Endoscopic surgery was based on the work of Messerklinger in the sixties and Wigand in the seventies. It was then made more popular by Stammberger in the eighties. Messerklinger was able to recognize the relationship between disease in the osteomeatal complex and maxillary and frontal sinusitis. Moreover, when the osteomeatal disease resolved, the irreversible disease in the secondarily involved sinuses frequently regressed.
The nasal cavity is examined by using the endoscope, the sinuses are assessed by the computed tomography. The coronal CT is particularly good at showing the fine bone architecture of the paranasal sinuses as well as areas of mucosal thickening and obstruction. The CT examination is best performed after the sinusitis has been medically treated. CT should be performed in every patient before endoscopic sinus surgery in order to identify the extent of the disease, to obtain a clear map of the sinuses in relation to skull base and orbital structure and for medicolegal reasons.
Endoscopic sinus surgery is indicated with rhinoplasty when the patient presents with small nasal polyps, concha bullosa and or concha ethmoidalis. But Functional Endoscopic Sinus Surgery should be avoided in combination with rhinoplasty in patients with excessive polyposis and infected sinuses.
Functional Endoscopic Sinus Surgery is best performed following septoplasty and before starting rhinoplasty, except, trimming of middle turbinates which should be postponed until the end of the operation.
- Local anaesthesia and nose preparation by vasoconstrictors, cocaine or Xylocaine gel with adrenaline for twenty minutes. The operation may be performed under general anaesthesia with hypotensive technique.
- It is best to use a zero degree nasal endoscope throughout most of the procedure. The 300 or 700 are used at the maxillary ostium enlargement and frontal recess clearance.
- Take the sickle knife and make the “infundibulotomy incision” just anterior to the uncinate process between middle and inferior turbinates. When the cut is made too much to the anteriorly, the lacrimal duct will be damaged, too much to the posteriorly leaves the uncinate process intact and it gives a bad entrance to the ethmoid infundibulum. If the cut is too deep the ethmoid bulla will also be cut.
|Fig. 15 – 2. Bilateral extensive nasal polyposis.|
|Fig. 15 – 3. Cross-section of the anterior ethmoid.|
- 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.