Concepts of Endoscopic Concepts of Endoscopic Sinus Surgery: Sinus Surgery:
Causes of FailureCauses of Failure
Cummings Chp. 52Cummings Chp. 52Wed 1/9/13Wed 1/9/13
Irene A. KimIrene A. Kim
Key PointsKey Points Long-term success rate of Long-term success rate of
FESS + medical therapy: FESS + medical therapy: 80-90%.80-90%.
Anatomic variants no longer Anatomic variants no longer considered underlying considered underlying etiology of diseaseetiology of disease
FESSFESS GOALGOAL:: Surgically remove Surgically remove
inflamed tissue from inflamed tissue from critical points in critical points in mucociliary clearance mucociliary clearance pathwayspathways
ABSOLUTE Indications ABSOLUTE Indications for Sinus Surgeryfor Sinus Surgery
1. Rhinosinusitis 1. Rhinosinusitis complicationscomplications
2. Expansile mucoceles2. Expansile mucoceles
3. Allergic/Invasive fungal 3. Allergic/Invasive fungal rhinosinusitisrhinosinusitis
4. Suspected neoplasia4. Suspected neoplasia
MucocelesMucoceles Frontal sinus mucocelesFrontal sinus mucoceles
Skull base identified in Skull base identified in posterior ethmoidposterior ethmoid
Follow anteriorly until Follow anteriorly until bone of lesion foundbone of lesion found
Remove inferior Remove inferior portionportion
Remove all osteitic bone Remove all osteitic bone from region of obstructionfrom region of obstruction
Bony margins flush Bony margins flush should beshould be
flush with surrounding wallflush with surrounding wall
Fungal SinusitisFungal Sinusitis
Invasive Invasive Chronic invasive fungal rhinosinusitisChronic invasive fungal rhinosinusitis Fulminant invasive diseaseFulminant invasive disease
NoninvasiveNoninvasive Fungal ballsFungal balls Allergic fungal rhinosinusitisAllergic fungal rhinosinusitis
Indications for Tumors, Skull Base Indications for Tumors, Skull Base Defects, Other Noninflammatory Defects, Other Noninflammatory
LesionsLesions
Benign tumorsBenign tumors Inverted papillomaInverted papilloma Juvenile angiofibromaJuvenile angiofibroma Skull base defectsSkull base defects Orbital problemsOrbital problems Encephaloceles, meningocelesEncephaloceles, meningoceles Closure of CSF rhinorrheaClosure of CSF rhinorrhea Malignant tumorsMalignant tumors
Relative Indications Relative Indications for Sinus Surgeryfor Sinus Surgery
Symptomatic nasal polypsSymptomatic nasal polyps Unresponsive to medical therapyUnresponsive to medical therapy
Symptomatic chronic or recurrent acute Symptomatic chronic or recurrent acute rhinosinusitisrhinosinusitis Unresponsive to medical therapyUnresponsive to medical therapy
***Medical therapy is cornerstone of mgmt ***Medical therapy is cornerstone of mgmt of inflammatory diseaseof inflammatory disease
Poor Indicators of Poor Indicators of Successful FESSSuccessful FESS
Persistent environmental exposuresPersistent environmental exposures Uncontrolled allergiesUncontrolled allergies Continued chemical exposuresContinued chemical exposures SmokingSmoking
Increased granulation tissueIncreased granulation tissue Increased incidence of frontal recess stenosisIncreased incidence of frontal recess stenosis
Extent of SurgeryExtent of Surgery
Mucosal preservation is *key* (ethmoid)Mucosal preservation is *key* (ethmoid) Resection of inflamed bone importantResection of inflamed bone important Removal of osteitic partitions Removal of osteitic partitions
Uncinate processUncinate process Ethmoid sinusesEthmoid sinuses
Avoid leaving exposed bone behindAvoid leaving exposed bone behind
Pre-op Evaluation & ManagementPre-op Evaluation & Management
Know amount and duration of:Know amount and duration of: Antibiotic therapyAntibiotic therapy Anti-inflammatory treatments Anti-inflammatory treatments
Treat severe polyposis, hyperreactive Treat severe polyposis, hyperreactive mucosamucosa Oral steroids (Prednisone 20-30mg x 3-10 Oral steroids (Prednisone 20-30mg x 3-10
days)days)
ImagingImaging
CT key, but CT key, but MRIMRI needed when CT shows needed when CT shows disease adjacent to skull base erosiondisease adjacent to skull base erosion
Evaluate Evaluate lateral cribiform plate lamella lateral cribiform plate lamella Evaluate Evaluate vertical height of post ethmoidvertical height of post ethmoid Evaluate Evaluate sphenoid sinus sphenoid sinus in axial/coronal in axial/coronal
planesplanes Evaluate Evaluate frontal recessfrontal recess in triplanar views in triplanar views
Concepts of AntrostomyConcepts of Antrostomy
Maxillary sinus opening should Maxillary sinus opening should communicate with natural ostium to communicate with natural ostium to PREVENT surgical failurePREVENT surgical failure
Long term causes of failureLong term causes of failure Ostenoneogenesis from stripped mucosaOstenoneogenesis from stripped mucosa Retained foreign bodyRetained foreign body Mucous draining into sinus from persistent Mucous draining into sinus from persistent
frontal recess inflammationfrontal recess inflammation
EthmoidectomyEthmoidectomy Work from “known” to “unknown”Work from “known” to “unknown” Medial orbital wall is first critical landmarkMedial orbital wall is first critical landmark Goal: Marsupialized cavity lined by healthy, Goal: Marsupialized cavity lined by healthy,
intact mucosaintact mucosa Skull base is second critical landmarkSkull base is second critical landmark Common results of failed ethmoidectomy:Common results of failed ethmoidectomy:
Lateralized middle turbinateLateralized middle turbinate Retained uncinate processRetained uncinate process Failure of removal of uncinate superiorlyFailure of removal of uncinate superiorly Residual agger nasi cellsResidual agger nasi cells
SphenoidotomySphenoidotomy Re-review scans: coronal and axial planesRe-review scans: coronal and axial planes Review course of optic n., carotid a.Review course of optic n., carotid a. Endoscopic transnasal approachEndoscopic transnasal approach Transethmoid/transmaxillary approachTransethmoid/transmaxillary approach Transseptal approachTransseptal approach
Sphenoid Anatomy:Sphenoid Anatomy:Key StructuresKey Structures
Carotid arteryCarotid artery Optic nerveOptic nerve Cavernous sinusCavernous sinus 33rdrd, 4, 4thth, 5, 5thth CN CN
Frontal SinusotomyFrontal Sinusotomy
Most challengingMost challenging Potential for persistent, recurrent diseasePotential for persistent, recurrent disease Most difficult decision: to explore or notMost difficult decision: to explore or not Review coronal, axial, sagittal viewsReview coronal, axial, sagittal views Review AP/lateral diametersReview AP/lateral diameters Examine pneumatization of sinusExamine pneumatization of sinus Frontal recess dissectionFrontal recess dissection
Turbinate ManagementTurbinate Management
Remove exposed bone (MT)Remove exposed bone (MT) Stabilize floppy MTStabilize floppy MT
Controlled scar to nasal septumControlled scar to nasal septum Postoperatively, can lyse adhesionsPostoperatively, can lyse adhesions Suture turbinate to septumSuture turbinate to septum
Postop Medical ManagementPostop Medical Management Long-term topical steroid spraysLong-term topical steroid sprays Saline spraySaline spray Nasal saline irrigationNasal saline irrigation DebridementDebridement Loss of olfaction: sensitive sign of return of Loss of olfaction: sensitive sign of return of
disease disease
Management of the Management of the Frontal SinusesFrontal Sinuses
Cummings Chp. 53Cummings Chp. 53
Wed 1/9/13Wed 1/9/13
Irene A. KimIrene A. Kim
Key PointsKey Points
Frontal sinus drains Frontal sinus drains into middle meatus into middle meatus through frontal recessthrough frontal recess
Frontal recess located Frontal recess located at junction of frontal at junction of frontal sinus and is most sinus and is most anterosuperior part of anterosuperior part of ethmoid sinusethmoid sinus
Preserve mucosa Preserve mucosa around frontal recessaround frontal recess
Acute Frontal SinusitisAcute Frontal Sinusitis
SymptomsSymptoms Low-grade feverLow-grade fever MalaiseMalaise Frontal headacheFrontal headache Tenderness of medial aspect of infraorbital Tenderness of medial aspect of infraorbital
marginmargin Common organismsCommon organisms
S.pneumo, H. flu, anaerobic strep, Bacteroides, S.pneumo, H. flu, anaerobic strep, Bacteroides, S. aurus, S. epidermidis, S. milleriS. aurus, S. epidermidis, S. milleri
Treatment ApproachesTreatment Approaches
Topical decongestant high in middle meatusTopical decongestant high in middle meatus Trephine the frontal recess by:Trephine the frontal recess by:
Incision in medial aspect of eyebrowIncision in medial aspect of eyebrow Open frontal sinus endoscopically by Open frontal sinus endoscopically by
removing ethmoid air cells surrounding removing ethmoid air cells surrounding recessrecess
Complications of SurgeryComplications of Surgery
Damage to mucosaDamage to mucosa AdhesionsAdhesions StenosisStenosis
Periorbital cellulitisPeriorbital cellulitis Periorbital abscess, subdural empyema, meningitis, Periorbital abscess, subdural empyema, meningitis,
cavernous, sup sagittal sinus thrombosiscavernous, sup sagittal sinus thrombosis *Obtain URGENT CT if:*Obtain URGENT CT if:
CNS involvement seenCNS involvement seen Visual problemsVisual problems Spiking pyrexia not resolving in 36 hoursSpiking pyrexia not resolving in 36 hours
Surgery in Chronic Frontal Surgery in Chronic Frontal Sinusitis Sinusitis
Disease likely started by Disease likely started by unnecessary instrumentation unnecessary instrumentation of frontal recessof frontal recess
PRIMARY indication for instrumentation:PRIMARY indication for instrumentation: When maximal medical treatment partial anterior When maximal medical treatment partial anterior
ethmoidectomy have failedethmoidectomy have failed Primary fungal diseasePrimary fungal disease BarotraumaBarotrauma MucoceleMucocele OsteomaOsteoma OsteomyelitisTumorsOsteomyelitisTumors
Causes of Frontal Sinus Causes of Frontal Sinus Surgery FailureSurgery Failure
Remnant frontal recess cellsRemnant frontal recess cells Retained uncinate processRetained uncinate process Middle turbinate lateralizationMiddle turbinate lateralization OsteoneogenesisOsteoneogenesis Scarring or inflammatory mucosal thickeningScarring or inflammatory mucosal thickening Recurrent polyposisRecurrent polyposis
Endoscopic Frontal Endoscopic Frontal SinusotomySinusotomy
Boundaries of frontal Boundaries of frontal recessrecess AnteriorAnterior
Agger nasiAgger nasi
LateralLateral Lamina papyraceaLamina papyracea
MedialMedial Most ant/superior portion Most ant/superior portion
of middle turbof middle turb
PosteriorPosterior Ethmoid bulla, bulla Ethmoid bulla, bulla
lamella lamella
Frontal Recess CellsFrontal Recess Cells
Type I: Single cell superior to agger nasi cellType I: Single cell superior to agger nasi cell Type II: Tier of two or more cells above the Type II: Tier of two or more cells above the
agger nasi cellagger nasi cell Type III: Single cell extending from the agger Type III: Single cell extending from the agger
cell into the frontal sinuscell into the frontal sinus Type IV: Isolated cell within the frontal sinusType IV: Isolated cell within the frontal sinus
Frontal Recess CellsFrontal Recess Cells
Bulla frontalisBulla frontalis High anterior ethmoid cell that has pneumatized into High anterior ethmoid cell that has pneumatized into
frontal bonefrontal bone Can displace frontal recess posteriorly and mediallyCan displace frontal recess posteriorly and medially
Supraorbital cellSupraorbital cell Posterior cell in ant ethmoid complex that is well pneumatizedPosterior cell in ant ethmoid complex that is well pneumatized
Can extend laterally into frontal bone over orbitCan extend laterally into frontal bone over orbit Can also narrow frontal recess by pushing forwardCan also narrow frontal recess by pushing forward
*Prevalance of these variations does NOT appear to *Prevalance of these variations does NOT appear to correlate with presence or absence of frontal sinus correlate with presence or absence of frontal sinus diseasedisease
Opening the Frontal RecessOpening the Frontal Recess
Goal:Goal: 1. Deflating the cells of ethmoid air cells1. Deflating the cells of ethmoid air cells 2. Preserve mucosa around recess2. Preserve mucosa around recess
Median frontal sinus drainage procedureMedian frontal sinus drainage procedure Obliteration of frontal sinusesObliteration of frontal sinuses
Median Frontal Sinus Median Frontal Sinus Drainage ProcedureDrainage Procedure
Frontal recesses Frontal recesses opened by removing:opened by removing: top of septumtop of septum Frontal interspinus Frontal interspinus
septumseptum Anterior beak of frontal Anterior beak of frontal
bonebone
Frontal Sinus ObliterationFrontal Sinus Obliteration
Coronal flap or eyebrow incisionCoronal flap or eyebrow incision Make outline of frontal sinus with template, Make outline of frontal sinus with template,
image guidance, or endoscopicallyimage guidance, or endoscopically Remove anterior plateRemove anterior plate Remove all mucosa of frontal sinuses Remove all mucosa of frontal sinuses
before obliterationbefore obliteration Frontal recess separated from nasal Frontal recess separated from nasal
airway with sheet of fascia lataairway with sheet of fascia lata Use fat to obliterate sinusesUse fat to obliterate sinuses
Indications for External ApproachIndications for External Approach
Situations where removal of pathology Situations where removal of pathology and/or drainage is difficult to achieve and/or drainage is difficult to achieve endoscopicallyendoscopically Lateral loculation, lateral mucoceleLateral loculation, lateral mucocele Fibrosis or new bone around frontal recessFibrosis or new bone around frontal recess Paget’s disease of frontal bone, osteomyelitis, Paget’s disease of frontal bone, osteomyelitis,
SCCaSCCa Gross prolapse of orbital contentsGross prolapse of orbital contents
Riedel’s ProcedureRiedel’s Procedure Important role in mgmt of patients with Important role in mgmt of patients with
recurrent infectionsrecurrent infections Removes ant wall and floor of frontal sinus Removes ant wall and floor of frontal sinus
and all its mucosal liningand all its mucosal lining Help eradicate frontal sinus disease whenHelp eradicate frontal sinus disease when
Drainage and obliteration have failed andDrainage and obliteration have failed and There is persistent disease involving the ant There is persistent disease involving the ant
wall of the frontal sinus or the sinus itselfwall of the frontal sinus or the sinus itself Main complaint: postoperative Main complaint: postoperative
disfigurementdisfigurement
Cranialization of Frontal SinusesCranialization of Frontal Sinuses Performed for:Performed for:
Requirement for posterior wall removalRequirement for posterior wall removal Anterior skull base tumorsAnterior skull base tumors Severe communication of posterior wall with Severe communication of posterior wall with
frontal sinusfrontal sinus Ant intracranial contents separated from Ant intracranial contents separated from
paransal sinuses and nasal airway by:paransal sinuses and nasal airway by: Fascia lataFascia lata Pericranial flapPericranial flap
Specific Pathologic Specific Pathologic ConditionsConditions
Pneumosinus DilatansPneumosinus Dilatans Rare, benign expansion of an aerated sinus Rare, benign expansion of an aerated sinus
beyond normal margin of frontal bonebeyond normal margin of frontal bone Hypersinus: enlarged sinus with normal wallsHypersinus: enlarged sinus with normal walls
MucocelesMucoceles Epithelium-lined sac containing inspissated Epithelium-lined sac containing inspissated
mucousmucous OsteomaOsteoma
Only complaints are cosmeticOnly complaints are cosmetic Very common, 3% of people have themVery common, 3% of people have them
Fractures of Frontal SinusFractures of Frontal Sinus Ant wall fractures do not require exploration UNLESS:Ant wall fractures do not require exploration UNLESS:
It affects the frontonasal ductIt affects the frontonasal duct POSTERIOR wall fracturesPOSTERIOR wall fractures
Nondisplaced and w/o complications: manage Nondisplaced and w/o complications: manage conservativelyconservatively
Compound comminuted fracture affecting posterior Compound comminuted fracture affecting posterior wall or near frontonasal duct:wall or near frontonasal duct:
Cranialization of frontal sinusCranialization of frontal sinus
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