Complications of Endoscopic Sinus Surgery
Endoscopic sinus surgery carries an overall complication rate of 3.1% per patient (1.7% per operated side), with hemorrhage being the most common complication, followed by orbital complications and cerebrospinal fluid leak. 1
Major Complications
Intracranial complications are rare but potentially catastrophic and include:
- CSF leak (most common major complication at 0.85% incidence) 2
- Cribriform plate injury with frontal lobe damage and hematoma 3
- Anterior cerebral artery damage (can be fatal) 3
- Meningitis secondary to skull base violation 4
Orbital complications occur in approximately 1.4% of cases and include: 1
- Bilateral blindness from optic nerve damage 3
- Extraocular muscle injury (particularly medial rectus) 3
- Orbital hematoma requiring urgent decompression 4
- Diplopia from muscle or fat injury 2
Minor Complications
Hemorrhage is the most frequent complication overall, occurring in 41 of 105 complicated cases in one large series. 1 Intraoperative bleeding was the most common minor complication in another prospective study. 5
Adhesions and synechiae between the middle turbinate and lateral nasal wall occur in approximately 6.9% of cases and can lead to recurrent obstruction. 2
Special Population Considerations
Patients with Asthma
Asthma is a significant independent risk factor for perioperative complications. 5 Multivariate analysis demonstrated that asthma presence correlates significantly with increased complication rates. 5 However, when CRS is successfully treated surgically, asthma control improves, exacerbations decrease, and the need for systemic and inhaled corticosteroids is reduced. 6
Patients with Allergic Rhinitis
Patients with chronic rhinosinusitis and allergic rhinitis fare better after endoscopic sinus surgery if their allergies are managed optimally. 6 Allergic factors should be evaluated and managed preoperatively, as allergic reactions can exacerbate symptoms. 7
Patients with Cystic Fibrosis
CRS occurs in 30-67% of CF patients across all age groups. 6 Upper airway colonization in CF patients may precede spread of bacteria to the lower airways, with concordance between microorganisms isolated in upper and lower airways. 6 CF represents a presumably irreversible contraindication when associated with congenital mucociliary clearance alterations that prevent resolution of chronic sinusitis. 6
High-Risk Factors for Complications
The following patient and surgical factors significantly increase complication risk: 1
- Revision surgery (highest risk factor)
- Extensive disease on CT imaging
- Nasal polyps (higher polyp scores correlate with increased complications) 5
- Anatomic variations including skull base dehiscences
- Use of powered instrumentation 1
- Advanced age 1
- Vascular disease 5
- Medications affecting coagulation 1
Post-Surgical Complications
Relapses after surgery are not infrequent and include: 6
- Allergic or nonallergic chronic inflammation
- Chronic infection
- Fungal colonization (particularly Aspergillus in susceptible patients)
- Hyperplastic mucosa
- Recurrent nasal or sinus polyposis
- Aspirin hypersensitivity reactions
Common causes of persistent symptoms after surgery include synechiae formation, recirculation of mucus, inadequate initial surgery, and patient noncompliance. 7
Critical Pitfalls to Avoid
Even experienced surgeons are not immune to complications - surgical experience and image guidance do not eliminate complication risk. 1 The key to prevention requires knowledge of anatomy, thorough preparation, anticipation of difficulties, and recognition that complications can occur despite optimal technique. 1, 3
Patients with extensive pathology require particular caution, especially when general anesthesia is used or excessive bleeding occurs. 3 Early recognition and proper management of complications are critical to minimize disability or prevent death. 3
Confirm presence of lower airway disease, especially asthma, before operating and determine the grade of nasal polyps, as both significantly increase complication risk. 5