Complications of Endoscopic Sinus Surgery (ESS)

Describes various complications of Endoscopic Sinus Surgery : their reasons, avoidance and management.

1. Dr. Ausaf Ahmed Khan Professor of ENT/Head & Neck Surgery Hamdard College of Medicine & Dentistry Hamdard University, Karachi Pakistan Complications of Endoscopic Sinus Surgery

2. Introduction Endoscopic Sinus Surgery (ESS) is effective in improving the symptoms of chronic rhinosinusitis. It helps improving the quality of life in these pts. An important drawback is the potential for serious complications. Proximity of critical anatomic structures : orbit, skull base, the internal carotid arteries, dura, and brain.

3. Introduction Complications are both minor and major Most common – hemorrhage, synechia, orbital complications, CSF leak . . . Population at increased risk ; revision surgery, polyps and extensive disease, anatomic variation Their avoidance depends on preoperative awareness of potential surgical pitfalls, proper knowledge of sinonasal anatomy , meticulous surgical technique, and adequate intraoperative hemostasis. When complications do occur , prompt recognition and appropriate management usually result in good outcomes .

4. C o m p l i c a t i o n s MAJOR (1%) CSF leak / Meningitis Orbital hematoma Internal c arotid injury Blindness or  ed vision Major epistaxis Diplopia Anosmia Nasolacrimal duct trauma Intracranial hemorrhage MINOR (7%) Minor epistaxis Adhesions (synechiae) Hyposmia Periorbital ecchymosis Periorbital hematoma Headache Dental / facial pain

5. I - Preoperative considerations II - Intraoperative complications III - Postoperative complications

6. C o m p l i c a t i o n s Intraoperative Intranasal complications Diffuse hemorrhage Arterial injury Intra-orbital complications Orbital fat exposure Intraorbital hematoma Extraocular muscles injury Optic nerve injury Intra-cranial complications CSF leak Carotid Artery injury Postoperative Intranasal complications Epistaxis Sinusitis Olfactory dysfunction Synechia formation Orbital complications Corneal abrasions Diplopia Epiphora Or bital infections Intracranial Complications CSF leak Parenchymal brain injury CNS infections

7. Preoperative considerations

8. By failing to prepare, you are preparing to fail. Benjamin Franklin Preoperative considerations

9. Preoperative considerations WORK-UP Appropriate pre-op. workup: History , bleeding disorders, risk factors for bleeding : antiplatelet medicines, family history of bleeding disorders and excessive bleeding with prior surgery Labs , Consultations – control asthma, allergies, HTN. Documented “failed medical management”? Documented informed consent Explain the risks , benefits, alternatives and complications. Preoperative medical treatment with antibiotics and steroids  decreased mucosal inflammation & edema  reduced intra-op. bleeding & allows better visualization.

10. Preoperative considerations IMAGING Review of pertinent Radiologic imaging studies Can alert the sinus surgeon to potential surgical pitfalls Defect in the lamina papyracea, low-lying cribriform plate (Keros type 3) or dehiscence of a carotid canal. Anterior and Posterior Ethmoidal arteries : especially important in revision surgery, where protective bone in these regions may have been removed Preoperative recognition of anatomic variants : hypoplastic maxillary sinus, sphenoethmoidal (Onodi) cell, undeveloped frontal sinus

11. A defect in the right lamina papyracea with herniation of orbital fat ( arrow) into the ethmoid sinus is evident on this preoperative computed tomography scan. Intraoperative view of Onodi cell at the time of sphenoethmoidectomy. - Preoperative CT scan shows the presence of an Onodi cell ( OC) above the left sphenoid sinus (SS). - The optic nerve (arrowhead) and carotid artery (arrow), which run along the lateral wall of this cell, are at increased risk for injury during a posterior ethmoidectomy

12. Hypotensive anesthesia DEFINITION Reduction of systolic blood pressure to 80-90 mm Hg Reduction of mean arterial pressure (MAP) to mmHg 30% reduction of baseline MAP Propofol Remifentanil 30% reduction in blood loss using IV Propofol infusion versus inhaled anaesthetics. Topical decongestant/vasoconstrictor…..  Head-up position 10-15 

13. REMEMBER !! The 3-D Anatomy of Paranasal Sinuses should be in your head Anatomy Anatomy Anatomy Anatomy

14. Intra operative Complications

15. Intraoperative complications Intranasal complications Diffuse hemorrhage Arterial injury Intra-orbital complications Orbital fat exposure Intraorbital hematoma Extraocular muscles injury Optic nerve injury Intra-cranial complications CSF leak Carotid Artery injury

16. Intraoperative complications Intranasal Complications Diffuse Hemorrhage Diffuse bleeding typically occurs in presence of extensive mucosal inflammation or large nasal polyps. Adequate hemostasis  proper pre-op. preparation (Use of topical decongestants (e.g., oxymetazoline 0.5% or cocaine 4%) / submucosal injection of vasoconstrictive agents (lidocaine with adrenaline) Communication with the anesthesia to maintain hypotensive anesthesia Put intermittent nasal packs soaked in a topical decongestant ; xylo/oxymetazoline with adrenaline (be careful in Cardiovascular conditions).

17. Intraoperative complications Intranasal Complications Diffuse Hemorrhage Microdebrider instrumentation is helpful in such cases because of its ability to simultaneously suction blood from the surgical field and remove tissue. When bleeding cannot be sufficiently controlled to see anatomic landmarks, surgery may be halted  A staged second procedure to remove residual disease when bleeding is no longer an issue.

18. Intraoperative complications Intranasal Complications Arterial Injury Various causes; Resection of the middle turbinate near its posterior insertion site along the lateral nasal wall (pulsatile bleeding from the sphenopalatine artery or one of its branches). How to avoid : Preserve the posterior third of MT. Overly aggressive enlargement of the maxillary ostium in a posterior direction ( bleeding from the region of the sphenopalatine foramen).

19. Intraoperative complications Intranasal Complica tions Arterial Injury How to control such bleeding; Use either monopolar or bipolar cautery If bleeding is brisk  use suction cautery Avoid excessive cauterization : delayed healing and postoperative discomfort from crust formation and osteitis. For more definitive control of arterial bleeding  apply a clip on the sphenopalatine artery where it exits from the pterygopalatine fossa

20. Endoscopic image of two clips placed on the left sphenopalatine artery ( SPA ) for control of severe epistaxis following endoscopic sinus surgery. The SPA is located between the posterior wall of the maxillary sinus ( MS) and the horizontal insertion of the middle turbinate ( MT). FS, Frazier suction tip.

21. Intraoperative complications Intranasal Complications Arterial Injury Avoid damaging Posterior septal branch of SPA during enlargement of natural ostium of sphenoid sinus in inferior direction Pulsatile bleeding may occur because the vessel runs transversely in the soft tissue located below the natural sphenoid ostium and above to the choanal arch. Use Monopolar or bipolar cautery, with or without suction. Consider Prophylactic cauterization and transaction of this vessel.

22. Endoscopic visualization and anatomical scheme of the posterior septal branch of the SPA, arrow head is pointing out the same bleeding artery

23. Intraoperative complications Intranasal Complications Arterial Injury Injury to the anterior or posterior ethmoid artery along the ethmoid roof can result in significant intraoperative bleeding. The posterior ethmoid artery : runs @ 5 mm anterior to the sphenoethmoid angle. The anterior ethmoid artery : traverses the skull base @12 mm anterior to the posterior ethmoid artery.

24. Intraoperative complications Intranasal Complications Arterial Injury Why injury occurs there is bony dehiscence of their canals or when they are mistaken for an ethmoid septation. In the extensively pneumatized ethmoid labyrinth, the AEA (and, rarely, the PE Artery) may lie below the level of the skull base, traversing the ethmoid along a mesentery. In such cases, the artery may be particularly susceptible to injury, but this anatomic variant can be anticipated by a careful preoperative review of CT images.

25. Intraoperative complications Intranasal Complications Arterial Injury Blood flow through the ethmoid arteries occurs from lateral to medial direction (via ophthalmic artery)  their disruption must be meticulously managed to avoid retraction of the arterial stump into the orbit co uld lead to intraorbital hemorrhage . If electrocautery is used : use Bipolar cautery (to avoid transmitting current to skull base and orbit) Consider external or endoscopic ligation of AEA in complicated cases.

26. Intraoperative complications Intraorbital Complications Orbital fat exposure REASONS during uncinectomy near the start of sinus surgery  Incision of the UP that is directed too far lateral or posterior Hypoplastic or atelectatic maxillary sinus Aggressive lateral dissection during ethmoidectomy Inadvertent penetration or removal of the lamina with exposure of the periorbita usually does not have adverse consequences if it is recognized promptly and the periorbita has not been violated . Avoid powered instrumentation to minimize risk of inadvertent damage to orbital contents

27. ??? Sign STANKIEWICZ SIGN

28. Intraoperative complications Intraorbital Complications Orbital fat exposure WHAT TO DO ? If the periorbita has been violated & orbital fat seen  avoid further manipulation of exposed fat within the ethmoid. No repair of this defect is needed. If vision is not obscured  surgery be continued as planned. Perform serial examinations of eye during the remainder of surgery to ensure that I/Orbital hemorrhage has not developed. Avoid Nasal packing  Placement of packing over the orbital defect can create a one-way valve and trap air or blood within the orbit  periorbital edema, ecchymosis, subcutaneous emphysema, or proptosis may develop Continue close monitoring of the eye, including vision testing

29. Intraoperative complications Intraorbital Complications Intraorbital Hematoma Synonyms : Retro-orbital or Retrobulbar hemorrhage A potentially devastating complication of ESS Favourable outcome if recognized promptly and treated appropriately Reasons of Bleeding into the orbit injury to vessels within the orbit retraction of a bleeding anterior or posterior ethmoid artery Consequence increased intraorbital pressure with retinal ischemia. ** The retina can tolerate 30 to 90 minutes of ischemia before irreversible damage.

30. Intraoperative complications Intraorbital Complications Intraorbital Hematoma    Medical management of a slowly expanding Orbital Hematoma without visual loss ; Immediate Ophthalmology consultation, Serial examination of visual acuity and IOP., Removal of nasal packing and eye massage, I/V Dexamethasone (0.2 mg/kg), Mannitol (1 to 2 g/kg IV), Acetazolamide (10 to 15 mg/kg IV). Signs & Symptoms Tense globe , increased Intraocular pressure , loss of pupillary reflex , eye pain , limited eye mobility & decreased vision . 

31. Intraoperative complications Intraorbital Complications Intraorbital Hematoma For rapidly expanding hematomas  Perform Lateral canthotomy and cantholysis without delay A simple and effective procedure that can be done in the OR, Recovery or bedside LATERAL CANTHOTOMY Incision of the lateral canthal tendon CANTHOLYSIS Canthotomy combined with disinsertion of at least the inferior crus of the lateral canthal tendon

32. lateral canthotomy and cantholysis healed without the need for repair Lateral canthotomy performed by advancing a scissor to the bone of the lateral orbital rim and incising full thickness of skin and underlying canthal tendon Additional reduction in intraorbital pressure can be achieved with an inferior cantholysis Right eye of a patient who underwent a lateral canthotomy with cantholysis

33. Intraoperative complications Intraorbital Complications Intraorbital Hematoma If these measures do not bring clinical improvement  perform M edial orbital decompression done either by an endoscopic or external approach removal of the lamina papyracea Exploration of the orbit for ligation of a specific bleeding vessel  generally not recommended.

34. (a)-completed ethmoidectomy with extirpation of the ethmoid (E) and maxillary sinuses (M) and removal of medial and part of inferior orbital walls to expose the orbital periosteum (OP). The middle turbinate (MT) is seen in the medial part of the surgical field. (b)-Slitting of the orbital periosteum with resultant prolapse of the orbital fat (OF) left endoscopic orbital decompression

35. Intraoperative complications Intraorbital Complications Extraocular muscle injury Occurs if violation of the lamina papyracea is not recognized at the time of surgery and dissection continues through periorbita Muscles injured ; Med. Rectus > Inf. Rectus > Sup. Oblique. Use of microdebrider poses greater risks of injury Range of Injuries : muscle contusion  complete transection If an EOM injury recognized at the time of surgery :  urgent intraoperative consultation with ophthalmologist  determine the extent of injury and the need for immediate orbital exploration with muscle repair. Consider strabismus surgery later on to treat diplopia

36. Postoperative computed tomography scan of a patient who suffered orbital injury during sinus surgery. Passage of a motorized instrument through the lamina papyracea resulted in transection of the medial rectus muscle ( arrow). Preoperative recognition of the atelectatic right maxillary sinus with an unusually low right orbital floor ( arrowhead) might have prevented the injury.

37. Axial CT of a patient who underwent ESS. Pt. complained of postoperative diplopia. The CT reveals a large dehiscence of bone along the right orbit and evacuation of the orbital contents. This Injury was sustained when the surgeon violated the LP with a microdebrider. In this situation, the suction power of the microdebrider drew orbital fat as well as extraocular muscle.

38. Intraoperative complications Intraorbital Complications Optic Nerve injury Prevention of optic nerve injury during ESS is critical Severe morbidity (blindness or partial loss of vision) Lack of treatment options When it occurs; If Lamina papyracea is violated, accidental instrumentation within the orbital apex can result in optic nerve injury During manipulation within the superolateral sphenoid sinus if the optic canal is dehiscent. An unrecognized Onodi cell can place patients at risk for optic nerve injury during a posterior ethmoidectomy.

39. Intraoperative complications Intraorbital Complications Optic Nerve injury How to prevent Perform Sphenoidotomy by careful enlargement of the natural sphenoid ostium, (anteromedial aspect of the sphenoid), so that bone removal begins as far away from the optic nerve as possible. Identify Onodi cell on the preoperative CT scan. If present, care should be taken during dissection in this region If injury to the optic nerve is suspected during surgery Give high-dose systemic corticosteroids Ophthalmologic consultation should be obtained Patient awakened in a timely fashion to assess visual acuity. A postoperative CT scan is necessary

40. Fig. 29.2 (A) Preoperative computed tomography scan demonstrates the presence of an Onodi cell ( OC) located above the left sphenoid sinus ( SS). The optic nerve (arrowhead) and carotid artery (arrow), which run along the lateral wall of this cell, are at increased risk for injury during a posterior ethmoidectomy. (B) Intraoperative view of the Onodi cell at the time of a sphenoethmoidectomy.

41. Intraoperative complications Intracranial Complications CSF leak Incidence of CSF leak ; around 0.5% When it occurs ; violation of the skull base during surgery, Excessive intraoperative bleeding  obscured landmarks  surgical disorientation. What to do when surgery becomes technically difficult and anatomic landmarks are obscured  better to leave the disease along the skull base and terminate the procedure. Image guidance technology can help to confirm the location of skull base : BUT can not be solely relied upon !!

42. Intraoperative complications Intracranial Complications CSF leak Where it occurs most :  Anywhere along skull base junction of the AEA and MT along the anterior ethmoid roof (thinnest and most susceptible to injury area) posterior ethmoid roof, cribriform plate, posterior wall of the frontal sinus, roof of the sphenoid sinus.

43. Intraoperative complications Intracranial Complications CSF leak How it appears ; Stream of clear fluid OR A dark stream coursing running through blood. If only minimal bleeding is present, alternating streams of clear CSF and red blood are seen. Oh my God Its CSF !  step back and collect you thoughts and act accordingly : seek help if u want . . . . Likelihood of success if recognized per-operatively and managed correctly : > 90%

44. Intraoperative complications Intracranial Complications CSF leak Intraoperative leaks during ESS are usually small <1 cm Mostly repair with a single layer consisting of a free intranasal mucosal graft from septum or turbinate. Occasional larger defects require additional layer : septal bone or cartilage placed on the intracranial side The mucosal graft is stabilized and protected with SURGICEL or GELFOAM. Additional layer of nonabsorbable packing, such as strip gauze or MEROCEL.

45. Intraoperative complications Intracranial Complications CSF leak The nonabsorbable packing is removed after 1 week Absorbable packing is left & allowed to dissolve. Obtain CT Scan once the patient is awake and out of the operating room : pneumocephalus or intracranial injury. Antibiotics ( I/V with CSF Penetration/Oral antistaphylococcal antibiotics) : Controversial Lumbar drain +/- CT scan 3 to 6 mo post-op. for surveillance of repair

46. Intraoperative complications Intracranial Complications Carotid Artery injury One of the most catastrophic complications that can occur during ESS INCIDENCE is less than 0.1%. Devastating Consequences with stroke WHEN DOES IT OCCURS ? When the sphenoid sinus is entered too far laterally When surgical dissection is performed along the lateral sphenoid wall and the carotid canal is penetrated. Microdebrider used within the SS HOW TO AVOID ? Enter the sphenoid sinus medially through natural sphenoid ostium Enlarge this opening in an inferio-medial direction Avoid instrumentation within the sphenoid sinus : If required, approached with extreme caution. Avoid removing the intersphenoid septum

47. Bolger's Box: boundaries: lateral – Lamina Papyracea, Superior – Skull base, Inferior – Ground lamella Medial – Septum & Superior turbinate.

48. Intraoperative complications Intracranial Complications Carotid Artery injury WHAT WILL HAPPEN Profuse bleeding will rapidly fill the nasal cavity. WHAT TO DO IMMEDIATELY Pack the sphenoid sinus. Aggressive fluid resuscitation Hemodynamic control to maintain cerebral perfusion. Arrange blood and blood products Call Neurosurgeon and interventional Neuroradiologist Shift to a tertiary care canter THE CAROTID DRILL 

49. Treatment of Carotid Artery Injury THE CAROTID DRILL Tertiary care center 1. For every sinus operation, have available, on momentary notice, two long polyvinyl acetate (Merocel) sponges, petroleum-impregnated gauze, two 18F Foley catheters and umbilical damps for nasal packing. 2. Pack nose immediately at the first sign of severe hemorrhage. 3. Compress the carotid artery in the neck on the affected side. 4. Begin anesthesia to induce controlled hypotension. 5. Ready blood for transfusion. 6. Call neurosurgeon immediately. 7. If patient's condition is unstable, the neuroradiologist should perform intraoperative arteriography. If patient's condition is stable, transfer the patient to neuroradiology suite. 8. Perform balloon occlusion under EEG surveillance. a. If there is no evidence of a change in perfusion or lateralization, ligate the carotid A. b. If changes are present on the EEG (dangerous recording), deflate the balloon, maintain packing, and observe. 9. Insert Swan-Ganz catheter. Put the patient in a hyperdynamic state by using high molecular weight starch to increase cerebral perfusion. 10. After cerebral perfusion has been increased, reinflate the balloon and check the EEG. a. If lateralization occurs, try carotid bypass. b. If bypass is possible, reinflate the balloon and ligate the carotid artery.

50. Nontertiary hospital 1. Call neurosurgeon . 2. Expose the carotid artery in the neck . 3. Temporarily occlude the carotid artery with a clamp or tape. 4. Ligate the carotid artery. 5. Perform a trapping procedure: Clip the carotid artery below the anterior communicating artery to isolate this segment from blood flow Treatment of Carotid Artery Injury THE CAROTID DRILL

51. Postoperative Complications

52. Postoperative complications 1) Intranasal complications Epistaxis Sinusitis Olfactory dysfunction Synechia formation 2) Orbital complications Corneal abrasions Diplopia Epiphora Orbital infections 3) Intracranial Complications CSF leak Parenchymal brain injury CNS infections

53. Post-operative complications Intranasal Complications Epistaxis Incidence ; 2% When occurs; immediately following surgery from inadequate hemostasis 5 to 7 days after surgery when intranasal scabs dislodge Most common sites : turbinates and septum How to prevent ; placement of packing material/absorbable hemostatic agents NB: If excessive bleeding is not present at the conclusion of surgery, studies have suggested that nasal packing need not be placed at the conclusion of routine endoscopic sinus surgery

54. Post-operative complications Intranasal Complications Epistaxis Management Mild bleeding  topical decongestant sprays Severe bleeding  check vitals, control hypertension, draw blood sample: Hb., Crossmatch, IV , fluid volume replacement. identify the site of bleeding with an endoscope silver nitrate cauterization under direct visualization. absorbable or nonabsorbable nasal packing tamponade balloons operative exploration with electrocauterization SPA, AEA, PEA ligation (endoscopic/open approach) embolization of bleeding vessel interventional radiologist

55. Post-operative complications Intranasal Complications Sinusitis Incidence; up to 16 % of patients Reason Raw mucosal surfaces intranasal bacterial colonization decreased mucociliary clearance of nasal secretions How to reduce incidence Prophylactic use of antistaphylococcal antibiotics frequent nasal saline irrigations postoperative sinus debridement If sinusitis develops in the postoperative period endoscopically directed cultures appropriate antibiotic

56. Post-operative complications Intranasal Complications Olfactory dysfunction May present during healing period for 1 to 2 weeks. If abnormal olfaction persists after the healing of the sinus cavities  do nasal endoscopy and a sinus CT scan If symptoms persist after topical or oral corticosteroids  olfactory testing Avoid mucosal trauma along the olfactory cleft or cribriform plate during surgery.  Postoperative adhesions b/w MT and septum

57. Post-operative complications Intranasal Complications Synechiae Mostly small, asymptomatic and noted as incidental findings at the time of nasal endoscopy following sinus surgery . Dense adhesions and synechiae  postoperative anosmia, recurrent sinusitis , and mucocele formation One study showed its incidence was 56 % Contributing factor for failure in up to 31% of patients If the middle turbinate mucosa is traumatized  adhesion may form between MT and lateral nasal wall  obstruction of sinus drainage pathways. Adhesion between the medial surface of the middle turbinate and septum  postoperative airway obstruction & anosmia.

58. Post-operative complications Intranasal Complications Synechiae How to prevent ; insert a spacer or packing material How to treat; If adhesions noted at the time of office endoscopy in early post-op. period  can be divided with minimal discomfort. Once healing is completed  divide under lo cal or general anesthesia  splints

59. Post-operative complications Orbital Complications Corneal abrasions Reason inadvertent contact with the surgeon’s hands or instruments. Symptom eye pain and foreign body sensation Refer to ophthalmologist : fluorescence staining and slit-lamp examination. Treatment Topical antibiotic ointment and patching. How to prevent ophthalmic ointment and taping of the eyelids scleral shell or a large contact lens

60. Post-operative complications Orbital Complications Diplopia Indicative of injury to an EOM or its motor nerve Medial rectus muscle most commonly injured Reason ; Violation of lamina papyracea and periorbita with the passage of an instrument into the orbital cavity Complete rectus muscle transection with microdebrider If superficial muscle injury or intraorbital inflammation : Spontaneous resolution of diplopia What to do ophthalmic consultation to document visual acuity and globe status CT scan to localize the site and extent of injury eye patch or an eyeglass prism Strabismus surgery to correct persistent double vision

61. Post-operative complications Orbital Complications Epiphora Injury to the nasolacrimal duct during maxillary antrostomy. Reason ; Use of back-biting forceps or a microdebrider is used to enlarge maxillary ostium too far in an anterior direction

62. Post-operative complications Orbital Complications Epiphora Injury to the nasolacrimal duct during maxillary antrostomy. How to avoid ; avoiding removal of the bone anterior to the maxillary line when enlarging the ostium. Symptoms ; epiphora or dacryocystitis Treatment ; probing, irrigation, or intubation of the lacrimal system. endoscopic dacryocystorhinostomy (DCR)

63. Post-operative complications Orbital Complications Orbital infection Reasons; Direct spread of bacteria through bony dehiscence in LP Retrograde thrombophlebitis from valveless veins. Signs ; eye pain , periorbital edema, and erythema Treatment Broad-spectrum oral or intravenous antibiotics Removal of any intranasal packing close monitoring for an extension of the infection into the orbital compartment If symptoms worsens  CT imaging to rule out orbital cellulitis, abscess, or cavernous sinus thrombosis.

64. Post-operative complications Intracranial Complications CSF leak SYMPTOM persistent , unilateral and watery rhinorrhea after ESS. clear nasal drainage when the patient leans forward NASAL ENDOSCOPY Look for pulsatile tissue or clear fluid drainage CT SCAN evaluate the integrity of the skull base, Look for the presence of a bony defect or pneumocephalus Beta -2 transferrin assay Use of prophylactic oral antibiotics in patients with CSF leaks is controversial Pts. must be counselled regarding the signs and symptoms of meningitis and instructed to seek immediate medical care if any clinical changes develop. Conservative measures , including lumbar drainage catheter and bed rest , have been described for the treatment of CSF leaks, May consider early surgical repair to decrease the risk of meningitis.

65. Post-operative complications Intracranial Complications Parenchymal brain injury Parenchymal brain injury and intracranial bleeding may occur if an instrument is passed through an unrecognized skull base defect. Mental status change or neurologic deficits in the immediate postoperative period are suggestive of such neurologic injury . Do an urgent CT scan or MRI Neurosurgical consultation to determine the site and extent of brain tissue injury.

66. Post-operative complications Intracranial Complications CNS infections Rare nowadays 1- Meningitis Usually the result of an unidentified CSF leak, There is direct bacterial spread from the sinonasal cavity through a skull base defect. Severe Headache , high fever , photophobia, and nuchal rigidity after sinus surgery Emergent evaluation with CT scan, lumbar puncture, and neurologic consultation Intravenous antibiotics.

67. Post-operative complications Intracranial Complications CNS infections 2- Intracranial abscesses Can develop in the epidural, subdural , or intraparenchymal spaces Need Neurosurgical drainage . 3- Cavernous sinus thrombosis Occurs from venous extension of sinus or orbital infection Signs : Proptosis , chemosis, and ophthalmoplegia MRI/Magnetic resonance venography Neurology and Infectious disease consultation Intravenous antibiotics and anticoagulation

68. Conclusion Complications of both minor and major consequence are associated with the performance of endoscopic sinus surgery. Their avoidance depends on preoperative awareness of potential surgical pitfalls, proper knowledge of sinonasal anatomy , meticulous surgical technique, and adequate intraoperative hemostasis. When complications do occur , prompt recognition and appropriate management usually result in good patient outcomes

69. Thank You