Safe FESS To Avoid

Complication
CT-scan Interpretation

Vicky Riyadi , MD ORL

Fatmawati Hospital
Identification anatomical variation method

I II III IV

2
 Nose & Paranasal Sinuses
Anatomical Variations
OMC Another Ant & Post Sphenoid
Dangerous Area Drainage Pathway
Occlusion structure Ethmoid Sinus

Ethmoid Roof Frontal Cell Frontal Maxillary Basal

Concha bulosa
(Keros) (Kuhn) Sinus Sinus Lamella

UP Lateral Resesus
AEA Position Haller Cell Ostium
Deflection frontal

Septal
PEA Position Agger Nasi Infundibulum
Deviation

Onodi Cell

Lamina papiracea
CT Scan
Pneumatization of Anterior Clinoid
Process
 Use CT scan as a roadmap - guidance
Hold an endoscope for the entire procedure
An instrument inserted along the natural
nasal corridor
Follow certain surgical techniques

The Relevant Standard

Care of FESS
 Bleeding
LCS leakage
Fat herniation
Medial rectus damage
Retro-orbital injuries
Optic nerve lesion
Brain injury

FESS Intervention & Injuries Due To

 Revision FESS
Surgery for nasal polyposis
Skull base surgery
Right side of nose paranasal sinuses
Certain anatomical variations

Higher Probability of Injuries

Uncinate Procces &
Lamina Papiracea
 Sac and duct lie close to the ethmoid
Agger nasi cells are adjacent to the sac
Natural ostium of maxillary sinus lie close
to the duct

Orbit & Nasolacrimal Duct

 Nasolacrymal duct
Axial CT 1 2

3 4 Coronal
CT

Inferior
meatus
Epiphora, Fat Herniation, reduce ocular
motility
Identify Location of
Anterior Ethmoid Artery
Posterior ethmoid artery
 Direct injury to the nerve
Direct injury to the vessel : central retina
artery, posterior cilliary artery
Increase intraocular pressure

Blindness
Ecchymosis Orbital hematoma
Preseptal accumulation Post septal accumulation
Injury to angular vein Injury to the vein aroun
lamina/ a. ethmoidal ant
Causes more lid edema or post
Conjunctiva and pupil Lid edem is less
normal Conjunctival chemosis/
no proptosis pupil changes
Proptosis

Bleeding
Temporary blindness
increasing orbital
preasure due to hematom
compromises blood
supply to optic nerve
intraocular presure may
reduce within 2 hours
pupil -- 2 days to recover
Bleeding Blindness
(Optic Nerve Lesion)
Permanent blindness
Disaster
Retrobulbar/retroorbital
hematom
Optic nerve can tolerate
extrem of pressure only for
2 hours
Intervention should be less
the 2 hours
Arterial bleeding--window
period within half an hour
Orbital injury test
Lateral canthotomy
LCS Leakage /
pneumoenchepal
Ethmoid roof
LCS Leakage
 Beware of type III keros
Avoid excesive medialization of middle
turbinate
Always keep skull base in view

LCS leakage
Sphenoid
Dissection landmark
 ONODI SEL

Sel Onodi
Dehiscence ICA
Dehiscence optic nerve
 Knowledge of anatomy is a must
Proper instrument and skill
100 diagnostic endoscopies
Cadaveric dissection
Supervised surgery
Staged surgery
Imaging and image guidance
Hipotensive anesthesia
Informed consent
PRAY

Take Home Message

Thank You
Potential of LCS Leakage
Superior Attachment of UP & Frontal Sinusitis

Uncinate Process Attachment Frontal Sinusitis (+) Frontal Sinusitis (-) Total
Lamina Papyracea 102 (63.3%) 142 (55.7%) 244
Middle Turbinate or Skull Base 59 (26.7%) 83 (44.3%) 142
Total 161 (100%) 225 (100%) 386
OR=1.01; 95% CI=0.7 1.5; p=0.96
Sphenoid Sinus
 Relationship of Supraorbital Cell,
Keros Configuration and AEA Position
AEA Position
Supraorbital Pneumatisation /
Hanging Non- p OR 95% CI
Keros Configuration
Hanging
Pneuma (+) / deep 132 6 0.0 122.5 44.7 356.2

Pneuma (+) / shallow 136 2 0.0 378.8 82.6 2400.4

Pneuma (-) / deep 53 85 0.0 3.4 1.8 6.4

Pneuma (-) / shallow 21 117 OR calculation based