1. Contemporary indications for external approaches to the PNS :
Caldwell-Luc,
External Ethmoidectomy,
Frontal Sinus Trephine,
Lynch Procedure,
Osteoplastic Frontal Sinus Surgery.

2. The Caldwell-luc procedure
Radical antrostomy.
Definition-
Entering the maxillary sinus through mouth through an incision in buccal mucosa in canine region of maxilla with removal of all diseased mucosa and formation of antrostomy in inferior meatus.

3. History
Christopher Heath Of University College in London-1889:trephination of canine fossa.
1893: George Caldwell( ) –American surgeon-New York medical journal-antrostomy.
1897 Henri Luc( ) –French laryngologist of Paris.
Luc - Europe
Caldwell – America.

4. Indications: Chronic maxillary sinusitis: Intractable sinus infection:
irreversibly diseased epithelial lining of maxillary antrum-
failure from conservative treatment:
Incessant purulent discharge even with patent transnasal antromeatal window.
Repeated sinus infection:
conservative treatment+ to prevent chronicity, involvement of adjoining sinuses or complications.
Endoscopic surgery:
Failure
unapprochable sites

5. revision of transnasal antromeatal window:
Failiure of transnasal operation to maintain antromeatal fenestra.
Better visualization with wider fenestra-increased patency.
Maxillary sinusitis +bronchiectasis:
Presistent purulent drainage from antrum calls for radical eradication.

6. Biopsy : antrochoanal polyp- oroantral fistula:
evulsion– recurrance-polyp excised at its wall of maxillary antrum.
oroantral fistula:
Biopsy :
maxillary antrum.
Antrostomy prior to radiotherapy
ICU—persistent fever,CT/MRI muucosal thickening or opacification---remove NG tube ,topical decongestant.c/s by aspiration---if fail—surgery.

7. cysts: Odontogenic cysts: Non specific cysts: Teratomatous cysts:
Developmental – primodial,dentigerous cysts.
inflamatory-periodontal(radicular) cyst.
Non specific cysts:
Pseudocysts
Retention cysts & mucoceles
Teratomatous cysts:
Cholesteatomas
Dermoids.

8. Mucocele: Mucous retention cyst: Open approach: Signs of growth
ESS: accessible through middle meatus antrostomy
Away from natural ostium: post CL procedure.
Post traumatic extension of mucocele outside sinus through anterior and lateral wall
Mucous retention cyst:
Signs of growth
Bone erosion
Obstructing drainage.
Subtotal or total removal via ESS
Recur /large to cause bony errosion then CL.
Mucosa trapped during closure ---cyst ,mucocele.cyst is in Dependant position outside sinus .

9. Obtaining graft material:
Lateral wall of maxillary sinus +lining
Residual defect-unnoticed functionally+ cosmetically.
Bone graft:
blow out fracture of orbit-lateral bony wall
Composite graft:
periosteum+bone+mucosa(medium sized septal perforation)
Epithelial graft:
respiratory epithelium-mucoperiosteal grafts-nasal septum,tracheal lumen.
Infraorbital n as it emerges fm foramen.

10. Facial trauma Foreign body: displaced dental root, missile:
Blow out fracture of orbit:
Fresh fractures-periorbital tissues reduced —antrum packed/balloon placed.
Delayed fracture-bone graft
Tripod fracture of the zygoma:
malar fracture-reduction +packing.
Fractures of maxillary tuberosity:
(zygomatic+maxillary bone-roof and lateral wall of antrum

11. The American Academy Of Otolaryngology Head And Neck Surgeryclinical indication for Caldwell-Luc :

12. Contemporary indications:
Non physiological:
Distorted ciliary physiology:
Ciliary dyskinesia
Cystic fibrosis
Fungal mycetoma
Antro choanal polyps
Tumor: inverted papilloma
Orbital decompression
Intractible posterior epistaxis
Endoscope inaccessibility.
Mini Caldwell-Luc:

13. Principle of operation:
Antrum is opened—irreversibly damaged mucosa removed—fresh opening into inferior meatus.

14. Technique: Incision 5 mm above GBS-
Two army-navy retractors used to expose undersurface of lip.Pack with a tag in the cheek.
gingiva has little or no elasticity so doesnt support suture.the cuff of mucosa preserved so closure possible. No.15 scalpel.
Electrocautery:improved hemostasis at the cost of damage to surrounding mucosa.
Incision 5 mm above GBS-
3-5 cm long.Close to midline ----end of alveolar ridge laterally
inferior orbital nerve.

15. Exposure:
Superiorly infraorbital nerve: mid pupillary line about 1cm below infraorbital rim.
antrostomy:
5mm square marked by 4mm osteotome-
Mucocele,extensive mucosal disease,polyp,transantral ethmoidectomy,tumor surgery, orbital decompression-entire anterior wall removed,nerve encased by peninsula of bone.
Final exposure extending from pyriform aperture medially to end of alveolar ridge sup-till infraorbital nerve.stretch injury fm retraction.
Size of antrostomy-depends upon procedure:removal of inspissated secretions-cystic fibrosis,fungal sinusitis or limited disease-small opening

16. Removal of pathologic material:
Preservation of normal mucosa.
Extensive disease-
intramucosal debridement:
periosteum preserved: oseitis and bone thickening minimised.
Recesses,loculi & septas,groove
between anterior and medial wall.
Herberhold’s sinus abrasion-a boring attachment with brush shaped arrangement of nylon fibers 1cm long applied to commercially available gimlet.rotating nylon brush removes thickened parts of mucosa.

17. Antrostomy Sublabial approach. few mm above the floor
inferior vs middle meatus
Sublabial approach.
few mm above the floor
midway between anterior and posterior
Intranasally also.
Injury to ascending palatine artery. nasolacrimal duct

18. Middle meatus antrostomy:
Begins at natural ostium.
Incise and remove posterior fontanelle along the floor of orbit along the top of inferior turbinate.
Fontanelle pedicled on posterior wall of sinus-cut.
Uncinectomy edges smoothened.
Anterior part of trubinate removed:

19. Closure: Layered in anterior-to-posterior from medial to lateral.
Pack removal is painful,bac colonisation,delaying healing or post op infection.
Layered in anterior-to-posterior from medial to lateral.
Hemostasis good -filled with antibiotic ointment only.

20. Modifications & alternate procedures:
Osteoplastic flap:
Anterior wall preserved and elevated as flap attached to overlying periosteum.
Minimizes trauma to infraorbital nerve
Preserve sinus post surgery:prevents collapse of ant wall+ingrowth of fibrous tissue due to large anterior wall defect.
contracture
obliteration

21. Submucosal flap eleveted
Periosteal incision medially along pyriform aperture laterally along maxillary buttress with central area left attached.
Osteotomy –anterior surface of maxilla through inferior , medial & lateral incision
Superiorly fracture just below level of infraorbital nerve

22. Osteoplastic antrostomy-Feldmann et al.
Anterior wall lid removed temporarily with fine keyhole saw.
Lid replaced with sutures through small burr holes.
Limitations:
radical antrostomy-trauma, after Denker’s operation, malignant tumor.

23. Denker’s operation Extended radical antrostomy
not extended inferiorly to damage tooth buds in 2nd dentition.
Extended radical antrostomy
anterior bony supporting pillar as far as pyriform aperture removed.
Access through antrum to nasopharynx. posterior part of nasal cavity
Localized resection of tumor.

24. Landmarks and danger points
Infraorbital nerve-point of exit and course in the floor of orbit.lack bony covering lying free within the antrum.
Root of canine and 1st molar, tooth buds of 2nd dentition in children.
Sphenopalatine artery and its end branches.
Ostium of nasolacrimal duct.
Erroded Posterior wall of antrum-damage to maxillary artery
Penetration through thin orbital roof –diplopia, damage to orbital contents.

25. Typical mistakes
Incision too downwards on alveolar crest-wound closure difficult.
Denture-as superiorly as possible.
Preservation of Frenulum of upper lip- b/l operation.
Excessive retraction of soft tissue-crushing of infraorbital nerve in its foramen or hematoma of cheek.
First blow of chisel for opening anterior wall of antrum parallel to inferior edge of orbit below edges of infraorbital nerve to prevent fracture or entry to bony canal of nerve.
Excessive curettage around infraorbital canal-neuralgia/injury.
Inferior meatus opened accidently if wall of nose bulges laterally.

26. Complications Bleeding,Hematoma ,absecess
Infraorbital nerve injury-9-46%
Parasesthesia / hyposthesia
Neuralgia—chronic pain syndrome.
Superior alveolar nerve.
Massive secondary haemorrhage
Subcutaneous emphysema.
Globe injury/ orbital floor injury/extraoccular muscle injury.
Orbital hematoma/proptosis/blindness.
Foetid suppuration—FB
Osteomyelitis of maxilla.
Nasolacrimation duct injury
Injury to roots of teeth.
Vesibuar fistula.
Oroantral fistula
Stretch injury,nerve entrapment by scar tissue,aberrant nerve regeneration.

27. Frontal sinus trephine:
Kuemmel-Beck frontal trephine
Principle:
Burr hole in anterior wall of frontal sinus
Blunt cannula introduced into lumen of sinus.
Indications
Acute frontal sinusitis
Diagnosis and function of ostium.
Not responding within 48hrs of medical treatment.
symptoms worsens/ complications.
Early intracranial complications

28. Chronic sinusitis: Mucocele: Inspissated secretions
unable to locate internal ostium
Mucocele:
Removal/Drain into sinus lumen or nasal cavity
Inaccessible mucocele:
Recess, lateral or superiorly.
Loculation of frontal sinus
Intrafrontal sinus cell
Adjunct to endoscopic or other intranasal surgery.

29. Contemporary indications
Classical indication-acute sinusitis –quick,small well camouflaged incision,preservation of normal sinus function
Control acute infection before fat obliteration osteoplastic flap
Acute frontal sinusitis: trephination vs. Endoscopic:
Operative time
Surgical skills
Image guidance
Risk of permanent scaring the frontal recess--revision
Difficult endoscopic approach :
Identify sinus-revision cases.
Instillation of saline or catheter—sinus drainage tract.
No scaring of outflow tract or frontal recess...cosmetically acceptable. Challenging frontal recess endoscopic sinus surgery esp revision case

30. Technique: Incision: Radiological confirmation of sinus.
Ext ethmoidectomy+ caldwell luc=GA
Incision:
Radiological confirmation of sinus.
short curved inferomedial aspect of eyebrow

31. Supraorbital foramen:inferior aspect of superior orbital rim 1-2 cm lateral to nasion

32. Drilling & Closure:
Underside at jun of medial and superior orbital rims cm opening.

33. Modifications & alternative procedures:
Frontal sinoscopy - rigid telescope
Ogston’s frontal sinus operation:
Unsuccessful Kuemmel-Beck’s in U/L sinusitis.
Contralateral drainage :excision of interfrontal septum.
Office procedure:
Turkel bone biopsy needle.

34. Hints,Rules & mistakes:
Radiographs in 2 planes prior to trephination.
Exclusion of loculation.
Lateral extension avoided
Cosmetic eyebrow incision.
Burr must be guarded
Ostium & frontonasal duct-contrast.
Osteomyelitis
Increasing swelling of soft tissue around trephine—remove + antibiotics

35. Complications: Failiure to resolve infection. Relapse.
Supraorbital & supratrochlear nerve injury.
Hematoma
Medial canthal injury.
Orbital injury
Intracranial injury: dura, frontal lobe
Hypertrophic scar
Placing suture at drain site at time of surgery and tying it down while removing drain. Scar revision after 6-12 mths.

36. External ethmoidectomy
Ferris Smith in 1933 originally described.
“External ethmoidectomy”-
distinguish transorbital approach to ethmoid labirynth from transnasal appproach.
Etmoidectomy:intranasal,external,transmaxillary. Increased bleeding & decreased bony strength. Inadequate first procedure.

37. Acute sinusitis:
Intranasal approach difficult due to severe mucosal reaction.
Chronic sinusitis:
Extensive : supraorbital ethmoid
Recurrent:
Anatomical distortion
Damaged orbital content
Require Extensive resection
Orbital infection:
Pyogenic infection of ethmiod labyrinth:Exclude intraorbital abcess .
Subperiosteal abcess, orbital abcess: orbital decompression procedures.
Mucormycosis :orbital exploration + exenteration.
Mucocele with orbital extension.
Complications of acute ethmnoid or frontal sinusitis:
repair of CSF leak in cribriform ,fovea ethmoidalis, ethmoidal, sphenoidal region

38. Control of epistaxis
Combined procedures:
Sphenoidectomy
Lynch frontal sinus operation
Caldwell-Luc procedure
Transethmoid hypophysectomy
Dacrocystorhinostomy
Access to to frontal,ethmoidal,sphenoidal sinus tumors
Craniofacial resection
Medial maxillectomies

39. Contemporary indications:
Anterior ethmoidal artery ligation:
Intractable epistaxis.
Inaccessible to interventional radiologist.
Endoscopic approach:medial orbitalwall removal—orbital collpase into ethmoid.
Reduction of nasoethmoid complex fractures.
Subperiosteal abcess & orbital abcess:
Drainage of infected site into ethmoid cavity.
Exenteration of acutely infected ethmoid cells.
identification of abcess pocket in inflamed field.
Cranial base tumor surgery:
Bicornal flaps, facial translocation,external ethmoidectomy.

40. The American Academy Of Otolarygology And Head And Neck Surgery For Ethmoidectomy:

41. Preoperative consideration:
Ophthalmological examination:
Basic: VA, EOM, pupillary response.
Orbital involvement: complete examination

42. Technique: Incision: Standard Lynch incision.
sup :below supraorbital foramen,inf: inferior edge of lacrimal fossa.
Angular artery branches in Submuscular layer

43. Exposure: Orbital side periosteum elevated
Superiorly :above nasofrontal suture.
Inferiorly: anterior lacrimal crest.
Elevation of Orbital content,lacrimal sac
Anterior ethmoid artery:
Posterior ethmoid artery:

44. Ethmoidectomy: middle turbinate-preservation.
Careful removal on medial ethmoid to preserve nasal mucosa.
Posteriorly based mucosal flap created to enter nasal cavity.
Inferior portion of medial turbinate resected,superior attachment-cribriform plate preserved.
Orbital wall anterior to ant ethmiod artery preserved:

45. Complications: Bleeding/crusting Epiphora: Recurrance: Diplopia:
Blindness
CSF leak
Intracranial hemorrhage
Hypertrophic scar formation
Medial canthal scarring
Telecanthus
Supraorbital nerve dysesthesia
Diplopia:enophthalmos –orbital roof+lamina paparacea...injury to medial rectus+transgression of orbital periosteum..

46. Lynch Procedure: External Frontoethmoidectomy
1920.
Ethmoidectomy + middle turbinectomy + resection of entire floor of frontal sinus.

47. Chronic sinusitis:
Failiure to medical therapy.+ lesser procedure:
septoplasty, intranasal ethmoidectomy.
Polyps, hyperplastic sinusitis or anatomical obstruction of frontal sinus drainage.
Goal –normal mucociliary clearance.
Failure of endoscopic frontal sinusotomy.
Cant tolerate osteoplastic operation.
Others:
Mucocele.
Orbital complications :
Frontocutaneous and ethmoidcutaneous fistula.
Recurrent sinusitis or polyposis after failure of endoscopic approach.

48. Contemporary indications:
Benign neoplasm of superior nasal cavity,ethmoid,frontal sinuses and anterior skull base.
Malignant tumors.
Closure of CSF leak.
Contemporary indications:
Endoscopic, drills not available
Surgeon not comfortable with endoscopic approach.
Chronic rhinosinusitis in large well areated frontal sinuses with extensive pneumatization-complete obliteration difficult.
Severely scarred frontal recess with osteitic bone after multiple endoscopic approaches.

49. Techniques: Incision: Nasofrontal connection created:
With: by reaching up in frontal recess...without:frontal sinus and lamina papyracea.
Incision:
Nasofrontal connection created:
With intact bridge of bone:lateral wall of frontal recess+
Complete frontoethmoidectomy: collapse of frontal recess-stenosis.

50. Reconstruction: Intact bridge: Stent : Silastic or rubber :
Stenosis.
Stent : Silastic or rubber :
Tube ( multiple side holes)
Rolled sheet.
Sewell-Boyden flap
90% patency
1-2 cm wide, 2-3 cm long
Rotating distal end on itself laterally & superiorly into frontal sinus through external incision.
It will line medial and posterior wall of frontal recess with mucosa facing lumen of frontal sinus.
Stent.

51. Complications: Postoperative care: Stent removal:
5-7th POD vs. 6 wks or longer
Flap: 1-2 wks.
irrigation:
FU- 1st 3 mths post op.
Areated sinus= annually X 5yrs
Opacified = revision surgery.
Complications:
Poor cosmetic result
Recurrance: mucocele
90% patency
30% revision surgery-

52. Osteoplastic frontal sinus surgery
Principle:
Inferiorly hinged ‘trap door’ of bone fashioned from anterior wall of frontal sinus, sinus cleared, wide drainage duct created to nose, closure of sinus with bone flap.
Late 19th century.
Popularized in US Montgomery and colleagues.
Goal:
Remove /obliterate the sinus- air space-non physiological.

53. Indications: Acute sinusitis: Chronic sinusitis:
Intraorbital or intracranial complications:
Definitive surgical management.
Recurrent acute frontal sinusitis: Failed Endoscopic approach.
Chronic sinusitis:
Failiure of endoscopic and frontoethmoidectomy : recurrent infection.
Anatomical limitations of endoscope
Inherent mucosal disease requiring functional restoration of sinus: cystic fibrosis, ciliary dyskinesia, sarcoidosis.

54. Allergic fungal sinusitis: Mucocele:
Recurrance to avoid chronic steroid use+ complications.
Mucocele:
Endoscopic drainage not possible:
Loculated mucocele: not connected to frontal recess.
Anatomical limitations.
Others:
Extensive sinus requiring supplemantary removal of anterior wall
Extensive fractures with dislocation-dura tear, frontal lobe injury

55. Contemporary indications:
Chronic rhinosinusitis or polyposis:
Refractory to endoscopic approach : mucocele.
Scared /+ osteitic frontal recess
Unfavorable anatomic conditions:
Narrow frontal recess
Type IV frontal recess cells
Symptomatic osteomas.
Lateral symptomatic disease non responding to endoscope.
Altered physiology:
Ciliary dyskinesia,
cystic fibrosis
Frontal sinus fractures
Tumors: inverted papilloma.

56. Preoperative preparation:
Contraindications:
Hypoplastic sinus
Comminuted fractures
Advantages:
Direct approach:
No facial deformity.
Less morbidity.
Both sinuses simultaneously.
Preoperative preparation:
Radiological assessment of frontal sinus margin.

57. Incision: Brow incision: Mid forehead incision: Bicoronal incision:
Cosmetically hidden.
Sacrifises sensation.
Mid forehead incision:
Anterior or frontal baldness with deep forehead crease.
preserves some sensation
Bicoronal incision:
Forehead sensation preserved.
Hidden by hair.

58. 2-3cm behind the hairline.
Laterally to level of preauricular crease.
subgaleal plane, laterally superficial to temporalis fascia.
Superficial temporal artery
Hemostasis achieved in each layer.

59. Flap elevation: Subgaleal flap: Periosteal flap:
Knife,scissors,electrocautery.
Coagulation mode, along the dissection plane
Continuous tight traction on flap till supraorbital rims
Periosteal flap:
Periostium incised from one temporal fossa to another,
Periosteal flap elevated with Freer elevator till nasal dorsum in midline and orboial rims laterally: supraorbital foramen and nerve.

60. Osteoplastic flap: Template of the sinus
Coin placed on forehead above nasion so that 1:1 representation.
Template of the sinus
Intersinus septum cut 1cm curved osteotome.
Flap elevated at three points simultaneously

61. Mucosal resection Sinus Content-C/S Elevation of mucosa
complete removal by drill with diamond and cutting burr:
interior of anterior wall,
intersinus septum: antinf-nasal septum,post-crista galli,bony overhange.
orbital and cranial surface of sinus,
frontal recess,
ethmoid sinus
Supraorbital ethmoid cells.

62. Obliteration: Muscle: Temporalis muscle-resolves
Ethmoid sinus at level of anterior ethmoidal artery.
Bone:
Osseous and fibrous plug preventing mucosal growth from below.
1.5X5cm Calvarial graft + bone dust.
Outer cortex from calvarium of parietal bone
Graft broken into 2-3 mm pieces packed in frontal recess+ bone dust.
Temporalis fascia graft : over frontal recess
Fat graft: adequately filling the sinus.

63. Closure:
Osteoplastic flap repositioned :26 gauge wires - 2 & 10 o’clock.
Periosteal flap sutured.
Drains:
Over eyebrow
Across the top of skull behind incision.
Hemostais achieved.
Skin closure.
U/L procedure:

64. Complications: Wound problem: Blood transfusion Orbital injury
Hematoma,seroma
infection,
Flap necrosis.
Blood transfusion
Orbital injury
Recurrent
Mucocele
Chronic headache:
Frontal numbness/parasthesia
Cosmetic alterations: absorption of bone flap/bone thickening due to excessive periosteal reaction.

65. Summary Endoscopic approach vs. External approach:
Advancements in endoscopic sinus surgery:
Surgical skills
Easy availability of instrumentaions in operating theaters

66. THANK YOU!!!
Dr. Diva Shrestha