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Surgical management of sinusitis
Dr. Hitesh
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
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
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- Trocar advance till it abuts opposite antral wall.- Withdrawn several mm, trocar removed.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.
- 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
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.
Complications
-hemorrage ( inferior meatal branch of sphenopalatine A)
-injury to anterior superior alveolar nerve
-nasolacrimal duct injury
-narrowing of opening
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
Method-gingivobuccal sulcus injectedIncision 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 removed2×1cm inferior meatus antrostomy donePacking &suturing done
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
Modifications of Caldwell-luc operation1.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
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
Intranasal ethmoidectomy
Indication-polyps, tumors, foreign bodies and chronic rhinosinusitis not
responsive to medical therapy.Usually under GA1% with 1:100000 LA givenWith the help of head light and speculumMiddle turbinate medialized to improve middle meatus exposureOften 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.
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 GAIncision is extended superiorly over the orbital rim into the
eyebrow (Lynch Howarth).
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
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
Comparison of open frontal sinus procedures:
LYNCHPROCEDURE
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
LOTHROP PROCEDURE
u/l or b/l ant ethmoidectomy,with or without middle turbinectomy,interfrontal 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
External Ethmoidectomy
Indication
-acute or chronic sinusitis unresponsive to medical therapy.
- In orbital complications- Usually done under GA
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 ethmoidsFollow 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
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
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)
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
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
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
Sphenoid sinus irrigation
Methods-through natural ostium-by making opening in anterior wallAnterior 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
Osteoplastic flap/frontal sinus oblitration
Indication -large mucocele, tumors-chronic rhinosinusitis (unresponsive to both medical therapy &
endoscopic approach)-frontal sinus fracture and osteomasRadiology to known outline of frontal sinusSurgery perform under GA Incision made 1cm posterior to hair line. Mid-forehead or brow incision can be usedBicoronal flap elevated, leaving the pericranium intact to expose
the anterior table of frontal sinus
.. 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%
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.
Incision made above or below the eyebrows and connect across glebella ( small sinus, in male with male pattern baldness)
Endoscopic sinus surgery
Endoscopic anatomy
-Ethmoid bone
-Osteomeatal complex
1-inferior hiatus semilunaris
2-ethmoid infundibulum 3-superior hiatus
semilunaris 4- sinus lateralis Ethmoid cells
Uncinate process
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
Lateral wall
Endoscopic sinus surgery
Indication-absolute1-tumors2-complications of rhinosinusitis3-failed sinus surgery4-mucoceles5-fungal infection6-encephalocele7-CSF rhinorrhea-relative1chronic rhinosinusitis2headache & facial pain3-recurrent acute sinusitis4-epistaxis5-nasal polyps
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 variationAnesthesia –LA or GA
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
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)
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
Maxillary antrostomy
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.
Anterior ethmoidectomy
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
Middle turbinate
Attachments1-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
Anterior &posterior attachment of middle turbinate should preserved to maintain stability.
Lateralized middle turbinate can cause post operative obstruction of sinus drainage
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.
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.
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
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
Curved probe and curette help in identification of frontal recess
30 degree scope help in visualization Disease remove to provide adequate
drainage area
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)
Complication of ESS
Minor complications-minor epistaxis-hyposmia-adhesions-headache-periorbital ecchymosisPeriorbital emphysema (lamina injury- positive
pressure, patient cough, vomits)-dental of facial pain
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
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
Thank you
