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As a consequence the intra-ocular pressure was raised up to a pressure level of 54 mmHg IOP. Canthotomy and inferior cantholysis reduced the pressure to 32 mmHg and there were no relevant permanent damages [ ].
In other cases, a paraffinoma may develop especially within the region of the eyelids after a sinus operation. In the event of a often minimal injury of the lamina papyracea with a often mild orbital haemorrhage and if a paraffinic nasal packing ointment strip or ointment is inserted into the nose the paraffin can be absorbed via the mucosal wound in individual cases and transported via blood into the soft tissue of the orbit, respectively eyelids.
In rare cases, the inflammation continues as sclerosing lipogranulamatosis or as orbital pseudotumour, in a rare case this may lead to the development of a sinogen orbital phlegmon.
Spontaneous, partial regressions are rare. Classic paraffinomas should not occur any longer due to modern types of nasal packing in use and due to tendencies to disclaim packing at all.
Despite this fact, appropriate casuistic case reports still exist [ ], [ ], [ ], [ ], [ ], [ ]. If the history of the patient does not include a sinus operation, differential diagnoses are, among others: Two special cases of a lipogranulomatous tissue reaction were reported 2 to 14 days following an endonasal sinus operation, where no oily material was inserted.
There was a palpable tumour of the eyelid, eye movement disorder and proptosis. The granulomas were externally removed by surgery and oral corticoids and also an antibiotic were administered.
Concerning pathogenesis, an intraoperative injury of the orbit with focal fat necrosis and a consecutive tissue reaction on extracellular fat were assumed [ ].
The treatment of paraffinomas is surgical excision. A complete resection is usually impossible because of the diffuse tissue infiltration [ ].
Myospherulosis is related to the paraffinoma. It corresponds to a foreign body reaction of the mucosa to ointments containing lipids.
Typical aggregates of erythrocyte residuals are histologically found in the vacuoles. Factors that predispose the development of myospherulosis are not yet clarified.
Patients tend to present a higher rate of postoperative synechia leading to a high number of revision surgeries [ ]. Myospherulosis granulomas also may form within the area of the eyelid following sinus surgeries with intraoperative haemorrhage of the eyelids and perioperative use of nasal packing with ointment [ ].
The microanatomy of the pterygopalatine fossa and the sphenopalatine foramen plays an important role in sinus surgery [ ].
Further terminal branches of the maxillary a. If the routine opening of the maxillary sinus in the middle nasal meatus is systematically enlarged in dorsal direction, up to the level of the posterior wall of the maxillary sinus, then, in individual cases, it will be necessary, for anatomical reasons, to cut through a branch of the sphenopalatine a.
Bleeding from the root of the sphenopalatine a. During extended surgical procedures in the area of the infratemporal fossa severe bleeding from the maxillary a.
Instructions to identify the sphenopalatine a. In rare cases, a pseudoaneurysm may form as a result of an injured sphenopalatine artery.
It was discovered 13 days after sinus surgery took place, which is quite early. The authors prefer embolization rather than targeted endoscopic treatment clipping of the maxillary a.
When entering the sphenoid sinus, the surgeon encounters the septal branch of the sphenopalatine a. In the area of the anterior wall of the sphenoid sinus, it is mostly divided into three branches which supply the nasal mucous membrane [ ].
Within the scope of ENT routine surgery, an electrosurgical handling of this vessel is possible without any complication.
In case or repeated perioperative bleeding, angiography with selective embolization will only be performed in extremely rare cases [ ], [ ], [ ], [ ].
This applies especially for embolization in case of a treatment-resistant nose bleeding after routine sinus surgery when the source of bleeding does not evolve the internal carotid artery.
The exposure of radiation during embolization is relevant around 18 minutes in single series. The pharyngeal ramus of the sphenopalatine a.
It is a rare source of bleeding, e. The anterior ethmoidal a. In some of the cases the artery is located directly in the area of the osseous skull base, and more frequently ca.
According to anatomical studies, the anterior ethmoidal a. Arteries at risk are those with a larger distance to the skull base, arteries with bony dehiscences or those running within a ground lamella [ ].
Lateral injuries in the area of a funnel-shaped, medial-directed protrusion of the orbital wall can result in a threatening orbital hematoma, after retraction of the vessel stump see above.
It is situated in the level below the superior oblique m. If the artery has been injured and is bleeding into the ethmoidal cavity, a bipolar or monopolar coagulation is generally used to stop the bleeding [ ].
Many authors avoid the monopolar coagulation at the skull base due to possible secondary damage to the meninges [ ], [ ], [ ]. Alternatively, clips are suggested, which, however, are not always effective, due to anatomical reasons [ ], [ ], [ ].
With a diameter of ca. The distance between the anterior and the posterior ethmoidal artery is approximately 10—14 mm and the distance from the latter to the optic nerve as well as to the anterior wall of the sphenoid is about 8—9 mm [ 12 ], [ ], [ ], [ ].
In a coronal CT, a tip-like protrusion of the medial orbital wall at the location of the posterior ethmoidal a.
As a general rule, the posterior ethmoidal a. A case report depicts a secondary orbital hematoma without significant proptosis, but with blindness [ ].
A subperiosteal orbital hematoma with visual impairment should be equally rare — symptoms were reversible after an emergency hematoma decompression [ ].
Uncomplicated hemorrhages in the posterior shaft of the ethmoid bone are treated with electrocoagulation [ ]. There are important neighbouring anatomical structures, especially the optic n.
The distance between the internal carotid a. Surgery performed in the sphenoid sinus requires sufficient preoperative diagnostic measures based on cross-sectional imaging [ 95 ], [ 97 ].
Particularly in the axial CT, significant anatomical details or variants are displayed: In principle, the carotid a. Dorsally, another prominence of the artery can occur in the lateral wall of the sphenoid sinus.
The bony canal of the artery is 0. The exact incidence rate of carotid injuries in paranasal sinus surgery is unknown. According to literature, carotid artery injuries occur with a rate of 0.
In the last mentioned operations, the risk increases considerably in revision surgery, after radiation therapy or if there is a tumor infiltration of the carotid [ ].
In routine paranasal sinus surgery, the most frequent defect site of the carotid a. In the scope of extensive rhino-neurosurgical procedures, further sources of bleeding, also from smaller branches of the carotid a.
As a matter of principle, every ENT surgeon and every clinic should therefore have clear action plan at hand for the emergency of an internal carotid a.
For paranasal sinus surgery, the following measures are recommended in case of an injury of the cavernous internal carotid a Revision surgery of the respective sphenoid sinus revealing a partly exposed coil green arrow: Additionally, the arterial injury can no longer be identified in the angiographic image, so that the otolaryngologist has to loosen the nasal packing and the angiography is repeated [ 95 ], [ ], [ ], [ ].
Due to the former reason the otolaryngologist should be present during neuroradiological diagnostics and intervention [ ]. In case of a very small lesion in the carotid vessel — provided appropriate local conditions, sufficient medical status of the patient and capabilities to pack the nose repeatedly — the surgeon should at first create an optimum access to the sphenoid sinus.
The placement of an autologous muscle graft or allogenic material is recommended. This construction is fixed with fibrin glue and is tightened with packing.
Alternatively, under favorable conditions, a specific vessel clip may be used [ 97 ], [ ]. Occasional reports point out that such a supply was permanently successful preserving the arterial circulation [ 96 ].
For this reason an angiography is indicated postoperatively [ 95 ], [ 97 ], [ ], [ ], [ ], [ ], [ ], [ ], [ ]. In case of an aneurysm secondary neuroradiological treatment is performed.
During a primary neuroradiological intervention after an accidental lesion of the carotid a. Here, specific complications, such as a vessel dissection, thrombosis, embolism or a vessel perforation have to be kept in mind.
Balloons can get displaced and then may increase the risk of new bleeding. Postoperatively, patients with vessel stents receive anticoagulant drugs Clopidogrel, ASS mg [ 95 ], [ ], [ ], [ ], [ ], [ ], [ ].
Within the first 24 hours after the neuroradiological intervention, a CCT control should be performed. Later on a control angiography should take place [ ], [ ].
The defect site in the sphenoid sinus should be covered secondarily, for example with fascia [ 95 ] Figure 9 Fig. Hemorrhages from the cavernous sinus are mostly much less demanding.
Bleeding is interrupted by placing hemostatic material directly and applying smooth pressure. The material is inserted, covered with neuro-cotton wool and lightly pressed [ ].
In principle, hemostasis during rhino-neurosurgical procedures as well as during sinus surgery is based upon bipolar coagulation, compression, nasal packing or ligature as well as upon the application of clips.
However, in case of an exposed dura, a sufficient compression is not always possible and an external nasal packing additionally creates the risk of bleeding in intracranial direction.
Immediately after the incidence, a second suction is introduced into the operating field and the endoscope is directed to a protected place; if applicable, equipped with a rinsing and suction device.
In favorable individual cases, it might be possible to direct the jet of blood into the suction, to display small lacerations of the artery and to fuse and glue them by means of bipolar coagulation [ ], [ ], [ ].
The use of an intraoperative Doppler is recommended as a measure of prevention [ ], [ ]. If an ordinary hemostasis is not successful, further nasal packing is applied and an emergency transfer of the patient to the neuroradiological ward is carried out [ ].
The prognosis of an injury of the carotid a. An injury of the carotid a. This condition is treated through neuroradiological intervention [ 89 ], [ ], [ ].
Even after a successful occlusion-test complications following the definitive occlusion cannot be excluded [ 95 ], [ 97 ], [ ], [ ].
In this regard, very different frequencies are found in literature: The average bone thickness in the direction of the sphenoid sinus is 0.
Hence it is even more important to look out for a history of previous eye defects preoperatively. Perioperatively, this damage might only appear to deteriorate, e.
As a consequence, unnecessary emergency measures might be taken, even medico-legal problems might arise [ ]. Perioperative blindness in paranasal sinus surgery occurs in case of a direct injury of the nerve, a drug-induced interruption of local blood supply or a hematoma in extremely rare cases also by an emphysema, see above or in case of damaging the central nervous system, as, for instance through meningitis [ 76 ].
Direct mechanical damage to the optic nerve is only reported in exceptional individual cases [ ], [ ]. Here, during removal of the covering bone, the nerve can be damaged or destroyed in the cranial, lateral wall of the sphenoid sinus [ ] or within the orbit [ ].
In other cases, injuries of the optic n. A case report of a severe, direct injury of the eyeball across the lamina papyracea caused by an electrosurgical tube without direct nerve damage seems to be exceptional [ ].
In case of an injury of the optic n. Compared with direct lesions, indirect injuries of the optic nerve caused by a retrobulbar hematoma occur more frequently [ 83 ], [ ].
Loss of vision as a complication of adrenaline-soaked e. Adrenaline resorption with consecutive spasm of the vessel network around the optic n.
After every postoperatively noticed or supposed visual reduction, an ophthalmological emergency consultation should occur. MRI is strongly recommended [ ].
After mechanical injury of the nerve, collateral damage has to be searched for, e. If the optic n. Even if nerve continuity is preserved, the immediate treatment of the perioperative visual reduction is problematic.
The regimen is individualized and is under ophthalmological guidance. If neurapraxia or a hematoma is suspected, a high dose corticosteroid treatment is followed out e.
The concept is aligned to the treatment of traumatic optic neuropathy — evidence of which, however, still remains a subject of debate [ 71 ].
Traumatology and neurology provide some experimental evidence to suggest that corticosteroids may also hinder the restitution of an optic nerve [ ], [ ], [ ], [ ], [ ].
In specific cases, decompression of the nerve may be discussed — however, its benefit has not been proven yet [ 12 ], [ 76 ]. Under certain, adverse conditions, the symptoms of an ischemic optic-neuropathy may appear within the scope of sinus surgery, a disease of which little is known.
In these rare cases, neither mechanical injury of the nerve has occurred nor has the lamina papyracea been damaged.
The exact pathogenesis is not yet known. The resulting loss of vision or visual field reduction emerges immediately or with a delay of several hours to days.
MRI displays a vaguely defined and swollen optic n. A decompression of the optic nerve does not always seem appropriate.
Administration of cortisone e. An immediate normalization of blood pressure and hemoglobin by means of transfusions seems essential [ ].
A case report described residual ethmoidal cells revealing opacification. An emergency revision surgery was performed with decompression of the orbit and periorbital incisure.
Additionally, high dose corticosteroid treatment Prednisolone mg intravenously and calculated antibiotic treatment was initiated.
Within a period of 4 weeks the condition of the patient improved. In another case, the optic n. These two cases were interpreted as a consequence of an infectious impairment of the optic n.
In endonasal surgery of the paranasal sinuses, an impairment of the medial rectus m. In general, these injuries result of a fracture of the inferior lamina papyracea with perforation, destruction or incarceration of the muscle.
The middle or posterior ethmoid is most at risk — as hardly any fat is situated between the muscle and the bony orbital wall [ 76 ], [ ], [ ], [ ]. In rare cases, there is a particular risk due to a congenital or posttraumatic bulge of the lamina papyracea with or without direct embedding of parts of the muscle [ ], [ ].
Other eye muscles are distinctly less often injured intraoperatively: The inferior rectus muscle may be damaged in surgeries involving the maxillary sinus and the superior oblique trochlea muscle may be lacerated in extended endonasal frontal sinus surgery with a drill for instance.
Injuries of the inferior oblique m. In the majority of cases, only one eye muscle is damaged, with a relevant orbital hematoma developing additionally in one quarter of patients.
Occasionally, however, severe combined damage affecting three muscles, for example, has been observed with additional bleeding, retinal damage or lesions of the optic n.
Generally 5 typical causes for a postoperative motility disorder of the eye may be distinguished:. Muscle tissue that is surprisingly evident in routine histologic specimens Figure 10 Fig.
In general, periorbital damage should be detectable intraoperatively by means of the bulbus pressure test [ ]. If, beyond that, intraoperatively suspected eye muscle damage occurs, an ophthalmologist should be notified and consulted immediately [ ], [ ].
With few exceptions, diplopia appears immediately after the operation as a result of the injury [ ]. All relevant findings should be submitted immediately for evaluation by means of imaging.
The clarification of an eye muscle injury with displacement or incarceration or the display of a contraction of the dorsal muscle parts most likely succeeds after complete sectioning with a contrast-enhanced MRI; evaluation is done in three planes.
At best, multipositional MR imaging might allow to draw conclusions about the contractility of the muscles. In the further course, a repeated MRI may also document stages of repair, as swelling of muscle tissue is followed by atrophy.
Other sources recommend a CT as initial diagnostic measure for all orbital complications, as differentiated analysis of the injury is hindered initially through hematomas and accompanying edema [ 71 ], [ 76 ], [ ], [ ], [ ], [ ], [ ].
Generally, the findings of CT and MRI correlate well with the ophthalmological functional examinations [ ]. Regarding treatment of acute, iatrogenic eye muscle damage, an early surgical intervention should be performed within 1 to 2 weeks, if a muscle was completely intersected or if an incarceration of tissue or a skewering of bone fragments into the muscle is suspected clinically or via imaging [ 71 ], [ ], [ ], [ ].
A reconstruction of the medial rectus m. In case of excessive destruction, a muscle transposition might be sought; alternatives are graft interpositions or specific suturing techniques [ ], [ ], [ ], [ ].
In order to exclude corresponding damage in revision surgery, aggressive orbital dissections should be avoided during further surgical therapy [ ].
Reconstruction of the medial orbital wall directed to the ethmoidal cavity, using alloplastic material, often cannot prevent a secondary, bothering scar formation [ ], [ ].
In individual cases, an immediate cortisone therapy is applied in an effort to minimize the inflammatory response of the orbital tissue [ 71 ].
In case of partial damage, literature recommends both an observant and an active approach [ ]. Contractures of the antagonists of damaged muscles can already be observed after 2 weeks.
Especially in cases of severe injuries, revision surgery performed before fibrosis begins to occur, i. In contrast, spontaneous improvements were observed within a period of three months after slighter neuronal, vascular or direct muscle damage [ 71 ], [ ], [ ].
By means of botulinum toxin injections into the antagonists of damaged muscles, diplopic images can be improved faster, a secondary contracture of the antagonist is prevented and the traction force applied to the damaged muscle is reduced.
For reasons which are not fully known, the injection can make a positive contribution to a long-term functional alignment of the extraocular muscles [ 76 ], [ ], [ ], [ ].
In appropriate cases, the injection is combined with a surgical muscle reconstruction [ ], [ ]. Other forms of impairment are treated conservatively in the beginning [ ].
If the muscle is only affected by bruising, neural or vascular damages, it may be justified to wait for 3—12 months [ 71 ], [ ], [ ].
Two to three months after a damage caused to the medial rectus m. In two thirds of cases, several operations will be necessary [ ], [ ].
Extremely severe damages of the ocular muscles and the orbital tissue have been reported after the use of the microdebrider [ 71 ], [ 76 ], [ ], [ ].
The medial rectus m. This may also occur without any prominent orbital injury. Often the surgeon is not even aware of the damage.
The perforation in the lamina papyracea may be difficult to identify, even in postoperative imaging [ 17 ], [ 71 ], [ ], [ ], [ ].
In other cases, motility limitations can be distinctly higher than the damage seen at imaging. After injuries caused by the shaver, chances to reconstruct the medial rectus muscle successfully are rather limited [ ].
In rhino-neurosurgical operations, especially in the parasellar and suprasellar region, in the area of the cavernous sinus or the clivus, thermal injuries or transections may lead to injuries of the abducens n.
Frequently the oculomotor nerve recovers postoperatively from damages as long as the continuity of the nerve is preserved [ ]. For various reasons, a mydriasis can occur during paranasal sinus surgery:.
In individual cases, pupil differences without pathological substrate can occur during anesthesia. In a small percentage of the population, an observable anisocoria i.
Under general anesthesia, the light reflex cannot be judged. Therapy with opiates e. Fentanyl leads to miosis which, however, can decrease, due to an intraoperative sympathicus stimulus.
Individual factors affect the size of the pupils during extubation; in some cases even, side differences, lasting about 20 minutes may occur during this process.
Based on the described circumstances, a number of recommended precautions can be deduced:. During the operation, the eyes should always remain free from textile covering.
The scrub nurse should get used to control the eye from the outside while surgery continues in the inside of the nose.
Hence complications are indicated by a passive concurrent movement of the globe and can be noticed early. Generally, a serious acute narrow angle glaucoma can be triggered by sympathomimetica in predisposed patients [ ].
The placeholder had perforated the dorsal orbital apex and caused permanent changes in the pupils. Even an emergency revision surgery with removal of the foreign material did not result in an improvement [ ].
Paranasal sinus surgery, in the broader sense, with extensive removal of the mucosa can cause a scarred distortion of the entire ethmoidal cavity in adults, combined with a medialization of the lamina papyracea.
These transformations can be identified by postoperative imaging and may be associated with a subclinical enophthalmos [ ], [ ].
In children, after paranasal sinus surgery, a postoperative hypoplasia of the maxillary sinus with no external changes was described radiologically [ ].
After unilateral ethmoidectomy in a pediatric case of an imminent orbital complication, merely a minimal facial asymmetry was visible in the postoperative CT [ ].
A similar case of a postoperative scarred stenosis of the maxillary ostium and a secondary maxillary sinus atelectasis with postoperative enophthalmos 3 mm was also observed in an adult patient [ ].
Studies in traumatology revealed that even with minor injuries 0. Individual cases are reported which tend to concur with this observation, describing a postoperative enophthalmos after injury of the medial orbital wall and the medial rectus m.
Surgeons performing a paranasal sinus operation should be familiar with position and size of the efferent lacrimal ducts: In half of the cases, the lacrimal sac is covered by parts of the agger nasi and in almost two thirds of all cases, the uncinate process is overlapping the lacrimal sac [ ].
The distance between the free edge of the uncinated process and the anterior edge of the lacrimal sac is 5 mm 0—9 mm [ ], for the maxillary sinus ostium the distance is approximately 4 mm 0.
The lacrimal bone is very fragile, compared to the frontal process of the anterior maxilla. Epiphora develops in about 0. Under favorable circumstances, such cases correlate with an unintended dacryocystorhinostomy [ ], [ ], [ ] Figure 11 Fig.
An injury mostly occurs during infundibulotomy uncinectomy , during surgery on the anterior frontal recess or during maxillary sinus fenestration in the anterior middle nasal passage — in the latter, particularly during the use of the backward cutting punch [ 71 ], [ ].
Injuries occurring during a fenestration in the inferior nasal meatus should have become rare [ 91 ]. During the course of a routine sinus operation, frequently parts of the lacrimal bone or parts of the frontal process of the maxilla are removed in an undirected manner, without any direct malfunctions resulting.
In right handed surgeons, the left side is supposed to be affected more frequently [ ]. Pressure applied on the medial angle of the eye under endonasal endoscopic control can help to identify the tissue of the lacrimal sac and to prevent it from damaging during further manipulations [ ].
After a relevant lesion of the efferent major tear ducts, the symptoms appear directly after the operation or with a delay of weeks. Postoperative epiphora can subside spontaneously if the inflammatory reaction caused by the surgery has decreased [ 68 ], [ ].
Each patient with postoperative epiphora should be examined thoroughly. In case of doubt, an ophthalmologist should be consulted. There are often no direct consequences and the patient is kept under observation.
If after one week, epiphora is still present, advanced diagnostic measures are indicated. In special cases, a CT with dacryocystogram can produce additional information.
The treatment of symptomatic iatrogenic lacrimal duct stenosis in general is dacryocystorhinostomy [ 98 ], [ ], [ ].
Success of the operation may be limited due to an insufficient position or size of the lacrimal duct fenestration, combined with portions of bone or remains of the medial lacrimal sac left behind.
During the first 4 weeks after the operation, the intranasal neo-ostium is shrinking regularly and then remains stable.
The result of the surgery is affected by an excessive scar formation or enhanced granulations, for instance after extensive resection of mucosa.
Further causes are synechiae, e. Irregular scars can trigger frontal sinusitis. Mechanical rinsing of the tear ducts from outside is retained in these cases [ ], [ ], [ ], [ ], [ ].
Skin injury in the medial corner of the eye should be extremely rare, additionally, retrobulbar hematomas, eye muscle injury, burns at the nostril, stenosis of the canaliculi or conjunctival fistulas may occur [ ].
The same applies for a case report of a cerebrospinal fluid fistula during the mechanical reclination of a deviated nasal septum for the purpose of exposing the lacrimal ducts [ ].
If splints for lacrimal ducts stents are applied intraoperatively, this may result in a conjunctival irritation for example, the formation of a loop , secondary injury of the lacrimal punctum or a premature loss of the splinting [ ].
In individual cases, problems arise during or after removal of the splint, e. In case of doubt, an inefficient dacryocystorhinostomy should be followed by endonasal revision surgery.
Depending on their location, synechiae can be treated by a reduction of the tip of the medial turbinate or even correction of the nasal septum [ ].
Patients should be reminded that postoperatively, even after a successful surgery, air might get constantly blown into the medial corner of the eye whilst blowing their noses.
A pneumocephalus is the presence of gas air in the cranial cavity. In most cases, it is based on a communication between extracranial and intracranial space.
The air can be present in epidural, subdural, subarachnoid, intraventricular or intracerebral spaces. It might be tolerated well in one case, yet in other cases it could be responsible for dangerous findings and symptoms [ ].
However, air entrapment is not obligatory in every skull base injury Figure 12 Fig. A second pathomechanism is air being sucked in, after cerebrospinal fluid has been discharged.
As a result intracranial pressure increases gradually and a tension pneumocephalus develops. Symptoms are an altered state of consciousness, restlessness, headache, nausea, vomiting, eye motility disorders, ataxia, and spasms.
If the underlying process is not interrupted, a pressure effect in the interhemispheric fissure close to the motor cortex might induce a diplegia.
Additionally rupture of bridging veins may cause subdural hematomas and finally cardiac arrest [ ], [ ], [ ], [ ].
In individual cases, the neurological symptoms may have a latent period of several days [ ]. The mass effect of air does not always have to be spectacular and is not always bilateral [ ].
After the diagnosis has been confirmed in the emergency CT scan, immediate neurosurgical decompression has to take place, e.
Intracerebral tension pneumocephelus may occur in rare cases. In those few cases, ineffective defect closure at the skull base was followed by a progressive accumulation of air subcortically in the frontal brain.
The pathophysiology and therapy are consistent with the usual tension pneumocephalus; the intracerebral air bubble may be released by means of a puncture.
The same applies for extremely rare cases of an intraventricular tension pneumocephalus after paranasal sinus surgery. The specific cause for this intraventricular accumulation of air is not yet known [ ], [ ].
Postoperative meningitis is rare, although it represents the most frequent intracranial complication in paranasal sinus surgery. It spreads through dural lesions, perivascular or vascular paths or even via perineural spaces of the olfactory fibers [ 90 ].
In rare individual cases only, an intracranial abscess or septic thrombosis of the cavernous sinus can be classified as a true complication of paranasal sinus surgery [ ].
More frequently, they develop on the basis of a preexisting inflammation of the mucosa in the paranasal sinuses [ 90 ]. The incidence is within the same range as in conventional intracranial surgery or in pituitary surgery [ ], [ ], [ ], [ ], [ ], [ ].
Meningitis may occur with a delay of e. When suspecting meningitis a CT scan has to be ordered immediately followed by a lumbar puncture.
Symptoms or findings are e. The patient should be monitored intensively and an active cerebrospinal fluid fistula needs to be detected [ ].
Mainly responsible are staph. Acute sinusitis is more frequent postoperatively, for instance in the area of the surgical corridor of the sphenoid bone.
Here, revision surgery including a microbial probe is recommendable [ ], [ ]. Most studies imply that prophylactic administration of antibiotics does not reduce the risk of meningitis or brain abscess in skull base surgery [ ].
In case of antibiotic prophylaxis, it should be applied half an hour before the first incision; in uncomplicated rhino-neurosurgical operations, it may be restricted to 24—48 h [ ], [ ], [ ], [ ].
Other rhinological references recommend antibiotic treatment 3 days preoperatively for 7—14 days — depending on the duration of nasal packing [ ], [ ], [ ], [ ].
Preoperative microbial swabs are inappropriate for calculated antibiotic treatment [ ], [ ]. When there is an intolerance, vancomycin or clindamycin are also recommended [ ], [ ], [ ], [ ], [ ], [ ].
Uncomplicated cerebrospinal fluid fistulas have been mentioned in 4. They may lead to severe complications, e.
Additionally this may result in an epidural, subdural or intracerebral haematoma, a localized cerebral infarction or even a traumatic aneurysm [ 90 ], [ 91 ], [ ].
Instantaneous fatal bleeding can possibly occur due to an injury of the internal carotid a. Serious damage can also be triggered by induced arterial spasms [ 90 ].
The defect at the skull base can cause a secondary herniation of brain tissue [ ]. An iatrogenic encephalocele can develop slowly within months and might only become apparent though meningitis [ ].
After extensive reconstruction of the frontobasal region and after a large amount of CSF has been discharged, intracranial pressure may drop, which in turn can result in displacement of the graft or tension on the bridging veins causing a subdural haematoma.
For these reasons, a lumbar drainage is contraindicated in case of a prominent pneumocephalus. After extensive surgical procedures, a CT control must be performed on the first or second postoperative day [ ].
Fatal, partially lethal complications with mechanical destruction of cerebral tissue are limited to extremely rare cases in routine paranasal sinus surgery.
Corresponding reports are mostly from earlier decades [ ], [ ]. In individual cases, severe combined injuries of brain and vessels can occur, e.
Smaller case series report a clustering of corresponding incidents, partly on the right hand side and partly on the left hand side [ ], [ ]. The same applies for the accidental discovery of cerebral tissue during routine histology.
Serious injury patterns have also been induced accidentally with the shaver. Postoperatively, patients show suspicious symptoms such as lasting clouding of consciousness, disorientation or somnolence, and, in addition, focal neurological signs, for instance myoclonia or headaches in recovery phase.
In other cases, postoperative bleeding with liquorrhea occurs [ ], [ ], [ ], [ ], [ ], [ ]. In rare cases, after a supposedly normal operation and healing process, only atypical or strikingly intense headaches were observed [ ].
In case of doubt, a cCT or an MRI should be ordered immediately, in order to determine the existence and extent of the damage and to exclude a pneumocephalus or bleeding requiring therapy.
The MRI displays more subtle parenchymal damage and also the chronological sequence of a resorption of hemorrhages [ ], [ ].
In an acute case, emergency neurosurgical consultation has to be performed directly after imaging. In medico-legal assessment of cerebral trauma during routine sinus surgery, the discussion erratically accentuates regarding surgical negligence, if cerebral tissue is evident in routine histology and if the patient does not display anatomical or constitutional abnormalities.
Another topic of discussion is the putative direct damage of brain tissue by instruments. The intracerebral injury pattern as revealed by imaging might provide guiding hints: In contrast, an unknowingly triggered subarachnoid hemorrhage in case of a superficial injury of the skull base does not unambiguously indicate negligence, even if severe secondary neurological damages occur [ ].
In rhino-neurosurgery, the continuously increasing complexity of surgical procedures naturally also induces a higher number of differentiated neurological complications.
In positive case series, temporary neurological deficiencies are reported in 2. In the area of the pituitary, e.
The rate of severe intra- or perioperative complications including infections and organ failure was 2.
Here, patients older than 60 years, patient with complex surgeries and patients with postoperative CSF fistula were particularly affected [ 70 ].
The primary infection often is not very distinctive. However, released toxins act as superantigens and quickly generate a progressive disease with a disease pattern similar to sepsis.
In otorhinolaryngology the transition from the nasal colonization to infection by staph. In a large number of cases the initial source is nasal packing.
Rare cases have occurred in connection with the use of septum foils, due to a special postoperative formation of crusts or following chronic or acute rhinosinusitis without any abnormalities [ ], [ ], [ ], [ ].
In a single case a TTS with primary, life-threatening phlegmonous gastritis occurring shortly after sinus surgery was reported [ ].
Individual cases of illness may develop with a delay, i. A secure protection by perioperative prophylactic antibiotics or antibacterial ointments does not exist [ ].
The resulting sepsis develops rapidly, e. The first therapeutic goal is eliminating the bacterial source. Blood cultures are taken.
Therapy is based on substituting fluid, adjusting the acid-base balance and electrolytes as well as monitoring renal function. Regarding combined antibiotic therapy, recommendations should be taken into consideration where certain substances have shown to lead to a reduced toxin release e.
Further treatment, if necessary, is performed according to guidelines for bacterial sepsis. Criteria of toxic shock syndrome TTS from [ ]:.
The topography of the olfactory mucosa and postoperative hyposmia was noted in chapter 4. The rate of postoperative anosmia as a complication of sinus surgery is about 0.
In rhino-neurosurgical surgery, anosmia may be an inevitable consequence due to tumour resection e. Hence, detailed preoperative informational conversation is useful, but currently still not common [ ], [ ].
Adequate instrumentation is fundamental in endonasal endoscopic sinus surgery. The hospital manager has the duty to equip the surgeon with appropriate instruments [ ].
In the present context these necessarily include optical aids such as endoscopes in different angles. Requirements are significantly enhanced for Rhino-Neurosurgery [ ].
Recently video system standards have improved significantly HDTV. In light of this, previous studies need an update in regard of technical standards [ ].
In contrast, it must be noted that endonasal procedures using headlights are still considered as equal [ ], [ ].
These kind of problems occur especially after lengthy rhino-neurosurgeries [ ]. For endonasal haemostasis an equipment for bipolar coagulation is necessary.
Monopolar instruments are generally appropriate, but its use in the sphenoid sinus, the base of the skull and intracranially rhino-neurosurgery is not recommended [ ].
After using the shaver, faster healing with a lower rate of interfering crusts, synechia or scarring displacements of the middle turbinate was reported in literature [ ].
From other sides, no corresponding benefits have been described [ ], [ ]. The particular risk of shavers has been pointed out in detail [ ], [ ].
There is no valid data on the absolute rate of complications compared to conventional instruments. However, the dimension of the damage caused by accidents with a shaver is often increased see above.
For the overall result, true cutting micro-instruments neither provide specific benefits [ ], [ ]. They lead to a reduced rate of postoperative synechiae- but they have no effect on the subjective and objective surgical outcome [ ].
Similar problems were reported due to damaged isolation of electrosurgical devices [ 65 ]. Robot systems in sinus surgery are in their early stages of development [ ], their use in routine surgery is in remote future.
Generally the balloon dilatation of sinus ostia may be considered as a safe surgical procedure [ ], [ ], [ ]. The most common problem in dealing with these systems is that the ostium or channel is impassable for the guide wire.
This may be caused by scars, anatomical irregularity or local polyp growth. As a result, a complication of inadvertent dilation of the secondary maxillary ostium, a submucosal passage of the guide wire and balloon or an injury of the orbit may occur [ ], [ ].
The dilatation of the frontal sinus ostium might cause local microfractures, which in turn may lead to sinusitis relapse via local inflammation respectively osteitis [ ].
In a single case, a local lymphoma was overlooked during dilatation [ ]. In a single case, a septal hematoma occurred during dilation of the sphenoid ostium — the patient though was under a permanent warfarin therapy due to cardiac disease [ ].
In addition, one case report deals with a lesion of the skull base during dilatation of the frontal sinus, probably caused by the rigid guide catheter [ ].
This image has changed: The numbers reflect an increase of navigation use in routine surgery [ 11 ], [ 13 ], [ ]. In anatomical preparation, inexperienced surgeons had less complications when using the navigation device.
Identification of landmarks is more accurate, though surgery takes longer time [ ]. Statistical evidence for a reduced rate of complications in clinic, however, is almost impossible - under normal conditions several thousand subjects would be required in each cohort [ 15 ], [ ], [ ].
A tendency in favour of lesser complications when using navigation has been observed, especially less injuries of the orbital cavity and CSF fistulas [ 15 ], [ ], [ ], [ ].
Surgeries were less frequently interrupted due to bleedings, although the total blood loss in the use of navigation was higher [ ].
Other authors did not notice any effect on intraoperative complications or the subjective or objective result of the operation [ 15 ], [ ], [ ], [ ], [ ], [ ], [ ].
Complications were also caused by navigation- in some cases e. In regard of these facts, the surgeon must be advised to control the system repeatedly during the operation by means of identified landmarks [ ], [ ].
Generally a divergence of mm in routine surgery can be expected [ ], [ ], [ ], [ ], [ ], [ ], [ ]. For the economic evaluation of medical navigation devices a setup time of about 15 min per case must be taken into account.
For new systems, these values may be higher [ ], [ ], [ ], [ ], [ ], [ ], [ ], [ ], [ ], [ ]. Also, in case of an inexperienced surgeon the surgery itself is prolonged by approximately 16 min [ ].
When technical inadequacies occur, time loss is significantly higher, and an additional amount of time is needed to adjust the data set [ ].
Technical problems of navigation devices can lead to the termination of the procedure [ 65 ]. Other authors deny the loss of time, stating that especially during long procedures, time for setup is balanced by straightforwardness of the surgery [ ], [ ], [ ], [ ].
Generally, the costs increase with the use of navigation systems. Here additional costs and stress must be taken into account [ ], [ ].
Other authors limit this range of indications in surgery for chronic rhinosinusitis to e. Due to a survey of surgeons, the extent of the disease does not imply a benefit of the navigation system [ ].
However, is a system available, it is often used in routine [ ], [ ]. It promotes the subjective safety and the anatomical precision, but does not replace the expertise [ ], [ ], [ ] — the otorhinolaryngologist must master the anatomy and must not rely on a navigation system [ ], [ ].
As reflected in literature navigation systems are thus not indispensable components of the technical standards in routine paranasal sinus surgery.
In other non-routine exceptional cases, however, not using navigation assistance needs to be justified [ ], [ ], [ ], [ ]. Regarding rhino-neurosurgery other conditions are applied: It reduces the duration of the surgery and reduces the rate of complications [ ], [ ].
Experienced and inexperienced surgeons have a different access to navigation systems:. Experienced surgeons use the navigation system in routine surgery in order to save time and to reduce personal time constraints.
The basic surgical strategy does not change, although comparatively more extensive procedures e. There are different views concerning the influence of navigation on the completeness of routine interventions [ ], [ ].
In any case, subjective safety is higher and confidence in the technology increases with experience [ ], [ ], [ ], [ ], [ ]. Junior otorhinolaryngologists benefit from navigation systems during their training [ ], [ ], [ ], [ ].
Untrained surgeons use the system more frequently than advanced surgeons, preferably in the area of the sphenoid sinus, the lamina papyracea, the skull base and frontal sinus.
The completeness of the procedure increases subjectively and objectively [ ], [ ]. For this reason, a general application is not recommended by different authors [ ].
It has become customary to retrieve routine procedures by specific preoperative checklists before and during surgery.
A positive impact on formal procedures in the operating room was proven, a desired effect on the rate of complications can statistically not be secured [ ], [ ].
Standards of care in documentation and cooperation must be followed in sinus surgery. Operative reports should generally be written within 24 hours, and should not be modified at a later stage [ 76 ], [ ].
During the entire hospitalization flaws in communication between physicians, patients and nurses or among physicians can lead to significant therapeutic and medico-legal problems [ 65 ].
Clinical procedures must be planned, secured and controlled taking into account the fact that monitoring and patient care is shared [ ].
When complications occur, the attending physicians are well advised to pay attention to document all measures of diagnosis and therapy intensely.
The surgeon is personally obliged to accurately inform all following physicians even at inconvenient times. For means of prevention different strategies are applied.
A strict, systematic, direct analysis of preoperative imaging of each patient by the surgeon just before surgery in the OR is recommended. In the last decade preoperative imaging was not necessarily performed in every case, even a survey radiograph had been commonly used [ ], [ ].
The standard of preoperative imaging has changed, however: Reconstructions from axial spiral CT data sets are acceptable regarding certain quality standards [ ], [ ], [ ].
In case of complex surgeries or extended frontal sinus surgery all three planes should be available [ 82 ], [ ], [ ].
Special instructions for evaluation of preoperative CT scans were presented [ ], [ ] Table 2 Tab. In particular, pre-existing anomalies malformation, condition after surgery, condition after trauma, destruction of tumours should be taken into account [ ] Figure 15 Fig.
Minor anatomical irregularity revealing asymmetry of the ethmoidal roof of the left and right side. According to some authors, the rate of intraoperative complications is definitely higher if the corresponding CT images are not present in the operating room [ 76 ].
Other authors explicitly did not notice any corresponding influence [ 86 ], [ ]. Nevertheless, the majority of authors supports the view, that constant access to imaging modalities during sinus surgery represents currents standards.
In analogy with this view there are reports dealing with an injury of the internal carotid artery due to missing axial CT scans [ ] or an encephalocele which was overlooked, resulting in CSF fistulas [ 76 ].
Rhinologic literature presents various forms and properties of nasal packing with their specific risks [ ]. Nationally and internationally, there is an increasing tendency to abolish nasal packing in routine sinus surgery [ ], [ ].
Accidentally remaining nasal packing in the nasal cavity is very rare [ ]. In literature spectacular cases are known where nasal packs have been left behind for years [ ], [ ].
In a single case the packing remained for about 8 years. At the location of the fistula an encephalocele had formed additionally [ ].
In literature apart from these special cases, the rate of residual nasal packing is indicated with a rate of 0. Against the background of this issue security threads in nasal packing units must be recalled.
The patient population subjected to outpatient surgery is often exclusive: According to literature, patients subjected to a number of specific other interventions, such as advanced, isolated frontal sinus surgery, may be observed overnight and are released on the 1st postoperative day [ 77 ].
In outpatient cases the patient is released when he is fully awake and oriented postoperatively [ ]. In the federal republic, guidelines for ambulatory surgery and day surgery of the German Society of Anaesthesiology and Intensive Care Medicine have to be taken into account note the appendix.
In some cases following symptoms apply: Patients with comorbidities such as asthma or patients with conspicuous history of drugs ondansetron were preferentially affected in one study [ ], [ ], [ ].
The overall risk may be increased in elective, ambulatory surgery. As a consequence, medico-legal issues may occur more frequently [ ].
The histological examination of tissue removed during surgery can secure the diagnosis of chronic sinusitis; furthermore information regarding individualized postoperative treatment is obtained e.
Yet the benefit of the routine examination of tissue samples in chronic rhinosinusitis is called into question: In any case, histological examination of resected specimens is indicated for unilateral or macroscopically suspicious intraoperative findings, respectively in case of unusual pain or a history of epistaxis [ ], [ ], [ ].
For dacryocystorhinostomy, the situation is similar from a statistical point of view: The use of shavers does not exclude adequate processing of resected specimens by the pathologist.
In the worst case additional non-decisive information in the diagnosis of incident lymphoma is lost [ ], [ ]. It has to be considered that a histological examination can be useful in regard to medico-legal view.
The histological specimen may function as a building block for evidence of a carefully performed surgery absence of local foreign tissue in the resected specimen and as detection of relevant tissue changes as proof for the indication.
Due to this fact, histological examination of resected specimens in routine sinus surgery seems to be sensible by all means. With an increasing molecular phenotyping of chronic rhinosinusitis the importance of histological examination may increase.
Sinus surgery can generally be performed in local anaesthesia with anxiolytics midazolam and analgesia fentanyl or alfentanil e.
Much more common, however, is general anaesthesia. From the perspective of an anaesthesiologist special aspects of sinus surgery are e. In —18, Blum played only 36 minutes over the whole season,  but still scored two goals, one in the second round of the cup in a 4—0 win at 1.
FC Schweinfurt 05 on 24 October. In the summer of , Blum converted from Christianity to Sunni Islam. Edit Read in another language Danny Blum.
Danny Blum Blum with 1. Retrieved 14 February Retrieved 20 August Sport-Kurier Mannheim in German. Bielefeld verliert mit 0: Bielefeld lose 0—1 to Frankfurt] in German.
Retrieved 21 August Retrieved 27 August Wikimedia Commons has media related to Danny Blum. Danny Blum at fussballdaten.
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