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