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Pediatric Sinusitis Surgery Treatment & Management

  • Author: John E McClay, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Aug 03, 2015
 

Medical Therapy

Medical therapy is covered extensively in the Medscape Reference article Medical Treatment of Pediatric Sinusitis. Therefore, it is summarized here.

Medical therapy starts with antibiotics directed at the 3 most common pathogens of sinusitis cultured in acute sinusitis, including S pneumoniae, H influenzae, and M catarrhalis. For nonresistant strains of bacteria, most beta-lactam antibiotics, such as the penicillin and cephalosporin family or the macrolides, are good choices. Resistant strains of bacteria have been reported more frequently in the past several years, and conferences on an appropriate step-wise approach to treating bacterial upper respiratory infections have been published. If infections are refractory to multiple courses of initial trials of antibiotics, attempt treatment with intramuscular ceftriaxone daily for 3 days, oral double-dose amoxicillin with or without clavulanic acid, or oral clindamycin.

Prescribe oral doses of antibiotics for chronic sinusitis for 3-4 weeks at a time. Other important bacteria cultured from the sinuses at the time of ESS include alpha-hemolytic streptococci, S aureus, and rarely, anaerobes. Anaerobes are more often observed in adults with chronic sinusitis. Clindamycin is often an appropriate treatment for these other pathogens, especially anaerobes.

Always prescribe adjuvant medical therapy for a child with recurrent or chronic sinusitis. Adjuvant therapy includes oral decongestants, oral or nasal antihistamines, nasal steroid sprays, histamine stabilizer nasal sprays, oral expectorants, and hypertonic and isotonic nasal saline irrigation and sprays. Consider a 1- to 2-month trial of a proton pump inhibitor for presumed or discovered gastroesophageal reflux (GER). Consider endoscopic sinus surgery (ESS) if a child continues to have recurrent or chronic sinusitis despite maximum medical therapy.

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Surgical Therapy

The aforementioned clinical consensus statement on pediatric chronic rhinosinusitis listed the following statements regarding endoscopic sinus surgery[12] :

  • Endoscopic sinus surgery is an effective procedure for treating pediatric chronic rhinosinusitis that is best performed after medical therapy and/or adenoidectomy have failed
  • Prior to endoscopic sinus surgery, a CT scan of the paranasal sinuses is indicated to assess structure, development, and extent of disease
  • Image-guided endoscopic sinus surgery is useful for revision endoscopic sinus surgery cases and/or for patients with extensive nasal polyposis that can distort anatomic landmarks
  • Convincing evidence is lacking that endoscopic sinus surgery for pediatric chronic rhinosinusitis causes clinically significant impairment of facial growth
  • Postoperative debridement after endoscopic sinus surgery for pediatric chronic rhinosinusitis is not essential for treatment success
  • Current evidence cannot be used to determine the effectiveness of balloon sinuplasty compared with traditional endoscopic sinus surgery for pediatric chronic rhinosinusitis
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Preoperative Details

Take care to explain possible complications of the procedure and that maximum medical therapy has been exhausted, including evaluation for immunodeficiency syndrome, immotile ciliary syndromes, and gastroesophageal disease in selected patients. Pretreat any child with nasal polyposis with steroids to help shrink the polyps and decrease bleeding during intraoperative removal.

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Intraoperative Details

Surgical techniques are described for each area of the sinuses.

Messerklinger technique

Messerklinger described the most popular technique used in endoscopic sinus surgery (ESS). It involves performing sinus surgery in the anterior-to-posterior direction. The initial concern is opening the outflow track for drainage of the anterior sinuses by first performing a uncinectomy. The portion of the uncinate process is incised in its midportion with the backbiter, forming a small window. The uncinate bone and free mucosal edges of the lateral and medial mucosa of the uncinate process can then be removed with the surgical microdebrider.

Alternatively, the uncinate process can be incised at its base with a sickle knife or caudal elevator. However, injury to the lamina papyracea of the medial orbital wall may occur when the incision is made because the uncinate process can be in close proximity to the lamina papyracea in children of all ages. The uncinate process is usually attached superiorly to the lamina papyracea. Alternatively, it can attach to the skull base centrally or medially. Incising the uncinate at its mid or inferior portion helps prevent injury through the lamina. When performing uncinectomy with either technique, but especially with the caudal or sickle knife, take care to remove the bone and lateral mucosa, not just the medial mucosa. Failure to perform a complete uncinectomy results in difficulty identifying the remaining anatomy of the lateral nasal wall. Occasionally, a curve ball probe, ie, Lusk seeker, or curved curette can be used to pull the residual uncinate anteriorly so it can be removed.

Once uncinectomy is complete, the maxillary ostia can be identified. Natural ostia always lie under the uncinate process inferiorly. In 50 pediatric patients, Parsons found the maxillary ostia 1-2 mm from the attachment of the uncinate process to the lateral nasal wall. The most common mistake in failing to identify the maxillary ostia is incomplete removal of the uncinate process inferiorly. If the maxillary antrostomy has not been identified, visualization with a 30° endoscope and palpation of the lateral nasal wall just over the inferior turbinate with a small ball probe can be performed.

Care is taken not to punch in to the maxillary sinus with a curved instrument, especially suction because the force may strip the mucosa from the posterior/superior wall of the sinus. This actually occludes the ostia of the maxillary sinus with persistence of disease. In addition, if false iatrogenic ostia are formed by opening into the sinus in the posterior fontanelle of the medial wall of the maxilla posterior to the ostia, symptoms and signs of maxillary sinusitis persist until the natural ostia are opened.

Once identified, the maxillary ostia can be widened or left alone. Some rhinologists believe that the ostia should only be widened on the posterior and inferior areas. This may avoid any cicatricial scar formation while opening the ostia up and allowing them to drain. In a 1996 report, Setliff advocates avoiding the maxillary ostia completely.[20, 21] If the ostia are widened, it should be done in the most atraumatic fashion to prevent stripping of any mucosa. Usually, this involves using punch-biting forceps or true-cut forceps or using a surgical microdebrider.

Once the maxillary ostia are open, the bulla ethmoidalis is then entered. The status of the mucosa is visualized, and the disease is removed. Anterior ethmoids are removed completely, forming a common cavity. Each individual ethmoid air cell has an ostium. However, technically, these tiny ostia cannot be individually opened, so a common cavity is established by removing the cells completely, eradicating disease, and forming a large area where the frontal and maxillary sinus can drain. Once the anterior ethmoid air cells are removed, the grand lamella is identified.

The grand lamella is the division between the anterior and posterior ethmoid air cells and is entered when posterior ethmoid disease is present or when the sphenoid sinus needs to be approached. Care is taken to preserve the inferior portion of the grand lamella that attaches the middle turbinate to the lateral nasal wall. Stabilization of the middle turbinate away from the lateral nasal wall maintains patency of the outflow tract of the anterior sinuses. The ethmoid cavity, maxillary ostia, and grand lamella are identified in the postoperative picture.

Tissue in the nasal cavity and paranasal sinuses can be removed with the straight-ahead and angled-punch or Weil-Blakesley grasping forceps or the surgical microdebrider. Use small pediatric forceps for precise removal of tissue and prevention of trauma to the surrounding structures, mainly the middle turbinate. Abrasion of the lateral surface of the middle turbinate can result in an increased potential for scarring between the middle turbinate and lateral nasal wall. Scarring in this area could cause obstruction of the outflow tracts of the sinuses and return of disease and symptoms.

The surgical microdebrider has been advocated for is effectiveness and safety. Several attachment blades are available, which have different degrees of cutting potential. Sizes range from 3.0-5.5 mm, depending on the company that manufactures them, the particular surgical microdebrider being used, and the size of the handpiece.

If the surgical microdebrider is used, bony fragments are usually left in the ethmoid cavity after the mucosa and disease have been cut, suctioned, and removed. These bony fragments are then grasped and removed with pediatric Weil-Blakesley forceps. Microguarded burrs are also available and can be used to remove bone. These are not indicated for routine endoscopic sinus surgery (ESS). In 1996, Gross reported use of microguarded burrs in removing the anterior lip of the frontal sinus recess when the agger nasi is not well pneumatized.[22] If the surgical microdebrider is used, 2 suctions should be available for the surgery, 1 attached to the microdebrider and 1 for routine suctions.

Different angles and diameters of suction are available and should be used for different areas of the sinuses. Straight suctions have centimeter markings on them to readily identify the depth of surgery from the anterior nasal spine. Suctions can be used for gentle palpation of different structures in the sinuses, including the sloping skull base, opening of the frontal sinus, face of the sphenoid sinus, and sphenoid ostia.

Sphenoid sinus

Approaches to the sphenoid sinus can be made through the posterior ethmoids or medial to the middle turbinate by locating the natural ostia of the sphenoid sinus. When locating the sphenoid sinus through the posterior ethmoid cavity, begin the search in the inferior and medial area. Often, the posterior portion of the middle turbinate is traversed to find the ostia. Because the superior turbinate lies lateral to or covers the sphenoid ostia, the superior turbinate must be pushed medial to uncover the sinus ostia or the inferior half must be removed. The ostia can then be widened inferiorly and medially to prevent cicatricial scar formation and to avoid damage to the lateral sphenoid wall that houses the internal carotid artery and optic nerve.

If the sphenoid cannot be identified through this approach, the turbinate can be lateralized, and the sphenoid ostia can be found medial to the middle and superior turbinate. This may destabilize the middle turbinate, so care must be taken. However, if the grand lamella of the middle turbinate is left intact, destabilization is less likely. Again, the superior turbinate may require partial resection. Once the sphenoid ostium is identified, it can be widened with punch forceps or the surgical microdebrider. Again, care is taken to stay inferior and medial. If access is limited to open the sphenoid sinus medially, a thin suction can be placed in the sinus. Attention can turn back laterally to the middle turbinate to look again for the sphenoid sinus. The same techniques must be used, but now, an artificial landmark is placed for absolute identification.

Straight suctions of various diameters with distance markings are also used to determine the depth of dissection. In adults, the anterior face of the sphenoid sinus is roughly 7 cm, and the posterior wall is roughly 9 cm from the anterior nasal spine. For children, the height of the patient correlates with the distance of the anterior and posterior sphenoid wall. Roughly, once the child reaches 3 feet tall, the distance from the anterior nasal spine to the anterior sphenoid wall is roughly 7 cm. Care must be taken when making these comparisons because the minor variability that exists in these measurements can cause disastrous results.

Using both axial and coronal preoperative CT scanning to determine the exact anatomy and anatomic variants of the sphenoid sinus is the best way to prevent complications. The centimeter scale on the CT scan can be used as well to determine the true dimensions and depth of the sinus. Chambers found 4% of optic nerves and 8% of internal carotid arteries dehiscent, covered only by mucosa. Kennedy reported the incidence of carotid artery dehiscence to be as high as 32%.

Frontal sinus

The frontal sinus in children does not develop fully until age 8-12 years. Because of this, usually an approach to the frontal sinuses is unnecessary if one is not present. Opening the anterior ethmoids, especially the bulla ethmoidalis, ventilates the frontal sinus or frontal sinus recess in most cases, allowing it to drain and clear, even if disease is present. Care must be taken to prevent violating the frontal sinus recess in situations where it is not specifically addressed. If the frontal sinus recess is violated, scarring and obstruction of the outflow tract can occur. Frontal sinusitis in children may be reversible; iatrogenic anatomic changes causing scar tissue may be more problematic, leading to multiple surgeries.

If the patient is a preteen or teenager with developed frontal sinuses, 2 approaches can be performed. One is to approach the frontal sinus after performing the uncinectomy and visualizing the bulla ethmoidalis. The bulla is followed superiorly to the posterior portion of the frontal sinus recess. The face of the bulla is in continuity with the posterior wall of the frontal sinus recess. Care must be taken to watch for the anterior ethmoid artery that is at this junction. It is usually protected by the face of the bulla. The alternative approach is to perform a complete ethmoidectomy and identify the sloping skull base. The skull base is followed from posterior to anterior until the frontal sinus recess and fovea ethmoidalis are identified.

Once identified, the preoperative CT scan is reviewed to evaluate the agger nasi in the anterior portion of the frontal sinus recess. The agger region is the main obstruction for the outflow tract of the frontal sinus. If a large agger nasi air cell is present, the frontal recess is able to open widely. Visualization of the frontal sinus requires a 30° and possibly a 70° telescope. Angled curettes and giraffe forceps, with arcs from 45-110°, are required to access this area. The instruments are generally intended for use below the telescope, reaching around its anterior end. The 45° instruments work well with the 30° telescope, and the 90° angled instruments work well with the 70° telescope. Curettes are used to pull the bony cell walls forward and down. Giraffe forceps can be used to delicately remove bony fragments, small polyps, and diseased mucosa. Care is taken to leave as much mucosa as possible to prevent stenosis.

Dissection at the anterior skull base should never occur medial to the middle turbinate because injury to the cribriform plate could occur. The lateral lamella of the cribriform plate is the thinnest area of the anterior skull base and is subject to injury. Several variations of the anterior skull base have been identified. These can be identified by preoperative CT scanning to prevent iatrogenic injury and cerebral spinal fluid leak.

Middle turbinate

Controversy exists concerning treatment of the middle turbinate. Management options range from never removing it to routinely removing all of it. Advocates of partial resection of the middle turbinate believe it affords them better access to the middle meatus, intraoperatively and posteriorly, with less scarring and without crusting or anosmia. Many authors have shown increased antrostomy patency rates, increased airflow, and decreased revision rates. In 1993, May offered general guidelines for partial turbinate removal.[23] These include when the turbinate is thin and floppy, when it is replaced by polypoid tissue, when it obstructs the surgeon's view intraoperatively or postoperatively, and when an anatomic variant (eg, concha bullosa) exists.

In children, take a conservative approach. In 1996, Mair reported that the middle turbinate remnant becomes a problem in the pediatric nose.[24] He has seen it lateralize and occlude the frontal sinus, causing recurrent symptoms. Lusk and Parsons also advocate leaving the middle turbinate in children. Certainly, the affected portion of a significantly altered middle turbinate caused by polypoid disease or expansion and pressure of the maxillary sinus should be removed. However, only resecting the anterior portion as described by Biedlingmaier is best. This leaves enough of a remnant for further identification of normal anatomic structures and relationships if revision surgery becomes necessary.

No real controversy exists concerning whether or not to open up a concha bullosa. It should be opened. Most surgeons advocate removing the lateral portion of the concha. This provides good access to the middle meatus during surgery and better ventilation and visualization after surgery.

In adults, techniques to stabilize the middle turbinate have been reported. These include creating a controlled synechiae between the septum and middle turbinate and performing a transturbinate stitch. The transturbinate stitch requires suturing the middle turbinates to the septum. This maneuver is difficult in the pediatric nasal cavity because of its small volume.

Minimally invasive technique

Surgical approaches to pediatric sinus disease undoubtedly have become more conservative, both in indications for surgery and amount of surgery performed. Certainly, only those sinus cavities showing disease on CT scanning should be considered for surgical drainage. Because the OMC, which includes the uncinate process and infundibular area around the ethmoid complex, is the bottleneck for outflow of the anterior sinuses, many pediatric sinus surgeons have advocated only performing a mini-FESS. This involves removing the uncinate process, finding or opening the maxillary ostia, and performing an ethmoid bullectomy or anterior ethmoidectomy. All report as good or better success rates with lower complications. In 1996, Talbot advocated removal only of OMC disease to clear the frontal sinus and frontal recess, and Smith reported that the sphenoid clears by opening the ethmoids.[25]

Also in 1996, Setliff advocated a minimally invasive or small-hole technique.[20, 21] This technique involves removing only the mucosa and bone of the uncinate process for maxillary sinus disease, leaving the maxillary sinus ostia untouched. He does not create a large hole to drain the maxillary sinus. Minimally invasive surgery is based on a theory that narrow mucous membrane–lined clefts are the predisposing factor to clinical disease, not the small ostia of the maxillary, ethmoid bulla, or frontal sinuses. The sinuses may not need a large hole to drain. In fact, when normal CT scan findings are viewed, the actual size of the tortuous and narrow draining pathway for the anterior sinuses is surprising.

The minimally invasive technique was performed in adults and pediatric patients. First, an uncinectomy was performed with the pediatric backbiter and surgical microdebrider to open up the draining pathway of the sinuses, the infundibulum. A maxillary antrostomy was not performed, regardless of the appearance of the maxillary ostia, whether it was normal appearing, polypoid, or edematous.

According to Setliff's 1996 report, edema or obscuration of the maxillary sinus ostium, with or without polyps, pus, or cysts in the maxillary sinus, was present in most patients. He did not comment on his surgical technique for the ethmoid, sphenoid, or frontal sinus. Of 300 patients on whom he performed this procedure, only 1 required revision surgery to open the maxillary sinus. Overall, his surgical revision rate dropped from 15% to 7% since he adopted the minimally invasive technique. The whole uncinate must be removed so that the maxillary ostia can drain. However, Mendelsohn and Gross in 1997 advocated widening the ostia to 3-5 times its normal size, as well as creating an even larger mega-ostia for patients with ciliary abnormalities.[18]

Technique for nasal polyps in children

Nasal polyposis in adults and children can be a difficult disease to treat based on the alteration of normal landmarks, the tendency for abundant bleeding, and the predisposition for recurrence. Certainly in children, cystic fibrosis (CF) must be ruled out. Other diseases, such as allergic polyposis or allergic fungal sinusitis (AFS), can cause nasal polyposis in children. Successful techniques require removing the polypoid disease using the tenets of endoscopic sinus surgery (ESS). Polyps should be removed and the sinuses should be opened using the Messerklinger technique. Preoperative and postoperative steroids can help shrink the fibrovascular nature of the polyps, decreasing the amount of bleeding during surgery and helping to prevent recurrence.

However, the best advance in performing endoscopic sinus surgery (ESS) in children with nasal polyposis is the surgical microdebrider. Any bleeding encountered is suctioned away while the polyps are efficiently resected and removed. Several authors advocate the increased safety when the surgical microdebrider is used. Nothing, however, takes the place of complete knowledge of the normal anatomy and anatomic variants of the nasal cavity, lateral nasal wall, and paranasal sinus in children of various ages. Preoperative CT scanning again is stressed to determine the extent of disease and changes the polyps have created to the nasal cavity and paranasal sinuses.[26]

Children with CF uniformly have nasal and sinus disease. The hallmark is thick inspissated exocrine gland mucus that causes obstruction. CF nasal mucus is 30-60 times more viscous than non-CF mucus and blocks the outflow tract of the sinuses. Therefore, the surgical technique used is the same in patients with CF and chronic sinusitis as that used in patients with chronic sinusitis only. However, a minimally invasive or small-hole technique may provide inadequate access to the sinuses because some of the thick mucus must be mechanically flushed routinely to aid in clearing the sinuses.

For patients with allergic fungal sinusitis (AFS) with polyposis, the disease process has usually expanded the sinuses, particularly the ostia. Allergic mucin and thick tenacious fungal elements are found in the sinuses. Usually, the anatomy of the lateral nasal wall is distorted, but invasion of surrounding boundaries (eg, periorbita, dura) is never found, despite expansion into the orbit or brain. An example of a 15-year-old boy with extensive disease is shown in the Medscape Reference article Allergic Fungal Sinusitis. This adolescent had extensive expansion of the sinuses, which is observed uniformly in allergic fungal sinusitis (AFS). He had expansion into the orbit and anterior cranial fossa. The frontal sinus recess had been expanded to 3 cm, so access to the lateral superior orbital fungal elements could be performed endoscopically. His polypoid disease was effectively removed with the microdebrider.

The thick tenacious allergic mucin and pasty fungal elements usually clog the microdebrider and require removal with a curette or suction. Often, much of the dissection is done for the surgeon, so removing the polyps and allergic mucin constitutes the bulk of the surgery. However, fungal elements can expand each ethmoid air cell, requiring the surgeon to continue the dissection to make sure that the cells are completely eradicated. Retained fungal elements can cause persistent edema and polyposis. Preoperative and postoperative steroids are used to control edema of the opened cavities while they are healing.

Lasers

The use of lasers for endoscopic sinus surgery (ESS) has been reported in adults but not children. These include the carbon dioxide (CO2) laser, argon laser, potassium-titanyl-phosphate (KTP) laser, erbium yttrium-aluminum-garnet (YAG) laser, and holmium YAG laser. The holmium YAG laser has had the most applications. It is efficient in excising or contouring bone. It produces adequate hemostasis, affecting only capillary bleeding. Positive attributes of using the laser include better hemostasis and greater precision in sculpting bone.

Negative features include increased postoperative tissue edema, increased length of surgery, more elaborate surgical setup, increased cost, increased collateral thermal deposition causing more synechia and scarring, and decreased visualization through the endoscope from the splatter effect of the tissue upon contact with the laser pulse. The KTP/532 laser has been used successfully in turbinate reduction and vascular disorders such as hereditary hemorrhagic telangiectasia. Use of lasers in pediatric endoscopic sinus surgery (ESS) for chronic sinusitis can usually be avoided.

Computer-assisted sinus surgery

Over the last several years, computer-assisted sinus surgery has become more popular. Sinus surgeons usually reserve this technique for revision cases or for cases where anatomy has been distorted.

The computer uses stereotactic software that integrates data it receives from a sensor mechanical wand. Sensors, usually 5-8 in number, are placed on the patient's face and forehead in multiple places. Axial CT scanning with 3-mm slice thickness and 3-mm increments is performed from the top of the forehead to the upper incisors. CT scan data are entered into the computer and the sensing wand. The registration process then begins by touching a sensor and marking it on the CT scan images that were entered into the computer.

Alternatively, facial structures (eg, lateral canthus) can be used for registering the patient with the computer images. Once registration is complete, a 3-dimensional reconstruction is then displayed on a screen as sagittal, coronal, and axial images. Accuracy of the probe tip is approximately 2 mm with a range of 0-3.7 mm. During surgery, the wand can be placed intranasally to provide a corresponding image outlining the location of the wand on the screen in 3 planes. This technique has been helpful in adult revision cases and large sinonasal lesions where normal anatomy has been altered or obscured. Recent reports have shown its effectiveness in the pediatric population. Increased technology has made it easier to use as well, with multiple systems currently available.

Packing

Once surgery is complete, the decision is made on whether or not to pack. Lusk popularized stenting the pediatric ethmoid cavity with a roll of gel film. This involves a second-look procedure at 2 weeks postoperatively to evaluate the status of surgery and remove any debris and granulation that could form synechia. Other ethmoid stents have been used with success. The author currently has had the best success with a Merocel sponge wrapped in a finger cot or portion of a glove. This easily slips out on the first postoperative visit at 5-7 days. It is attached to a string that is taped to the side of the face with adhesive and Steri-Strips or paper tape.

The main goal of packing is to keep the middle turbinate from lateralizing and scarring to the lateral nasal wall, resulting in obstruction with recurrence or persistence of disease.

Occasionally, packing may not be required. In children where the disease has expanded the sinuses and middle meatus and has not destabilized the middle turbinate (eg, extensive polyposis), usually from allergic fungal sinusitis or mucoceles, packing may be avoided. Extensive polyposis in patients with CF usually destabilizes the middle turbinate, so packing or partial resection of the middle turbinate may be indicated.

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Postoperative Details

Postoperative care is critical. In adults, this involves saline irrigations and weekly debridements in the office. Postoperative care must continue until the cavities are well healed, usually 4-6 weeks. Postoperative care in young children is difficult. For the most part, they do not like nasal saline irrigations, much less manipulation of the nasal cavity with endoscopes. Preteens and some teenagers occasionally allow adequate visualization or cleaning in the office setting, similar to adult postoperative care. Any trick to keep their nasal cavities moist for the month or so following surgery is beneficial. The author has them spray isotonic sodium chloride solution 3-4 times a day and use the Rhinotherm (a machine to force moist steam into the nasal cavities) weekly or twice weekly. If patients perform saline irrigations, saline spray is substituted.

For young children, the second-look procedure may or may not be needed, depending on the ability of the parent or child to use nasal irrigations or a water pic to clean debris from the sinuses. Proponents argue that granulation and debris can be cleaned from the sinus cavity and that adhesions that have formed can be lysed. Postoperative care in any sinus procedure is as important as the procedure itself. Synechia form, with recurrence of disease and symptoms, if crust and debris are not removed by the surgeon or by the patient with saline irrigations. Some have begun to question the second-look procedure, evaluating outcomes of endoscopic sinus surgery (ESS) surgery in children who have and have not had a second-look procedure. In 1998, Walner found that the rate of revision surgery was the same (at roughly 20%) whether the second-look procedure was or was not performed.[27]

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Follow-up

All follow-up care is at the discretion of the treating physician. For the author's practice, once the initial 4-6 weeks of postoperative care is complete, follow-up depends on the disease present. For chronic sinusitis without allergic rhinitis or polyposis, follow-up may only be necessary if the child is symptomatic. If the child has allergic rhinitis with or without polyps, follow-up depends on how symptomatic the child is and if immunotherapy is required. Most children need to be tested for allergies preoperatively. If allergies are present, most children are on immunotherapy. If the allergist is comfortable with a nasal endoscopic examination, the allergist may be able to do intermittent follow-up because the child is seen once a week for shots. Most often, symptoms dictate when an evaluation is necessary.

For children with allergic fungal sinusitis (AFS), close follow-up is mandatory. The disease in these children, like adults, has a propensity to recur. For a child with allergic fungal sinusitis (AFS) who does not tolerate examinations in the clinic, a baseline CT scan 4-6 weeks postoperatively is advisable to establish that all disease has been eradicated. Immunotherapy may not be effective if residual disease is present. Preliminarily, patients with AFS apparently benefit from immunotherapy, with decreased need for oral steroids and decreased recurrence (see the Medscape Reference article Allergic Fungal Sinusitis).

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Complications

Relatively few complications of pediatric endoscopic sinus surgery (ESS) have been reported in the literature (see Table 1, Table 2). Complications occur more often in adults (see Table 3, Table 4), possibly secondary to generally more aggressive surgery or a greater degree of disease requiring more extensive surgery. However, the risks that apply to pediatric sinus surgery are the same as those that apply to surgery in adults. The aim of this section is to discuss the potential complications of pediatric sinus surgery and their management and to focus on techniques that help prevent complications from occurring.

In general, complications of pediatric functional endoscopic sinus surgery (FESS) can be divided into major complications, which may be life threatening or require further surgical intervention or advanced treatment. The other complications are considered minor.

Major complications

Major complications are uncommon, occurring in less than 1% of pediatric functional endoscopic sinus surgery (FESS) cases. The major complications of pediatric functional endoscopic sinus surgery (FESS) are similar to those of adult functional endoscopic sinus surgery (FESS) and include intraorbital, intracranial, and intranasal injury. Intraorbital injury encompasses blindness, extraocular muscle damage, and orbital hematoma. Intracranial complications include cerebrospinal fluid leak and brain damage. Major intranasal complications include nasal lacrimal duct injury and major hemorrhage.

  • Intraorbital complications
    • Blindness
      • Blindness secondary to functional endoscopic sinus surgery (FESS) can occur from 2 etiologies. The first and most common cause is a rapidly expanding intraorbital hematoma, usually secondary to damage to the anterior ethmoid artery. The anterior ethmoid artery runs along the superior portion of the medial orbital wall between the superior oblique and medial rectus muscles. If the artery is damaged, it can retract into the orbit, leading to a rapidly expanding retrobulbar hematoma. Increased orbital pressure causes a compromise of the vascular supply to the optic nerve. If not corrected within 60-90 minutes, blindness can result. More commonly, orbital hematoma occurs secondary to damage to the orbital veins lining the lamina. Hematoma accumulation is much slower, and proptosis and pupillary changes are much less common.
      • The second cause of blindness is damage to the optic nerve itself, which is very rare. Injuries usually occur from poor intraoperative visualization or inadequate knowledge of the optic nerve anatomy. The optic nerve is especially vulnerable to injury in several anatomic sites. The optic nerve courses in the superior lateral aspect of the sphenoid sinus. In some individuals, the bone overlying the nerve may be thin or even dehiscent. Careful attention to the preoperative CT scanning frequently reveals this finding. The most posterior and lateral posterior ethmoid cells (ie, Onodi cells) are separated from the optic nerve by a thin layer of bone only, and damage to the nerve can also occur here.
      • Prevention of permanent vision loss begins prior to surgery with careful preoperative screening to identify patients with risk factors for orbital injury (eg, prior surgery, long-standing disease, history of bleeding problems). A thorough review of the preoperative CT scanning enables identification of anatomic variations that may predispose to injury.
      • Intraoperatively, keeping the patient's eyes uncovered at all times is very important. An assistant may be assigned to monitor the eye for any early signs of injury. Because pediatric functional endoscopic sinus surgery (FESS) must be performed under general anesthesia, the surgeon is unable to use the patient's perception of pain as an early indicator of orbital penetration, usually through the lamina papyracea on the medial orbital wall, which is the lateral wall of the ethmoid cavity. Have an assistant palpate the eye as the surgeon is observing the lamina papyracea endoscopically for its location as it moves back and forth for evidence of orbital fat or damage. If a question remains as to whether a specimen represents polyp or orbital fat, the material can be placed in saline. Orbital fat floats, whereas diseased mucosa or polyp does not float.
      • When injury to the orbit becomes apparent, either with proptosis or pupillary change, urgent attention is required. Eye massage should be started immediately to decrease intraorbital pressures and redistribute the hematoma. Mannitol, an osmotic diuretic, should be started to decrease orbital pressures. The ophthalmology service should be consulted immediately for evaluation. If the above measures do not adequately reduce orbital pressures, surgical decompression is warranted. Initially, this consists of lateral cantholysis that usually suffices to immediately reduce dangerous intraorbital pressures. Occasionally, medial orbital decompression is necessary, either endoscopically or via an external ethmoidectomy (see Procedure for managing orbital hematoma).
    • Penetration of the lamina papyracea
      • Injury to the lamina papyracea is not a complication of endoscopic sinus surgery (ESS). In fact, to gain access to the orbital vault, to drain an orbital or subperiosteal abscess, or to decompress the eye, the lamina must be removed or penetrated. However, inadvertent penetration may cause complications to the eye, such as blindness or injury to the orbital contents (eg, extraocular muscle if not recognized). Injury can be avoided by carefully noting the position of the uncinate process during uncinectomy. In children, the attachment of the uncinate process may be very close to the medial wall of the orbit, so during uncinectomy with the sickle knife, the orbit may be entered. The lamina could potentially be damaged when evaluating the lateral nasal wall for the maxillary ostium with a curved instrument (eg, suction, ball-tip probe). Identification of the maxillary ostium should begin at the level of the superior portion of the inferior turbinate. Drifting superiorly risks injury to the lamina.
      • Inadvertent penetration of the lamina papyracea occurs more commonly on the patient's right side when the surgeon is right-handed. This occurs because of differences in the visualized anatomy through the endoscope. The right ethmoids appear to be more straight back than they are in reality, leading to orbital injury. This can be avoided by staying medial against the middle turbinate.
    • Damage to the extraocular muscles
      • Extraocular muscle damage is very uncommon but is usually permanent. The 2 muscles most likely to be injured during functional endoscopic sinus surgery (FESS) are the superior oblique and medial rectus because of their proximity to the sinuses. If injury is suspected, immediate consultation with an ophthalmologist is in order.
      • The superior oblique muscle is less commonly injured than the medial rectus because of its location high in the orbit, lateral to the ethmoid cavity. The prognosis for recovery following superior oblique muscle injury is better than for medial rectus injury, and an observation time of 6 months is often recommended prior to surgical treatment to allow for adaptation.
      • Medial rectus injury carries a poor prognosis. This may be secondary to the increased incidence of direct muscle injury in addition to scar tissue formation from lamina papyracea penetration. Most affected patients require multiple surgical treatments. Prognosis may be improved with immediate high-dose steroids and surgical treatment within 3 weeks of injury.
  • Intracranial complications
    • Cerebrospinal fluid fistula
      • Cerebrospinal fluid (CSF) leakage can occur at any number of sites. Certain anatomic subsites are more conducive to injury during functional endoscopic sinus surgery (FESS). Most commonly, CSF leaks occur at the cribriform plate, fovea ethmoidalis, posterior ethmoid roof, roof of the sphenoid sinus, and the skull base above the anterior wall of the sphenoid sinus. The lateral cribriform plate, where the anterior ethmoidal artery enters the olfactory fossa, is the weakest site in the anterior skull base. To avoid injury to this area, dissection should stay lateral to the vertical portion of the middle turbinate. Traction on the middle turbinate can also cause fracture of the cribriform plate and resultant CSF fistula. The surgeon must remember that anteriorly, the cribriform plate is lower than the fovea ethmoidalis. In the sphenoid, the surgeon must be cautious when removing disease from the superior wall or roof because most CSF leaks in the sphenoid occur in these regions.
      • CSF leaks can usually be identified at the time of injury by observation of the washout sign. The CSF washes away the surrounding blood, making the fistula evident. Treatment should be initiated immediately. The site can be patched endoscopically with muscle, fat, septal, or other mucosal grafts or fascial grafts.
      • Delayed CSF fistulae may manifest with meningitis, which often seals the leakage site secondary to dural inflammation. The site of dural dehiscence can often be identified with high-resolution CT scanning or with MRI cisternography. Occasionally, administration of intrathecal fluorescein is necessary to identify the site. Repair may be undertaken endoscopically or via craniotomy with the assistance of a neurosurgeon. Placement of a lumbar drain facilitates the speed of closure and enhances surgical treatment by shunting pressure from the site of the leak.
    • Brain injury: Injury to the anterior communicating artery and its feeding vessels, intracerebral hematoma, encephalocele, and perforation of the ventricular system with massive pneumocephalus have been reported, although uncommonly, following sinus surgery. The proximity of the anterior communicating artery to the cribriform plate makes it vulnerable to injury if the cribriform plate is penetrated. These injuries are easily avoided if adequate visualization is available and the surgeon has appropriate knowledge of the anatomy of the sinus cavities. If visualization becomes inadequate secondary to hemorrhage, the procedure should be terminated immediately rather than compromise the patients' health.
  • Intranasal complications
    • Major hemorrhage
      • Severe hemorrhage is rare and usually occurs in patients with underlying bleeding disorders, a history of multiple sinus surgeries, or extensive polyposis. Bleeding may occur from damage to any of several arteries.
      • As discussed earlier, the anterior ethmoid artery may be injured during removal of disease in the anterosuperior region of the anterior ethmoid air cells or during work in the frontal recess. Often, the lacerated artery can be identified and cauterized at the time of injury. However, the artery may retract into the orbit, leading to hematoma. The posterior ethmoidal artery is most commonly injured during removal of disease in the posterior ethmoidal air cells or sphenoid sinus. Cautery is difficult in this region, and intranasal packing is usually required to stop hemorrhage.
      • The sphenopalatine artery may also be injured during removal of disease in the posterior ethmoidal air cells or the sphenoid sinus. It may also be injured when enlarging the middle meatus antrostomy posteriorly or when removing a portion of the middle turbinate. Electrocautery or nasal packing usually is sufficient in halting the hemorrhage.
      • Damage to the internal carotid artery is unusual but immediately life threatening. Injury usually occurs when the carotid artery protrudes medially into the sphenoid sinus. In addition, as many as 20-25% of patients may have only a thin bony wall separating the vessel from the sphenoid sinus. In the case of injury, Sofferman suggests a management plan that includes immediate nasal packing, compression of the affected carotid in the neck, immediate neurosurgical consultation, intraoperative arteriography, and ligation of the artery pending results of a balloon occlusion study to assess cerebral perfusion.
    • Nasolacrimal duct injury
      • Injury to the nasolacrimal duct and sac occurs frequently, although in most cases, the damage is not manifested clinically. Bolger et al found a 15% incidence of occult nasolacrimal duct injury in a study of 24 adult patients. None, however, had epiphora at 11 months of follow-up. The natural ostium of the maxillary sinus and the ethmoid sinuses in children lie in very close approximation to the nasolacrimal system, even closer than in adults. Injury usually occurs when attempting to enlarge the ostium anteriorly. The bone overlying the nasolacrimal duct is thicker, alerting the surgeon to the proximity of the duct. The nasolacrimal sac may also be injured, especially in the region of the superior aspect of the uncinate process, which is only several millimeters from the sac itself.
      • Patients with postoperative epiphora should be observed initially because most cases resolve without additional treatment. However, the ophthalmology service should be consulted in all cases, and if the symptoms continue after several months, a dacryocystorhinostomy may be necessary to correct the stenosis. This may be performed intranasally or externally.

Minor complications

Minor complications of pediatric sinus surgery occur much more frequently than do major complications but have minimal, if any, long-term effects. Often, multiple minor complications occur in the same patient. Minor complications include synechiae formation, ecchymosis, sinus ostia stenosis, minor bleeding, and subcutaneous emphysema.

  • Synechiae: Synechiae are the most common complications of pediatric functional endoscopic sinus surgery (FESS), with reported rates of 6-30%. Synechiae most often form between the middle turbinate and the lateral nasal wall or between the middle turbinate and the septum. Any disruption of 2 opposing mucosal surfaces can lead to scar band formation. Careful attention to surgical technique, especially when manipulating the middle turbinate, can decrease the incidence of synechiae formation. The placement of a spacer between the lateral nasal wall and the middle turbinate can decrease scar formation. Telfa, Merocel, Gelfilm, and silastic have been used with success. Use of intranasal steroids at the completion of the procedure has been recommended in the past to decrease synechiae formation, but recent work has shown little benefit. Most synechiae can be lysed under general anesthesia during a planned second-look procedure. Occasionally, revision surgery is necessary.
  • Sinus ostium stenosis
    • Incidence of middle meatal antrostomy stenosis is not known. In 1993, Stankiewicz reported nearly a 50% incidence of antrostomy closure visualized at routine second-look endoscopy 2 weeks to 2 months following functional endoscopic sinus surgery (FESS).[28] Lazar, however, in a 1992 study of 260 children with an average of 20 months of follow-up, found only a 2% incidence of stenosis.[29] Stenosis may occur secondary to extensive scarring in the middle meatus, recurrent polyposis, or insufficient widening of the antrostomy during the initial surgery. Unfortunately, stenosis of the middle meatal antrostomy is one of the most common reasons for revision surgery. Stenosis may be minimized by only opening the meatus inferiorly and posteriorly, thereby avoiding circumferential damage to the mucosa, which increases stenosis rates.
    • In a 1996 article, Setliff reportedly decreased his rate of maxillary ostial stenosis in adults and children with the minimally invasive technique.[21] This technique involves removing the mucosa and bone of the uncinate process without touching the maxillary ostium, regardless of its appearance. In a review of 300 patients treated with this technique, only one has required revision surgery for a closed ostium, and his revision rate has decreased from 15% to 7% with short-term follow-up.
  • Ecchymosis: Orbital ecchymosis can occur with violation of the lamina papyracea and minor hemorrhage. This condition resolves within 7-14 days, gradually progressing from a black and blue color to a yellow hue prior to return to normal skin color.
  • Subcutaneous emphysema: Penetration of the lamina papyracea can lead to subcutaneous emphysema. Often, this is not noted until the patient awakens and begins to struggle or until aggressive bag-mask ventilation is begun. The air may dissect through various fascial planes involving the orbit, neck, face, or mediastinum. Treatment mainly is supportive because resolution is spontaneous. The patient should be told to avoid sneezing because this may increase the amount and duration of the emphysema. The patient should be placed on antibiotics, and all nasal packing should be removed.
  • Minor hemorrhage
    • Minor bleeding is a very common finding in functional endoscopic sinus surgery (FESS) and usually originates from a mucosal surface. Adequate preoperative vasoconstriction with local decongestants and lidocaine with epinephrine is key to preventing bleeding complications. Intraoperative bleeding is controlled with intranasal cautery or with 10 minutes of Afrin or cocaine-soaked cottonoid packing. Occasionally, nasal packing coated with Bactroban is necessary. Systemic antibiotics should be used as well if packing is necessary because several cases of toxic shock syndrome have been linked to the use of nasal packing.
    • Patients with active infection, extensive polyposis, and possible bleeding diathesis are at increased risk for bleeding complications and should be identified preoperatively. Surgery should be delayed in patients with active infection for adequate treatment with antibiotics and nasal steroid sprays. Patients with extensive polyposis should undergo a course of oral steroids for 5-7 days preoperatively to decrease intraoperative bleeding. Patients with a history suggestive of bleeding abnormalities should undergo a prothrombin time (PT), activated partial thromboplastin time (aPTT), bleeding time, and platelet count. Any abnormalities warrant evaluation by a hematologist prior to surgery.
  • Effects on facial growth
    • Effects of early endoscopic sinus surgery (ESS) on facial growth are not completely known. In a 1996 piglet study, Mair et al found that facial growth was impaired following unilateral functional endoscopic sinus surgery (FESS).[24] Although differences were evident on CT scanning, no clinical differences were noted. Stankiewicz reported 1 patient with a change in growth in the ethmoid and maxillary sinuses following subperiosteal abscess drainage 4 years previously. Of note, the patient had no clinically detectable differences in the 2 sides of the face.
    • Examination of uncinate and ethmoid bone in humans reveals that mature lamellar bone is present by age 9 years. This implies that functional endoscopic sinus surgery (FESS) may have more effects on facial growth in patients younger than 9 years.
    • Certainly, more information is needed about facial development after functional endoscopic sinus surgery (FESS). About 3.5% of individuals have unilateral maxillary sinus hypoplasia on CT scanning but have no detectable differences clinically. The differences in sinus growth noted on CT scanning following unilateral functional endoscopic sinus surgery (FESS) may not be clinically important.

Comments

Complications occur with any surgical procedure. Experience has a role in complication rates. However, most complications can easily be prevented by meticulous attention to preoperative planning. Knowledge of pediatric sinus anatomy is key to preventing poor outcomes. Become familiar with the anatomic variations that predispose to problems, such as a dehiscent optic nerve or carotid artery in the sphenoid sinus or an extremely high or low fovea ethmoidalis. Strict attention to preoperative coronal CT scans is a must. Many potential problems can be avoided by addressing the situation prior to surgery.

By adhering to the principles of careful preoperative planning, sound knowledge of pediatric sinus anatomy, meticulous surgical technique, and strict postoperative care, most complications can be avoided.

Table 1. Reported Major Complications of Pediatric FESS (Open Table in a new window)

Authors Major Bleeding CSF Leak Orbital Hematoma Nasolacrimal Duct Injury
Lusk and Muntz, 1990 0% 0% 0% 0%
Lazar et al, 1992 0% 0% 0% 1.4%
Lazar et al, 1993 0% 0% 0% 2%
Stankiewicz, 1995 0% 0% 0% 1.2%
Younis and Lazar, 1996 0.2% 0.4% 0% NR*
*NR = Results not reported

Table 2. Reported Minor Complications of Pediatric FESS (Open Table in a new window)

Authors Synechiae Minor Bleeding Sinus Ostium Stenosis Periorbital Ecchymosis
Lusk and Muntz, 1990 6% 0% NR* 0%
Lazar et al, 1992 20% 0% 0% 2.4%
Lazar et al, 1993 20% 5% 2% 3%
Stankiewicz, 1995 29.7% 0% 47% 0%
Younis and Lazar, 1996 17% 4% NR* NR*
*NR = Results not reported

Table 3. Reported Major Complications of Adult FESS (Open Table in a new window)

Authors Major Hemorrhage CSF Leak Orbital Hematoma Nasolacrimal Duct Injury
Levine, 1990 0% 0% 0% 0%
May, 1994 0.19% 0.47% 0.05% 0.14%
Stankiewicz, 1989 2% 1% 3% NR*
Smith, 1993 0% 0% 0.5% 0.5%
*NR = Results not reported

Table 4. Reported Minor Complications of Adult FESS (Open Table in a new window)

Authors Synechiae Minor Bleeding Ostium Stenosis Orbital Fat Exposure or Ecchymosis
Levine, 1990 NR* 8.4% 4.1% 0.6%
May, 1994 1.7% 0.6% NR* 1.7%
Stankiewicz, 1989 3.3% 1% NR* 2%
Smith, 1993 NR* 6.5% NR* 1%
*NR = Results not reported

The procedure for managing orbital hematomais as follows:

  1. Awaken patient from general anesthesia.
  2. Initiate immediate ophthalmology consultation.
  3. Begin orbital massage (helps to redistribute hematoma and decrease pressures).
  4. Start osmotic diuretic, such as Mannitol (1g/kg).
  5. If no improvement in orbital pressures occurs, perform lateral canthotomy or medial orbital decompression via a Lynch excision.
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Outcome and Prognosis

Pediatric functional endoscopic sinus surgery (FESS) has been shown to provide effective treatment for children with chronic sinus disease refractory to maximum medical therapy with success rates from 80-93%.

In patients with polyposis, especially associated with CF, recurrence instead of cure is the norm. In patients with CF and polyposis, resolution of preoperative symptoms occurs in 40-70% of cases. Recurrence rates are over 50%.

For patients with allergic fungal sinusitis (AFS), decreased recurrence rates, which are quoted to be 10-100%, have been observed with immunotherapy.

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Future and Controversies

The main controversy is over whether or not any child should have sinus surgery because most rhinologists believe that the problem is basically a medical condition. Children have maturation of their immune system from birth to age 6-8 years. Over this time, if they are exposed to pathogens repeatedly, they are likely to have recurrent or chronic infections of the upper respiratory tract. Certainly, avoidance of social situations where multiple young children reside in the same physical space (eg, day care, preschool, nurseries) may decrease the likelihood of infections. Drastic measures of avoidance must be weighed against financial needs of the family and social needs of the child in this situation, and staunch proponents of both sides of the debate are easily found. New medical breakthroughs, including new antimicrobials, vaccines, and anti-inflammatory drugs rooted in basic science, may eliminate the need for surgery altogether.

If surgery is indicated for chronic sinusitis refractory to medical therapy in the absence of polyposis or an underlying medical condition, some controversy exists as to how aggressive the approach should be. Several authors advocate minimal surgery to open the outflow tracts to the sinuses, occasionally improving the status of adjacent sinuses without specifically manipulating them (see Minimally invasive technique in the Treatment section). In pediatric sinus surgery, sometimes less is more.

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Contributor Information and Disclosures
Author

John E McClay, MD Associate Professor of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of Dallas, University of Texas Southwestern Medical Center

John E McClay, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Ted L Tewfik, MD Professor of Otolaryngology-Head and Neck Surgery, Professor of Pediatric Surgery, McGill University Faculty of Medicine; Senior Staff, Montreal Children's Hospital, Montreal General Hospital, and Royal Victoria Hospital

Ted L Tewfik, MD is a member of the following medical societies: American Society of Pediatric Otolaryngology, Canadian Society of Otolaryngology-Head & Neck Surgery

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Jennifer Jordan, MD, to the development and writing of this article.

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Table 1. Reported Major Complications of Pediatric FESS
Authors Major Bleeding CSF Leak Orbital Hematoma Nasolacrimal Duct Injury
Lusk and Muntz, 1990 0% 0% 0% 0%
Lazar et al, 1992 0% 0% 0% 1.4%
Lazar et al, 1993 0% 0% 0% 2%
Stankiewicz, 1995 0% 0% 0% 1.2%
Younis and Lazar, 1996 0.2% 0.4% 0% NR*
*NR = Results not reported
Table 2. Reported Minor Complications of Pediatric FESS
Authors Synechiae Minor Bleeding Sinus Ostium Stenosis Periorbital Ecchymosis
Lusk and Muntz, 1990 6% 0% NR* 0%
Lazar et al, 1992 20% 0% 0% 2.4%
Lazar et al, 1993 20% 5% 2% 3%
Stankiewicz, 1995 29.7% 0% 47% 0%
Younis and Lazar, 1996 17% 4% NR* NR*
*NR = Results not reported
Table 3. Reported Major Complications of Adult FESS
Authors Major Hemorrhage CSF Leak Orbital Hematoma Nasolacrimal Duct Injury
Levine, 1990 0% 0% 0% 0%
May, 1994 0.19% 0.47% 0.05% 0.14%
Stankiewicz, 1989 2% 1% 3% NR*
Smith, 1993 0% 0% 0.5% 0.5%
*NR = Results not reported
Table 4. Reported Minor Complications of Adult FESS
Authors Synechiae Minor Bleeding Ostium Stenosis Orbital Fat Exposure or Ecchymosis
Levine, 1990 NR* 8.4% 4.1% 0.6%
May, 1994 1.7% 0.6% NR* 1.7%
Stankiewicz, 1989 3.3% 1% NR* 2%
Smith, 1993 NR* 6.5% NR* 1%
*NR = Results not reported
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