Transcript Document
Surgical Treatment of Sinusitis Dr. Vishal Sharma Maxillary Sinusitis Surgical Treatment Methods: 1. Antral Washout 2. Intra-nasal Inferior meatal antrostomy (INA) 3. Caldwell - Luc surgery 4. Middle meatal antrostomy 5. Functional Endoscopic Sinus Surgery (FESS) Antral Washout (proof puncture, antral lavage) Indications Diagnosis & treatment of chronic maxillary sinusitis not responding to conservative medications Cytology/culture sensitivity of antral contents Contraindications Age < 3 yrs Hypoplastic maxilla with thick bony walls Acute maxillary sinusitis untreated by antibiotics Trauma to maxillary sinus or Fracture of orbital floor Drainage of maxillary antral hematoma Tilley Lichwitz Antrum Puncture Trocar & Cannula Higginson Syringe Trocar directed towards I/L tragus Hole made 1.25 cm behind anterior end of inferior turbinate Antral irrigation Anesthesia: L.A. for adults. G.A. for children & uncooperative pt. Position: Sitting / supine. Technique: Puncture lateral wall of inferior meatus with Tilley-Litchwitz antral trocar & cannula, just anterior to turbinate genu, trocar directed towards tragus of ipsilateral ear, with gentle boring action. Advance till it hits posterior wall, then withdraw slightly. Remove trocar & wash sinus with saline at 370 C with pt leaning forwards & saying k k. Wash till clear fluid comes. Remove cannula. Complications 1. Hemorrhage ( Lateral Sphenopalatine artery) 2. Pain & swelling of cheek (breach of anterior wall) 3. Orbital damage (perforation of orbital floor) 4. Perforation of posterior wall (maxillary artery injury) 5. Vasovagal attack 6. Fatal air embolism Intranasal antrostomy (INA) • Region of antral puncture in inferior meatus perforated with Tilley's antral harpoon. • Antrostomy enlarged with Tilley's antral burr or Myle’s nasoantral perforator. Caldwell – Luc Surgery George Caldwell, 1893, New York Henri Luc, 1897, Paris Indications Chronic refractory maxillary sinusitis Oro-antral fistula closure Foreign body removal from maxillary antrum Fungal maxillary sinusitis Elevation of orbital floor fractures Ethmoidectomy (trans-antral) Biopsy of suspicious neoplasm of maxillary antrum Orbital floor decompression Antrochoanal polyp (recurrent) Route to pterygo-palatine fossa (Vidian nerve, Max Artery) Dental / dentigerous cyst (maxillary antrum) removal Exposure of incision site Incision 4 cm long, sub-labial, horizontal incision made 3 mm above & parallel to the gingival margin, from lateral incisor to 2nd molar tooth. Incision deepened till periosteum Anterior wall broken with osteotome Hole made in anterior wall Suction of maxillary sinus Inferior meatal antrostomy Packing of maxillary sinus Packing of sinus & nose Incision closed Complications Facial: Cheek edema, ecchymosis, subcutaneous emphysema, infraorbital n. paresthesia Orbital: Hematoma, extraocular muscle trauma, diplopia, globe trauma, blindness Oral: Trauma to teeth roots, Superior alveolar nerve damage, Dental anesthesia, Oroantral fistula Vascular: Internal maxillary artery injury Ethmoid Sinusitis Surgical Treatment Methods: 1. Intra-nasal microscopic ethmoidectomy 2. Extra-nasal Ethmoidectomy a. Lynch Howarth procedure b. Patterson trans-orbital procedure c. Trans-antral (Jansen Horgan procedure) 3. Functional Endoscopic Sinus Surgery Lynch Howarth ethmoidectomy Patterson ethmoidectomy Trans-antral ethmoidectomy • Caldwell – Luc surgery done to reach maxillary antrum • Ethmoid cells approached via postero-supero- medial angle of maxillary antrum Frontal Sinusitis Surgical Treatment Methods: 1. Trephination of frontal sinus 2. Modified Lothrop procedure 3. Osteoplastic Flap surgery 4. Functional Endoscopic Sinus Surgery Frontal sinus trephination Frontal sinus trephination 2-cm incision made 1 cm below medial end of eyebrow & deepened up to bone. Frontal sinus floor opened by drilling with burr. Opening enlarged with Citelli’s punch forceps to drain pus. Drainage tube inserted inside frontal sinus cavity & sutured in place. Regular lavage of the frontal sinus done through drainage tube for 48-72 hours post-operatively. Frontal sinus trephination Osteoplastic flap procedure Osteoplastic flap procedure Lothrop Procedure Removal of frontal sinus (inferior septum + floor) + superior part of nasal septum Lothrop Procedure Sphenoid sinus Surgical Treatment Methods: 1. Trans-nasal trans-septal approach 2. Sublabial trans-septal approach 3. External ethmoidectomy approach 4. Endoscopic intra-nasal approach 5. Functional Endoscopic Sinus Surgery Sublabial trans-septal approach External ethmoidectomy approach Endoscopic approach Functional Endoscopic Sinus Surgery F.E.S.S. Anatomy of lateral wall Steps of F.E.S.S. 1. Uncinectomy (Infundibulotomy) 2. Anterior ethmoidectomy 3. Middle meatal antrostomy 4. Perforation of basal lamella 5. Posterior ethmoidectomy 6. Sphenoid sinus exploration 7. Skull base disease clearance 8. Frontal recess exploration Steps of F.E.S.S. Left nasal cavity Left middle meatus Left middle meatus Incision on uncinate process Incision completed Uncinate process removed Opening of bulla ethmoidalis Bulla ethmoidalis removed Natural & accessory ostia exposed Middle meatal antrostomy done Opening made on basal lamella Basal lamella removed Posterior ethmoidectomy done Anterior sphenoid sinus wall Interior of sphenoid sinus Skull base clearance done Frontal recess opened Final FESS cavity Surgical Navigation Complications Major (1%) Major epistaxis Orbital hematoma Diplopia Blindness or ed visual acuity Internal carotid injury Intracranial hemorrhage CSF leak / Meningitis Pneumocephalus Anosmia Nasolacrimal duct trauma Minor (7%) Minor epistaxis Hyposmia Adhesions (synechiae) Headache Periorbital echhymosis Periorbital hematoma Dental / facial pain Thank You