Fatal and Other Major Complications of Endoscopic Sinu s Sur gery Anthony J. Maniglia , MD, FACS Endosco pic sinus surgery has become an accept· able techniqu e for the treatme nt of chronic sinus disease. This report analyze s five complic ations which came to my attention . Two cases were orbital: 1 bilateral blindnes s due to damage of the optic nerves, and 1 damage of medial rectus muscle. The other 3 cases were intracra nial: two cribrifor m plate damage with frontal lobe injury and hematom a, and 1 damage of the anterior cerebral artery, resultin g in death. This rather novel techniqu e, especial ly when used by less-exp erienced surgeon s, has major complication s similar to what has been reported with the tradition al intranas al sphenoet hmoidec tomy. Knowl· edge of anatomy , good training , and meticulo us surgical techniqu e are very importa nt. Endosco pic sinus surgery in patients with extensiv e patholog y should be used with caution, especial ly if general anesthes ia is selected or if excessiv e bleeding occurs. It would be benefici al to otolaryn gologist s to have previous experience in the tradition al techniqu e before adopting endosco pic sinus surgery to their armame ntarium . Even then, major complic ations may occur in the hands of very experien ced surgeon s. Early recognition and proper managem ent of these complic ations are of utmost importa nce in order to minimiz e disability or prevent death.
INTROD UCTION Although nasal and sinus diagnostic endoscopy was attempte d in the beginnin g of this century, endoscopic sinus surgery started to become popular less than a decade ago.1-4 Traditio nal ethmoidectomy and sinus surgery are rather safe procedures, but major and fatal complications may occur. In 1,000 intranas al ethmoidectomies, Freedma n and Kern 5 report a low incidence of complications (2.8%), most of them of a minor type. In 1990, Friedma n and Katsanto nis6 also reported a low Presented at·t he Meeting of the Southern Section of the American Laryngological, Rhinological and Otological Society, Inc., White Sulphur Springs, W.Va., January 11, 1990. From the Departmen t ofOtolaryngology- Head and Neck Surgery, Case Western Reserve University, University Hospit als of Cleveland. Send Reprint Requests to Anthony J. Maniglia, MD, Departmen t of Otolaryngo logy-Head and Neck Surgery, Case Western Reserve Universi· ty, University Hospitals of Cleveland, 2074 Abington Road, Cleveland, OH 44106.
Laryngos cope 101: April 1991
incidence of complications secondary to intranas al ethmoidectomy (2.06% minor; 0.94% major). Intracranial and orbital complications are rare.7,S In 1987, Stankiewicz9 reported his experience with endoscopic sinus surgery and indicated a complication rate of29% in 90 patients (17% in 150 ethmoidectomies). In 1989, StankiewiczlO again discusse d the complication results in 300 ethmoid ectomie s performed in 180 patients . His overall complication rate had dropped to 9.3%. Most complications were minor. However, 2 cases of cerebros pinal fluid (CSF) leak and 1 case of tempora ry blindnes s occurred . The author credited the lower incidence of complications in the latter group of patients to experience. Schaefer, et az.11 reported an incidence of 14% minor complications and 0% major. In 458 procedures, Levinel2had 8.3% minor complications and 0. 7% major. Most major complications reported are CSF leaks. On the other hand, Stammberger, 13, 14 one of the pioneers to populari ze the Messerk linger techniqu e of endoscopic endonas al sinus surgery, states, "to date, more than 2,500 endoscopic ethmoid operatio ns have been carried out on the basis of [the] aforementioned concept at Graz Universi ty ENT-Clinic without any serious complications. Blood losses were always negligible and never required adminis tration of conserved blood. None of the patients has suffered injury to the roofof the ethmoid or even dura:• Stammb erger reported complications consistin g of emphyse ma in the orbit, scars, and synechia between the middle turbinat e and lateral nasal wall. Stenosis of the extended maxillar y ostium was very rare. With the exception of children, he stresses the importan ce of using local and surface anesthes ia when performing endoscopic sinus surgery. Endoscopic sinus surgery has become more and more popular due to the many courses being presented in the United States and abroad. Fortunately, several of these courses are designed to provide hands-on experience to surgeons who are committ ed to adopting this rather novel surgical technique. Th the best of my knowledge, there are no other reports of total blindnes s, intracra nial hemorrh age, or death due to endoscopic sinus surgery. This report describe s and analyzes five cases of fatal and other major complications of endoscopic sinus surgery. Maniglia: Endoscopic Sinus Surgery
349
Patient 1 A 67-year-old woman with a history of bilateral serous otitis media and chronic sinusitis underwent bilateral tympanostomy, PE tube insertion, and bilateral endoscopic intranasal ethmoidectomy under general anesthesia. Immediately postoperatively, right scleral hemorrhage, eyelid chemosis, and proptosis occurred. She was unable to adduct her right eye and, with left gaze, had a large exotropia. This was due to a n injury of the medial rectus muscle a nd was confirmed by ophthalmological consultation. A computed tomography (CT) scan revealed damage of the right lamina papyracea and medial rectus muscle (Fig. 1.) Her visual acuity was not affected. An attempt several weeks later by another surgeon to re-explore the orbit to correct the damage was unsuccessful. The patient has permanent diplopia . The pathology report revealed chonic infla mmatory mucosa and fibroadipose tissue.
Patient 2
Fig . 1. Patient 1. Proptosis of (R) orbit. Osseous defect in the region of the lami na papyracea bilaterally. The right medial rectus appeared to be bowed laterally by soft-tissue mass (arrow).
MATERIALS AND METHODS Two cases of orbital complications are described : 1 case of intraorbital invasion and damage to the medial rectus mu scle, and 1 case of bilateral, complete blindness due to optic nerve injury. Three cases of intracranial complications are also reported: 2 cases of damage to the cribriform plate with brain injury and intracerebral hematoma, and 1 case of damage to the cribriform plate with extensive intracranial hemorrhage and death. None of these cases are derived from my personal surgical experience. These cases came to my attention either for consultation or for various other reasons.
A 39-year-old woman presented with bilateral nasal obstruction due to extensive nasal polyposis and chronic sinusiti s. She underwent bilateral intranasal endoscopic sinus surgery under general anesthesia. The procedure consisted of bilateral nasal polypectomy, septoplasty, bil ateral anterior and posterior ethmoidectomy, and bilateral sphenoidectomy. She awoke with bilateral total blindness. In spite of conservative medical management, she failed to recover any vision. Both optic nerves were damaged, with complete severance on one side (Fig. 2).
Patient 3 A 40-year-old woman complained of bilateral nasal obstruction secondary to polyps. She underwent bil ateral endoscopic intranasal ethmoidectom ies, antrostomies , a nd bilateral inferior turbinectomies under general anesthesia. Postoperatively, the patient developed right CSF rhinorrhea, and the pathologi st alerted the surgeon to the presence ofglial tissue and neurons in the specimen. A CT scan showed a bony defect in the a rea of the cribriform plate, bilaterally (Fig. 3, top). A magnetic resonance imaging scan (MRD revealed the presence ofintracerebral hemorrhage in the frontal lobe (Fig. 3, bottom ). An anterior frontal craniec-
Fig . 2. Patient 2. CT scan (axial plane). A. Intact optic nerves, preoperatively. B. Both lamina papyracea are damaged. Optic nerve on the right is anatomically intact, but completely severed on the left (arrow).
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Fig . 3. Patient 3. Top. Coronal cut of CT scan showing bony defect of cribriform plate bilaterally (arrows). Bottom. Axial and longitudinal MRls of an intracerebral hematoma (right frontal lobe) (arrows).
tomy, 1 week later, detected bilateral cribriform plate defects (1.5 cm on the right side) which were repaired with a fascia lata, fat, and split-thickness calvarial graft. Postoperatively, the patient did well and has had no further problems.
Patient4 A 61-year-old man complained of nasal obstruction. A CT scan revealed cloudiness and a lesion with bone destruction involving the sphenoid sinus and skull base on the left. Laryngoscope 101 : Apri I 1991
The left internal carotid artery was displaced. Bilateral sixth-nerve paresis was also detected. Under general anesthesia, the patient underwent endoscopic sinus surgery for removal and biopsy of the lesion. ~xcessive bleeding occurred and the procedure was termmated. Postoperatively, left extensive intracerebral hemorrhage due to laceration of the anterior cerebral artery was diagnosed. An emergency craniectomy was performed, but the patient died 2 days following surgery. The autopsy Maniglia: Endoscopic Sinus Surgery
351
treated conservatively, similarly to a closed head injury. Following the emergency CT scan and neurosurgical evaluation, it was decided to extracrani ally repair the cribriform plate defect. The problem was properly disclosed and discussed with the patient's family. While still under general anesthesia from the previous surgical procedure, the cribriform plate defect was repaired through an external ethmoidectomy approach using a nasal septa] flap. The neurosurgical team inserted a lumbar subarachnoid spinal drain for decompression. Postoperatively, the patient was monitored in the intensive care unit and was placed on large doses of dexamethasone and prophylactic intravenous triple antibiotic thera py (cephalosporin, metronidazole, a nd aminoglycosides). The postoperative period was uneventful, and the patient was discharged in good condition with no apparent neurological deficits.
DISCUSSION In the cases reported, invasion of orbital and intracranial cavities has occurred, resulting in major complications a nd even death. Permanent ophthalmologica l disability was the final outcome of patients 1 and 2. The complication of patient 3 was recognized early and properly treated by the neurosurgeon with no residual neurological deficit.
Fig . 4. lntraoperative lateral view of th e skull (plain x-rays) showing the endoscope (arrow), which was introduced intracranlally 7-8 cm deep.
revealed squamous cell carcinoma.
Patient5 A 49-year-old man complained of a long-standing nasal obstruction and was found to have extensive intranasal polyps and chronic sinusitis. Preoperative evaluation, including CT scan, revealed primarily anterior and posterior thmoidal disease. Under general anesthesia, nasal polypectomy and anterior and posterior ethmoidectomies were carried out using the endoscopic si nus surgery technique. The surgeon tried to identify and see the sphenoid si nus usi ng a 30° telescope and later realized that the scope had inadvertently been introduced too deeply intracranially. Aware of this mishap, and in order to evaluate the magnitude and significance of this complication, a lateral skull x-ray was obtai ned. Indeed, the endoscope had been introduced through the cribriform plate deeply intracranially (about 7-8 cm) (Fig. 4). Neurosurgical consultation resulted in a recommendation of a CT scan of the brain to rule out intracranial hemorrhage (Fig. 5). This was arranged, and the patient was taken to the radiology department immediately from the operating room, remaining intubated and under general anesthesia. The intracerebral hematoma was minimal, and the neurosurgeons felt that the brain damage could be Laryngoscope 101 : April 1991
352
Patient·5 h ad a preventable complication which fortunately, .was r ecognized during the operation; proper surgical procedure corrected the anterior skull-base defect in a most appropriate way. On-thespot n eurosurgical consultation and CT scan ruled out the need to intervene intracranially. The brain injury was treated similarly to a closed head injury. Subarachnoid lumbar spinal drainage . for 1 week postoperatively was helpful in preventing a permanen t CSF fi stula, which may result in meningitis . In 1989, Maniglia 8 discussed the mechanism and pathophysiology of similar surgical complications and alluded to precautions necessa ry to minimize or prevent such mi shaps. Some of these complications should be preventable. Thorough knowledge of the anatomy and meticulous surgical technique are essential for their prevention. Good training and experience in traditional sinus surgery, with special attention to intranasal ethmoidectomy, is very beneficial as a background for the surgeon who decides to use endoscopes. If a s urgeon is using the endoscopes and excessive bleeding occurs, a switch to the traditional or microscopic s urgical technique with continuous suction irrigation should be done in order to safely remove pathology. The endoscopic sinus surgeon should h ave in his/her armamentarium the ability to master other techniques which may very well be necessary. The endoscopes provide magnification and a close look at the pathology. But monocular visualization is unavoidable; therefore, depth perception is jeopardized. On the other hand, another advantage of the endoscopes (30°, etc. ) is the angular view of areas Maniglia : Endoscopic Sinus Surgery
Fig . s. CT scan done while the patient w_as ~e~ng operated o.n under general anesthesia shows a small intracerebral hematoma (curved arrow). Free intracranial air 1s shown anteriorly (straight arrow).
which cannot be seen with straight vision. Proper selection of patients and ~ne surgical technique must be exercised when adoptmg the use of the nasal endoscopes. An alternative to endoscopic sinus surgery is ~he use of the operating microscope (300-mm.len~), which affords magnification, binocular visuahzat10n, and excellent illumination and allows the surgeon to exercise bimanual instru~entation. This well-established technique provides better topographic, thre~-dim~n sional, anatomical orientation. Low magmficat10n ( x 6) should be used most of the time. Prior to the use of the microscope, removal of gross, bulky pa~~ology such as nasal polyps is better don~ expedi~iously using the traditional surgical techmque relyu~g . on cold-wire snares and different forceps . Self-retammg nasal specula provide good exposure. Suction-irrigation and instrumental manipulation can be. done c?ncomitantly. A small posterior rhinosc?PY mirror, with antifog solution, allows an angular view through the operating microscope. Recently, using microscopic sinus surgery, I have experienced two major complication~ among many hundreds of uneventful ethmoidectomies: 1. retrobulbar hematoma with severe proptosis and increased intraocular pressure. Immediate lateral canthotomy, evacuation of hematoma through the external ethmoidectomy approach and decompression incisions along the periorbita, combined with 80 mg of DecaLaryngoscope 101 : April 1991
dron®(intravenously) and 500 mg ofDiamox®(intravenously) prevented any ophthalmological disability; and 2. CSF leak, which was identified immediately with the aid of the microscope. Temporalis fascia graft and local septa} flap were sufficient to repair the CSF leak successfully. Perhaps the best of the two worlds would be the combination of endoscopic and microscopic sinus surgery, used intermittently.15 In 1972, Takahashi and Ashikawa 16 analyzed the Japanese literature experience of 83 ocular complications secondary to sinus surgery from 1926 to 1967. In their report, the earlier the onset of symptoms postoperatively, the worse the loss of visual acuity and prognosis. Direct damage of the optic nerve, thrombosis of the central retinal artery, and intraorbital hemorrhage, edema, and inflammation were the causes. Ocular paralysis was mainly due to injury of the medial rectus muscle. They stated, "assuming that the active professional life of a surgeon is 30 years, from the age of 30 to 60, this means that the chances of experiencing a case of severe ocular complication following sinus operations could occur once during the lifetime of every otorhinologist, which is indeed worthy of note".1 6 Informed consent is necessary. Patients should be aware of these potential problems and other alternaManiglia : Endoscopic Sinus Surgery
353
tive forms of medical treatment. Complications resulting from excessive bleeding, such as visual loss due to retrobulbar hematoma, injury to lamina papyracea, and cribriform plate with CSF leak, may very well be unavoidable, even in experienced hands. Patients undergoing endoscopic sinus surgery should be properly selected. This procedure, especially in the hands of less-experienced surgeons, should be reserved for cases with lesser pathology. Office inspection of nasal pathology helps in the learning of endoscopic anatomical landmarks. Topical and local anesthesia provides better bleeding control as compared with general anesthesia; therefore, they add a
dimension of safety. Television monitoring with magnification may be of help, especially as a teaching tool. The choice of traditional, microscopic, or endoscopic sinus surgery should be based on the ability and training of the surgeon. When properly used, these surgical techniques are all satisfactory. I am comfortable with the three surgical modalities and use them interchangeably, but I prefer not to use endoscopic sinus surgery, as a single modality, in cases done under general anesthesia. Even in the hands of experienced operators, regardless of what type of technique is selected, complications may occur. Fortunately, most of them are minor, with no permanent disabilities.
BIBLIOGRAPHY 1. Dra f, W. : Endoscopy of the Paranasal Sinuses. Springer-Verlag, Inc., New York, 1983. 2. Maltz, M.: New Instrument: The Sinuscope. LARYNGOSCOPE, 35:805-811. 1925. 3. Messerklinger, W.: Endoscopy of the Nose. Urban and Schwarzenberg, Baltimore, 1978. 4. Kennedy, D.W., Zinreich,J., Rosenbaum, A.E., et al.: Functional Endoscopic Sinus Surgery. Arch Otolaryngol, 111:576-582, 1985. 5. Freedman, H.M. and Kern, E.B .: Complications of Intranasal Ethmoidectomy: A Review of 1,000 Consecutive Operations. LARYNGOSCOPE, 89:421-434, 1979. 6. Friedman, W.H. and Katsantonis, G.P.: Intranasal and Transantral Ethmoidectomy: A 20-Year-Experience. LARYNGOSCOPE, 100:343-348, 1990. 7. Maniglia, A.J., Chandler, J.R., Goodwin, W.J., et al.: Rare Complications Following Ethmoidectomies: A Report of Eleven Cases. LARYNGOSCOPE, 91:1234-1244, 1981. 8. Maniglia, A.J. : Fatal and Major Complications Secondary to Nasal and Sinus Surgery. LARYNGOSCOPE, 99 :276-283, 1989. 9. Stankiewicz, J.A. : Complications of Endoscopic Nasal Surgery: Occurrence and Treatment. Am J Rhinol, 1:45-49, 1987. 10. Stankiewicz, J.A. : Complications in Endoscopic Intranasal
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11. 12. 13.
14. 15.
16.
Ethmoidectomy: An Update. LARYNGOSCOPE, 99:686-690 • 1989. Schaefer, S.D., Manning, S. and Close, L.G. : Endoscopic Paranasal Sinus Surgery: Indications and Considerations. LARYNGOSCOPE, 99:1-5, 1989. Levine, H.L.: Functional Endoscopic Sinus Surgery: Evaluation, Surgery, and Follow-up of250 Patients. LARYNGOSCOPE • 100:79--84, 1990. Stammberger, H.: Endoscopic Endonasal Surgery: Concepts in Treatment of Recurring Rhinosinusitis. Part I. Anatomic and Pathophysiologic Considerations. Otolaryngol Head Neck Surg, 94:143-146, 1986. Stammberger, H.: Endoscopic Endonasal Surgery: Concepts of Recurring Rhinosinusitis. Part II. Surgical Technique. Otolaryngol Head Neck Surg, 94:147-156, 1986. Teatini , G.P., Stomeo, F. and Bozzo, C.: Ethmoidectomy Through Combined Microscopic and Endoscopic Technique. International Symposium on Infection and Allergy of the Nose. International Rhinology Conference. Abstract 57. The Johns Hopkins School of Medicine. June 11, 1989. Takahashi, R. and Ashikawa, R.: Severe Visual Complications of Sinus Operation : A Collection of Ear, Nose and Throat Studies. Kyoya Co. LTD, Thkyo, pp. 524-542, 1972.
Maniglia: Endoscopic Sinus Surgery
INTROD UCTION Although nasal and sinus diagnostic endoscopy was attempte d in the beginnin g of this century, endoscopic sinus surgery started to become popular less than a decade ago.1-4 Traditio nal ethmoidectomy and sinus surgery are rather safe procedures, but major and fatal complications may occur. In 1,000 intranas al ethmoidectomies, Freedma n and Kern 5 report a low incidence of complications (2.8%), most of them of a minor type. In 1990, Friedma n and Katsanto nis6 also reported a low Presented at·t he Meeting of the Southern Section of the American Laryngological, Rhinological and Otological Society, Inc., White Sulphur Springs, W.Va., January 11, 1990. From the Departmen t ofOtolaryngology- Head and Neck Surgery, Case Western Reserve University, University Hospit als of Cleveland. Send Reprint Requests to Anthony J. Maniglia, MD, Departmen t of Otolaryngo logy-Head and Neck Surgery, Case Western Reserve Universi· ty, University Hospitals of Cleveland, 2074 Abington Road, Cleveland, OH 44106.
Laryngos cope 101: April 1991
incidence of complications secondary to intranas al ethmoidectomy (2.06% minor; 0.94% major). Intracranial and orbital complications are rare.7,S In 1987, Stankiewicz9 reported his experience with endoscopic sinus surgery and indicated a complication rate of29% in 90 patients (17% in 150 ethmoidectomies). In 1989, StankiewiczlO again discusse d the complication results in 300 ethmoid ectomie s performed in 180 patients . His overall complication rate had dropped to 9.3%. Most complications were minor. However, 2 cases of cerebros pinal fluid (CSF) leak and 1 case of tempora ry blindnes s occurred . The author credited the lower incidence of complications in the latter group of patients to experience. Schaefer, et az.11 reported an incidence of 14% minor complications and 0% major. In 458 procedures, Levinel2had 8.3% minor complications and 0. 7% major. Most major complications reported are CSF leaks. On the other hand, Stammberger, 13, 14 one of the pioneers to populari ze the Messerk linger techniqu e of endoscopic endonas al sinus surgery, states, "to date, more than 2,500 endoscopic ethmoid operatio ns have been carried out on the basis of [the] aforementioned concept at Graz Universi ty ENT-Clinic without any serious complications. Blood losses were always negligible and never required adminis tration of conserved blood. None of the patients has suffered injury to the roofof the ethmoid or even dura:• Stammb erger reported complications consistin g of emphyse ma in the orbit, scars, and synechia between the middle turbinat e and lateral nasal wall. Stenosis of the extended maxillar y ostium was very rare. With the exception of children, he stresses the importan ce of using local and surface anesthes ia when performing endoscopic sinus surgery. Endoscopic sinus surgery has become more and more popular due to the many courses being presented in the United States and abroad. Fortunately, several of these courses are designed to provide hands-on experience to surgeons who are committ ed to adopting this rather novel surgical technique. Th the best of my knowledge, there are no other reports of total blindnes s, intracra nial hemorrh age, or death due to endoscopic sinus surgery. This report describe s and analyzes five cases of fatal and other major complications of endoscopic sinus surgery. Maniglia: Endoscopic Sinus Surgery
349
Patient 1 A 67-year-old woman with a history of bilateral serous otitis media and chronic sinusitis underwent bilateral tympanostomy, PE tube insertion, and bilateral endoscopic intranasal ethmoidectomy under general anesthesia. Immediately postoperatively, right scleral hemorrhage, eyelid chemosis, and proptosis occurred. She was unable to adduct her right eye and, with left gaze, had a large exotropia. This was due to a n injury of the medial rectus muscle a nd was confirmed by ophthalmological consultation. A computed tomography (CT) scan revealed damage of the right lamina papyracea and medial rectus muscle (Fig. 1.) Her visual acuity was not affected. An attempt several weeks later by another surgeon to re-explore the orbit to correct the damage was unsuccessful. The patient has permanent diplopia . The pathology report revealed chonic infla mmatory mucosa and fibroadipose tissue.
Patient 2
Fig . 1. Patient 1. Proptosis of (R) orbit. Osseous defect in the region of the lami na papyracea bilaterally. The right medial rectus appeared to be bowed laterally by soft-tissue mass (arrow).
MATERIALS AND METHODS Two cases of orbital complications are described : 1 case of intraorbital invasion and damage to the medial rectus mu scle, and 1 case of bilateral, complete blindness due to optic nerve injury. Three cases of intracranial complications are also reported: 2 cases of damage to the cribriform plate with brain injury and intracerebral hematoma, and 1 case of damage to the cribriform plate with extensive intracranial hemorrhage and death. None of these cases are derived from my personal surgical experience. These cases came to my attention either for consultation or for various other reasons.
A 39-year-old woman presented with bilateral nasal obstruction due to extensive nasal polyposis and chronic sinusiti s. She underwent bilateral intranasal endoscopic sinus surgery under general anesthesia. The procedure consisted of bilateral nasal polypectomy, septoplasty, bil ateral anterior and posterior ethmoidectomy, and bilateral sphenoidectomy. She awoke with bilateral total blindness. In spite of conservative medical management, she failed to recover any vision. Both optic nerves were damaged, with complete severance on one side (Fig. 2).
Patient 3 A 40-year-old woman complained of bilateral nasal obstruction secondary to polyps. She underwent bil ateral endoscopic intranasal ethmoidectom ies, antrostomies , a nd bilateral inferior turbinectomies under general anesthesia. Postoperatively, the patient developed right CSF rhinorrhea, and the pathologi st alerted the surgeon to the presence ofglial tissue and neurons in the specimen. A CT scan showed a bony defect in the a rea of the cribriform plate, bilaterally (Fig. 3, top). A magnetic resonance imaging scan (MRD revealed the presence ofintracerebral hemorrhage in the frontal lobe (Fig. 3, bottom ). An anterior frontal craniec-
Fig . 2. Patient 2. CT scan (axial plane). A. Intact optic nerves, preoperatively. B. Both lamina papyracea are damaged. Optic nerve on the right is anatomically intact, but completely severed on the left (arrow).
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Fig . 3. Patient 3. Top. Coronal cut of CT scan showing bony defect of cribriform plate bilaterally (arrows). Bottom. Axial and longitudinal MRls of an intracerebral hematoma (right frontal lobe) (arrows).
tomy, 1 week later, detected bilateral cribriform plate defects (1.5 cm on the right side) which were repaired with a fascia lata, fat, and split-thickness calvarial graft. Postoperatively, the patient did well and has had no further problems.
Patient4 A 61-year-old man complained of nasal obstruction. A CT scan revealed cloudiness and a lesion with bone destruction involving the sphenoid sinus and skull base on the left. Laryngoscope 101 : Apri I 1991
The left internal carotid artery was displaced. Bilateral sixth-nerve paresis was also detected. Under general anesthesia, the patient underwent endoscopic sinus surgery for removal and biopsy of the lesion. ~xcessive bleeding occurred and the procedure was termmated. Postoperatively, left extensive intracerebral hemorrhage due to laceration of the anterior cerebral artery was diagnosed. An emergency craniectomy was performed, but the patient died 2 days following surgery. The autopsy Maniglia: Endoscopic Sinus Surgery
351
treated conservatively, similarly to a closed head injury. Following the emergency CT scan and neurosurgical evaluation, it was decided to extracrani ally repair the cribriform plate defect. The problem was properly disclosed and discussed with the patient's family. While still under general anesthesia from the previous surgical procedure, the cribriform plate defect was repaired through an external ethmoidectomy approach using a nasal septa] flap. The neurosurgical team inserted a lumbar subarachnoid spinal drain for decompression. Postoperatively, the patient was monitored in the intensive care unit and was placed on large doses of dexamethasone and prophylactic intravenous triple antibiotic thera py (cephalosporin, metronidazole, a nd aminoglycosides). The postoperative period was uneventful, and the patient was discharged in good condition with no apparent neurological deficits.
DISCUSSION In the cases reported, invasion of orbital and intracranial cavities has occurred, resulting in major complications a nd even death. Permanent ophthalmologica l disability was the final outcome of patients 1 and 2. The complication of patient 3 was recognized early and properly treated by the neurosurgeon with no residual neurological deficit.
Fig . 4. lntraoperative lateral view of th e skull (plain x-rays) showing the endoscope (arrow), which was introduced intracranlally 7-8 cm deep.
revealed squamous cell carcinoma.
Patient5 A 49-year-old man complained of a long-standing nasal obstruction and was found to have extensive intranasal polyps and chronic sinusitis. Preoperative evaluation, including CT scan, revealed primarily anterior and posterior thmoidal disease. Under general anesthesia, nasal polypectomy and anterior and posterior ethmoidectomies were carried out using the endoscopic si nus surgery technique. The surgeon tried to identify and see the sphenoid si nus usi ng a 30° telescope and later realized that the scope had inadvertently been introduced too deeply intracranially. Aware of this mishap, and in order to evaluate the magnitude and significance of this complication, a lateral skull x-ray was obtai ned. Indeed, the endoscope had been introduced through the cribriform plate deeply intracranially (about 7-8 cm) (Fig. 4). Neurosurgical consultation resulted in a recommendation of a CT scan of the brain to rule out intracranial hemorrhage (Fig. 5). This was arranged, and the patient was taken to the radiology department immediately from the operating room, remaining intubated and under general anesthesia. The intracerebral hematoma was minimal, and the neurosurgeons felt that the brain damage could be Laryngoscope 101 : April 1991
352
Patient·5 h ad a preventable complication which fortunately, .was r ecognized during the operation; proper surgical procedure corrected the anterior skull-base defect in a most appropriate way. On-thespot n eurosurgical consultation and CT scan ruled out the need to intervene intracranially. The brain injury was treated similarly to a closed head injury. Subarachnoid lumbar spinal drainage . for 1 week postoperatively was helpful in preventing a permanen t CSF fi stula, which may result in meningitis . In 1989, Maniglia 8 discussed the mechanism and pathophysiology of similar surgical complications and alluded to precautions necessa ry to minimize or prevent such mi shaps. Some of these complications should be preventable. Thorough knowledge of the anatomy and meticulous surgical technique are essential for their prevention. Good training and experience in traditional sinus surgery, with special attention to intranasal ethmoidectomy, is very beneficial as a background for the surgeon who decides to use endoscopes. If a s urgeon is using the endoscopes and excessive bleeding occurs, a switch to the traditional or microscopic s urgical technique with continuous suction irrigation should be done in order to safely remove pathology. The endoscopic sinus surgeon should h ave in his/her armamentarium the ability to master other techniques which may very well be necessary. The endoscopes provide magnification and a close look at the pathology. But monocular visualization is unavoidable; therefore, depth perception is jeopardized. On the other hand, another advantage of the endoscopes (30°, etc. ) is the angular view of areas Maniglia : Endoscopic Sinus Surgery
Fig . s. CT scan done while the patient w_as ~e~ng operated o.n under general anesthesia shows a small intracerebral hematoma (curved arrow). Free intracranial air 1s shown anteriorly (straight arrow).
which cannot be seen with straight vision. Proper selection of patients and ~ne surgical technique must be exercised when adoptmg the use of the nasal endoscopes. An alternative to endoscopic sinus surgery is ~he use of the operating microscope (300-mm.len~), which affords magnification, binocular visuahzat10n, and excellent illumination and allows the surgeon to exercise bimanual instru~entation. This well-established technique provides better topographic, thre~-dim~n sional, anatomical orientation. Low magmficat10n ( x 6) should be used most of the time. Prior to the use of the microscope, removal of gross, bulky pa~~ology such as nasal polyps is better don~ expedi~iously using the traditional surgical techmque relyu~g . on cold-wire snares and different forceps . Self-retammg nasal specula provide good exposure. Suction-irrigation and instrumental manipulation can be. done c?ncomitantly. A small posterior rhinosc?PY mirror, with antifog solution, allows an angular view through the operating microscope. Recently, using microscopic sinus surgery, I have experienced two major complication~ among many hundreds of uneventful ethmoidectomies: 1. retrobulbar hematoma with severe proptosis and increased intraocular pressure. Immediate lateral canthotomy, evacuation of hematoma through the external ethmoidectomy approach and decompression incisions along the periorbita, combined with 80 mg of DecaLaryngoscope 101 : April 1991
dron®(intravenously) and 500 mg ofDiamox®(intravenously) prevented any ophthalmological disability; and 2. CSF leak, which was identified immediately with the aid of the microscope. Temporalis fascia graft and local septa} flap were sufficient to repair the CSF leak successfully. Perhaps the best of the two worlds would be the combination of endoscopic and microscopic sinus surgery, used intermittently.15 In 1972, Takahashi and Ashikawa 16 analyzed the Japanese literature experience of 83 ocular complications secondary to sinus surgery from 1926 to 1967. In their report, the earlier the onset of symptoms postoperatively, the worse the loss of visual acuity and prognosis. Direct damage of the optic nerve, thrombosis of the central retinal artery, and intraorbital hemorrhage, edema, and inflammation were the causes. Ocular paralysis was mainly due to injury of the medial rectus muscle. They stated, "assuming that the active professional life of a surgeon is 30 years, from the age of 30 to 60, this means that the chances of experiencing a case of severe ocular complication following sinus operations could occur once during the lifetime of every otorhinologist, which is indeed worthy of note".1 6 Informed consent is necessary. Patients should be aware of these potential problems and other alternaManiglia : Endoscopic Sinus Surgery
353
tive forms of medical treatment. Complications resulting from excessive bleeding, such as visual loss due to retrobulbar hematoma, injury to lamina papyracea, and cribriform plate with CSF leak, may very well be unavoidable, even in experienced hands. Patients undergoing endoscopic sinus surgery should be properly selected. This procedure, especially in the hands of less-experienced surgeons, should be reserved for cases with lesser pathology. Office inspection of nasal pathology helps in the learning of endoscopic anatomical landmarks. Topical and local anesthesia provides better bleeding control as compared with general anesthesia; therefore, they add a
dimension of safety. Television monitoring with magnification may be of help, especially as a teaching tool. The choice of traditional, microscopic, or endoscopic sinus surgery should be based on the ability and training of the surgeon. When properly used, these surgical techniques are all satisfactory. I am comfortable with the three surgical modalities and use them interchangeably, but I prefer not to use endoscopic sinus surgery, as a single modality, in cases done under general anesthesia. Even in the hands of experienced operators, regardless of what type of technique is selected, complications may occur. Fortunately, most of them are minor, with no permanent disabilities.
BIBLIOGRAPHY 1. Dra f, W. : Endoscopy of the Paranasal Sinuses. Springer-Verlag, Inc., New York, 1983. 2. Maltz, M.: New Instrument: The Sinuscope. LARYNGOSCOPE, 35:805-811. 1925. 3. Messerklinger, W.: Endoscopy of the Nose. Urban and Schwarzenberg, Baltimore, 1978. 4. Kennedy, D.W., Zinreich,J., Rosenbaum, A.E., et al.: Functional Endoscopic Sinus Surgery. Arch Otolaryngol, 111:576-582, 1985. 5. Freedman, H.M. and Kern, E.B .: Complications of Intranasal Ethmoidectomy: A Review of 1,000 Consecutive Operations. LARYNGOSCOPE, 89:421-434, 1979. 6. Friedman, W.H. and Katsantonis, G.P.: Intranasal and Transantral Ethmoidectomy: A 20-Year-Experience. LARYNGOSCOPE, 100:343-348, 1990. 7. Maniglia, A.J., Chandler, J.R., Goodwin, W.J., et al.: Rare Complications Following Ethmoidectomies: A Report of Eleven Cases. LARYNGOSCOPE, 91:1234-1244, 1981. 8. Maniglia, A.J. : Fatal and Major Complications Secondary to Nasal and Sinus Surgery. LARYNGOSCOPE, 99 :276-283, 1989. 9. Stankiewicz, J.A. : Complications of Endoscopic Nasal Surgery: Occurrence and Treatment. Am J Rhinol, 1:45-49, 1987. 10. Stankiewicz, J.A. : Complications in Endoscopic Intranasal
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11. 12. 13.
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Ethmoidectomy: An Update. LARYNGOSCOPE, 99:686-690 • 1989. Schaefer, S.D., Manning, S. and Close, L.G. : Endoscopic Paranasal Sinus Surgery: Indications and Considerations. LARYNGOSCOPE, 99:1-5, 1989. Levine, H.L.: Functional Endoscopic Sinus Surgery: Evaluation, Surgery, and Follow-up of250 Patients. LARYNGOSCOPE • 100:79--84, 1990. Stammberger, H.: Endoscopic Endonasal Surgery: Concepts in Treatment of Recurring Rhinosinusitis. Part I. Anatomic and Pathophysiologic Considerations. Otolaryngol Head Neck Surg, 94:143-146, 1986. Stammberger, H.: Endoscopic Endonasal Surgery: Concepts of Recurring Rhinosinusitis. Part II. Surgical Technique. Otolaryngol Head Neck Surg, 94:147-156, 1986. Teatini , G.P., Stomeo, F. and Bozzo, C.: Ethmoidectomy Through Combined Microscopic and Endoscopic Technique. International Symposium on Infection and Allergy of the Nose. International Rhinology Conference. Abstract 57. The Johns Hopkins School of Medicine. June 11, 1989. Takahashi, R. and Ashikawa, R.: Severe Visual Complications of Sinus Operation : A Collection of Ear, Nose and Throat Studies. Kyoya Co. LTD, Thkyo, pp. 524-542, 1972.
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