1. niyada

2. Orbital hematoma - Ophthalmologist consultation -Orbital massage,Off packing -Manitol 1-2 g/Kg IV - Lateral canthotomy -Orbital decompression Control bleeding -Optic nerve decompression Observe,Bed rest sedation F/U success FAIL Observe : IOP,VA,Pupil reflex proptosis Recovery : IOP 2-3 hrs. (10-21 mm Hg.) Light perception within 24 hrs. Pupillary reflex : 24-48 hrs.

3. Prevention Pre-op CT scan evaluate unusual orbit anatomy Both eyes should be include in surgical field Preferred LA due to pain response Identify ant. ethmoidal artery that locate on posterior to ant. wall of EB

4. Prevention Palpate and compress the orbit when suspected LP injury

5. Blindness Temporary : transient increase IOP Permanent : directed optic nerve injury and prolonged IOP (60-90 min.)

6. Blindness Optic nerve injury may be in –Orbit –Sphenoid sinus –Sphenoethmoidal cell (Onodi cell)

7. Blindness Optic canal –98% at superolateral of sphenoid sinus –4-12% bony dehiscence –78% bony covering <0.5 mm. thickness –65% of the optic nerve in Asians was present in the posterior ethmoid

8. Blindness Symptoms & signs –Severe pain –Acute VA drop –Pupil dilate and not react to light –Orbital hemorrhage

9. Blindness Treatment as orbital hemorrhage –Ophthalmologic consultation –Remove nasal packing –Systemic steroid (controversy) Dexamethasone 1 mg/kg then 0.5 mg/kg q 6 hr –Optic nerve decompression if failure to conservation

10. Prevention Beware Intraoperation –Post. ethmoid sinus –Sphenoid sinus –Onodi cell

11. Diplopia Damage to ocular musculature or its nerve or vascular supply Temporary due to edema or local anesthesia

12. Most common are medial rectus and superior oblique MR closed to LP within 2-3 mm. Break LP and pulling orbital content with a microdebrider Diplopia

14. Symptoms & Signs Significant pain Diplopia Limitation of eye movement Subconjunctival hemorrhage at medial side Force duction test Diplopia

15. Urgent MRI evaluate muscle damage Immediate repair by ophthalmologist Poor prognosis Prevent as orbital hematoma

16. Nasolacrimal duct injury Cause –Over opening of ant. edge of the maxillary sinus ostium Post-op epiphora immediately or 1-2 wk. post-op Occult injury about 15%

17. Nasolacrimal duct injury DCR in symptomatic patient DCR : Dacryocystorhinostomy

18. Prevention Not performed anterior to ant. margin of MT Bone covering NLD is harder

19. Prevention Agger nasi cell is closed to lacrimal sac

20. Subcutaneous emphysema Small fracture of LP Positive pressure via mask ventilation Cough, vomit, or blow nose Periorbital subcutaneous crepitation Spontaneous resolve in 7-10 days

21. Intracranial complications

22. CSF fistula (most common) Meningitis Brain abscess ICH Brain injury Pneumocephalus

23. CSF fistula Incidence : 1 in every 200 to 500 cases Risk factors –Performed under GA due to loss of pain at skull base –Revision case –Extensive disease

24. CSF fistula Danger areas –Fovea ethmoidalis –Cribiform plate

25. CSF fistula Danger areas –Roof of ethmoid and sphenoid –Area posterior to ant. ethmoidal artery

26. Olfactory Groove Keros Classification

27. CSF fistula Onset –Intra-op leakage –Delayed post-op leakage Occult CSF fistula about 2.9%

28. Intra-op leakage Diagnosis –Washout sign –Compress bilateral IJN 10-12 sec. (Queckenstedt-stookey test)

29. Intra-op leakage IT fluorescine –Most popular –No FDA approved –0.1 ml. of 10% fluorescine (IV prep.) + 10 ml. of CSF –Infused slowly >30 min. –Grand Mal seizure : dose related complication

30. Treatment Repaired immediately –Soft tissue patch : nasal mucosa, temporalis fascia, fat, muscle, or dermal graft –Bone or cartilage bridge –Fibrin glue

31. Treatment Defect < 1 cm. –Mucosal graft or fascia Defect > 1 cm. –Solid graft

32. Delayed post-op leakage Diagnosis –Days, weeks, months, or years after procedure –Clear intermittent rhinorrhea –Associated lean forward position

33. Delayed post-op leakage Diagnosis –Hyposmia or headache –Halo sign : clear ring, central bloody spot –Endoscopic exam

34. Delayed post-op leakage Confirmed CSF leakage –Glucose oxidase test strip : high false +ve and false -ve –Beta-2 transferrin : most specific –Radionuclide cisternography : I 131, Tc 99, and In 111

35. Delayed post-op leakage Locate leakage site –Endoscopic exam –High resolution CT –IT fluorescein –CT cisternography (metrizamide) –MR cisternography T2- weighted with fat suppression

36. Treatment Small leakage often close spontaneously Conservative for 1-2 wk. Surgery when unresponsive Mostly need surgical intervention

37. Conservative treatment Strict bed rest Head elevation Stool softener Avoid cough, sneezing, nose blowing, and straining Lumbar drainage

38. Draining rate = 5-10 ml/hr Complication –Pneumocephalus : low ICP –Meningitis Prophylaxis ATB in case of sinusitis Unwarranted prophylaxis ATB in traumatic case ATB prevent cellulitis at puncture site

39. Surgical treatment Transcranial approach Extracranial approach –Trans-sinus external approach –Endoscopic transnasal approach

40. Transcranial approach Craniotomy Tissue graft + fibrin glue –Fascia lata –Muscle plugs –Pedicle galeal flap

41. Transcranial approach Advantage –Multiple areas –Identify leakage site –Associated intracranial problem Disadvantage –Morbidity & mortality –Prolong hospital stay –Limited sphenoid sinus approach

42. Transcranial approach Morbidity –Brain compression –Hematoma –Seizure –Anosmia

43. Endoscopic transnasal approach Advantage –Excellent visualization –Well tolerated –Excellent outcome (85-90%)

44. Endoscopic transnasal approach IT fluorescine locate leakage site Free graft is preferable (low failure rate) Underlayer is ideal A : dura B : fascial autograft C : bone/cartilage D : fascial autograft E : mucosal free autograft F : surgical sealant

45. Endoscopic transnasal approach Mucosal graft should never placed intracranially (intracranial mucocele) Nasal packing –Absorbable packing is placed adjacent the graft –Non-absorbable packing support beneath Excellent access to ethmoid roof, cribiform plate, and sphenoid sinus

46. Endoscopic transnasal approach

47. Post-op care –Bed rest –Anti -staphylococcal ATB –Monitor intracranial complication in first 24 hr. –CSF drainage continued for 4-5 days –Avoid strenuous activity, sneezing, and cough for 6 wks.

48. Direct brain injury Wide spectrum –Injury to dura –SAH –ICH –Secondary meningoencephalitis Poor prognosis and high mortality

49. Direct brain injury Frontal lobe is common site Treatment –Immediate rhinological closure –Consult neurosurgeon

50. Prevention Preferred LA More yellow color at ethmoid roof Attention at ant. ethmoid artery enter ethmoid sinus Keep lateral to MT

51. Synechiae Incidence : 1.2-8% 15-20% symptomatic and need treatment Location : raw surface between middle turbinate and lateral nasal Treatment : lysis synechiae and silastis spacer for 4 wks.

52. Prevention –Minimal injury to surrounded mucosa –Preserve mucosa of MT –Serial post-op cleanning –Silastic stent Synechiae

53. Other complications Asthma exacerbation –Usually occur in LA Infection –Sinus surgery + septorhinoplasty risk to severe infection Mucocele –Long term sequelae

54. Conclusion Prevention is the best Pre-op assessment and decision to operate Knowledge of anatomy relationship and its variation Informed about complication to the patient

55. Conclusion Adequate training CT-scan Expose the eye during surgery Do not blind dissection Early detection and treatment