Complications in Endoscopic Sinus Surgery: Diagnosis, Prevention and Management SK Kaluskar, Sanjay Sachdeva
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1COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY: Diagnosis, Prevention and Management2
3COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY: Diagnosis, Prevention and Management
Second Edition
SK Kaluskar MS FRCS DLO (Eng) Consultant Otorhinolaryngologist Tyrone County Hospital Northern Ireland, UK Sanjay Sachdeva MS (ENT) DCH Consultant Otorhinolaryngologist Indraprastha Apollo Hospitals New Delhi, India Foreword by Prof. W. Draf
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Complications in Endoscopic Sinus Surgery: Diagnosis, Prevention and Management
© 2006, SK Kaluskar, Sanjay Sachdeva
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the authors and the publisher.
First Edition: 2002
Second Edition: 2006
9788180617058
Typeset at JPBMP typesetting unit
Printed at Gopsons Papers Ltd., Sector 60, Noida
5
To
Our Patients Who have
Placed Their
Faith in us
6
7Foreword
The number of books dealing with endonasal surgery using microscope and endoscope increases after the start in the late seventies (Buiter, Draf, Messerklinger) from year to year. It is much more popular to discuss surgical success rather than complications being caused by the surgeon or occurring after surgery.
Therefore, it can be appreciated enough, that experienced surgeons like Dr Kaluskar and his co-worker Dr Sachdeva have worked out a monograph dealing with diagnosis, prevention and management of complications in endoscopic sinus surgery.
It has to be emphasized that the most important factor for avoiding complications is the prevention by detailed understanding of pathophysiology, proper diagnosis, a thorough knowledge of surgical anatomy, feeling comfortable with handling the instruments, the thorough preoperative preparation of the nose and a systematic assessment of medical conditions, that may affect nose and sinuses. Consequently the authors are giving in a stepwise manner important recommendations for the beginner in this very special type of surgery.
The authors touch all groups of complications as haemorrhage during operation, orbital complications, intracranial complications, perioperative and delayed postoperative complications, complications in revision surgery, and complications of more advanced endonasal techniques. They give tips and quips for the beginners and excellent recommendations for the documentation and instruments. As an annexa the reader will find a reasonable selection of literature. The text is written in a most didactic manner and well understandable for beginners as well as for more advanced surgeons. Most important is the excellent documentation of anatomy, radiology, and intraoperative findings.
In conclusion this book includes not only diagnostic pieces of advice but also clear recommendations how to deal with complications in a very concentrated but also detailed way. I am sure, it has been expected by many general ENT surgeons and more specialized rhinologists for a long time and will find a wide distribution.
Prof Dr Med Wolfgang Draf md phd frcs
Director
Department of ENT Diseases
Head & Neck and Facial Plastic Surgery
Klinikum, Fulda
Teaching Hospital of Warburg University
Germany
8
9Preface to the Second Edition
It is with great pleasure that we now write a preface for the second edition for this book. This is not because we have encountered more or varied complications. However, as the medicine is an ever evolving science and we owe to our readers recent advances in the same. Therefore we decided to add on more of our clinical and surgical experiences of the last four years.
The spectrum of para sinus infection is changing globally. There is an increasing awareness of the fungal infections of the para nasal sinuses due to better investigative facilities, imaging modalities and mycological identification. Resistance to the present antifungal drugs is becoming a reality and newer antifungal drugs are being added to control the disease process. Unfortunately fungal infection, even apparently showing a benign course such as fungal balls and allergic fungal sinusitis may produce serious complications due to local destruction of the tissues and distorted surgical anatomy. Depending upon the host response the fungus can be invasive in nature to produce serious intracranial and intraorbital complications. The surgery in this situation demands an extra care and meticulous handling of the tissues during surgery to prevent serious complications.
We have also taken this opportunity to discuss several common challenges in the routine work of endoscopic sinus surgery which requires special consideration and decision making process during surgery. We have tried to outline our method of approach to the solution of these types of problems.
SK Kaluskar
Sanjay Sachdeva
10Preface to the First Edition
Among many aphorisms of Hippocrates (460 BC), perhaps the most important one is “to avoid injuring your patient”. Regarding surgery he wrote “surgery is concerned with the patient, operator, assistants, instruments, the light, what sort and where, for the individual patient.” A surgeon must learn to use his fingers through regular use and practice. The fingers of the surgeon must train in all kinds of work, individually as well as together they should function well, rapidly, easily, cleanly and immediately.
Sushurta, a notable Indian surgeon of his time and a pioneer in ancient Indian medicine around 800 BC emphasized the importance of learning surgery on cucumbers, watermelons and wax murals. Sushurta also placed great emphasis on preparation of the patient prior to surgery. Interestingly these principles also apply today in endoscopic sinus surgery.
An eminent rhinologist Maurice Cottle of Chicago described five letters to be kept in mind during surgery, i.e. P.Q.R.S.T. The P stands for pain, the Q for querulousness, R is for restlessness, S for swelling and T for temperature. When any of these symptoms appear in the postoperative period, he advised that all dressings are removed and the tissues of the nose examined. This may prevent a minor complication developing into one of major proportions.
With the advent of multiangled endoscopes, better imaging facilities such as CT scanning and better understanding of the pathogenesis of chronic sinusitis, the scope of endoscopic sinus surgery has enhanced all over the world in the last 15 years. Unfortunately at the same time some of the dreadful complications have also been reported in the literature. Complications associated with endoscopic sinus surgery have increased due to the large number of procedures being performed. Working with the variable intricate anatomy of the nose and sinuses under the “brain and between the orbits” leaves little margin for error. Two constant themes appear in the literature while discussing complications of endoscopic sinus surgery, i.e. disorientation and the learning curve. Disorientation of the surgeon is usually secondary to the lack of knowledge of precise sinus anatomy. This is combined with poor exposure of the operative area secondary to bleeding during surgery. To proceed with the operation under these circumstances, can lead to the disastrous complications and this is where the learning curve comes into play.
In this book we have humbly tried to explain minor to major complications that have occurred or likely to occur in endoscopic sinus surgery, and more importantly discussed in details how to prevent and manage them. The book is aided by profuse illustrations of anatomy and surgical photographs to give to the reader as clear understanding of the problems as possible. We strongly emphasize on adequate training in surgical principles and technique.
There are two kinds of working with the “hands”, i.e. one in which when surgery is accompanied by safety and one in which surgery ends in a disaster. We have drawn reader's attention in this book to the kind of work that can be performed safely. A surgeon should seek greater degree of excellence and diligence for himself and safety for his patients
SK Kaluskar
S Sachdeva
11Acknowledgements
I sincerely wish to express my thanks to my son Anup who has helped me tirelessly, in my endeavour to all my publications including this book. I specially appreciate his expert help in preparation of photographs.
I wish to take this opportunity to express my sincere thanks to Prof. Wolfgang Draf, Head and Director of Otorhinolaryngology, Fulda University, Germany from whom I have learned many aspects from his vast experience in this field especially Frontal Sinus Surgery.
I wish to thank Mrs Hugh Mills, Chief Executive, Mrs Bernie McCrory, General Services Manager and Mrs Martina Corrigan, Asst. General Services Manager of Sperrin Lakeland Health Trust for their unyielding support in my work. I also wish to thank medical and nursing staff at Tyrone County Hospital, Omagh, N. Ireland, for their support for the last twenty years. Last but not least, I wish to thank my wife Hema, and children Komal, Anup and Soniya for their understanding throughout protracted process of publications and my work.
Finally on behalf of my co-author I wish to thank sincerely Jaypee Brothers Medical Publishers for their expertise in the publication of this book.
SK Kaluskar
I am indebted to my parents who educated me with right values in life. I am grateful to my teachers who taught me during my educational career.
I would like to express my thanks to Prof. Wolfgang Draf, Head and Director of Otorhinolaryngology, Fulda University, Germany from whom I have learned many aspects of Endoscopic Sinus Surgery, including Skull Base Surgery.
I also wish to express my sincere thanks to Dr SK Kaluskar, who has always been a source of inspiration and made me understand the importance of hard work.
I would like to take this opportunity to express my sincere thanks to my wife Sonia, and children Sukriti, Smriti and Stuti who have borne my absence with grace and patience so as to let me complete this work.
Sanjay Sachdeva