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Complications Infection Post-FESS intracranial infections may present as meningitis, intracranial abscess or cavernous sinus thrombosis. The risk of meningitis with a persistent CSF leak is 19%, decreasing after repair of the skull base defect [38]. Abscesses will require urgent neurosurgical drainage and therefore should be managed in the appropriate tertiary unit. All intracranial infections should be managed in a multidisciplinary environment, involving physicians, neurology and microbiology. Pneumocephalus Pneumocephalus is an uncommon complication of FESS. Tension pneumocephalus post-FESS is incredibly rare; only a handful of isolated cases have been described in the literature [39,40,41,42]. All cases of pneumocephalus must be managed in conjunction with neurosurgical teams in a tertiary unit. While very small, uncomplicated cases may be managed with bed rest and administration of 100% oxygen; the majority will require surgical repair of the underlying bony defect [43]. Tension pneumocephalus will require urgent surgical decompression along with repair of the defect to prevent brain herniation [40]. As with all surgical interventions, the aim of FESS should be to provide appropriate resolution of pathology without recurrence of disease. Despite this admirable aim, the reality is that up to 20% of patients will require revision FESS within 5 years, 43% of which will be within the first post-operative year [5]. A lack of anatomical and physiological understanding can increase the need for revision surgery [44]. Risk factors for requirement of revision surgery are listed in Table 2 [6, 45,46,47]. Both the surgeon and patient should be aware that revision FESS carries an increased overall risk of complications and need for further revision surgery More Extensive Surgery In patients with conditions known to have high recurrence rates, there is an argument for early, extensive surgical intervention [51]. Aspirin-exacerbated respiratory disease is frequently associated with nasal polyps, a trio of disease known as Samter’s triad (Fig. 5). These patients typically have more severe nasal polyposis as compared with aspirin-tolerant patients [52]. Recurrence rates post-FESS of up to 90% have been reported in this group [6]. Indeed, the authors have managed patients previously treated at other units who have presented for their 18th FESS procedure. A low threshold for maxillary antrostomy, complete sphenoethmoidectomy and modified Lothrop procedure can reduce recurrence to 22.5% [53].Typical coronal CT scan of patient with aspirin-sensitive airway disease and nasal polyposisThe inverted papilloma, a subtype of Schneiderian papilloma, is a benign but locally aggressive tumour with malignant potential [54], commonly affecting the nose and paranasal sinuses. Increasing Krouse staging score [55] will necessarily require more extensive resection. Identification of the location of attachment and adequate resection reduce risk of recurrence [56]. The importance of sending abnormal-looking tissue and nasal polyps for histopathological analysis cannot be overemphasised. Missed inverted papilloma can continue to progress in situ, presenting with complications including frontal pyoceles [57]. Resection of frontal sinus inverted papilloma is associated with up to 37% incidence of mucocele formation; this is higher in combined endoscopic and open techniques than endoscopic alone [58, 59]. Obstruction of the frontal sinus outflow tract (FSOT) following FESS or EDCR can lead to the formation of frontal mucocele. This may be due to adhesions or lateralisation of the middle turbinate [60], both of which can obstruct the FSOT. This may expand into the orbit or become infected leading to a pyocele and associated intracranial complications. The nasalisation technique, involving giant middle meatus antrostomy, middle turbinate resection, complete sphenoethmoidectomy and dissection of the FSOT cells, is associated with reduced incidence of recurrence but increased incidence of mucoceles; this can be reduced by preserving the horizontal portion of the basal lamella and the lateral insertion to the palatine bone [61]. Adhesions Adhesions post-FESS can cause nasal obstruction and recurrence of CRS, requiring revision FESS. Instillation of topical hyaluronic acid with hydroxyethyl starch or
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