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Endoscopic Sinus Surgery: Indications and Complications

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Endoscopic Sinus Surgery: Indications and Complications

Endoscopic Sinus Surgery: Indications and Complications

Haitham Abdul-Malik Alnori

FIBMS/ lecturer. Dept of Surgery, College of Medicine, Mosul, Iraq.

Email: H_alnori@yahoo.com

Abstract
Objectives: The aim of the present study is to assess the spectrum of paranasal sinus diseases which can be
treated by endoscopic sinus surgery and to determine the complications of this surgery. Aims of the study:
The aims of this study is to assess the spectrum of paranasal sinus diseases which can be treated by
endoscopic sinus surgery and to determine the complications of this surgery. Patients and Methods: This is a
retrospective analysis of 78 patients who underwent endoscopic sinus surgery for different paranasal sinus
conditions. The study was carried out at Al-Jumhori Teaching Hospital/ Mosul- IRAQ from March 2009 to
March 2012. Results: Indications for ESS were bilateral ethmoidal polyps in 39 patients (50 %), chronic
sinusitis in 21 patients (26.9 %) and antrochoanal polyp in 16 patients (20.5 %). There was one patient with
frontal sinus polyp and another patient with sphenoid sinus polyp. The most common minor complication of
ESS was crustations (28.2%). There was no major complication in our series. Conclusion: Endoscopic sinus
surgery is reliable method for treatment of many nasal diseases with acceptable incidence of minor
complications.

Key words: Endoscopic sinus surgery, complications of ESS.

Introduction Sinus Surgery (FESS) was coined by Kennedy in

Nasal endoscopy has become a standard part of
the diagnosis and treatment of many sinonasal
diseases. Nasal and sinus endoscopy was first
performed by Hirchman in 1903 using a modified
Nitze cystoscope which he used in the nasal cavity
and in the maxillary sinus via a tooth socket [1].
Endoscopic sinus surgery was introduced in the
1960s by Professors Messerklinger and Wigand. It
was popularized in Europe by Stammberger and
subsequently in North America by Kennedy. The
use of this approach has become more popular
with improvement in the understanding of the
anatomy of the lateral nasal wall and surgical
training [2, 3]. The term Functional Endoscopic
Tikrit Medical Journal 2013;19(1): 89-94
1985 [1]. He observed that chronic sinusitis is
usually due to stenosis of the anterior ethmoid
region [2]. Infection can spread from the anterior
ethmoid and the middle meatal regions, to
secondarily affect the maxillary and the frontal
sinuses. He noted that the mucosal changes that
occur secondary to obstruction of the ostiomeatal
unit (OMU), resolve when normal ventilation and
mucocilliary clearance is restored [1- 3]. Another
study done by Bassiouny et al. in 2003 showed
that maxillary sinus mucosa in chronic sinusitis
returns normal with the improvement of
ventilation and drainage of maxillary sinus
following FESS[4]. Since then, FESS has become
the standard treatment of chronic sinusitis [5].
98
Endoscopic Sinus Surgery: Indications and Complications
However the spectrum of Endoscopic Sinus
Surgery (ESS) have grown far beyond FESS and
now include other nasal, orbital and anterior skull
base procedures such as treatment of nasal
polyposis, endoscopic dacryocystorhinostomy,
CSF leak repair, orbital decompression, thyroid
orbitopathy, drainage of orbital abscess and
hematoma, decompression of the optic nerve, and
surgical management of circumscribed neoplasms
[6].
Endoscopic sinus surgery is not free of
complications, and the incidence of these
complications is increased in revision surgery and
in the hands of less experienced surgeons [7-11]. It
is therefore essential to point out that this type of
surgery also bears all the risks and hazards of
intranasal surgery in general, and that it is not the
method of choice for the untrained surgeon.
Complications of ESS have been traditionally
divided into major and minor complications. Major
complications include injury to skull base with
subsequent CSF leak and meningitis, orbital
trauma or hemorrhage and optic nerve injury.
Minor complications include bleeding, orbital fat
prolapse, synechiae, crustation and periorbital
hemorrhage [12].
Aims of the study
The aims of this study is to
1. assess the spectrum of paranasal sinus
diseases which can be treated by
endoscopic sinus surgery.
2. determine the complications of this
surgery.
Patients and Methods
A retrospective analysis of 78 patients who
underwent endoscopic sinus surgery by the same
surgeon from March 2009 to March 2012. Sixteen
patients had surgery on one side only; they had
antrochoanal polyp. The rest 62 patients had
surgery on both sides. In addition septoplasty was
required in 16 patients. Patients were referred from
outpatient department or private clinic, and surgery
was done at Al- Jamhori Teaching Hospital. All
patients had adequate medical therapy before
surgery which usually included antibiotic and
topical nasal steroid. If there is failure of medical
therapy, patients were referred to surgery. Patients
were examined before surgery by zero degree
nasal endoscope and sometimes by thirty degree
endoscope also. All patients were sent for X-ray of
89
Tikrit Medical Journal 2013;19(1): 89-94
paranasal sinuses (occipito-mental view), and most
of them for CT scan of the paranasal sinuses. CT
scan was sometimes not done in patients with
antrochoanal polyp. Also there are few patients in
this series who was subjected to ESS for nasal
polyposis without CT scan, because CT scan was
unfortunately not available at that time. All
operations were done under general anesthesia and
endo-tracheal intubation. Patients were given 10
mg Propranolol orally two hours before surgery,
except in asthmatic patients. Beta-blockers
improve operative field by preventing tachycardia
and causing vasodilation. The nose was lightly
packed with gauze soaked in 2 ml Xylocain 2%
and one ml Xylometazolin 0.1% one hour before
surgery. Bleeding is further reduced by putting the
patient into 30 degree head-up position. If the
patient had septal deviation, septoplasty was done
before ESS. Misserklinger technique was used in
this series; uncinectomy is usually the first step of
surgery except when there were large polyps
which were removed first. Middle meatal
antrostomy was done by curved suction tube and
enlarged by forward and backward biting forceps.
Bulla ethmoidalis was opened and air cells were
cleaned. If there was disease in the posterior
Ethmoid cells also, they were opened by entering
ground lamella and these air cells were cleaned.
The sphenoid and frontal sinuses were opened only
when there was disease in these sinuses. At the end
of surgery, the nose was packed with Vaseline
pack.
Patients were given Ceftriaxone injection 1 gm
once daily for three days and then oral amoxi-clav
1 gm twice daily for seven days. The pack was
removed after 24 hours. Patients were instructed to
clean the nose by alkaline nasal douche several
times daily. Patients with allergic rhinitis and nasal
polyps were given nasal steroids for 3 months.
Patients were examined by endoscope weekly in
the first month and then monthly for 6 months.
Each time the nasal cavity is inspected for
bleeding, crustation, clots, polyps or any other
pathology.
Results
Our study included 78 patients, 49 males and 29
females with a male to female ratio of 1.7: 1. The
mean age of our patients is 32 years with a range
from 9- 57 years. All patients underwent
endoscopic sinus surgery (ESS); 16 had
antrochoanal polyp (20.5 %), 21 had chronic
sinusitis (26.9 %) and 39 had bilateral ethmoidal
Endoscopic Sinus Surgery: Indications and Complications
polyps (50 %). There was one patient with frontal
sinus polyp (1.3 %) and another patient with
sphenoid sinus polyp (1.3 %). Sixty patients (76.9
%) had primary surgery while the remaining were
revision procedures (Table 1).
The commonest presenting symptoms of patients
were nasal obstruction followed by rhinorrhea with
percentage of 76.9 % and 67.9 % respectively
(Table 2). Other symptoms were postnasal drip
(48.7 %), headache and facial pain (39.7 %),
sneezing (29.4 %), smell disturbances (28.2 %),
snoring (20.5 %), and nasal bleeding (7.7 %).
Table 3 summarizes the endoscopic findings
during surgery; Ethmoid polyps were seen in 39
patients (50 %) and mucopurulent discharge in 23
patients (29.4 %). Eighteen patients (24 %)
required septoplasty due to significant septal
deviation.
The commonest complication of ESS is crust
formation in the nasal cavity which was
encountered in 22 (28.2 %) patients (Table 4),
however during follow up these crusts were
removed so that after 3 months there was no
crustation in any patient. Severe bleeding occurred
in 9 patients (11.5 %), which was controlled by
packing of the nose only, no blood transfusion was
required. Orbital fat prolapsed was noticed in one
patients (1.3 %) who had revision surgery for
ethmoidal polyps. There was no effect on vision
and the condition resolved within two weeks
spontaneously. Another patient (1.3 %) developed
peri-orbital ecchymosis after the operation;
although this complication may be frightening to
the patient, it resolved within 2 weeks without
complication. Nasal synechiae was first noticed
two weeks after surgery in 6 patients (9.2%).
These synechiae was removed during follow up so
that they were absent after 3 months.
Discussion
Seventy eight patients underwent endoscopic
sinus surgery (ESS); 16 had antrochoanal polyp
(20.5 %), 21 had chronic sinusitis (26.9 %) and 39
had bilateral ethmoidal polyps (50 %); these
results are slightly different from other studies in
which there is higher proportion of patients with
chronic sinusitis [6]. Also there was 23.1%
revision cases which is higher than other studies,
probably due to the limited experience in ESS in
our locality [6, 13]. Common presenting
symptoms of patients are nasal obstruction (76.9
%) and nasal discharge (67.9%). These findings
are consistent with many other studies which
Tikrit Medical Journal 2013;19(1): 89-94
found these two symptoms the commonest
symptoms that make patients seek surgery [14,
15]. Endoscopic assessment during surgery
revealed that 29.4 % of patients had mucopurulent
discharge and 14.1 % had accessory ostium of the
maxillary sinus, these results are comparable to the
results of Bonfils [16].
Most studies found that crust formation in the
nasal cavity is the most common complication of
ESS [17, 18], in this series it was 28.2 %. Crusts
are formed due to loss of mucosal surfaces or
exposed bone. Patients are instructed to clean their
noses with alkaline nasal douche, otherwise these
crusts may predispose to infection leading to
recurrence of disease and surgical failure [17].
Minor hemorrhage is defined as excessive
perioperative bleeding that does not require arterial
ligation or blood transfusion. In our series its
incidence was 11.5%, this is higher than the results
of a national audit in England and Wales which
was 5.8%; this difference is probably related to
better operative conditions like hypotensive
anesthesia and also to the experience of surgeons
[18]. In all our patients bleeding was controlled by
packing only. Orbital fat prolapsed (1.3%) and
periorbital hemorrhage (1.3%) occur due to injury
to lamina papyracea; this complication is
encountered when surgical landmarks are distorted
by previous surgery or extensive nasal polyposis.
Our results are compatible with the results of Re
M. et al. [12] who found the incidence of orbital
complications 1.5%. This is a transient
complication which resolves within two weeks.
The formation of adhesions in the nasal cavity is
commonly seen in those patients who don't attend
regularly for follow-up, and it is seen in our
patients in 9.2%. This complication is encountered
in 2.6% in the previous study [12]. There are two
patients in this series one of them had frontal sinus
polyp and the other had sphenoid sinus polyp; both
of them had smooth postoperative period without
complications. There was no major complication
in this series namely: CSF leak, diplopia, optic
nerve injury and meningitis, this is in agreement to
other studies[19, 20].
Conclusion
Endoscopic sinus surgery is reliable method for
treatment of many nasal diseases with acceptable
incidence of minor complications. Most
complications are transient and can be effectively
managed by regular follow up and endoscopic
examination.
89
Endoscopic Sinus Surgery: Indications and Complications
References
1. Kennedy DW, Zinreich J, Rosenbaum AE,
Johns M. Functional Endoscopic Sinus Surgery.
Theory and diagnostic evaluation. Arch
Otolaryngol 1985; 111:576-582.
2. Stammberger H, Posawetz W. Functional
endoscopic sinus surgery, concept, indications and
results of the Messerklinger technique. Eur Arch
Otolaryngol 1990;247:63-76.
3.Kennedy DW. Functional endoscopic sinus
surgery. Arch Otolaryngol 1985;111:643-9.
4. Bassiouny A, Atef AM, Raouf MA, Nasr SM.
Ultrastructural ciliary changes of maxillary sinus
mucosa following functional endoscopic sinus
surgery: an image analysis quantitative study.
Laryngol Otol 2003;117(4): 273-9.
5. Lund VJ. Evidence based surgery in chronic
rhinosinusitis. Acta Otolaryngol (Stockh)
2001;121:5–9.
6.Schaffer SD, Manning S, Close LG. Endoscopic
paranasal sinus surgery: indications and
considerations. Laryngoscope 1989;99:1-5.
7. Vleming M, Middelweerd RJ, de Vries N.
Complications of endoscopic surgery. Arch
Otolaryngol Head Neck Surg. 1992;118: 617-23.
8. Stankiewics JA. Complications in endoscopic
intranasal ethmoidectomy: an update.
Laryngoscope 1989; 99: 686-90.
9. Corey JP, Bumsted R, Panje W, Namon A.
Orbital complications in functional endoscopic
sinus surgery. Otolaryngol Head Neck Surg 1993;
109: 814-20.
10. Cumberworth VL, Sudderick RM, Mackay IS.
Major complications of functional endoscopic
sinus surgery. Clin Otolaryngol 1994;19: 248-53.
11. Ribeiro RB, Reis CP, Castro SS, Ferreira JP,
Sousa CA. Endoscopic sinus surgery: A safe
procedure among the less experienced surgeons?
Auris Nasus Larynx 2012; 39: 490–495.
Table (1) Main Indications for ESS
Indication Primary
No. % No. %
Chronic sinusitis 17 21.8
Bilateral Ethmoidal polyps 28 35.9
Antro-choanal polyp 14 17.9
Sphenoid sinus polyp
Frontal sinus polyp 1 1.3
Total 60 76.9
89
Tikrit Medical Journal 2013;19(1): 89-94
12. Re M, Massegur H, Magliulo G, Ferrante
L, Sciarretta V, Farneti G, Macri G, Mallardi
V, Pasquini E. Traditional endonasal and
microscopic sinus surgery complications versus
endoscopic sinus surgery complications: a meta-
analysis. Eur Arch Otorhinolaryngol 2012;
269:721–729.
13. Matthews BL, Smith LE, Jones R, Miller C
Brookschmidt JK. Endoscopic sinus surgery:
outcome in 155 cases. Otolaryngol Head Neck
Surg 1991; 104: 244-6.
14. Benninger MS, Ferguson BJ, Hadley JA.
Adult chronic rhinosinusitis: definitions, diagnosis,
epidemiology and pathophysiology. Otolaryngol
Head Neck Surg 2003;129: 31–32
15. Lund V, Scadding GK. Objective assessment
of endoscopic sinus surgery in the management of
chronic rhinosinusitis: an update. J Laryngol Otol
1994; 108: 749-53.
16. BONFILS P. Evaluation of the combined
medical and surgical treatment in nasal polyposis.
I: Functional results Acta Oto-Laryngologica
2007; 127: 436_446
17. Nair S, Dutta A, Rajagopalan R, Nambiar S.
Endoscopic sinus surgery in chronic rhinosinusitis
and nasal polyposis: a comparative study. Indian J
Otolaryngol Head Neck Surg 2011;63:50-5.
18. Hopkins C, Browne JP, Slack R, Lund VJ,
Topham J, Reeves BC, Copley LP, Brown P, van
der Meulen JH. Complications of surgery for nasal
polyposis and chronic rhinosinusitis: the results of
a national audit in England and Wales.
Laryngoscope 2006;116:1494-9.
19. Kennedy DW Prognostic factors outcomes
and staging in ethmoid sinus surgery.
Laryngoscope 1992;102:1–18.
20. Guerriero J, Molina B, Echeverria L, Arribas I,
Rivera T. Endoscopic sinonasal surgery: study of
110 patients with nasal polyposis and chronic
rhinosinusitis. Acta Otorrinolaringol Esp
2007;58:252–256.
Revision All
No. %
4 5.3 21 26.9
11 14.1 39 50
2 2.6 16 20.5
1 1.3 1 1.3
1 1.3
18 23.1 78 100
Endoscopic Sinus Surgery: Indications and Complications

Table (2) Presenting symptoms

Symptom Number Percentage
Nasal obstruction 60 76.9 %
Nasal discharge 53 67.9 %
Postnasal drip 38 48.7 %
Headache/ facial pain 31 39.7 %
Sneezing 23 29.4 %
Smell disturbance 22 28.2 %
Snoring 16 20.5 %
Nasal bleeding 6 7.7 %

Table (3) Endoscopic findings during surgery

Finding Number Percentage
Ethmoid polyp 39 50 %
Mucopurulent discharge 23 29.4 %
Significant septal deviation 18 24 %
Antrochoanal polyp 16 20.5 %
Accessory ostium 11 14.1 %
Funagal debris in sinuses 3 3.8 %
Concha bullosa 2 2.6 %
Paradoxical middle turbinate 2 2.6 %
Frontal sinus polyp 1 1.3 %
Sphenoid sinus polyp 1 1.3 %

Table (4) Postoperative follow-up

Follow-up No. of Crustation Bleeding Orbital fat Peri-orbital Synechiae

patients prolapse ecchymosis
N % N % N % N % N %
1st week 78 22 28.2 9 11.5 1 1.3 1 1.3 0
2nd week 78 17 21.8 1 1.3 1 1.3 1 1.3 3 3.8
3rd week 72 8 11.1 0 0 0 4 5.6
1st month 65 3 4.6 0 0 0 6 9.2
2nd month 62 2 3.2 0 0 0 5 8.1
3rd month 60 0 0 0 0 0
6th month 45 0 0 0 0 0

89
Tikrit Medical Journal 2013;19(1): 89-94
 ‫‪Endoscopic Sinus Surgery: Indications and Complications‬‬

‫الخالصة‬

‫األٌذاف‪ :‬جٍذف انذساسة انحانٍة إنى جقٍٍم طٍف أمشاض اندٍُب األوفٍة انقابهة نهعالج باندشاحة انمىظاسٌة َنححذٌذ‬
‫مضاعفات ٌزي اندشاحة‪.‬‬

‫انطشق‪ :‬جحهٍم اسحشخاعً ل ‪ 87‬مشٌضا ممه أخشٌث نٍم عمهٍة اندٍُب األوفٍة بانمىظاس نحاالت مخحهفة مه‬
‫أمشاض اندٍُب األوفٍة‪ .‬أخشٌث انذساسة فً مسحشفى اندمٍُسي انحعهٍمً مه آراس ‪ 9002‬نغاٌة آراس ‪. 9009‬‬

‫انىحائح‪ :‬دَاعً انعمهٍة كاوث سهٍالت األوف عىذ ‪ 92‬مشٌضا‪ ,‬انحٍاب اندٍُب األوفٍة انمزمه عىذ ‪ 90‬مشٌضا‪,‬‬
‫َانسهٍهة انُخىٍة عىذ ‪ 01‬مشٌضا‪ .‬كان ٌىاك مشٌض َاحذ نذًٌ سهٍهة خبٍٍة َمشٌض أخش نذًٌ سهٍهة اسفٍىٍة‪ .‬أكثش‬
‫انمضاعفات انثاوٌُة شٍُعا كاوث قششٌات داخم األوف بىسبة ‪ .% 97.9‬نم جحذخ أي مضاعفات سئٍسٍة فً ٌزي‬
‫انذساسة‪.‬‬

‫االسحىحاج‪ :‬إن خشاحة اندٍُب األوفٍة بانمىظاس ًٌ مه انطشق انمُثُقة نعالج انكثٍش مه أمشاض اندٍُب األوفٍة‪,‬‬
‫َبمعذل مقبُل مه انمضاعفات انثاوٌُة‪.‬‬

‫الكلمات الدليلة‪ :‬خشاحة اندٍُب بانمىظاس‪ ,‬مضاعفات خشاحة األوف انمىظاسٌة‪.‬‬

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‫‪Tikrit Medical Journal 2013;19(1): 89-94‬‬

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