Sinus Surgery Management

Educational Objectives

The goal of this program is to improve the outcomes of sinus surgery. After hearing and assimilating this program, the clinician will be better able to:

1. Identify major causes of sinus surgery complications.
2. Determine the factors that increase the risk for cerebrospinal fluid leakage.

Summary

Complications of sinus surgery: include periorbital ecchymosis, emphysema (especially in patients who blow their nose and have coughing episodes), epistaxis, intranasal adhesions, and corneal abrasions; major complications are much more severe and may involve the eye, hematoma, blindness, diplopia, and intracranial injuries; the major reasons for injury are usually intraoperative loss of orientation, loss of landmarks, and excessive bleeding that obscures visualization

Preoperative evaluation: orientation should be obtained preoperatively by computed tomography (CT); the typical CT for sinus surgery is an axial CT with coronal and sagittal reconstructions; analyze anatomy and make a plan before surgery on how to perform it; make contingency plans for conditions that may require stopping the surgery; study the imaging in detail; analyze the skull base, medial orbital wall, and height of the posterior ethmoid in the scan and review the plan; evaluate the olfactory groove to determine anatomic characteristics and sphenoid (dehiscence, carotid nerve, optic nerve, pituitary); clinicians should also focus on the orbits, including the nasolacrimal duct, medial wall, and orbit floor; analyze the uncinate process for atelectasis; evaluate the anterior ethmoid artery for abnormal configurations; the posterior ethmoid artery is not significantly seen at the skull base; assess the height of the ethmoid sinus, going to the highest point on the maxillary sinus and measuring the height; the speaker prefers a cutoff of ≈1.5 cm for the height of the posterior ethmoid; review the sagittal view, which includes the skull base, sphenoid sinus, and the angle of the skull base; the angle of the skull base is important to determine a cerebrospinal fluid (CSF) leak; a CSF leak is unlikely in a flat skull base; risk for a CSF leak is higher with a steep skull base; review the axial plane CT to analyze the medial orbital walls and the length of the sphenoid; the "queen's cell" refers to the posterior ethmoid cell that completely pneumatizes the skull base, the medial orbit, and the medial-most part of the resection; only ≈33% of patients have the queen’s cell; the queen’s cell allows the surgeon to view the roof, orbit, and other structures

Management of bleeding: ask about family history and any drugs or alternative medicines the patient is taking; control bleeding preoperatively; speaker’s method─for patients with polyps, consider a steroid burst and taper 1 wk before surgery to shrink the polyps and stabilize the vessels; consider injecting near the uncinate process; greater palatine blocks (through the mouth) may be used if the surgery involves the posterior ethmoid or sphenoid sinus; use cotton pledgets and 1:1000 topical epinephrine to control intraoperative bleeding; use warm irrigation for diffuse mucosal bleeding; this activates the clotting pathway and reduces generalized oozing; irrigate for 1 to 2 min; the sphenopalatine artery is at the back edge of the middle turbinate; consider base cauterization with suction bovie during resection of middle turbinate; examine the coronal CT to identify the artery; patients with supraorbital ethmoid cells always have low hanging interior ethmoid arteries; clean the ethmoid roof during surgery followed by 1:1000 topical epinephrine; consider using bipolar forceps in case of anterior ethmoid artery

Violation of the lamina papyracea: identify the medial orbital wall and uncinate to avoid entry into the orbit at the initial phase of the surgery; look for the integrity of the lamina and presence of the onodi cell (an ethmoid cell) that pneumatizes the maxillary sinus

Silent sinus syndrome: consider removing the uncinate from posterior to anterior by teasing it away from the orbit; identify fat in the ethmoid during preoperative evaluation; the presence of polyps makes its identification difficult; the optic nerve may traverse the posterior ethmoid cell; an onodi cell may be recognized on CT; it is usually a horizontal septation in the sphenoid sinus where the optic nerve is located; identify the lamina papyracea early; use antrostomy for orientation to view the posterior wall, the roof of the maxillary sinus and the orbit, and curve up to the medial orbital wall; entry into the orbit can be assessed by applying pressure to the eyes back and forth and looking for medial bulging through the endoscope

Orbital hematoma: results in increased ocular pressure, ecchymosis, proptosis, and visual loss (sometimes); venous bleeding is slower than arterial bleeding; it is an emergency that presents during recovery or on emergence; remove any packing; if the eye is tense and there is visual loss, consider lateral canthotomy and cantholysis; refer to an ophthalmologist; perform eye massage to redistribute blood flow; consider high dose (1 mg/kg) dexamethasone (Decadron) or mannitol (less common); an orbital decompression may be required

Nasolacrimal duct injury: is asymptomatic in >90% of cases; palpate the uncinate process to avoid injury

Violation of the fovea: the fovea is strongest laterally; the speaker tends to angle laterally rather than medially during sinus surgery; use xeroscope for correct orientation; repair CSF leaks intraoperatively if detected

CSF leak: the Keros classification is used to determine the medial skull base depth as it is a vulnerable area; speaker’s group (Heaton et al [2012]) reported a higher slope of the ethmoid roof and steeper skull base as risk factors for CSF leak during sinus surgery; surgeons must differentiate CSF leak from irrigation; CSF may have a black swirl if there is superior bleeding; consult a neurosurgeon; order imaging of all patients after surgery to identify potential complications; try to repair the leak during the same procedure

Readings

Han JK, Higgins TS. Management of orbital complications in endoscopic sinus surgery. Curr Opin Otolaryngol Head Neck Surg. 2010;18(1):32-36. doi:10.1097/MOO.0b013e328334a9f1; Heaton CM, Goldberg AN, Pletcher SD, et al. Sinus anatomy associated with inadvertent cerebrospinal fluid leak during functional endoscopic sinus surgery. Laryngoscope. 2012;122(7):1446-1449. doi:10.1002/lary.23305; Homsi MT, Gaffey MM. Sinus endoscopic surgery. StatPearls Publishing. 2022 Sep 12. Available from: https://www.ncbi.nlm.nih.gov/books/NBK563202/; Rodriguez Valiente A, Roldan Fidalgo A, Laguna Ortega D. Bleeding control in endoscopic sinus surgery: A systematic review of the literature. Rhinology. 2013;51(4):298-305. doi:10.4193/Rhino12.048; Stankiewicz JA. Complications of endoscopic intranasal ethmoidectomy. Laryngoscope. 1987;97(11):1270-1273. doi:10.1288/00005537-198711000-00004; Svider PF, Baredes S, Eloy JA. Pitfalls in sinus surgery: An overview of complications. Otolaryngol Clin North Am. 2015;48(5):725-737. doi:10.1016/j.otc.2015.05.002.

Disclosures

For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content: Dr. Goldberg is a stockholder with Sleep Evolution and Siesta Medical. Members of the planning committee reported nothing relevant to disclose. Dr. Goldberg's lecture includes information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Goldberg was recorded at Pacific Rim Otolaryngology-Head and Neck Update, held February 17-20, 2024, in Honolulu, HI, and presented by the University of California, San Francisco. For information on future CME activities from this presenter, please visit pacto.ucsf.edu. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

OT571901

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.