 10.39

FIGURES 10.37 to 10.39: Coronal CT scans showing extensive

destruction of the nasal structures and invading into orbit
and cranium in a case of allergic fungal sinusitis. Note
multiple large concretions which are diagnostic of allergic
fungal sinusitis. Once again great care must be taken
during endoscopic surgery to avoid damage to the orbit
FIGURE 10.38 and dura mater.

FIGURE 10.40
160 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 10.41

FIGURE 10.42
FIGURES 10.40 to 10.42: Operative and coronal CT scan views of the fungal
ball in the left maxillary sinus with tissue destuction of the lateral wall of
the nose and lamina papyracea. A thorough local cleansing of all the
fungal material is very important.
 NEW HORIZONS 161

FIGURE 10.43 FIGURE 10.45

FIGURES 10.43 to 10.45: Endoscopic view of the sphenoid

sinus with a 4 mm. 0 degree endoscope showing fungal
ball in the sinus. Note left ophthalmoplegia as a result of
FIGURE 10.44 sphenoid fungal ball in Figure 10.45.

FIGURE 10.46: An isolated infection of the

sphenoid sinus is unusual but it can present
with frontal headaches and pain in the vertex
region. A coronal CT scan of the sphenoid sinus
shows such an infection.This case was treated
with transnasal endoscopic sphenoidotomy
with a 4mm. 0 degree endoscope.
162 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 10.47

FIGURE 10.48
NEW HORIZONS 163

FIGURE 10.49

FIGURE 10.50
164 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 10.51
FIGURES 10.47 to 10.51: Coronal CT scans,
intraoperative and clinical photograph of a
patient showing invading mucormycosis
infection. Figure 10.50 shows extention
into the hard palate.This variety of fulminant
invading fungus in immunocompromised
patients shows a rapid clinical progress
and has to be treated as an acute emer-
gency. Invading fungal mass or mucor can
be removed endoscopically including its
intraorbital and intracranial extension. Due
to intraorbital extension patient may show
signs of ophthalmoplegia as seen in Figure
10.51.

TRANSITIONAL CELL PAPILLOMA (TCP)

Authors have removed localised, tumours with the
help of an endoscope. Tissue destruction is apparent
on CT/MRI scan and should be carefully studied
before embarking upon endoscopic approach to
removal of these tumours.
Excision of these tumours near the orbit and the
skull base should be performed meticulously under
direct vision with the help of angled endoscopes if
required (Figs 10.60 and 10.61).

TRANS NASAL ENDOSCOPIC SPHENO

PALATINE ARTERY LIGATION (ESPAL)
The treatment of posterior epistaxis has been
revolutionised with the advent of endoscopes.If a
bleeding point can be identified with the help of
endoscopes, it is usually quite easy to cauterise
(Kaluskar 1996). However, in a smaller number of
patients this is not possible inspite of deligent
vasoconstriction of the nasal cavity in which case
an endoscopic ligation of the spenopalatine artery
is an ideal alternative and is minimally invasive.
Patients admitted with posterior epistaxis are
usually elderly with poor haemodynamics and
FIGURE 10.52
 NEW HORIZONS 165

FIGURE 10.53

FIGURE 10.54
FIGURES 10.52 to 10.54: Same patient - Clinical and coronal CT scans showing large ethmoidal osteoma attached to the
lamina papyracea and the skull base. Note different window settings on the scanner gives different definitions of the
surrounding structures. The surgeon must be very careful while drilling the osteoma not to damage the skull base or
lamina papyracea with a high speed rotating burr.
166 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 10.55

FIGURE 10.56
 NEW HORIZONS 167

FIGURES 10.57 FIGURES 10.58

FIGURES 10.55 to 10.58: Same patient—Clinical and CT scans of the subperiosteal abscess following
acute sinusitis showing proptosis of the left eye and bowing of the lamina papyracea. The abscess
was drained and the sinus disease was removed through an endoscopic approach.

FIGURE 10.59: Prior to the days of endoscopic approach a case of right subperiosteal
abcess treated with external drainage by performing right ethmoidectomy and antral
washout with insertion of indwelling tubes.
168 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 10.60

FIGURE 10.61
FIGURES 10.60 AND 10.61: A coronal CT scan showing transitional cell papilloma invading
orbit and skull base. The surgeon should exercise great care while removing tumour
from the lamina papyracea and the skull base.
 NEW HORIZONS 169

FIGURE 10.62: Right nasal cavity in a dry skull .Note the sphenopalatine artery existing
from the pterygopalatine fossa (PPF) through the sphenopalatine foramen into the
nasal cavity. Anterior to the artery is the perpendicular plate of the palatine bone
and an incision (blue line) for the exposure of the artery.

of the middle turbinate (Fig. 10.62). A small vertical

incision is made just below the bulla on the lateral
wall and the mucoperiosteum is elevated. The
sphenopalatine artery is easily seen pulsating as it
enters the nasal cavity. The artery is clamped with
titanium clips with the help of a specially designed
forcep or a bipolar diathermy can be used to
cauterise the artery (Figs 10.63A to 10.63B).

COMBINED APPROACH FRONTAL OSTIO

FIGURE 10.63A
concurrent medical conditions. Conventional post
nasal packing with the BIPP carries a great deal of
postoperative morbidity and longer stay in the
hoispital.
The sphenopalatine artery can be accessed as it
exists from the sphenopalatine foramen on the
lateral wall of the nose at the level of posterior end
PLASTY (CAFOP)
Out of all paranasal sinuses, the frontal sinus
surgery perhaps is an ultimate challange to the
endoscopic surgeon.The frontal sinus ostium is
usually postero medial to the agger nasi cell and is
related to the thin lateral lamella of the cribriform
plate medially and the orbit laterally. An angled
endoscope preferably 70 degree need to be used in
order to expose the operative area adequately.
However, in some revision cases identifying frontal
recess and /or frontal sinus ostium may not be easy
170 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 10.63B
FIGURES 10.63A and 10.63B: Intraoperative views of the exposed and clipped
sphenopalatine artery accessed endoscopically. Note muco perichondrial flap
being raised off the perpendicular plate of the palatine (PPP) bone.

FIGURES 10.64
 NEW HORIZONS 171

FIGURE 10.65 FIGURE 10.67

FIGURES 10.64 to 10.67: 4mm 70 degree endoscopic intra-

operative view in a case of revision frontal sinus surgery.
Sometimes it is difficult to localise the exact position of
the frontal sinus ostium intranasally especially in revision
cases. In this situation an external trephining (Figures
10.65 and 10.66) can be performed and irrigation carried
out to localise the precise position of the ostium.
Indwelling soft silicon tube as seen in Figure 10.67 can be
FIGURE 10.66 inserted for several weeks.

or may end up with serious complications, i.e. CSF

leak and/or orbital injury. In this situation a
trephine should be made on the anterior wall of the
frontal sinus following a small incision. A suitable
soft catheter or an indwelling tube could be inserted
through the trephine externally through the sinus
ostium into the nasal cavity. The ostium is then
enlarged at the expense of the nasofrontal beak (Draf
II procedure). The indwelling tube should be soft
and must not be a “tight fitting” through the ostium
or else necrosis of the mucous membrane will occur
with excessive scar tissue formation resulting fur-
ther narrowing of the drainage of the frontal sinus
and subsequent infection (Figs 10.64 to 10.67). If FIGURE 10.68
both frontal sinuses are involved a median
drainage through the floor of the sinuses can be deal of endoscopic expertise and a thorough
performed by Draf III procedures (Draf W. 1991). knowledge of the anatomy of the region and
These frontal sinus procedures demands a great should not be attempted by an inexperienced
172 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY
FIGURE 10.69
FIGURE 10.70
surgeon. These techniques should be learned and
practised on cadavers first and then gradually
developed on patients. Certain special equipments
such as burr with irrigation system and a few long
frontal sinus instruments are required for these
procedures.
UNUSUAL CONDITIONS AFFECTING
SINUSES
An Unusually Large Concha Bullosa
Author has treated a few cases of extremely large
concha bullosa obstructing entire nasal cavity and
restricting the development of the inferior turbinate
and /or maxillary sinus. Surgical treatment includes
meticulous study on the CT scan and complete
reconstruction of the middle turbinate. Sometimes
in this situation concha bullosa directly commu-
nicates with the frontal sinus (Figs 10.68 to 10.73).
Dentigerous Cyst
This is an unusual condition where the cyst of
dental origin expands gradually in the maxillary
sinus. Conventional technique of Caldwell Luc
approach can be employed to remove the cyst but
an endoscopic nasal approach can also tackle the
cyst through a middle meatal antrostomy using
70 degree endoscope (Fig. 10.74).
 NEW HORIZONS 173

FIGURE 10.72

FIGURES 10.68 to 10.72: Same patient—Intraoperative and

coronal CT scan of the sinuses shows an unusually giant
concha bullosa on both sides in a 11 year old girl. Note
rudimentary inferior turbinates and hypoplastic maxillary
sinuses. A complete reconstruction of the middle turbi-
nate is performed by excision of the lateral and medial
lamella of the concha bullosa as seen in Figure 10.72. In
this case concha bullosa was in direct communication
FIGURE 10.71 with the ipsilateral frontal sinus.

FIGURE 10.73: Giant concha bullosa

in an adult with right hypoplastic
maxillary sinus. Reconstruction of
the concha (conchoplasty) was
performed and nasal airways
restored.
174 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 10.74: An unusual case of right dentigerous cyst in the maxillary

sinus was removed endoscopically through middle meatal antrostomy
avoiding external invasive approach through the canine fossa.

FIGURE 10.75: A localised small nasopharyngeal angio fibroma can be removed

endoscopically following thorough assessement by CT/MRI scan and following
embolisation of the feeding arterial supply to the tumour. Needless to say that
these types of advanced surgery endoscopically should only be performed
following some experience in routine endoscopic sinus surgery.
bleeding is excessive during surgery, it can lead to
Nasopharyngeal Angiofibroma serious complications. Only following thorough
Only small tumours can be dealt with endoscopic assessment of these tumours espcially by CT/MRI,
approach. Arterial embolisation of the feeding a decision may be taken to remove these endo-
vessel is advisable prior to surgery. However, if the scopically (Fig. 10.75).
 K
EY POINTS TO PREVENT
COMPLICATIONS

Case No. 1: Nasal Cavity

This 18 years patient mainly comp-
lained of nasal obstruction. CT
scanning and MRI images T1 and T2 (Figs 11.1 to
11.3) confirms massive encephalocele. Excision
along with the neurosurgeon and the repair of the
cranial defect with dural pericranial flap has to be
done meticulously.

FIGURE 11.3: MRI of sagittal scan showing T2 image of a

massive meningoencephalocele

FIGURE 11.1: Coronal CT scan showing

massive meningoencephalocele

FIGURE 11.4: Hypoplastic right maxillary sinus. Note late-

rally placed uncinate process close to the lamina papyracea

Case No. 2: Maxillary Sinus

This patient has symptomatic right maxillary
sinusitis (Fig. 11.4) in spite of medical line of
treatment.

Problem
Hypoplastic sinus, laterally displaced uncinate
FIGURE 11.2: MRI of sagittal scan showing T1 image of a process in close contact with probably dehiscent
massive meningoencephalocele lamina papyracea.
178 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 11.6: Coronal CT scan showing diseased right

maxillary sinus and out fractured right inferior turbinate
FIGURE 11.5: Mucous cyst in the right maxillary sinus
recurrent sinusitis which has not been successful
Solution in relieving the symptoms (Fig. 11.6).
Identify natural maxillary Os using angled endo-
scope with ball probe and then resect meticulously Solution
uncinate process with ball probe. Address the
Identify natural maxillary Os with angled endo-
slightly paradoxical middle turbinate with
scope, excise most lateral part of the attachment
pneumatization. This needs wedge resection of the
of the inferior turbinate in its anterior segment
middle turbinate. A meticulous postoperative care
avoiding damage to the nasolacrimal duct.
is required to prevent any scar tissue obstructing
natural Os of the maxillary sinus.
Case No. 5: Ethmoid Sinus Osteoma
Case No. 3 Patient who had multiple surgeries has residual
disease and an osteoma which appears to be not
Accidental findings of a mucous retention cyst in
in contact with lamina papyracea in Figure 11.7.
the posterior part of the right maxillary sinus (Fig.
11.5). This may or may not be symptomatic
however if it gets infected then it needs to be
treated.

Solution
It can be marsupialized using angled endoscope
through middle meatal antrostomy following
excision of uncinate process. Any instrumentation
in the maxillary sinus should be done under
endoscopic control and damage to the infraorbital
nerve should be avoided.

Case No. 4
This patient had inferior meatal antrostomy and FIGURE 11.7: Coronal CT scan showing bilateral ethmoid
out fracture of the inferior turbinate for chronic and maxillary disease and a osteoma in right ethmoid sinus
 SITUATIONS AND SOLUTIONS 179

FIGURE 11.8: Coronal CT scan showing different window

setting showing osteoma is closely attached to the right
lamina papyracea
FIGURE 11.10: Postoperative view of the patient following
excision of left frontal osteoma by combined technique

FIGURE 11.11: Coronal view of the same patient showing

FIGURE 11.9: Coronal CT scan showing prolapse of orbital large osteoma of the frontal sinus extending posteriorly
contents including right medial rectus muscle in the ethmoid into the left orbit
sinus
However, in a situation like this, a different
window setting (Fig. 11.8) shows clearly that the
osteoma is in fact attached to the lamina papyracea
and extra care should be taken while drilling
osteoma.
Case no. 5 Note dehiscence of the right lamina
papyracea with the prolapse of the orbital content
(Fig. 11.9).
Any operative intervention in posterior ethmoid
has to be performed with extreme care, to avoid
injury to the orbit.
FIGURE 11.12: Axial cut of the same patient showing
Case No. 6: Frontal Sinus Osteoma large osteoma of the left frontal sinus
A middle aged patient complained of left orbital A large fronto orbital osteoma can be seen in
swelling, an epiphora and frontal headaches for Figures 11.11 and 11.12. Note the posterior
the previous several months (Fig. 11.10). extension of the osteoma and any trauma while
180 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY
FIGURE 11.13: Patient with right proptosis and chemosis
FIGURE 11.14: Coronal CT scan view of the same patient
showing opacity of the both frontal sinuses with erosion of
posterior wall of right frontal sinus
drilling with high speed drill would damage optic
nerve hence utmost care should be taken, while
removal of osteoma.
Case No. 7
An elderly patient presented in emergency with
severe pain in his right eye, proptosis and history
of intermittent Epistaxis over a period of six
months (Fig. 11.13).
The CT scan showed wide spread opacity in
all sinuses with bone erosion (Figs 11.14 and 11.15).
Solution
An emergency decompression of the right orbit
was performed and biopsy was taken from
different parts of the sinuses which revealed non-
FIGURE 11.15: Coronal CT scan of the same patient
showing opacity of both ethmoid sinuses
FIGURE 11.16: CT scan of the same patient following
treatment. Note clear osteomeatal complex
Hodgkin’s lymphoma. Further investigation
showed no evidence of any systemic disease.
Patient responded very well to chemotherapy (Fig.
11.16).
Case No. 8
An eleven years old girl presented with left propto-
sis of previous few months duration (Fig. 11.17).
CT scan shows homogenous opacity with well
defined margins extending into posterior ethmoids
and pushing left orbit laterally and inferiorly. Note
erosion of the posterior wall of the frontal sinus.
MRI imaging with T1 and T2 images show
enhanced lesion (Figs 11.18 to 11.21).
Solution
A careful endoscopic approach was performed on
the left side.The wall of the lesion was identified
 SITUATIONS AND SOLUTIONS 181

FIGURE 11.17: Young girl with left proptosis

FIGURE 11.20: T2 weighted MRI image of the same

patient showing the extent of the lesion

FIGURE 11.18: Coronal CT scan showing erosion of the

posterior wall of left frontal sinus and opacity of the frontal
recess

FIGURE 11.21: MRI-T2 weighted image in axial

position showing extent of the lesion

and needle aspiration was performed prior to

incision on the lesion. This revealed a collection of
FIGURE 11.19: Coronal CT scan of the same patient showing blood. The thick walled lesion was marsupialised.
large homogenous lesion in left orbital and anterior skull The patient made uneventful recovery and
base remained symptom free.
T
he best way of avoiding complications
is to approach the whole concept of
endoscopic sinus surgery in a very
reverend and methodical way. The
surgeon has to have a total dedication
to this subject. An “occasional“ endoscopic surgeon
with a cavalier attitude is more likely to experience
problems and complications to the detriment of the
patient that he/she is supposed to help. There are
no “quick fixes” in this type of surgery by virtue of
the fact that the sinus anatomy is very variable not
only in different patients but also in the two sides
of the same patient. Its close proximity to the skull
base, orbit and other important vascular structures
makes this type of surgery more treacherous and
patient could be harmed in a serious way sometimes
permanently.
Following are the guidelines for the beginner
who is keen to embark upon this perilous but
rewarding surgery.
1. Basic concept: Understand the philosophy of
endoscopic sinus surgery. The aim of surgery is to
improve the drainage and ventilation of the
FIGURE 12.1: A well epithelialised right ethmoid cavity
several years following FESS. The natural ostia remain
patent and the patient remains symptom free.
paranasal sinuses through their natural ostia (Figs
12.1 to 12.1b).
Endoscope is only a tool, which allows the
surgeon to diagnose the disease preoperatively and
intraoperatively, accessing the nooks and crannies
of the nasal cavity and sinuses.
Simply because the surgeon can see every thic-
kened mucosa or a polyp through the endoscope, it
does not need to be removed (Fig. 12.2). Only
pathology, which is obstructing the drainage and
ventilation of the sinus ostia, need to be tackled.
2. Diagnosis
This may sound simple but often patients are
subjected to the endoscopic sinus surgery when
it is not appropriate. In this situation patient under-
goes multiple procedures with great deal of des-
truction of the normal structures resulting into scar
tissue and subjecting patient to more hazardous
complications. Develop good diagnostic skills with
the endoscope in the outpatient. A systematic nasal
endoscopy as described (Kaluskar 1992) in the
outpatient should be mastered so as to diagnose the
disease precisely. Figures 12.3 to 12.34 illustrates
various normal and pathological conditions in the
nose and sinuses.
It is beyond the scope of this book to go into
details of basic concepts and diagnosis for chronic
inflammatory diseases of the paranasal sinuses.
Aggressive operative trauma in patients suffering
from primary or secondary ciliary dyskinesia, cystic
fibrosis, Sampter’s syndrome, multiple allergy with
panpolyposis, certain systemic diseases etc. is to be
avoided. The surgeon should be well acquainted
with these hyper reactive state of the mucosal
disease prior to operating on these patients.
3. Radiological evaluation
Develop good understanding of the CT scan
anatomy of the paranasal sinuses and interpret the
abnormal CT scan findings in relation to the
patient’s symptoms and endoscopic examination
(Figs 12.35 to 12.55). Close liaison with the radio-
logist interested in this field is very rewarding.
Remember surgeon is not treating a “CT scan“ but
the patient! CT scan performed in the presence of
acute upper respiratory infection is likely to show
a pansinusitis and obviously does not need any sur-
186 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURES 12.1A and B: Right lateral wall of the nose. It is very difficult to view the
natural ostium of the maxillary sinus unless a 70 degree endoscope is used.
Note the ostium is behind the lower one third of the uncinate process and antero
inferior to the bulla ethmoidalis.The accessory ostium must not be mistaken for
the natural ostium which are in the sagittal plane.
 TIPS AND QUIPS FOR THE BEGINNERS 187

FIGURE 12.2: Left nasal cavity few days post operative

view. Note thickened polypoidal mucosa in the left
maxillary sinus with draining mucus. This recovers
well over a period of time once the natural ventilation
and drainage of the sinuses have been established
and the ethmoid disease have been cleared.

FIGURE 12.3: Routinely used nasal endoscopes are 4mm, 0 and 30

degree for the diagnostic purpose in the out patient clinic. A 2.7
mm, 30 degree endoscope is an ideal for adults with septal spurs
and also for use in children. A 70° degree endoscope as shown is
mainly used for frontal recess/sinus surgery and sometimes in
maixllay sinus surgery.
188 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 12.4: First pass of the left nasal cavity. Note

polypoidal disease emerging from the left maxillary
sinus through inferior meatal antrostomy (IMA). Also
persistent disease in the middle meatus.

FIGURE 12.5: A right turbinochoanal polyp

resulting in nasal obstruction.
 TIPS AND QUIPS FOR THE BEGINNERS 189

FIGURE 12.6: A left septochoanal polyp arising

from the nasal septum.This is an isolated polyp
arising from the septum going towards the
choana and is not a part of the generalised nasal
polyposis commonly seen.

FIGURE 12.7: A Thornwald’s cyst in the post nasal

space resulting in nasal obstruction. This was
marsupialised under local anaesthetic with 4mm,
0 degree endoscope.
190 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 12.8: Endoscopy of the right nasal cavity

in a case with acute sinusitis. Note pus in agger
nasi cells under pressure giving rise to
excruciating pain to the patient.

FIGURE 12.9: Right nasal cavity in acute sinusitis

with pus seen in the anterior part of the middle
meatus.This endoscopic finding reveals that the
pathology is in the frontal and /or in the anterior
ethmoid sinuses.
 TIPS AND QUIPS FOR THE BEGINNERS 191

FIGURE 12.10: Left nasal cavity with medially

placed uncinate process (UP).

FIGURE 12.11: Endoscopic view of the left middle

meatus. Medially placed uncinate process (UP) and
the bulla (B) ethmoidalis are clearly visible.
192 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 12.12: Right nasal cavity showing agger nasi

cells displacing uncinate process (UP) medially. Note
rudimentary middle turbinate.

FIGURE 12.13: Endoscopic view of the right nasal

cavity displays almost separate uncinate
process(UP) from the lateral wall of the nose.
 TIPS AND QUIPS FOR THE BEGINNERS 193

FIGURE 12.14: Right paradoxical turbinate (PT)

in close contact with the lateral wall of the
nose forming a polyp.

FIGURE 12.15: Left concha bullosa along with high

deviated nasal septum and laterally placed uncinate
process obstructs ostiomeatal complex and
ventilation and drainage of the anterior group of
sinuses.
194 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 12.16: Left infected large concha bullosa

with pus extruding from its anterior surface. Note
polyp (P) in the middle meatus.

FIGURE 12.17: Left large polypoidal concha bullosa

obstructing nasal airway completely.
 TIPS AND QUIPS FOR THE BEGINNERS 195

FIGURE 12.18: Left vertical bifid middle turbinate

(MT) with polypoidal disease in the middle
meatus.

FIGURE 12.19: Right middle meatus with

oedematous lateral wall of the nose with polyps
in the middle meatus.
196 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 12.20: Left middle meatus

showing rudimentary bulla

FIGURE 12.21: Acute infection of the anterior

group of sinuses with polyps and pus seen in
the left middle meatus.
 TIPS AND QUIPS FOR THE BEGINNERS 197

FIGURE 12.22: Endoscopic view of right nasal cavity

showing medially placed uncinate process (UP).
Also note “hanging“ bulla between uncinate process
and the middle turbinate (MT).

FIGURE 12.23: Right posterior aspect of middle

meatus showing horizontal and vertical parts of
ground lamella (GL)
198 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 12.24: Left oedematous ground lamella (GL)

In an attempt to remove this polypoidal mucosa
the surgeon may inadvertently enter the posterior
ethmoids.

FIGURE 12.25: Right nasal cavity showing

posterior end of middle turbinate and the site
for the injection for sphenopalatine block to
anaesthetise branches of the sphenopalatine
nerves.
 TIPS AND QUIPS FOR THE BEGINNERS 199

FIGURE 12.26: Left nasal cavity at the

beginning of the “third pass” to examine the
sphenoethmoidal recess.

FIGURE 12.27: Right sphenoethmoidal recess

showing pus cascading from infected posterior
ethmoids and/or sphenoid sinus.
200 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 12.28: Polyp arising from posterior

ethmoid or sphenoid sinus seen in the right
sphenoethmoidal recess (SER).

FIGURE 12.29: Left nasal cavity in a revision case with

persistent disease in the ethmoids. Note active
infection with pus exuding from the ethmoids. Note
upper and lower stump of the middle turbinate (MT).
 TIPS AND QUIPS FOR THE BEGINNERS 201

FIGURE 12.30: Right sphenoethmoidal recess

with polypoidal disease in posterior ethmoids
and sphenoid sinus.

FIGURE 12.31: Endoscopic view of the left nasal cavity

in a case of revision surgery. Note pinhole middle
meatal antrostomy and presence of uncinate process
(UP) and bulla ethmoidalis.
 202 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 12.32: Infected infundibulum and persistent

maxillary sinus disease in a revision case in the
right nasal cavity.

FIGURE 12.33: Persistent left ethmoidal

and maxillary sinus disease in a revision
case. Note upper and lower stumps of
the middle turbinate (MT)
 TIPS AND QUIPS FOR THE BEGINNERS 203

FIGURE 12.34: Whitish, sometimes golden brown

fungal ball in the left nasal cavity with partial
destruction of the middle turbinate (MT)

FIGURE 12.35
204 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 12.36

FIGURE 12.37
FIGURES 12.35 to 12.37: Coronal CT scan showing agger nasi cells obstructing
drainage of the frontal recess leading to frontal sinus disease.
 TIPS AND QUIPS FOR THE BEGINNERS 205

FIGURE 12.38: Occasionally frontal cell can lead to obstruction of the outflow tract
of the mucociliary mechanism resulting in frontal sinus disease.

FIGURE 12.39
206 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 12.40

FIGURE 12.41
FIGURES 12.39 to 12.41: Coronal CT scans displaying narrowing of the
ethmoidal infundibulum by uncinate process(UP) or lateral lamella of
the concha bullosa which can lead to persistent maxillary sinus disease.
 TIPS AND QUIPS FOR THE BEGINNERS 207

FIGURE 12.42

FIGURE 12.43
FIGURES 12.42 and 12.43: Coronal CT scans showing large bulla
ethmoidalis (BE) obstructing infundibulum with persistent maxillary
sinus disease.
208 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 12.44

FIGURE 12.45
 TIPS AND QUIPS FOR THE BEGINNERS 209

FIGURE 12.46
FIGURES 12.44 to 12.46: Coronal CT scans showing hypoplastic maxillary sinuses. In this
situation especially with laterally displaced uncinate process, there is a significant risk of
surgeon entering into the orbit. Great care must be taken while identifying the natural
ostium of the maxillary sinus and subsequent middle meatal antrostomy.

FIGURE 12.47
210 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURES 12.47 and 12.48: Coronal CT scans showing dehiscent lamina

papyracea with orbital contents prolapsing into the orbit. Also note
unequal fovea ethmoidales in Figure 12.47

FIGURE 12.49: Coronal CT scan showing unequal sphenoid sinuses.

Endoscopic surgeon must be aware of this anomaly of the sphenoid
sinus. The surgeon may enter one sided large sphenoid sinus from
the posterior ethmoid without being aware of it.
 TIPS AND QUIPS FOR THE BEGINNERS 211

FIGURE 12.50: Coronal CT scan in a revision case showing complete distortion

of normal anatomy and persistent disease in ethmoid and maxillary sinuses.
Note particularly absence of middle turbinates (MT) and previous left sided
inferior meatal antrostomy and Caldwell Luc operation.

FIGURE 12.51: Coronal CT scan of a patient who underwent various procedure for
her facial pains including septal and inferior turbinate surgery.CT scan showed
infected mucus cyst attached to the infraorbital nerve.
212 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 12.52: Coronal CT scan showing skull base destruction as a result of

transitional cell papilloma along with right maxillary sinus disease.

FIGURE 12.53: Coronal CT scan showing considerable tissue destruction on

the right side as a result of fungal sinusitis.
 TIPS AND QUIPS FOR THE BEGINNERS 213

FIGURE 12.54: Revision case showing “pseudo middle meatal antrostomy” through
fontanelle without correcting obstruction at the natural ostium of the maxillary
sinus.Note persistent disease in the ethmoid and maxillary sinuses.

FIGURE 12.55: Coronal CT scan showing persistent obstruction of the infundibulum

and maxillary disease as a result of out fracture of the right inferior turbinate for
a patient complaining of right nasal obstruction.
214 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 12.56: Coronal section of the dry skull showing thin fovea ethmoidalis,
lamina papyracea (LP), cribriform plate (CP) and vidian canal (VC).

FIGURE 12.57
 TIPS AND QUIPS FOR THE BEGINNERS 215

FIGURE 12.58
FIGURES 12.57 and 12.58: Lateral wall of the nose in a dry skull showing
turbinates, position of sphenopalatine formen (SPF) and the distance from
the upper border of the posterior choana to the anterior wall of the sphenoid
sinus which is about 1 to 1.5 cm.

gical intervention. Surgery is only to be embarked
upon failing proper medical line of treatment.
4. Surgical anatomy
A comprehensive knowledge of surgical anatomy
of the nose and paranasal sinuses is of paramount
importance to the endoscopic surgeon, if he/she is
to avoid getting “lost” in the nose or sinuses. It is
obligatory for the endoscopic surgeon to acquire a
“three dimensional” picture in his/her mind regard-
ing the relationship of vital structures surrounding
the sinuses and the ability to think beyond his/her
endoscope and the instruments during operation.
The anatomy of the nose and sinuses is quite
variegated from patient to patient and also in the
same patient from side to side. The following should
be the first steps that a potential endoscopic surgeon
should take.
Refresh and master both the “hard and soft”
parts of the head and neck anatomy in the anatomy
department. Particularly study the coronal, axial
and sagittal section of the nose and sinuses in
relation to the skull base and the orbit (Figs 12.56
to 12.62).
5. Surgical technique
Following some experience of “looking” into
cadaver nose and sinuses, use a 0-degree endoscope
in out patient clinic to identify the structures that
one has already seen on different sections on hard
and soft parts of the head and neck anatomy. This
process not only gives the diagnostic skill to the
surgeon but also allows him/her to get to know
handling of the endoscopes both in the outpatient
and in the operating theatre. For the first time, the
experience on patients while performing nasal
endoscopy or operating with the endoscope is quite
different in the presence of various pathology.
a. Once some expertise has been achieved in hand-
ling the endoscopes, then go back to cadaver,
216 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 12.59
FIGURE 12.61

FIGURES 12.59 to 12.61: Lateral and coronal views of the

cadaver showing position of the internal carotid artery in
the sphenoid sinus, relation of the bulla to the orbit and
supraorbital cells which are extension of the ethmoid
FIGURE 12.60 cells.

FIGURE 12.62: Schematic dia-

gram of frontal recess encroa-
ched upon by upper part of the
uncinate process, agger nasi
cells, upper extension of the
bulla and sometimes anterior
extension of the ground lamella.
Note position of the anterior
ethmoid artery(AEA), skull base
and narrow frontal ostium with
frontal sinus above.
 TIPS AND QUIPS FOR THE BEGINNERS
FIGURE 12.63
FIGURE 12.64
FIGURES 12.63 and 12.64: Left endoscopic views with 4mm.
0 degree endoscope during FESS under local anaes-
thesia. Note position of the anterior ethmoidal and spheno-
palatine injection of local anaesthetic with adrenaline.
preferably fresh ones, in mortuary and practice
surgery such as uncinectomy, excision of the
bulla and middle meatal antrostomy.
b. As some degree of confidence has been gained
in operating on cadavers, then in a properly
selected patients, limited surgery such as
uncinectomy, excision of the bulla and middle
meatal antrostomy should be performed under
local anaesthesia. There is no doubt that for
the novice operating under local anaesthesia is
safer as the patient inspite of local anaesthesia
and sedation will not allow the surgeon to go
near skull base and the orbit. These being
extremely pain sensitive structures, patient will
217
FIGURE 12.65: Left uncinectomy. Note position of the sickle
knife which is at an angle in the upper part which becomes
vertical in its lower part and to end up horizontal in its
posterior part. It is important that the surgeon should not
traumatise the upper border of the inferior turbinate during
uncinectomy to avoid bleeding .
always complain of discomfort or pain. Also
form a habit of identifying and keeping as many
surgical landmarks intact as possible during
surgery
c. Following some experience in anterior ethmoi-
dectomy, the surgeon should now go through
the ground lamella and enter into posterior
ethmoids and then gradually approaching the
anterior wall of the sphenoid sinus to perform
sphenoidotomy and finally tackling frontal
recess sinus surgery, with 70° endoscope (Figs
12.63 to 12.74).
d. Remember zero degree endoscope with least
distortion of the operative field is much safer
218 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 12.66: Operative endoscopic photograph with 4mm. 0 degree endoscope

illustrates identification of the natural ostium of the maxillary sinus which is
always anterior to the bulla ethmoidalis.

FIGURE 12.67
 TIPS AND QUIPS FOR THE BEGINNERS 219

FIGURES 12.68 FIGURE 12.69: 4 mm. 70 degree endoscopic view of the left
FIGURES 12.67 and 12.68: Operative photographs showing natural ostium of the maxillary sinus with presence of a
removal of the uncinate process (UP) and identification of Galler cell
the natural ostium of the maxillary sinus. If the original
incision for the uncinectomy is correct then it is easier to
identify the natural ostium of the maxillary sinus.

FIGURE 12.70: Left maxillary sinus showing an occasional dehiscent infraorbital

nerve seen with 4mm 70 degree endoscope. The surgeon must be very careful
in this sitution not to damage the dehiscent nerve.
220 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 12.71: Right nasal cavity showing excision of

bulla in its medial and then lateral part.

FIGURE 12.72: Endoscopic view in a case of revision frontal sinus surgery shows
absence of middle turbinate and position of agger nasi cells to be vapourised
with KTP/532 laser. The laser parameters used are 6 watts, 600 micron spot
size, 80 percent calibration of the fibre and continuous mode.
 TIPS AND QUIPS FOR THE BEGINNERS 221

FIGURE 12.73: 4mm 70 degree endoscope showing left frontal recess and
ostium. Note the proximity of lateral lamella of cribriform plate to the frontal
sinus ostium.

FIGURE 12.74: Mucopus from right frontal sinus seen FIGURE 12.75
through 4mm 70 degree endoscope.
222 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 12.76 FIGURE 12.78

FIGURE 12.75 to 12.78: Operative views of KTP/532 laser
in use for uncinectomy and removal of agger nasi cells
at different locations in the right nasal cavity. Note close
relation of the agger nasi cells and lateral lamella of the
cribriform plate (CP).

FIGURE 12.77

than angled endoscopes. A large part of the

operation can be accomplished with zero degree
endoscope.
FIGURE 12.79: Complete view of the right frontal recess
6. Advanced techniques and sinus seen with 4mm 70 degree endoscope.
Once the surgeon is well-experienced in common
inflammatory disease, he/she can start tackling
8. In the early stages do not select cases with
advanced conditions such as mucocele, tumours etc
extensive disease or the patient who had multiple
(Figs 12.75 to 12.84).
surgical intervention in the past.
7. Prevent tissue trauma: Always avoid unneces-
9. When in doubt, stop and think of an alternative
sary trauma to the mucous membrane with suction,
approach.
instruments, ribbon gauze or any packing material.
Think of middle ear surgery in respect of handling 10. Develop meticulous technique for the post
the tissues and the structures while operating in the operative cavity care. This is equally important as
nose. performing an atraumatic surgery.
 TIPS AND QUIPS FOR THE BEGINNERS 223

FIGURE 12.80 FIGURE 12:81

FIGURES 12.80 and 12.81: Same patient—Right endoscopic view in a case of revision middle meatal antrostomy. Note
complete exposure of orbital periosteum due to previous surgery. KTP/532 laser is being used to vaporise anterior
fontanelle following identification of the natural ostium of the maxillary sinus.

FIGURE 12.82 FIGURE 12.83

FIGURES 12.82 and 12.83: 4mm 70 degree endoscopic view of the right revision frontal sinus
surgery performing draf II procedure with the drill to remove naso frontal beak.
224 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY

FIGURE 12.84: Cadaver photograph showing complete ethmoidectomy, sphenoidotomy,

frontal sinusotomy and middle meatal antrostomy (MMA)

11. If unable to identify the natural ostium during
surgery for middle meatal antrostomy, consider
Combined Approach Middle Meatal Antrostomy
(CAMMA) (Kaluskar SK et al 1992) through the
canine fossa. This will prevent the surgeon going
into the orbit!
12. Beware of hypoplastic maxillary sinus while
performing middle meatal antrostomy. In this
situation the surgeon is likely to enter inadvertently
into the orbit.
G
Good vision of the operating field
and proper instruments are essential
part of endoscopic sinus surgery.
There should not be any compromise
on instruments and a crisp clear
picture of the surgical field helps in performing
proper surgery thus avoiding complications.
SURGICAL INSTRUMENTS
Hand held surgical instruments are of two types i.e.,
grasping and thru’ cut. Grasping instruments
generally tear the tissues and need to be handled
properly with minimal trauma so as to avoid mucosal
bleed. In case of polyps if the surgeon grasps and
pulls the polyp, this is likely to result in tearing of
the tissue which will inevitably lead to mucosal
bleeding or sometimes larger blood vessel may be
damaged. The thru’ cut instruments are preferable
as these do not tear the tissues but only cut the tissue
which is grasped in the instruments. This results in
less tissue trauma, less bleeding , better preservation
of the mucous membrane and rapid healing in the
postoperative period. In any case the surgeon must
form a habit of “feeling “ the tissue with the one
blade of the instrument before grasping or cutting.
Surgical instruments need to be properly cared for
in terms of handling and sterilisation.
Besides handheld surgical instruments one need
a set of endoscopes, CCD camera, light source, high
resolution monitor and a light cable.
CCD CAMERA
Charge Coupled Device, is available in a single chip
or three chip camera. Single chip contains single
silicon chip, which consists of a large number of
photoelectric cells. When light strikes on the
photoelectric cell, a current is produced which is
converted into an image on the screen. A single chip
camera on an average produces 450 horizontal lines
of resolution. A three chip camera can give a
resolution of more than 700 horizontal lines with
better colour reproduction.
Most of the cameras have an automatic light
intensity control to prevent glare and a white
balancing memory system. This can be tested by
moving the endoscopes with the camera in front of
a white object. Zoom lens of a variable focal length
is available with the camera, but most of the surgery
require a panoramic view (wide angle) to keep the
surgeon oriented to as many surgical landmarks as
possible. This is especially true in revision surgery
where surgical landmarks have already been
destroyed and are fewer.
VIDEO MONITOR
Ordinary domestic television has a resolution of
250 horizontal lines. If this is used with a camera
which has a resolution of 450 horizontal lines, it is
most likely that the quality of the image would be
compromised when the surgeon is operating off the
television screen. It is important that the resolution
of the camera system and the monitor should match
properly. A 14 inches screen is preferable as a
monitor as it has a better resolution. Monitors have
a Y/C or a composite video connection which can
be used for the recording on a video cassettes. RGB
connections yield better resolution.
LIGHT SOURCE
Commonly used light sources are halogen 250 watt
and Xenon 175 or 300 watt. Halogen is a yellow light
as compared to Xenon which is whiter and more
akin to natural light. A xenon light source is
preferable. However, it is important to note that the
Xenon light bulbs are very expensive.
LIGHT CABLE
Light carrying capacity of a cable depends on a
number of fibre-optic bundles. The fibre-optic cable
with a larger number of bundles transmits more
light and hence are preferable. A fibre optic light
cable should be at least 4.5 mm. in diameter.
ENDOSCOPES
Commonly used endoscopes are 0, 30, 45 and 70
degree, with a diameter of 4 mm, and 2.7 mm.
Most of the endoscopes available now are auto-
clavable and have Hopkins rod lens system with
wide-angle panoramic view.
228 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY
ADVANCED INSTRUMENTATION TO AVOID
COMPLICATIONS
C-Arm
The provision of C-arm during operation especially
in revision and transsphenoidal pituitary surgery
helps to localise proximity of important structures
in two dimensions in relation to the instruments. In
addition to this in cases of pituitary surgery
complete excision of the tumour can be monitored
using C-arm as an air encephalogram.
VTI (Video Technique Imaging) or
Image Guided Surgery
In this technique a CT scan of the patient is
performed preoperatively using reference markers
on the head. These images are then transferred to
the operating room with the same reference
markers. With the help of sensor probe inserted in
the nose during surgery, images are displayed in
three dimensions on the high resolution screen in
front of the surgeon. These images consist of
coronal, axial and sagittal planes and guides the
surgeon for the location of instruments in relation
to the skull base and orbit.
Although the system is helpful, it is quite expen-
sive, needs frequent calibration every time patient’s
head is moved. It also has an inherent error of about
2mm of location and this fact must be borne in mind
by the surgeon during operation. It is debatable that
system would prove to be standard equipment for
routine sinus surgery of inflammatory diseases.
Recently newer optical sensor image guided system
is being introduced and further refinements are a
constant feature in this technology. In any case,
image guided systems cannot replace surgical
anatomy and the skill of a surgeon.
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Index
A anatomical considerations 85 diagnosis 185
clinical features 82 meticulous technique 222
Acute sinusitis 155, 156, 167, 190
endonasal endoscopic approach 96 prevent tissue trauma 222
intra-orbital complications 155 materials used for the repair 97 radiological evaluation 185
Adhesions 11, 27, 103-107, 109, 119, 123,
technique of endoscopic repair 97 surgical anatomy 215
130, 133
external drainage of CSF 96 surgical technique 215
formation 103 historical view 81 middle meatal antrostomy 15
prevention 105
operative technique of CSF leak repair bulla ethmoidalis 31
by the patient 107
94 middle turbinate 15
by the surgeon 107 operative technique to prevent CSF leak natural ostium of the maxillary
Agger nasi cells 26, 42, 43, 46, 117, 119,
89 sinus 29
121, 122, 126, 128, 129, 190, 192,
physiology 82 uncinate process 21
204, 216, 220, 222 CSF rhinorrhea 81, 83 upper border of inferior turbinate 34
Anaesthesia 4, 5, 11, 48, 55, 65, 75, 96,
Cyst 113, 159, 172, 174, 189, 211 posterior ethmoidectomy and
103, 113, 117, 147, 217
sphenoidotomy 36
D Endoscopic trans-sphenoidal pituitary
B surgery 148
Bleeding 2-4, 11, 18, 27, 29, 39, 45, 48, 49, Dacryocystorhinostomy 11, 73, 113, 145 complications of 148
55-57, 59-61, 65, 68, 73, 75, 89, complications of 147 Epidural abscess 99
103, 105, 108, 117, 119, 121-123, haemorrhage 147 treatment 100
125, 126, 131, 133, 147, 164, 174, infection 148 Epiphora 9, 71, 72, 75, 103, 113, 145, 147
217 orbital emphysema 147 Epistanis 153, 164
arterial orbital haemorrhage 147 Ethmoidectomy 3, 4, 9, 15, 36, 75, 96,
anterior ethmoidal artery 56 problem of stenosis 148 167, 217, 224
sphenopalatine artery 56, 57 problems with silastic tubes 147 intranasal 3, 9
mucosal 55 important points 147 Ethmoids and sphenoid 128
Brain abscess 81, 98, 100 physiology 145 Ethmoid sinus osteoma 178
clinical features 98 preoperative assessment 147
Bulla ethmoidalis 15, 16, 18, 23, 27, 28, specific conditions 145
Decompression 74-76, 78
F
31, 33, 93, 117, 123, 128, 186,
201, 207, 218 Dentigerous 172, 174 Frontal osteoplasty 169
Dentigerous cyst 172 Frontal recess 3, 4, 11, 15, 21, 24, 26-28,
C Diabetic ketoacidosis 140 31, 34, 36, 40, 42-47, 169, 187,
Dura 9, 47, 86-88, 90, 91, 94, 97-100, 151, 204, 216, 221, 222
Camera 227 153, 157 Frontal recess and sinus 27, 42, 45, 47,
CAMMA 224 117, 222
Canthotomy 75, 76 Frontal sinus osteoma 179
Carotid artery 40-42, 58-60, 81, 100, 149,
E
Fungal infections 65, 154
152, 153, 216 Ecchymosis 65, 68, 71 Fungal sinusitis 138
Cavernous sinus 81, 98, 100, 148, 152, Endoscopic sinus surgery 3-5, 9, 10, 15, clinical features 139
153, 156 51, 55, 56, 58, 65, 73-75, 78, 81, complications 140
Cerebral blood flow 59 89, 91, 107, 117, 122, 125, 126, diagnosis 139
Chronic sinusitis 9, 125 128, 131, 174, 185 etiopathogenesis 139
Concha bullosa 20, 21, 91, 131, 172, 193, anatomic problems 10 types 138
194, 206 anterior ethmoidectomy 15 Fungus 137
Cribiform plate 9, 15, 17, 43, 45, 47, 49, frontal recess and frontal sinus surgery
81, 86, 90, 97, 117, 120, 121, 125, 40
G
169, 214, 221, 222 guidelines for the beginner 185
Crusting 103, 112, 113, 147, 148 advanced techniques 222 Ground lamella 4, 15, 18-20, 31, 35, 36,
CSF leak 10, 11, 15, 47, 51, 61, 81, 83-85, alternative approach 222 91, 93, 117, 122, 126, 128, 197,
87, 90-94, 96, 98, 100, 153, 170 basic concept 185 198, 216, 217
 234 COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY
H Muco cells 4, 65, 124, 151, 153, 154
Haemorrhage 9, 11, 57, 61, 65, 71, 73, 74,
76, 81, 100, 103, 147
Haller cell 15, 17
Hiatus semilunaries 21, 23, 30, 31, 129
I Nasal cavity 5, 15, 17-25, 27, 28, 30, 32,
Infection 4, 27, 91, 96, 98-100, 103, 109,
112, 113,145, 147, 148, 154, 161
164, 171, 185, 196, 200
Inferior meatal antrostomy 118, 120, 188,
211
Infundibulum 16, 23, 27, 29-31, 33, 121,
202, 206, 207, 213
Intact bulla technique 34
Internal carotid artery 40-42, 58, 60, 81,
100, 148, 149, 153, 216
injury 58
postoperative haemorrhage
reactionary 61
secondary 61
prevention of injury 60
Intracranial complications 9, 81, 92, 155
L clinical features 70
Lamina papyracea 11, 15, 17, 21, 24, 27,
65, 67-69, 71, 72, 75, 78, 93, 117,
120, 122-125, 160, 165, 167, 168,
210, 214
Laser 57, 105, 117, 119, 121-123, 125,
126, 128, 130, 220, 222, 223
advantages of 122
disadvantages 125
laser parameters 126
types 125
KTP/532 125
Lateral nasal wall 9
Light source 147, 227
M 194, 200, 227
Magnetic resonance imaging 78, 85
Maxillary sinus 3, 9, 15, 20, 21, 23, 26, 28-
31, 34, 104, 113, 119-122, 124-126,
128, 131, 155, 160, 172-174, 178,
186-188, 202, 206-208, 212, 213,
218, 219, 223, 224
Maxillary sinusitis 177
Meatal antrostomy 128
Medial rectus 9, 10, 24, 68, 72, 125
Meningitis 10, 81, 83, 94, 98, 153
clinical features 98
diagnosis 98
Microdebrider 56, 81, 105, 131-133
advantages 133
disadvantages 133
Middle meatal antrostomy 4, 10, 15, 26,
29, 31, 65, 69, 119, 120, 122, 124,
128, 130, 131, 133, 172, 174, 201,
209, 213, 217, 223
S
Mucormycosis 140
Sinus lateralis 31
Mucous cyst 113
Sinuses 3, 4, 10, 24, 27, 29, 32, 39, 42, 45,
Mycetoma 139
55, 60, 65, 72, 75, 78, 81, 82, 85,
87, 94, 98, 100, 103, 105, 109,
N 112, 113, 125, 126, 130, 131,
152-157, 169, 170, 172, 173, 185,
33, 35-37, 44, 45, 47, 55, 56, 61, 187, 193, 209-211, 213, 215
69, 75, 82, 83, 86, 88, 103, 107, Sphenoid sinus 22, 36, 38-43, 57-60, 81, 85,
91, 94, 120, 122, 125, 148, 150, 153,
111, 112, 117, 119, 120, 122, 123,
158, 161, 199-201, 210, 215-217
125, 126, 132, 133, 148, 165, 169,
171, 172, 177, 185, 187, 188, Stenosis 9, 147
Subdural empyema 99, 100
190-192, 197-203, 220, 222
clinical manifestations 99
Nasolacrimal apparatus 9, 69, 145
Nasolacrimal sac 9, 10, 145 Surgical complication 3
Surgical instrument 227
Nasopharyngeal angiofibroma 174
C-arm 228
Natural and accessory ostia 30
CCD camera 227
endoscopes 227
O image guided surgery 228
Onodi cell 36, 65, 76-78, 91 light cable 227
Optic nerve injury 9, 10, 76, 78, 153 light source 227
Orbital complications 10, 45, 65, 155 video monitor 227
damage to the medial rectus muscle 68 video technique imaging 228
damage to the nasolacrimal duct 68
T
damage to the periorbita 65
Target sign 83
intraorbital haemorrhage 73
optic nerve injury 76 Toxic shock syndrome 109
Transitional cell papilloma 60, 67, 88, 164,
periorbital surgical emphysema 68
168, 212
Orbital decompression 74-76
Orbital haematoma 74 Trans nasal endoscopic spheno palatine
artery ligation 164
Orbital haemorrhage 74, 147
Trans-sphenoid approach for pituitary
Orbital space 74, 75
Osteitis 90, 103, 112, 129, 132 surgery 151
Tumours 151, 154, 155, 164, 174, 222
Osteomeatal complex 21, 106
P U
Pneumocephalous 100 Uncinate process 15-18, 20-26, 29, 65, 69,
Polyp 18, 39, 60, 131, 185, 188, 189, 193, 89, 117, 121, 123, 126, 129, 186,
191-193, 197, 201, 206, 209, 216
Postoperative care 10, 105, 131
Prevention of complications 4
preoperative evaluation 5
V
preoperative preparation 4 Vidian nerve 149
CT scan 5 Visual loss 61, 73
general precautions 4
local anaesthesia 5 W
preoperative steroids 5
Proptosis 180 Wedge resection of the middle turbinate
59, 105, 107
R
X
Recirculation of mucus 103, 113
Residual disease 18, 29, 117, 128
Xenon light 227
anatomical sites of 117
arch of the middle turbinate 117
inferior turbinate 122 Z
posterior part of the nasal septum 120
superior turbinate 120 Zoom lens 227