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Surgical Treatment of Sinusitis

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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Surgical Treatment of Sinusitis

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  1. Surgical Treatment of Sinusitis Dr. Vishal Sharma

  2. 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)

  3. Antral Washout (proof puncture, antral lavage)

  4. 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

  5. Tilley Lichwitz Antrum Puncture Trocar & Cannula

  6. Higginson Syringe

  7. Trocar directed towards I/L tragus

  8. Hole made 1.25 cm behind anterior end of inferior turbinate

  9. Antral irrigation

  10. 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.

  11. 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

  12. 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.

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

  14. 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

  15. Exposure of incision site

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

  17. Incision deepened till periosteum

  18. Anterior wall broken with osteotome

  19. Hole made in anterior wall

  20. Suction of maxillary sinus

  21. Inferior meatal antrostomy

  22. Packing of maxillary sinus

  23. Packing of sinus & nose

  24. Incision closed

  25. 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

  26. 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

  27. Lynch Howarth ethmoidectomy

  28. Patterson ethmoidectomy

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

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

  31. Frontal sinus trephination

  32. 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.

  33. Frontal sinus trephination

  34. Osteoplastic flap procedure

  35. Osteoplastic flap procedure

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

  37. Lothrop Procedure

  38. 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

  39. Sublabial trans-septal approach

  40. External ethmoidectomy approach

  41. Endoscopic approach

  42. Functional Endoscopic Sinus Surgery

  43. F.E.S.S.

  44. Anatomy of lateral wall

  45. 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

  46. Steps of F.E.S.S.

  47. Left nasal cavity

  48. Left middle meatus

  49. Left middle meatus

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