Problems And Complications Of Pess

For most sinus surgeons, the scope of PESS has been reduced sufficiently that it is now a relatively safe and well-tolerated procedure. Some concerns remain. Most importantly, the surgery may not achieve the expected results. For example, we have seen many children who have undergone one or more sinus surgeries with a period of improvement, only to exhibit similar radiographic and clinical findings again, and to become surgical candidates once again. In these cases, what are the goals of surgery in a patient who continues to have episodic pansinusitis whose sinus ostia are already widely patent?

The true incidence of nasal synechiae or other abnormal intranasal scars is unknown but is undoubtedly underreported. Most of the pediatric intranasal synechiae that we have seen have not been reported to the family by the operating surgeon. An occasional case of PESS becomes markedly dysfunctional. This patient, who initially may have had relatively limited OMC mucosal disease during an episodic case of rhinosinusitis develops chronic staphylococcal, pseudomonal, or fungal sinusitis and osteitis after PESS, with years of symptomatology, intravenous antibiotics (usually unsuccessful), and multiple operations. There may be important functional and protective reasons that sinus ostia developed in such anatomically protected locations. Most of us caring for a significant number of sinus surgery cases note the creation of a small number of "sinus cripples." They exist in two varieties. The first type is the patient with the unrelenting opportunistic infection in a sinus that has been operated on, as described above. The second type, seen in patients or their families, reflects a reinforced obsession about the sinonasal symptoms, CT scans, or various treatments. We have to wonder how many of those cases could have been avoided by a more balanced and conservative management.

The impact of PESS on facial growth has received a fair amount of attention since Maier and colleagues reported that intranasal surgery on piglets interfered with growth of the midface.21 Abnormal growth, particularly midface hypoplasia, has been reported anecdotally in children.22, 24 The significance of this problem has been downplayed by some surgeons, noting that facial growth in piglets was much greater than in humans over the period of infancy to adulthood, and therefore, the impact on cosmesis was significantly less in humans. Although the alterations in facial growth may not be obvious to the casual observer in most cases, alterations in maxillary growth will probably impact dental occlusion—a problem that has not been investigated.

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