11 surgical treatment of sinusitis

Surgical Treatment of

SinusitisDr. Vishal Sharma

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

Antral Washout (proof puncture,

antral lavage)

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

Tilley Lichwitz Antrum Puncture Trocar & Cannula

Higginson Syringe

Trocar directed towards I/L tragus

Hole made 1.25 cm behind anterior end of inferior turbinate

Antral irrigation

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.

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

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

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

Exposure of incision site

Incision

4 cm long, sub-labial,

horizontal incision made

3 mm above & parallel to

the gingival margin,

from lateral incisor to

2nd molar tooth.

Incision deepened till periosteum

Anterior wall broken with osteotome

Hole made in anterior wall

Suction of maxillary sinus

Inferior meatal antrostomy

Packing of maxillary sinus

Packing of sinus & nose

Incision closed

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

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

Lynch Howarth ethmoidectomy

Patterson ethmoidectomy

Trans-antral ethmoidectomy• Caldwell – Luc

surgery done to

reach maxillary

antrum

• Ethmoid cells

approached via

postero-supero-

medial angle of

maxillary antrum

Surgical Treatment Methods:

1. Trephination of frontal sinus

2. Modified Lothrop procedure

3. Osteoplastic Flap surgery

4. Functional Endoscopic Sinus Surgery

Frontal Sinusitis

Frontal sinus trephination

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.

Frontal sinus trephination

Osteoplastic flap procedure

Osteoplastic flap procedure

Lothrop ProcedureRemoval of frontal sinus (inferior septum +

floor) + superior part of nasal septum

Lothrop Procedure

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

Sublabial trans-septal approach

External ethmoidectomy approach

Endoscopic approach

Functional Endoscopic Sinus

Surgery

F.E.S.S.

Anatomy of lateral wall

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

Steps of F.E.S.S.

Left nasal cavity

Left middle meatus

Left middle meatus

Incision on uncinate process

Incision completed

Uncinate process removed

Opening of bulla ethmoidalis

Bulla ethmoidalis removed

Natural & accessory ostia exposed

Middle meatal antrostomy done

Opening made on basal lamella

Basal lamella removed

Posterior ethmoidectomy done

Anterior sphenoid sinus wall

Interior of sphenoid sinus

Skull base clearance done

Frontal recess opened

Final FESS cavity

Surgical Navigation

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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