Transcript Endoscopic Sinus Surgery

ENDOSCOPIC SINUS SURGERY
Bakhshaee M, MD
Rhinologist, Assistant Prof. MUMS
Course Plan
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Principles of Practice
Patient Selection
Optimizing Diagnosis, Medical Treatment, and Timing of Surgery
Goals of Surgery in Patients with Rhinosinusitis
Operative Procedures: A Step-by-Step Safe and Logical Approach
Endoscopic Examination, Anatomical Variations, and Specific Conditions
The Place of Radiology
Preoperative Checklist
Patient Consent and Information
Preventing and Dealing with Complications
Postoperative Management
Principles of Practice
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Accurate Diagnosis Is the Key to Success
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A good surgeon is also a good physician
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The best surgical results are often obtained by
optimizing medical treatment both preoperatively and
postoperatively.
Optimizing medical treatment before surgery makes it
less traumatic, reduces the chances of complications,
and helps preserve olfactory mucosa
Before Treatment
After Treatment
Mucosal Disease
The surgeon needs to have a good understanding of
mucosal disease
1.
Erythema
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Edema
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Hyperplastic mucosa
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Polyposis
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Granular mucosa
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Purulent secretion
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Dry mucosa
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Idiopathic rhinitis with erythema
Hyperplastic
mucosa due to allergic rhinitis
Severe hypertrophy with
edema
Polyposis in a nonatopic patient
Granular mucosa
Dry mucosa
Underlying pathology
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In the light of history and examination, along with
the relevant special investigations, the physician can
obtain an idea of the underlying pathology.
Normal middle meatus
Serous secretions in marked allergic
rhinitis
Purulent bacterial secretions
Purulent fungal
secretions
Pathology of rhinosinusitis
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Infectious
Viral
Bacterial (including TB, leprosy, syphilis, etc.)
Fungal
Noninfectious
Allergy [Seasonal (intermittent) Perennial (persistent)]
Idiopathic (no systemic evidence of allergy or local infection)
Rhinitis medicamentosa ( Excessive use of local sympathomimetic agents)
Hormonal ( High-estrogen contraceptive pill; pregnancy)
Autonomic
Sarcoidosis
Vasculitis (Wegener granulomatosis, systemic lupus erythematosis, overlap syndrome)
Drug induced
Focus on the Patient’s Main Complaint
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There are four primary symptoms that are always
worth asking about:
Nasal obstruction
Sense of smell
Secretions
Pain or pressure
The amount of secretions produced per day
Dealing with the Patient’s Expectations
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The patient’s priorities may differ from what the
surgeon can achieve.
For example, the patient’s main concern might be
their postnasal discharge, but the surgeon may only
be able to improve the symptoms of obstruction with
little alteration to the postnasal drip.
Optimize Medical Treatment
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Medical treatment
Will complement surgery in making the mucosa as
healthy as possible
Can be a useful predictor of what can be
achieved by surgery
Tailor the Surgery to Fit the Extent of the Problem
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There is a price to be paid for extensive tissue removal.
That price may include :
The loss of olfactory mucosa
Frontonasal stenosis
Altered sensation
Dryness
An increased risk of violating the boundaries of the
paranasal sinuses
Minimize Surgical Morbidity
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Morbidity can be caused by poor surgical
technique, but it can also arise from excessive tissue
removal.
Good surgical technique is based on setting explicit
goals and achieving these with the minimal amount
of tissue trauma
Overzealous removal
How Can This Be Achieved?
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You must decide which step needs to be done next
and then do this as less traumatically as possible.
This means:
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Punching tissue rather than tearing it
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Preserving mucosal integrity in the frontonasal
recess.
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Respecting olfactory mucosa
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Avoiding mucosal damage to adjacent surfaces
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Sense of Smell Should Be Preserved at All Costs
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Surgeons unfortunately often underestimate the
importance of sense of smell to the patients
The Importance of Postoperative Treatment
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Unfortunately, surgery on its own cannot achieve or
maintain healthy nasal mucosa in most patients with
noninfective rhinosinusitis.
Patients need to be made aware of the need for
continuing treatment in order to achieve the best
possible result and an improved quality of life