niyada

Prevention

• Avoid dangerous cases : revision, massive diseases, bleeding tendency

• Pre op. CT scan, CT aid ESS

• Pre op. preparation

• Intra op. observation

• Post op. care

Intra-operative observation

• Sedation, Hypotensive anesthesia

• Draping, Eye observation

• CT review

• Bulb press test

• Be careful ; Microdebrider, Over packing

• Image-guided ESS

Hemorrhage

Minor hemorrhage

• Common and require minimal intervention

• Mucosal cause

• Tendency to bleeding in long term local steriod use / Post infection

Minor hemorrhage

• Treatment – Cotton soaked with epinephrine– Packing – Local Electrocautery

Minor hemorrhage

• Prevention – Adequate prepare nasal mucosa with

vasoconstrictor– Avoid tearing mucosa– Meticulous and careful dissection – Good quality sharp or non-tearing instrument– Gently and non-traumatizing packing

Major hemorrhage

• Anterior ethmoidal artery– Usually in bony canal

but can be dehiscense– Bipolar cauterization

and packing

Major hemorrhage

• Sphenopalatine artery– Posterior septal

branch and branch to MT

– Related to the MT removal

– High pressure

Sphenopalatine artery

Major hemorrhage

• Cauterization or endoscopic ligation

Internal carotid artery injury

• Rare and high mortality

• Risk in surgery of sphenoid sinus and posterior ethmoid air cell

• ICA locate on lateral wall of sphenoid sinus• Dehiscence of the bony canal about 23 %

Management

Prevention

• Assess distance with measured probe

Prevention

• Avoid trauma to intersphenoid septum

• Sphenoidotomy should be performed inferomedial

• Not blind manipulate in sphenoid sinus

Orbital complications

Orbital complications

• Orbital hematoma

• Blindness

• Diplopia

• Nasolacrimal duct injury

• Subcutaneous emphysema

Predisposing factors

• Dehiscence of LP• Revision surgery• Distorted anatomy• Sphenoethmoidal cell (Onodi cell)• Extensive nasal polyp• General anesthesia• Bony destructive lesion

Predisposing factors

• DNS

• Concha bullosa

• Lateralized paradoxical turbinate

• Hypoplastic maxillary sinus

“ Uncinate process close to LP ”

Orbital hematoma

• Occur intra-op until post-op 10 hr.

• High potential to blindness

• Cause – Ant. ethmoidal artery injury

and retracted into orbit : sudden raise in IOP

– Vein lining the LP tearing : slow progress hematoma

Orbital hematoma

• Hematoma produce pressure on central retina artery

• Retinal ischemia persists >90 min. cause blindness

Orbital hematoma

• Symptoms & signs– Eye pain– Rapid proptosis– Ecchymosis usually at

medial first– Subconjunctival hemorrha

ge

• Symptoms & signs– VA drop or blindness– Marcus Gunn’s pupil

Orbital hematoma

• Treatment– Aim to relieve pressure on arterial supply of

optic nerve– Reverse from GA– Ophthalmologist consultation– Conservative treatment– Medical treatment – Surgical treatment

Conservative treatment

• Remove nasal packing

• Stop bleeding in the sinus

• Head elevation

• Control Blood pressure

• IOP measurement q 5-10 min.

• Orbital massage

(contraindicate in previous eye surgery)

Medical treatment

• Indicate in elevated IOP and VA drop• 20% Mannitol 0.5-1 mg/kg IV. drip in 20-30

min.– Osmotically drawing fluid out of orbital spa

ce– Early onset of action

Medical treatment

• Azetazolamide 500 mg. IV – Decrease aqueous humor production– Delayed onset of action

• Avoid Fimolol or Pilocarpine (masking pupil exam)

• Systemic steroid (controversy)– Dexamethasone 1 mg/kg then 05. mg/kg q 6 hr

Surgical treatment

• Indicate in conservative failure • Lateral canthotomy and inferior cantholysis

Surgical treatment

• Orbital decompression – External

ethmoidectomy– Endoscopic approach

• Optic nerve decompression (last choice)