Braz. j. . vol.83 número3

www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

ORIGINAL

ARTICLE

Ophthalmic

complications

of

endoscopic

sinus

surgery

夽

Malgorzata

Seredyka-Burduk

,

Pawel

Krzysztof

Burduk

,

Malgorzata

Wierzchowska

_,

_Bartlomiej

_Kaluzny

,

Grazyna

Malukiewicz

a_{NicolausCopernicusUniversityinToru´n,FacultyofMedicine,DepartmentofOptometryCollegiumMedicum,Toru´n,Poland} b_{NicolausCopernicusUniversityinToru´n,FacultyofMedicine,DepartmentofOphthalmologyCollegiumMedicum,Toru´n,Poland} c_{NicolausCopernicusUniversityinToru´n,FacultyofMedicine,DepartmentofOtolaryngologyandLaryngologicalOncology}

CollegiumMedicum,Toru´n,Poland

Received7March2016;accepted8April2016 Availableonline4May2016

KEYWORDS

Endoscopicsinus surgery; Orbital/ocular; Chronicrhinosinusitis

Abstract

Introduction:Theproximityoftheparanasalsinusestotheorbitanditscontentsallowsthe occurenceofinjuriesinbothprimaryorrevisionsurgery.Themajorityoforbitalcomplications areminor.Themajorcomplicationsareseenin0.01---2.25%andsomeofthemcanbeserious, leadingtopermanentdysfunction.

Objective:Theaimofthisstudywastodeterminetheriskandtypeofophthalmiccomplications amongpatientsoperatedduetoachronicrhinosinusitis.

Methods:Thisisaretrospectivestudyof1658patientswhounderwentendoscopicsinussurgery forchronicrhinosinusitiswithorwithoutpolypsormucocele.Surgerieswereperformedunder generalanesthesiainall casesandconsisted ofpolyps’ removal,followed by middlemetal antrostomy,partialorcompleteethmoidectomy,frontalrecess surgeryandsphenoidsurgery ifnecessary.Theophthalmiccomplicationswereclassifiedaccordingtotype,frequencyand clinicalfindings.

Results:Inourmaterial32.68%ofthepatients requiredrevisionsurgeryandonly10.1%had beenpreviouslyoperated inourDepartment.Overallcomplicationsoccurred in11 patients (0.66%).Minorcomplicationswereobservedin5patients(0.3%)withthemostfrequentbeing periorbitalecchymosiswithorwithoutemphysema.Majorcomplicationswereobservedinone patient(0.06%)andwererelatedtoalacrimalductinjury.Severecomplicationsoccurredin5 cases(0.3%),with2casesandreferredtoaretroorbitalhematoma,opticnerveinjury(2cases) andonecaseofextraocularmuscleinjury.

夽 _{Pleasecitethisarticleas:Seredyka-BurdukM,BurdukPK,WierzchowskaM,KaluznyB,MalukiewiczG.Ophthalmiccomplicationsof}

endoscopicsinussurgery.BrazJOtorhinolaryngol.2017;83:318---23. ∗_{Correspondingauthor.}

E-mail:pburduk@wp.l(P.K.Burduk).

PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial.

http://dx.doi.org/10.1016/j.bjorl.2016.04.006

Conclusions: Orbital complications of endoscopic nasal surgery are rare. The incidence of seriouscomplications, causingpermanent disabilitiesisless than0.3%.The mostimportant parameters responsiblefor complicationsareextensionofthedisease,previousendoscopic surgeryandcoexistinganticoagulanttreatment.

© 2016 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).

PALAVRASCHAVE

Cirurgiaendoscópica doseionasal; Orbital/ocular; Rinossinusitecrônica

Complicac¸õesoftálmicasdacirurgiaendoscópicadosseiosnasais

Resumo

Introduc¸ão: A proximidade dos seiosparanasais àórbita e seu conteúdotornam possível a ocorrênciadelesõestantonacirurgiaprimáriacomonaderevisão.Amaioriadascomplicac¸ões orbitaissãomenores.Asmaioressãoobservadasem0,01%-2,25%ealgumasdelaspodemser graveslevandoadisfunc¸ãopermanente.

Objetivo: Oobjetivodesteestudofoiidentificaroriscoeotipodecomplicac¸õesoftalmológicas empacientesoperadosdevidoarinossinusitecrônica.

Método: Foi realizado um estudo retrospectivo de 1.658 pacientes submetidos a cirurgia endoscópicasinusaldevidoarinossinusitecrônicacomousempóliposoumucocele.Ascirurgias foram realizadas sob anestesia geralem todos os casos e consistiramde remoc¸ão de póli-pos,seguidadeantrostomiameatalmédiaouetmoidectomiaparcialoucompleta,cirurgiade recesso frontalecirurgiadeesfenoidesenecessário. Ascomplicac¸ões oftalmológicasforam classificadasdeacordocomotipo,frequênciaeachadosclínicos.

Resultados: Emnossomaterial32,68%dospacientesnecessitaramdecirurgiaderevisãoe ape-nas10,1%haviamsidoanteriormenteoperadosemnossodepartamento.Ascomplicac¸õesgerais ocorreramem11pacientes(0,66%).Complicac¸õesmenoresforamobservadasem5pacientes (0,3%),sendoqueamaisfrequentefoiequimoseperiorbitalcomousemenfisema.Complicac¸ões maiores foram observadas em um paciente (0,06%) e atribuída à lesão do ducto lacrimal. Complicac¸õesgravesocorreramem5casos(0,3%)eforamreferidascomohematomaretrorbital (2casos),lesãodonervoóptico(2casos)eumcasodelesãomuscularextraocular.

Conclusões: Ascomplicac¸õesorbitaisdacirurgiaendoscópicanasalsãoraras.Aincidênciade complicac¸õesgravesquecausamincapacidadepermanenteédemenosde0,3%.Osparâmetros maisimportantesresponsáveisporcomplicac¸õessãoextensãodadoenc¸a,cirurgiaendoscópica anterioretratamentoanticoagulantecoexistente.

© 2016 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).

Introduction

Functional Endoscopic Sinus Surgery (FESS) is the most appropriate surgical procedure for sinus pathology treat-ment. Over the last decade the procedure developed to relativelysafe.1---4_{Theoverallincidenceofminorandmajor}

complicationafterFESSisrangefrom0.4%to30%.1,2,5,6_The

anatomy proximity of the paranasal sinuses to the orbits exposesitistotheriskoftrauma.2,6_{Themajorityoforbital}

complications are minor ones (3.9---20.24%). The major complications are seen in 0.01---2.25%, but some of them couldbeserious,leadingtopermanentdysfunction.1,2,5---8

The ophthalmic complications could be classified as: minor (grade I) included injury to the lamina papyracea, major(gradeII)injurytothelacrimalductandfinally seri-ous(gradeIII)asretroorbitalhemorrhage,injurytotheoptic nerveoranyreductionofvisionor blindnessandinjuryof orbital muscle.1,6,9,10 _{As the minor and major ophthalmic}

complicationsarenormallywithoutanypermanent disabil-itiestheseriousonesarepotentiallyharmful.1,2,5,6

To reduce or eliminate the incidence of ophthalmic complicationstheprecisepreoperativeComputer Tomogra-phy(CT),MagneticResonanceImagine(MRI),utilizationof the Lund---MacKay Index and novel technique are recom-mended. The even more important thing is training and learningcurvesexperienceinFESSsurgery.1,2,11,12

We analyzed 1658 patients who underwentendoscopic surgeryduetoinflammatorydiseaseoftheparanasalsinuses atourDepartmentover9yearsfrom2005to2013.The oph-thalmiccomplicationswerematchedwithtype,frequency andclinicalfindings.

Methods

Table1 RateofophthalmiccomplicationsintotalFESS.

Typeofcomplication No %

Minor

Injurytothelamina papyraceaand periorbital ecchymosisand emphysema 5 0.3 Major

Lacrimalductinjury 1 0.06

Serious 5 0.3

Retroorbital hematoma

2 0.12

Injuryofopticnerve 2 0.12 Injuryoforbital

muscle

1 0.06

through 2013 at the Department of Otolaryngology. The study protocol was reviewed and approved by the Ethic Committee(decision number366/2015). All patients with CRS with or without polyps and patients with mucoceles were included in the study. The patients with diagnosed benignandmalignanttumorswereexcludedfromthestudy. ThediagnosisofCRS wasmadeinaccordancewithhistory and objective findings. The cases were graded according tothe Lund MacKay score and the surgical extent tothe Lund Kennedy grading were done.11,12 _{Age, gender, Lund}

MacKayscore,symptoms,typeofsurgerywerecorrelated with frequency of minor, major and serious ophthalmic complications.Thesurgerywasperformedbytwosenior sur-geons.Surgicalexperiencewasrated frombeginners(0---5 years) toward experienced more than 5 years. The oph-thalmiccomplicationsareshowninTable1.

Surgery wasperformed undergeneral anesthesiain all cases.Asurgeryconsistedofpolyp’sremovalwith microde-brider, followed by middle metal antrostomy, partial or completeethmoidectomy,frontalrecess surgeryand sphe-noid surgery if necessary. After the surgery the middle meatus was packed with removable gauze packing for 7 days.

Statistical analysis was performed with Stat Soft Inc. (2011)Statisticasoftwareversionno.10.TheMann---Whitney U test and x2_{-test were used to evaluate differences} betweenthepositiveor negativepossibilitiesof complica-tion.Univariate andmultivariateanalysisweredone using logistic regression to obtain risk factors for ophthalmic complicationsofFESS.Thelevelofsignificancewasdefined asp<0.05.

Results

The age ranged from 17 to 69 years (mean 45.6 years). Pathological findingsand symptomsare shown in Table2. ThetypesofsurgeryarepresentedinTable3.Inour mate-rial 32.68% of the patients required revision surgery and only 10.1% had been done previously in our Department. The surgery procedures were done by two surgeons with dependent level of experience Table 4. All the patients

withophthalmiccomplicationswerediagnosed,treatedand followed up by one senior clinical ophthalmologist. Over-allcomplications occurredin11 patients(0.66%).Aminor complications was observed in 5 patients (0.3%) with the most frequent being periorbital ecchymosiswith or with-outemphysema.Majorones wereobservedinonepatient (0.06%) and were referred to lacrimal duct injury which wasrepairedduringthesamesurgery.Aserious complica-tionoccurredin5cases(0.3%)andreferredtoretroorbital hematoma(2 cases),opticnerveinjury (2cases) andone caseofextraocularmuscleinjury.Amongthegroupof seri-ous complications in 2 cases of rtetroorbital hematoma weperformed immediateorbitaldecompressionwithgood results andcomplete recovery.In onecase of extraocular muscleinjury(medialrectusmuscle)aftertheophthalmic surgery correction and rehabilitation we do not achieved completerecoveryandthepatienthasstilldiplopia.Inboth cases of optic nerve injury the decompression wasdone, but only in onecase the visual acuityimproved to0.1at Snellen chart. The second patient visual acuity was only hand motion. These 2 cases werequalified aspermanent ophthalmiccomplications(0.12%ofallsurgeries).

Discussion

Nevertheless,theincidenceofocularcomplicationsduring ESSisratherlow;theycouldbeserious,leadingto perma-nentdysfunction.TheoverallincidenceofESScomplications arereportedinseveralmetaanalysispointeditsoccurrence between4.2---23%or0.9---3.1%.1,3,5_{Thereareonlyfew}

anal-ysis oforbitalcomplicationsduringESS.13,14_{The incidence}

ofthistypeofcomplicationsisrangefrom0.5%to5%.13 _In

our investigation we tried toevaluate the frequency and types of ophthalmic complications usingthenovel system of classification tominor, major and serious proposed by Siedek.1 _{The exact incidencefor orbital injury during ESS}

is unclear, but is stillless than 1%.1,3,5,13 _{The same result}

wasobtainedinourstudy,andtherateofall ophthalmol-ogycomplications was0.66%.The orbit andits contentis at risk during ESS because the lamina papyracea is very thin or may be incomplete.5,6,15,16 _{This site is the most}

potentialriskarea,especiallywhenwedonothaveagood qualityof visionor usingpoweredinstrumentation.1,3,5,6,17

Theminorcomplicationsarereferredtolaminapapyracea injury mostly during maxillary antrostomy or ethmoidec-tomy.Thiscomplications aremostlyseen withhypoplastic maxillarysinusorSilentSinusSyndrome(SSS).4,5,11,13,18,19_In

this anatomic variants the uncinate very tightly connects tothelaminapapyraceaandshouldberesectedwithgreat attention.5,11,13_{InourmaterialwehadoneSSSandtwocases}

ofhypoplasticmaxillarysinuswhichhadbeencomplicated withinjurytothelamina papyracealeadingtoperiorbital ecchymosis and in one case emphysema. The other two cases of minorcomplications occurred during ethmoidec-tomyafterbrakingthelaminapapyracea.All5cases(0.3%) donotneedanyinterventionexceptstandardpostoperative treatmentandcontrol.Themajorcomplicationsaslacrimal ductinjuryisalsoconnectedwithuncinectomy,ifitis per-formed too far anterioly.5,13 _{If the nasolacrimal duct will}

still drain, it is the best toleave it.2,5,13 _{In ourone case}

Table2 Pathophysiologicalfindingsandcomplicationsrate.

n Complications positive(n=11)

Complications negative(n=1647)

p-Value

Age(years) 45.6±13.8 45.1±12.3 47±10.8 ns

Sex(male/female) 987/671 6/5 981/666 ns

Lund---MacKayscore 12.4±7.3 14.7±8.9 9.4±5.4 <0.028

Polypscore 2.6±1.4 3.1±1.5 1.7±1.1 <0.05

Prevoiussinussurgery 542 9±5.3 2±1.1 <0.05 Treatmentwithanticoagulants 331 7±3.8 4±2.9 <0.05

CRS 675 3±1.1 672±15.6 ns

CRSwithpolyps 973 8±3.4 965±16.7 <0.05

Mucocele 10 0 10±2.8 ns

ns,notsignificant.

Table3 Typeandextensionofsurgeryinanalyzedgroupofpatients.

Surgery n % Complications(N) p-Value

Infundibulotomy 5 0.3 1 ns

Partialanteriorethmoidectomy 118 7.12 0

---Completeethmoidectomy 187 11.29 6 <0.05

Sphenoethmoidectomy 68 4.1 2 ns

Anteriorfrontoethmoidectomy 296 17.85 0

---Completefrontoethmoidectomy 886 53.44 2 ns

Frontosphenoethmoidectomy 98 5.9 0

---Total 1658 100 11 ns

ns,notsignificant.

Table 4 Percentage of operations done by beginners (0---5 years) and experienced (>5 years) surgeons with ophthalmic complicationsoccurrence.

0---5years >5years

Surgeon1 Surgeon2 Surgeon1 Surgeon2

Numberofcases 402 280 378 598

Complication(N)andtype 3 2 3 3

Minor 0 1 2 2

Major 0 0 0 1

Serious 3 1 1 0

p-Value ns ns ns ns

ns,notsignificant.

not absolutelysure ifit is open, sowe performed dacry-ocystorhinostomy with silicon tube intubation. The most devastating orbital complications as orbital hematoma, opticnerveinjuryorexternal ocularmusclerupturecould occurredduring ethmoidectomy, sphenoethmoidectomyor frontoethmoidectomy.2,5,13 _{Orbital hematomacould}

devel-opedasarterialinjury(anteriororposteriorethmoidartery) orvenoushemorrhageresultsfromentryoftheorbitthrough the lamina papyracea1,3,5,9,13 _{The incidence of this most}

common seriouscomplication is about 0.12%, as wasalso observedinourstudy.5,9_{Thehemorrhagecanresultinvisual}

loss from optic nerve or retinal ischemia. This situation demandedveryfastidentificationandurgenttreatment.If therisk islow(low ocularpressure andvisionis not com-promised) medicaltreatment is adequate. In high ocular

pressure and visual dysfunction immediate surgical inter-ventionincludedlateralcanthotomy,cantholysisandorbital decompressionisrecommended.2,3,5,13 _{Inmostcases,asin}

our2patients(0.12%)after ophthalmologytreatmentand surgerytheresultsareverygood,withcompleterecovery.

Directopticnerveinjury is veryrareandwasfound in our material in 2 cases (0.12%) as compared with litera-turereview.1,3,5,13 _{The nerveiscommonlydehiscentinthe}

sphenoidsinusorposteriorethmoid.Theinjurymaybe indi-rect(vascular) ordirect(mechanical).1,3,5,13,20 _Inourwork

the injury was caused by hematoma and compression of the nervein posterior ethmoid. In spite of intense intra-venouscorticosteroids andopticnerve decompressionthe resultsisnotsosatisfied.1,3,5_{We obtainedvisual}

Table5 Riskfactorsforophthalmiccomplicationsduring endoscopicsinussurgery.

Univariateanalysis crudOR 95%CI p-Value

Lund---MacKayscore 1057 1.012---1.118 <0.021 Polypscore 1521 1.161---1.910 <0.016 Previoussurgery 2031 1.576---2.114 <0.024 Anticoagulants 1594 1.478---1.810 <0.022

Multivariateanalysis AdjustedOR 95%CI p-Value

Lund---MacKayscore 1015 1.001---1.062 <0.562 Polypscore 1201 1.044---1.583 <0.030 Previoussurgery 1902 1.246---1.671 <0.041 Anticoagulants 967 0.901---1.057 <0.638

one.Also the injury of orbital muscle is one of the most devastatingcomplication,frequentlyleadingtopermanent dysfunction.1,5,6,13 _{Directmuscletransectionismostlyseen}

withpoweredinstrumentationsurgery.Thedeviceextracts tissue veryrapidly with very low tactile feedback tothe surgeon about removable material.1,2,14 _{In our study we}

observed one patient (0.06%) with direct rectus muscle injury after microdebrider usage. Despite of ophthalmic surgeryandrehabilitationthepatienthasstilldiplopia.

The risk factors for ESS complication depends on the extent of the disease and surgery, Lund---MacKay score, poweredsurgery,coexistingcomorbidities,primaryor revi-sion surgery or surgeons experience.3,5,6,13,21 _{Asaka et al.}

reportedthattherisk dependsonpolypscoreandasthma whereastheLund---MacKayscoredidnot.3_Inourstudy

uni-variateanalysisfoundthatpolypscore,Lund---MacKayscore, previous surgery and also anticoagulant treatment corre-lated significantly withthe ophthalmic complications. We havetopointed thatpatients treated withanticoagulants haddefinitelyworsequalityofoperativefieldduetomore intensebleeding.Moreover,thispatientsmorebleedsdueto thebloodpressurecouldnotbeloweredenoughduringthe surgery.1_{Multivariateanalysisshowedthatonlypolypscore}

andpervioussurgerycorrelatedsignificantlywiththe occur-renceofcomplications,whereastheLund---MacKayscoreand anticoagulantsdidnot(Table5).Astheextentofmucosal lesioninfluencedtoclear visionforsurgicallandmarksthe scaring in revisionsurgery muchmore changed it.3,21 _The

surgeons experience did not influenced on complications rate,asit wasalso showedin other studies.1,3,5,6 _{We can}

expectthatsurgeonswhoaremoreexperiencedareableto performmoredifficultcasesandfellmoresavewith anatom-icalvariantsor powereddevices.Itis nottruth,thesame level of complications are observed at the beginners and experienced ones. Moreover, the rate of complications is notregardtothenumberofsurgeriesperformed bysingle surgeon.Ontheotherhand,whenweoperatedtheextent disease,especially nasal polyps we should performed not only total ethmoidectomies but also sphenoidectomy and frontoethomidectomywhicharemorepredictablefor unex-pectedcomplications. The management of thesepatients withpathologyinclosetotheorbitcouldbeassociatedwith seriousinjuries, leadingtopermanentdysfunction.It was provedthattheextentofthesurgeryalsoinfluencedtothe

rate of complications. There were observed especially in completeethmoidectomies(p<0.05).

Conclusions

Orbitalcomplicationsofendoscopicnasalsurgeryarerare, butcouldbepotentially harmful.Theincidenceofserious complications, causing permanent disabilities is less than 0.3%butweshouldworktominimalizeit.Themost impor-tantparametersresponsibleforcomplicationsareextension ofthedisease,previousendoscopicsurgeryandcoexisting anticoagulanttreatment.Nevertheless,akeepgoingonCT reading,newdevicesandtrainingarethebestmethodsfor savesurgery.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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