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
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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
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Orbital hematoma
Blindness
Diplopia
Nasolacrimal duct injury
Subcutaneous emphysema
Predisposing factors
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Dehiscence of LP
Revision surgery
Distorted anatomy
Sphenoethmoidal cell (Onodi cell)
Extensive nasal polyp
General anesthesia
Bony destructive lesion
Predisposing factors
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DNS
Concha bullosa
Lateralized paradoxical turbinate
Hypoplastic maxillary sinus
“ Uncinate process close to LP ”
Orbital hematoma
• Occur intra-op until postop 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
hemorrhage
• 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
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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
space
– 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 0.5 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)