Medical and Surgical Complications in the Treatment of Chronic Rhinosinusitis

Contents
Preface: Medical and Surgical Complications in the Treatment of Chronic
Rhinosinusitis

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James A. Stankiewicz
Pitfalls in Sinus Surgery: An Overview of Complications

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Peter F. Svider, Soly Baredes, and Jean Anderson Eloy

There is a potential for significant complications from the medical and surgical treatment of rhinosinusitis because of the intimate relationship between
the paranasal sinuses and surrounding vital structures. Familiarity with the
complex anatomic relationships between the skull base and other critical
structures and knowledge of pharmacologic properties of commonly used
medical therapies are essential for preventing serious and harmful seqsuelae. The authors hope that this review represents a valuable addition to the
otolaryngologist-in-trainings therapeutic armamentarium, and also serves
as a reminder of the potential pitfalls for the experienced sinus surgeon.
Anatomy and Complications: Safe Sinus

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Muhamad A. Amine and Vijay Anand

Safe sinus surgery is predicated on a clear understanding and knowledge
of the anatomy. The paranasal sinuses are surrounded by vital vascular
and neurologic structures. In every step during the surgical procedure,
one should know the regional surrounding anatomy and the potential complications that can be encountered if the procedures traverse these areas.
Preoperative assessment of the imaging is important to identify potential
hazardous areas.
Orbital Complications Associated with the Treatment of Chronic Rhinosinusitis

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Alpen B. Patel, Joseph M. Hoxworth, and Devyani Lal

Orbital injuries from endoscopic sinus surgery are rare but potentially catastrophic. The most feared complications from sinus surgery include blindness and diplopia. Recent publications note that the rate of orbital
complications has decreased when compared with the past, reflecting
the use of endoscopes, better technology, and improved training. The
sinus surgeon must have mastery over the procedure she or he plans to
undertake and be aware of the specific potential for orbital injury given
the patients anatomy and disease. The sinus surgeon must also have
expert knowledge of the appropriate and immediate medical and surgical
management of orbital complications.
Neurologic Complications and Treatment

Kevin C. Welch
Risk is inherent with all surgical procedures. Most endoscopic sinus surgery (ESS) is uncomplicated. Among the many complications inherent

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with ESS are the neurologic complications, which include cerebrospinal

fluid rhinorrhea, traumatic soft tissue and vascular injuries, infection, and
seizures. Despite intense review of a patients preoperative scans, use
of stereotactic image guidance, and an expert understanding of anatomy,
neurologic complications occur. An understanding of these complications
and how to manage them can help to reduce long-term patient injury as
well as help prevent recurrence.
Hemorrhagic Complications of Endoscopic Sinus Surgery

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Ashleigh A. Halderman, Raj Sindwani, and Troy D. Woodard

Major complications during endoscopic sinus surgery are rare and occur in
0.36% to 3.1% of patients. Postoperative hemorrhage accounts for 23%
to 39% of complications. Despite being rare, major hemorrhage can be
serious for the patient. This article discusses hemorrhagic complications
during and following endoscopic sinus surgery, focusing on a review of
the surgical anatomy, common pitfalls to avoid, preventative measures,
and management of certain catastrophic complications for which preparedness can mean the difference between life and death.
Olfaction in Endoscopic Sinus and Skull Base Surgery

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Christopher F. Thompson, Robert C. Kern, and David B. Conley

Olfactory dysfunction is a common complaint for patients with chronic rhinosinusitis, because smell loss decreases a patients quality of life. Smell
loss is caused by obstruction from polyps, nasal discharge, and mucosal
edema, as well as inflammatory changes within the olfactory epithelium.
Addressing olfaction before endoscopic sinus and skull base surgery is
important in order to set postoperative expectations, because an improvement in smell is difficult to predict. Several commercially available olfactory
testing measures are available and can easily be administered in clinic.
During surgery, careful dissection within the olfactory cleft is recommended in order to optimize postoperative olfactory function.
Imaging of the Paranasal Sinuses: Mitigation, Identification, and Workup of
Functional Endoscopic Surgery Complications

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Salvatore V. Labruzzo, Nafi Aygun, and S. James Zinreich

The purpose of this article is to identify and define the appropriate imaging
techniques in the evaluation of postfunctional endoscopic surgery (FESS)
complications. Although most complications encountered during FESS
are identified readily during surgery, some are less conspicuous and
require postoperative imaging. As illustrated in this article, these include
cerebrospinal fluid leak, vascular injury, brain injury, orbital injury, and infectious complications of the brain and meninges. Some of the common
anatomic variants of the paranasal sinuses are identified, and how these
may predispose to surgical complications is discussed.
Medicolegal Implications of Common Rhinologic Medications

David M. Poetker and Timothy L. Smith

As otolaryngologists, we prescribe many medications to our patients. The
objective of this article is to review the potential side effects and medicolegal risks of the common medications used to treat chronic rhinosinusitis.

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The authors evaluate some of the common side effects as well as the published literature on the lawsuits associated with those medications. Finally,
the authors review the informed consent discussion and opportunities to
improve patient care and decrease the risk of litigation.
Medicolegal Issues in Endoscopic Sinus Surgery and Complications

827

James A. Stankiewicz and Jeffrey Hotaling

Complications occur during and after endoscopic sinus surgery. Complications leading to temporary or most commonly permanent injury often
are involved in litigation for malpractice. This article concentrates on areas
of importance that are considered during medicolegal deliberations.
Early Practice: External Sinus Surgery and Procedures and Complications

839

John S. Schneider, Andrew Day, Matthew Clavenna, Paul T. Russell III,

and James Duncavage
External approaches to the paranasal sinuses are rarely used in the endoscopic era. However, their indications for use have not changed, and in
every surgeons career those indications may present themselves. For residents training in the endoscopic era, these procedures are also very rarely
seen. In this article, the external approaches to the maxillary, ethmoid, and
frontal sinuses are described: their original descriptions, modern use, and
potential complications. It is hoped that this article will serve to instruct
residents and practitioners alike in these techniques.
Does Image-Guided Surgery Reduce Complications?

851

Vijay R. Ramakrishnan and Todd T. Kingdom

Image-guided surgery (IGS) is progressively used in endoscopic sinus surgery (ESS), and surgeon comfort with the technology has increased. It remains a challenge to determine if the use of IGS in ESS leads to a reduction
in surgical complications and improved outcomes. Current literature does
not show a clear reduction in surgical complications. The routine use of
IGS in ESS as a deterrent to medicolegal liability is not substantiated by
recent reported data. There are particular situations in which IGS may
be helpful, but its use is likely not required for routine ESS and seems
best left to surgeon discretion.
Rare and Other Notable Complications in Endoscopic Sinus Surgery

861

James R. Martin and Monica O. Patadia

This article focuses on the rare and obscure complications of endoscopic
sinus surgery. The majority of surgeons will not encounter these complications in their practice, but should be aware of their possibility. With knowledge of these rare complications, the surgeon can understand the
possible avoidance as well as urgent management of these problems.
Avoiding Complications in Endoscopic Sinus Surgery

Ian M. Humphreys and Peter H. Hwang

Complications of endoscopic sinus surgery (ESS) can range from the
mundane to the catastrophic, with nasal hemorrhage being the most

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common. Intraorbital and intracranial complications are much less common. Despite the rarity of complications, they are often avoidable. Certain
identifiable risk factors can be appreciated during the preoperative, intraoperative, and postoperative evaluations of the sinus patient. With awareness of these risk factors the rhinologist can develop a strategic plan of risk
factor mitigation. This article identifies areas of increased risk that are
amenable to preventive strategies before complications become realized.
Index

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