Principles of Functional Endoscopic Sinus Surgery

1
Principles of Functional Endoscopic Sinus Surgery

• Shahin Bastaninejad, MD
• Assistant Prof. of ORL-HNS
• TUMS
• AmirAlam Hospital

2
Outline

• Definition
• Anatomy
• Patient evaluation
• FESS Concepts of Surgery

3
Definition
4
Functional Endoscopic Sinus Surgery

• Replaced old practice of obliterating sinuses and
  removing mucosa. Concept of irreversibly diseased
  mucosa refuted.
• Functional aspect refers to
• Preserving normal structures
• Removing only obstruction
• Preserving mucosa
• Attempt to restore function

5
Anatomy
6
Ethmoid anatomy

• Ethmoid anatomy is complex Labyrinth
• Lamellae
• 1st - Uncinate
• 2nd - Ethmoid bulla
• 3rd - Basal lamella of middle turbinate
• 4th - Superior turbinate

7
Drainage

• Frontal, anterior ethmoid maxillary OMC
• Posterior Ethmoids Superior meatus
• Sphenoid sinus Sphenoid-ethmoidal recess

8
Middle Turbinate

• Three components
• First Anterior, oriented in a sagittal plane
  and attached to skull base
• Second Middle, oriented in a Vertical plane and
  attached to lamina papyracea (basal lamella and
  separates ant from post ethmoids)
• Third Posterior, oriented in a horizontal plane
  and attaches to perpendicular plate of palate
  (forms roof of middle meatus, anterior to
  sphenopalatine foramen)

9
Middle Turbinate
10
Ostiomeatal Complex (OMC)

• Common drainage for frontal, maxillary and
  anterior ethmoid sinuses.

11
OMC
12
OMC

• Infundibulum funnel shaped area whereby the
  maxillary, ant ethmoid and frontal sinuses
  drains
• Uncinate process Sickle shaped bony ethmoidal
  structure
• Hiatus Semilunaris Half-moon shape opening of
  infundibulum

13
Uncinate Process

• Attaches to the following structures
• Inf far post. To ethmoid process of inf. Turb

14
Uncinate Process

• Ant far sup. To lamina papyracea, skull base
  or mid turb

15

• Laterally Lamina papyracea and fontanelle area

16
Uncinate Process
52
17
(No Transcript)
18
Bulla Ethmoidalis

• The greatest anterior ethmoid air cell, attached
  to lamina papyrcea and usually open into lateral
  sinus

19
(No Transcript)
20
Sinus Lateralis Suprabullar recess and
retrobullar recess
21
Middle turbinate Horizontal and vertical basal
lamella
SBR
Sinus Lateralis
RBR
22
Sphenoid Ostium

• Medial to posterior sup. turbinate
• Located between nasal septum and inferior aspect
  of sup. turbinate
• Located at the same level as the roof of the
  maxillary sinus
• Located 4 microdebrider/suction tip breaths above
  the choanae
• Located 7cm from nasal crest at 30

23
Sphenoid Ostium
24
Sphenoid Sinus

• Relationships of important structures
• Optic nerve superior-lateral
• Carotid artery/cav sinus mid-lateral
• Vidian nerve and maxillary nerve
  inferior-lateral

25
Square ant clinoid process, Circles optic
canals, triangle vidian nerve Asterisk
pneumatization of pterygoid process
26
Sphenoid Classification
27
Presellar
Sellar
Conchal
Post sellar
28
Onodi Cells or Sphenoethmoid cells
29
Optic Canal in Onodi Cells
30
anatomic keyhole in SBS
31
LOCR
32
Cribriform plate
Keros classification
1-3mm
3-7mm
7-16mm
33
Keros Classification

• Type I
• 1-3mm
• Type II
• 3-7mm
• Type III
• 7-16mm

34
Fovea and Ethmoidal arteries
35
Lens 70 degree End of surgery
36
Frontal Cells
Kuhn Cells
37
Frontal Recess

• Anatomic Boundries
• Ant unicate process agger nasi
• Post bulla ethmoidalis and suprabullar lamella
• Lateral lamina papyracea
• Medially hiatus semilunaris or middle turb
• Inf Ethmoid infundibulum
• Sup Fovea ethmoidalis, supraorbital air cell,
  anterior ethmoid artery and frontal ostium

38
Draf IIA
Draf I
39
Draf III
Draf
40
Frontal Sinus Mucociliary Pattern
? Save Mucosal Layer in Lateral part while
performing Draf III opertation
41
Patient evaluation
42
Pre-op CT Evaluation

• CLOSE Technique
• C Cribriform
• L Lamina Papyracea
• O Orbits, onodi cell, Optic Nerve
• S Sphenoid, Skull Base
• E Ethmoid Arteries

43
C - Cribriform

• Assess the Keros type
• Look for assymetry

44
(No Transcript)
45
L Lamina Papyracea

• Check for dehiscence or pathologic fractures

46
O Orbit, Optic Nerve, Onodi Cells

• Check for dehiscence
• Assess for onodi cells (superior-lateral to
  sphenoid)
• Orbital slope

47
S Sphenoid, Skull base

• Assess for Carotid dehiscence and aeration
  patterns
• Conchal, Pre-sellar, Sellar (thickness of
  clivus)

48
Skull base

• Assess slope of skull base
• Assess if roof of sphenoid is level with skull
  base

49
E Ethmoid Artery
50
FESS

• Concepts of surgery

51
Role of surgery

• Should be considered as adjunctive to medical
  therapy
• CRS is an inflammatory and multifactorial disease
• Institute medical therapy first prior to surgery
  unless impending complications
• Continued medical therapy is required following
  surgery to avoid recurrence

52

• Defined surgical substeps are defined according
  to specific pathophysiologic obstruction that
  exist based on microanatomy

53
Antrostomy

• Some speculate nitric oxide produced in maxillary
  sinus has bacteriostatic properties, therefore
  better to keep antrostomy small
• Uncinate must be completely removed, source of
  recurrence.
• Mucociliary clearance remains to natural os
• Antrostomy must include the natural osium and
  accessory osium if present

54
Recirculation
55
Frontal Sinusotomy

• Question on to perform or not
• Do as little as possible but as much as necessary
• Some advocate ethmoid dissection and monitor
• Graduated approach to frontal sinuses
• Should evaluate with sagittal reconstruction
• Evaluate A-P and Mediolateral dimensions, asses
  neo-osteogenesis and pneumatization

56
Ethmoidectomy Sphenoidotomy

• Continue operation Anteroposteriorly toward the
  Sphenoid sinus, then open it
• Now it is time to go on with Posteroanterior
  approach with a 30 degree lens and cutting
  forceps

57
References

1. Dr Quinn online Text book
2. Diseases of the Sinuses Diagnosis and
   Management. Kennedy. Chapters 1, 2, 3, 15, and
   16
3. Head and Neck Otolaryngology. Bailey. Chapters
   21, 25, 26.
4.  Endoscopic Sinus Surgery Dissection Manual With
   Cdrom. Casiano
5. Endoscopic Anatomy of the lateral nasal wall,
   ostiomeatal complex and anterior skull base, a
   step-by-step guide. Reda Kamel
6. Endoscopic diagnosis and surgery of the paranasal
   sinuses and the anterior skull base. Heinz
   Stammberger
7. Rhinology and Sinus Disease, a problem-oriented
   approach. Steven D. Schaefer
8. Nasal and Sinus Surgery. Steven Marks. Sections
   1, 2, and 3.
9. Surgical anatomy and physiology for the skull
   base surgeon. Ameet Singh, et al. Operative
   Techniques in Otolaryngology (2011) 22, 184-193
10. FRONTAL SINUS SURGERY 2004 UPDATE OF CLINICAL
    ANATOMY AND SURGICAL TECHNIQUES. MICHAEL
    FRIEDMAN, et al. OPERATIVE TECHNIQUES IN
    OTOLARYNGOLOGYHEAD AND NECK SURGERY, VOL 15, NO
    1 (MAR), 2004 PP 23-31

58
Thank You!