external approaches to sinus surgery

Dr T Balasubramanian

When equipment are not available When anatomy is distorted due to repeated

surgeries in the area To remove tumors (benign / malignant) To manage traumatic lesions involving facial bones

Are external approaches warranted?

drtbalu's otolaryngology online 2

With the advent of nasal endoscopes and

instruments indications for external approaches to maxillary sinus are very few

Caldwell Luc approach is the commonly used one Caldwell Luc approach can be modified to access

other areas of paranasal sinuses

External approaches to Maxillary sinus


Antrum is opened via its anterior wall in the canine fossa

region through sublabial incision sited at the bucco gingival sulcus preserving about 5 mm of gingival mucosa. In edentulous patient the incision is made along the maxillary alveolus to facilitate early wearing of dentures

Mucosal lining of the maxillary antrum / mass if any are removed

A window is created through inferior meatus in to the antrum

This procedure can be performed under both LA / GA

Caldwell Luc procedure steps


During immediate post op period the head of the

patient is kept elevated at 30 º. Icepacks may be applied to the face to prevent

edema from developing Packs if used should be removed within 48 hours Broad spectrum antibiotics to be prescribed if packs

are used Regular douching of nose with saline nasal spray

will prevent crust formation

Caldwell Luc post op care


To remove benign tumors like inverted papilloma &

angiofibroma Chronic intractable maxillary sinusitis that fail to respond

to medical / ESS management (Kartagener’s syndrome / Young’s syndrome)

A/C polyp originating from the anterior wall of maxillary sinus

Mycotic maxillary sinusitis Oroantral fistula repair Blow out # repair Approach to petrygopalatine fossa

Caldwell Luc procedure - Indications


Normal mucociliary clearance mechanism is ignored Regenerating maxillary antral mucosa lacks cilia Difficulties in post op follow up with imaging

modalities like x-ray PNS and CT PNS because the resultant fibrosis will cause misleading artifacts

Difficult to perform in patients with maxillary sinus hypoplasia (commonly encountered)

Caldwell- Luc pitfalls


Useful when extensive resection of mucoperiosteal

lining of the maxillary sinus is performed. This can be used to irrigate the maxillary sinus

antrum facilitating hygiene Residual hematoma following surgery can be

periodically evacuated preventing development of creeping periostitis

The maxillary sinus cavity can be periodically inspected for evidence of recurrence of disease through this opening

Inferior meatal antrostomy


Bone over the canine fossa area of anterolateral wall

of maxilla is the thinnest Canine fossa is bounded by: Canine eminence – medially Root of zygoma – laterally Superior alveolus – inferiorly (This bone is the thickest) Infraorbital nerve - Apex

Surgical anatomy


Cheek edema (ecchymosis) Infraorbital nerve dysesthesia Epiphora Oroantral fistula

Caldwell – Luc complications


External ethmoidectomy – Provides excellent access

to ethmoid sinuses, medial wall of orbit, cribriform plate and fronto nasal area.

Indications for external approaches to ethmoid sinuses are dwindling with the advent of nasal endoscopes and other ESS instruments like debriders and shavers.

External surgeries for ethmoid sinus diseases


In managing complications of ethmoid and frontal

sinusitis like orbital and periorbital abscesses In patients with trauma involving ethmoid and frontal

sinuses To biopsy mass lesions from ethmoids / orbit Trauma / fractures involving ethmoid, frontal, and

sphenoid Control of anterior ethmoidal artery Orbital decompression Optic nerve decompression CSF leak repair


Indications for external ethmoidectomy

Is complex & variable Lamina papyracea forms its lateral wall Superiorly horizontal plate of ethmoid separates it

from anterior skull base Perpendicular plate of ethmoid forms part of nasal

septum Basal lamella separates anterior & posterior

ethmoidal air cells


Anatomy of ethmoid

First described by Ferris Smith in 1933 Ideally performed under GA 1% xylocaine with 1 in 100,000 adrenaline is

infiltrated from the medial extent of eyebrow to the side of the dorsum of nose

Nasal cavity is decongested with pledgets soaked in 0.05% oxymetazoline

Temporary tarsorrhapy is performed to protect the eyes.


External ethmoidectomy


Incision

Begins at the inferior margin of medial aspect of eyebrow. Extends straight down towards the medial canthus The incision is carried up to the level of periosteum Angular vessels cauterized Supratrochlear bundle is preserved

Ensures integrity of medial canthal ligament Trochlea is preserved Lacrimal sac is protected Herniation of orbital fact is prevented as it would

obstruct the surgical field


Periosteal preservation - importance


Medial orbital wall - exposure

Anterior ethmoidal artery is coagulated in the

frontoethmoidal suture line. Bipolar cautery should be used.

Periorbita is protected with a malleable retractor Posterior ethmoidal artery lies 10 mm behind the

anterior ethmoidal artery. Dissection behind the level of posterior ethmoidal

artery should be done carefully as it would cause retro bulbar hemorrhage leading to loss of vision


Medial orbital wall exposure - contd

Lacrimal bone Frontal process of maxilla Lamina papyracea Ethmoid sinus is entered by breaching the lamina papyracea.

It is removed using kerrison’s punch in a circumferential manner

Fronto ethmoidal suture is an important landmark for cribriform plate area of anterior cranial fossa

Middle turbinate if possible should be left alone to prevent CSF leaks

Bone over the medial orbital wall should be preserved as much as possible to avoid prolapse of orbital fat into the surgical area.

Integrity of periorbita should be preserved


Surgical field – External ethmoidectomy

Cottonoids dipped in oxymetazoline can be used to

gently pack the ethmoidal cavity Packing should be light enough not to increase

intraorbital pressure These packs are ideally removed within the first 48

hours Antibiotics should be routinely administered to

prevent infections.


Role of nasal packing after surgery

Crusting Bleeding Epiphora Cosmetic defects of nose Scarring involving medial canthus CSF leak Supra orbital nerve anesthesia Blindness /diplopia


Complications of external ethmoidectomy

Vital structures like carotid artery and optic nerve

lie in proximity Cavernous sinus involvement in diseases involving

sphenoid sinus adds to the difficulty Optimal approach should be tailored taking into

consideration the contiguous structures involved All inflammatory lesions involving sphenoid sinuses

are better managed endoscopically Anatomy is highly variable Sphenoid septum is rarely seen in midline


Surgery – Sphenoid pitfalls


Sphenoid sinus - Anatomy

To remove pituitary microadenomas To repair CSF leaks To decompress mucoceles To remove tumors involving sphenoid sinus


Indications for Trans septal approaches for sphenoid

Sublabial transeptal approach Transnasal transeptal approach External rhinoplasty transeptal approach Columellar flap modification approach


Trans septal approaches - Types

Commonest trans septal approach Performed under GA 1% xylocaine with 1:100,000 units adrenaline is

infiltrated into median gingivo buccal sulcus, nasal septum and floor of the nose.

Incision is made 5-10mm superior to the gingiva and is carried down to the bone of premaxilla. The periosteum is elevated up to the inferior margin of pyriform aperture.


Sublabial transeptal approach

Anterior nasal spine is exposed. It can be fractured for

exposure but left attached to the septum Anterior & inferior tunnels are created over nasal septum

by elevating mucoperichondrium Cartilaginous portion of nasal septum is dislocated from

the floor and pushed to one side Perpendicular plate of ethmoid and maxillary crest

displaced to one side. Inferior turbinate can be out fractured for creating more space

Sphenoid speculum is introduced and the sphenoid sinus is entered through midline


Sublabial transeptal contd

Easy procedure Scarless Use of midline speculum increases visibility Minimal post op nasal deformity Suited for nasal cavity of any size


Sublabial transeptal - advantages

Oral contamination of wound ++ Incisions may cause problems with dentures Dental complications like devitalization of teeth is a

possibility


Sublabial transeptal - disadvantages

This approach is without sublabial incision Allows direct access to the rostrum of sphenoid Incisions used include: Hemitransfixation, Killian’s,

vertical and bony cartilaginous junction incisions. This approach may not be suitable for small noses

because of difficulties faced in inserting the speculum


Transnasal transeptal approach


Incisions used in transeptal sphenoid surgeries

1. Freer 2. Killian 3. Vertical 4. Bony cartilaginous junction

Oral cavity contamination is avoided Scarless Septal incisions can be placed anteriorly /

posteriorly Posterior incisions are useful in septal reoperations


Trans nasal transeptal approach - advantages

High risk of nasal disfigurement Requires meticulous post op wound care Ideally suited only for large nasal cavities Columellar incision scar may be visible in some

patients


Trans nasal transeptal approach - Disadvantages


External rhinoplasty transeptal approach

Exposure is excellent Midline approach Oral cavity contamination is avoided Nasal deformities present preoperatively can also be

corrected Can be used in noses of any size


External rhinoplasty transeptal - advantages

Bleeding Crusting Epiphora Septal perforation Nasal deformities CSF leaks Intracranial bleed Synechiae


External approach to sphenoid - complications

Trephination External frontoethmoidectomy Frontal sinusotomy without osteoplastic flap Frontal sinusotomy with osteoplastic flap Frontal sinus ablation Lothrop procedure Lynch procedure


External approaches to frontal sinus

In this procedure a small opening is made in the

floor of frontal sinus to drain its contents This procedure is the oldest known for accessing

frontal sinuses


Frontal sinus trephining

Acute frontal sinusitis with orbital / cranial

complications To localize frontonasal tract during endoscopic

sinus surgery In above below approach to frontal sinus surgery To prevent stenosis of frontal outflow tract

following endoscopic sinus surgery


Trephination - Indications


Frontal trephining - procedure

X-ray occipitofrontal view

GA/LA Infiltration of xylocaine

should block trochlear nerve

Incision is sited as shown in the figure

Drill is used to perforate the bone

Radiographic assessment of the size of frontal sinus Meticulous location of frontal sinus Control aspiration using a needle is a must Irrigation of frontal sinus should be performed in a

slow and gentle manner Trephination should not be performed if

pneumatization does not reach up to the superior limit of orbit


Frontal sinus trephining – safety guidelines

Brain injury Cellulitis Orbital complications due to needle shift


Complications of frontal trephining

This surgery can be performed with a small and

cosmetically acceptable incision Sphenoid sinus can also be accessed by this

approach It does not cause any facial deformity


External frontoethmoidectomy - Advantages

It is unilateral Exposure is limited and complete removal of

mucosa is not possible in a large and septate frontal sinus

Frequently causes closure of nasofrontal duct causing recurrence of the disease


External frontoethmoidectomy - Disadvantages


External frontoethmoidectomy - Incision

Curved incision is made towards medial canthus of the eye

The incision should divide the distance between the dorsum of the nose and medial canthus of the eye as shown in the figure


External frontoethmoidectomy - contd

Frontal sinus can be opened by resecting the lacrimal bone, frontal process of maxilla and floor of frontal sinus

Ethmoid cell system should be resected with care.

The end result is a single cavity comprising of frontal sinus, ethmoid, and nasal cavity.

About 2/3 of bony margins of frontal sinus drainage channel is resected causing scarring and mucocele formation

Stent should be left here at least for 6 months to prevent mucocele formation

Supraorbital and supra trochlear nerve is at risk

Frontal sinusotomy with / without osteoplastic flap


1. This technique is used to obliterate frontal sinus 2. To restore the functioning of frontal sinus 3. Incisions used include bicoronal, brow and mid forehead infections 4. This procedure is useful in treating patients with tumors involving the

frontal sinuses

Indicated in patients with irreversible frontal sinus

outflow tract obstruction In patients with diffuse mucosal disease not

responding to conservative management Mucosa of frontal sinus and supra orbital ethmoidal

cells are totally removed Bone within the sinus should be drilled to remove

mucosa from the foramina of Breschet Abdominal fat / pericranium can be used to

obliterate the sinus


Frontal sinusotomy with obliteration of sinus

Interpretation of CT / MRI in patients with

obliterated frontal sinus could be dicey Hyper pneumatized supraorbital ethmoid cells may

make the procedure difficult Presence of fungal sinusitis is a contraindication for

the procedure


Problems with obliterated frontal sinus

One method of frontal sinus ablation Anterior wall & floor of frontal sinus is removed Orbital soft tissues & collapsing anterior wall soft

tissues will obliterate the frontal sinus Causes disfigurement of face


Reidel procedure

This procedure allows for drainage of both frontal

sinuses through a common pathway The frontal sinus is entered via a large trephine just

below the eyebrow. The interfrontal septum is removed through the same opening facilitating drainage through a common channel


Lothrop procedure


Miniosteoplastic flap

Provides adequate exposure of frontal sinus Modified Lynch Howarth incision is used Image guidance system will be of use in

identification of the sinus


Advantages of Miniosteoplastic flap

external approaches to sinus surgery

Health & Medicine

maxillary sinus antrum

maxillary sinus cavity

maxillary sinus hypoplasia

maxillary alveolus

ethmoid sinuses

anatomy of ethmoid

maxillary antrum mass

caldwell luc approach