avoiding complications in sinus surgery: did you check … · avoiding complications in sinus...
TRANSCRIPT
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Avoiding Complications in Sinus Surgery: Did you check that?
Mark A. Zacharek, MD, FACSAssociate ProfessorDepartment of Otolaryngology-HNSUniversity of Michigan Health System
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Complications
• Major Minor-Intracranial - Synechiae-Intra-orbital -Atrophic rhinitis-Blood loss requiring -Crustingblood transfusion -Epiphora
-Hyposmia/anosmia-Nasal obstruction-Iatrogenic sinusitis
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Incidence of Complications
• <0.05%• Most common – hemorrhage, orbital complications, CSF
leak• Populations at increased risk:
-Revision surgery-Polyps and extensive disease-Anatomic variation
Stankiewicz et al. Laryngoscope (2011)
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“By failing to prepare, you are preparing to fail”
Benjamin Franklin
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Preoperative Checklist• Established the right diagnosis?• Documented “failed medical management”?• Performed the appropriate preoperative workup?
-History and physical exam, labs, consultations• Documented informed consent?• Explain the risks, benefits, and alternatives and
complications• Teach back
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Preoperative Checklist
• Review sinus/skull base anatomy imaging (CT/MRI)• Maxillary-to-ethmoid sinus ratio• Slope of the skull base• Anterior and posterior ethmoid artery• Lamina papyracea (prior orbital fracture?)• Optic nerve and carotid artery in sphenoid• Anatomic Variants
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Preventing Complications
• Try to minimize intra-operative bleeding
• Poor visualization = complications
Patient
Surgeon Anesthesia
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Pre-operative steroids – Decrease mucosal inflammation• Extensive nasal polyps
-Asthmatic sinusitis, AFS, Aspirin triad-Preoperative oral steroid if no contra-indications-Prednisone 30mg po QD for 3-7 days-Postoperative oral steroid after FESS-Consider effects of oral steroid
Minimal effects on total blood loss but significant effects on visual fields
-Sieskiewicz et al. Pre-operative corticosteroid oral therapy and intraoperative bleeding during FESS in patients with severe nasal polyposis, Ann Otol Rhinol Larngol (2006)
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Peri-operative antibiotics (EBM?)
• Start 1 week prior and continue for 2 weeks after• Levofloxacin, moxifloxacin – gram-negative coverage,
QD dosing• Clindamycin- gram positive, gram negative, anaerobe,
bone penetration• Clarithromycin/erythromycin – low dose macrolide for
anti-inflammatory due to infection (remember Q-T prolongation and predisposition to Torsade de pointes and Ventricular tachycardia)
• Please consider side effects of antibiotics (C. dificile, effects on nasal and pulmonary biome)
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Bleeding in FESS; Anesthesia Factors
• Hypotensive anesthesia• -Orthopedic literature• -Revision hip replacement – 30% reduction in blood loss
using IV propofol infusion versus inhaled anesthestics
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Anesthesia Factors
• Key to limit bleeding = Decrease in venous bleeding
• Physiologic way to do so = decreased central venous pressure
• Communicate with anesthesia team to control blood pressure
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Decrease CVP• Decrease fluid intake• LMA vs. Endotracheal tube• -Decrease catecholamine surge in initial 15 minutes of
surgery with LMA vs ETT• Maintain HR < 60• Preoperative clonidine (alpha 2 agonist/imidazoline
receptor agonist) – acts centrally
• TIVA (Total Intravenous Anesthesia) –-Total intravenous propofol infusion with remi-fentanyl infusion
Wormald PJ et al. The effect of total intravenous anesthesia on the surgical field during endoscopic sinus surgery. Am J Rhinol 2005;19(5):514-20.
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Reverse Trendelenburg reduces CVP
30 degrees
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Preparation• Position – arterial flow• 38.3% reduction of nasal blood flow with head elevation
(at head of IT)• 4.7% change with PPF injection• Gurr et al. Laser-Dopler blood flowmetry measurement of nasal mucosa
blood flow after injection of the greter palatine canal. Journal of Laryngology and Otology. 110(2):124-8, Feb (1996).
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Intra-op Maneuvers
• Topical Thrombin/epinephrine• -2 ampules thrombin (1:10,000) in 1 ampule of
epinephrine (1:1000)• Plain epinephrine (1:1000)• Not used in children, diluted (1/2 or 1/4 in patients with
cardiac history)
• Warm/hot saline flushes• Though to stimulate intrinsic coagulation cascade (tissue
thromboplastin)
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Orbital Hematoma
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Orbital Hematoma
• Peri-orbital Injury• Incidence has direct correlation with surgeon experience• 1-20 cases 8.3%• 20-100 cases 4.7%• 100-200 cases 2.5%• 200-300 cases 0.2%• Stankiewicz (1999)• 15/3500
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Orbital Bleeding• Three types of orbital hematoma
-Spontaneous-Traumatic-Iatrogenic associated with endoscopic sinus surgery
Intra-operative bleeding-Arterial bleed- Acute process- Anterior or posterior ethmoid artery
-Venous bleed- Slow process- Several hours after FESS
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Slow Orbital Bleed• Slow (venous) orbital hematoma• -Injury to orbital or ophthalmic veins
With slow accumulation of blood or Defect in lamina papyracea with Blackflow of bleeding
• -Gradual onset-Ecchymosis, proptosis,Pupillary dilation, decreasedVisionRise in intraocular pressure
• -Ophtho consult – measure IOP• Observation
Most common cause-Inadvertantentry into orbit during maxillary antrostomy or ethmoidectomy
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How to prevent orbital injury: Understand relation of the uncinate process to medical orbital wall:
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Understand the Maxillary sinus Ostium and relation to the lamina• Maxillary Ostium is typically• Located between the inferior 1/3
and superior 2/3 of the uncinateprocess along the maxillary line
• Visualize line prior to uncinectomy
• Move uncinate away from orbit usingback end of ball tip probe to createspace between orbit and uncinate
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Understand Relation between Uncinate and Lamina
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Early Detection
• Fat ExposureMicrodebriders can suck a lot of fat and muscle very rapidly
• Do not manipulate or remove fat-Do not use a monopolar cautery to “shrink fat”-If fat is obstructing further dissection, use bipolar
• Minimize nasal packing• Avoid noise blowing or sneezing
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Ethmoid Arteries
• Ethmoid arteries branchesof ophthalmic artery
• Enter nasal cavity alongthe fronto-ethmoidal Suture• 24-12-6 rule from the
anterior lacrimal crest
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Anterior Ethmoid Artery 20% Below skull base
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Posterior Ethmoidal Artery
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Intra-op Orbital Hematoma
• Arterial orbital hematoma-Injury to anterior/posterior ethmoidal artery with retraction into orbit
• Within minutes of injury:-Proptosis, chemosis, pupillary dilation-----vision loss-Rise in intraocular pressure – 90 minutes of retinal artery occlusion results in permanent blindness
• Requires urgent treatment
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Orbital Hematoma
• Bulb Test-Gently palpate globe
• Examine lamina Papyracea withEndoscope
• Evaluate for movementof periorbita and/or fat
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Orbital Hematoma
• Ophthalmology Consult• -Ascertain APD• -Measure IOP of both orbits• -20mg Hg of MAP• -Observe
• <20mm Hg of MAP or visual• Change• -Decompress
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Orbital Hematoma
• Eye massage• -Redistributes intraocular and extraocular fluids• Topical timolol (0.5%)• Acetazolamide 500mg IV• Mannitol 20% (1-2g/kg over 20-30 minutes)• Steroids (Dexamethasone or Solumedrol)• Remove any non-absorbable packs• Surgical maneuvers
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Orbital Hematoma
• Surgical Maneuvers-Canthotomy and CantholysisMedial orbital wall decompressionOrbital floor decompressionEndoscopic artery ligationExternal artery ligation
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Lateral Canthotomy and Inferior Cantholysis
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Extraocular Muscle Injury
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Extraocular Muscle Injury• Most common structures• -Medial rectus > superior oblique > inferior rectus• Forced duction to rule out entrapment or laxity• If viable muscle found, repair per neuro-ophthamology• If not detected until post op period, then early exploration• And repair advised
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Blindness – causes
• Direct injection of cocaine or epinephrine
• Orbital compartment syndrome (OCS)-Retro-orbital hematoma-Orbital emphysema
• Retinal artery spasm• Optic nerve transection
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Onodi Cell
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Epiphora
• Post-FESS epiphora• -0.3-1.7% (Unulu, 2001)• -15% occult injuries via • cadaver study (Bolger 1992)
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Iatrogenic Cerebrospinal Fluid Leak
• Frequency of iatrogenic • CSF leaks
-1-20 FESS: 3.3-4%-20-100 FESS: 1%- >100 FESS: 0.05%
• Increase in peri-orbitalComplications in cases31-180
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Anatomy – Skull Base
Keros I1-3mm deep
Keros II4-7mm deep
Keros III8-16mmdeep
Danger
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Anatomy – Skull Base
Keros IVAsymmetric
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Maxillary to Ethmoid Ratios
• High Risk Feature/Variant Percentage (%)
Maxillary-to-Ethmoid ratio 1:1 38.6
Maxillary-to-Ethmoid ratio 2:1 54.3
Maxillary-to-Ethmoid ratio >2:1 7.1
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Maxillary to Ethmoid ratioTip – Use roof of the maxillary sinus as vertical limit when moving anterior to posterior
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Intraoperative Maneuvers – CSF Leak
• Step 1• -Stop and Recompose
-Hemostasis-Review the anatomy-Ct or MRI-Correlate to endoscopicAnatomy
-Make sure you are honestwith yourself regarding sizeand number of defects
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Can’t identify site? Large Defect? Is brain in the defect?• Step II• -Antibiotics• -Hemostasis• -Aspirate stomach• -Anti-emetics• -Quiet wake-up• -Stat Head CT/CT• -Angiogram if microdebrider• entry
Can identify site
Repair if possible
Can’t identify site
Lightly pack nosePerioperative IVAntibioticsQuiet wake upCT of head
Consult colleagueTransfer to rhinologist
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Intraoperative Maneuvers II
• Site preparation – don’t compound the problem-Maximally open surrounding sinuses-Prevent obstruction secondary to packing-Control bleeding intracranial hematoma
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Intraoperative Maneuvers II
• Step II• -Measure defect size• -Graft selection• -multiple variables• -location of injury• -Rarely need bone graft
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Intraoperative Maneuvers - II
• Mucosa-Inferior turbinate -Middle turbinate-Septum-Nasal floor-Naso-septal flap if extremely large defect-Closure with graft pressureusing dissolvable nasal packing-multiple methods
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Post-Op
• Full Disclosure – be honest with patient and family• Expect bad headaches if brain has been bruised• IV abx, head of bed 15 degrees• Bedrest for 24 hours• Keep packing in for 5 days• Frontal sinus stent for 10 to 14 days• Limit post-operative debridements
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Summary of Complications
• Be prepared and plan ahead for each sinus case • Study preoperative imaging• -Ethmoid height, skull base position, anomalies• Take time to have as bloodless of a field as possible• When you the a complication, take a few moments to
compose yourself, and execute• Bring in a colleague or call a local rhinologist to help you
think through things
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Imhotep: Egyptian God of MedicineTemple of Sobek and Haroeris, Aswan
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It’s all about the nose