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Surgical Treatment of Sinusitis. Dr. Vishal Sharma. Maxillary Sinusitis. Surgical Treatment Methods: 1. Antral Washout 2. Intra-nasal Inferior meatal antrostomy (INA) 3. Caldwell - Luc surgery 4. Middle meatal antrostomy 5. Functional Endoscopic Sinus Surgery (FESS).
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Surgical Treatment of Sinusitis Dr. Vishal Sharma
Maxillary Sinusitis Surgical Treatment Methods: 1. Antral Washout 2. Intra-nasal Inferior meatal antrostomy (INA) 3. Caldwell - Luc surgery 4. Middle meatal antrostomy 5. Functional Endoscopic Sinus Surgery (FESS)
Indications Diagnosis & treatment of chronic maxillary sinusitis not responding to conservative medications Cytology/culture sensitivity of antral contents Contraindications Age < 3 yrs Hypoplastic maxilla with thick bony walls Acute maxillary sinusitis untreated by antibiotics Trauma to maxillary sinus or Fracture of orbital floor Drainage of maxillary antral hematoma
Anesthesia: L.A. for adults. G.A. for children & un-cooperative pt. Position: Sitting / supine. Technique:Puncture lateral wall of inferior meatus with Tilley-Litchwitz antral trocar & cannula, just anterior to turbinate genu, trocar directed towards tragus of ipsilateral ear, with gentle boring action. Advance till it hits posterior wall, then withdraw slightly. Remove trocar & wash sinus with saline at 370 C with pt leaning forwards & saying k k. Wash till clear fluid comes. Remove cannula.
Complications 1. Hemorrhage ( Lateral Sphenopalatine artery) 2. Pain & swelling of cheek (breach of anterior wall) 3. Orbital damage (perforation of orbital floor) 4. Perforation of posterior wall (maxillary artery injury) 5. Vasovagal attack 6. Fatal air embolism
Intranasal antrostomy (INA) • Region of antral puncture in inferior meatus perforated with Tilley's antral harpoon. • Antrostomy enlarged with Tilley's antral burr or Myle’s nasoantral perforator.
Caldwell – Luc Surgery George Caldwell, 1893, New York Henri Luc, 1897, Paris
Indications Chronic refractory maxillary sinusitis Oro-antral fistula closure Foreign body removal from maxillary antrum Fungal maxillary sinusitis Elevation of orbital floor fractures Ethmoidectomy (trans-antral) Biopsy of suspicious neoplasm of maxillary antrum Orbital floor decompression Antrochoanal polyp (recurrent) Route to pterygo-palatine fossa (Vidian nerve, Max Artery) Dental / dentigerous cyst (maxillary antrum) removal
Incision 4 cm long, sub-labial, horizontal incision made 3 mm above & parallel to the gingival margin, from lateral incisor to 2nd molar tooth.
Complications Facial: Cheek edema, ecchymosis, subcutaneous emphysema, infraorbital n. paresthesia Orbital:Hematoma, extraocular muscle trauma, diplopia, globe trauma, blindness Oral: Trauma to teeth roots, Superior alveolar nerve damage, Dental anesthesia, Oroantral fistula Vascular:Internal maxillary artery injury
Ethmoid Sinusitis Surgical Treatment Methods: 1. Intra-nasal microscopic ethmoidectomy 2. Extra-nasal Ethmoidectomy a. Lynch Howarth procedure b. Patterson trans-orbital procedure c. Trans-antral (Jansen Horgan procedure) 3. Functional Endoscopic Sinus Surgery
Trans-antral ethmoidectomy • Caldwell – Luc surgery done to reach maxillary antrum • Ethmoid cells approached via postero-supero- medial angle of maxillary antrum
Frontal Sinusitis Surgical Treatment Methods: 1. Trephination of frontal sinus 2. Modified Lothrop procedure 3. Osteoplastic Flap surgery 4. Functional Endoscopic Sinus Surgery
Frontal sinus trephination 2-cm incision made 1 cm below medial end of eyebrow & deepened up to bone. Frontal sinus floor opened by drilling with burr. Opening enlarged with Citelli’s punch forceps to drain pus. Drainage tube inserted inside frontal sinus cavity & sutured in place. Regular lavage of the frontal sinus done through drainage tube for 48-72 hours post-operatively.
Lothrop Procedure Removal of frontal sinus (inferior septum + floor) + superior part of nasal septum
Sphenoid sinus Surgical Treatment Methods: 1. Trans-nasal trans-septal approach 2. Sublabial trans-septal approach 3. External ethmoidectomy approach 4. Endoscopic intra-nasal approach 5. Functional Endoscopic Sinus Surgery
Steps of F.E.S.S. 1.Uncinectomy (Infundibulotomy) 2. Anterior ethmoidectomy 3. Middle meatal antrostomy 4. Perforation of basal lamella 5. Posterior ethmoidectomy 6. Sphenoid sinus exploration 7. Skull base disease clearance 8. Frontal recess exploration