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Principles of Functional Endoscopic Sinus Surgery

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Presentation on theme: "Principles of Functional Endoscopic Sinus Surgery"— Presentation transcript:

1 Principles of Functional Endoscopic Sinus Surgery
Shahin Bastaninejad, MD Assistant Prof. of ORL-HNS TUMS Amir’Alam Hospital

2 Outline Definition Anatomy Patient evaluation FESS Concepts of Surgery

3 Definition

4 Functional Endoscopic Sinus Surgery
Replaced old practice of obliterating sinuses and removing mucosa. Concept of irreversibly diseased mucosa refuted. Functional aspect refers to: Preserving normal structures Removing only obstruction Preserving mucosa Attempt to restore function

5 Anatomy

6 Ethmoid anatomy Ethmoid anatomy is complex: Labyrinth Lamellae
1st - Uncinate 2nd - Ethmoid bulla 3rd - Basal lamella of middle turbinate 4th - Superior turbinate

7 Drainage Frontal, anterior ethmoid & maxillary – OMC
Posterior Ethmoids – Superior meatus Sphenoid sinus – Sphenoid-ethmoidal recess

8 Middle Turbinate Three components
First – Anterior, oriented in a sagittal plane and attached to skull base Second – Middle, oriented in a Vertical plane and attached to lamina papyracea (basal lamella and separates ant from post ethmoids) Third – Posterior, oriented in a horizontal plane and attaches to perpendicular plate of palate (forms roof of middle meatus, anterior to sphenopalatine foramen)

9 Middle Turbinate

10 Ostiomeatal Complex (OMC)
Common drainage for frontal, maxillary and anterior ethmoid sinuses.

11 OMC

12 OMC Infundibulum – funnel shaped area whereby the maxillary, ant ethmoid and frontal sinuses drains Uncinate process– Sickle shaped bony ethmoidal structure Hiatus Semilunaris – Half-moon shape opening of infundibulum

13 Uncinate Process Attaches to the following structures:
Inf & far post. – To ethmoid process of inf. Turb

14 Uncinate Process Ant & far sup. – To lamina papyracea, skull base or mid turb

15 Laterally – Lamina papyracea and fontanelle area

16 Uncinate Process 52%


18 Bulla Ethmoidalis The greatest anterior ethmoid air cell, attached to lamina papyrcea and usually open into lateral sinus


20 Sinus Lateralis = Suprabullar recess and retrobullar recess

21 Middle turbinate: Horizontal and vertical basal lamella
SBR Sinus Lateralis RBR

22 Sphenoid Ostium Medial to posterior sup. turbinate
Located between nasal septum and inferior aspect of sup. turbinate Located at the same level as the roof of the maxillary sinus Located 4 microdebrider/suction tip breaths above the choanae Located 7cm from nasal crest at 30°

23 Sphenoid Ostium

24 Sphenoid Sinus Relationships of important structures:
Optic nerve – superior-lateral Carotid artery/cav sinus – mid-lateral Vidian nerve and maxillary nerve – inferior-lateral

25 Square – ant clinoid process, Circles – optic canals, triangle – vidian nerve
Asterisk – pneumatization of pterygoid process

26 Sphenoid Classification

27 Presellar Sellar Conchal Post sellar

28 Onodi Cells or Sphenoethmoid cells

29 Optic Canal in Onodi Cells

30 anatomic keyhole in SBS


32 Cribriform plate Keros classification 1-3mm 3-7mm 7-16mm

33 Keros Classification Type I 1-3mm Type II 3-7mm Type III 7-16mm

34 Fovea and Ethmoidal arteries

35 Lens 70 degree – End of surgery

36 Kuhn Cells Frontal Cells

37 Frontal Recess Anatomic Boundries: Ant – unicate process & agger nasi
Post – bulla ethmoidalis and suprabullar lamella Lateral – lamina papyracea Medially – hiatus semilunaris or middle turb Inf – Ethmoid infundibulum Sup – Fovea ethmoidalis, supraorbital air cell, anterior ethmoid artery and frontal ostium

38 Draf IIA Draf I

39 Draf III Draf

40 Frontal Sinus – Mucociliary Pattern
 Save Mucosal Layer in Lateral part while performing Draf III opertation

41 Patient evaluation

42 Pre-op CT Evaluation CLOSE Technique C – Cribriform
L – Lamina Papyracea O – Orbits, onodi cell, Optic Nerve S – Sphenoid, Skull Base E – Ethmoid Arteries

43 C - Cribriform Assess the Keros type Look for assymetry


45 L – Lamina Papyracea Check for dehiscence or pathologic fractures

46 O – Orbit, Optic Nerve, Onodi Cells
Check for dehiscence Assess for onodi cells (superior-lateral to sphenoid) Orbital slope

47 S – Sphenoid, Skull base Assess for Carotid dehiscence and aeration patterns Conchal, Pre-sellar, & Sellar (thickness of clivus)

48 Skull base Assess slope of skull base
Assess if roof of sphenoid is level with skull base

49 E – Ethmoid Artery

50 FESS Concepts of surgery

51 Role of surgery Should be considered as adjunctive to medical therapy
CRS is an inflammatory and multifactorial disease Institute medical therapy first prior to surgery unless impending complications Continued medical therapy is required following surgery to avoid recurrence

52 Defined surgical substeps are defined according to specific pathophysiologic obstruction that exist based on microanatomy

53 Antrostomy Some speculate nitric oxide produced in maxillary sinus has bacteriostatic properties, therefore better to keep antrostomy small Uncinate must be completely removed, source of recurrence. Mucociliary clearance remains to natural os Antrostomy must include the natural osium and accessory osium if present

54 Recirculation

55 Frontal Sinusotomy Question on to perform or not
Do as little as possible but as much as necessary Some advocate ethmoid dissection and monitor Graduated approach to frontal sinuses Should evaluate with sagittal reconstruction Evaluate A-P and Mediolateral dimensions, asses neo-osteogenesis and pneumatization

56 Ethmoidectomy & Sphenoidotomy
Continue operation Anteroposteriorly toward the Sphenoid sinus, then open it Now it is time to go on with Posteroanterior approach with a 30 degree lens and cutting forceps

57 References Dr Quinn online Text book
Diseases of the Sinuses: Diagnosis and Management. Kennedy. Chapters 1, 2, 3, 15, and 16 Head and Neck – Otolaryngology. Bailey. Chapters 21, 25, 26.  Endoscopic Sinus Surgery Dissection Manual With Cdrom. Casiano Endoscopic Anatomy of the lateral nasal wall, ostiomeatal complex and anterior skull base, a step-by-step guide. Reda Kamel Endoscopic diagnosis and surgery of the paranasal sinuses and the anterior skull base. Heinz Stammberger Rhinology and Sinus Disease, a problem-oriented approach. Steven D. Schaefer Nasal and Sinus Surgery. Steven Marks. Sections 1, 2, and 3. Surgical anatomy and physiology for the skull base surgeon. Ameet Singh, et al. Operative Techniques in Otolaryngology (2011) 22, FRONTAL SINUS SURGERY 2004: UPDATE OF CLINICAL ANATOMY AND SURGICAL TECHNIQUES. MICHAEL FRIEDMAN, et al. OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY—HEAD AND NECK SURGERY, VOL 15, NO 1 (MAR), 2004: PP 23-31

58 Thank You!

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