niyada
Orbital hematoma
-Ophthalmologist consultation
-Orbital massage,Off packing
success Observe ,Bed rest
sedation F/U
-Manitol 1-2 g/Kg IV
FAIL
Observe :
IOP,VA,Pupil reflex
proptosis
-Lateral canthotomy
Recovery :
-Orbital decompression
IOP 2-3 hrs. (10-21 mm Hg.)
Control bleeding
Light perception within 24 hrs.
-Optic nerve decompression
Pupillary reflex : 24-48 hrs.
Prevention
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Pre-op CT scan evaluate unusual orbit anatomy
Both eyes should be include in surgical field
Preferred LA due to pain response
Identify ant. ethmoidal artery that locate on
posterior to ant. wall of EB
Prevention
Palpate and compress the orbit when suspected LP injury
Blindness
• Temporary : transient increase IOP
• Permanent : directed optic nerve injury
and prolonged IOP (60-90 min.)
Blindness
• Optic nerve injury may be in
– Orbit
– Sphenoid sinus
– Sphenoethmoidal cell (Onodi cell)
Blindness
• Optic canal
– 98% at superolateral of sphenoid sinus
– 4-12% bony dehiscence
– 78% bony covering <0.5 mm. thickness
– 65% of the optic nerve in Asians was present
in the posterior ethmoid
Blindness
• Symptoms & signs
– Severe pain
– Acute VA drop
– Pupil dilate and not react to light
– Orbital hemorrhage
Blindness
• Treatment as orbital hemorrhage
– Ophthalmologic consultation
– Remove nasal packing
– Systemic steroid (controversy)
• Dexamethasone 1 mg/kg then 0.5 mg/kg q 6 hr
– Optic nerve decompression if failure to
conservation
Prevention
• Beware Intraoperation
– Post. ethmoid sinus
– Sphenoid sinus
– Onodi cell
Diplopia
• Damage to ocular
musculature or its
nerve or vascular
supply
• Temporary due to
edema or local
anesthesia
Diplopia
• Most common are
medial rectus and
superior oblique
• MR closed to LP
within 2-3 mm.
• Break LP and pulling
orbital content with a
microdebrider
Diplopia
• Symptoms & Signs
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Significant pain
Diplopia
Limitation of eye movement
Subconjunctival hemorrhage at medial side
Force duction test
Diplopia
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Urgent MRI evaluate muscle damage
Immediate repair by ophthalmologist
Poor prognosis
Prevent as orbital hematoma
Nasolacrimal duct injury
• Cause
– Over opening of ant. edge of the maxillary sinus ostium
• Post-op epiphora immediately or 1-2 wk. post-op
• Occult injury about 15%
Nasolacrimal duct injury
• DCR in symptomatic
patient
DCR : Dacryocystorhinostomy
Prevention
• Not performed
anterior to ant. margin
of MT
• Bone covering NLD is
harder
Prevention
• Agger nasi cell is closed to lacrimal sac
Subcutaneous emphysema
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Small fracture of LP
Positive pressure via mask ventilation
Cough, vomit, or blow nose
Periorbital subcutaneous crepitation
Spontaneous resolve in 7-10 days
Intracranial complications
Intracranial complications
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CSF fistula (most common)
Meningitis
Brain abscess
ICH
Brain injury
Pneumocephalus
CSF fistula
• Incidence : 1 in every
200 to 500 cases
• Risk factors
– Performed under GA
due to loss of pain at
skull base
– Revision case
– Extensive disease
CSF fistula
• Danger areas
– Fovea ethmoidalis
– Cribiform plate
CSF fistula
• Danger areas
– Roof of ethmoid
and sphenoid
– Area posterior to
ant. ethmoidal
artery
Olfactory Groove
Keros Classification
CSF fistula
• Onset
– Intra-op leakage
– Delayed post-op
leakage
• Occult CSF fistula
about 2.9%
Intra-op leakage
• Diagnosis
– Washout sign
– Compress bilateral IJN
10-12 sec.
(Queckenstedt-stookey
test)
Intra-op leakage
• IT fluorescine
– Most popular
– No FDA approved
– 0.1 ml. of 10% fluorescine
(IV prep.) + 10 ml. of CSF
– Infused slowly >30 min.
– Grand Mal seizure : dose
related complication
Treatment
• Repaired immediately
– Soft tissue patch : nasal mucosa, temporalis
fascia, fat, muscle, or dermal graft
– Bone or cartilage bridge
– Fibrin glue
Treatment
• Defect < 1 cm.
– Mucosal graft or fascia
• Defect > 1 cm.
– Solid graft
Delayed post-op leakage
• Diagnosis
– Days, weeks, months,
or years after
procedure
– Clear intermittent
rhinorrhea
– Associated lean
forward position
Delayed post-op leakage
• Diagnosis
– Hyposmia or headache
– Halo sign : clear ring , central bloody spot
– Endoscopic exam
Delayed post-op leakage
• Confirmed CSF
leakage
– Glucose oxidase test
strip : high false +ve
and false -ve
– Beta-2 transferrin :
most specific
– Radionuclide
cisternography : I 131,
Tc 99, and In 111
Delayed post-op leakage
• Locate leakage site
– Endoscopic exam
– High resolution CT
– IT fluorescein
– CT cisternography
(metrizamide)
– MR cisternography T2weighted with fat
suppression
Treatment
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Small leakage often close spontaneously
Conservative for 1-2 wk.
Surgery when unresponsive
Mostly need surgical intervention
Conservative treatment
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Strict bed rest
Head elevation
Stool softener
Avoid cough, sneezing, nose blowing, and
straining
• Lumbar drainage
Lumbar drainage
• Draining rate = 5-10 ml/hr
• Complication
– Pneumocephalus : low ICP
– Meningitis
• Prophylaxis ATB in case of sinusitis
• Unwarranted prophylaxis ATB in traumatic case
• ATB prevent cellulitis at puncture site
Surgical treatment
• Transcranial approach
• Extracranial approach
– Trans-sinus external approach
– Endoscopic transnasal approach
Transcranial approach
• Craniotomy
• Tissue graft + fibrin glue
– Fascia lata
– Muscle plugs
– Pedicle galeal flap
Transcranial approach
• Advantage
– Multiple areas
– Identify leakage site
– Associated intracranial problem
• Disadvantage
– Morbidity & mortality
– Prolong hospital stay
– Limited sphenoid sinus approach
Transcranial approach
• Morbidity
– Brain compression
– Hematoma
– Seizure
– Anosmia
Endoscopic transnasal approach
• Advantage
– Excellent visualization
– Well tolerated
– Excellent outcome (85-90%)
Endoscopic transnasal approach
A : dura
B : fascial autograft
C : bone/cartilage
D : fascial autograft
E : mucosal free autograft
F : surgical sealant
• IT fluorescine locate
leakage site
• Free graft is
preferable (low failure
rate)
• Underlayer is ideal
Endoscopic transnasal approach
• Mucosal graft should never placed
intracranially (intracranial mucocele)
• Nasal packing
– Absorbable packing is placed adjacent the
graft
– Non-absorbable packing support beneath
• Excellent access to ethmoid roof, cribiform
plate, and sphenoid sinus
Endoscopic transnasal approach
Endoscopic transnasal approach
• Post-op care
– Bed rest
– Anti -staphylococcal ATB
– Monitor intracranial complication in first 24 hr.
– CSF drainage continued for 4-5 days
– Avoid strenuous activity, sneezing, and cough
for 6 wks.
Direct brain injury
• Wide spectrum
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Injury to dura
SAH
ICH
Secondary
meningoencephalitis
• Poor prognosis and
high mortality
Direct brain injury
• Frontal lobe is common site
• Treatment
– Immediate rhinological closure
– Consult neurosurgeon
Prevention
• Preferred LA
• More yellow color at
ethmoid roof
• Attention at ant.
ethmoid artery enter
ethmoid sinus
• Keep lateral to MT
Synechiae
• Incidence : 1.2-8%
• 15-20% symptomatic
and need treatment
• Location : raw surface
between middle
turbinate and lateral
nasal
• Treatment : lysis
synechiae and silastis
spacer for 4 wks.
Synechiae
• Prevention
– Minimal injury to surrounded mucosa
– Preserve mucosa of MT
– Serial post-op cleanning
– Silastic stent
Other complications
• Asthma exacerbation
– Usually occur in LA
• Infection
– Sinus surgery + septorhinoplasty risk to
severe infection
• Mucocele
– Long term sequelae
Conclusion
• Prevention is the best
• Pre-op assessment and decision to
operate
• Knowledge of anatomy relationship and its
variation
• Informed about complication to the patient
Conclusion
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Adequate training
CT-scan
Expose the eye during surgery
Do not blind dissection
Early detection and treatment