Interpretation of the dilated pupil during endoscopic sinus surgery

Pharmacological pupil dilatation after sinus surgery

Orbital complications after endoscopic sinus surgery are serious problems. Inadvertent contamination of the eye by pharmacological solution can lead to early postoperative anxiety to patients and high concern to surgeons. This is a rare case report of retrograde epinephrine flow through lacrimal duct in sinus surgery with learning tips during postoperative assessment for reassurance in temporary pharmacological effect rather than serious complication.

Complications in Sinus Surgery and New Classification Proposal

Complication overviews may lead to measures directed toward quality improvement and to better information for patients. When evaluating the rhinological literature from 1979 to 1999, a detailed comparison could not be made because of differences in reporting. With the advent of electronically stored medical data, events can be registered better than before. To be able to compile very diverse data from electronic dossiers into concise overviews for feedback, a simple general scale with broad categories is needed. These feedback overviews enable insight in the complication rates of different kinds of sinus surgery and monitoring of changing trends in sinus surgery. An example of a general classification based on severity is presented for use when electronically storing medical data. This scale varies from adverse events (grade A) to death (grade D). A consensus on categorization of complications is a prerequisite for a valid comparison with other clinics. To instigate a discussion about consensus, this classification is presented as an example. Our proposal is presented together with an overview of sinus surgery complications in recent literature for reference.

Case report: unilateral mydriasis following nasal cautery

We report a case of unilateral mydriasis following nasal electrocautery presumed to be the result of retrograde flow of adrenaline and/or xylometazoline hydrochloride (Otrivine) through the nasolacrimal duct into the eye. We review the literature and highlight the importance of correct interpretation of finding a dilated pupil post-operatively. To our knowledge. we report the first such case involving xylometazoline hydrochloride and also following nasal electrocautery. Unilateral mydriasis is alarming after nasal surgery but must be interpreted with caution. During minimally invasive procedures it is likely to be due to the effects of topical medication to the nose rather than surgical trauma.

Extended applications of endoscopic sinus surgery and its reference to cranial base and pituitary fossa

Sinus surgery has the potential of allowing ENT surgeons to encroach the boundaries of our colleagues in ophthalmology and neurosurgery. The advent of nasal endoscope and lately powered instrumentation and computer-assisted navigational systems has avoided the use of the conventional and more radical approaches by the ENT surgeon for the treatment of inflammatory pathology or tumors of the orbit and skull base. As rhinologists have gained more experience in endoscopic surgery, more areas related to the orbit and the anterior skull base are accessible and surgery is safer.

Intraoperative dilated pupil during nasal polypectomy

In endoscopic sinus surgery, it is often desirable to prepare the nasal mucosa with a nasal decongestant to minimise blood loss and enhance the operative field during surgery. A widely used commercially available preparation for such a purpose is a solution containing 5% Lidocaine Hydrochloride and 0.5% Phenylepherine Hydrochloride. We report a case of a unilateral dilated pupil occurring during nasal polypectomy. A dilated pupil during sinus surgery is associated with an intraorbital injury but many commonly used nasal decongestive agents can also cause mydriasis and this knowledge may prevent some anxiety for the unwary ENT surgeon undertaking sinonasal surgery.

Pupil size and reaction during functional endoscopic sinus surgery (FESS)

This aim of this study was to evaluate the size and light reflex of the pupils during endoscopic sinus surgery (FESS). Pupil size and light reflexes were recorded prospectively in 20 patients undergoing FESS under general anaesthesia. Nasal mucosal vasoconstriction was induced by Moffett's solution. A control group of 20 patients underwent other standard ENT operations under general anaesthesia. Myosis occurred in all 40 patients after induction of general anaesthesia. During surgery, the light reflex was negative for all 40 patients. However, the light reflex became positive in 22 patients within 5 min of surgery, and in all patients after 20 min. Monitoring pupillary size and reflexes during FESS as a means of assessing trauma to the orbital structures is difficult because of the presence of myosis induced by anaesthetic agents. Moffett's solution did not have a mydriatic effect from the systemic absorption of cocaine during the operative period.

Dilated pupil during endoscopic sinus surgery: what does it mean?

Endoscopic sinus surgery has become the standard of care for the surgical management of chronic sinus disease. Sinus disease and its surgical treatment carry the risk of orbital complications, irrespective of the approach. Orbital complications associated with sinus surgery include nasolacrimal duct damage, extraocular muscle injury, intraorbital hemorrhage/emphysema, and direct optic nerve damage, resulting in blindness. The finding of an unequal pupil at the end of a procedure would be a cause of considerable concern, but it is most likely due to the topical contamination of the eye with a mydriatic pharmacological agent commonly used in endoscopic sinus surgery.