Shahin Bastaninejad, Shahin Bastaninejad, MDMD

Assistant Prof. of ORL-HNSAssistant Prof. of ORL-HNS

TUMSTUMS

Amir’Alam Hospital Amir’Alam Hospital

Outline

Definition

Anatomy

Patient evaluation

FESS Concepts of Surgery

FunctionalFunctional Endoscopic Sinus Surgery

Replaced old practice of obliterating sinuses and removing mucosa. Concept of irreversibly diseased mucosa refuted.

Functional aspect refers to:Preserving normal structuresRemoving only obstructionPreserving mucosaAttempt to restore function

Ethmoid anatomy is complex: LabyrinthLamellae

1st - Uncinate2nd - Ethmoid bulla3rd - Basal lamella of

middle turbinate4th - Superior turbinate

Ethmoid anatomy

DrainageFrontal, anterior

ethmoid & maxillary – OMC

Posterior Ethmoids – Superior meatus

Sphenoid sinus – Sphenoid-ethmoidal recess

Middle TurbinateThree 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)

Middle Turbinate

Ostiomeatal Complex (OMC)Common drainage for frontal, maxillary and

anterior ethmoid sinuses.

OMC

OMCInfundibulum Infundibulum – funnel shaped area whereby

the maxillary, ant ethmoid and frontal

sinuses drains

Uncinate processUncinate process– Sickle shaped bony

ethmoidal structure

Hiatus Semilunaris Hiatus Semilunaris – Half-moon shape

opening of infundibulum

Uncinate ProcessAttaches to the

following structures:1. Inf & far post. – To

ethmoid process of inf. Turb

Uncinate Process2. Ant & far sup. – To

lamina papyracea, skull base or mid turb

3. Laterally – Lamina papyracea and fontanelle area

Uncinate Process

52%52%

Bulla EthmoidalisThe greatest anterior

ethmoid air cell, attached to lamina papyrcea and usually open into lateral sinus

Sinus Lateralis = Suprabullar recess and retrobullar recess

SBR

RBR

Sinus Lateralis

Middle turbinate: Horizontal and vertical basal lamella

Sphenoid OstiumMedial to posterior sup. turbinateLocated between nasal septum and inferior

aspect of sup. turbinate Located at the same level as the roof of the

maxillary sinusLocated 4 microdebrider/suction tip breaths

above the choanaeLocated 7cm from nasal crest at 30°

Sphenoid Ostium

Sphenoid Sinus Relationships of important structures:

Optic nerve – superior-lateral

Carotid artery/cav sinus – mid-lateral

Vidian nerve and maxillary nerve – inferior-

lateral

Square – ant clinoid process, Circles – optic canals, triangle – vidian nerveAsterisk – pneumatization of pterygoid process

Sphenoid Classification

SellarPresellar

Conchal Post sellar

Onodi Cells or Sphenoethmoid cells

Optic Canal in Onodi Cells

anatomic keyhole in SBS

LOCR

Keros classificationCribriform plate

1-3mm 3-7mm

7-16mm

Keros ClassificationType I

1-3mmType II

3-7mmType III

7-16mm

Fovea and Ethmoidal arteriesFovea and Ethmoidal arteries

Lens 70 degree – End of surgery

Frontal CellsKuhn Cells

Frontal RecessAnatomic Boundries:

Ant – unicate process & agger nasiPost – bulla ethmoidalis and suprabullar lamellaLateral – lamina papyraceaMedially – hiatus semilunaris or middle turbInf – Ethmoid infundibulumSup – Fovea ethmoidalis, supraorbital air cell, anterior

ethmoid artery and frontal ostium

Draf IDraf IDraf IIADraf IIA

Draf

Draf IIIDraf III

Frontal Sinus – Mucociliary Pattern

Save Mucosal Layer in Lateral part while performing Draf III opertation

Pre-op CT EvaluationCLOSE Technique

C – CribriformL – Lamina PapyraceaO – Orbits, onodi cell, Optic NerveS – Sphenoid, Skull BaseE – Ethmoid Arteries

C - CribriformAssess the Keros typeLook for assymetry

L – Lamina PapyraceaCheck for dehiscence or pathologic fractures

O – Orbit, Optic Nerve, Onodi CellsCheck for dehiscence Assess for onodi cells (superior-lateral to

sphenoid)Orbital slope

S – Sphenoid, Skull baseAssess for Carotid dehiscence and aeration

patternsConchal, Pre-sellar, & Sellar (thickness of

clivus)

Skull baseAssess slope of

skull base Assess if roof

of sphenoid is level with skull base

E – Ethmoid Artery

Concepts of surgery

Role of surgeryShould 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

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

AntrostomySome 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 osAntrostomy must include the natural osium

and accessory osium if present

Recirculation

Frontal SinusotomyQuestion on to perform or notDo as little as possible but as much as

necessarySome advocate ethmoid dissection and monitor

Graduated approach to frontal sinuses

Should evaluate with sagittal reconstructionEvaluate A-P and Mediolateral dimensions,

asses neo-osteogenesis and pneumatization

Ethmoidectomy & Sphenoidotomy

Continue operation Anteroposteriorly Anteroposteriorly toward the

Sphenoid sinus, then open it

Now it is time to go on with PosteroanteriorPosteroanterior

approach with a 30 degree lens and cutting forcepscutting forceps

References1. Dr Quinn online Text book 2. Diseases of the Sinuses: Diagnosis and Management. Kennedy.

Chapters 1, 2, 3, 15, and 163. Head and Neck – Otolaryngology. Bailey. Chapters 21, 25, 26.4.  Endoscopic Sinus Surgery Dissection Manual With Cdrom.

Casiano5. Endoscopic Anatomy of the lateral nasal wall, ostiomeatal

complex and anterior skull base, a step-by-step guide. Reda Kamel

6. Endoscopic diagnosis and surgery of the paranasal sinuses and the anterior skull base. Heinz Stammberger

7. Rhinology and Sinus Disease, a problem-oriented approach. Steven D. Schaefer

8. Nasal and Sinus Surgery. Steven Marks. Sections 1, 2, and 3.9. Surgical anatomy and physiology for the skull base surgeon.

Ameet Singh, et al. Operative Techniques in Otolaryngology (2011) 22, 184-193

10. 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