Transcript Endoscopic Sinus Surgery

ENDOSCOPIC SINUS SURGERY
Section 6 (‫)قسمت ششم فایل‬
Bakhshaee M, MD
Rhinologist, Assistant Prof. MUMS
Frontosphenoethmoidectomy
Frontosphenoethmoidectomy
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This includes an anterior ethmoidectomy, posterior
ethmoidectomy, sphenoid sinusotomy along with
opening the frontal recess
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This is mainly reserved for those with persistent
symptoms after anterior ethmoid surgery.
In patients with severe recurrent polyposis, the best
way to provide the patient with a longer symptomfree interval is to open up all the cells including the
frontal recess
Sphenoid Sinusotomy (I, II, III)
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Sphenoid sinusotomy I: Identifying the sphenoid ostium
without further instrumentation.
Sphenoid sinusotomy II: Opening the sphenoid
inferiorly to half its height and upward to the skull
base.
Sphenoid sinusotomy III: The sphenoid sinusotomy is
extended to the floor of the sinus and laterally to the
vital structures
Indications
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2.
3.
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5.
Isolated sphenoid sinus disease, e.g.,
Aspergillosis
Purulent bacterial infection
Inverted papilloma
Mucocele
Biopsy of skull base lesions
Surgical Technique
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The sphenoid ostium can be found at the level of the
superior turbinate. It is often necessary to lateralize
the middle and superior turbinate in order to
visualize it
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If visibility is poor because of polyps or bleeding,
the sphenoid sinus can safely be approached by
staying close to the septum in the midline and
palpating with the straight sucker up the posterior
wall of the sphenoid
At 1−1.5 cm above the posterior choana, the bone
of the anterior wall of the sphenoid sinus is thin and
it can be punctured by applying moderate pressure
with a straight sucker
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It is advisable not to open the sphenoid ostium
downward to a level lower than half the total height
of the sinus, as a branch of the sphenopalatine
artery runs along its anterior wall and if cut this can
bleed briskly.
Occasionally, the intersinus septum of the sphenoid
is so oblique that one side can be very small.
Comment on the Management of the
Middle and Superior Turbinates
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By preserving “all” the mucosa in the olfactory area on
the septum and the turbinates, as well as opening the
olfactory cleft.
It is difficult to resist the temptation to remove or debulk
polyps medial to the middle turbinate, but it is best to
preserve this mucosa.
A course of preoperative steroids will help reduce the
size of the polyps.
Only remove polyps that come from the posterior
ethmoid cells under the superior turbinate and not
polyps that are based on the septum or the middle
turbinate.
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If there is a concha bullosa, the lateral half of the
turbinate can be resected.
This can be done by incising the anterior surface
with a sickle knife and then removing the lateral
portion by cutting it free with microscissors or with
straight through-cutting forceps
The Endoscopic Tour
Step 1
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involves advancing the endoscope along the inferior
meatus
Step 2
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involves coming forward a little and angling the
endoscope upward to see the sphenoethmoid
recess area
Step 3
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is accomplished by gently rolling the endoscope
under the middle turbinate to see whether mucopus
is tracking under the ethmoid bulla from the
maxillary sinus
Anatomical Variations
Agger Nasi Air Cells
Concha Bullosa
Paradoxical Middle Turbinate
Bifid Middle Turbinate
Polypoidal Anterior End of the Middle
Turbinate
Paradoxical Uncinate Process
Pneumatized Uncinate Process
Accessory Ostium of the Maxillary Sinus
An Atlas of Specific Conditions
Allergy
Hypertrophied inferior turbinate
Edematous middle turbinate
Infection
Bacterial rhinosinusitis
Aspergillosis
Inflammatory Diseases
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Pyogenic granuloma
Wegener granulomatosis
Sarcoidosis
Benign Tumors
Antrochoanal polyp
Inverted papilloma
Benign Tumors
Chondroma
Angiofibroma
Malignant Tumors
Olfactory neuroblastoma
Lymphoma
Malignant Tumors
Amelanotic melanoma
Adenocarcinoma
Hereditary hemorrhagic telangiectasia
The Place of Radiology
The Role of Conventional Radiology
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Plain radiographs have a limited role in the modern
management of paranasal sinus disease because
they have so many false-positive and false-negative
findings
In acute maxillary or frontal sinusitis, they can help
confirm the diagnosis
The Role of Computed Tomography
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This provides a map for endoscopic sinus surgery
Although CT has good sensitivity for diagnosing
paranasal sinus disease, it has poor specificity; for
example, there are many false-positive changes.
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Important not to request a CT scan in the initial
management if patients unless there are specific
reasons to do so.
These include:
Suspected intracranial or intraorbital involvement as
a complication of rhinosinusitis
Suspected atypical infection or malignancy
Specific pathology, e.g., mucoceles, benign tumors of
the paranasal sinuses, where the extent of the lesion
Needs to be defined Prior to orbital or optic nerve
decompression
When to Request CT
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CT for rhinosinusitis is best reserved for patients who
have not responded to maximum medical treatment
CT Parameters
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Axial sections with coronal reconstruction will
remove any dental artifacts; these can be excluded
because they lie in the axial plane, and this
produces better images with less artifact
Sagittal reconstructions
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Helpful for frontal surgery, giving the surgeon a
better understanding of the complex relationship
between the anterior ethmoid sinuses and the
frontal recess
Intravenous contrast
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is only required for tumors, vascular lesions, and the
orbital and intracranial complications of infection
Indications for MRI
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The prevalence of incidental changes on MRI is so
great that the technique is of little use in the
diagnosis of rhinosinusitis
This is particularly helpful in defining the
boundary of pathology in relation to the dura,
orbital apex, or optic nerve.
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A comparison between a T2-weighted image (fluid
bright), a T1-weighted image (fluid dark), and a
T1-weighted image with nonionic contrast provides
useful information about soft-tissue lesions
MRI is complementary to CT
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Where malignancy has reached the dura of the
anterior skull base, the orbital apex, and the optic
nerve
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If there is intracranial or intraorbital involvement
from an atypical infection or inflammatory process
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In vascular tumors like a juvenile angiofibroma.
internal carotid artery aneurysm
Meningocele
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In congenital midline lesions such as meningocele,
meningoencephalocele, or sinonasal glioma