Endoscopic Sinus Surgery

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Endoscopic Sinus Surgery
Section 6 (???? ??? ????)

• Bakhshaee M, MD
• Rhinologist, Assistant Prof. MUMS

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Frontosphenoethmoidectomy
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Frontosphenoethmoidectomy

• 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
  symptom-free interval is to open up all the cells
  including the frontal recess

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Sphenoid Sinusotomy (I, II, III)

• 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

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Indications

• Isolated sphenoid sinus disease, e.g.,
• Aspergillosis
• Purulent bacterial infection
• Inverted papilloma
• Mucocele
• Biopsy of skull base lesions

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Surgical Technique

• 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.

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Comment on the Management of theMiddle 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

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The Endoscopic Tour
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Step 1

• involves advancing the endoscope along the
  inferior meatus

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Step 2

• involves coming forward a little and angling the
  endoscope upward to see the sphenoethmoid recess
  area

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Step 3

• 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

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Anatomical Variations
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Agger Nasi Air Cells
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Concha Bullosa
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Paradoxical Middle Turbinate
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Bifid Middle Turbinate
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Polypoidal Anterior End of the Middle Turbinate
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Paradoxical Uncinate Process
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Pneumatized Uncinate Process
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Accessory Ostium of the Maxillary Sinus
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An Atlas of Specific Conditions
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Allergy

• Hypertrophied inferior turbinate

• Edematous middle turbinate

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Infection

• Bacterial rhinosinusitis

• Aspergillosis

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Inflammatory Diseases

• Pyogenic granuloma

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Wegener granulomatosis
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Sarcoidosis
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Benign Tumors

• Antrochoanal polyp

• Inverted papilloma

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Benign Tumors

• Chondroma

• Angiofibroma

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Malignant Tumors

• Olfactory neuroblastoma

• Lymphoma

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Malignant Tumors

• Amelanotic melanoma

• Adenocarcinoma

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Hereditary hemorrhagic telangiectasia
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The Place of Radiology
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The Role of Conventional Radiology

• 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

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The Role of Computed Tomography

• 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

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When to Request CT

• CT for rhinosinusitis is best reserved for
  patients who have not responded to maximum
  medical treatment

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CT Parameters

• 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

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Sagittal reconstructions

• Helpful for frontal surgery, giving the surgeon a
  better understanding of the complex relationship
  between the anterior ethmoid sinuses and the
  frontal recess

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Intravenous contrast

• is only required for tumors, vascular lesions,
  and the orbital and intracranial complications of
  infection

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Indications for MRI

• 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

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MRI is complementary to CT

• 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.

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internal carotid artery aneurysm
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Meningocele

• In congenital midline lesions such as
  meningocele, meningoencephalocele, or sinonasal
  glioma

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