Complications of endonasal paranasal sinus surgery--diagnostic and therapeutic consequences

BACKGROUND: Functional endoscopic sinus surgery has been proven the therapeutic method of choice in surgical therapy of chronic sinusitis. On the other hand, endonasal sinus surgery may cause severe complications even when performed by a skilled surgeon. This is easily explained by the close vicinity of many functionally important structures to the operative site. CASE REPORTS: Three histories are reported that involve possible complications even in apparently simple cases. Diagnostic and therapeutic consequences are discussed. In a case previously diagnosed histologically as chronic unspecific sinusitis, an endonasal biopsy resulted in endocranial bleeding requiring neurosurgical intervention. Midline granuloma was found to be the correct diagnosis. Another patient was seen with a normal X-ray of the sinuses and solitary polypoid structure in his left nose. Polypectomy was planned and a CT scan was performed, which demonstrated a meningocele. Transfacial surgery was then performed to remove the meningocele. Another patient presented with a traumatic impression of the frontal sinus, and open reposition by transfacial surgery of the frontal and ethmoid sinus was planned. When CT scans revealed an uncovered optic nerve in the sphenoid sinus of the fractured side, we abandoned ethmodectomy and performed reposition of the frontal sinus as the only surgical procedure. RESULTS AND CONCLUSIONS: In this paper, we show typical complications of endonasal sinus surgery and strategies for avoiding them. If any complication occur, prompt treatment is required. Three groups of complications can be defined: perforation of frontobasal dura resulting in cerebrospinal fluid (CSF) fistula, severe bleeding, and orbital or optic nerve injury. When the surgeon discovers an intraoperative complication, possible consequences must be considered immediately to minimize side effects for the patient. A CSF fistula should be closed in the same procedure, and transfacial surgery may be necessary. Hemorrhage resulting from an ethmoidal artery may require frontoorbital surgery and ligation of this vessel. If retrobulbar hemorrhage caused by retraction of an ethmoid artery occurs, immediate intervention is necessary. Usually a transfacial approach, resection of the medial orbital wall and retrobulbar decompression are performed. In some cases lateral canthotomy may be the best way to drain haematoma and decompress the optic nerve. Subsequently, orbital revision and ligation of the retracted artery must be performed. Any delay can result in persistent visual loss. We conclude that the extranasal frontoorbital approach should be part of the residency training program in ENT departments. Any surgeon performing endonasal sinus surgery must be trained in transfacial emergency procedures, which should be part of anatomic preparations in teaching courses, thus avoiding severe damage in case of intraoperative complication.     

Using a rotating suction debridement instrument with power generator in endonasal paranasal sinus surgery

Necrotizing fasciitis is rare in the orofacial region, with fewer than 20 cases reported in the literature. Extension of the disease process to involve the underlying bone has not been previously reported. A patient is presented in whom destruction of superficial skin and fascia, necrosis of a portion of the mandible, and involvement of the parotid gland complicated reconstruction.     

Delayed toxic shock syndrome after functional endonasal sinus surgery

Esophagopericardial fistula is a rare entity, usually associated with benign esophageal disorders. Clinically they present as an acute illness associated with characteristic clinical findings and have an extremely high mortality rate. A case of a chronic esophagopericardial fistula is presented in an individual who remained asymptomatic and presented as a sudden unexpected death secondary to cardiac tamponade from refluxed gastric contents.     

Paranasal sinus mycoses in north India

Recognizing the high incidence of paranasal sinus mycoses in north India, we analysed retrospectively the clinical, mycological and management aspects of 178 patients with proven disease attending our institute. On the basis of clinical, radiological, histopathological and mycological findings, the patients could be categorized into those with allergic (8), non-invasive (92) and invasive (78) disease types. Bony erosion without mucosal invasion by fungi was seen in 16 patients with non-invasive disease. Young men from rural areas were the most commonly affected. Rhinorrhoea with nasal polyposis (45.8%) and proptosis (46.4%) was the most common presentation. Concurrent involvement of the maxillary and ethmoid sinuses was common in these patients, whereas isolated sphenoid and frontal sinuses were involved in the invasive variety only. Orbital and intracranial extensions were detected in 100% and 13.2%, respectively, of patients with the invasive type of disease. Aspergillus flavus (79.7%) was the most common isolate. Surgical debridement and sinus ventilation were adequate for the effective management of the non-invasive disease. However, adjuvant medical therapy was included in treatment of the semi-invasive and invasive varieties of the disease. Itraconazole was found to be most useful in prevention of recurrence in the invasive type. Mortality was highest (33.3%) among patients with zygomycotic infection. Invasive fungal granuloma with orbital and intra-cranial invasion is a distinct entity in terms of its clinical course and treatment compared with non-invasive fungal sinusitis, and it needs to be treated aggressively with surgical excision and postoperative itraconazole.     

Iatrogenic complications of endonasal surgery

It has been suggested that the most likely cause of the Testicular Regression Syndrome (TRS) is ante-natal torsion of the testis. As testicular torsion is twice as common on the left this theory cannot explain the incidence of right sided or bilateral cases. From a 5-year retrospective surgical and pathological review, we confirmed that the left testis was the most commonly affected, that boys with TRS tended to be delivered closer to term, and that frequently both testes were present at birth, but one or both subsequently vanished. We also found that direct trauma can produce histological findings indistinguishable from TRS. Close to term, fetal testes are liable to be intrascrotal and therefore susceptible to direct trauma. As the left testis descends into the scrotum at an earlier stage than the right, it is therefore at greater risk of injury. Since the findings of TRS can be produced by direct trauma, we suggest that intra-partum trauma may predispose to the TRS.     

Malignant schwannoma arising in a paranasal sinus

Bechterew's disease is a chronic-inflammatory condition of the spine, with a tendency toward stiffening and relatively frequent involvement also of the hip, knee and shoulder joints. Contrary to most other rheumatic diseases, drug therapy plays a rather minor role. The focus is on movement, in line with the motto that "Bechterew patients need movement". The sports therapy concept of the Münster University Bechterew group as well as initial experience are set out.     

Cavernous sinus syndrome caused by a primary paranasal sinus non-Hodgkin's lymphoma

Although uncommon, non-Hodgkin's lymphomas occasionally arise from the nose and paranasal sinuses. Rarely, they may invade into the cavernous sinus and produce signs and symptoms that characteristically include unilateral ophthalmoplegia, sensation loss in the distribution of the ophthalmic and other divisions of the trigeminal nerve, sympathetic nerve paralysis and proptosis. In this report, we present a case of cavernous sinus syndrome (CSS) caused by infiltration of non-Hodgkin's lymphoma from the adjacent paranasal sinuses and address issues regarding its diagnosis and treatment.     

Good results of endoscopic paranasal sinus surgery for chronic or recurrent sinusitis and for nasal polyps

Endoscopic sinus surgery is being applied increasingly for chronic or recurrent sinusitis and nasal polyps. We investigated the results, which we classified as subjective results (i.e. the opinion of the patient) and objective results (i.e. the result as seen with nasal endoscopy). The subjective result was 'good' in 85% of 92 patients with chronic or recurrent sinusitis, the objective result in 77% of the treated sides, with a median follow-up of 46 months. In 90 patients with nasal polyps the percentages were 90% and 65% respectively, with a follow-up of 24 months. In 63% of 30 patients with chronic obstructive lung disease and nasal polyps the pulmonary function increased postoperatively (FEV1). In 4.2% of 1235 operated sides in 593 patients local complications were seen. These were mainly minor complications. Only in 0.3% serious complications as a orbital hematoma or a CSF leak were seen. Endoscopic sinus surgery has good results and little morbidity.     

Gas embolism during endonasal YAG laser surgery

The authors describe a case of air embolism during an endonasal YAG laser surgery in a 10-year-old child. This accident was caused by the coaxial air cooling system of the laser ruby tip. The importance of end tidal CO2 monitoring and precordial auscultation during laser surgery even in patients without risk factors is underlined.     

Case of paranasal sinus osteoma with cerebrospinal rhinorrhea and pneumocephalus

The authors describe a case of osteoma of the paranasal sinuses growing into the anterior cranial fossa with liquorrhoea and aerocele treated successfully surgically from an osteoplastic transsinusal approach.     

Nasal splint--space holder for after-care in endoscopic paranasal sinus operations

A clinical study of patients with male urethritis (n=316) was undertaken to determine the sensitivity potential for a new dual amplified immunoassay (IDEIA PCE Chlamydia). Increased sensitivity (98.8%, 84/85) was obtained for IDEIA PCE Chlamydia compared to a conventional antigen detection test (IDEIA Chlamydia, 81.2%, 69/85) when testing urine samples. In a smaller patient population (n=104) the positivity rate for the first-void urine tested with IDEIA PCE Chlamydia of 30.8% (32/104) was similar to the 27.9% (29/104) obtained from urethral swabs tested with a DNA probe assay (PACE 2). The increased sensitivity of the test was confirmed with a commercial PCR kit (Amplicor) and nested PCR. The IDEIA PCE Chlamydia kit has the sensitivity potential to be a clinically reliable alternative for detecting Chlamydia trachomatis.     

Clinical features and characteristics of paranasal sinus effusion in allergic sinusitis

Paraproteins or monoclonal proteins are the result of clonal B-cell or plasma cell proliferation of a malignant, premalignant or non-malignant nature. Monoclonal proteins may consist of intact immunoglobulin molecules or of heavy or light chains only. Depending on their rate of production and/or secretion they may accumulate in the serum and/or urine of patients. Their presence in the circulation may remain silent, as in monoclonal gammopathy of undetermined significance (MGUS), or may lead to clinical syndromes such as Hyperviscosity, Acrocyanosis, Cold hemagglutination, hemolysis and hemorrhagic manifestations. Their tissue deposition may be localized, with the kidney being the most frequent target as in Myeloma Cast Nephropathy or systemic, as in AL amyloidosis where heart, liver, nerves, tongue are usual targets, in addition to the kidneys.     

Atypical localization of a small cell carcinoma in the paranasal sinus area--case report

BACKGROUND: Malignant neoplasms of the paranasal sinuses are estimated at 3 to 5% of all head and neck malignant neoplasms. More than 50% of the cases are classified as squamous cell or anaplastic undifferentiated carcinomas. Extremely rare are small cell carcinomas localized in the paranasal sinuses. METHOD AND PATIENT: A 60-year-old male patient was seen in February 1996 in our ENT Department with unspecific pain on the left maxillary sinus and alveolar ridge. Anterior rhinoscopy revealed an extended tumor on the left nasal fossa; histopathological examination showed a small cell carcinoma. No other primary tumors or metastases were detected in extended staging. Due to the extended paranasal tumor as well as the histopathological findings, the patient was given induction chemotherapy followed by radiation therapy. RESULTS: To date (4/97), we achieved partial remission without any clinical complaints. CONCLUSIONS: The therapeutical result is comparable to other therapeutical regimens.     

MR-guided endoscopic sinus surgery

We describe an interactive, intraoperative imaging-guided method for performing endoscopic sinus surgery (ESS) within a vertically open MR system. The procedure was performed with intraoperative imaging using a 0.5-T magnet with a 56-cm vertical gap. Interactive control of imaging planes was accomplished by optical tracking with two infrared light-emitting diodes mounted on an aspirator probe. The probe's position defined the location of the orthogonal imaging planes. Twelve patients with varying degrees of sinus disease underwent ESS with MR imaging guidance. Patients had acute and chronic sinusitis, nasal polyposis causing airway obstruction, or tumor requiring tissue biopsy. All procedures were performed with the patients under general anesthesia. The integration of endoscopy with optical tracking and intraoperative interactive imaging allowed localization of anatomic landmarks during ESS. No complications were encountered.     

Effects of functional endoscopic sinus surgery on maxillary sinus mucosa

OBJECTIVE: To compare the preoperative and postoperative changes on ciliary surface of maxillary sinus mucosa in patients treated with functional endoscopic sinus surgery. DESIGN: The maxillary mucosa of both the superolateral wall and the ostium were sampled during the operation and 6 to 12 months (mean duration, 7.6 months) after the operation. Ciliary surface was determined using scanning electron microscopy in combination with an image analyzer and was expressed in terms of ciliary area, which is the percentage of mucosal surface occupied by cilia. SETTING: The samples were taken at a hospital-based clinic. An electron microscopic study was performed at Mie University School of Medicine, Mie, Japan. PATIENTS: Sixteen patients (20 maxillary sinuses) undergoing functional endoscopic sinus surgery for treatment of chronic sinusitis. RESULTS: The mean (+/-SD) ciliary area before the surgery was 60.7%+/-28.8% and 39.9%+/-21.5% in the superolateral wall of the maxillary sinus and the ostium of the maxillary sinus, respectively. The ciliary area of the superolateral wall was significantly higher than that of the ostium (P<.001). The mean (+/-SD) postoperative ciliary area value was 74.3%+/-22.6% in the superolateral wall and 51.3%+/-16.1% in the ostium. These postoperative values were significantly higher than the preoperative values (P<.001). CONCLUSIONS: This study showed that the maxillary sinus mucosa in chronic sinusitis is capable of regeneration, and the damaged ciliated epithelium could return toward normal with the improvement of ventilation and drainage of the maxillary sinus following functional endoscopic sinus surgery.     

Medical treatment of paranasal sinus polyposis: a prospective study in 181 patients

Treatment of naso-sinus polyposis has been the subject of much controversy. The large number of reports in the literature suggest that role of surgical treatment is on the uprise. There is however general agreement that medical treatment is fundamental although an insufficient number of studies have evaluated its efficacy. The aim of this prospective study was to evaluate results 6 months, 12 months and 2 years after medical treatment of polyposis in 181 patients. Despite a well-coduced information protocol, nearly 19% of the patients were lost to follow-up. Less than 32% of the patients have been operated. Patients treated medically were given a standard regimen according to a protocol combining short-term oral corticosteroids (prednisolone) and steroid nasal spray (beclometasone). Treatment was successful in 68% of the patients given medical treatment alone. Mean symptom intensity declined by 35 to 80% at 6 months then remained unchanged to the end of the study (2 years follow-up). Mean doses of prednisolone and beclomethasone were evaluated. Doses could be tapered off progressively allowing satisfactory nasal comfort. Medical treatment should be the first line therapy for nasal polyposis. Surgery should not be proposed until corticosteroid therapy has been found to be unsuccessful over a mean 6 months of a well-conducted treatment and good patient compliance.