AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y H EA D A N D N E CK ME D I CI NE AN D SUR G E RY 3 5 ( 2 0 14 ) 32 43 2 8

Available online at www.sciencedirect.com

ScienceDirect
www.elsevier.com/locate/amjoto

Clinical pearls in endoscopic sinus surgery: Key steps

in preventing and dealing with complications,
Jean Anderson Eloy, MD, FACS a, b, c,, Peter F. Svider, MD a , Michael Setzen, MD, FACS d, e
a

Department of OtolaryngologyHead and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
c
Center for Skull Base and Pituitary Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
d
Rhinology Section, North Shore University Hospital, Manhasset, NY, USA
e
Department of Otolaryngology, New York University School of Medicine, New York, NY, USA
b

ARTI CLE I NFO

A BS TRACT

Article history:

Increasing prevalence of patients undergoing endoscopic sinus surgery (ESS) makes

Received 2 January 2014

understanding methods to preventing complications important to otolaryngologists. This

commentary details clinical pearls and perioperative strategies that may minimize
complications and increase preparedness for appropriate decision making in the event of
a complication. Preoperative preparation is an important factor in preventing adverse
events in ESS. This includes ensuring the presence of objective radiographic findings before
pursuing operative management, both for patients' safety as well as medicolegal reasons,
and providing adequate preoperative patient education. Appreciating variants in skull base
and orbital wall anatomy through preoperative imaging is crucial for avoidance of
intracranial and orbital complications. The importance of optimal visualization
intraoperatively and the appropriate role of CT-guided imaging are also discussed. Finally,
strategies for dealing with postoperative sequelae of more common complications are
noted. This article represents a brief review for introductory sinus surgeons and is not
meant as an all encompassing review.
2014 Elsevier Inc. All rights reserved.

1.

Introduction

The increase in patients undergoing endoscopic sinus surgery

(ESS) over the past two decades and accompanying technological innovations necessitate an understanding of inherent
risks as well as approaches to prevent complications. Critical
intracranial and orbital structures surrounding the paranasal
sinuses make adverse events potentially devastating. Several
straightforward precautions combined with sound perioperative strategies may prevent complications and ensure

preparedness for an appropriate course of action in the case

of an unfortunate event, ultimately limiting medicolegal
liability and improving patient safety.

2.

Preoperative considerations

Adequate preoperative evaluation is crucial for prevention of

complications, as understanding variants in patient's sinonasal anatomy and the extent of disease is necessary to facilitate

Financial disclosures: None.

Conflicts of interest: M.S.: speaker for TEVA and MEDA on their Speakers Bureau (not related to the current subject).
Corresponding author at: Department of OtolaryngologyHead and Neck Surgery, Rutgers New Jersey Medical School, 90 Bergen St., Suite
8100, Newark, NJ 07103, USA. Tel.: + 1 973 972 4588; fax: +1 973 972 3767.
E-mail address: jean.anderson.eloy@gmail.com (J.A. Eloy).

0196-0709/$ see front matter 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjoto.2014.01.013

AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y H EA D A N D N E CK ME D I CI N E AN D SUR G E RY 3 5 ( 2 0 14 ) 32 43 2 8

appropriate decision making. ESS should not be undertaken

without radiographic evidence of disease or maximal medical
management. If complications were to occur and a patient
initiates litigation, it may be nearly impossible to justify
the necessity of ESS in such a case. Indeed, the degree of
pathology on imaging is the strongest predictive prognostic
factor after ESS [1]. For symptomatic patients without
radiographic evidence of disease, medical management
alone may satisfy the goals of enhancing patient safety
while minimizing liability. Utilizing the LundMackay staging
assists in CT interpretation in this regard, as a very low score
(at or near 0) is less likely to gain maximal benefit from
operative management [2].
Appreciating variants in skull base anatomy is essential to
avoid intracranial complications [3]. Length of the lamina
lateralis (Fig. 1A), categorized by Keros type [4], plays an
important role in the preoperative review of CT imaging. A
type 3 lamina lateralis has a depth of 816 mm. While this is
found in a smaller percentage of the population, this skull
base configuration is most often violated during ESS [5]. In
contrast, shorter and smaller lamina lateralis, such as type 1,
are less often breached. The majority of patients fall
somewhere in between these two extremes, with a Keros
type 2 that has a depth between 4 and 7 mm.
Another critical aspect of evaluating skull base anatomy
includes disease abutting the skull base. When this is noted
on preoperative imaging, ESS surgeons can be more conser-

325

vative by avoiding complete skeletonization of the skull base

[6]. This ensures that if there are skull base defects, direct and
aggressive manipulation is kept to a minimum. Additionally,
the slope (Fig. 1B) of the skull base and the presence of
dehiscence (Fig. 1C) should be noted on preoperative imaging.
Location of the ethmoidal arteries should be identified on
the preoperative CT. Generally, the posterior ethmoidal artery
is located intracranially. The anterior ethmoidal artery,
however, may be found in the ethmoid sinus mesentery in
20%40% of cases, and is typically adjacent to the superior
oblique muscle (Fig. 1D) [7]. If transection is necessary, it is
preferable to divide these arteries farther from the orbit to
prevent retraction of the cut end of these vessels into the orbit
which could lead to a retrobulbar hemorrhage. Dividing these
arteries closer to the cribriform leaves a remnant vasculature
that can be cauterized even in the case of partial retraction
toward the orbit.
Examination of the medial orbital wall anatomy is also
important preoperatively. The location of the lacrimal sac and
duct and the presence of visible dehiscence of the lamina
papyracea should be noted. The relationship of the uncinate
process to the medial orbital wall is important. If adequate
space exists between the uncinate process and the medial
orbital wall, the former can be dissected away using a sickle
knife. If the uncinate process, however, is against the medial
orbital wall, a frontal sinus probe may be used to gently peel it
away from the orbit.

Fig. 1 Factors to consider in evaluating skull base anatomy preoperatively. (A) Keros type 3 lamina lateralis (dotted line depicts
skull base height). (B) Sagittal CT showing downward sloping of the skull base. (C) Left posterior frontal sinus table dehiscence
(arrow). (D) Coronal CT indicating left anterior ethmoidal artery adjacent to the left superior oblique muscle (asterisk).

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Sinus anatomy variants are important to recognize during

review of preoperative imaging. These include variant
ethmoid cells such as Haller cells, Onodi cells, and agger
nasi cells. Haller cells are found below the orbital floor (Fig. 2A)
and should be noted to avoid intraorbital penetration. Agger
nasi cells are anteriorly located ethmoid cells (Fig. 2B) and may
be viewed anterior to the middle turbinate on coronal CT
imaging (Fig. 2C) [8,9]. Agger nasi cells are important in
deciding optimal approach in surgery involving the frontal
recess [8]. Onodi cells are posteriorly located ethmoid air cells,
lying directly superior to the sphenoid sinus (Fig. 2D). The
optic nerve and carotid arteries may be located within or
nearby Onodi cells; therefore, identifying whether they are
present on preoperative CT is crucial in avoiding serious
sequelae associated with injury of these structures [10,11].
Thorough discussion with patients of informed consent
detailing risks, benefits, and alternatives should be undertaken
prior to ESS. This includes meticulous discussion of potential
intracranial and intraorbital injuries. Recent analysis of
litigation related to iatrogenic orbital injury [12] and cerebrospinal fluid (CSF) leak [13] found that inadequate
informed consents played a significant role in initiation of
litigation. Factors such as orbital injury, CSF leak, bleeding,
infection, and anosmia and hyposmia, should be discussed
with patients [13,14], and documented in writing on
informed consent forms and potentially on an ESS preoperative and postoperative instruction sheets to facilitate
patient comprehension.

3.

Intraoperative approach

Although adequate preoperative preparation is paramount,

there are several intraoperative considerations that should
be noted. Preoperative CT scans should be available in the
operating room for review. Adequate intraoperative visualization is important, given the association between limited
visualization and complications in ESS. Proper bleeding
control is necessary to optimize the surgical field. Achieving
this goal begins preoperatively with a comprehensive history
and providing patients with a written list of both prescription
and non-prescription medications to avoid. Corticosteroid
and antibiotic administration may be considered for patients
with sinonasal polyps and active infections respectively
[1517]. Intraoperatively, it is important to allow adequate time
for the full effects of vasoconstrictive agents. Optimal control of
bleeding includes infiltration of the vasoconstrictive agents in
multiple key sites, including the uncinate process, the anterior
superior attachment of the middle turbinate, the tail of the
middle turbinate, the sphenopalatine region, and the nasal
septum. Greater palatine canal (GPC) infiltration may be
considered in patients with polyposis obstructing transnasal
access to the previously stated injection sites [18]. GPC infiltration is effectively achieved using a needle bent 25 mm from the
tip at a 45-degree angle [19]. In case of bleeding near the skull
base or medial orbital wall, bipolar cauterization is preferable to
unipolar devices. Powered tools such as microdebriders and

Fig. 2 (A) Coronal CT scan showing Haller cell (arrow). Sagittal (B) and coronal (C) CT scans depicting an agger nasi cell (arrows).
(D) Coronal CT of a mucocele from an Onodi cell with skull base and orbital dehiscence.

AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y H EA D A N D N E CK ME D I CI N E AN D SUR G E RY 3 5 ( 2 0 14 ) 32 43 2 8

drills should be kept away from vital structures and due diligence
should be used regarding the speed of these devices.
The increase availability of image guidance systems over
the past decade has resulted in a subsequent increase in their
intraoperative use. Although helpful, image guidance is a complement, rather than a substitute for knowledge of sinonasal
anatomy. The American Academy of OtolaryngologyHead
and Neck Surgery has endorsed image guidance use in select
cases, particularly patients with complex anatomy. Calibrating theses systems may add to surgical time, but they can be
useful in difficult anatomy [20]. Nonetheless, no evidencebased data exist that definitively prove a decreased incidence
in surgical complications or improvement in surgical outcomes with image guidance use [21,22].

4.
Management of postoperative
complications
Retrobulbar hemorrhage occurs from avulsion of ethmoidal
arteries that subsequently retract into the orbit. Ophthalmologic consultation should be sought immediately, as this may
improve patient care and help with potential malpractice
litigation [12]. This complication may present with abrupt
orbital swelling over a span of minutes, extreme pain, diplopia,
proptosis, and ecchymosis [7,23]. Concerns for orbital compression syndrome should be noted if tonometric pressure is within
20 mm Hg of the mean arterial pressure, as this requires urgent
management [24]. Treatment includes head elevation, removal
of nasal packing, control of epistaxis, and various maneuvers to
decrease intraocular pressure and inflammation such as
systemic corticosteroids, topical vasoconstrictors, mannitol,
and acetazolamide. If conservative management fails, timely
canthotomy and/or cantholysis and endoscopic medial orbital
wall decompression should be performed. External orbital
decompression should be reserved for failure of the aforementioned interventions. Occasionally, venous orbital hemorrhage
occurs following violation of the lamina papyracea, and has a
more subacute presentation that includes orbital swelling, pain,
and visual loss over hours in comparison to minutes seen in
arterial causes.
Extraocular muscle injury and resultant dysmotility usually occur from direct muscle injury, muscle entrapment,
orbital fat prolapse, or orbital fibrosis [25]. In the absence of
entrapment or direct muscle injury, conservative measures
such as observation are sufficient [26]. However, a visible
medial orbital wall defect and medial rectus muscle entrapment necessitate exploration and debridement of fractures,
and possible repair with an implant. For direct muscle
transections, reattachment is necessary. Although early
intervention is recommended, long-term injury can be
improved with rectus muscle transposition, although patients
should expect persistent functional impairment [27]. Orbital
emphysema represents another potential injury, which usually occurs from fracture of the lamina papyracea and
subsequent nose blowing, leading to periorbital ecchymosis
[28]. Treatment of this condition includes ophthalmologic
evaluation, antibiotics, and avoidance of nose blowing.
Another potential complication of ESS is injury to the
nasolacrimal system. This usually occurs during maxillary

327

antrostomy, though it typically does not result in epiphora.

Treatment may be conservative, with corticosteroids, antibiotics, and reassurance postoperatively. If the patient does
develop long-term epiphora, dacryocystorhinotomy may
be required.
Direct optic nerve damage is rare following ESS. When it
occurs, it is usually during sphenoid sinusotomy; the presence of
Onodi cells may contribute to the occurrence of this injury [10].
Although there is no proven treatment, a trial of high-dose
corticosteroids may be attempted. Ophthalmologic consultation
should be obtained if this injury is suspected. For optic nerve
injury resulting from direct compression by a bony fragment,
decompression has been helpful if performed in a timely fashion.
Intracranial complications from ESS may have serious
sequelae. Parenchymal brain injury and carotid artery injury
may occur, but are less common than iatrogenic CSF leak [29]. The
latter typically occurs in the setting of excessive intraoperative
bleeding and is present in 0.5% of surgical cases. CSF leak usually
occurs at the area of the lamina lateralis, as previously
mentioned, but can occur anywhere along the skull base.
Treatment involves neurosurgical consultation, and repair of
the defect. A two-layered closure may be helpful, using an
acellular dermal allograft intracranially to plug the defect, and a
free intranasal mucosal graft harvested from the septum or
middle turbinate. Demucosalization of the skull base around the
defect is necessary to prevent intracranial entrapment of mucosa
and later development of intracranial mucocele [30].

5.

Conclusions

Preoperative evaluation and preparation are paramount in

preventing complications in ESS. Clear indications and the
presence of objective radiographic findings should be documented before operative management, both for patient safety and for
legal protection. Attention to patient education and adequate
informed consent may decrease liability should complications
arise. Intraoperatively, optimal visualization may decrease
complications. Although not a substitute for careful planning
and knowledge of sinonasal anatomy, image guidance is helpful
in select cases. In case of orbital and intracranial complications,
timely ophthalmologic and neurosurgical consultation may
minimize adverse outcomes and decrease liability.

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