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Endoscopic Sinus Surgery. Section 6 ( قسمت ششم فایل ). Bakhshaee M, MD Rhinologist, Assistant Prof. MUMS. Frontosphenoethmoidectomy. Frontosphenoethmoidectomy. This includes an anterior ethmoidectomy, posterior ethmoidectomy, sphenoid sinusotomy along with opening the frontal recess.
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Endoscopic Sinus Surgery Section 6 (قسمت ششم فایل) Bakhshaee M, MD Rhinologist, Assistant Prof. MUMS
Frontosphenoethmoidectomy • This includes an anterior ethmoidectomy, posterior ethmoidectomy, sphenoid sinusotomy along with opening the frontal recess
This is mainly reserved for those with persistent symptoms after anterior ethmoid surgery. • In patients with severe recurrent polyposis, the best way to provide the patient with a longer symptom-free interval is to open up all the cells including the frontal recess
Sphenoid Sinusotomy (I, II, III) • Sphenoid sinusotomy I: Identifying the sphenoid ostium without further instrumentation. • Sphenoid sinusotomy II: Opening the sphenoid inferiorly to half its height and upward to the skull base. • Sphenoid sinusotomy III: The sphenoid sinusotomy is extended to the floor of the sinus and laterally to the vital structures
Indications • Isolated sphenoid sinus disease, e.g., • Aspergillosis • Purulent bacterial infection • Inverted papilloma • Mucocele • Biopsy of skull base lesions
Surgical Technique • The sphenoid ostium can be found at the level of the superior turbinate. It is often necessary to lateralize the middle and superior turbinate in order to visualize it
If visibility is poor because of polyps or bleeding, the sphenoid sinus can safely be approached by staying close to the septum in the midline and palpating with the straight sucker up the posterior wall of the sphenoid • At 1−1.5 cm above the posterior choana, the bone of the anterior wall of the sphenoid sinus is thin and it can be punctured by applying moderate pressure with a straight sucker
It is advisable not to open the sphenoid ostium downward to a level lower than half the total height of the sinus, as a branch of the sphenopalatine artery runs along its anterior wall and if cut this can bleed briskly. • Occasionally, the intersinus septum of the sphenoid is so oblique that one side can be very small.
Comment on the Management of theMiddle and Superior Turbinates
By preserving “all” the mucosa in the olfactory area on the septum and the turbinates, as well as opening the olfactory cleft. • It is difficult to resist the temptation to remove or debulk polyps medial to the middle turbinate, but it is best to preserve this mucosa. • A course of preoperative steroids will help reduce the size of the polyps. • Only remove polyps that come from the posterior ethmoid cells under the superior turbinate and not polyps that are based on the septum or the middle turbinate.
If there is a concha bullosa, the lateral half of the turbinate can be resected. • This can be done by incising the anterior surface with a sickle knife and then removing the lateral portion by cutting it free with microscissors or with straight through-cutting forceps
Step 1 • involves advancing the endoscope along the inferior meatus
Step 2 • involves coming forward a little and angling the endoscope upward to see the sphenoethmoid recess area
Step 3 • is accomplished by gently rolling the endoscope under the middle turbinate to see whether mucopus is tracking under the ethmoid bulla from the maxillary sinus
Allergy Hypertrophied inferior turbinate Edematous middle turbinate
Infection Bacterial rhinosinusitis Aspergillosis
Pyogenic granuloma Inflammatory Diseases
Benign Tumors Antrochoanal polyp Inverted papilloma
Benign Tumors Chondroma Angiofibroma
Malignant Tumors Olfactory neuroblastoma Lymphoma
Malignant Tumors Amelanotic melanoma Adenocarcinoma
The Role of Conventional Radiology • Plain radiographs have a limited role in the modern management of paranasal sinus disease because they have so many false-positive and false-negative findings • In acute maxillary or frontal sinusitis, they can help confirm the diagnosis
The Role of Computed Tomography • This provides a map for endoscopic sinus surgery • Although CT has good sensitivity for diagnosing paranasal sinus disease, it has poor specificity; for example, there are many false-positive changes.
Important not to request a CT scan in the initial management if patients unless there are specific reasons to do so. • These include: • Suspected intracranial or intraorbital involvement as a complication of rhinosinusitis • Suspected atypical infection or malignancy • Specific pathology, e.g., mucoceles, benign tumors of the paranasal sinuses, where the extent of the lesion • Needs to be defined Prior to orbital or optic nerve decompression
When to Request CT • CT for rhinosinusitis is best reserved for patients who have not responded to maximum medical treatment
CT Parameters • Axial sections with coronal reconstruction will remove any dental artifacts; these can be excluded because they lie in the axial plane, and this produces better images with less artifact
Sagittal reconstructions • Helpful for frontal surgery, giving the surgeon a better understanding of the complex relationship between the anterior ethmoid sinuses and the frontal recess
Intravenous contrast • is only required for tumors, vascular lesions, and the orbital and intracranial complications of infection
Indications for MRI • The prevalence of incidental changes on MRI is so great that the technique is of little use in the diagnosis of rhinosinusitis • This is particularly helpful in defining the boundary of pathology in relation to the dura, orbital apex, or optic nerve.
A comparison between a T2-weighted image (fluid bright), a T1-weighted image (fluid dark), and a T1-weighted image with nonionic contrast provides useful information about soft-tissue lesions
MRI is complementary to CT • Where malignancy has reached the dura of the anterior skull base, the orbital apex, and the optic nerve
If there is intracranial or intraorbital involvement from an atypical infection or inflammatory process
