2.
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
3.
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
drtbalu's otolaryngology online 3
4.
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
drtbalu's otolaryngology online 4
5.
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
drtbalu's otolaryngology online 5
6.
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
drtbalu's otolaryngology online 6
7.
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
drtbalu's otolaryngology online 7
8.
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
drtbalu's otolaryngology online 8
9.
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
drtbalu's otolaryngology online 9
11.
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
drtbalu's otolaryngology online 11
12.
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
drtbalu's otolaryngology online 12
Indications for external
ethmoidectomy
13.
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
drtbalu's otolaryngology online 13
Anatomy of ethmoid
14.
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.
drtbalu's otolaryngology online 14
External ethmoidectomy
15.
drtbalu's otolaryngology online 15
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
16.
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
drtbalu's otolaryngology online 16
Periosteal preservation -
importance
18.
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
drtbalu's otolaryngology online 18
Medial orbital wall
exposure - contd
19.
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
drtbalu's otolaryngology online 19
Surgical field – External
ethmoidectomy
20.
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.
drtbalu's otolaryngology online 20
Role of nasal packing
after surgery
21.
Crusting
Bleeding
Epiphora
Cosmetic defects of nose
Scarring involving medial canthus
CSF leak
Supra orbital nerve anesthesia
Blindness /diplopia
drtbalu's otolaryngology online 21
Complications of
external ethmoidectomy
22.
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
drtbalu's otolaryngology online 22
Surgery – Sphenoid
pitfalls
24.
To remove pituitary microadenomas
To repair CSF leaks
To decompress mucoceles
To remove tumors involving sphenoid sinus
drtbalu's otolaryngology online 24
Indications for Trans septal
approaches for sphenoid
26.
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.
drtbalu's otolaryngology online 26
Sublabial transeptal
approach
27.
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
drtbalu's otolaryngology online 27
Sublabial transeptal
contd
28.
Easy procedure
Scarless
Use of midline speculum increases visibility
Minimal post op nasal deformity
Suited for nasal cavity of any size
drtbalu's otolaryngology online 28
Sublabial transeptal -
advantages
29.
Oral contamination of wound ++
Incisions may cause problems with dentures
Dental complications like devitalization of teeth is a
possibility
drtbalu's otolaryngology online 29
Sublabial transeptal -
disadvantages
30.
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
drtbalu's otolaryngology online 30
Transnasal transeptal
approach
32.
Oral cavity contamination is avoided
Scarless
Septal incisions can be placed anteriorly /
posteriorly
Posterior incisions are useful in septal reoperations
drtbalu's otolaryngology online 32
Trans nasal transeptal
approach - advantages
33.
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
drtbalu's otolaryngology online 33
Trans nasal transeptal
approach - Disadvantages
35.
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
drtbalu's otolaryngology online 35
External rhinoplasty
transeptal - advantages
38.
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
drtbalu's otolaryngology online 38
Frontal sinus trephining
39.
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
drtbalu's otolaryngology online 39
Trephination - Indications
40.
drtbalu's otolaryngology online 40
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
41.
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
drtbalu's otolaryngology online 41
Frontal sinus trephining –
safety guidelines
42.
Brain injury
Cellulitis
Orbital complications due to needle shift
drtbalu's otolaryngology online 42
Complications of frontal
trephining
43.
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
drtbalu's otolaryngology online 43
External frontoethmoidectomy -
Advantages
44.
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
drtbalu's otolaryngology online 44
External frontoethmoidectomy -
Disadvantages
45.
drtbalu's otolaryngology online 45
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
46.
drtbalu's otolaryngology online 46
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
47.
Frontal sinusotomy with /
without osteoplastic flap
drtbalu's otolaryngology online 47
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
48.
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
drtbalu's otolaryngology online 48
Frontal sinusotomy with
obliteration of sinus
49.
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
drtbalu's otolaryngology online 49
Problems with obliterated
frontal sinus
50.
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
drtbalu's otolaryngology online 50
Reidel procedure
51.
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
drtbalu's otolaryngology online 51
Lothrop procedure
53.
Provides adequate exposure of frontal sinus
Modified Lynch Howarth incision is used
Image guidance system will be of use in
identification of the sinus
drtbalu's otolaryngology online 53
Advantages of
Miniosteoplastic flap