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International consensus statement on rhinosinusitis

TABLE XII-28 Complications of endoscopic sinus surgery Minor

Complications of Sinus Surgery Aggregate Grade of Evidence: B (level 1: 4 studies; level 2: 4 studies; level 3: 6 studies; level 4: 5 study; level 5: 3 study; Table XII-27).

Temporary, no intervention Violation of lamina papyracea Subcutaneous periorbital emphysema Periorbital ecchymosis

Dental/lip pain or numbness Temporary, with intervention Adhesions Epistaxis (requiring packing) Infection (frontal, maxillary, or sphenoid sinus) Permanent despite intervention (persist beyond 1 year) Dental/lip pain or numbness

XIII Pediatric Rhinosinusitis XIII.A Pediatric Acute Rhinosinusitis XIII.A.1 Pediatric ARS: Incidence and Prevalence Acute rhinosinusitis (ARS) is a common disorder in chil dren, usually occurring in the context of an URI. 31–33,2290 In a longitudinal study of 112 children aged 6-35 months, 623 URIs were observed over a 3-year period, and episodes of ARS were documented by the investigators in 8% of cases. 2291 In an older study, 244 full term infants were fol lowed prospectively for 3 years, and the incidence of URIs complicated by ARS was evaluated. 474 The authors defined ARS as the duration of URI symptoms exceeding 2 stan dard deviations (range 16-22 days) above the mean (7.3 days). The incidence of ARS as a complication of a URI ranged from 4-7.3% and was highest for children in their first year of life and in day care or group care as compared to home care. Another study evaluating 2135 children with respiratory complaints found that 139 fulfilled diagnostic criteria for ARS (6.5%). 35 In 2 studies that queried children presenting to pediatric practices for any reason, ARS was identified (based on symptoms) in 9.3% (121/1307) 2292 and 8.3% (249/3001). 2293 respectively. In another study of 2013 children, the addition of a positive Water’s view to clini cal symptoms decreased the incidence estimate negligibly (7.2-6.7%). 2294 More recent studies have used large databases to study the incidence of ARS in children. An analysis of United States national survey databases evaluated ambulatory vis its to office-based physicians as well as visits to hospital emergency and outpatient departments between 2005 and 2012. 36 A total of 2.1 billion visits by patients 0-20 years of age were included, and diagnoses were based on ICD 9 codes. Analysis showed that ARS was diagnosed in 13.1 million visits, or 0.6% of the total. In comparison, CRS accounted for 2.1% of visits, upper respiratory tract infec tion for 8%, allergic rhinitis for 2.6%, and acute otitis media for 6.7%. One study from Canada suggests a recent decline in the incidence of pediatric ARS. The Canadian Disease and Therapeutic Index and Statistics Canada databases

Major Orbital

Orbital hematoma Vision loss Diplopia Epiphora (requiring dacrocystorhinostomy) Blindness Hemorrhage requiring transfusion ( > 1000mL) Carotid artery injury Intracranial Cerebrospinal fluid (CSF) leak Meningitis Brain abscess Focal brain hemorrhage Pneumocephalus Stroke Central nervous system deficit Death Table adapted from May et al. 104 and Asaka et al. 100

higher incidence of complications with IGS use, however these studies do not take into account the surgeon experi ence or the complexity of the case. 98,2275 Aside from preoperative preparation, several strategies can be utilized to mitigate intraoperative and postopera tive complications. Bleeding during surgery can signifi cantly affect visibility of the surgical field. Intraoperatively, blood loss can be mitigated by positioning the patient in reverse Trendelenburg, maintaining tight blood pres sure control (MAP between 60 and 70 mmHg), using TIVA (propofol and remifentanil), and applying topical agents such as 1:1000 epinephrine or oxymetazoline in a deliberate fashion. 1838,1847,2276,2287 Although a minor com plication, adhesions resulting in middle turbinate lat eralization and synechiae formation can contribute to suboptimal outcomes and potentially a need for revi sion surgery. 105,2210,2288 The use of middle meatal spac ers, both absorbable and non-absorbable material, con trolled synechiae formation, or middle turbinate suturing can reduce middle turbinate lateralization and adhesion formation. 105,2207