External approaches to sinus surgery


 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


 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


 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


 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


 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


 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


 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


 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


 Cheek edema (ecchymosis)
 Infraorbital nerve dysesthesia
 Epiphora
 Oroantral fistula
Caldwell – Luc
complications


 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


 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
Indications for external
ethmoidectomy


 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
Anatomy of ethmoid


 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.
External ethmoidectomy


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


 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
Periosteal preservation -
importance


Medial orbital wall -
exposure


 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
Medial orbital wall
exposure - contd


 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
Surgical field – External
ethmoidectomy


 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.
Role of nasal packing
after surgery


 Crusting
 Bleeding
 Epiphora
 Cosmetic defects of nose
 Scarring involving medial canthus
 CSF leak
 Supra orbital nerve anesthesia
 Blindness /diplopia
Complications of
external ethmoidectomy


 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
Surgery – Sphenoid
pitfalls


Sphenoid sinus -
Anatomy


 To remove pituitary microadenomas
 To repair CSF leaks
 To decompress mucoceles
 To remove tumors involving sphenoid sinus
Indications for Trans septal
approaches for sphenoid


 Sublabial transeptal approach
 Transnasal transeptal approach
 External rhinoplasty transeptal approach
 Columellar flap modification approach
Trans septal approaches
- Types


 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.
Sublabial transeptal
approach


 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
Sublabial transeptal
contd


 Easy procedure
 Scarless
 Use of midline speculum increases visibility
 Minimal post op nasal deformity
 Suited for nasal cavity of any size
Sublabial transeptal -
advantages


 Oral contamination of wound ++
 Incisions may cause problems with dentures
 Dental complications like devitalization of teeth is a
possibility
Sublabial transeptal -
disadvantages


 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
Transnasal transeptal
approach


Incisions used in transeptal
sphenoid surgeries
1. Freer
2. Killian
3. Vertical
4. Bony cartilaginous junction


 Oral cavity contamination is avoided
 Scarless
 Septal incisions can be placed anteriorly /
posteriorly
 Posterior incisions are useful in septal reoperations
Trans nasal transeptal
approach - advantages


 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
Trans nasal transeptal
approach - Disadvantages


External rhinoplasty
transeptal approach


 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
External rhinoplasty
transeptal - advantages


 Bleeding
 Crusting
 Epiphora
 Septal perforation
 Nasal deformities
 CSF leaks
 Intracranial bleed
 Synechiae
External approach to sphenoid -
complications


 Trephination
 External frontoethmoidectomy
 Frontal sinusotomy without osteoplastic flap
 Frontal sinusotomy with osteoplastic flap
 Frontal sinus ablation
 Lothrop procedure
 Lynch procedure
External approaches to frontal
sinus


 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
Frontal sinus trephining


 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
Trephination - Indications


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


 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
Frontal sinus trephining –
safety guidelines


 Brain injury
 Cellulitis
 Orbital complications due to needle shift
Complications of frontal
trephining


 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
External frontoethmoidectomy -
Advantages


 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
Disadvantages


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


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


Frontal sinusotomy with /
without osteoplastic flap
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


 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
Frontal sinusotomy with
obliteration of sinus


 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
Problems with obliterated
frontal sinus


 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
Reidel procedure


 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
Lothrop procedure


Miniosteoplastic flap



 Provides adequate exposure of frontal sinus
 Modified Lynch Howarth incision is used
 Image guidance system will be of use in
identification of the sinus
Advantages of
Miniosteoplastic flap

External approaches to sinus surgery

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