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Concepts of Endoscopic Sinus Surgery: Causes of Failure Cummings Chp. 52 Wed 1/9/13 Irene A. Kim.

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Presentation on theme: "Concepts of Endoscopic Sinus Surgery: Causes of Failure Cummings Chp. 52 Wed 1/9/13 Irene A. Kim."— Presentation transcript:

1 Concepts of Endoscopic Sinus Surgery: Causes of Failure Cummings Chp. 52 Wed 1/9/13 Irene A. Kim

2 Key Points Long-term success rate of FESS + medical therapy: 80-90%. Long-term success rate of FESS + medical therapy: 80-90%. Anatomic variants no longer considered underlying etiology of disease Anatomic variants no longer considered underlying etiology of disease FESS GOAL: FESS GOAL: Surgically remove inflamed tissue from critical points in mucociliary clearance pathways Surgically remove inflamed tissue from critical points in mucociliary clearance pathways

3 ABSOLUTE Indications for Sinus Surgery 1. Rhinosinusitis complications 1. Rhinosinusitis complications 2. Expansile mucoceles 2. Expansile mucoceles 3. Allergic/Invasive fungal rhinosinusitis 3. Allergic/Invasive fungal rhinosinusitis 4. Suspected neoplasia 4. Suspected neoplasia

4 Mucoceles Frontal sinus mucoceles Frontal sinus mucoceles Skull base identified in posterior ethmoid Skull base identified in posterior ethmoid Follow anteriorly until bone of lesion found Follow anteriorly until bone of lesion found Remove inferior portion Remove inferior portion Remove all osteitic bone from region of obstruction Remove all osteitic bone from region of obstruction Bony margins flush should be Bony margins flush should be flush with surrounding wall

5 Fungal Sinusitis Invasive Invasive Chronic invasive fungal rhinosinusitis Chronic invasive fungal rhinosinusitis Fulminant invasive disease Fulminant invasive disease Noninvasive Noninvasive Fungal balls Fungal balls Allergic fungal rhinosinusitis Allergic fungal rhinosinusitis

6 Indications for Tumors, Skull Base Defects, Other Noninflammatory Lesions Benign tumors Benign tumors Inverted papilloma Inverted papilloma Juvenile angiofibroma Juvenile angiofibroma Skull base defects Skull base defects Orbital problems Orbital problems Encephaloceles, meningoceles Encephaloceles, meningoceles Closure of CSF rhinorrhea Closure of CSF rhinorrhea Malignant tumors Malignant tumors

7 Relative Indications for Sinus Surgery Symptomatic nasal polyps Symptomatic nasal polyps Unresponsive to medical therapy Unresponsive to medical therapy Symptomatic chronic or recurrent acute rhinosinusitis Symptomatic chronic or recurrent acute rhinosinusitis Unresponsive to medical therapy Unresponsive to medical therapy ***Medical therapy is cornerstone of mgmt of inflammatory disease ***Medical therapy is cornerstone of mgmt of inflammatory disease

8 Poor Indicators of Successful FESS Persistent environmental exposures Persistent environmental exposures Uncontrolled allergies Uncontrolled allergies Continued chemical exposures Continued chemical exposures Smoking Smoking Increased granulation tissue Increased granulation tissue Increased incidence of frontal recess stenosis Increased incidence of frontal recess stenosis

9 Extent of Surgery Mucosal preservation is *key* (ethmoid) Mucosal preservation is *key* (ethmoid) Resection of inflamed bone important Resection of inflamed bone important Removal of osteitic partitions Removal of osteitic partitions Uncinate process Uncinate process Ethmoid sinuses Ethmoid sinuses Avoid leaving exposed bone behind Avoid leaving exposed bone behind

10 Pre-op Evaluation & Management Know amount and duration of: Know amount and duration of: Antibiotic therapy Antibiotic therapy Anti-inflammatory treatments Anti-inflammatory treatments Treat severe polyposis, hyperreactive mucosa Treat severe polyposis, hyperreactive mucosa Oral steroids (Prednisone 20-30mg x 3-10 days) Oral steroids (Prednisone 20-30mg x 3-10 days)

11 Imaging CT key, but MRI needed when CT shows disease adjacent to skull base erosion CT key, but MRI needed when CT shows disease adjacent to skull base erosion Evaluate lateral cribiform plate lamella Evaluate lateral cribiform plate lamella Evaluate vertical height of post ethmoid Evaluate vertical height of post ethmoid Evaluate sphenoid sinus in axial/coronal planes Evaluate sphenoid sinus in axial/coronal planes Evaluate frontal recess in triplanar views Evaluate frontal recess in triplanar views

12 Concepts of Antrostomy Maxillary sinus opening should communicate with natural ostium to PREVENT surgical failure Maxillary sinus opening should communicate with natural ostium to PREVENT surgical failure Long term causes of failure Long term causes of failure Ostenoneogenesis from stripped mucosa Ostenoneogenesis from stripped mucosa Retained foreign body Retained foreign body Mucous draining into sinus from persistent frontal recess inflammation Mucous draining into sinus from persistent frontal recess inflammation

13 Ethmoidectomy Work from “known” to “unknown” Work from “known” to “unknown” Medial orbital wall is first critical landmark Medial orbital wall is first critical landmark Goal: Marsupialized cavity lined by healthy, intact mucosa Goal: Marsupialized cavity lined by healthy, intact mucosa Skull base is second critical landmark Skull base is second critical landmark Common results of failed ethmoidectomy: Common results of failed ethmoidectomy: Lateralized middle turbinate Lateralized middle turbinate Retained uncinate process Retained uncinate process Failure of removal of uncinate superiorly Failure of removal of uncinate superiorly Residual agger nasi cells Residual agger nasi cells

14 Sphenoidotomy Re-review scans: coronal and axial planes Re-review scans: coronal and axial planes Review course of optic n., carotid a. Review course of optic n., carotid a. Endoscopic transnasal approach Endoscopic transnasal approach Transethmoid/transmaxillary approach Transethmoid/transmaxillary approach Transseptal approach Transseptal approach

15 Sphenoid Anatomy: Key Structures Carotid artery Carotid artery Optic nerve Optic nerve Cavernous sinus Cavernous sinus 3 rd, 4 th, 5 th CN 3 rd, 4 th, 5 th CN

16 Frontal Sinusotomy Most challenging Most challenging Potential for persistent, recurrent disease Potential for persistent, recurrent disease Most difficult decision: to explore or not Most difficult decision: to explore or not Review coronal, axial, sagittal views Review coronal, axial, sagittal views Review AP/lateral diameters Review AP/lateral diameters Examine pneumatization of sinus Examine pneumatization of sinus Frontal recess dissection Frontal recess dissection

17 Turbinate Management Remove exposed bone (MT) Remove exposed bone (MT) Stabilize floppy MT Stabilize floppy MT Controlled scar to nasal septum Controlled scar to nasal septum Postoperatively, can lyse adhesions Postoperatively, can lyse adhesions Suture turbinate to septum Suture turbinate to septum

18 Postop Medical Management Long-term topical steroid sprays Long-term topical steroid sprays Saline spray Saline spray Nasal saline irrigation Nasal saline irrigation Debridement Debridement Loss of olfaction: sensitive sign of return of disease Loss of olfaction: sensitive sign of return of disease

19 Management of the Frontal Sinuses Cummings Chp. 53 Wed 1/9/13 Irene A. Kim

20 Key Points Frontal sinus drains into middle meatus through frontal recess Frontal sinus drains into middle meatus through frontal recess Frontal recess located at junction of frontal sinus and is most anterosuperior part of ethmoid sinus Frontal recess located at junction of frontal sinus and is most anterosuperior part of ethmoid sinus Preserve mucosa around frontal recess Preserve mucosa around frontal recess

21 Acute Frontal Sinusitis Symptoms Symptoms Low-grade fever Low-grade fever Malaise Malaise Frontal headache Frontal headache Tenderness of medial aspect of infraorbital margin Tenderness of medial aspect of infraorbital margin Common organisms Common organisms S.pneumo, H. flu, anaerobic strep, Bacteroides, S. aurus, S. epidermidis, S. milleri S.pneumo, H. flu, anaerobic strep, Bacteroides, S. aurus, S. epidermidis, S. milleri

22 Treatment Approaches Topical decongestant high in middle meatus Topical decongestant high in middle meatus Trephine the frontal recess by: Trephine the frontal recess by: Incision in medial aspect of eyebrow Incision in medial aspect of eyebrow Open frontal sinus endoscopically by removing ethmoid air cells surrounding recess Open frontal sinus endoscopically by removing ethmoid air cells surrounding recess

23 Complications of Surgery Damage to mucosa Damage to mucosa Adhesions Adhesions Stenosis Stenosis Periorbital cellulitis Periorbital cellulitis Periorbital abscess, subdural empyema, meningitis, cavernous, sup sagittal sinus thrombosis Periorbital abscess, subdural empyema, meningitis, cavernous, sup sagittal sinus thrombosis *Obtain URGENT CT if: *Obtain URGENT CT if: CNS involvement seen CNS involvement seen Visual problems Visual problems Spiking pyrexia not resolving in 36 hours Spiking pyrexia not resolving in 36 hours

24 Surgery in Chronic Frontal Sinusitis Disease likely started by unnecessary instrumentation of frontal recess Disease likely started by unnecessary instrumentation of frontal recess PRIMARY indication for instrumentation: PRIMARY indication for instrumentation: When maximal medical treatment partial anterior ethmoidectomy have failed When maximal medical treatment partial anterior ethmoidectomy have failed Primary fungal disease Primary fungal disease Barotrauma Barotrauma Mucocele Mucocele Osteoma Osteoma OsteomyelitisTumors OsteomyelitisTumors

25 Causes of Frontal Sinus Surgery Failure Remnant frontal recess cells Remnant frontal recess cells Retained uncinate process Retained uncinate process Middle turbinate lateralization Middle turbinate lateralization Osteoneogenesis Osteoneogenesis Scarring or inflammatory mucosal thickening Scarring or inflammatory mucosal thickening Recurrent polyposis Recurrent polyposis

26 Endoscopic Frontal Sinusotomy Boundaries of frontal recess Boundaries of frontal recess Anterior Anterior Agger nasi Agger nasi Lateral Lateral Lamina papyracea Lamina papyracea Medial Medial Most ant/superior portion of middle turb Most ant/superior portion of middle turb Posterior Posterior Ethmoid bulla, bulla lamella Ethmoid bulla, bulla lamella

27 Frontal Recess Cells Type I: Single cell superior to agger nasi cell Type I: Single cell superior to agger nasi cell Type II: Tier of two or more cells above the agger nasi cell Type II: Tier of two or more cells above the agger nasi cell Type III: Single cell extending from the agger cell into the frontal sinus Type III: Single cell extending from the agger cell into the frontal sinus Type IV: Isolated cell within the frontal sinus Type IV: Isolated cell within the frontal sinus

28 Frontal Recess Cells Bulla frontalis Bulla frontalis High anterior ethmoid cell that has pneumatized into frontal bone High anterior ethmoid cell that has pneumatized into frontal bone Can displace frontal recess posteriorly and medially Can displace frontal recess posteriorly and medially Supraorbital cell Supraorbital cell Posterior cell in ant ethmoid complex that is well pneumatized Posterior cell in ant ethmoid complex that is well pneumatized Can extend laterally into frontal bone over orbit Can extend laterally into frontal bone over orbit Can also narrow frontal recess by pushing forward Can also narrow frontal recess by pushing forward *Prevalance of these variations does NOT appear to correlate with presence or absence of frontal sinus disease *Prevalance of these variations does NOT appear to correlate with presence or absence of frontal sinus disease

29 Opening the Frontal Recess Goal: Goal: 1. Deflating the cells of ethmoid air cells 1. Deflating the cells of ethmoid air cells 2. Preserve mucosa around recess 2. Preserve mucosa around recess Median frontal sinus drainage procedure Median frontal sinus drainage procedure Obliteration of frontal sinuses Obliteration of frontal sinuses

30 Median Frontal Sinus Drainage Procedure Frontal recesses opened by removing: Frontal recesses opened by removing: top of septum top of septum Frontal interspinus septum Frontal interspinus septum Anterior beak of frontal bone Anterior beak of frontal bone

31 Frontal Sinus Obliteration Coronal flap or eyebrow incision Coronal flap or eyebrow incision Make outline of frontal sinus with template, image guidance, or endoscopically Make outline of frontal sinus with template, image guidance, or endoscopically Remove anterior plate Remove anterior plate Remove all mucosa of frontal sinuses before obliteration Remove all mucosa of frontal sinuses before obliteration Frontal recess separated from nasal airway with sheet of fascia lata Frontal recess separated from nasal airway with sheet of fascia lata Use fat to obliterate sinuses Use fat to obliterate sinuses

32 Indications for External Approach Situations where removal of pathology and/or drainage is difficult to achieve endoscopically Situations where removal of pathology and/or drainage is difficult to achieve endoscopically Lateral loculation, lateral mucocele Lateral loculation, lateral mucocele Fibrosis or new bone around frontal recess Fibrosis or new bone around frontal recess Paget’s disease of frontal bone, osteomyelitis, SCCa Paget’s disease of frontal bone, osteomyelitis, SCCa Gross prolapse of orbital contents Gross prolapse of orbital contents

33 Riedel’s Procedure Important role in mgmt of patients with recurrent infections Important role in mgmt of patients with recurrent infections Removes ant wall and floor of frontal sinus and all its mucosal lining Removes ant wall and floor of frontal sinus and all its mucosal lining Help eradicate frontal sinus disease when Help eradicate frontal sinus disease when Drainage and obliteration have failed and Drainage and obliteration have failed and There is persistent disease involving the ant wall of the frontal sinus or the sinus itself There is persistent disease involving the ant wall of the frontal sinus or the sinus itself Main complaint: postoperative disfigurement Main complaint: postoperative disfigurement

34 Cranialization of Frontal Sinuses Performed for: Performed for: Requirement for posterior wall removal Requirement for posterior wall removal Anterior skull base tumors Anterior skull base tumors Severe communication of posterior wall with frontal sinus Severe communication of posterior wall with frontal sinus Ant intracranial contents separated from paransal sinuses and nasal airway by: Ant intracranial contents separated from paransal sinuses and nasal airway by: Fascia lata Fascia lata Pericranial flap Pericranial flap

35 Specific Pathologic Conditions Pneumosinus Dilatans Pneumosinus Dilatans Rare, benign expansion of an aerated sinus beyond normal margin of frontal bone Rare, benign expansion of an aerated sinus beyond normal margin of frontal bone Hypersinus: enlarged sinus with normal walls Hypersinus: enlarged sinus with normal walls Mucoceles Mucoceles Epithelium-lined sac containing inspissated mucous Epithelium-lined sac containing inspissated mucous Osteoma Osteoma Only complaints are cosmetic Only complaints are cosmetic Very common, 3% of people have them Very common, 3% of people have them

36 Fractures of Frontal Sinus Ant wall fractures do not require exploration UNLESS: Ant wall fractures do not require exploration UNLESS: It affects the frontonasal duct It affects the frontonasal duct POSTERIOR wall fractures POSTERIOR wall fractures Nondisplaced and w/o complications: manage conservatively Nondisplaced and w/o complications: manage conservatively Compound comminuted fracture affecting posterior wall or near frontonasal duct: Compound comminuted fracture affecting posterior wall or near frontonasal duct: Cranialization of frontal sinus Cranialization of frontal sinus

37 Images Abnormal.html&ig=http://t0.gstatic.com/images?q=tbn:ANd9GcQAB-0_DUmc13JMscXED8RGxcG5ubw62-944bbpTn6vUB4- gZtWI704bZU&h=377&w=395&q=expansile+mucocele&babsrc=SP_ss Abnormal.html&ig=http://t0.gstatic.com/images?q=tbn:ANd9GcQAB-0_DUmc13JMscXED8RGxcG5ubw62-944bbpTn6vUB4- gZtWI704bZU&h=377&w=395&q=expansile+mucocele&babsrc=SP_ss articles/Nasal%20Polyps.html&ig=http://t2.gstatic.com/images?q=tbn:ANd9GcTvstLF-0MDNGBmYBkVL1rd2nncNJwGQVtt7_Ov0KaR5uEP17- Ih8Hn45E&h=337&w=344&q=fungal+sinsuitis+flow+chart&babsrc=SP_ss articles/Nasal%20Polyps.html&ig=http://t2.gstatic.com/images?q=tbn:ANd9GcTvstLF-0MDNGBmYBkVL1rd2nncNJwGQVtt7_Ov0KaR5uEP17- Ih8Hn45E&h=337&w=344&q=fungal+sinsuitis+flow+chart&babsrc=SP_ss p://t2.gstatic.com/images?q=tbn:ANd9GcRoFmf0M41wC03FDJe_k8DmR6V- oTg7ZfOY2irnRDknCnNHBvTch6zP2Hk&h=290&w=409&q=sphenoid+sinus+anatomy&babsrc=SP_ss p://t2.gstatic.com/images?q=tbn:ANd9GcRoFmf0M41wC03FDJe_k8DmR6V- oTg7ZfOY2irnRDknCnNHBvTch6zP2Hk&h=290&w=409&q=sphenoid+sinus+anatomy&babsrc=SP_ss


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