surgical treatment of sinusitis
DESCRIPTION
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). - PowerPoint PPT PresentationTRANSCRIPT
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Surgical Treatment of
SinusitisDr. Vishal Sharma
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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)
Maxillary Sinusitis
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Antral Washout (proof puncture,
antral lavage)
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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
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Tilley Lichwitz Antrum Puncture Trocar & Cannula
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Higginson Syringe
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Trocar directed towards I/L tragus
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Hole made 1.25 cm behind anterior end of inferior turbinate
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Antral irrigation
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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.
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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
Complications
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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.
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Caldwell – Luc Surgery
George Caldwell, 1893, New York
Henri Luc, 1897, Paris
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IndicationsChronic 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
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Exposure of incision site
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Incision
4 cm long, sub-labial,
horizontal incision made
3 mm above & parallel to
the gingival margin,
from lateral incisor to
2nd molar tooth.
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Incision deepened till periosteum
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Anterior wall broken with osteotome
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Hole made in anterior wall
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Suction of maxillary sinus
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Inferior meatal antrostomy
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Packing of maxillary sinus
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Packing of sinus & nose
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Incision closed
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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
Complications
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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
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Lynch Howarth ethmoidectomy
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Patterson ethmoidectomy
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Trans-antral ethmoidectomy• Caldwell – Luc
surgery done to
reach maxillary
antrum
• Ethmoid cells
approached via
postero-supero-
medial angle of
maxillary antrum
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Surgical Treatment Methods:
1. Trephination of frontal sinus
2. Modified Lothrop procedure
3. Osteoplastic Flap surgery
4. Functional Endoscopic Sinus Surgery
Frontal Sinusitis
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Frontal sinus trephination
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Frontal sinus trephination2-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.
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Frontal sinus trephination
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Osteoplastic flap procedure
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Osteoplastic flap procedure
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Lothrop ProcedureRemoval of frontal sinus (inferior septum +
floor) + superior part of nasal septum
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Lothrop Procedure
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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
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Sublabial trans-septal approach
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External ethmoidectomy approach
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Endoscopic approach
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Functional Endoscopic Sinus
Surgery
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F.E.S.S.
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Anatomy of lateral wall
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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
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Steps of F.E.S.S.
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Left nasal cavity
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Left middle meatus
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Left middle meatus
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Incision on uncinate process
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Incision completed
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Uncinate process removed
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Opening of bulla ethmoidalis
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Bulla ethmoidalis removed
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Natural & accessory ostia exposed
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Middle meatal antrostomy done
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Opening made on basal lamella
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Basal lamella removed
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Posterior ethmoidectomy done
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Anterior sphenoid sinus wall
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Interior of sphenoid sinus
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Skull base clearance done
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Frontal recess opened
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Final FESS cavity
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Surgical Navigation
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Complications Major (1%)
Major epistaxis
Orbital hematoma
Diplopia
Blindness or ed visual acuity
Internal carotid injury
Intracranial hemorrhage
CSF leak / Meningitis
Pneumocephalus
Anosmia
Nasolacrimal duct trauma
Minor (7%)
Minor epistaxis
Hyposmia
Adhesions
(synechiae)
Headache
Periorbital
echhymosis
Periorbital
hematoma
Dental / facial pain
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Thank You