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Endoscopic Sinus Surgery

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ENDOSCOPIC SINUS SURGERY Section 6 ( ) Bakhshaee M, MD Rhinologist, Assistant Prof. MUMS Malignant Tumors Olfactory neuroblastoma Lymphoma ... – PowerPoint PPT presentation

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Title: Endoscopic Sinus Surgery


1
Endoscopic Sinus Surgery
Section 6 (???? ??? ????)
  • Bakhshaee M, MD
  • Rhinologist, Assistant Prof. MUMS

2
Frontosphenoethmoidectomy
3
Frontosphenoethmoidectomy
  • This includes an anterior ethmoidectomy,
    posterior ethmoidectomy, sphenoid sinusotomy
    along with opening the frontal recess

4
  • 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

5
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

6
Indications
  • Isolated sphenoid sinus disease, e.g.,
  • Aspergillosis
  • Purulent bacterial infection
  • Inverted papilloma
  • Mucocele
  • Biopsy of skull base lesions

7
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

8
  • 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

9
  • 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.

10
Comment on the Management of theMiddle and
Superior Turbinates
11
  • 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.

12
  • 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

13
The Endoscopic Tour
14
Step 1
  • involves advancing the endoscope along the
    inferior meatus

15
Step 2
  • involves coming forward a little and angling the
    endoscope upward to see the sphenoethmoid recess
    area

16
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

17
Anatomical Variations
18
Agger Nasi Air Cells
19
Concha Bullosa
20
Paradoxical Middle Turbinate
21
Bifid Middle Turbinate
22
Polypoidal Anterior End of the Middle Turbinate
23
Paradoxical Uncinate Process
24
Pneumatized Uncinate Process
25
Accessory Ostium of the Maxillary Sinus
26
An Atlas of Specific Conditions
27
Allergy
  • Hypertrophied inferior turbinate
  • Edematous middle turbinate

28
Infection
  • Bacterial rhinosinusitis
  • Aspergillosis

29
Inflammatory Diseases
  • Pyogenic granuloma

30
Wegener granulomatosis
31
Sarcoidosis
32
Benign Tumors
  • Antrochoanal polyp
  • Inverted papilloma

33
Benign Tumors
  • Chondroma
  • Angiofibroma

34
Malignant Tumors
  • Olfactory neuroblastoma
  • Lymphoma

35
Malignant Tumors
  • Amelanotic melanoma
  • Adenocarcinoma

36
Hereditary hemorrhagic telangiectasia
37
The Place of Radiology
38
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

39
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.

40
  • 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

41
When to Request CT
  • CT for rhinosinusitis is best reserved for
    patients who have not responded to maximum
    medical treatment

42
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

43
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

44
Intravenous contrast
  • is only required for tumors, vascular lesions,
    and the orbital and intracranial complications of
    infection

45
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.

46
  • 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

47
MRI is complementary to CT
  • Where malignancy has reached the dura of the
    anterior skull base, the orbital apex, and the
    optic nerve

48
  • If there is intracranial or intraorbital
    involvement from an atypical infection or
    inflammatory process

49
  • In vascular tumors like a juvenile angiofibroma.

50
internal carotid artery aneurysm
51
Meningocele
  • In congenital midline lesions such as
    meningocele, meningoencephalocele, or sinonasal
    glioma

52
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