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Revision Functional Endoscopic Sinus Surgery
CHAPTER
14 Revision Functional Endoscopic Sinus Surgery: Completion Sphenoethmoidectomy Randy Leung and Rakesh Chandra
INTRODUCTION n
n
n
n
ompletion sphenoethmoidectomy refers to a reviC sion sinus procedure in a patient in whom a maxillary antrostomy and partial ethmoidectomy have been previously performed. Patients with nasal polyposis and moderate to severe inflammatory disease commonly have persistent symptoms despite a partial ethmoidectomy and limited sinus surgery. Completion sphenoethmoidectomy is often combined with a frontal recess dissection in hopes that it will be the last surgery ever needed by the patient. Often in these cases, there are remnant osteitic ethmoid bony partitions along the medial orbital wall and skull base that can be a source of persistent overlying mucosal inflammation (Fig. 14.1). Persistent inflammation in the bone and sinuses can often result in a bloody visual field. Surgeons must be careful and meticulous in their technique to achieve a safe and effective surgery.
ANATOMY n
See Chapters 7 and 8 for the anatomy of the ethmoid and sphenoid sinuses.
PREOPERATIVE CONSIDERATIONS Medical optimization should be accomplished. – Preoperative administration of an oral corticosteroid may lessen surgical difficulty both subjectively1 and in terms of blood loss.2 n
– Decongesting agents may be applied to minimize bleeding and facilitate surgical access. Options include the following: – Topical α-agonists, including pseudoephedrine, oxymetazoline, xylometazoline – Topical cocaine, 4% – Topical adrenaline, 1:1000
Radiographic Considerations omputed tomography (CT) scans of the sinuses C with coronal reformats should be available for review intraoperatively. Resolution should be at least 2 to 3 mm per slice. n Preoperative review of images is critical to identify danger areas, as detailed later. n Review preoperative CT scans. – Evaluate for the presence of bony dehiscences in the orbit and skull base. – Identify the depth of the lateral lamella to avoid inadvertent intracranial entry and cerebrospinal fluid (CSF) leak during dissection along the skull base. – Identify remnant ethmoid partitions along the medial orbital wall and skull base. – Identify the presence of a lateralized middle turbinate remnant. – Diagnose polypoid disease within the maxillary and/or sphenoid sinuses. n Evaluate the path of the anterior ethmoid artery as it courses between the orbit and the skull base. If it has a long course through the sinonasal cavity, it may be at risk of injury during ethmoid dissection along the ethmoid skull base. Retraction of the artery into the orbit may risk retro-orbital hematoma. n
115
116 n
n
PART 3 Revision Endoscopic Sinus Surgery for Inflammatory Disease
Identify the presence of Onodi cells, which are posteriorly pneumatized posterior ethmoid cells. Recognition of such cells is important, because the optic nerve may be dehiscent into these sinuses and vulnerable to injury. Equally important is evaluation of the skull base. Identification of a low-lying skull base or asymmetry is critical to avoid inadvertent injury. Look for a short posterior ethmoid height, particularly in the context of a well pneumatized
n
maxillary sinus. If the ratio of the maxillary sinus height to the height of the posterior ethmoid exceeds 2:1, the surgeon may be led erroneously on a trajectory to the skull base instead of the sphenoid sinus, which puts the patient at risk of CSF leak.3 Identify bony dehiscences of the optic nerve and internal carotid artery in the sphenoid sinus. – Carotid dehiscences in the sphenoid sinuses have been found in 5% to 25% of cases in r adiographic and cadaveric examinations.4,5 – Note the sphenoid intersinus septum. When the sphenoid sinuses are asymmetric, the intersinus septum typically attaches to the carotid canal on one side.
INSTRUMENTATION - and 30-degree rigid endoscopes 0 Manual instruments – Straight and 90-degree J-curettes – Straight and 45-degree Blakesley forceps – Straight and 45-degree through-cutting forceps – Kerrison rongeur n Powered instruments – Straight and 40-degree microdébriders n n
Ethmoid roof
Ethmoid roof
Lamina papyracea
Osteitic bone Residual ethmoid partitions
SURGICAL PROCEDURE Fig. 14.1. Triplanar computed tomography images for a patient scheduled to undergo a revision completion sphe noethmoidectomy. Note the presence of numerous osteitic ethmoid partitions along the medial orbital wall and skull base.
Step 1: Debulk Polyps in the Nasal Cavity With a Microdébrider n Make sure to débride just the polyps; leave the bony dissection to hand instruments, which have a greater tactile feel (Fig. 14.2).
Residual ethmoid partitions
Maxillary antrum
A
B
Inferior turbinate
Fig. 14.2. Endoscopic view of polyps within the left middle meatus of a patient before (A) and after (B) débridement of polyps with a straight microdébrider.
CHAPTER 14 Revision Functional Endoscopic Sinus Surgery: Completion Sphenoethmoidectomy Step 2: Revise the Maxillary Antrostomy n Nasal polyps from the ethmoid cavity can often block the maxillary sinus, which results in the presence of polyps and allergic mucin within the sinus itself (Fig. 14.3). n Revising the maxillary antrostomy often requires removing the remnant uncinate process with a backbiter, which maximizes the antrostomy size (Fig. 14.4).
Maxillary antrum
Natural maxillary ostium often with edema or scarring
Polyps in maxillary sinus
Fig. 14.3. Thirty-degree endoscopic view of the left maxillary sinus with polyps and allergic mucin.
Natural maxillary ostium with scarring causing recirculation
Fig. 14.4. Endoscopic view of the use of a backbiter to remove the remnant left uncinate process back to its attachment to the lacrimal bone.
n
117
ébride polyps and mucin within the maxillary sinus. D It is important to flush out any remaining mucin in the sinus. This can be accomplished using a 60-mL syringe of saline attached to a curved olive-tip suction.
Step 3: Remove the Posterior Maxillary Air Scoop n The posterior maxillary sinus often becomes osteitic and polypoid; the posterior fontanelle can often act as an air scoop and serve as a persistent nidus for inflammation. n Use straight through-cut forceps to remove the posterior fontanelle back to the posterior wall of the maxillary sinus (Fig. 14.5). Step 4: Skeletonize the Medial Orbital Wall n Osteitic bony partitions along the medial orbital wall are another persistent nidus of inflammation. n Failure to remove the osteitic bone will often result in persistent mucosal edema and nasal polyposis. n The curvature of the orbital floor is contiguous with the medial orbital wall. Follow this curvature to help in anticipating the medial orbital contour. n 2- and 4-mm Kerrison punches and 45-degree through-cutting forceps are useful to remove these hard partitions (Fig. 14.6). Step 5: Dissect the Remaining Posterior Ethmoid Air Cells Down to the Sphenoid Face n The last posterior ethmoid cell typically has the appearance of a pyramid, formed by the junction of the basal lamella of the superior turbinate with the skull base. n The posterior maxillary wall will curve posteriorly and approximate the location of the face of the sphenoid, which provides another clue to the location of the sphenoid sinus. Step 6: Enlarge the Sphenoidotomy n In many patients with nasal polyposis, allergic mucin resides in the bottom of the sphenoid sinus, causing persistent mucosal edema. Maximally enlarging the sphenoid can make it easier to remove the mucin postoperatively and allow the patient to irrigate the sphenoid more efficiently. n Posterior ethmoid bony partitions and the lateral sphenoid face are often left behind. Removal is best performed with a Kerrison punch or straight mushroom punch. Dissect from medial to lateral starting with the natural os of the sphenoid sinus (Fig. 14.7). n Enlarging the sphenoidotomy often requires removing the inferior face of the sphenoid with a Kerrison punch. n Use a suction elevator to retract the mucosa inferiorly, in turn protecting the septal branch of the
118
PART 3 Revision Endoscopic Sinus Surgery for Inflammatory Disease
Lamina papyracea
Posterior fontanelle
Maxillary sinus
Maxillary sinus
Natural ostium maxillary sinus Through-cut forceps
Medial wall maxillary sinus removed to flush with posterior wall
Inferior turbinate
Fig. 14.5. Endoscopic view of the removal of the left posterior maxillary bone and polypoid tissue with through-cut forceps.
Remove bony lamella attached to medial orbital wall
Fig. 14.6. Endoscopic view of skeletonization of the left medial orbital wall using a Kerrison rongeur.
Natural os sphenoid sinus
Natural os sphenoid sinus Lamina papyracea
Lamina papyracea
Septum Maxillary sinus Maxillary sinus Choana Kerrison rongeur
Fig. 14.7. Endoscopic view of enlargement of the left sphenoidotomy using a Kerrison rongeur.
CHAPTER 14 Revision Functional Endoscopic Sinus Surgery: Completion Sphenoethmoidectomy
Sphenoid sinus
Maxillary sinus
119
Sphenoid sinus
Maxillary sinus
Septum
Septal branch sphenopalatine artery Choana Choana
A
B
Septal branch sphenopalatine artery
Fig. 14.8. Endoscopic view of the technique for enlarging the left sphenoidotomy while avoiding the posterior septal branch of the left sphenopalatine artery. (A) A Freer elevator is gently used to inferiorly retract the mucosa of the inferior sphenoid face bone. A Kerrison rongeur can then be employed to remove the bone only. (B) Endoscopic view after resection of the inferior sphenoid face. Black outline is location of the septal branch of the sphenopalatine artery running through the mu cosa of the anterior-inferior face of the sphenoid sinus. n
Ethmoid skull base
n
Middle turbinate remnant n
Maxillary sinus
Fig. 14.9. Endoscopic view of the use of a curved 40-degree microdébrider to gently débride polyps off of the ethmoid bony partitions along the left ethmoid skull base.
s phenopalatine artery. Use a Kerrison rongeur to remove the underlying bone (Fig. 14.8). Step 7: Skeletonize the Skull Base of Superior Ethmoid Partitions n Identify the skull base within the sphenoid sinus. n The bone of the skull base is typically thicker and more ivory colored than the ethmoid septations, although this is not always true, particularly in cases of chronic infection or revision surgery.
ecall that the posterior ethmoid skull base is shaped R like a cone or pyramid, which tapers to a point at the skull base and posterior-superior orbit. Dissect in a posterior-to-anterior direction along the skull base to minimize the risk of CSF leak. Because the skull base slopes inferiorly in the medial portion of the ethmoid cavity, dissection should also err laterally against the lamina, which is skeletonized and preserved throughout. Dissection is best done using a microdébrider to remove nasal polyps while leaving bone behind (Fig. 14.9), and then using 45-degree through-cut forceps to remove the bone. If you can feel behind and see in front of the bone, the partition is safe to remove (Fig. 14.10).
Step 8: Remove the Superior Uncinate Process n Working anteriorly, make sure to remove the superior uncinate process as it lies against the anterior-medial orbital wall (Fig. 14.11).
POSTOPERATIVE CONSIDERATIONS he patient should avoid nose blowing for the folT lowing reasons: – To minimize the risk of postoperative bleeding – To minimize orbital or subcutaneous emphysema in case an inadvertent breach of the orbit has occurred n Intranasal dressing, packing, and spacers can be con sidered. – Depending on the structural integrity of the middle turbinates and their ability to stay medialized, the n
120
PART 3 Revision Endoscopic Sinus Surgery for Inflammatory Disease
Residual ethmoid partition Cleared ethmoid partition
Maxillary sinus
Maxillary sinus
A
B
Fig. 14.10. (A) Endoscopic view of the use of a 45-degree through-cut forceps to feel behind, see in front, and remove the ethmoid bony partitions along the left ethmoid skull base. (B) Endoscopic view after removal of the partition.
Residual uncinate partition Residual uncinate partition
Medial orbital wall
Medial orbital wall
Medial orbital wall
Fig. 14.11. Endoscopic views of removal of the remnant left superior uncinate process along the superior medial orbital wall.
CHAPTER 14 Revision Functional Endoscopic Sinus Surgery: Completion Sphenoethmoidectomy
surgeon may elect to place middle meatal spacers or gels to help reduce the risk of synechiae formation. – If there is concern about hemostasis, a variety of absorbable and nonabsorbable packing materials and hemostatic agents may be considered at the surgeon’s discretion. – Routine use of packing is likely unnecessary. Orlandi and Lanza reported that 87% of 165 patients did not require use of any hemostatic agents or packing.6 A review of the use of nasal spacers after surgery demonstrated little effect on postoperative
121
bleeding. However, there was a significant reduction in postoperative synechiae formation.7 – Overall, selection of a postoperative intranasal dressing should consider the benefits and risks of bleeding, synechiae formation, ease of removal and débridement, and patient discomfort.
REFERENCES Access the reference list online at ExpertConsult.com.
This page intentionally left blank
REFERENCES 1. Wright ED, Agrawal S. Impact of perioperative systemic steroids on surgical outcomes in patients with chronic rhinosinusitis with polyposis: evaluation with the novel Perioperative Sinus Endoscopy (POSE) scoring system. Laryngoscope. 2007;117(11 pt 2 suppl 115):1–28. 2. Sieskiewicz A, Olszewska E, Rogowski M, et al. Preoperative corticosteroid oral therapy and intraoperative bleeding during functional endoscopic sinus surgery in patients with severe nasal polyposis: a preliminary investigation. Ann Otol Rhinol Laryngol. 2006;115:490–494. 3. Meyers RM, Valvassori G. Interpretation of anatomic variations of computed tomography scans of the sinuses: a surgeon’s perspective. Laryngoscope. 1998;108:422–425.
4. Arslan H, Aydinlioğlu, Bozkurt M, et al. Anatomic variations of the paranasal sinuses: CT examination for endoscopic sinus surgery. Auris Nasus Larynx. 1999;26:39–48. 5. Stammberger H, Posawetz W. Functional endoscopic sinus surgery. Concept, indications and results of the Messerklinger technique. Eur Arch Otorhinolaryngol. 1990;247:63–76. 6. Orlandi RR, Lanza DC. Is nasal packing necessary following endoscopic sinus surgery? Laryngoscope. 2004;114:1541–1544. 7. Tan BK, Chandra RK. Postoperative prevention and treatment of complications after sinus surgery. Otolaryngol Clin North Am. 2010;43:769–779.
122.e1
14 Revision Functional Endoscopic Sinus Surgery: Completion Sphenoethmoidectomy Randy Leung and Rakesh Chandra
INTRODUCTION n
n
n
n
ompletion sphenoethmoidectomy refers to a reviC sion sinus procedure in a patient in whom a maxillary antrostomy and partial ethmoidectomy have been previously performed. Patients with nasal polyposis and moderate to severe inflammatory disease commonly have persistent symptoms despite a partial ethmoidectomy and limited sinus surgery. Completion sphenoethmoidectomy is often combined with a frontal recess dissection in hopes that it will be the last surgery ever needed by the patient. Often in these cases, there are remnant osteitic ethmoid bony partitions along the medial orbital wall and skull base that can be a source of persistent overlying mucosal inflammation (Fig. 14.1). Persistent inflammation in the bone and sinuses can often result in a bloody visual field. Surgeons must be careful and meticulous in their technique to achieve a safe and effective surgery.
ANATOMY n
See Chapters 7 and 8 for the anatomy of the ethmoid and sphenoid sinuses.
PREOPERATIVE CONSIDERATIONS Medical optimization should be accomplished. – Preoperative administration of an oral corticosteroid may lessen surgical difficulty both subjectively1 and in terms of blood loss.2 n
– Decongesting agents may be applied to minimize bleeding and facilitate surgical access. Options include the following: – Topical α-agonists, including pseudoephedrine, oxymetazoline, xylometazoline – Topical cocaine, 4% – Topical adrenaline, 1:1000
Radiographic Considerations omputed tomography (CT) scans of the sinuses C with coronal reformats should be available for review intraoperatively. Resolution should be at least 2 to 3 mm per slice. n Preoperative review of images is critical to identify danger areas, as detailed later. n Review preoperative CT scans. – Evaluate for the presence of bony dehiscences in the orbit and skull base. – Identify the depth of the lateral lamella to avoid inadvertent intracranial entry and cerebrospinal fluid (CSF) leak during dissection along the skull base. – Identify remnant ethmoid partitions along the medial orbital wall and skull base. – Identify the presence of a lateralized middle turbinate remnant. – Diagnose polypoid disease within the maxillary and/or sphenoid sinuses. n Evaluate the path of the anterior ethmoid artery as it courses between the orbit and the skull base. If it has a long course through the sinonasal cavity, it may be at risk of injury during ethmoid dissection along the ethmoid skull base. Retraction of the artery into the orbit may risk retro-orbital hematoma. n
115
116 n
n
PART 3 Revision Endoscopic Sinus Surgery for Inflammatory Disease
Identify the presence of Onodi cells, which are posteriorly pneumatized posterior ethmoid cells. Recognition of such cells is important, because the optic nerve may be dehiscent into these sinuses and vulnerable to injury. Equally important is evaluation of the skull base. Identification of a low-lying skull base or asymmetry is critical to avoid inadvertent injury. Look for a short posterior ethmoid height, particularly in the context of a well pneumatized
n
maxillary sinus. If the ratio of the maxillary sinus height to the height of the posterior ethmoid exceeds 2:1, the surgeon may be led erroneously on a trajectory to the skull base instead of the sphenoid sinus, which puts the patient at risk of CSF leak.3 Identify bony dehiscences of the optic nerve and internal carotid artery in the sphenoid sinus. – Carotid dehiscences in the sphenoid sinuses have been found in 5% to 25% of cases in r adiographic and cadaveric examinations.4,5 – Note the sphenoid intersinus septum. When the sphenoid sinuses are asymmetric, the intersinus septum typically attaches to the carotid canal on one side.
INSTRUMENTATION - and 30-degree rigid endoscopes 0 Manual instruments – Straight and 90-degree J-curettes – Straight and 45-degree Blakesley forceps – Straight and 45-degree through-cutting forceps – Kerrison rongeur n Powered instruments – Straight and 40-degree microdébriders n n
Ethmoid roof
Ethmoid roof
Lamina papyracea
Osteitic bone Residual ethmoid partitions
SURGICAL PROCEDURE Fig. 14.1. Triplanar computed tomography images for a patient scheduled to undergo a revision completion sphe noethmoidectomy. Note the presence of numerous osteitic ethmoid partitions along the medial orbital wall and skull base.
Step 1: Debulk Polyps in the Nasal Cavity With a Microdébrider n Make sure to débride just the polyps; leave the bony dissection to hand instruments, which have a greater tactile feel (Fig. 14.2).
Residual ethmoid partitions
Maxillary antrum
A
B
Inferior turbinate
Fig. 14.2. Endoscopic view of polyps within the left middle meatus of a patient before (A) and after (B) débridement of polyps with a straight microdébrider.
CHAPTER 14 Revision Functional Endoscopic Sinus Surgery: Completion Sphenoethmoidectomy Step 2: Revise the Maxillary Antrostomy n Nasal polyps from the ethmoid cavity can often block the maxillary sinus, which results in the presence of polyps and allergic mucin within the sinus itself (Fig. 14.3). n Revising the maxillary antrostomy often requires removing the remnant uncinate process with a backbiter, which maximizes the antrostomy size (Fig. 14.4).
Maxillary antrum
Natural maxillary ostium often with edema or scarring
Polyps in maxillary sinus
Fig. 14.3. Thirty-degree endoscopic view of the left maxillary sinus with polyps and allergic mucin.
Natural maxillary ostium with scarring causing recirculation
Fig. 14.4. Endoscopic view of the use of a backbiter to remove the remnant left uncinate process back to its attachment to the lacrimal bone.
n
117
ébride polyps and mucin within the maxillary sinus. D It is important to flush out any remaining mucin in the sinus. This can be accomplished using a 60-mL syringe of saline attached to a curved olive-tip suction.
Step 3: Remove the Posterior Maxillary Air Scoop n The posterior maxillary sinus often becomes osteitic and polypoid; the posterior fontanelle can often act as an air scoop and serve as a persistent nidus for inflammation. n Use straight through-cut forceps to remove the posterior fontanelle back to the posterior wall of the maxillary sinus (Fig. 14.5). Step 4: Skeletonize the Medial Orbital Wall n Osteitic bony partitions along the medial orbital wall are another persistent nidus of inflammation. n Failure to remove the osteitic bone will often result in persistent mucosal edema and nasal polyposis. n The curvature of the orbital floor is contiguous with the medial orbital wall. Follow this curvature to help in anticipating the medial orbital contour. n 2- and 4-mm Kerrison punches and 45-degree through-cutting forceps are useful to remove these hard partitions (Fig. 14.6). Step 5: Dissect the Remaining Posterior Ethmoid Air Cells Down to the Sphenoid Face n The last posterior ethmoid cell typically has the appearance of a pyramid, formed by the junction of the basal lamella of the superior turbinate with the skull base. n The posterior maxillary wall will curve posteriorly and approximate the location of the face of the sphenoid, which provides another clue to the location of the sphenoid sinus. Step 6: Enlarge the Sphenoidotomy n In many patients with nasal polyposis, allergic mucin resides in the bottom of the sphenoid sinus, causing persistent mucosal edema. Maximally enlarging the sphenoid can make it easier to remove the mucin postoperatively and allow the patient to irrigate the sphenoid more efficiently. n Posterior ethmoid bony partitions and the lateral sphenoid face are often left behind. Removal is best performed with a Kerrison punch or straight mushroom punch. Dissect from medial to lateral starting with the natural os of the sphenoid sinus (Fig. 14.7). n Enlarging the sphenoidotomy often requires removing the inferior face of the sphenoid with a Kerrison punch. n Use a suction elevator to retract the mucosa inferiorly, in turn protecting the septal branch of the
118
PART 3 Revision Endoscopic Sinus Surgery for Inflammatory Disease
Lamina papyracea
Posterior fontanelle
Maxillary sinus
Maxillary sinus
Natural ostium maxillary sinus Through-cut forceps
Medial wall maxillary sinus removed to flush with posterior wall
Inferior turbinate
Fig. 14.5. Endoscopic view of the removal of the left posterior maxillary bone and polypoid tissue with through-cut forceps.
Remove bony lamella attached to medial orbital wall
Fig. 14.6. Endoscopic view of skeletonization of the left medial orbital wall using a Kerrison rongeur.
Natural os sphenoid sinus
Natural os sphenoid sinus Lamina papyracea
Lamina papyracea
Septum Maxillary sinus Maxillary sinus Choana Kerrison rongeur
Fig. 14.7. Endoscopic view of enlargement of the left sphenoidotomy using a Kerrison rongeur.
CHAPTER 14 Revision Functional Endoscopic Sinus Surgery: Completion Sphenoethmoidectomy
Sphenoid sinus
Maxillary sinus
119
Sphenoid sinus
Maxillary sinus
Septum
Septal branch sphenopalatine artery Choana Choana
A
B
Septal branch sphenopalatine artery
Fig. 14.8. Endoscopic view of the technique for enlarging the left sphenoidotomy while avoiding the posterior septal branch of the left sphenopalatine artery. (A) A Freer elevator is gently used to inferiorly retract the mucosa of the inferior sphenoid face bone. A Kerrison rongeur can then be employed to remove the bone only. (B) Endoscopic view after resection of the inferior sphenoid face. Black outline is location of the septal branch of the sphenopalatine artery running through the mu cosa of the anterior-inferior face of the sphenoid sinus. n
Ethmoid skull base
n
Middle turbinate remnant n
Maxillary sinus
Fig. 14.9. Endoscopic view of the use of a curved 40-degree microdébrider to gently débride polyps off of the ethmoid bony partitions along the left ethmoid skull base.
s phenopalatine artery. Use a Kerrison rongeur to remove the underlying bone (Fig. 14.8). Step 7: Skeletonize the Skull Base of Superior Ethmoid Partitions n Identify the skull base within the sphenoid sinus. n The bone of the skull base is typically thicker and more ivory colored than the ethmoid septations, although this is not always true, particularly in cases of chronic infection or revision surgery.
ecall that the posterior ethmoid skull base is shaped R like a cone or pyramid, which tapers to a point at the skull base and posterior-superior orbit. Dissect in a posterior-to-anterior direction along the skull base to minimize the risk of CSF leak. Because the skull base slopes inferiorly in the medial portion of the ethmoid cavity, dissection should also err laterally against the lamina, which is skeletonized and preserved throughout. Dissection is best done using a microdébrider to remove nasal polyps while leaving bone behind (Fig. 14.9), and then using 45-degree through-cut forceps to remove the bone. If you can feel behind and see in front of the bone, the partition is safe to remove (Fig. 14.10).
Step 8: Remove the Superior Uncinate Process n Working anteriorly, make sure to remove the superior uncinate process as it lies against the anterior-medial orbital wall (Fig. 14.11).
POSTOPERATIVE CONSIDERATIONS he patient should avoid nose blowing for the folT lowing reasons: – To minimize the risk of postoperative bleeding – To minimize orbital or subcutaneous emphysema in case an inadvertent breach of the orbit has occurred n Intranasal dressing, packing, and spacers can be con sidered. – Depending on the structural integrity of the middle turbinates and their ability to stay medialized, the n
120
PART 3 Revision Endoscopic Sinus Surgery for Inflammatory Disease
Residual ethmoid partition Cleared ethmoid partition
Maxillary sinus
Maxillary sinus
A
B
Fig. 14.10. (A) Endoscopic view of the use of a 45-degree through-cut forceps to feel behind, see in front, and remove the ethmoid bony partitions along the left ethmoid skull base. (B) Endoscopic view after removal of the partition.
Residual uncinate partition Residual uncinate partition
Medial orbital wall
Medial orbital wall
Medial orbital wall
Fig. 14.11. Endoscopic views of removal of the remnant left superior uncinate process along the superior medial orbital wall.
CHAPTER 14 Revision Functional Endoscopic Sinus Surgery: Completion Sphenoethmoidectomy
surgeon may elect to place middle meatal spacers or gels to help reduce the risk of synechiae formation. – If there is concern about hemostasis, a variety of absorbable and nonabsorbable packing materials and hemostatic agents may be considered at the surgeon’s discretion. – Routine use of packing is likely unnecessary. Orlandi and Lanza reported that 87% of 165 patients did not require use of any hemostatic agents or packing.6 A review of the use of nasal spacers after surgery demonstrated little effect on postoperative
121
bleeding. However, there was a significant reduction in postoperative synechiae formation.7 – Overall, selection of a postoperative intranasal dressing should consider the benefits and risks of bleeding, synechiae formation, ease of removal and débridement, and patient discomfort.
REFERENCES Access the reference list online at ExpertConsult.com.
This page intentionally left blank
REFERENCES 1. Wright ED, Agrawal S. Impact of perioperative systemic steroids on surgical outcomes in patients with chronic rhinosinusitis with polyposis: evaluation with the novel Perioperative Sinus Endoscopy (POSE) scoring system. Laryngoscope. 2007;117(11 pt 2 suppl 115):1–28. 2. Sieskiewicz A, Olszewska E, Rogowski M, et al. Preoperative corticosteroid oral therapy and intraoperative bleeding during functional endoscopic sinus surgery in patients with severe nasal polyposis: a preliminary investigation. Ann Otol Rhinol Laryngol. 2006;115:490–494. 3. Meyers RM, Valvassori G. Interpretation of anatomic variations of computed tomography scans of the sinuses: a surgeon’s perspective. Laryngoscope. 1998;108:422–425.
4. Arslan H, Aydinlioğlu, Bozkurt M, et al. Anatomic variations of the paranasal sinuses: CT examination for endoscopic sinus surgery. Auris Nasus Larynx. 1999;26:39–48. 5. Stammberger H, Posawetz W. Functional endoscopic sinus surgery. Concept, indications and results of the Messerklinger technique. Eur Arch Otorhinolaryngol. 1990;247:63–76. 6. Orlandi RR, Lanza DC. Is nasal packing necessary following endoscopic sinus surgery? Laryngoscope. 2004;114:1541–1544. 7. Tan BK, Chandra RK. Postoperative prevention and treatment of complications after sinus surgery. Otolaryngol Clin North Am. 2010;43:769–779.
122.e1