- Remove the uncinate process and look in the ethmoid infundibulum. Looking upwards you will find the frontal recess. If obscured by disease, gently strip out the disease and polyps.
- Follow the disease. Do not remove mucosa, use small instruments.
- Locate the maxillary ostium (situated low in the infundibulum and just above the inferior turbinate). Remove disease around it, enlarge it downwards and backwards. Do not enlarge forwards to avoid lacrimal duct stenosis.
- Remove the bulla, taking care to leave the ground lamella intact. Sometimes the bulla is only a few millimeters deep. Also remove the lateral wall of the bulla. Keep following the disease. (Fig. 15 – 6)
- Now you look into the maxillary sinus and the frontal recess and perhaps the frontal sinus. Widen the maxillary ostium in inferior and posterior directions.
- Locate the ground lamella and penetrate it (low) with a small Blakesley forceps. If you do this too high you risk penetrating the ethmoid roof. Now one looks into the fewer but bigger cells of the posterior ethmoid. Remove the ground lamella and look carefully at this oblique position in the ethmoid. Clear the roof of the ethmoid. It is very important to look thoroughly at the ethmoid roof, cribriform plate and frontal recess. This is an accident prone region! The anterior part of the ethmoid roof is always situated at a higher level than the cribriform plate (four to six mm, sometimes more).
- Explore the region of the frontal recess. In most cases you can look with a zero degree (straight forward) lens into the frontal sinus. Do not operate on the frontal sinuses. Operate on the frontal recess. Remove disease from the recess, remove all polyps and obstructive disease. Open the sphenoid sinus, remove disease and try to locate the sella turcica and the impression of the carotid artery and optic nerve in its lateral wall. The optic nerve is occasionally dehiscent.
- Try to locate the anterior and posterior ethmoid artery. (Sometimes they are not surrounded by bone).
Take care to leave the lamina papyracae intact. If in doubt of lamina papyracea push the eye down, if it is orbital fat, the eye will move.
- If there’s bleeding throughout the process use adrenaline tipped cotton to control it.
- If intraorbital bleeding happens, consider the external ethmoidectomy approach. Remove the lamina papyracea and incise the periostium to release the pressure from the optic nerve. This is an emergency situation. If happening postoperative, the patient complains of loss of vision. Surgical intervention should be done within ninety minutes without delay.
|Fig. 15 – 4. The lateral nasal wall (after fenestrating the medial concha).*|
- According to the disease you may need to partially trim the middle or the inferior turbinates. Never pull the middle turbinate because it has a superior attachment to the floor of the anterior cranial fossae. Pulling may cause dural tear and CSF leak.Partial trimming of middle turbinate is required in a few situations. First, the middle turbinate may be a source of pathological obstruction (polyps) of the osteomeatal complex. Secondly, the middle turbinate may be displaced laterally in the postoperative period predisposing for adhesions which block the osteomeatal complex and natural ostiums. Thirdly, the middle turbinate may be enlarged enough to touch the nasal septum or lateral wall causing midfacial pain (Slutter’s syndrome).
- Use intranasal splints to avoid adhesions. The splint is usually kept in for ten days.
- Light Sofratulle nasal packs are used to control postoperative bleeding. The nasal packs are removed after twenty four hours.
- Patient receives three doses of intravenous antibiotics. In cases of fungal disease, antifungal agents are used.
- Close follow-up of the patients in out patient for six weeks to remove crusts and divide any adhesions.
- Nasal irrigations should be started immediately following pack removal, usually with normal saline, five times a day, and is continued for three months. In order to keep the operative site free of clots and crusts, it may be done effectively with 20cc syringe attached to a rubber bulb.
- Perioperative medication: our regime is as follows:
- Zinnat (Cefuroxim) 500mg BID for ten days
- Prednisolone 10mg once a day for two weeks
Then reduce to 5mg for a further two weeks
- Claretine (Loratadine) one tablet at bedtime for three months
If the basic indication was chronic sinusitis, antibiotic treatment may be considered for a longer period according to culture and sensitivity.
- Long term medications:
- Steroid nasal sprays: to be used indefinitely.
- Nasal irrigations with normal saline are used permanently at least twice a day. The commercially available Sea or Ocean nasal washes are recommended.
- In cases of polyposis: Predinisolone 5mg once a day for one week, this is repeated
|Fig. 15 – 5. Drainage pathways of the paranasal sinuses (after opening the ethmoid and resection of the concha media).*|
- every five weeks for two years or may be for life in severe cases of allergic or vasomotor rhinitis with recurrent polyposis.
- In cases of chronic purulent sinusitis despite surgery and antibiotic treatment, a fungus aetiology should be considered. Prolonged treatment with antifungal agent such as Sphoronox (Itraconazol) is recommended.