External approaches to sinus surgery


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This presentation describes the various external surgical approaches used to address sinus pathologies

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External approaches to sinus surgery

  1. 1. Dr T Balasubramanian
  2. 2.   When equipment are not available  When anatomy is distorted due to repeated surgeries in the area  To remove tumors (benign / malignant)  To manage traumatic lesions involving facial bones Are external approaches warranted? drtbalu's otolaryngology online 2
  3. 3.   With the advent of nasal endoscopes and instruments indications for external approaches to maxillary sinus are very few  Caldwell Luc approach is the commonly used one  Caldwell Luc approach can be modified to access other areas of paranasal sinuses External approaches to Maxillary sinus drtbalu's otolaryngology online 3
  4. 4.   Antrum is opened via its anterior wall in the canine fossa region through sublabial incision sited at the bucco gingival sulcus preserving about 5 mm of gingival mucosa. In edentulous patient the incision is made along the maxillary alveolus to facilitate early wearing of dentures  Mucosal lining of the maxillary antrum / mass if any are removed  A window is created through inferior meatus in to the antrum  This procedure can be performed under both LA / GA Caldwell Luc procedure steps drtbalu's otolaryngology online 4
  5. 5.   During immediate post op period the head of the patient is kept elevated at 30 º.  Icepacks may be applied to the face to prevent edema from developing  Packs if used should be removed within 48 hours  Broad spectrum antibiotics to be prescribed if packs are used  Regular douching of nose with saline nasal spray will prevent crust formation Caldwell Luc post op care drtbalu's otolaryngology online 5
  6. 6.   To remove benign tumors like inverted papilloma & angiofibroma  Chronic intractable maxillary sinusitis that fail to respond to medical / ESS management (Kartagener’s syndrome / Young’s syndrome)  A/C polyp originating from the anterior wall of maxillary sinus  Mycotic maxillary sinusitis  Oroantral fistula repair  Blow out # repair  Approach to petrygopalatine fossa Caldwell Luc procedure - Indications drtbalu's otolaryngology online 6
  7. 7.   Normal mucociliary clearance mechanism is ignored  Regenerating maxillary antral mucosa lacks cilia  Difficulties in post op follow up with imaging modalities like x-ray PNS and CT PNS because the resultant fibrosis will cause misleading artifacts  Difficult to perform in patients with maxillary sinus hypoplasia (commonly encountered) Caldwell- Luc pitfalls drtbalu's otolaryngology online 7
  8. 8.   Useful when extensive resection of mucoperiosteal lining of the maxillary sinus is performed.  This can be used to irrigate the maxillary sinus antrum facilitating hygiene  Residual hematoma following surgery can be periodically evacuated preventing development of creeping periostitis  The maxillary sinus cavity can be periodically inspected for evidence of recurrence of disease through this opening Inferior meatal antrostomy drtbalu's otolaryngology online 8
  9. 9.   Bone over the canine fossa area of anterolateral wall of maxilla is the thinnest  Canine fossa is bounded by: Canine eminence – medially Root of zygoma – laterally Superior alveolus – inferiorly (This bone is the thickest) Infraorbital nerve - Apex Surgical anatomy drtbalu's otolaryngology online 9
  10. 10.   Cheek edema (ecchymosis)  Infraorbital nerve dysesthesia  Epiphora  Oroantral fistula Caldwell – Luc complications drtbalu's otolaryngology online 10
  11. 11.   External ethmoidectomy – Provides excellent access to ethmoid sinuses, medial wall of orbit, cribriform plate and fronto nasal area.  Indications for external approaches to ethmoid sinuses are dwindling with the advent of nasal endoscopes and other ESS instruments like debriders and shavers. External surgeries for ethmoid sinus diseases drtbalu's otolaryngology online 11
  12. 12.   In managing complications of ethmoid and frontal sinusitis like orbital and periorbital abscesses  In patients with trauma involving ethmoid and frontal sinuses  To biopsy mass lesions from ethmoids / orbit  Trauma / fractures involving ethmoid, frontal, and sphenoid  Control of anterior ethmoidal artery  Orbital decompression  Optic nerve decompression  CSF leak repair drtbalu's otolaryngology online 12 Indications for external ethmoidectomy
  13. 13.   Is complex & variable  Lamina papyracea forms its lateral wall  Superiorly horizontal plate of ethmoid separates it from anterior skull base  Perpendicular plate of ethmoid forms part of nasal septum  Basal lamella separates anterior & posterior ethmoidal air cells drtbalu's otolaryngology online 13 Anatomy of ethmoid
  14. 14.   First described by Ferris Smith in 1933  Ideally performed under GA  1% xylocaine with 1 in 100,000 adrenaline is infiltrated from the medial extent of eyebrow to the side of the dorsum of nose  Nasal cavity is decongested with pledgets soaked in 0.05% oxymetazoline  Temporary tarsorrhapy is performed to protect the eyes. drtbalu's otolaryngology online 14 External ethmoidectomy
  15. 15.  drtbalu's otolaryngology online 15 Incision Begins at the inferior margin of medial aspect of eyebrow. Extends straight down towards the medial canthus The incision is carried up to the level of periosteum Angular vessels cauterized Supratrochlear bundle is preserved
  16. 16.   Ensures integrity of medial canthal ligament  Trochlea is preserved  Lacrimal sac is protected  Herniation of orbital fact is prevented as it would obstruct the surgical field drtbalu's otolaryngology online 16 Periosteal preservation - importance
  17. 17.  drtbalu's otolaryngology online 17 Medial orbital wall - exposure
  18. 18.   Anterior ethmoidal artery is coagulated in the frontoethmoidal suture line. Bipolar cautery should be used.  Periorbita is protected with a malleable retractor  Posterior ethmoidal artery lies 10 mm behind the anterior ethmoidal artery.  Dissection behind the level of posterior ethmoidal artery should be done carefully as it would cause retro bulbar hemorrhage leading to loss of vision drtbalu's otolaryngology online 18 Medial orbital wall exposure - contd
  19. 19.   Lacrimal bone  Frontal process of maxilla  Lamina papyracea  Ethmoid sinus is entered by breaching the lamina papyracea. It is removed using kerrison’s punch in a circumferential manner  Fronto ethmoidal suture is an important landmark for cribriform plate area of anterior cranial fossa  Middle turbinate if possible should be left alone to prevent CSF leaks  Bone over the medial orbital wall should be preserved as much as possible to avoid prolapse of orbital fat into the surgical area.  Integrity of periorbita should be preserved drtbalu's otolaryngology online 19 Surgical field – External ethmoidectomy
  20. 20.   Cottonoids dipped in oxymetazoline can be used to gently pack the ethmoidal cavity  Packing should be light enough not to increase intraorbital pressure  These packs are ideally removed within the first 48 hours  Antibiotics should be routinely administered to prevent infections. drtbalu's otolaryngology online 20 Role of nasal packing after surgery
  21. 21.   Crusting  Bleeding  Epiphora  Cosmetic defects of nose  Scarring involving medial canthus  CSF leak  Supra orbital nerve anesthesia  Blindness /diplopia drtbalu's otolaryngology online 21 Complications of external ethmoidectomy
  22. 22.   Vital structures like carotid artery and optic nerve lie in proximity  Cavernous sinus involvement in diseases involving sphenoid sinus adds to the difficulty  Optimal approach should be tailored taking into consideration the contiguous structures involved  All inflammatory lesions involving sphenoid sinuses are better managed endoscopically  Anatomy is highly variable  Sphenoid septum is rarely seen in midline drtbalu's otolaryngology online 22 Surgery – Sphenoid pitfalls
  23. 23.  drtbalu's otolaryngology online 23 Sphenoid sinus - Anatomy
  24. 24.   To remove pituitary microadenomas  To repair CSF leaks  To decompress mucoceles  To remove tumors involving sphenoid sinus drtbalu's otolaryngology online 24 Indications for Trans septal approaches for sphenoid
  25. 25.   Sublabial transeptal approach  Transnasal transeptal approach  External rhinoplasty transeptal approach  Columellar flap modification approach drtbalu's otolaryngology online 25 Trans septal approaches - Types
  26. 26.   Commonest trans septal approach  Performed under GA  1% xylocaine with 1:100,000 units adrenaline is infiltrated into median gingivo buccal sulcus, nasal septum and floor of the nose.  Incision is made 5-10mm superior to the gingiva and is carried down to the bone of premaxilla. The periosteum is elevated up to the inferior margin of pyriform aperture. drtbalu's otolaryngology online 26 Sublabial transeptal approach
  27. 27.   Anterior nasal spine is exposed. It can be fractured for exposure but left attached to the septum  Anterior & inferior tunnels are created over nasal septum by elevating mucoperichondrium  Cartilaginous portion of nasal septum is dislocated from the floor and pushed to one side  Perpendicular plate of ethmoid and maxillary crest displaced to one side. Inferior turbinate can be out fractured for creating more space  Sphenoid speculum is introduced and the sphenoid sinus is entered through midline drtbalu's otolaryngology online 27 Sublabial transeptal contd
  28. 28.   Easy procedure  Scarless  Use of midline speculum increases visibility  Minimal post op nasal deformity  Suited for nasal cavity of any size drtbalu's otolaryngology online 28 Sublabial transeptal - advantages
  29. 29.   Oral contamination of wound ++  Incisions may cause problems with dentures  Dental complications like devitalization of teeth is a possibility drtbalu's otolaryngology online 29 Sublabial transeptal - disadvantages
  30. 30.   This approach is without sublabial incision  Allows direct access to the rostrum of sphenoid  Incisions used include: Hemitransfixation, Killian’s, vertical and bony cartilaginous junction incisions.  This approach may not be suitable for small noses because of difficulties faced in inserting the speculum drtbalu's otolaryngology online 30 Transnasal transeptal approach
  31. 31.  drtbalu's otolaryngology online 31 Incisions used in transeptal sphenoid surgeries 1. Freer 2. Killian 3. Vertical 4. Bony cartilaginous junction
  32. 32.   Oral cavity contamination is avoided  Scarless  Septal incisions can be placed anteriorly / posteriorly  Posterior incisions are useful in septal reoperations drtbalu's otolaryngology online 32 Trans nasal transeptal approach - advantages
  33. 33.   High risk of nasal disfigurement  Requires meticulous post op wound care  Ideally suited only for large nasal cavities  Columellar incision scar may be visible in some patients drtbalu's otolaryngology online 33 Trans nasal transeptal approach - Disadvantages
  34. 34.  drtbalu's otolaryngology online 34 External rhinoplasty transeptal approach
  35. 35.   Exposure is excellent  Midline approach  Oral cavity contamination is avoided  Nasal deformities present preoperatively can also be corrected  Can be used in noses of any size drtbalu's otolaryngology online 35 External rhinoplasty transeptal - advantages
  36. 36.   Bleeding  Crusting  Epiphora  Septal perforation  Nasal deformities  CSF leaks  Intracranial bleed  Synechiae drtbalu's otolaryngology online 36 External approach to sphenoid - complications
  37. 37.   Trephination  External frontoethmoidectomy  Frontal sinusotomy without osteoplastic flap  Frontal sinusotomy with osteoplastic flap  Frontal sinus ablation  Lothrop procedure  Lynch procedure drtbalu's otolaryngology online 37 External approaches to frontal sinus
  38. 38.   In this procedure a small opening is made in the floor of frontal sinus to drain its contents  This procedure is the oldest known for accessing frontal sinuses drtbalu's otolaryngology online 38 Frontal sinus trephining
  39. 39.   Acute frontal sinusitis with orbital / cranial complications  To localize frontonasal tract during endoscopic sinus surgery  In above below approach to frontal sinus surgery  To prevent stenosis of frontal outflow tract following endoscopic sinus surgery drtbalu's otolaryngology online 39 Trephination - Indications
  40. 40.  drtbalu's otolaryngology online 40 Frontal trephining - procedure  X-ray occipitofrontal view  GA/LA  Infiltration of xylocaine should block trochlear nerve  Incision is sited as shown in the figure  Drill is used to perforate the bone
  41. 41.   Radiographic assessment of the size of frontal sinus  Meticulous location of frontal sinus  Control aspiration using a needle is a must  Irrigation of frontal sinus should be performed in a slow and gentle manner  Trephination should not be performed if pneumatization does not reach up to the superior limit of orbit drtbalu's otolaryngology online 41 Frontal sinus trephining – safety guidelines
  42. 42.   Brain injury  Cellulitis  Orbital complications due to needle shift drtbalu's otolaryngology online 42 Complications of frontal trephining
  43. 43.   This surgery can be performed with a small and cosmetically acceptable incision  Sphenoid sinus can also be accessed by this approach  It does not cause any facial deformity drtbalu's otolaryngology online 43 External frontoethmoidectomy - Advantages
  44. 44.   It is unilateral  Exposure is limited and complete removal of mucosa is not possible in a large and septate frontal sinus  Frequently causes closure of nasofrontal duct causing recurrence of the disease drtbalu's otolaryngology online 44 External frontoethmoidectomy - Disadvantages
  45. 45.  drtbalu's otolaryngology online 45 External frontoethmoidectomy - Incision  Curved incision is made towards medial canthus of the eye  The incision should divide the distance between the dorsum of the nose and medial canthus of the eye as shown in the figure
  46. 46.  drtbalu's otolaryngology online 46 External frontoethmoidectomy - contd  Frontal sinus can be opened by resecting the lacrimal bone, frontal process of maxilla and floor of frontal sinus  Ethmoid cell system should be resected with care.  The end result is a single cavity comprising of frontal sinus, ethmoid, and nasal cavity.  About 2/3 of bony margins of frontal sinus drainage channel is resected causing scarring and mucocele formation  Stent should be left here at least for 6 months to prevent mucocele formation  Supraorbital and supra trochlear nerve is at risk
  47. 47.  Frontal sinusotomy with / without osteoplastic flap drtbalu's otolaryngology online 47 1. This technique is used to obliterate frontal sinus 2. To restore the functioning of frontal sinus 3. Incisions used include bicoronal, brow and mid forehead infections 4. This procedure is useful in treating patients with tumors involving the frontal sinuses
  48. 48.   Indicated in patients with irreversible frontal sinus outflow tract obstruction  In patients with diffuse mucosal disease not responding to conservative management  Mucosa of frontal sinus and supra orbital ethmoidal cells are totally removed  Bone within the sinus should be drilled to remove mucosa from the foramina of Breschet  Abdominal fat / pericranium can be used to obliterate the sinus drtbalu's otolaryngology online 48 Frontal sinusotomy with obliteration of sinus
  49. 49.   Interpretation of CT / MRI in patients with obliterated frontal sinus could be dicey  Hyper pneumatized supraorbital ethmoid cells may make the procedure difficult  Presence of fungal sinusitis is a contraindication for the procedure drtbalu's otolaryngology online 49 Problems with obliterated frontal sinus
  50. 50.   One method of frontal sinus ablation  Anterior wall & floor of frontal sinus is removed  Orbital soft tissues & collapsing anterior wall soft tissues will obliterate the frontal sinus  Causes disfigurement of face drtbalu's otolaryngology online 50 Reidel procedure
  51. 51.   This procedure allows for drainage of both frontal sinuses through a common pathway  The frontal sinus is entered via a large trephine just below the eyebrow. The interfrontal septum is removed through the same opening facilitating drainage through a common channel drtbalu's otolaryngology online 51 Lothrop procedure
  52. 52.  drtbalu's otolaryngology online 52 Miniosteoplastic flap 
  53. 53.   Provides adequate exposure of frontal sinus  Modified Lynch Howarth incision is used  Image guidance system will be of use in identification of the sinus drtbalu's otolaryngology online 53 Advantages of Miniosteoplastic flap
  54. 54. drtbalu's otolaryngology online 54