Transcript Contemporary indications for external approaches to

Caldwell-Luc,
External Ethmoidectomy,
Frontal Sinus Trephine,
Lynch Procedure,
Osteoplastic Frontal Sinus Surgery.
The Caldwell-luc procedure
 Radical antrostomy.
 Definition Entering the maxillary sinus through mouth through an
incision in buccal mucosa in canine region of maxilla
with removal of all diseased mucosa and formation of
antrostomy in inferior meatus.
History
 Christopher Heath Of University College in London
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1889:trephination of canine fossa.
1893: George Caldwell(1866-1946) –American surgeon-New
York medical journal-antrostomy.
1897 Henri Luc(1855-1925) –French laryngologist of Paris.
Luc - Europe
Caldwell – America.
Indications:
Chronic maxillary sinusitis:
 Intractable sinus infection:
irreversibly diseased epithelial lining of maxillary antrum1.
failure from conservative treatment:
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Incessant purulent discharge even with patent
transnasal antromeatal window.
 Repeated sinus infection:
conservative treatment+ to prevent chronicity,
involvement of adjoining sinuses or complications.
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Endoscopic surgery:
 Failure
 unapprochable sites
 revision of transnasal antromeatal window:
Failiure of transnasal operation to maintain antromeatal
fenestra.
Better visualization with wider fenestra-increased
patency.
 Maxillary sinusitis +bronchiectasis:
Presistent purulent drainage from antrum calls for
radical eradication.
antrochoanal polyp evulsion– recurrance-polyp excised at its wall of
maxillary antrum.
 oroantral fistula:
 Biopsy :
 maxillary antrum.
 Antrostomy prior to radiotherapy
cysts:
 Odontogenic cysts:
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Developmental – primodial,dentigerous cysts.
inflamatory-periodontal(radicular) cyst.
 Non specific cysts:
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Pseudocysts
Retention cysts & mucoceles
 Teratomatous cysts:
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Cholesteatomas
Dermoids.
 Mucocele:
 Open approach:
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ESS: accessible through middle meatus antrostomy
Away from natural ostium: post CL procedure.
Post traumatic extension of mucocele outside sinus through
anterior and lateral wall
 Mucous retention cyst:
 Signs of growth
 Bone erosion
 Obstructing drainage.
 Subtotal or total removal via ESS
 Recur /large to cause bony errosion then CL.
 Obtaining graft material:
 Lateral wall of maxillary sinus +lining
 Residual defect-unnoticed functionally+ cosmetically.
 Bone graft:
blow out fracture of orbit-lateral bony wall
 Composite graft:
periosteum+bone+mucosa(medium sized septal
perforation)
 Epithelial graft:
respiratory epithelium-mucoperiosteal grafts-nasal
septum,tracheal lumen.
Facial trauma
Foreign body:
displaced dental root, missile:
Blow out fracture of orbit:
 Fresh fractures-periorbital tissues reduced —antrum
packed/balloon placed.
 Delayed fracture-bone graft
Tripod fracture of the zygoma:
malar fracture-reduction +packing.
Fractures of maxillary tuberosity:
The American Academy Of Otolaryngology Head And Neck
Surgeryclinical indication for Caldwell-Luc :
Contemporary indications:
 Non physiological:
 Distorted ciliary physiology:
 Ciliary dyskinesia
 Cystic fibrosis
 Fungal mycetoma
 Antro choanal polyps
 Tumor: inverted papilloma
 Orbital decompression
 Intractible posterior epistaxis
 Endoscope inaccessibility.
 Mini Caldwell-Luc:
 Principle of operation:
 Antrum is opened—irreversibly damaged mucosa
removed—fresh opening into inferior meatus.
Technique:
 Incision 5 mm above GBS 3-5 cm long.Close to midline ----end of alveolar ridge laterally
 inferior orbital nerve.
Exposure:
 Superiorly infraorbital nerve: mid
pupillary line about 1cm below
infraorbital rim.
 antrostomy:
 5mm square marked by 4mm
osteotome Mucocele,extensive mucosal
disease,polyp,transantral
ethmoidectomy,tumor surgery,
orbital decompression-entire
anterior wall removed,nerve
encased by peninsula of bone.
Removal of pathologic material:
 Preservation of normal mucosa.
 Extensive disease-
intramucosal debridement:
periosteum preserved: oseitis
and bone thickening minimised.
 Recesses,loculi & septas,groove
between anterior and medial
wall.
Antrostomy
inferior vs middle meatus
 Sublabial approach.
 few mm above the floor
 midway between
anterior and posterior
 Intranasally also.
 Injury to ascending
palatine artery.
nasolacrimal duct
Middle meatus antrostomy:
 Begins at natural ostium.
 Incise and remove posterior fontanelle along the floor of orbit along the
top of inferior turbinate.
 Fontanelle pedicled on posterior wall of sinus-cut.
 Uncinectomy edges smoothened.
 Anterior part of trubinate removed:
Closure:
 Layered in anterior-to-posterior from medial to lateral.
 Hemostasis good -filled with antibiotic ointment only.
Modifications & alternate procedures:
 Osteoplastic flap:
 Anterior wall preserved and elevated as flap attached to
overlying periosteum.
 Minimizes trauma to infraorbital nerve
 Preserve sinus post surgery:prevents collapse of ant
wall+ingrowth of fibrous tissue due to large anterior wall
defect.
 contracture
 obliteration
 Submucosal flap eleveted
 Periosteal incision medially along pyriform aperture laterally along maxillary
buttress with central area left attached.
 Osteotomy –anterior surface of maxilla through inferior , medial & lateral
incision
 Superiorly fracture just below level of infraorbital nerve
Osteoplastic antrostomy-Feldmann et al.
 Anterior wall lid removed temporarily with fine keyhole saw.
 Lid replaced with sutures through small burr holes.
 Limitations:
 radical antrostomy-trauma, after Denker’s operation, malignant tumor.
Denker’s operation
 Extended radical antrostomy
 anterior bony supporting pillar as far as pyriform aperture removed.
 Access through antrum to nasopharynx. posterior part of nasal cavity
 Localized resection of tumor.
Landmarks and danger points
 Infraorbital nerve-point of exit and course in the floor of
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orbit.lack bony covering lying free within the antrum.
Root of canine and 1st molar, tooth buds of 2nd dentition
in children.
Sphenopalatine artery and its end branches.
Ostium of nasolacrimal duct.
Erroded Posterior wall of antrum-damage to maxillary
artery
Penetration through thin orbital roof –diplopia, damage to
orbital contents.
Typical mistakes
 Incision too downwards on alveolar crest-wound closure
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difficult.
Denture-as superiorly as possible.
Preservation of Frenulum of upper lip- b/l operation.
Excessive retraction of soft tissue-crushing of infraorbital
nerve in its foramen or hematoma of cheek.
First blow of chisel for opening anterior wall of antrum
parallel to inferior edge of orbit below edges of infraorbital
nerve to prevent fracture or entry to bony canal of nerve.
Excessive curettage around infraorbital canalneuralgia/injury.
Inferior meatus opened accidently if wall of nose bulges
laterally.
Complications
 Bleeding,Hematoma ,absecess
 Infraorbital nerve injury-9-46%
 Parasesthesia / hyposthesia
 Neuralgia—chronic pain syndrome.
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Superior alveolar nerve.
Massive secondary haemorrhage
Subcutaneous emphysema.
Globe injury/ orbital floor injury/extraoccular muscle injury.
Orbital hematoma/proptosis/blindness.
Foetid suppuration—FB
Osteomyelitis of maxilla.
Nasolacrimation duct injury
Injury to roots of teeth.
Vesibuar fistula.
Oroantral fistula
Frontal sinus trephine:
 Kuemmel-Beck frontal trephine
 Principle:
 Burr hole in anterior wall of frontal sinus
 Blunt cannula introduced into lumen of sinus.
• Indications
 Acute frontal sinusitis
 Diagnosis and function of ostium.
 Not responding within 48hrs of medical treatment.
 symptoms worsens/ complications.
 Early intracranial complications
Chronic sinusitis:
 Inspissated secretions
 unable to locate internal ostium
 Mucocele:
 Removal/Drain into sinus lumen or nasal cavity
 Inaccessible mucocele:
 Recess, lateral or superiorly.
 Loculation of frontal sinus
 Intrafrontal sinus cell
Contemporary indications
 Classical indication-acute sinusitis –quick,small well
camouflaged incision,preservation of normal sinus function
 Control acute infection before fat obliteration osteoplastic flap
 Acute frontal sinusitis: trephination vs. Endoscopic:
 Operative time
 Surgical skills
 Image guidance
 Risk of permanent scaring the frontal recess--revision
 Difficult endoscopic approach :
 Identify sinus-revision cases.
 Instillation of saline or catheter—sinus drainage tract.
Technique:
 Incision:
 Radiological confirmation of sinus.
 short curved inferomedial aspect of eyebrow
 Supraorbital foramen:inferior aspect of superior orbital
rim 1-2 cm lateral to nasion
Drilling & Closure:
Underside at jun of medial and superior orbital rims
0.5-1.5cm opening.
Modifications & alternative procedures:
 Frontal sinoscopy - rigid telescope
 Ogston’s frontal sinus operation:
 Unsuccessful Kuemmel-Beck’s in U/L sinusitis.
 Contralateral drainage :excision of interfrontal septum.
 Office procedure:
 Turkel bone biopsy needle.
Hints,Rules & mistakes:
 Radiographs in 2 planes prior to trephination.
 Exclusion of loculation.
 Lateral extension avoided
 Cosmetic eyebrow incision.
 Burr must be guarded
 Ostium & frontonasal duct-contrast.
 Osteomyelitis
Complications:
 Failiure to resolve infection.
 Relapse.
 Supraorbital & supratrochlear nerve injury.
 Hematoma
 Medial canthal injury.
 Orbital injury
 Intracranial injury: dura, frontal lobe
 Hypertrophic scar
External ethmoidectomy
 Ferris Smith in 1933 originally described.
 “External ethmoidectomy” distinguish transorbital approach to ethmoid labirynth
from transnasal appproach.
 Acute sinusitis:
Intranasal approach difficult due to severe mucosal reaction.
 Chronic sinusitis:
 Extensive : supraorbital ethmoid
 Recurrent:
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Anatomical distortion
Damaged orbital content
Require Extensive resection
 Orbital infection:
 Pyogenic infection of ethmiod labyrinth:Exclude intraorbital abcess .
 Subperiosteal abcess, orbital abcess: orbital decompression procedures.
 Mucormycosis :orbital exploration + exenteration.
 Mucocele with orbital extension.
 Complications of acute ethmnoid or frontal sinusitis:
 repair of CSF leak in cribriform ,fovea ethmoidalis, ethmoidal,
sphenoidal region
 Control of epistaxis
 Combined procedures:
 Sphenoidectomy
 Lynch frontal sinus operation
 Caldwell-Luc procedure
 Transethmoid hypophysectomy
 Dacrocystorhinostomy
 Access to to frontal,ethmoidal,sphenoidal sinus tumors
 Craniofacial resection
 Medial maxillectomies
Contemporary indications:
 Anterior ethmoidal artery ligation:
 Intractable epistaxis.
Inaccessible to interventional radiologist.
 Endoscopic approach:medial orbitalwall removal—orbital
collpase into ethmoid.
 Reduction of nasoethmoid complex fractures.
 Subperiosteal abcess & orbital abcess:
 Drainage of infected site into ethmoid cavity.
 Exenteration of acutely infected ethmoid cells.
 identification of abcess pocket in inflamed field.
 Cranial base tumor surgery:
 Bicornal flaps, facial translocation,external
ethmoidectomy.
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The American Academy Of Otolarygology And Head And Neck Surgery
For Ethmoidectomy:
 Preoperative consideration:
 Ophthalmological examination:
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Basic: VA, EOM, pupillary response.
Orbital involvement: complete examination
Technique:
 Incision:
 Standard Lynch incision.
 sup :below supraorbital foramen,inf: inferior edge of lacrimal fossa.
 Angular artery branches in Submuscular layer
Exposure:
 Orbital side periosteum elevated
 Superiorly :above nasofrontal suture.
 Inferiorly: anterior lacrimal crest.
 Elevation of Orbital content,lacrimal sac
 Anterior ethmoid artery:
 Posterior ethmoid artery:
Ethmoidectomy:
middle turbinate-preservation.
Careful removal on medial ethmoid to preserve nasal mucosa.
Posteriorly based mucosal flap created to enter nasal cavity.
Inferior portion of medial turbinate resected,superior attachment-cribriform plate
preserved.
 Orbital wall anterior to ant ethmiod artery preserved:
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Complications:
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Bleeding/crusting
Epiphora:
Recurrance:
Diplopia:
Blindness
CSF leak
Intracranial hemorrhage
Hypertrophic scar formation
Medial canthal scarring
Telecanthus
Supraorbital nerve dysesthesia
Lynch Procedure:
External Frontoethmoidectomy
 1920.
 Ethmoidectomy + middle turbinectomy +
resection of entire floor of frontal sinus.
 Chronic sinusitis:
 Failiure to medical therapy.+ lesser procedure:
septoplasty, intranasal ethmoidectomy.
 Polyps, hyperplastic sinusitis or anatomical obstruction
of frontal sinus drainage.
 Goal –normal mucociliary clearance.
 Failure of endoscopic frontal sinusotomy.
 Cant tolerate osteoplastic operation.
 Others:
 Mucocele.
 Orbital complications :
 Frontocutaneous and ethmoidcutaneous fistula.
 Recurrent sinusitis or polyposis after failure of
endoscopic approach.
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Benign neoplasm of superior nasal
cavity,ethmoid,frontal sinuses and anterior skull base.
Malignant tumors.
Closure of CSF leak.
Contemporary indications:
 Endoscopic, drills not available
 Surgeon not comfortable with endoscopic approach.
 Chronic rhinosinusitis in large well areated frontal
sinuses with extensive pneumatization-complete
obliteration difficult.
 Severely scarred frontal recess with osteitic bone after
multiple endoscopic approaches.
Techniques:
 Incision:
 Nasofrontal connection created:
 With intact bridge of bone:lateral wall of frontal recess+
 Complete frontoethmoidectomy: collapse of frontal recess-stenosis.
Reconstruction:
 Intact bridge:
 Stenosis.
 Stent : Silastic or rubber :
 Tube ( multiple side holes)
 Rolled sheet.
 Sewell-Boyden flap
 90% patency
 1-2 cm wide, 2-3 cm long
 Rotating distal end on itself laterally & superiorly into frontal sinus
through external incision.
 It will line medial and posterior wall of frontal recess with mucosa facing
lumen of frontal sinus.
 Stent.
Postoperative care:
 Stent removal:
 5-7th POD vs. 6 wks or longer
 Flap: 1-2 wks.
 irrigation:
FU- 1st 3 mths post op.
 Areated sinus= annually X 5yrs
 Opacified = revision surgery.
 Complications:
 Poor cosmetic result
 Recurrance: mucocele
 90% patency
 30% revision surgery-
Osteoplastic frontal sinus surgery
 Principle:
 Inferiorly hinged ‘trap door’ of bone fashioned from
anterior wall of frontal sinus, sinus cleared, wide
drainage duct created to nose, closure of sinus with bone
flap.
 Late 19th century.
 Popularized in US Montgomery and colleagues.
 Goal:
 Remove /obliterate the sinus- air space-non
physiological.
Indications:
 Acute sinusitis:
 Intraorbital or intracranial complications:
 Definitive surgical management.
 Recurrent acute frontal sinusitis: Failed Endoscopic
approach.
 Chronic sinusitis:
 Failiure of endoscopic and frontoethmoidectomy :
recurrent infection.
 Anatomical limitations of endoscope
 Inherent mucosal disease requiring functional
restoration of sinus: cystic fibrosis, ciliary dyskinesia,
sarcoidosis.
 Allergic fungal sinusitis:
 Recurrance to avoid chronic steroid use+ complications.
 Mucocele:
 Endoscopic drainage not possible:
 Loculated mucocele: not connected to frontal recess.
 Anatomical limitations.
 Others:
 Extensive sinus requiring supplemantary removal of
anterior wall
 Extensive fractures with dislocation-dura tear, frontal
lobe injury
Contemporary indications:
 Chronic rhinosinusitis or polyposis:
 Refractory to endoscopic approach : mucocele.
 Scared /+ osteitic frontal recess
 Unfavorable anatomic conditions:
 Narrow frontal recess
 Type IV frontal recess cells
 Symptomatic osteomas.
 Lateral symptomatic disease non responding to endoscope.
 Altered physiology:
 Ciliary dyskinesia,
 cystic fibrosis
 Frontal sinus fractures
 Tumors: inverted papilloma.
Contraindications:
 Hypoplastic sinus
 Comminuted fractures
Advantages:
 Direct approach:
 No facial deformity.
 Less morbidity.
 Both sinuses simultaneously.
Preoperative preparation:
 Radiological assessment of frontal sinus margin.
Incision:
 Brow incision:
 Cosmetically hidden.
 Sacrifises sensation.
 Mid forehead incision:
 Anterior or frontal
baldness with deep
forehead crease.
 preserves some
sensation
 Bicoronal incision:
 Forehead sensation
preserved.
 Hidden by hair.
 2-3cm behind the hairline.
 Laterally to level of preauricular crease.
 subgaleal plane, laterally superficial to temporalis fascia.
 Superficial temporal artery
 Hemostasis achieved in each layer.
Flap elevation:
 Subgaleal flap:
 Knife,scissors,electrocautery.
 Coagulation mode, along the dissection plane
 Continuous tight traction on flap till supraorbital rims
 Periosteal flap:
 Periostium incised from one temporal fossa to another,
 Periosteal flap elevated with Freer elevator till nasal
dorsum in midline and orboial rims laterally: supraorbital
foramen and nerve.
Osteoplastic flap:
 Template of the sinus
 Intersinus septum cut 1cm curved osteotome.
 Flap elevated at three points simultaneously
Mucosal resection
 Sinus Content-C/S
 Elevation of mucosa
 complete removal by drill
with diamond and cutting
burr:
 interior of anterior wall,
 intersinus septum: antinfnasal septum,post-crista
galli,bony overhange.
 orbital and cranial
surface of sinus,
 frontal recess,
 ethmoid sinus
Obliteration:
 Muscle:
 Temporalis muscle-resolves
 Ethmoid sinus at level of anterior
ethmoidal artery.
 Bone:
 Osseous and fibrous plug
preventing mucosal growth from
below.
 1.5X5cm Calvarial graft + bone
dust.
 Outer cortex from calvarium of
parietal bone
 Graft broken into 2-3 mm pieces
packed in frontal recess+ bone
dust.
 Temporalis fascia graft : over
frontal recess
 Fat graft: adequately filling the
sinus.
Closure:
 Osteoplastic flap repositioned :26 gauge wires - 2 & 10
o’clock.
 Periosteal flap sutured.
 Drains:
 Over eyebrow
 Across the top of skull behind incision.
 Hemostais achieved.
 Skin closure.
 U/L procedure:
Complications:
 Wound problem:
 Hematoma,seroma
 infection,
 Flap necrosis.
 Blood transfusion
 Orbital injury
 Recurrent
 Mucocele
 Chronic headache:
 Frontal numbness/parasthesia
 Cosmetic alterations: absorption of bone flap/bone
thickening due to excessive periosteal reaction.
Summary
 Endoscopic approach vs. External approach:
 Advancements in endoscopic sinus surgery:
 Surgical skills
 Easy availability of instrumentaions in operating
theaters
THANK YOU!!!
Dr. Diva Shrestha