Complications of frontal sinus surgery

Abstract

Every surgeon and every patient must consider the potential for complications in making decisions about forthcoming frontal sinus surgery. An often quoted figure is that the risk of serious complications of sinus surgery is approximately half of one percent [1]. This figure is for sinus surgery in general and while discrete figures are not available for isolated frontal sinus surgery, the risk is unlikely to be lower. Challenging intranasal access to the frontal sinus, as well as close proximity to the brain and orbit, make frontal sinus surgeries among the most difficult to perform. Appropriate informed consent requires a full and frank discussion of potential complications as well as alternative treatments. The possibility of "surgical failure" or failure of the operation to successfully correct the patient's symptoms and the potential for revision surgery need also to be addressed. Surgical "success" and "failure" rates are covered in the appropriate chapters and will not be further discussed here. The impact of image-guided surgery on complication rates is as yet unclear.While a conceptually attractive argument can be made for increased safety of frontal sinus surgery using image guidance, complications still occur with its use [2], and its principal legacy thus far seems to be an increase in the number of sinuses opened. Safe and successful frontal sinus surgery requires careful planning and a deliberate effort to positively influence as many surgical variables as possible. First and foremost in minimizing surgical variables is the CT scan. The CT scan should be appropriately timed after intensive medical treatment and contain finely cut coronal images. Limited cut CT scans, while useful in resolving diagnostic issues, play no part in surgical planning. Axial cuts provide useful information in assessing frontal sinus wall integrity, and sagittal reconstructions provide invaluable information for endoscopic approaches to the frontal sinus. Imageguided surgery is an unquestioned advance in dealing with the complex anatomy of the frontal recess. While this is no substitute for surgical judgment and experience, it is of particular benefit in revision cases. All of our surgical efforts and planning are aimed at reducing intraoperative bleeding with consequent increased visualization and by implication, enhanced surgical safety. These efforts include reduction of inflammation by the use of antibiotics and, in selected cases, corticosteroids.Patients are instructed to avoid the use of any substances which may effect the bleeding time. Intraoperative use is made of topical vasoconstricting solutions as well as hemostatic injections at selected sites.Head of bed elevation and judicious control of blood pressure are employed. In the event that bleeding of sufficient severity to preclude adequate surgical endoscopic visualization persists, the surgery should be stopped. Intraoperative blood loss is, of course, recorded in the anesthetic record and, from a medico-legal point of view, an operative complication in the face of significant bleeding becomes difficult to defend. Similarly, total operative time is also recorded and defense of a claim is difficult where the operation may appear to be "rushed" or performed "too quickly." A further factor that is scrutinized should a complication occur is the original indication for surgery and whether an adequate trial of appropriate medical therapy had been initially employed. Complications related to surgery in general, not specific to frontal sinus operations, may also occur. Such events include anesthetic complications, postoperative wound infections, and pneumonias and will not be further discussed. In lengthy operations the use of prophylaxis against deep venous thrombosis and pulmonary embolism should be considered [3]. The remainder of this chapter will be devoted to particular complications which may occur with the variety of surgical approaches and operations that exist for the frontal sinus. © Springer-Verlag Berlin Heidelberg 2005.