Section 2

Look at the image below and answer the questions that follow. 

What is shown above and when is it used?

Image guidance for functional endoscopic sinus surgery

During this operation, which blood vessel is at risk during surgery and may cause increased intraocular pressure if damaged?

Anterior ethmoidal artery

How does this occur?

If damaged, the artery contracts into the orbit resulting in a retro-orbital haematoma

How can you treat this acutely?

Lateral canthotomy and inferior cantholysis

The patient complains of clear rhinorrhea when leaning forwards after their surgery. What is the likely diagnosis and how would you confirm this?

  • CSF leak
  • Collect fluid and test for Beta-2  transferrin

Supporting Information

Functional endoscopic sinus surgery (FESS) 
Indications – rhinosinusitis, nasal polyposis, epistaxis – cautery of SPA ligation, CSF leaks, orbital decompression, DCR, optic nerve decompression, pituitary surgery. 

CT scanning is key to define the anatomy.

Intraoperatively – use microdebrider or sharp instruments – take care, can cause scarring and impaired healing. Makes revision surgery more difficult. 

Risks – CSF leak- should be repaired immediately, orbital bleeding requiring decompression, nasolacrimal duct injury, carotid injury, optic nerve injury. 

Orbital bleeding/haematoma, causes ischemia of optic nerve due to increased pressure:

  • Breach of lamina papyracea and damage to:
    • Orbital veins– slow bleed
    • Anterior/posterior ethmoid arteries – fast bleed
  • Presentation- proptosis, reduced visual acuity, reduced visual fields
  • Management
    • Remove any nasal packs
    • Consider IV mannitol
    • Consider IV steroids
    • Senior ENT r/v
    • Urgent ophthalmology review
    • Surgery:
      • Local– Lateral canthotomy + inferior cantholysis

General – medial orbital decompression, superior canthotomy, ligation of bleeding vessels- if lateral canthotomy doesn’t work

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