Safety of endoscopic sinus surgery in a residency training program.Abstract
Over the past decade, endoscopic en·do·scope
An instrument for examining visually the interior of a bodily canal or a hollow organ such as the colon, bladder, or stomach.
en sinus surgery has become one of the most frequently performed operations in otolaryngology. Nevertheless, concerns have been raised about the safety of this procedure in a residency training program. To address this issue, we carried out a retrospective review retrospective review,
a posttreatment assessment of services on a case-by-case or aggregate basis after the services have been performed. to assess the complications of endoscopic sinus surgery performed by otolaryngology residents under close supervision. We reviewed the medical records of 597 patients who had undergone 719 operations performed by residents in the Department of Otolaryngology--Head and Neck Surgery at the University of Southern California--Los Angeles County Medical Center and at the University Hospital between June 1988 and December 1995. Most of these procedures were performed by junior residents under the supervision of either a senior resident or faculty member.
We found that the incidence of minor and major complications was 12.2 and 0.4%, respectively. The most common minor complications were vascular. The only major complication was excessive bleeding that required transfusion. There were no cases of blindness, cerebrospinal fluid rhinorrhea cerebrospinal fluid rhinorrhea
A discharge of cerebrospinal fluid from the nose. , or death. We conclude that endoscopic sinus surgery in an otolaryngology residency training program is a relatively safe procedure, especially when performed under faculty supervision.
The bulk of the current literature on endoscopic sinus surgery (ESS) has focused on the results of operations performed by experienced surgeons. [1-8] These reports indicate that ESS is a safe and effective procedure for the treatment of chronic sinusitis chronic sinusitis Chronic sinus infection ENT Inflammation of the sinuses that empty into the nasal cavity Etiology Allergic rhinitis, nasal obstruction, deviated nasal septum, tooth abscesses, URIs . There have been only two reports dealing with the safety of ESS in a residency training program. [9,10] In both of these papers, the surgeries were performed by senior residents under faculty supervision.
As ESS becomes more commonplace, there is pressure to provide residents with more experience with this procedure by having them perform the surgery at an earlier level of training. At the University of Southern California The U.S. News & World Report ranked USC 27th among all universities in the United States in its 2008 ranking of "America's Best Colleges", also designating it as one of the "most selective universities" for admitting 8,634 of the almost 34,000 who applied for freshman admission , residents begin performing ESS during postgraduate year (PGY PGY Post Graduate Year
PGY Planar Generalized Yee (algorithm) ) 2. Our study was undertaken to identify the complications of ESS in a teaching environment in which residents at all levels participate in the surgery, with supervision carried out by both senior residents and faculty.
Materials and methods
Between June 1988 and December 1995, 219 patients underwent ESS at the University Hospital (UH) and 378 patients at the Los Angeles County--University of Southern California Medical Center (MC). ESS was performed more than once on 107 patients, resulting in a total of 719 cases on 1,243 sides (table 1). Charts were reviewed to determine the relevant medical history, preoperative pre·op·er·a·tive
Preceding a surgical operation.
preceding an operation.
the preparation of a patient before operation. symptoms, previous treatments, physical examination findings, radiographic radiographic (rā´dēōgraf´ik),
adj relating to the process of radiography, the finished product, or its use. results, types of procedures performed, intraoperative findings, and complications, if any. All ESS was performed under general anesthesia Anesthesia, General Definition
General anesthesia is the induction of a state of unconsciousness with the absence of pain sensation over the entire body, through the administration of anesthetic drugs. as described elsewhere. 
Complications were classified as either major or minor. Major complications were defined as those that resulted in serious or permanent harm to the patient or those that would have caused such harm if they had not been treated. All other complications were categorized as minor.
Statistical analysis was performed with either the [X.sup.2] test or, when the cell frequencies were less than 5.0, Fisher's exact test Fisher's exact test
a statistical test for association in a two-by-two table based on the exact hypergeometric distribution of the frequencies within the table. . Comparison of the means was carried out using the student's t test (two-tailed; type I error: p[less than]0.05).
Residents at all levels performed ESS in this study (table 2); those in PGY 4 had the largest share (41%). Every case performed by a PGY 4 was supervised by a faculty member. More procedures were performed at the MC than at the UH (table 3).
There were 88 minor complications and3 major complications (table 4). The most common (n=47) were vascular (45 minor, 2 major). Others included synechia formation (28 minor), orbit-related complications (11 minor, 1 major), and miscellaneous complications (4 minor).
Bleeding. Bleeding was controlled in nearly all cases (table 5). Excessive intraoperative bleeding ([greater than]400 ml) occurred in 25 cases (mean blood loss: 641 ml); 19 of these (76%) occurred in patients with polyposis polyposis /pol·yp·osis/ (pol?i-po´sis) the formation of numerous polyps.
familial polyposis , familial adenomatous polyposis . Generalized oozing oozing
exudation of fluid. was encountered in all cases. Most patients were admitted overnight for observation, and all of them were sent home the next day without any sequelae sequelae Clinical medicine The consequences of a particular condition or therapeutic intervention .
Fourteen patients were packed anteriorly for bleeding in the peri- or postoperative period. Packing was performed in the postanesthesia recovery room in 12 of these cases. One patient bled on postoperative day 1, and another bled on postoperative day 5 after taking a warm shower. The average intraoperative blood loss in these 14 cases was 163 ml.
Six procedures were terminated prematurely because of excessive bleeding. All of these patients had diffuse polyposis and had never been operated on before. The average blood loss in these cases was 492 ml. Four of these 6 patients returned for revision surgery; the mean blood loss during the second procedure was 176 ml.
Major complications occurred in 2 patients who were pancytopenic from hematologic disorders hematologic disorders,
n.pl the diseases of the blood and blood-forming tissues. . Both required transfusion during emergency ESS for invasive fungal sinusitis sinusitis
Inflammation of the sinuses. Acute sinusitis, usually due to infections such as the common cold, causes localized pain and tenderness, nasal obstruction and discharge, and malaise. .
Synechiae. There were 28 cases of synechiae among the 719 cases. Eleven were mostly asymptomatic, while the other 17 were judged to have contributed significantly to the recurrence of sinusitis. Nineteen of these synechiae occurred in 411 cases of primary ESS (4.6%), and 9 occurred in 308 revision cases (2.9%). The most common location of scar formation was between the middle turbinate turbinate /tur·bi·nate/ (-nat)
1. shaped like a top.
2. any of the nasal conchae.
tur·bi·nate or tur·bi·nat·ed
1. Shaped like a top.
2. and the lateral nasal wall (n=18; 64%).
Synechiae developed in 4 of 68 patients (5.9%) in whom a partial middle turbinectomy was performed and in 24 of 651 cases (3.7%) in which the middle turbinate was left intact. The difference was not statistically significant (p=0.33).
Other complications. Three patients experienced violations of the lamina papyracea without any other sequelae. In 3 other cases, orbital fat was encountered. Orbital ecchymosis ECCHYMOSIS, med. jur. Blackness. It is an extravasation of blood by rupture of capillary vessels, and hence it follows contusion; but it may exist, as in cases of scurvy, and other morbid conditions, without the latter. Ryan's Med. Jur. 172. and subcutaneous air developed in 3 and 2 other cases, respectively. All of these 5 symptomatic patients experienced a resolution of their symptoms in 5 to 7 days.
Orbital abscess abscess, localized inflamation associated with tissue necrosis. Abscesses are characterized by inflamation, which is due to the accumulation of pus in the local tissues, and often painful swelling. developed in patient. This patient had undergone ESS 4 years earlier and had been referred for further treatment of recurrent polyposis. On preoperative computed tomography Computed tomography (CT scan)
X rays are aimed at slices of the body (by rotating equipment) and results are assembled with a computer to give a three-dimensional picture of a structure. , he was found to have severe polyposis with a defect in the right lamina papyracea. Postoperatively, this patient developed a right-sided orbital abscess, which resolved on intravenous antibiotics and drainage.
Anesthesia-related complications occurred in 2 cases. One patient developed brief hypotension hypotension
or low blood pressure
Condition in which blood pressure is abnormally low. It may result from reduced blood volume (e.g., from heavy bleeding or plasma loss after severe burns) or increased blood-vessel capacity (e.g., in syncope). during surgery as a result of an overzealous administration of anesthetic. The other patient experienced tachycardia tachycardia: see arrhythmia.
Heart rate over 100 (as high as 240) beats per minute. When it is a normal response to exercise or stress, it is no danger to healthy people, but when it originates elsewhere, it is an arrhythmia. and ST-segment depression during the administration of supplemental local anesthesia Anesthesia, Local Definition
Local or regional anesthesia involves the injection or application of an anesthetic drug to a specific area of the body, as opposed to the entire body and brain as occurs during general anesthesia. . Twelve-lead electrocardiography electrocardiography (ĭlĕk'trōkärdēŏg`rəfē), science of recording and interpreting the electrical activity that precedes and is a measure of the action of heart muscles. performed in the postanesthesia recovery room showed ST changes in the inferolateral leads; myocardial infarction myocardial infarction: see under infarction. was ruled out by serial creatine kinase creatine kinase /cre·a·tine ki·nase/ (ki´nas) an enzyme that catalyzes the phosphorylation of creatine by ATP to form phosphocreatine. measurements.
One patient experienced a seizure during extubation following combined external and endoscopic repair of a traumatic cerebrospinal fluid rhinorrhea. The seizure resolved after phenytoin sodium phenytoin sodium (diphenylhydantoin sodium)
Dilantin Kapseals, Diphenylan (CA), Epanutin (UK), Phenytek (CA)
Pharmacologic class: Hydantoin derivative
Therapeutic class: Anticonvulsant
One asthmatic patient experienced an exacerbation of his disease, which required respiratory therapy respiratory therapy
Medical profession concerned with assisting the respiratory function of individuals who have severe lung disorders. Practices include suctioning to clear secretions from the airway, use of aerosol mists (sometimes medicated) or gases to ease breathing, and intravenous steroids. He was admitted for overnight observation and was discharged the next day in good condition.
There were no incidents of internal carotid artery carotid artery
1. An artery that originates on the right from the brachiocephalic artery and on the left from the aortic arch, runs upward into the neck and divides opposite the upper border of the thyroid cartilage, with the external and injury, orbital hematoma hematoma /he·ma·to·ma/ (he?mah-to´mah) a localized collection of extravasated blood, usually clotted, in an organ, space, or tissue. , blindness, diplopia diplopia /di·plo·pia/ (di-plo´pe-ah) the perception of two images of a single object.
binocular diplopia , epiphora epiphora /epiph·o·ra/ (e-pif´or-ah) [Gr.] overflow of tears due to obstruction of lacrimal duct.
n. , cerebrospinal fluid rhinorrhea, pneumocephalus, brain injury, brain abscess Brain Abscess Definition
Brain abscess is a bacterial infection within the brain.
The brain is usually well insulated from infection by bacteria, protected by the skull, the meninges (tissue layers surrounding the brain), , meningitis, or death in this series.
Complication rates by each PGY class are shown in table 6. The only complication attributed to a faculty surgeon was 1 case of synechia formation. The 3 major complications were attributed to 1 resident in each of PGY 2, 3, and 4.
Of the 344 operations supervised by a faculty member, complications occurred in 32 (9.3%). When a senior resident was the supervising surgeon, the complication rate was 15.7% (59/375). The difference between the two complication rates was statistically significant (p=0.0l).
We determined the rates of complication in 719 cases of endoscopic sinus surgery performed over a period of 7.5 years. Allergy played a prominent contributory role in these patients' sinus pathology, as approximately one-third of them reported a history of atopy atopy /at·o·py/ (at´ah-pe) a genetic predisposition toward the development of immediate hypersensitivity reactions against common environmental antigens (atopic allergy), most commonly manifested as allergic rhinitis but also as . All patients had been treated extensively with various combinations of nasal steroid sprays, antibiotics, oral decongestants Decongestants Definition
Decongestants are medicines used to relieve nasal congestion (stuffy nose).
A congested or stuffy nose is a common symptom of colds and allergies. , and antihistamines Antihistamines Definition
Antihistamines are drugs that block the action of histamine (a compound released in allergic inflammatory reactions) at the H1 .
At our institution, ESS is performed by residents at all levels. Junior residents initially observe operations performed by faculty surgeons and senior residents, and they are given a greater role in the operating room operating room
n. Abbr. OR
A room equipped for performing surgical operations. as they gain more experience. PGY 4 residents perform most of the ESS cases at the UH under the close supervision of the senior author. Patients at the MC have their ESS done by the other 3 classes, and most of them (91%) were performed under the supervision of senior residents. All surgeries were performed with 4-mm Storz 0[degrees], 30[degrees], or 70[degrees] rigid endoscope endoscope, any instrument used to look inside the body. Usually consisting of a fiber-optic tube attached to a viewing device, endoscopes are used to explore and biopsy such areas as the colon and the bronchi of the lungs. attached to a beam splitter, camera, and video monitor. This system allows the assistant to constantly monitor the technique and progress of the primary surgeon.
Of the 306 cases that were performed at the UH, 216 (71%) were revision surgeries. This figure is significantly higher (p[less than]0.001) than the 22% rate of revision surgeries (92/413) performed at the MC. Referral patterns are different at the two hospitals. At the UH, all patients were referred to the senior author by private physicians. A significant number of them had already undergone sinus surgery. The MC patients came from the indigent indigent 1) n. a person so poor and needy that he/she cannot provide the necessities of life (food, clothing, decent shelter) for himself/herself. 2) n. one without sufficient income to afford a lawyer for defense in a criminal case. population of the Los Angeles County. For many of them, their evaluation at the ENT ENT ears, nose, and throat (otorhinolaryngology).
ear, nose, and throat
ear, nose and throat.
ENT Ears, nose & throat; formally, otorhinolaryngology clinic was the first time they had been seen for their sinus disease--hence the higher number of primary cases there.
In the literature, the most common type of complication varies from paper to paper. In some reports, synechia formation was the most prevalent, [1-3,8,10] while in others it was either bleeding [4,7] or orbital complications [6,9] Vascular problems accounted for the highest number of complications (47) in this series. Recently, microdebriders of various styles have been introduced. These devices offer great promise in helping decrease blood loss in ESS patients who have polyposis. When bleeding impairs vision, it is our practice to stop the surgery. This was indeed done in 6 cases. Four of these patients returned and underwent uncomplicated revision surgery.
Even though 28 cases of synechiae were observed, only 17 of them (61%) were symptomatic. Most of the scarring was found during the first few postoperative visits. Most of these patients (79%) were lysed under local anesthesia, given a Telfa spacer, and did not experience a recurrence. As was the case in other published reports, the most common location of synechiae was between the middle turbinate and the lateral nasal well. [1,2,6-8,10]
The rates of complications of ESS in recently reported series are listed in table 7. We reclassified each complication as either major or minor in order to allow for a meaningful comparison among the findings of the various papers. In our series, the complication rates in cases supervised by senior residents (15.2% minor, 0.5% major) were consistent with those reported elsewhere in the literature. The comparison becomes more favorable when only cases that were staffed by faculty are analyzed (9% minor, 0.3% major). Our overall complication rates (12.2% minor, 0.4% major) are well within the average range reported to date, with no statistical difference found at the 5% level.
We have shown that ESS can be performed safely by residents under close supervision. As residents gain more experience with each advancement in PGY level, the complication rates can be expected to decrease. The low rates of complication are even more remarkable given the participation by junior residents and the supervisory role of senior residents at this institution. This report confirms the safety of endoscopic sinus surgery in the modem otolaryngology training program.
We thank Meilin Tsai and John Morrison for their valuable assistance with data preparation and statistical analysis, respectively.
From the Department of Otolaryngology--Head and Neck Surgery, University of Southern California School of Medicine, Los Angeles.
Reprint requests: Dale H. Rice, MD, Department of Otolaryngology--Head and Neck Surgery, LAC-USC Medical Center, 1200 North State St., Box 795, Los Angeles, CA 90033. Phone: (323) 226-7315; fax: (323) 226-2780.
(1.) Rice DH. Endoscopic sinus surgery: Results at 2-year followup. Otolaryngol Head Neck Surg 1989;101:476-9.
(2.) Schaefer SD, Manning S, Close LG. Endoscopic paranasal sinus par·a·na·sal sinus
Any of the paired cavities, designated frontal, sphenoidal, maxillary, and ethmoidal, located in the bones of the face and lined by a mucous membrane continuous with that of the nasal cavity. surgery: Indications and considerations. Laryngoscope 1989;99:1-5.
(3.) Stankiewicz, JA. Complications in endoscopic intranasal in·tra·na·sal
Within the nose. ethinoidectomy: An update. Laryngoscope 1989;99:686-90.
(4.) Levine HL. Functional endoscopic sinus surgery functional endoscopic sinus surgery Functional endonasal endoscopic sinus surgery ENT A procedure that removes diseased nasal cavity and paranasal sinus tissue and restores mucociliary clearance Applications Chronic and/or recurrent sinusitis in Pts who fail : Evaluation, surgery, and follow-up of 250 patients. Laryngoscope 1990;100:79-84.
(5.) Matthews BL, Smith LE, Jones R, et al. Endoscopic sinus surgery: Outcome in 155 cases. Otolaryngol Head Neck Surg 1991;104:244-6.
(6.) Vleming M, Middelweerd RJ, de Vries de Vries. For some persons thus named use Vries. N. Complications of endoscopic sinus surgery. Arch Otolaryngol Head Neck Surg 1992;118:617-23.
(7.) Smith LF, Brindley PC. Indications, evaluation, complications, and results of functional endoscopic sinus surgery in 200 patients. Otolaryngol Head Neck Surg 1993;108:688-96.
(8.) Lazar RH, Younis RT, Long TE. Functional endonasal sinus surgery in adults and children. Laryngoscope 1993;103:1-5.
(9.) Sterman BM, DeVore RA, Lavertu P, Levine HL. Endoscopic sinus surgery in a residency training program. Am J Rhinol 1990;4:207-10.
(10.) Ramadan HH, Allen GC. Complications of endoscopic sinus surgery in a residency training program. Laryngoscope 1995; 105:376-9
(11.) Rice DH, Schaefer SD. Endoscopic functional paranasal sinus surgery: Anterior-to-posterior approach. In: Rice DH, Schaefer SD, eds. Endoscopic Paranasal Sinus Surgery. 2nd ed. New York: Raven Press, 1993:159-86.
Patient and case profile UH [*] MC [+] Total Patients Age range (mean) 5-74 (43) 5-71 (38) Male/female 105/114 219/159 No. of patients 219 378 597 Cases Primary 90 321 411 Revision 216 92 308 Total no. of cases 306 413 719 (*.)University Hospital (+.)Los Angeles County Medical Center Number (%) of cases according to the level of the operating and supervising surgeons' experience Primary surgeon (n=719) PGY [*] 2 191 (27) PGY 3 160 (22) PGY 4 295 (41) PGY 5 66 (9) Attending 7 (1) Supervising surgeon (n=719) Chief resident 375 (52) Faculty member 344 (48) (*.)Postgraduate year Comparison of the frequency of various endoscopic and concurrent procedures at the two hospitals No. procedures (%) UH [*] MC [+] Total Primary procedures Anterior ethmoidectomy 126 (41) 223 (54) 349 (49) Total ethmoidectomy 66 (22) 128 (31) 194 (27) Maxillary antrostomy 147 (48) 294 (71) 441 (61) Concurrent procedures Frontal sinusotomy 110 (36) 65 (16) 175 (24) Sphenoidostomy 65 (21) 46 (11) 111 (15) Polypectomy 54 (18) 172 (42) 226 (31) Septoplasty 30 (10) 43 (10) 73 (10) Partial middle turbinectomy 32 (11) 36 (8.7) 68 (9.5) Partial inferior turbinectomy 11 (3.6) 32 (7.7) 43 (6.0) Caldwell-Luc procedure 5 (1.6) 21 (5.1) 26 (3.6) Others [ss] 12 (3.9) 32 (7.7) 44 (6.1)
(+.)Los Angeles County Medical Center
(ss.)External ethmoidectomy, frontal sinus trephination trephination /treph·i·na·tion/ (tref?i-na´shun) the operation of trephining.
Removal of a circular piece of bone, especially of the skull, by a trephine. , repair of cerebrospinal fluid rhinorrhea, endoscopic dacryocystorhinostomy, endoscopic orbital decompression
Number (%) of complications in 719 cases at the USC Medical Center Minor complications: n=88 (12.2) Vascular: n=45 Excessive intraoperative 25 bleeding Postoperative packing 14 required Surgery terminated 6 Synechiae: n=28 Mildly symptomatic 11 or asymptomatic Symptomatic 17 Orbital: n=11 Violation of lamina papyracea 3 Orbital fat exposure 3 Orbital ecchymosis 3 Orbital subcutaneous air 2 Diplopia; epiphora 0 Miscellaneous: n=4 Anesthesia-related 2 Seizure 1 Asthma exacerbation 1 COPD exacerbation; tooth 0 pain; toxic shock syndrome Major complications: n=3 (0.4) Vascular: n=2 Excessive bleeding 2 requiring transfusion Arterial injury; need for ligation 0 Orbital: n=1 Abscess 1 Hematoma; blindness 0 CNS; death: n=0 Estimated mean blood loss during various procedures at the two hospitals Mean/ UH [*] MC [+] total ESS only 46 ml 69 ml 58 ml n=127 n=129 n=256 ESS with 145 ml 179 ml 172 ml polypectomy n=41 n=140 n=181 ESS with procedures 105 ml 139 ml 124 ml other than polypectomy n=96 n=121 n=217 All cases 83 ml l30ml 111 ml n=264 n=390 n=654 (*.)University Hospital (+.)Los Angeles Country Medical Center Number (%) of complications according to the level of the primary surgeon's experience No. cases Minor Major Total PGY [*] 2 191 36 (19) 1 (0.5) 37 (19.4) PGY 3 160 21 (13) 1 (0.6) 22 (13.8) PGY 4 295 24 (8.1) 1 (0.3) 25 (8.5) PGY 5 66 6 (9.1) 0 6 (9.1) Attending 7 1 (14) 0 1 (14.3) Total 719 88 (12.2) 3 (0.4) 91 (12.6) (*.)Postgraduate year Comparison of complication rates in this study with those reported in other studies Pct. per total Pct. per total no. of patients no. of cases Minor Major Minor Major Rice  10.0 0.0 9.4 0.0 Schaefer et al  14.0 0.0 13.5 0.0 Stankiewicz  11.1 4.4 10.8 4.3 Levine  9.2 0.0 8.8 0.0 Matthews et al  13.5 0.0 12.2 0.0 Vleming et al  6.6 1.0 6.6 1.0 Smith & Brindley  8.0 0.5 7.6 0.5 Sterman et al  6.0 0.0 6.0 0.0 Ramadan & Allen  15.7 0.9 15.7 0.9 Mean 10.5 0.8 10.1 0.7 Nguyen et al (USC) 14.7 0.5 12.2 0.4 Difference p=0.22 [*] p=0.94 [*] p=0.52 [*] p=0.94 [*] (*.)Student's t test; no statistically significant difference at the 5% level.