1. niyada

2. Prevention Avoid dangerous cases : revision, massive diseases, bleeding tendency Pre op. CT scan, CT aid ESS Pre op. preparation Intra op. observation Post op. care

3. Intra-operative observation Sedation, Hypotensive anesthesia Draping, Eye observation CT review Bulb press test Be careful ; Microdebrider, Over packing Image-guided ESS

4. Hemorrhage

5. Minor hemorrhage Common and require minimal intervention Mucosal cause Tendency to bleeding in long term local steriod use / Post infection

6. Minor hemorrhage Treatment –Cotton soaked with epinephrine –Packing –Local Electrocautery

7. Minor hemorrhage Prevention –Adequate prepare nasal mucosa with vasoconstrictor –Avoid tearing mucosa –Meticulous and careful dissection –Good quality sharp or non-tearing instrument –Gently and non-traumatizing packing

8. Major hemorrhage Anterior ethmoidal artery –Usually in bony canal but can be dehiscense –Bipolar cauterization and packing

9. Major hemorrhage Sphenopalatine artery –Posterior septal branch and branch to MT –Related to the MT removal –High pressure

10. Sphenopalatine artery

11. Major hemorrhage Cauterization or endoscopic ligation

12. Internal carotid artery injury Rare and high mortality Risk in surgery of sphenoid sinus and posterior ethmoid air cell

13. ICA locate on lateral wall of sphenoid sinus Dehiscence of the bony canal about 23 %

14. Management

15. Prevention Assess distance with measured probe

16. Prevention Avoid trauma to intersphenoid septum Sphenoidotomy should be performed inferomedial Not blind manipulate in sphenoid sinus

17. Orbital complications

18. Orbital hematoma Blindness Diplopia Nasolacrimal duct injury Subcutaneous emphysema

19. Predisposing factors Dehiscence of LP Revision surgery Distorted anatomy Sphenoethmoidal cell (Onodi cell) Extensive nasal polyp General anesthesia Bony destructive lesion

20. Predisposing factors DNS Concha bullosa Lateralized paradoxical turbinate Hypoplastic maxillary sinus “ Uncinate process close to LP ”

21. Orbital hematoma Occur intra-op until post- op 10 hr. High potential to blindness Cause –Ant. ethmoidal artery injury and retracted into orbit : sudden raise in IOP –Vein lining the LP tearing : slow progress hematoma

22. Orbital hematoma Hematoma produce pressure on central retina artery Retinal ischemia persists >90 min. cause blindness

23. Orbital hematoma Symptoms & signs –Eye pain –Rapid proptosis –Ecchymosis usually at medial first –Subconjunctival hemorrhage

24. Symptoms & signs –VA drop or blindness –Marcus Gunn’s pupil

25. Orbital hematoma Treatment –Aim to relieve pressure on arterial supply of optic nerve –Reverse from GA –Ophthalmologist consultation –Conservative treatment –Medical treatment –Surgical treatment

26. Conservative treatment Remove nasal packing Stop bleeding in the sinus Head elevation Control Blood pressure IOP measurement q 5-10 min.

27. Orbital massage (contraindicate in previous eye surgery)

28. Medical treatment Indicate in elevated IOP and VA drop 20% Mannitol 0.5-1 mg/kg IV. drip in 20-30 min. –Osmotically drawing fluid out of orbital space –Early onset of action

29. Medical treatment Azetazolamide 500 mg. IV –Decrease aqueous humor production –Delayed onset of action Avoid Fimolol or Pilocarpine (masking pupil exam) Systemic steroid (controversy) –Dexamethasone 1 mg/kg then 0.5 mg/kg q 6 hr

30. Surgical treatment Indicate in conservative failure Lateral canthotomy and inferior cantholysis

31. Surgical treatment Orbital decompression –External ethmoidectomy –Endoscopic approach Optic nerve decompression (last choice)