Question

Orbital complications of FESS.

Hint:

Orbital complications, though rare, are serious and can have lasting effects on vision. Careful surgical technique and vigilant postoperative monitoring are crucial for minimizing these risks during FESS.

Answer 1

Step 1: Overview of Functional Endoscopic Sinus Surgery (FESS).
Functional endoscopic sinus surgery (FESS) is a minimally invasive procedure used to treat chronic sinusitis and other sinonasal disorders. FESS uses an endoscope to visualize and remove obstructing tissue in the paranasal sinuses, often to restore normal drainage. While FESS has high success rates, it is not without potential complications, including orbital complications.
Step 2: Orbital Complications of FESS.
Orbital complications are among the most serious complications of FESS, as the orbit lies in close proximity to the sinonasal structures. These complications can occur if there is inadvertent injury to the thin orbital walls, particularly the medial orbital wall. The common orbital complications include:
(1) Orbital Hematoma: One of the most common complications of FESS, occurring due to bleeding during the surgery, which can accumulate in the orbit and exert pressure on the optic nerve. This can lead to visual disturbances or even permanent vision loss.
- Prevention: Careful dissection and use of cautery techniques to control bleeding. Postoperative monitoring of the orbital area is essential.
(2) Orbital Perforation or Injury: Accidental injury to the medial orbital wall during surgery can lead to the formation of an orbital communication, causing air or fluid to enter the orbit. This can result in orbital emphysema or infection.
- Management: In some cases, orbital perforation requires immediate surgical intervention to repair the damage and prevent infection or air embolism.
(3) Infection (Orbital Cellulitis): If bacteria are introduced into the orbit during surgery, it can lead to orbital cellulitis, a severe infection that may cause pain, swelling, redness, and vision impairment.
- Prevention: Proper sterile techniques and prophylactic antibiotics help reduce the risk of infection.
(4) Subcutaneous Emphysema: This occurs when air enters the orbital or periorbital tissues due to inadvertent injury to the sinuses during FESS. This air can cause swelling, and in severe cases, compromise vision.
- Management: Treatment includes monitoring the patient for signs of airway compromise and drainage of any significant air accumulation.
(5) Orbital Fat Prolapse or Herniation: Injury to the orbital septum or surrounding structures can cause fat from the orbit to herniate into the nasal cavity, leading to visual disturbances or cosmetic deformities.
- Management: Surgical repair may be required to reposition the orbital fat and restore anatomical integrity.
Step 3: Prevention and Management of Orbital Complications.
(1) Preoperative Planning: A detailed understanding of the anatomy, including imaging studies such as CT or MRI scans, is essential for identifying key structures and avoiding inadvertent injury to the orbital area.
(2) Intraoperative Caution: Surgeons should use careful and controlled dissection techniques, particularly when working near the medial orbital wall. If perforation is suspected, a more conservative approach may be required.
(3) Postoperative Monitoring: Close observation for signs of orbital complications, such as pain, swelling, visual changes, or diplopia, is necessary. Early detection allows for prompt management and improved outcomes.
(4) Steroid Use: Postoperative steroids may be administered to reduce inflammation and prevent complications like orbital swelling.