1. Surgical management of rhinosinusitis
Endoscopic surgery is traditionally divided into two schools
The primary objective of the Messerklinger approach, championed by Stammberger is the removal
of pathology in the ostiomeatal complex, sufficient to achieve ventilation & drainage. Hence the
term functional endorsed by kennedy.
A more radical approach has been proposed by Draf & Wigand particularly related to polyposis, in
which an absence of surgical landmarks & profuse pathology determines a back-to-front approach.
The title, FESS (functional endoscopic sinus surgery) is therefore only appropriate when performing
limited surgery with preservation of existing structures & should not be used for many surgical
indication,e.g.orbital decompression,dacrocystorhinostomy etc.
A large number of acronyms have since appeared MESS(microscopic endonasal sinus
surgery),MISS(minimally invasive sinus surgery),TSS(transitional space surgery). These have not
substantially altered practice but are largely variations on a theme.
Endoscopic sinus surgery
Indications
Chronic rhinosinusitis;
Acute recurrent rhinosinusitis
Nasal polyposis;
Mucocoeles;
Allergic fungal sinusitis & mycetoma;
Repair of cerebrospinal fluid(CSF) leaks;
Orbital & optic nerve decompression;
Repair of blow-out fractures
Dacrocystorhinostomy;
Choanal atresia;
Hypophysectomy;
Septal &turbinate surgery
Management of epistaxis;
Drainage of periorbital abscess;

2. Some benign & malignant tumours.
Only the treatment of chronic & acute recurrent rhinosinusitis could be regarded as a functional
approach,i.e.attempting to reverse pathophysiological process by conservative surgery.
Contraindications
In the presence of an intracranial complication of acute infection, such as meningitis,subperiosteal
or epidural abscess, cavernous sinus thrombosis.
Operations of paranasal sinuses for chronic rhinosinusits.
Conservative Radical
Maxillary sinus Antral washout
Intranasal antrostomy
(middlemeatal endoscopic)
Caldwell-luc
Frontoethmosphenoid Draf I-III endonasal drainage
Trephination of frontal sinus
Intranasal ethmoidectomy
Endoscopic uncinectomy,
Endoscopic ethmoidectomy
Endoscopic clearance of frontal
recess
Opening of sphenoid ostium
Transantral
ethmoidectomy(Jansen-horgan)
External
frontoethmoidectomy(lynch-
Howarth, Patterson)
Osteoplasty flap(with or
without obliteration)
Cranialization of the frontal
sinus
Anaesthesia
Endoscopic sinus surgery can be performed under local or general anaesthesia, originally
preferrance for local anaesthesia.
Local anaesthesia is carried out in a similar manner to that for antral lavage,except that further
injections 2% lignocaine into uncinate process, greater palatine foramen & middle turbinate (upto
4ml). Alternatively vasoconstrictor can be achieved with ribbon gauze soaked in 1:1000 adrenaline
packed around the middle meatus & surgical cavity.
With general anaesthesia Moffatt’s solution( 2ml of 2% sodium bicarbonate, 2ml of 2% cocaine&
1ml of 1:1000 adrenaline) half in each nostril. The patient’s head is left hyperextended for

3. 10minutes before transfer to the main operating room where the patient is placed on the table in
the supine position.
Surgical technique
The CT scan should always be available in the theatre& the eyes left uncovered throughout the
procedure. A 00 4-mm Hopkins rod should be used for most of the surgery, as it is easy to become
disorientated with angled endoscopes, though latter are necessary for inspecting recess &
performing middle meatal antrostomy or operating in the frontonasal recess.
An infundibulotomy is performed by incision the anterior attachment of the uncinate process with a
sickle knife or freer’s elevators. The elevator can be used to lift the uncinate process medially to
display the infundibulum & it is then grasped with forceps, the upper & lower attachments are cut
with fine fine scissors & the uncinate process detached with a twisting motion. Bone overlying the
nasolacrimal duct is hard. Any residual rim can be removed with backbittting forceps.
The ethmoidal bulla is opened with a fine straight Blakesley-wilde forceps & removed piecemeal.
The lamina papyracea is extremely thin, through which the yellow orbital fat can often be discerned.
Slight pressure on the globe will demonstrate whether the lamina is dehiscent.
Behind the bulla, a variable space is entered, the retrobullar recess (previously called the lateral
sinus), which extends above the bulla as the suprabullar recess. Superiorly the skull base may be
visible & anterior ethmoidal artery may be identified running posterior to the frontal recess. In many
cases, this may be all that is required.
To open the maxillary antrum, explore the frontal recess , posterior ethmoids & sphenoid will
depend upon the extent of disease as evidenced by the CT scan &operative findings.
The posterior ethmoids are entered by piercing the basal lamella,3-4 mm above horizontal
attachment of the turbinate adjacent to the vertical attachment of the turbinates. Posterior cells are
larger & pyramidal in shape. Optic nerve can be prominent in the lateral wall & overlying bone is
extremely thin. Sphenoethmoidal cell (Onodi cell) is posterior ethmoidal cell extending lateral &
superior to the sphenoid.
The sphenoid can be opened by entering inferiorly & medially from last cell.
Middle meatal antrostomy is not necessary if the natural maxillary ostium is found to be patent after
uncinectomy. If an accessory ostium is present, it should be joined to the natural ostium to avoid
abnormal recirculation of mucus. Any damage will lead to disruption of the mucus clearance,
particularly over the posterior ostial edge. Ostium can be enlarged posteriorly with forward biting
Grunwald forceps. Anteriorly & inferiorly with backbiting/downbiting punches respectively , again
taking care to avoid the nasolacrimal duct & lateral sphenopalatine artery.
Conservation of mucosa in the frontal recess is generally advisable, particularly in the absence of
frontal sinus infection so as to avoid scarring.
When the umcinate process attaches laterally on to the lamina papyracea, the infundibulum leads
into the blind-ending,terminal recess.

4. When the uncinate process attaches superiorly or rarely medially to the middle turbinate, it is
possible to visualize the frontal recess directly with a 300 or400 scope in most cases. Frontal recess is
an hourglass appearance found situated medial to an opening of a suprabullar ethmoidal cell which
extends over the orbital roof. Removal of this cell, so called uncapping the egg will open access to
the frontal sinus, ideally avoiding any circumferential removal of mucosa. Care to avoid damage to
the anterior ethmoidal artery.
Computer-assisted surgery(CAS) using a variety of navigation systems has provoked increasing
interest.
Post-operative management
Cleaning of the surgical cavity.
Prophylactic antibiotics for two weeks post-operatively in all patients combined with alkaline nasal
douche & an intranasal steroid.
Most patients with diffuse polyposis receive a course of oral steroids in reducing dosage
(prednisolone 30mg/20mg/10mg/day each for one week). In severe cases, a similar course is given
preoperatively & also intranasal steroids prior to surgery.
The patients are usually seen seven to ten days after the surgery, then usually 2weekly basis until
the cavities are well healed.
For the purpose of audit , the patients are seen at least at 3,6, 12, 24 months postoperatively(each
visit the cavity is cleaned under endoscopic control, adhesion divided, debris removed, further
polypoid mucosa removed).
Antral lavage
Antral lavage has been used both in the diagnosis of & treatment of rhinosinusitis though diagnostic
role to clarify plain x-ray by proof puncture is obsolete.
Indication:
1)The treatment of acute rhinosinusitis which has been failed to responsed to conservative
medication.
2) An adjunctive procedure to external drainage for acute orbital complications.
Antral washout is usually performed through the inferior meatus. One alternative to repeated
puncture was the insertion of an indwelling catheter through which daily irrigation could be
performed until the quantity & quality of secretion improves. Now rarely performed ,preferring a
definitive endoscopic middle meatal approach to enlarge the natural ostium.
Contraindications: 1) The proximity of the orbital floor & teeth in the small maxillary sinus of a child
under the age of three years makes antral puncture hazardous.
2)Hypoplastic maxilla
3)In the presence of trauma which may have disrupted the orbital floor.

5. Surgical technique
1) With the patient seated comfortably , the wool carriers are removed & inferior meatus is
visualization using a Thudicum speculum
2) A tilley-lichtwiz trocar &cannula passed under the attachment of the inferior turbinate up to
the genu where it will naturally come to rest.
3) The instruments are held with the body of the trocar in the palm of the hand& index finger
running alone the shaft.
4) Holding the patient’s head steady, the trocar is directed towards the tragus of the ipsilateral
ear.
5) Moderate pressure accompanied by a gentle boring action is usually sufficient to perforate
the inferior meatal wall at its thinnest point.
6) The trocar is advanced until abuts the opposite antral wall& then withdrawn several
millimetres. The trocar is then removed.
7) The patient now leans forwards, holding a bowl beneath the chin to collect the washings&
instructed to breathe through the mouth.
8) The washout is performed using a Higgison syringe & sterile normal saline or water at 370C.
As the fluid is flushed into the sinus, majority returns via anterior nares but any running
posteriorly runs out of the mouth into bowl.
9) If a purulent washout is obtained, lavage is continued until it is clear.
10) Following adequate lavage, cannula is removed & the patient is warned that fluid may come
out from the nose over next few hours.
If the procedure is performed under general anaesthesia, the patient is placed in the tonsil position
with a Boyle-Davis mouth gag in place or in reverse Trendelenberg position with 150 of head flexion
& a throat pack.
Complications
Anterior wall can be breached leading to pain & swelling.
Perforation of the orbital floor leads to immediate pain. Under G/A, bulging of the orbital contents
may be observed. So eyes must be untapped & upper eyelid gently elevated by an assistant. In
presence of dehiscent infraorbital canal ,even a correctly placed cannula can produce this
complication.
Inferior meatal antrostomy
This operation has traditionally been used in the treatment of acute,recurrent& chronic maxillary
sinusitis which has failed to respone to conservative management.

6. Caldwell-luc procedure
The operation is designed to remove irreversibly damaged mucosa of the maxillary sinus & to
facilitated gravitation drainage &aeration via an inferior meatal antrostomy. It has predominantly
been used for persistent chronic rhinosinusitis when medication, lavage,& inferior meatal
antrostomy has failed.
It is not normal ciliated respiratory epithelium which replaces diseased mucosa & cavity becomes
partially obliterated by fibrous tissue which may be associated with formation of the retention cysts.
Potential indications for Caldwell-luc operation, in reality it is principally utlilised as a route of access:
Chronicmaxillary sinusitis;
Removal of foreign bodies, ssuch as dental root, or amalgam;
Closure of an orantral fistula;
Dental cysts involving the antrum;
Access to the pterygopalatine fossa & pterygomaxillary fissure
Removal of recurrent antrochoanal polyps
Access to the orbital floor for elevation &stabilization for fractures or in imploding antra or
removal of the floor for orbital decompression.
It is not recommended as a route for biopsy of antral malignancy as it potentially open a hitherto
unaffected area to contamination.
Contraindications
It is rarely performed in children as damage to the secondary dentition can result.
Surgical technique
1) The patient is positioned in a reverse Trendelenberg position with 150 of flexion.
2) An incision is made down to the bone in the gum margin,3mm above & parallel to the
gingivolabial fold from the posterior edge of the lateral incisor to the 1st or 2nd molar tooth(3-
4cm). It is advisable that the incision does not directly overlie the opening in the anterior
face of the maxilla so as to lessen the risk of a ranula.
3) The mucoperiosteal flap is then dissected superiorly with a periosteal elevator to expose the
anterior wall of the sinus, taking care to avoid damage to the infraorbital nerve arising from
the foramen just below the orbital rim.
4) Anterior wall is opened in the canine fossa where the bone is relatively thin. The opening
can be enlarged approximately 1- 1.5 cm diameter. Inferior extension may lead to damage to
the teeth& their nerve supply.

7. 5) Entire lining of sinus is dissected & removed. This can be difficult to achieve in the
inferolateral angle & roof.
6) A large inferior meatal antrostomy (2×1) is fashioned. Packing of the nasal cavity & antrum
via antrostomy is required.
7) Suturing the buccal mucosa incision is recommended with absorbable suture material to
decrease the risk of fistula formation& should be sufficiently loose to allow drainage of
blood.
8) The patient is advised not to blowing of the nose for at least a week.
Complications
Pain & soft tissue swelling
Paraesthesia due to damage of the infra-orbital nerve.
Damage to the teeth & their innervations ,discolouration of teeth.
Orantral fistula
The mucosa which regrows in the maxillary sinus is abnormal both histologically& functionally.
Retention cysts may occur.