This document discusses various surgical approaches for treating sinusitis. It covers procedures for the maxillary, frontal, ethmoid, and sphenoid sinuses. For the maxillary sinus, approaches include antral washout/lavage, intranasal antrostomy, and Caldwell-Luc procedures. For the frontal sinus, approaches include trephination, intranasal ethmoidectomy, and external frontoethmoidectomy. Complications of each procedure are also outlined.

1. Surgical management of sinusitis
Dr. Hitesh

2. Surgical approaches
 Maxillary sinus
-conservative 1 antral washout
2 intranasal antrostomy ( inferior &middle meatus)
-radical Caldwell –Luc
 Frontoethmosphenoid
-trephination of frontal sinus & sphenoid sinus
-intranasal ethmoidectomy
-Functional endoscopic sinus surgery
-transantral ethmoidectomy
 Radical
- - external frontoethmoidosphenoidectomy ( Lynch
Howarth, Patterson)
- -osteoplastic flap

3. Antral lavage
 Indication
-diagnosis of sinusitis
-treatment of acute & subacute maxillary sinusitis and pansinusitis
(not responding to conservative management)
 Contraindication
-under 3 yr of age
-hypoplastic max sinus with thick wall
-acute febrile maxillary sinusitis ( osteomyelitis & septicemia)
-disruption of orbital floor
 Done under GA or LA

4.  Procedure
- 10%cocaine & 1:1000 adrenaline (spray/ cotton pledgets)
placed in inferior meatus at genu and middle meatus.
- Inferior meatus visualized with speculum. Tilley-Lichtwitz trocar
& cannula are used for puncture. Trocar directed towards
tragus of ipsilateral ear.
- Trocar advance till it abuts opposite antral wall.
- Withdrawn several mm, trocar removed. Patient leans
forward,holding a bowl beneath the chin. Advice to breathe
threw mouth. Washing is perform with higginson syringe with
normal saline or water at 37°C.
- Tonsillectomy position or reverse trendelenberg when done
under GA.

6. - Avoid air introduction ( air
embolus)
- Lavage continue until it is
clear, if clear initially
procedure continue as
mucoid material require
some loosening
 Complication
- mild hemorrhage
- pain & swelling of cheek
- perforation of orbital floor,
posterolateral wall

7. Inferior meatus antrostomy
 Indication
-Acute, recurrent &chronic
maxillary sinusitis not
responding to conservative
management.
-Primary mucociliary abnormality
(cystic fibrosis)
 LA or GA
 Reverse trendelenberg position
 Perforate the inferior meatus at
the highest point under genu of
turbinate (thinnest). Perforate
widened (2×1cm) and inferior
edge lowered as much as
possible.

8.  Complications
-hemorrage ( inferior meatal branch of
sphenopalatine A)
-injury to anterior superior alveolar nerve
-nasolacrimal duct injury
-narrowing of opening

9. Caldwell-Luc procedure
 Described by George Caldwell 1893 & Henry Luc 1897.
 Indication
-management of acute complicated or chronic rhinosinusitis.
-removal of foreign bodies
-inspection and biopsy from suspected neoplasm
-closure of oroantral fistula
-dental cyst involving the antrum
-access to pterygomaxillary fissure & pterygopalatine fossa
-removal of recurrent antrochonal polyp
-elevation and stabilization of orbital floor fractures or removal of orbital
floor in decompression
 Contraindication
-in children ( damage to secondary dentition)
 Usually in GA
 Reverse trendelenberg position

10.  Method
-gingivobuccal sulcus injected
Incision made 3mm above gingivobuccal sulcus extend from
posterior edge of lateral incisor to 1 or 2 molar.
Mucoperiosteal flap elevated to expose anterior wall of sinus
(avoid infraorbital nerve injury)
Wall open in canine fossa with gauge or drill.
Opening widened with punch forceps (1-1.5cm)
Entire lining of sinus removed
2×1cm inferior meatus antrostomy done
Packing &suturing done

12.  Complication
-pain and soft tissue swelling
-hemorrhage
-parasthesia due to injury of infraorbital nerve
-neuralgia in distribution of infraorbital nerve
-alteration of dental sensation
-oroantral fistula
-rarely retention cyst

13.  Modifications of Caldwell-luc operation
1.Canfield- intranasal incision made just behind the
vestibule. Periostium is elevated laterally over the
edge of pyriform aperture and into canine fossa.
Anterior angle of maxillary sinus is chiselled off to
expose the antral contents & opening is continued
backwards into an intranasal antrostomy.
2. Denker’s operation- incision is made as for a
Caldwell- Luc but continued further medially so that
nasal cavity and canine fossa is exposed

14.  Oblitration of maxillary sinus – McNeil 1966
Inverted U incision over the anterior wall of
antrum and then perforated the bone so as to
open it downward as a flap hinged inferiorly
to the soft tissue. Lining mucosa completely
removed & periosteal layer of antral wall
gently burred. Fat taken from anterior
abdominal wall was placed in cavity

15. Intranasal ethmoidectomy
 Indication
-polyps, tumors, foreign bodies and chronic rhinosinusitis not
responsive to medical therapy.
Usually under GA
1% with 1:100000 LA given
With the help of head light and speculum
Middle turbinate medialized to improve middle meatus exposure
Often a total middle tubinectomy performed. Small curette used to open
bulla and anterior ethmoid & posterior ethmoid (if require) removed.
Sphenoid may also entered
Complication rate-1.1-2.8%
- Periorbital hematoma
- Orbital fat prolapse, injury to medial rectus and optic nerve
- CSF leak, meningitis.

16. External Frontoethmoidectomy
 Indication
-removal of tumor, frontal or ethmoid mucoceles.
-orbital complications of chronic rhinosinusitis.
Chronic rhinosinusitis unresponsive to medical therapy.
-recurrent polyposis ( landmark lossed)
-access to ethmoid arteries ligation , transethmoid
hypophysectomy, dacrocystorhinostomy, orbital
decompression, CSF leak repair.
Usually under GA
Incision is extended superiorly over the orbital rim into the
eyebrow (Lynch Howarth).

17. The incision for a frontoethmoidectomy is curvilinear with extension over the orbital rim. B,
Once the inferior wall of the frontal sinus and the lateral wall of ethmoidal complex are
exposed, the ethmoids can be entered through the lamina papyracea. The inferior wall of the
frontal sinus is also opened so that a stent can be placed into the nasal cavity

18. Incision is carried through the periostium, subperiosteal flap elevated.
Lacrimal sac is elevated from fossa. Anterior ethmoid artery ligated or
cauterized. Entire lateral wall of ethmoid complex and inferior wall of
frontal sinus exposed. probe is used to enter into ethmoid sinus
through lamina papyracea & punch forceps is used to open additional
cell. Drill is used to extend the opening into frontal sinus. Frontal
recess is enlarged to removed diseases and allow the placement of
stent.
Incision closed in 2 layers. Packing removed after 3-4 days. Stent left in
place for 6-12 month
Failure rate 4-18%
Complications
-oedema and infection
-paresthesia of skin
-hemorrhage
-dural exposure and CSF leak
-fat prolapse

19. Comparison of open frontal sinus
procedures:
LYNCH
PROCEDURE
ethmoidectomy&
removal of floor of
frontal sinus with or
without middle
turbinectomy
Quick
&simple, good for small
malignant lesions
Difficult in tall frontal
sinuses, recurrent
infection or muococele,
pyocele
KILLIAN Ant ethmoidectomy, with
or without middle
turbinectomy, floor& ant
wall of
sinus(except10mm
supraorbital strut)
Good visualization even
in large frontal sinuses
Fails to obliterate ,there
may be forehead
deformity in a large
sinus or with bony strut
necrosis
REIDEL Complete removal of
ant wall & floor of frontal
sinus
Good exposure of entire
sinus, easy to obliterate
If narrow ant-post
diameter
Forehead concavity in
larger sinus ,fail to
obliterate if wide ant-
post diameter

20. LOTHROP
PROCEDURE
u/l or b/l ant
ethmoidectomy,wi
th or without
middle
turbinectomy,inter
frontal septum
and
superior nasal
septum and
nasofrontal ducts
connected
Good for b/l
disease
not effective if
narrow ant-post
diameter of
frontal sinus or
duct

21. External Ethmoidectomy
 Indication
-acute or chronic sinusitis unresponsive to medical
therapy.
- In orbital complications
- Usually done under GA

22. Trans antral ethmoidectomy
 Jansen Horgan procedure
-combined with Caldwell Luc approach with access to the
ethmoids
-also used for orbital decompression
 Contraindication
-inadequate approach afforded for ethmoids
Follow Caldwell-Luc, posterior ethmoid open through antrum with
Tilley Henchal forceps in upward medially and posteriorly at
upper and inner angle of antrum in the direction of opposite
parietal eminence
-can combine with intanasal ethmiodectomy

23. Transorbital ethmoidectomy
 Petterson’s operation
-indication same as Lynch Howarth. In addition allows assess to
orbital floor ( orbital trauma, decompression)
-2 cm length, made in natural skin crease below inferior orbital
margin

24. Orbicularis muscle is split and periosteum incised &
elevated to the orbital margin. orbital floor removed as far
as the infraorbital nerve. Posteriorly extend from behind
the nasolacrimal duct as far as hard bone of the sphenoid
surrouding orbital apex. Superiorly as high as ethmoid
vessels.
Complication same as Lynch Howarth ( transient epiphora
(oedema of orbicularis oculi/ or stretching of nasolacrimal
duct & parasthesia, diplopia (inferior oblique)

25. Frontal sinus trephination
 Indication
-acute sinusitis not responsive to medical management.
-complication of acute sinusitis
-with endoscopic approach to assess the patency of
frontal sinus ostium (revision surgery)
Under LA or GA
CT- size of frontal sinus

26.  1:100000 LA
 Incision marked on superomedial aspect of orbital rim
Incision made through periostium
 Drill with cutting burr for trephination is made in the floor (acute
rhinosinusitis) & for chronic rhinosinusitis through anterior wall.
 Frontal sinus can be approached endoscopically for inferior
exposure
 Trephination can be enlarged with rongeur or drill. Small
catheter is placed into the sinus for drainage. If irrigation
needed then double lumen catheter placed
 Drainage tube can be removed once the patency of frontal
sinus conformed (methylene blue test)
 Persistent obstruction- endoscopic or external
frontoethmoidectomy
 Chronic rhinosinusitis- frontal sinus stent

27. A, The incision for a frontal sinus trephination is marked in the superomedial aspect of
the orbital rim. B, The skin and periosteum are elevated to expose the frontal sinus. C, A
drill is used to create the trephination. D, A catheter then be placed to irrigate the sinus

28. Sphenoid sinus irrigation
 Methods
-through natural ostium
-by making opening in anterior wall
Anterior wall present 7cm from
anterior nasal spine.
Tremble described this technique.
probe used to identified natural
ostium and specially designed
trocar and cannula which either
inserted through the natural
ostium or is used to puncture
the anterior wall close to ostium

29. Osteoplastic flap/frontal sinus
oblitration
 Indication
-large mucocele, tumors
-chronic rhinosinusitis (unresponsive to both medical therapy &
endoscopic approach)
-frontal sinus fracture and osteomas
Radiology to known outline of frontal sinus
Surgery perform under GA
Incision made 1cm posterior to hair line.
Mid-forehead or brow incision can be used
Bicoronal flap elevated, leaving the pericranium intact to expose
the anterior table of frontal sinus

30.  .. Pericranium incised around the border of frontal sinus. Inferior rim of
pericranium should be intact because this will hinge of osteoplastic
flap. Saw used to enter frontal sinus. Bone is cut at nasion to allow
adequate back fracture of the osteoplastic flap. Follow entry diseased
mucosa and tumor removed. Sinus mucosa removed to avoid
mucocele formation.
 Drilling sinus with diamond burr to removed microscopic fragment.
Duct oblitrate with fascia or mucosa. Fat graft harvested from abd can
placed. Wound closed, pressure dressing for 1-2 days.
 Hydroxyapatite cement, cranialization (removes posterior wall) to
oblitrate.
 Seroma, hematoma and abscess are common complication. Dural
exposure or tear,nasal skin necrosis,anosmia, temporary ptosis.
 Revision surgery-6%

31. A bicoronal flap provides adequate exposure for an osteoplastic flap with frontal sinus
obliteration. The sinus is outlined with the help of a 6-foot Caldwell or a computerized
navigation system. The periosteum is then excised and bone cuts are made to elevate the
inferior based flap. B, The mucosal lining of the frontal sinus should be carefully drilled with a
diamond burr under magnification. The frontal ostia are plugged with fascia or muscle.

32.  Incision made above or
below the eyebrows
and connect across
glebella ( small sinus, in
male with male pattern
baldness)

33. Endoscopic sinus surgery
Endoscopic anatomy
-Ethmoid bone
-Osteomeatal complex

34.  1-inferior hiatus
semilunaris
 2-ethmoid infundibulum
 3-superior hiatus
semilunaris
 4- sinus lateralis
 Ethmoid cells

35. Uncinate process

36. Lateral wall
. 1. Frontal sinus
 2. Anterior ethmoid sinus
 3. Flow from frontal sinus
 4. Flow from middle
ethmoid
 5. Posterior ethmoid sinus
 6. Middle turbinate base
 7. Sphenoid sinus
 8. Inferior turbinate base
 9. Hard palate

37. Lateral wall

38. Endoscopic sinus surgery
 Indication
-absolute
1-tumors
2-complications of rhinosinusitis
3-failed sinus surgery
4-mucoceles
5-fungal infection
6-encephalocele
7-CSF rhinorrhea
-relative
1chronic rhinosinusitis
2headache & facial pain
3-recurrent acute sinusitis
4-epistaxis
5-nasal polyps

39.  Radiological evaluation
-To evaluate anatomy &pattern of inflammation
-Negative finding on anterior rhinoscopy or endoscopic
assessment.
-All paranasal sinus evaluate to known the extent of
disease.
-To known any anatomical variation
Anesthesia –LA or GA

40.  Endoscopic procedure
-Messerklinger- anterior to posterior approach ( begin
with removal of uncinate process)
-Wigand –posterior to anterior ( begin with partial
resection of middle turbinate, opening of posterior
ethmoid cells, then removal of anterior wall of
sphenoid sinus
Patient position
-reverse Trendelenberg position & rotation of patient
toward surgeon

41.  Nasal endoscopy
-looking for landmark and structures
-condition of mucosa
-structure abnormalities seen preoperatively identified
-first pass ( floor, nasolacrimal duct, nasopharynx)
-second pass (middle meatus & sphenoethmoid recess
-third pass ( frontal recess)

42.  Uncinate process
-identified with 0°endoscope into the
middle meatus
-initial incision is made in horizontal fashion between
inferior 1/3 and superior 2/3 in axial plane via hiatus
semilunaris. Incision continue anteriorly until hard
lacrimal bone encountered.
-uncinectomy can done with the help of sickle knife,
back biting forceps, microdebrider& laser

44. Maxillary antrostomy

45.  Removal of uncinate
process expose
infundibulum. Maxillary sinus
ostium present behind lower
3ed of the uncinate.
 Probe used to identified
ostium when not easy to
identified.
 Maxillary sinus ostium
widening done
 30°endoscope maxillary
sinus examined.

46. Anterior ethmoidectomy

49.  Largest cell of anterior ethmoid complex
 Should be entered along anterior and medial aspect
 Some surgeon keeping inferior wall intact to keep the turbinate
medial.
 Opening of agger nasi & suprabullar cells completes the
anterior ethmoidectomy
 Agger nasi most anterior to ethmoid cells. Appear as projection
of lateral nasal wall at the attachment of middle turbinate.
Superior aspect close to skull base &lateral &anterior may
contiguous with lacrimal sac
 Ground lamella- posterior limit of anterior ethmoid cell

50. Middle turbinate
 Attachments
1-anterior most (ethmoid crest of maxilla)
2 posterior most (ethmoid crest of palatine bone)
3 anterior 1/3 ( sagittal plane with skull base)
4 middle 1/3 ( frontal plane with lamina)
5 posterior 1/3 ( horizontal plane with lamina)
Dissection should not carry medial to middle turbinate
in superior aspect (risk of injury to cribriform plate or
fovea ethmoidalis

52. Anterior &posterior
attachment of middle
turbinate should
preserved to maintain
stability.
Lateralized middle
turbinate can cause
post operative
obstruction of sinus
drainage

53. Posterior ethmoidectomy
 Behind ground lamella
 Skull base &orbit identified.
posterior to anterior
dissection of superior
ethmoid
 Onodi cell- lateral and
superior extension of
posterior ethmoid over
sphenoid sinus
 Gentle pressure over orbit
externally while visualizing
the lamina, any dehiscent
area can be identified.

54.  Posterior ethmoid (superior
to sphenoid sinus) & anterior
ethmoid artery( posterior to
frontal recess at the level of
roof of ethmoid) identified
 Frontal recess &agger nasi
area is opened last since
bleeding from above can
reduce visualization. Also
the area most at risk for
scarring & iatrogenic injury.

55. Sphenoid sinusotomy
 Identification
-7cm from nostril at 30°angle
-1.5 cm above choana
-1cm lateral to septum
-postero inferior dissection of
posterior ethmoid cell
-resection of inferior 1/3 of superior
turbinate
- Anterior wall of sphenoid sinus
convex anteriorly where as skull
base concave
- Ostium located at middle of
anterior wall.
 Follow identification widening of
ostium

57. Frontal sinosotomy
 Frontal recess is cone
shaped below the ostium of
frontal sinus.
-medial wall formed by most
anterior aspect of middle
turbinate, lateral wall lamina
papyracea, anterior wall by
posterior wall of agger nasi

58.  Curved probe and curette help in
identification of frontal recess
 30 degree scope help in visualization
 Disease remove to provide adequate
drainage area

59.  Postoprative care
-head should elevated
-quick visual and mental status examination
-ice pack reduce facial swelling
-patient with comorbid illness need observation over
night
-medication
- 1st
post operative visit 3-6 days after surgery (pack
remove, nasal endoscopic examination)

60. Complication of ESS
 Minor complications
-minor epistaxis
-hyposmia
-adhesions
-headache
-periorbital ecchymosis
Periorbital emphysema (lamina injury- positive
pressure, patient cough, vomits)
-dental of facial pain

61.  Major complications
- major epistaxis
- Orbital hematoma ( arterial or venous)
- Diplopia (ocular muscle injury-medial rectus, superior oblique) t
- Blindness ( raised intraorbital pressure, injury to nerve)
- Decreased visual acuity
- Intracranial hemorrage
- CSF leak( injury to cribriform plate, fovea ethmoidalis)
- Anosmia
- Nasolacrimal duct trauma( dissection should never perform
anterior to anterior end of middle turbinate)
- Meningitis
- Pneumocephalus
- Stroke
- Carotid injury

62.  Nasal septal deviation
-can cause displacement of middle turbinate, leading to
obstruction of osteomeatal complex
 Concha bullosa
-aerated middle turbinate or cell found with in turbinate
- On examination- widened area of turbinate or
aerated on CT
- 28% with sinusitis, 26%without sinusitis

63.  Thank you