Safety of endoscopic sinus surgery in a residency training program.

Abstract

Over the past decade, endoscopic 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 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, 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.

Introduction

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. 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, residents begin performing ESS during postgraduate year (PGY) 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 symptoms, previous treatments, physical examination findings, radiographic results, types of procedures performed, intraoperative findings, and complications, if any. All ESS was performed under general anesthesia as described elsewhere. [11]

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. Comparison of the means was carried out using the student's t test (two-tailed; type I error: p[less than]0.05).

Results

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. Generalized oozing 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.

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. Both required transfusion during emergency ESS for invasive fungal sinusitis.

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 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 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 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, 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 during surgery as a result of an overzealous administration of anesthetic. The other patient experienced tachycardia and ST-segment depression during the administration of supplemental local anesthesia. Twelve-lead electrocardiography performed in the postanesthesia recovery room showed ST changes in the inferolateral leads; myocardial infarction was ruled out by serial creatine kinase 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 was administered.

One asthmatic patient experienced an exacerbation of his disease, which required respiratory therapy 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 injury, orbital hematoma, blindness, diplopia, epiphora, cerebrospinal fluid rhinorrhea, pneumocephalus, brain injury, brain abscess, 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).

Discussion

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. All patients had been treated extensively with various combinations of nasal steroid sprays, antibiotics, oral decongestants, and antihistamines.

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 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 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 population of the Los Angeles County. For many of them, their evaluation at the ENT 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.

Acknowledgment

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: [phone]; fax: [phone].

References

(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 surgery: Indications and considerations. Laryngoscope 1989;99:1-5.

(3.) Stankiewicz, JA. Complications in endoscopic intranasal ethinoidectomy: An update. Laryngoscope 1989;99:686-90.

(4.) Levine HL. Functional endoscopic sinus surgery: 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 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)

(*.)University Hospital

(+.)Los Angeles County Medical Center

(ss.)External ethmoidectomy, frontal sinus trephination, 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 [1]                  10.0        0.0             9.4       0.0
Schaefer et al [2]        14.0        0.0            13.5       0.0
Stankiewicz [3]           11.1        4.4            10.8       4.3
Levine [4]                 9.2        0.0             8.8       0.0
Matthews et al [5]        13.5        0.0            12.2       0.0
Vleming et al [6]          6.6        1.0             6.6       1.0
Smith & Brindley [7]       8.0        0.5             7.6       0.5
Sterman et al [9]          6.0        0.0             6.0       0.0
Ramadan & Allen [10]      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.