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
Hole made 1.25 cm behind anterior end of inferior turbinate
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 37 0 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 Myles nasoantral perforator.
Caldwell – Luc Surgery George Caldwell, 1893, New York Henri Luc, 1897, Paris
Indications Chronic 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.
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
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
2-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 Citellis 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 hours post-operatively.
Frontal sinus trephination
Osteoplastic flap procedure
Lothrop Procedure Removal of frontal sinus (inferior septum + floor) + superior part of nasal septum