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within the nasal cavity and three-dimensional interpretation of two-dimensional live images. The first 100 procedures performed by solo inexperienced surgeons generally have a higher complication rate [2]. Studies have shown that, when performed in a training environment under guidance of an experienced FESS surgeon, there is no increase in complication rate during the learning curve [2, 3]. Bleeding A thorough pre-operative history will alert the surgeon of potential increased bleeding risks. Anti-coagulants should be stopped with an appropriate time interval to allow clotting to normalise. Haematological advice should be sought when bridging heparinisation may be required. Patients with known bleeding disorders should be managed according to protocols agreed with the haematology team. Beware of patients using over-the-counter vitamins and herbal therapies as these can impact on the clotting time. Mucosal Bleeding Careful insertion of the Hopkins rigid endoscope and instruments will minimise mucosal trauma. Localised superficial bleeding can be controlled with topical epinephrine-soaked patties, reserving bipolar cautery for refractory bleeds. Hypotensive total intravenous anaesthesia (TIVA) provides a clearer surgical field with less bleeding compared with gaseous anaesthetic agents [10]. The post-operative removal of nasal packing is very distressing for the patient and causes unnecessary trauma to the mucosal lining. Dissolving nasal packs show some evidence of reducing post-operative adhesions [11]; despite a general subjective feeling that they reduce post-operative bleeding, this is not backed up by a recent systematic review [12]. Sphenopalatine Artery The sphenopalatine artery, or a branch of, may be traumatised at its point of exit from the sphenopalatine foramen during posterior enlargement of the middle meatal antrostomy, or at its septal branch during inferior enlargement of the sphenoidotomy (Fig. 1). The surgeon should be comfortable performing endoscopic ligation or bipolar cauterisation of this vessel if required. A submucosal elevation of the mucosa on face of sphenoid before enlarging the bony antrostomy can prevent damage to the septal branch. Anatomical dissection of the face of the right sphenoid demonstrating course of the septal branch of the sphenopalatine artery nterior Ethmoidal Artery Orbital haematoma from anterior ethmoidal artery (AEA) damage during FESS is rare, with an incidence of 0.3% [13]. The AEA may be within the canalis orbitocranialis in the skull base, caudal to the skull base in 60% of cases or dehiscent in up to 40% [14,15,16] (Fig. 2). An avulsed AEA may retract into the orbital cavity, presenting with severe rapid proptosis and a firm eye. It is therefore advisable to always use cutting instruments in the ethmoid roof. Immediate management with endoscopic medial orbital decompression or lateral canthotomy or a combination is required to prevent optic nerve ischaemia and loss of vision [17]. Coronal CT scan showing anterior ethmoid artery canal within the skull base (left) and below the skull base (right) Delayed-onset post-operative AEA bleeding typically presents in the recovery suite, possibly with lid bruising and ecchymosis before development of proptosis (Fig. 3). With less than 60 min before irreversible retinal ganglion neurodegeneration [18], urgent decompression by way of lateral canthotomy in the recovery suite may be required. The patient may then be returned to the operating room for formal endoscopic medial decompression if required. Clinical image of the patient with evidence of post-operative orbital haemorrhage in recovery. With any orbital damage, the ophthalmology team must be involved urgently, both to assess vision and to manage sequelae Internal Carotid Artery Damage to the internal carotid artery (ICA) with standard FESS is vanishingly rare, with an incidence historically quoted as 0.3% but commonly accepted as much lower with improved surgeon experience, CT scan quality and higher resolution endoscopy [2]. The cavernous segment of the ICA is at risk during sphenoidotomy due to its relationship with the lateral wall of the sphenoid sinus. The ICA may protrude significantly into the sphenoid sinus in 15% of cases; the overlying bone may be thin in 20%, and dehiscent in 15% of cases; 1% of patients may have an intersinus septation connecting with the ICA [2]. Sphenoethmoidal (Onodi) cells may be present in up to 40% of patients [19]; the ICA may be dehiscent within this cell and therefore at risk of damage Coronal and sagittal CT scan images demonstrating a posterior sphenoethmoid cellEndoscopic skull base surgery (ESBS) necessitates greater exposure of the ventral and anterior skull base, increasing the risk of ICA injury; thankfully, in
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