Ee3a Coclia70 Sinus Surgery

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  • Ee3a Coclia70 Sinus Surgery

    1. 1. COCLIA 70: Sinus Surgery
    2. 2. Embryology <ul><li>Frontal </li></ul><ul><ul><li>Begins to develop at age 5-6 yrs </li></ul></ul><ul><li>Maxillary </li></ul><ul><ul><li>Starts to develop in utero </li></ul></ul><ul><ul><li>Biphasic growth: 3yrs, 7-18yrs </li></ul></ul><ul><li>Ethmoid </li></ul><ul><ul><li>Most developed sinus at birth (3-4 cells) </li></ul></ul><ul><li>Sphenoid </li></ul><ul><ul><li>Nasal mucosa evaginates into sphenoid bone </li></ul></ul><ul><li>Sinuses reach adult size in mid-late teenage years </li></ul>
    3. 3. Osteomeatal Complex <ul><li>Area lateral to the middle turbinate </li></ul><ul><li>Uncinate process (ethmoid bone) – thin sickle-shaped bone, medial to the infundibulum, lateral to middle turbinate </li></ul><ul><ul><li>Superior attachment determines pattern of frontal sinus drainage </li></ul></ul><ul><ul><li>80% attaches to lamina papyracea: drains medial to the uncinate </li></ul></ul><ul><ul><li>20% attaches to skull base or middle turbinate: drains lateral to the uncinate </li></ul></ul><ul><li>Infundibulum (space containing the ostia draining the anterior ethmoid, frontal and maxillary sinuses) </li></ul>
    4. 5. Name that Cell
    5. 6. Name that Cell <ul><li>Haller cells </li></ul><ul><ul><li>Ethmoid cells that extend into the maxillary sinus </li></ul></ul><ul><ul><li>Pneumatized medial and inferior orbital walls </li></ul></ul><ul><li>Onodi cells </li></ul><ul><ul><li>“ Sphenoethmoidal cell” </li></ul></ul><ul><ul><li>A posterior ethmoidal cell that extends lateral and superior to the sphenoid sinus </li></ul></ul><ul><ul><li>Can be mistaken as the sphenoid sinus </li></ul></ul><ul><ul><li>Both the carotid artery and the optic nerve can be exposed within it </li></ul></ul><ul><li>Aggar nasi cells </li></ul><ul><ul><li>Most anterior of the anterior ethmoids (infundibular cells) </li></ul></ul><ul><ul><li>Lies anterior-superior to the attachment of the middle turbinate to the lateral nasal wall </li></ul></ul><ul><ul><li>Anterior wall of the frontal recess </li></ul></ul>
    6. 7. FESS: Overview <ul><li>Advantages </li></ul><ul><ul><li>Better visualization & precision </li></ul></ul><ul><ul><li>No external scar </li></ul></ul><ul><ul><li>Better preservation of function </li></ul></ul><ul><li>Disadvantages </li></ul><ul><ul><li>Distorted depth perception (monocular vision) </li></ul></ul><ul><ul><li>One-handed technique </li></ul></ul><ul><li>Contraindications </li></ul><ul><ul><li>Osteomyelitis </li></ul></ul><ul><ul><li>Inaccessible lateral frontal sinus disease </li></ul></ul>
    7. 8. FESS: Complications <ul><li>Orbital </li></ul><ul><ul><li>Blindness / Retrobulbar hematoma </li></ul></ul><ul><ul><li>Orbital fat penetration </li></ul></ul><ul><ul><li>Diplopia (medial or superior rectus muscle injury) </li></ul></ul><ul><ul><li>Epiphora (lacrimal duct injury) </li></ul></ul><ul><li>Intracranial </li></ul><ul><ul><li>CSF leak </li></ul></ul><ul><ul><li>Meningitis </li></ul></ul><ul><ul><li>Brain abscess </li></ul></ul><ul><ul><li>Hemorrhage </li></ul></ul><ul><li>Intranasal </li></ul><ul><ul><li>Synechia </li></ul></ul><ul><ul><li>Anosomia </li></ul></ul>
    8. 9. Relativity <ul><li>Middle meatus </li></ul><ul><ul><li>Lateral to the middle turbinate (medialize it) </li></ul></ul><ul><ul><li>Lateral to the uncinate process (excise it) </li></ul></ul><ul><li>Sphenoid ostium </li></ul><ul><ul><li>30-34 degrees from floor of nose </li></ul></ul><ul><ul><li>6.2-8.0 cm posterior to nasal spine </li></ul></ul><ul><ul><li>Sphenoethmoidal recess at junction of superior 2/3 and inferior 1/3 of the superior turbinate </li></ul></ul><ul><ul><li>Medial to middle and superior turbinates </li></ul></ul>
    9. 10. Sphenoid Sinus <ul><li>Most common local causes of failure </li></ul><ul><ul><li>Failure to enter at the original surgery </li></ul></ul><ul><ul><li>Stenosis </li></ul></ul><ul><li>Special considerations </li></ul><ul><ul><li>Intracerebral injury: CSF leak, meningitis, abscess, injury to pituitary gland </li></ul></ul><ul><ul><li>Vascular hemorrhage </li></ul></ul><ul><ul><li>Retrobulbar hematoma </li></ul></ul><ul><ul><li>Cranial nerve injury </li></ul></ul><ul><ul><li>Cavernous sinus fistula </li></ul></ul>
    10. 11. Nasal Antral Window <ul><li>Normal mucociliary flow sweeps contents from the maxillary sinus out the surgically enlarged maxillary sinus ostium </li></ul><ul><li>A patent antral nasal window can allow secretions to reenter the maxillary sinus and are prone to becoming infected </li></ul>
    11. 12. The Middle Turbinate <ul><li>MTR </li></ul><ul><ul><li>Decreased synechia formation </li></ul></ul><ul><ul><li>Higher long-term patency </li></ul></ul><ul><ul><li>Improved nasal airflow </li></ul></ul><ul><ul><li>Decreased nasal resistance </li></ul></ul><ul><li>MTP </li></ul><ul><ul><li>Preserve important anatomic landmark </li></ul></ul><ul><ul><li>Decreased risk of alteration of nasal function, </li></ul></ul><ul><ul><li>Decreased risk of atrophic rhinitis </li></ul></ul><ul><ul><li>Decreased risk of hyposmia </li></ul></ul><ul><ul><li>Decreased risk of frontal recess stenosis causing sinusitis </li></ul></ul>
    12. 13. Fate of the Middle Turbinate: Part 1 <ul><li>Havas (Ann Otol Rhinol Laryngol 2000) </li></ul><ul><li>Review of 509 pts (partial MTR) vs. 597 pts (MTP) – randomly divided, minimum one year follow-up </li></ul><ul><li>Partial MTR: anterior inferior third of MT resected using endoscopic scissors </li></ul><ul><ul><li>Important area in secretion of vasoactive sensory neuropeptides involved in hypersecretion, edema, polyposis, chronic rhinosinusitis </li></ul></ul><ul><li>Both groups: most important factor of FESS success was severity of rhinosinusitis preop </li></ul><ul><li>Partial MTR: less synechiae, less recurrent disease requiring revision surgery – RECOMMENDED! </li></ul>
    13. 14. Fate of the Middle Turbinate: Part 2 <ul><li>Giacchi (Am J Rhino 2000) </li></ul><ul><li>Retrospective review of 50 MTR and 50 MTP sides with minimum 2 year follow-up </li></ul><ul><li>Partial MTR: resect anterior-inferior third to half, preserve superior and lateral attachments </li></ul><ul><li>Not associated with increased complications (frontal recess stenosis with secondary frontal sinusitis) </li></ul><ul><li>Consider on case-by-case basis (improved surgical access and postoperative debridement) </li></ul>
    14. 15. Whoops! CSF Leak <ul><li>Refer to COCLIA page 62 (Dr. Lee 10/8/07) </li></ul>
    15. 16. External Approaches to Ethmoids <ul><li>Caldwell-Luc (transantral ethmoidectomy) </li></ul><ul><ul><li>Trans-maxillary middle meatal antrostomy with transantral ethmoidectomy </li></ul></ul><ul><ul><li>Disadvantages </li></ul></ul><ul><ul><ul><li>Does not expose anterior ethmoids </li></ul></ul></ul><ul><ul><ul><li>Risk of infraorbital nerve injury </li></ul></ul></ul><ul><li>Open external ethmoidectomy </li></ul><ul><ul><li>Access through lamina payracea and lacrimal fossa </li></ul></ul><ul><ul><li>Must ligate anterior ethmoid and angular arteries </li></ul></ul><ul><ul><li>Disadvantages </li></ul></ul><ul><ul><ul><li>Poor exposure of anterior ethmoids </li></ul></ul></ul><ul><ul><ul><li>Scar </li></ul></ul></ul>
    16. 17. Osteoplastic Flap <ul><li>Indications </li></ul><ul><ul><li>Recurrent or chronic frontal sinusitis </li></ul></ul><ul><ul><li>Frontal mucoceles </li></ul></ul><ul><li>Procedure </li></ul><ul><ul><li>Make template from a Caldwell view x-ray </li></ul></ul><ul><ul><li>Bicoronal incision for exposure </li></ul></ul><ul><ul><li>Using template, excise periosteal and bone flap </li></ul></ul><ul><ul><li>Remove diseased mucosa </li></ul></ul><ul><ul><li>Obliterate cavity and plug frontal recess </li></ul></ul>
    17. 18. Lothrop Procedure <ul><li>“ Chaput-Meyer” </li></ul><ul><li>Indication </li></ul><ul><ul><li>Chronic frontal sinus disease </li></ul></ul><ul><li>Procedure </li></ul><ul><ul><li>Remove bilateral anterior ethmoids, middle turbinates and frontal sinus septum </li></ul></ul><ul><ul><li>Creates large opening for frontal sinus drainage into the nasal cavity </li></ul></ul>
    18. 19. Frontal Cells <ul><li>Anatomy </li></ul><ul><ul><li>May contribute to mechanical obstruction of the frontal recess </li></ul></ul><ul><li>Classification (Bent and Kuhn) </li></ul><ul><ul><li>Type I: single cell superior to agger nasi </li></ul></ul><ul><ul><li>Type II: 2 or more cells </li></ul></ul><ul><ul><li>Type III: single large that pneumatizes into the frontal sinus </li></ul></ul><ul><ul><li>Type IV: cell contained completely within the frontal sinus </li></ul></ul>
    19. 21. Frontal Cells <ul><li>Meyer (Am J Rhino 2003) </li></ul><ul><li>768 CT scans met study criteria </li></ul><ul><li>Objective: are frontal cells associated with variants of pneumatization? </li></ul><ul><li>Frontal cells present in 20.4% of study population </li></ul><ul><li>Positively associated with hyperpneumatization of the frontal sinus and negatively with hypopneumatization </li></ul><ul><li>Increased prevalence of concha bullosa </li></ul><ul><li>In general, type III and IV individuals had increased prevalence of frontal mucosal thickening but not maxillary or ethmoid thickening </li></ul>
    20. 22. Orbital Complications <ul><li>Overall <0.5% serious FESS complication rate </li></ul><ul><li>Orbital complications </li></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Hemorrhage </li></ul></ul><ul><ul><li>Diplopia (medial rectus injury) </li></ul></ul><ul><ul><li>Blindness </li></ul></ul><ul><li>Minor complications using conventional instrumentation can become major complications with powered instrumentation </li></ul>
    21. 23. Post-Op Orbital Hematoma: Part 1 <ul><li>Graham (Laryngoscope 2003) </li></ul><ul><li>Case series 3 patients referred for orbital injury </li></ul><ul><li>Not every patient with orbital hematoma requires surgical intervention </li></ul><ul><li>Ophthalmology consult </li></ul><ul><ul><li>proptosis </li></ul></ul><ul><ul><li>intraocular pressure (observe if <30mmHg, poor vision likely if >40mmHg), </li></ul></ul><ul><ul><li>funduscopy (assess retinal blood flow) </li></ul></ul><ul><ul><ul><li>If retinal blood flow is normal, no immediate treatment </li></ul></ul></ul><ul><ul><ul><li>If retinal blood flow is compromised, immediate canthotomy with upper and lower cantholysis </li></ul></ul></ul>
    22. 24. Post-Op Orbital Hematoma: Part 2 <ul><li>Sharma (J Laryn Otol 2000) </li></ul><ul><li>Case series 7 patients </li></ul><ul><li>Minimize risk </li></ul><ul><ul><li>Preop: history prior sinus surgery, CT evaluation </li></ul></ul><ul><ul><li>Intraop: abort surgery if bleeding hampers visualization </li></ul></ul><ul><li>Recognize symptoms: acute onset/progression orbital pain, diplopia, visual loss </li></ul><ul><li>Assess “four P’s” </li></ul><ul><ul><li>Perception of light </li></ul></ul><ul><ul><li>Pupils (relative afferent pupil defect) </li></ul></ul><ul><ul><li>Pallor of optic nerve </li></ul></ul><ul><ul><li>Pulsatility of the central retinal artery </li></ul></ul>
    23. 25. Treatment of Orbital Hemorrhage <ul><li>Globe massage </li></ul><ul><li>Increase orbital space </li></ul><ul><ul><li>Cantholysis, canthotomy </li></ul></ul><ul><ul><li>Medial wall decompression: transcaruncular orbitomy, external ethmoidectomy, endoscopic </li></ul></ul><ul><ul><li>Orbital floor decompression: transconjunctival </li></ul></ul><ul><li>Decrease volume of orbital contents </li></ul><ul><ul><li>Steroids, topical beta blocker drops </li></ul></ul><ul><ul><li>Mannitol, acetazolamide </li></ul></ul><ul><ul><li>Paracentesis of the anterior chamber </li></ul></ul>
    24. 26. Minimize Risk of Orbital Injury <ul><li>Preop: history prior sinus surgery, CT evaluation </li></ul><ul><li>Intraop: abort surgery if bleeding hampers visualization </li></ul><ul><li>Place opening of blade at 90 degrees to the medial orbital wall and dissect superiorly or inferiorly </li></ul><ul><li>Assess vision, orbital appearance, and ocular motility during postop check </li></ul>
    25. 27. FESS Post-op Care <ul><li>Thaler (Arch Oto Head Neck Surg 2002) </li></ul><ul><li>Frequent debridement </li></ul><ul><ul><li>Post op week 1 then weekly or greater intervals until healed (approx 4-6 weeks) </li></ul></ul><ul><ul><li>Pros: remove large crusting and clot (traps mucous leading to infection, bridge for scar formation, retained bone fragments are nidus for infection) </li></ul></ul><ul><ul><li>Cons: histologically avulses epithelium until 2 nd postop week, pediatric FESS rarely tolerate debridement but have good outcomes </li></ul></ul><ul><li>Hypertonic saline irrigation </li></ul><ul><li>Nasal splints </li></ul><ul><li>Endoscopic exam to assess for obstructing crust or clot </li></ul>
    26. 28. Informed Consent <ul><li>Recall possible complications discussed earlier </li></ul><ul><ul><li>Orbital </li></ul></ul><ul><ul><li>Intracranial </li></ul></ul><ul><ul><li>Intranasal </li></ul></ul>
    27. 29. Balloon Sinuplasty <ul><li>Indications: maxillary, sphenoid and frontal disease </li></ul><ul><li>Safety: less injury to mucosa, less operative bleeding, eliminates need for nasal packing </li></ul><ul><li>Results: not long enough follow-up </li></ul>

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