IMPROVING NOSE AND SINUS SURGERY
Educational Objectives
| The goal of this program is to improve surgery of the nasal septum and prevent complications of endoscopic
sinus surgery (ESS). After hearing and assimilating this program, the clinician will be better able to:
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 | 1. Identify the symptoms of nasal septal perforation and choose a procedure for repair or an alternative
to repair.
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| 2. Describe a new procedure for repair of large septal perforations that uses the mucoperiosteum of the
bony septum.
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| 3. List the possible complications of ESS.
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| 4. Describe documentation that can be used to defend the surgeon should a malpractice suit be brought
as a result of a complication of ESS
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| 5. Explain how the more common complications of ESS arise, how they can be prevented, and how to
manage them.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the
planning committee to disclose relevant financial relationships within the past 12 months that might create any personal
conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes
quality in health care and not a proprietary business or commercial interest. For this program, the following has been
disclosed: Dr. Stankiewicz is a consultant for Gyrus and on the Medical Board of Entellus. Dr. Shikowitz and the
planning committee reported nothing to disclose
Acknowledgements
Dr. Shikowitz gave his presentation at Otolaryngology Annual Clinic Day, presented December 5, 2007, in Uniondale,
NY, by the Nassau Surgical Society, and the Brooklyn and Long Island chapters of the American College of Surgeons.
Dr. Stankiewicz addressed the 2008 Annual Clinical Conference in Otolaryngology of the Kansas City Society of
Ophthalmology and Otolaryngology, held January 11-12, 2008 in Overland Park, KS. The Audio-Digest Foundation
thanks the speakers and the sponsors for their cooperation in the production of this program.
| PREVENTION AND REPAIR OF NASOSEPTAL PERFORATIONS —Mark J. Shikowitz, MD, Professor, Department
of Otorhinolaryngology–Head and Neck Surgery, Albert Einstein College of Medicine of Yeshiva University,
Bronx, NY, and Vice Chair for Otolaryngology, Northshore Long Island Jewish Health Care System, New Hyde Park,
NY
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| History of nasal septal surgery: earliest surgical procedures resulted in many perforations, but these considered
“acceptable and tolerated”; development of Hartmann bone forceps enabled removal, straightening, and reinsertion
of cartilage; in early 1900s, Killian developed technique using dorsal and caudal struts, and this became standard
for septal surgery; Killian incisions still used; around same time, Freer developed surgical correction of deviated
septum without caudal strut (does not work well; strut needed); historically, cocaine used as anesthetic; at present,
cocaine cause of many perforations
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| Symptoms of perforation: majority asymptomatic; common symptoms whistling, bleeding, crusting, pain, and
obstruction; bleeding led speaker to develop new procedure
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| Choice of procedure: several procedures available; no single procedure best; individual surgeons have techniques
that work best in their hands; septal buttons used in patients who refuse surgery; small rotation flaps and bilobed
flaps work well for small perforations (≤1 cm); in literature, failure rate 30% to 70% for large perforations (>2 cm)
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| Alternatives to repair: reducing symptoms rather than closing perforation; (Nunez 1998)—reported symptom improvement
from partial closure of large perforations; Jackson and Coates (1945)—reported success with enlarging
perforation and healing of posterior edge where most crusting occurs; Eng et al (2001)—13 patients; enlarged
perforation, resected cartilage from posterior edge, and wrapped mucosa around; of 8 patients with epistaxis, 2
improved and 6 totally asymptomatic; crusting and other symptoms improved in remainder; complicated procedure
involving various flaps; speaker’s patient—recently presented for unrelated complaint; button placed 5 to 6
yr ago had fallen out, perforation now much larger, and symptoms disappeared
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| Development of procedure: for patient with 3-cm perforation of cartilaginous septum (result of rhinoplasty); arterial
supply to septum from terminal branches of external carotid and branches of internal carotid through skull base;
anything injected into area can go to brain and may cause sudden blindness; effects of lidocaine and epinephrine injection
reversible, steroid injection irreversible; most of blood comes in through mucoperiosteum of bony septum;
possible to mobilize periosteum, leave it attached to blood supply, and bring it in to close hole
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| Technique: periosteum pulled through septum to opposite side, so raw edge of mucoperiosteal surface faces inward
against cartilage and mucosa to reestablish blood supply; can be done open or endoscopically, depending on size
of perforation; blood from contralateral unoperated side, so posterior edge of perforation intact; superior and inferior
margins of resection not cut to edge of perforation because part of blood supply enters there; acellular soft
tissue grafts—used to line exposed bone and promote remucosalization of bone; also protect flap from drying
out, allowing edges to heal with scaffolding effect; can be combined with rhinoplasty or with endoscopic sinus
surgery (ESS); points—perforations usually go back to bony septum; important to be able to elevate flap all the
way back to face of sphenoid sinus if necessary, leaving 2 triangles intact and not separate it from posterior edge
(still part of vascular supply)
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| Instrumentation: regular septal set too bulky; most of procedure done with middle ear instruments, including canal
knife, sickle knife, and duckbill elevator; cut above and below with sickle knife; vertical incision made with canal
knife; retrograde elevation of flap done with canal knife, starting on bottom until small opening made; then duckbill
used to lift off periosteum; by pulling, flap becomes elevated from posterior to anterior direction; once elevated up
to edge of perforation, flap brought through to opposite side of septal cartilage and sewn in through mucosa and perichondrium;
acellular grafting material placed on either side, site covered with Teflon splints, and secured with suture;
caveat—suture must not be too tight, or blood supply to graft will be cut off; open rhinoplasty often done and
sewn with 5.0 or 6.0 Dexon or Vicryl sutures
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| Results so far: 22 patients with follow-up of 6 mo to 2 yr; ≥85% success rate; 3 flap losses—1 partial (patient diabetic
with perforation from cocaine use, so blood supply poor); 1 patient had 2 separate perforations that were not
detected until surgery in progress (if >1 perforation, do not try to repair both at same surgery; stage flaps); 1 patient
involved in motor vehicle accident after surgery, and began oxymetazoline (eg, Afrin) for congestion, damaging
flap; conclusion—speaker uses procedure for almost all perforations, except very small ones
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| Preventing perforation in septal surgery: undermine broadly; pull flap away from spur; use angled scissor to cut
above and below sharp bony edge, then remove; if perforation occurs repair at end of procedure, using autologous cartilage
or acellular graft; use splints; can use 4.0 plain double-arm septal needle inside nose to repair perforation with running
stitch
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| Conclusions: vascularized mucoperiosteal pull-through (VMP) flap method recommended for treating larger perforations,
but also excellent for endonasal closure of smaller perforations; no valve collapse or “pinched-nose look”
common with other flaps; pre- and postoperative care important; know limitations (eg, do not try to repair >1 perforation
during same surgery)
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| MEDICOLEGAL ASPECTS OF COMPLICATED ENDOSCOPIC SINUS SURGERY –James A. Stankiewicz, MD,
Professor and Chair, Department of Otolaryngology—Head and Neck Surgery, Loyola University, Chicago, Stritch
School of Medicine, Maywood, IL
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| Possible complications of ESS: blindness; double vision; nasolacrimal duct injury; enophthalmos; orbital emphysema;
hemorrhage (early or late); brain complications (cerebrospinal fluid [CSF] leaks, encephalocele, hemorrhage,
meningitis); death; chronic conditions, eg, open nose (everything removed); loss of smell, numbness, voice
change, eustachian tube dysfunction
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| Complications in speaker’s practice: 5000 surgeries over 22 yr; hemorrhage (41; mostly postoperative, some intraoperative);
CSF leaks (20); orbital hematomas (20); subcutaneous emphysema (4); deep venous thrombosis/ pulmonary
embolism (PE) (4); blindness (3; not due to direct injury to optic nerve); temporary blindness; meningitis
(2); toxic shock (2); cardiac shock (1); brain injury and death (1); cheek hematoma (1); postoperative chest pain;
temporary diplopia
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| Most litigated: ESS most litigated area in otolaryngology; diplopia—most litigation; usually involves damage to
medial rectus muscle, although superior rectus often injured; injuries to superior oblique and combination injuries
also occur; CSF leak—second most litigated complication
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| Handling malpractice suits: in 60% to 70% of cases, physician wins or case dropped
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| Medical therapy: must have evidence that patient received appropriate medical treatment before ESS, ie, topical steroid,
antibiotic for 3 to 4 wk, oral steroid
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| Reasons for surgery: failed medical therapy? tumor? revision surgery? did patient express desire to forgo medical
therapy and go directly to surgery?
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| Informed consent: plaintiffs often claim they were not informed that side effects of surgery could include blindness,
double vision, and brain injury; physician must talk to patient about possible complications and document in chart;
consent form must state that physician talked to patient about possible orbital and brain complications; after talk,
speaker has patient sign sticker to this effect and places sticker in chart; study—used cassette tapes or videos to inform
patients about complications; patients later claimed not to have heard information on tape or video
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| Operative issues: document problem and action taken; talk to family and document this
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| Postoperative care: stay with patient until problem resolved; example of orbital hematoma—document what was done;
follow patient in recovery room; inform nursing staff about problem; check patient’s vision and document
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| Missed diagnosis: if patient comes back to clinic complaining of clear drainage and physician does not pursue CSF
leak, patient may develop meningitis
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| Summary: make sure surgery indicated and document; make sure patient given or offered appropriate medical therapy
and document; obtain informed consent and document; write operative note (if no problems, write “true to
surgery performed and surgery needed”; dictate within 24 hr); do not change record (insert addendum instead);
document conversations with family; document treatment plans and expectations
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| Handling complications: most treatable, eg, decompress orbital hematoma, fix CSF leak; if patient admitted for
complication, inform nursing staff of nature of complication and signs for which to be on alert (example of patient
with slight ecchymosis after ESS; admitted for observation; physician failed to alert nurses; patient developed remarkable
ecchymosis and proptosis and became blind by next day); if lawsuit ensues, pick true expert and abide by
advice given; be involved in own defense
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| Hemorrhage: postoperative—from surgery until 3 wk postoperatively; most involve injury to sphenopalatine area, primarily
horizontal basal lamella where blood vessels exit to enter turbinate; from posterior septal artery, when performing
sphenoidotomy; can also get bleeding from anterior ethmoid artery (in skull base); usually stopped by cautery;
when artery retracts into orbit, orbital hematoma formed and decompression required; intraoperative—massive bleeding
can occur because of polyps and chronic disease; prevented or managed by cautery; if middle turbinate cut, remnant
in back must be cauterized to prevent subsequent hemorrhage
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| CSF leak: most in cases in which surgery extensive; most noted during surgery, patched immediately, and patient does
well
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| Orbital hematoma: if properly managed, blindness avoided; management includes decompression; emphysema may
occur
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| Deep venous thrombosis: speaker has seen 1 to 2 wk after outpatient sinus surgery; in one case, patient who had
been on bed rest for 3 to 4 days (recovering from CSF leak) reported to emergency department (ED) with PE; now,
even outpatients must use protective stockings and other preventive measures
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| Facial numbness: in removing disease from maxillary sinus, working too close to infraorbital nerve may result in
numbness; can also occur from Caldwell-Luc operation or sinuscopy
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| Blindness: 3 patients in speaker’s experience, 2 permanent; first patient—encephalocele discovered during surgery;
patient did not want to be admitted before repair; went home by commercial airliner against medical advice; developed
meningitis, herniated brain tonsils, and suffered cortical blindness; no litigation because speaker documented advice
against high-altitude flight; second patient—cardiac shock developed at start of ESS; patient admitted to hospital,
developed herniated cerebral tonsils, and became blind; third patient—developed orbital hematoma and became blind
immediately; vision returned after decompression
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| Brain injury and death: patient had previous radiation therapy to brain; any manipulation around skull base can
cause cranial problems in these patients
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| Cheek hematoma: caused by going too far laterally while working in maxillary sinus
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| Areas of concern: muscles of eye—in area of posterior ethmoid sinus, orbit narrow and very close to lamina papyracea;
if dehiscence present, medial rectus may be injured by microdebrider; keep blade of microdebrider up (in
medial direction), not turned toward lamina papyracea; severe muscle injury difficult for ophthalmologist to fix;
injury to carotid artery—can occur when surgeons think they are in posterior ethmoid sinus but are actually in
sphenoid sinus; they debride what they think is anterior wall of sphenoid (but is actually back wall of sphenoid)
and break through, causing injury to carotid; pack immediately to stop bleeding; have interventional radiologist
place coil
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| Low-lying skull base: variations in location of cribriform plate; plate may be even with fovea or in area of lateral
lamella (where most CSF leaks occur); always have x-ray in operating room (OR) and refer to it during surgery
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| Game plan: should contain what surgeon intends to do, areas of concern, eg, if revision surgery, whether skull base
low-lying, previous problems with orbit
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| Review computed tomography (CT) in OR: hypoplastic maxillary sinus with uncinate process resting on lamina papyracea
is “intraorbital injury waiting to happen”
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| Find landmarks: lamina papyracea, eye, skull base
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| Protecting eye: never biopsy anything on lateral wall until eye palpated for movement (“Stankiewicz maneuver”);
orbital fat, yellow, greasy, and unmistakable; fat float test; bulb press test
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| Localizing skull base: done by finding sphenoid sinus; weakest area in skull base where lateral lamella comes down;
no reason to be operating medially and superior here ( much weaker than laterally); know that fovea ethmoidalis
higher than cribriform level at lateral lamella
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| Sphenoid: only sinus opening medial to middle turbinate; start low; use computer guidance, but do not wholly rely
on because calibration may be off (use what you know, as well as technology)
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Suggested Reading
Al-Shammari L et al: Tension pneumo-orbit treated by endoscopic endonasal decompression: case report and literature
review. J Laryngol Otol 122:e8, 2008; Bachmann G et al: Incidence of occult cerebrospinal fluid fistula
during paranasal sinus surgery. Arch Otolaryngol Head Neck Surg 128:1299, 2002; Bhattacharyya N: Clinical outcomes
after revision endoscopic sinus surgery. Arch Otolaryngol Head Neck Surg 130:975, 2004; Castellarin A et
al: Iatrogenic open globe eye injury following sinus surgery. Am J Ophthalmol 137:175, 2004; Eng SP et al: Surgical
management of septal perforation: an alternative to closure of perforation. J Laryngol Otol 115:194, 2001; Foda
HM: The one-stage rhinoplasty septal perforation repair. J Laryngol Otol 113:728, 1999; Goh AY et al: Different
surgical treatments for nasal septal perforation and their outcomes. J Laryngol Otol 121:419, 2007; Jiang RS et al:
Revision functional endoscopic sinus surgery. Ann Otol Rhinol Laryngol 111:155, 2002; Kridel RW et al: Septal
perforation repair with acellular human dermal allograft. Arch Otolaryngol Head Neck Surg 124:73, 1998; Lee JC et
al: Height and shape of the skull base as risk factors for skull base penetration during endoscopic sinus surgery. Ann
Otol Rhinol Laryngol 116:199, 2007; Lin PW et al: Effects of functional endoscopic sinus surgery on intraocular
pressure. Arch Otolaryngol Head Neck Surg 133:865, 2007; Newton JR et al: Nasal septal perforation repair using
open septoplasty and unilateral bipedicled flaps. J Laryngol Otol 117:52, 2003; Nuñez-Fernández D et al: Bone
and temporal fascia graft for the closure of septal perforation. J Laryngol Otol 112:1167, 1998; Osma U et al: The
results of septal button insertion in the management of nasal septal perforation. J Laryngol Otol 113:823, 1999; Sanu
A et al: Pre-vertebral surgical emphysema following functional endoscopic sinus surgery. J Laryngol Otol 120:e38,
2006; Sautter NB et al: Endoscopic management of sphenoid sinus cerebrospinal fluid leaks. Ann Otol Rhinol
Laryngol 117:32, 2008; Stankiewicz JA: Sphenoid sinus mucocele. Arch Otolaryngol Head Neck Surg 115:735,
1989; Tzifa KT et al: Peri-orbital surgical emphysema following functional endoscopic sinus surgery, during extubation.
J Laryngol Otol 115:916, 2001; Woolford TJ et al: Repair of nasal septal perforations using local mucosal
flaps and a composite cartilage graft. J Laryngol Otol 115:22, 2001.
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