Navigating the orbital complications of endoscopic sinus surgery: a systematic review of 204,286 patients

Background: The association between endoscopic sinus surgery and orbital complications is a complex and multifaceted one. While the precise relationship between the two is not fully elucidated, there is increasing evidence indicating a significant correlation between endoscopic sinus surgery and orbital complications. Objectives: To comprehensively examine the orbital complications that can arise from endoscopic sinus surgery, including their incidence, etiology, clinical manifestations, management strategies, and outcomes. Methods: An extensive search was conducted across multiple relevant databases to identify studies meeting the established inclusion criteria. The databases examined included PubMed, MEDLINE, and Embase, and the following search terms were used: ("Endoscopic sinus surgery" OR "FESS" OR "ESS") AND ("Orbital complications" OR "Ocular injury" OR "Periorbital hemorrhage"). The search was limited to English-language publications from 2011 to 2023 and no restrictions were applied regarding study design during the search. Duplicate entries were removed, and the Rayyan QRCI tool was employed to streamline the selection and screening of studies. Due to heterogeneity in study designs, populations, and definitions of orbital complications among the included studies, a formal meta-analysis was not performed. Instead, a narrative synthesis was undertaken. The overall incidence of orbital complications was calculated by pooling the total number of reported complications across all included studies and dividing this by the total number of patients. Results: A total of eight studies, encompassing a combined population of 204,286 patients, were included in our final analysis. Of this population, 118,567 individuals (58%) were male. All patients underwent surgery for chronic rhinosinusitis. The reported orbital complication rates varied widely across studies, ranging from 0% in image-guided ESS to 27.6% in conventional ESS. Across the included studies, a total of 358 orbital complications were reported among 204,286 patients The most frequently reported orbital complications following sinus surgery were orbital injury, orbital hematoma, and orbital subcutaneous emphysema. Conclusion: ESS orbital complications are uncommon but have the potential to be dangerous. The available evidence suggests an association between the use of image-guided ESS and lower reported complication rates. Future prospective and randomized trials are required to determine the safest approach to ESS to avoid complications. Systematic Review Registration: Prospero CRD42024546806.