COCLIA 70:Sinus Surgery

Embryology• Frontal

– Begins to develop at age 5-6 yrs

• Maxillary– Starts to develop in utero– Biphasic growth: 3yrs, 7-18yrs

• Ethmoid– Most developed sinus at birth (3-4 cells)

• Sphenoid– Nasal mucosa evaginates into sphenoid bone

• Sinuses reach adult size in mid-late teenage years

Osteomeatal Complex• Area lateral to the middle turbinate• Uncinate process (ethmoid bone) – thin sickle-shaped bone,

medial to the infundibulum, lateral to middle turbinate– Superior attachment determines pattern of frontal sinus drainage– 80% attaches to lamina papyracea: drains medial to the uncinate– 20% attaches to skull base or middle turbinate: drains lateral to the

uncinate

• Infundibulum (space containing the ostia draining the anterior ethmoid, frontal and maxillary sinuses)

Name that Cell

Name that Cell• Haller cells

– Ethmoid cells that extend into the maxillary sinus– Pneumatized medial and inferior orbital walls

• Onodi cells– “Sphenoethmoidal cell”– A posterior ethmoidal cell that extends lateral and superior to the

sphenoid sinus– Can be mistaken as the sphenoid sinus– Both the carotid artery and the optic nerve can be exposed within it

• Aggar nasi cells– Most anterior of the anterior ethmoids (infundibular cells)– Lies anterior-superior to the attachment of the middle turbinate to the

lateral nasal wall– Anterior wall of the frontal recess

FESS: Overview• Advantages

– Better visualization & precision– No external scar– Better preservation of function

• Disadvantages– Distorted depth perception (monocular vision)– One-handed technique

• Contraindications– Osteomyelitis– Inaccessible lateral frontal sinus disease

FESS: Complications

• Orbital– Blindness / Retrobulbar hematoma– Orbital fat penetration– Diplopia (medial or superior rectus muscle injury)– Epiphora (lacrimal duct injury)

• Intracranial– CSF leak– Meningitis– Brain abscess– Hemorrhage

• Intranasal– Synechia– Anosomia

Relativity

• Middle meatus– Lateral to the middle turbinate (medialize it)– Lateral to the uncinate process (excise it)

• Sphenoid ostium– 30-34 degrees from floor of nose– 6.2-8.0 cm posterior to nasal spine– Sphenoethmoidal recess at junction of superior 2/3

and inferior 1/3 of the superior turbinate– Medial to middle and superior turbinates

Sphenoid Sinus

• Most common local causes of failure– Failure to enter at the original surgery– Stenosis

• Special considerations– Intracerebral injury: CSF leak, meningitis, abscess, injury

to pituitary gland– Vascular hemorrhage– Retrobulbar hematoma– Cranial nerve injury– Cavernous sinus fistula

Nasal Antral Window

• Normal mucociliary flow sweeps contents from the maxillary sinus out the surgically enlarged maxillary sinus ostium

• A patent antral nasal window can allow secretions to reenter the maxillary sinus and are prone to becoming infected

The Middle Turbinate

• MTR– Decreased synechia formation– Higher long-term patency– Improved nasal airflow– Decreased nasal resistance

• MTP– Preserve important anatomic landmark– Decreased risk of alteration of nasal function, – Decreased risk of atrophic rhinitis– Decreased risk of hyposmia– Decreased risk of frontal recess stenosis causing sinusitis

Fate of the Middle Turbinate: Part 1• Havas (Ann Otol Rhinol Laryngol 2000)• Review of 509 pts (partial MTR) vs. 597 pts (MTP) –

randomly divided, minimum one year follow-up• Partial MTR: anterior inferior third of MT resected

using endoscopic scissors – Important area in secretion of vasoactive sensory

neuropeptides involved in hypersecretion, edema, polyposis, chronic rhinosinusitis

• Both groups: most important factor of FESS success was severity of rhinosinusitis preop

• Partial MTR: less synechiae, less recurrent disease requiring revision surgery – RECOMMENDED!

Fate of the Middle Turbinate: Part 2

• Giacchi (Am J Rhino 2000)• Retrospective review of 50 MTR and 50 MTP sides

with minimum 2 year follow-up• Partial MTR: resect anterior-inferior third to half,

preserve superior and lateral attachments• Not associated with increased complications (frontal

recess stenosis with secondary frontal sinusitis)• Consider on case-by-case basis (improved surgical

access and postoperative debridement)

Whoops! CSF Leak

• Refer to COCLIA page 62 (Dr. Lee 10/8/07)

External Approaches to Ethmoids• Caldwell-Luc (transantral ethmoidectomy)

– Trans-maxillary middle meatal antrostomy with transantral ethmoidectomy

– Disadvantages • Does not expose anterior ethmoids• Risk of infraorbital nerve injury

• Open external ethmoidectomy– Access through lamina payracea and lacrimal fossa– Must ligate anterior ethmoid and angular arteries– Disadvantages

• Poor exposure of anterior ethmoids• Scar

Osteoplastic Flap• Indications

– Recurrent or chronic frontal sinusitis– Frontal mucoceles

• Procedure– Make template from a Caldwell view x-ray– Bicoronal incision for exposure– Using template, excise periosteal and bone flap– Remove diseased mucosa– Obliterate cavity and plug frontal recess

Lothrop Procedure

• “Chaput-Meyer”

• Indication– Chronic frontal sinus disease

• Procedure– Remove bilateral anterior ethmoids, middle

turbinates and frontal sinus septum– Creates large opening for frontal sinus drainage

into the nasal cavity

Frontal Cells

• Anatomy– May contribute to mechanical obstruction of the frontal

recess

• Classification (Bent and Kuhn)– Type I: single cell superior to agger nasi

– Type II: 2 or more cells

– Type III: single large that pneumatizes into the frontal sinus

– Type IV: cell contained completely within the frontal sinus

Frontal Cells

• Meyer (Am J Rhino 2003)• 768 CT scans met study criteria• Objective: are frontal cells associated with variants

of pneumatization?• Frontal cells present in 20.4% of study population• Positively associated with hyperpneumatization of the

frontal sinus and negatively with hypopneumatization• Increased prevalence of concha bullosa• In general, type III and IV individuals had increased

prevalence of frontal mucosal thickening but not maxillary or ethmoid thickening

Orbital Complications• Overall <0.5% serious FESS complication rate• Orbital complications

– Pain– Hemorrhage– Diplopia (medial rectus injury)– Blindness

• Minor complications using conventional instrumentation can become major complications with powered instrumentation

Post-Op Orbital Hematoma: Part 1• Graham (Laryngoscope 2003)• Case series 3 patients referred for orbital injury• Not every patient with orbital hematoma requires

surgical intervention • Ophthalmology consult

– proptosis– intraocular pressure (observe if <30mmHg, poor vision

likely if >40mmHg), – funduscopy (assess retinal blood flow)

• If retinal blood flow is normal, no immediate treatment• If retinal blood flow is compromised, immediate canthotomy with

upper and lower cantholysis

Post-Op Orbital Hematoma: Part 2• Sharma (J Laryn Otol 2000)• Case series 7 patients• Minimize risk

– Preop: history prior sinus surgery, CT evaluation– Intraop: abort surgery if bleeding hampers visualization

• Recognize symptoms: acute onset/progression orbital pain, diplopia, visual loss

• Assess “four P’s” – Perception of light– Pupils (relative afferent pupil defect)– Pallor of optic nerve– Pulsatility of the central retinal artery

Treatment of Orbital Hemorrhage• Globe massage• Increase orbital space

– Cantholysis, canthotomy– Medial wall decompression: transcaruncular orbitomy,

external ethmoidectomy, endoscopic– Orbital floor decompression: transconjunctival

• Decrease volume of orbital contents– Steroids, topical beta blocker drops– Mannitol, acetazolamide– Paracentesis of the anterior chamber

Minimize Risk of Orbital Injury• Preop: history prior sinus surgery, CT

evaluation• Intraop: abort surgery if bleeding hampers

visualization• Place opening of blade at 90 degrees to the

medial orbital wall and dissect superiorly or inferiorly

• Assess vision, orbital appearance, and ocular motility during postop check

FESS Post-op Care• Thaler (Arch Oto Head Neck Surg 2002)• Frequent debridement

– Post op week 1 then weekly or greater intervals until healed (approx 4-6 weeks)

– Pros: remove large crusting and clot (traps mucous leading to infection, bridge for scar formation, retained bone fragments are nidus for infection)

– Cons: histologically avulses epithelium until 2nd postop week, pediatric FESS rarely tolerate debridement but have good outcomes

• Hypertonic saline irrigation• Nasal splints • Endoscopic exam to assess for obstructing crust or clot

Informed Consent

• Recall possible complications discussed earlier– Orbital– Intracranial– Intranasal

Balloon Sinuplasty

• Indications: maxillary, sphenoid and frontal disease• Safety: less injury to mucosa, less operative

bleeding, eliminates need for nasal packing• Results: not long enough follow-up