Complications of Endoscopic Sinus Surgery Marleen

\s=b\

Vleming, MD, PhD;

Rene J.

Middelweerd, MD, PhD;

Endoscopic sinus surgery has become popular during re-

cent years. We report the complications of endoscopic sinus surgery in 593 patients in whom 1235 sides were oper-

ated on. Forty-five patients had complications, in three of whom they were systemic. The remaining 42 patients had complications on 52 (4.2%) sides; these complications were mostly minor. In 0.3% of the sides operated on, potentially serious complications, such as orbital hematoma or cerebrospinal fluid leak, were seen. None of these patients developed loss of vision or meningitis. Absence of the middle turbinate is a risk factor for developing complications. We conclude that endoscopic sinus surgery is a safe procedure in experienced hands. (Arch Otolaryngol Head Neck Surg. 1992;118:617-623) the work of Messerklinger,1_8 endoscopie introduced by Stammberger Based surgery (ESS) and later al913

sinus

on

was

et

made popular by Kennedy Europe et al1418 in the United States. Many reports on the technique of, indications for, and results of ESS have been However, few reports are devoted exclusively to the complications of ESS.19,20 It is unclear how the com¬ plication rate of ESS compares with that of other ap¬ proaches to the ethmoid sinus. In principle, there are three possible approaches to the ethmoid sinus: the external, the transantral, and the in

was

published.

approaches. Of those three approaches, the complications are reported to occur with the external approach.21 The morbidity and complications associated with this approach are an external scar, wound infections, and temporary orbital disease, such as perior¬ bital edema, supraorbital anesthesia, ptosis, and diplo¬ pia.22·23 The chief direct postoperative morbidity associ¬ ated with the transantral route is a painful swelling of the face.24 Its most important late complication is hypoesthesia or hyperesthesia of the infraorbital nerve, which transnasal

most "minor"

in 12% to 58% of cases.25"27 Devitalization in children may also occur.28 to teeth age occurs

or

dam¬

Complications of ESS (and of paranasal sinus surgery in general) can be divided into orbital, intracranial, and vasAccepted for publication January 3, 1992. From the Department of Otolaryngology/Head and Neck Surgery, Free University Hospital Amsterdam (the Netherlands). Reprint requests to the Department of Otolaryngology/Head and Neck Surgery, Free University Hospital Amsterdam, PO Box 7057, 1007 MB

Amsterdam, the Netherlands (Dr de Vries).

Nico de Vries, MD, PhD

cular

complications. Reports in the literature of serious complications of ESS are mostly case reports, which

makes its exact incidence unclear.29"32 The least serious perioperative orbital complication is a lamina papyracea lesion. With a concomitant lesion of the periorbita, it is usually detected during surgery because orbital fat is seen via the opening in the lamina papyracea or even bulges into the ethmoid sinus. When the presence of orbital fat is in doubt, gentle pressure on the eye can be helpful, as this may result in bulging of orbital fat into the ethmoid cavity.29 Manipulations of this orbital fat and further surgery within this region must be avoided. When indicated, surgery can be continued further posteriorly. Postoperatively, ecchymosis of the eyelids can occur, while blowing of the nose can lead to emphysema of the eyelids. In most cases, such lesions are so small that sur¬ gical closure is unnecessary. Larger lesions can be closed when necessary.33 When a perforation of the lamina pa¬ pyracea is detected too late, a lesion of the medial rectus muscle can occur, resulting in disturbances of eye move¬ ment.32 Intraorbital and retrobulbar hematomas can lead to loss of vision. An orbital hematoma can occur when the ante¬ rior or posterior ethmoidal artery is damaged or small vessies in orbital fat are torn and can develop quickly perioperatively or postoperatively with chemosis, ecchymo¬ sis of the eyelids, proptosis, and pain within the eye. The increased intraorbital and intraocular pressure can lead to blindness due to vascular obstruction and ischemia. With adequate timely therapy, the loss of vision can be re¬ versed.34·35 Therapy in cases of intraorbital bleeding with increased intraocular pressure and without loss of vision is massage of the eye combined with lowering of the in¬ traocular pressure with medication. In such cases, the di¬ agnostic workup and treatment are performed in cooper¬ ation with an ophthalmologist. Medical treatment can consist of acetazolamide (500 mg) and mannitol (0.5 to 1.0 mg/kg), both administered intravenously, to decrease the intraocular pressure and dexamethasone disodium phos¬ phate (0.1 to 0.5 mg/kg) to prevent edema of the optic nerve.29 Decompression of the orbit is indicated when the intraocular pressure does not decrease despite adequate treatment or when vision deteriorates. The orbit can be decompressed via a lateral canthotomy or via an incision of the medial and/or inferior periorbit after removal of the lamina papyracea and/or floor of the orbit. Orbital de-

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Table

of Endoscopie Sinus Surgery as 1.—Complications in the Literature and Present Series, Related to Reported Side Operated on (n 1235) or to Procedure (n 667)* =

=

Study, Stank-

Complication

Table 2. —Nonsystemic Complications to Location (Left or Right)*

iewicz,20 1989

No. of sides

et

al,47 Levine,48

1990

1.3

lesion

Complicationt

Sterman

300

Lamina papyracea

%

167 2.4

1990

458 0.6

1.6

Orbital hematoma Loss of vision

Present

Study 1235 1.3 (16) 0.16

(2)

0.3

Medial rectus muscle lesion Nasolacrimal duct stenosis CSF rhinorrhea

.

.

.

.

.

.

0.08 (1) 0.16t

.

.

.

.

.

.

(2)

Related

Left Right No. of Side Side Sides (n = 614) (N = 621) Patients (n 1235) =

7

16

16

Orbital hematoma CSF rhinorrhea

11

2

2

2

2

Bleeding Synechiae, symptomatic

8

7

9

15

7

8

11

15

Mucocele

1

1

1

lesion

Nasolacrimal duct stenosis

0.7

Meningitis

Lamina papyracea

as

Total

9 2

...

...

1

29

...

(4.7%) 23 (3.7%)

1

1

42

52

*CSF indicates cerebrospinal fluid. tin cases of bilateral complications, bleeding occurred six times and synechiae occurred four times bilaterally; this is shown at both sides.

0.16t

Pneumocephalus

(2)

Brain abscess 0.89

Bleeding, packs Bleeding,

(11)

1.7

transfusion

.

0.32 (4)

.

.

Synechiae, symptomatic

2

1.2 (15)

1.2

Obstruction of

maxillary sinus

ostium

1.3

Sinus 0.14

Exacerbation of COPD

(D* 0.29

m

Wound infection

Neuralgiform pain 0.08 (1)

Mucocele Death *CSF indicates

cerebrospinal fluid; COPD, chronic pulmonary disease; question mark, not reported.

obstructive

tSame

patients. ^Complications related

to

procedure.

compression must be performed within 60 to 120 minutes

the loss of vision will otherwise be irreversible.29·35·36 In cases of direct damage to the optic nerve, lateral to the posterior ethmoid sinus or sphenoid sinus, the loss of

because

vision is irreversible.

During ophthalmologic

tion, the direct and the consensual disturbed in such cases.29

pupil

examina¬ reactions are

A nasolacrimal duct lesion can result in stenosis of the nasolacrimal duct with subsequent epiphora.37 This oc¬ curs more frequently in cases of antrostomy in the lower meatus than in the middle meatus.38 The most frequent intracranial complication is cere¬ brospinal fluid (CSF) rhinorrhea. The penetration of the fila olfactoria of the dura mater and the lamina cribrosa results in a communication between the nasal mucosa and

the arachnoidal space.39 Whenever mucosa in the vicinity of the lamina cribrosa or the upper medial part of the middle and/or superior turbinate or the upper part of the septum is being removed, CSF rhinorrhea can occur in the absence of a direct lesion of the base of skull.33 This can be avoided by confining surgery to the region lateral to the middle turbinate. Direct lesions of the base of the skull are usually located in the medial part of the ethmoid sinus roof, where the anterior ethmoidal artery leaves the eth¬ moid sinus. The combination of a thin, bony layer and an adherent dura mater increases the risk of a lesion of the base of skull at this site.40 The anterior wall of the sphe¬ noid sinus is usually somewhat lower than the posterior ethmoid cell. This predisposes to a lesion of the base of the skull superolaterally in the posterior portion of the ethmoid sinus.17 When a CSF leak is noted during surgery, the lesion can be closed intranasally with mucosa of the inferior turbinate with the use of fibrin glue.33·41·42 Small defects detected postoperatively can also close defects, an external spontaneously.40 In cases of large better exposure.30 ethmoidectomy might provide A lesion of the base of the skull can lead to pneumocephalus, meningitis, an epidural or intracranial abscess, and a meningocele or encephalocele. Direct damage to the frontal lobe of the brain has also been reported.30 Vascular complications, including lesions of the ante¬ rior and posterior ethmoidal artery, can lead to bleeding within the ethmoid sinus, as well as to an intraorbital he¬ matoma. Lesions of the sphenopalatine artery and its branches are most common. Bleeding due to lesions of these arteries can usually be controlled by packing or by bipolar coagulation. In cases of persistent bleeding de¬ spite adequate conservative treatment, a transantral ap¬ proach to the sphenopalatine artery within the pterygopalatine fossa is sometimes indicated. Injury to the base of the skull can lead to bleeding of the intradural meningeal vessels and of the subarachnoidal branches of the anterior cerebral artery, leading to epi¬ dural, subdural, and intracerebral hematomas and to subarachnoidal bleeding, in some cases with traumatic

aneurysms.43

A lesion of the internal carotid

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artery or of the cavern-

Table

3.—Complications as

Related to Indication for Indication for

Surgery,

Surgery*

% (No.)

Sinusitis and Orbital

(N = 585)

(N 579)

Inverted Papilloma (N = 24)

1.37 (8)

1.04 (6)

5(1)

0.17 (1)

0.17 (1)

Polyposis

Sinusitis

=

Antrochoanal

Polyp (N

=

20)

Complications (N = 15)

Mucocele (N = 4)

Others (N 8) =

Lamina

papyracea lesion Orbital hematoma CSF rhinorrhea

0.68 (4)

0.34 (2) 1.55 (9)

2.05 (12)

0.52 (3)

.

Bleeding Synechiae, symptomatic

.

.

Nasolacrimal duct stenosis Mucocele

0.17(1)

Total

4.44 (26)

cerebrospinal

13.3 (2)

0.17 (1)

.

.

*CSF indicates

Table

.

3.79 (22)

5(1)

to the Presence Concha*

or

Middle Concha, % (No.) Present

lesion

Bleeding CSF rhinorrhea

Orbital hematoma Nasolacrimal duct stenosis

Synechiae Mucocele *CSF indicates

(n = 1128)

Absent (n = 107)

2

Analysis,

sinus

13.3

(2)

as Related to the Age 5.—Complications of the Patient

y

No. of Patients

Complications, % (No.)

0-9

5

10-19

35

20-29

98

5.7 (2) 7.1 (7)

0.97 (11)

4.7 (5)

.0012

30-39

110

3.6 (4)

1.06(12) 0.09 (1) 0.09 (1)

2.8(3) 0.9 (1) 0.9 (1)

.12

40-49

147

.038

50-59

111

8.2 (12) 7.2 (8)

.038

60-69

66

13.6 (9)

70-79

21

9.5 (2)

0

1.33 (15) 0.09 (1)

cerebrospinal

0.9 (1) 0

.0016

0

fluid.

during manipulations within the lat¬ eral portion of the sphenoid sinus. ous

Table

Age, I

I

Lamina papyracea

5(1)

fluid.

as Related 4.—Complications Absence of the Middle

Complication

5(1)

can occur

PATIENTS AND METHODS Between June 1986 and January 1991, ESS was performed in 593 patients. In 66 patients, ESS was performed more than once, for a total of 667 procedures on 1235 sides. The results have been reported elsewhere.44"47 The complications are presented in Ta¬ ble 1. Complications occurred in 45 patients, in three of whom they were systemic. The remaining 42 patients had complica¬ tions on 52 sides (4.2%). The localized complications will be re¬ lated to the number of sides operated on.

RESULTS A lamina papyracea lesion was the most common com¬ plication (1.3% of the 1235 sides operated on). This led, in some cases, to a hematoma and/or emphysema of the eyelids—nine times on the left side and se ven times on the right side (Table 2). After treatment with antibiotics, all patients were cured without residual lesions. A unilateral orbital hematoma developed in two pa¬ tients (0.16% of the sides operated on). One of these pa¬ tients, who was operated on because of nasal polyps, had undergone bilateral polypectomy six times previously.

Computed tomography revealed a complete opacification

of the nasal

cavity

and all sinuses; the middle turbinate

appeared to be absent, which was later confirmed during surgery. Postoperatively, proptosis and diminished eye movements bul undisturbed vision

were

noted. Nasal

packs were removed, and antibiotics were administered.

Intraocular pressure and vision were monitored inten¬ sively by the ophthalmologist, but no further therapy was necessary. The hematoma resorbed spontaneously with¬ out permanent sequelae. The other patient, operated on because of sinusitis, had undergone an inferior meatal antrostomy and a polypectomy. Computed tomography revealed a partial opacification of the anterior portion of the ethmoid sinus, the maxillary sinus, and the infundibulum. During surgery, a moderate polyposis in the right anterior portion of the ethmoid sinus was found. Perioperatively, a defect in the lamina papyracea was noted; postoperatively, a slight proptosis of the right eye without disturbed eye movements or loss of vision occurred. This patient was treated with antibiotics, and the complications resolved spontaneously. Epiphora oc¬ curred in one patient due to stenosis of the nasolacrimal duct. Synechiae occurred in 11 patients on 15 sides (1.2%). Only symptomatic synechiae leading to revision surgery were counted as complications. In those cases, an exten¬ sive adherence of the middle turbinate to the lateral nasal wall was present. Most synechiae were asymptomatic. When such adherence was found during follow-up ex-

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was cut with the patient under local anes¬ thesia. This occurred mostly in patients operated on be¬ cause of sinusitis (Table 3). Cerebrospinal fluid rhinorrhea was noted perioperatively in two patients (0.16% of sides) who underwent revision surgery for polyposis nasi. The defect was closed with a commercial product made of dura mater (Lyodura) and nasal packing or with nasal packing only. These two patients were placed in a half-seated position. Both developed a pneumocephalus. One pa¬ tient underwent a lumbar puncture to decrease the intracranial pressure. So as not to mask a possible meningitis, no antibiotics were administered. No men-

amination, it

Table

Related to the Form Anesthesia*

as 6.—Complications of

Complication

(No.)

Lamina papyracea lesion (16)

Local Anesthesia (n = 471)

General Anesthesia (n = 196)

11

5

Synechiae (11) Bleeding (9)

9

2

6

3

CSF rhinorrhea (2)

2

0

ingitis

Table 7. —Percent of Complications of

CSF rhinorrhea occurred after removal of the

three for sinusitis, and one for an acute sinusitis with an orbital complication (Table 3). It is very likely that a

simultaneous conchotomy of the inferior turbinate was the cause in one patient. A blood transfusion was neces¬ sary in two patients (0.3% of the 667 procedures) operated on for polyposis nasi, one after removal of the packing in a patient with chronic lymphatic leukemia. Only two patients (0.29% of the 667 procedures) re¬ ceived antibiotics postoperatively because of fever and headache due to wound infection. One patient developed a mucocele after surgery for polyposis, and one patient with asthma had an exacerbation postoperatively, which required medical treatment. Table 2 shows the sides on which complications oc¬ curred, but systemic complications are not included. Complications occurred on the left side in 4.7% and on the right side in 3.7% of procedures ( 2 analysis, difference not

1 1 Orbital hematoma (2) 1 1 Wound infection (2) stenosis 0 Nasolacrimal duct (1)1 0 1 Exacerbation of COPD (1) 32 (6.7%) 12 (6.1%) Total *CSF indicates cerebrospinal fluid; COPD, chronic obstructive pulmonary disease.

or

packing 2 days postoperatively. Bleeding occurred in nine patients (1.3% of the 667 procedures) on 15 sides (1.21% of the sides operated on), in three patients postoperatively and in six patients perioperatively. Five patients were operated on for polyposis,

significant).

of the 42 patients with local com¬ had plications undergone previous surgery. Of the total 593 patients, 335 (56%) had undergone previous surgery. Complications occurred in 8% of these 335 patients vs 6% of the patients who had not undergone previous surgery ( 2 analysis, difference not significant). The middle turbinate was absent in 107 (8.6%) of the sides operated on. In all cases of synechiae, the middle turbinate was present. In all other cases with complica-

Twenty-seven (64%)

Endoscopie Sinus Surgery as Reported Study,

No. of

patients

Lamina papyracea lesion Orbital hematoma

%

Stammberger and Posawetz,"

Schaefer et al,49

Hoffman et al,5'

1989

1990

1990

220

100

100

500

?

2

2

1.8

Hosemann et 1988

Complication

per Patient*

al,48

1

Loss of vision

Medial rectus muscle lesion Nasolacrimal duct stenosis CSF rhinorrhea

Meningitis

Pneumocephalus Brain abscess

Bleeding, packs Bleeding, transfusion Synechiae, symptomatic Obstruction of

maxillary sinus

ostium

Exacerbation of COPD Wound infection

Neuralgiform pain Mucocele Death *CSF indicates

cerebrospinal fluid; COPD,

chronic obstructive

pulmonary disease;

and

question mark,

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not

reported.

tions, the middle turbinate was absent significantly more

frequently than in the total group (Table 4). Complications were not related to age (Table 5), but no complications occurred in children. Table 6 shows that no differences in frequency of complications between patients under local or general anesthesia were present. COMMENT

recently published reports of results of ESS, complications, some serious,31 were reported1316·48"52 (Ta¬ bles 1 and 7). However, serious complications rarely oc¬ In

cur

was

some

in the hands of surgeons with experience in ESS, as confirmed in our study. Potentially dangerous corn-

Table

8.—Complications per Side Operated on per Year*

No. of Sides

Operated

Year

Complications, % (No.)

on

1986

68

5.9 (4)

1987

254

1988

298

2.0 (5) 4.7 (14)

1989

288

5.2 (15)

1990

327

4.3 (14)

Complications include bleeding, lamina papyracea lesion, syn¬ echiae, cerebrospinal fluid rhinorrhea, orbital hematoma, and na¬ solacrimal duct stenosis.

plications, such as CSF rhinorrhea and orbital hematoma, occurred in only 0.3% of procedures without permanent sequelae. Wigand33 reported CSF rhinorrhea in 1.6% of 372 endoscopie ethmoidectomies; Stammberger and Posawetz13 reported this complication in 0.07% of more than 4500 procedures. Stankiewicz19·20 reported exclusively on complications of ESS. In his first publication,19 a high complication rate —17% in 150 ethmoidectomies—was reported. These were mainly "minor" complications, such as lamina papyracea lesions with a hematoma or emphysema of the eyelids, synechiae, and stenosis of the widened ostium of the maxillary sinus. Serious complications, ie, CFS rhin¬ orrhea and temporary loss of vision, each occurred once on 1.3% of the sides operated on. In his later article,20 the complication rate had dropped, as was to be expected with increasing experience. In our study, the overall complication rate did not drop over time (Table 8), although cases of CSF rhinorrhea and orbital hematoma occurred in patients operated on in the early years. Endoscopie sinus surgery in our department is being performed partially by residents in the last year of their training under the supervision of a staff member, which may explain why the influence of increasing expe¬ rience is not reflected in a decrease in the overall compli¬ cation rate. The complications of ESS performed by resi¬ dents under supervision are reported to be equal to those reported in the literature52 (Tables 1 and 7).

Table 9.—Percent of Complications of Conventional Intranasal Ethmoidectomy Without the Use of the Nasendoscope*

Study,

Sphenoethmoidectomy

%

Friedman and

Freedman and Kern,51

Eichel,56 1982

Stevens and Blair,57 1988

Katsantonis,58

1000

236

230

1163

+

2.6

0.3

0.4

1.3

1979

No. of sides Lamina papyracea lesion Orbital hematoma Loss of vision

?

0.4t

1990

0.4

Medial rectus muscle lesion Nasolacrimal duct stenosis CSF rhinorrhea

Meningitis Pneumocephalus

0.1

?

0.1

0.4§ 0.4§ 0.4§

0.1

0.3

Brain abscess 1.2

Bleeding, packs Bleeding, transfusion Synechiae, symptomatic Obstruction of maxillary sinus ostium

Exacerbation of COPD Wound infection

0.4

0.3

?

0.4

1.3

0.3

?

+

?

?

?

?

?

?

?

?

1.5

0.1

?

?

?

0.1

+

?

?

30.3

Neuralgiform pain Mucocele

?

0.2

Death

*Question mark indicates

pulmonary disease.

not

reported; plus sign, percentage

tOrbital hematoma occurred in two tSame

patient. §Same patient.

patients

not

reported; CSF, cerebrospinal fluid;

due to intraorbital anesthesia to the ethmoidal

nerve.

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and COPD, chronic obstructive

complications were seen in the total group of who had undergone previous surgery. However, patients the complication rate increased significantly when the middle turbinate (an important landmark during surgery) was absent. This was found in association with all com¬ plications, with the exception of synechiae (Table 4). The indication for surgery did not affect the complica¬ tion rate, with the exception of patients operated on be¬ cause of sinusitis. In these patients, synechiae occurred more frequently (P .02, 2 analysis). This finding is likely due to the fact that, in these patients, the postoperative space between the middle turbinate and the lateral nasal wall is smaller than in patients with polyposis nasi. These synechiae can possibly be prevented in the immediate postoperative period by even more meticulous nasal toilet. Despite the fact that the literature11 usually stresses that the patient who undergoes surgery while under local an¬ esthesia is at lower risk for complications, particularly le¬ sions of the lamina papyracea and the base of the skull, than while under general anesthesia, we were unable to confirm this hypothesis (Table 5). The complication rate was equal for both forms of anesthesia. Our study shows that ESS can be performed safely in children, as reported in the literature.53,54 Table 9 shows the complications as reported in transnasal ethmoidectomies without the use of the of these complications nasendoscope.55"58 A comparison with those associated with ESS reveals that serious com¬ plications are rare with both techniques. "Minor" compli¬ cations, such as lamina papyracea lesions and synechiae, are usually not reported in articles about transnasal ethmoidectomy without the use of the nasendoscope. It is unlikely that these complications do not occur without the use of the nasendoscope, which enables better recogni¬ tion of these complications. According to Freedman and Kern,55 most complications associated with endonasal ethmoidectomies performed without the nasendoscope occur on the right side. Freed¬ man and Kern attribute this finding to the fact that inspection of and surgery on the right side is more diffi¬ cult for right-handed surgeons. In our series, no differ¬ ences between the left and right sides were found (Table 2). Although the right side is more difficult to operate on in ESS as well, this is not reflected with a higher compli¬ cation rate. Systemic complications, such as wound infections or exacerbation of preexisting asthma, were rare, despite the fact that perioperative or postoperative antibiotics were rarely used. In the literature, one case of toxic shock syn¬ drome after ESS has been reported.59 Although toxic shock syndrome did not occur in our series, we performed revision ESS in a case of toxic shock syndrome that occurred after ESS performed elsewhere. The possibility of toxic shock syndrome is a reason not to pack the nose No

more

=

postoperatively.60

CONCLUSION sinus Endoscopie surgery in our series was associ¬ ated with local complications in 4.2% of sides operated on and with systemic complications in 0.4% of proce¬ dures. Most complications were "minor"; potentially serious complications, such as orbital hematoma and CSF rhinorrhea, occurred in only 0.3% of the sides operated on. Patients in whom the middle turbinate

absent were particularly at risk. These findings confirm that ESS is a safe procedure when performed by an experienced surgeon. was

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Messerklinger W.

Schwarzenberg; 1978. Messerklinger W. Das Infundibulum ethmoidale und seine entz\l=u"\ndlichenErkrankungen. Arch Otorhinolaryngol Suppl. 1979;222:11\x=req-\ &

6.

22. 7.

Messerklinger W. Uber den Recessus frontalis und seine Klinik. Laryngol Rhinol Otol. 1982;61:217-223. 8. Messerklinger W. Die Rolle der lateralen Nasenwand in der Pathogenese: Diagnose und Therapie der rezidivierenden und chronischen Rhinosinusitis. Laryng Rhinol Otol. 1987;66:293-299. 9. Stammberger H. Endoscopic surgery for mycotic and chronic recurring sinusitis. Ann Otol Rhinol Laryngol. 1985;119(suppl 94):1-11. 10. Stammberger H. Endoscopic endonasal surgery: concepts in treatment of recurring rhinosinusitis, I: anatomic and pathophysiologic considerations. Otolaryngol Head Neck Surg. 1986;94:143-147. 11. Stammberger H. Endoscopic endonasal surgery: concepts in treatment of recurring rhinosinusitis, II: surgical technique. Otolaryngol Head Neck Surg. 1986;94:147-156. 12. Stammberger H, Zinreich SJ, Kopp W, Kennedy DW, Johns ME, Rosenbaum AE. Zur operativen Behandlung der chronisch rezidivierenden Sinusitis: Caldwell-Lucversusfunktionelle endoskopischeTech-

nik. HNO. 1987;35:93-105. 13. Stammberger H, Posawetz W. Functional endoscopic sinus surgery: concept, indications and results of the Messerklinger technique. Eur Arch Otorhinolaryngol. 1990;247:63-76. 14. Kennedy DW, Zinreich SJ, Rosenbaum A, Johns ME. Functional endoscopic sinus surgery: theory and diagnostic evaluation. Arch Oto-

laryngol. 1985;111:576-582. 15. Kennedy DW. Functional endoscopic sinus surgery: technique. Arch Otolaryngol. 1985;111:643-649. 16. Kennedy DW, Zinreich SJ, Shaalan H, Kuhn F, Nacleroi R, Loch E. Endoscopic middle meatal antrostomy: theory, technique, and patency. Laryngoscope. 1987;43(suppl 97):1-9. 17. Kennedy DW, Zinreich SJ. The functional endoscopic approach to inflammatory sinus disease: current perspectives and technique modifications. Am J Rhinol. 1988;2:89-96. 18. Kennedy DW, Josephson JS, Zinreich SJ, Mattox DE, Goldsmith MM. Endoscopic sinus surgery for mucoceles: a viable alternative.

Laryngoscope. 1989;99:885-895. 19. Stankiewicz JA. Complications of endoscopic intranasal ethmoidectomy. Laryngoscope. 1987;97:1270-1273. 20. Stankiewicz JA. Complications in endoscopic intranasal ethmoidectomy: an update. Laryngoscope. 1989;99:686-690. 21. Watson DJ, Griffiths MV. The safety and efficacy of intra-nasal ethmoidectomy. J Laryngol Otol. 1988;102:802-804. 22. Kimmelman CP, Weisman RA, Osguthorpe JD, Kay SL. The efficacy and safety of transantral ethmoidectomy. Laryngoscope. 1988;98:1178-1182. 23. Bernard PJ, Biller HF, Lawson W, LeBenger J. Complications fol-

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Announcement American

Academy of Cosmetic Surgery Trisymposium Meeting

The American Academy of Cosmetic Surgery is sponsoring a Trisymposium Meeting from August 7 through 10,1992, in Philadelphia, Pa, featuring "Cosmetic Breast Sur¬ gery" (Howard Tobin, MD, program chairman); "Body and Facial Contouring" (Ri¬ chard T. Caleel, DO, program director); and "Sclerotherapy and Phlebology" (Vida T. Vida, MD, program director). For further information, contact American Academy of Cosmetic Surgery, 159 E Live Oak Ave, Suite 204, Arcadia, CA 91006-5249; (818) 447-1579; fax (818) 447-7880.

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Complications of endoscopic sinus surgery.

Endoscopic sinus surgery has become popular during recent years. We report the complications of endoscopic sinus surgery in 593 patients in whom 1235 ...
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