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Surgical Treatment of Sinusitis Dr. Vishal Sharma.

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Presentation on theme: "Surgical Treatment of Sinusitis Dr. Vishal Sharma."— Presentation transcript:

1 Surgical Treatment of Sinusitis Dr. Vishal Sharma

2 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

3 Antral Washout (proof puncture, antral lavage)

4 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

5 Tilley Lichwitz Antrum Puncture Trocar & Cannula

6 Higginson Syringe

7 Trocar directed towards I/L tragus

8 Hole made 1.25 cm behind anterior end of inferior turbinate

9 Antral irrigation

10 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.

11 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

12 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.

13

14 Caldwell – Luc Surgery George Caldwell, 1893, New York Henri Luc, 1897, Paris

15 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

16 Exposure of incision site

17 Incision 4 cm long, sub-labial, horizontal incision made 3 mm above & parallel to the gingival margin, from lateral incisor to 2nd molar tooth.

18 Incision deepened till periosteum

19 Anterior wall broken with osteotome

20 Hole made in anterior wall

21 Suction of maxillary sinus

22 Inferior meatal antrostomy

23 Packing of maxillary sinus

24 Packing of sinus & nose

25 Incision closed

26 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

27 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

28 Lynch Howarth ethmoidectomy

29 Patterson ethmoidectomy

30 Trans-antral ethmoidectomy Caldwell – Luc surgery done to reach maxillary antrum Ethmoid cells approached via postero-supero- medial angle of maxillary antrum

31 Surgical Treatment Methods: 1. Trephination of frontal sinus 2. Modified Lothrop procedure 3. Osteoplastic Flap surgery 4. Functional Endoscopic Sinus Surgery Frontal Sinusitis

32 Frontal sinus trephination

33 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.

34 Frontal sinus trephination

35 Osteoplastic flap procedure

36

37 Lothrop Procedure Removal of frontal sinus (inferior septum + floor) + superior part of nasal septum

38 Lothrop Procedure

39 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

40 Sublabial trans-septal approach

41 External ethmoidectomy approach

42 Endoscopic approach

43 Functional Endoscopic Sinus Surgery

44 F.E.S.S.

45 Anatomy of lateral wall

46 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

47 Steps of F.E.S.S.

48 Left nasal cavity

49 Left middle meatus

50

51 Incision on uncinate process

52 Incision completed

53 Uncinate process removed

54 Opening of bulla ethmoidalis

55 Bulla ethmoidalis removed

56 Natural & accessory ostia exposed

57 Middle meatal antrostomy done

58 Opening made on basal lamella

59 Basal lamella removed

60 Posterior ethmoidectomy done

61 Anterior sphenoid sinus wall

62 Interior of sphenoid sinus

63 Skull base clearance done

64 Frontal recess opened

65 Final FESS cavity

66

67 Surgical Navigation

68 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

69 Thank You


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