Surgical Treatment of Sinusitis Dr Vishal Sharma Maxillary

Surgical Treatment of Sinusitis Dr. Vishal Sharma

Maxillary Sinusitis 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)

Antral Washout (proof puncture, antral lavage)

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

Tilley Lichwitz Antrum Puncture Trocar & Cannula

Higginson Syringe

Trocar directed towards I/L tragus

Hole made 1. 25 cm behind anterior end of inferior turbinate

Antral irrigation

Anesthesia: L. A. for adults. G. A. for children & uncooperative 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 370 C with pt leaning forwards & saying k k. Wash till clear fluid comes. Remove cannula.

Complications 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

Intranasal antrostomy (INA) • Region of antral puncture in inferior meatus perforated with Tilley's antral harpoon. • Antrostomy enlarged with Tilley's antral burr or Myle’s nasoantral perforator.

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

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

Exposure of incision site

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

Incision deepened till periosteum

Anterior wall broken with osteotome

Hole made in anterior wall

Suction of maxillary sinus

Inferior meatal antrostomy

Packing of maxillary sinus

Packing of sinus & nose

Incision closed

Complications 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

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

Lynch Howarth ethmoidectomy

Patterson ethmoidectomy

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

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

Frontal sinus trephination

Frontal sinus trephination 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 Citelli’s 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 48 -72 hours post-operatively.

Frontal sinus trephination

Osteoplastic flap procedure

Osteoplastic flap procedure

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

Lothrop Procedure

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

Sublabial trans-septal approach

External ethmoidectomy approach

Endoscopic approach

Functional Endoscopic Sinus Surgery

F. E. S. S.

Anatomy of lateral wall

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

Steps of F. E. S. S.

Left nasal cavity

Left middle meatus

Left middle meatus

Incision on uncinate process

Incision completed

Uncinate process removed

Opening of bulla ethmoidalis

Bulla ethmoidalis removed

Natural & accessory ostia exposed

Middle meatal antrostomy done

Opening made on basal lamella

Basal lamella removed

Posterior ethmoidectomy done

Anterior sphenoid sinus wall

Interior of sphenoid sinus

Skull base clearance done

Frontal recess opened

Final FESS cavity

Surgical Navigation

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

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