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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).

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maxillary sinusitis
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)

slide4
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

slide10
Anesthesia: L.A. for adults. G.A. for children & un-cooperative 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
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
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

Caldwell – Luc Surgery

George Caldwell, 1893, New York

Henri Luc, 1897, Paris

indications
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

incision
Incision

4 cm long, sub-labial,

horizontal incision made

3 mm above & parallel to

the gingival margin,

from lateral incisor to

2nd molar tooth.

complications26
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
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

trans antral ethmoidectomy
Trans-antral ethmoidectomy
  • Caldwell – Luc surgery done to reach maxillary antrum
  • Ethmoid cells approached via postero-supero- medial angle of maxillary antrum
frontal sinusitis
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 trephination33
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.

lothrop procedure
Lothrop Procedure

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

sphenoid sinus
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

steps of f e s s
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

complications68
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

Complications