Download Endoscopic Sinus Surgery

ENDOSCOPIC SINUS SURGERY
Section 7 (‫)قسمت هفتم فایل‬
Bakhshaee M, MD
Rhinologist, Assistant Prof. MUMS

When a high-resolution CT scan has shown the skull
base defect, MRI can help define any pathology
associated with a CSF leak, e.g., brain, hematoma,
CSF.
Inverted Papilloma
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MRI can complement CT in determining how
extensive an inverted papilloma is.
It defines how much of the opacification shown on
CT is due to secretions and how much is due to the
tumor. This is important in planning surgery if it
involves the frontal or maxillary sinus.
MR Angiography
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MR angiography (MRA) delineates flow within
vessels by suppressing the signal from stationary
tissue.
It is performed as part of an MR examination and
does not necessarily require contrast injection.
MRA provides information with respect to the
principal feeding arteries in vascular tumors (such
as angiofibromas, hemangiopericytomas, or
paragangliomas, and certain metastases) and in
vascular lesions (such as angiomas or aneurysms
located at the skull base).
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A negative result on MRA does not definitively rule
out a vascular lesion.
A minor amount of flow or the presence of slow flow
such as in a capillary hemangioma,
esthesioneuroblastoma, and even in an
angiofibroma may be invisible to MRA.
Digital Subtraction Angiography
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2.
Digital subtraction angiography (DSA) is the best
method to delineate the vascular supply of a
specific anatomical area or lesion
In a lesion (e.g., chordoma or neoplasm) that abuts
the internal carotid artery at the foramen lacerum
or within the cavernous sinus.
In recurrent epistaxis, DSA may be required as a
means to verify the source of repeated
hemorrhage.
Points to Mention on a CT Request
1.
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6.
Write down the provisional diagnosis, e.g., “severe
polyposis unresponsive to medical treatment.”
Say why you want the scan, e.g., to define the anatomy
before surgery.
Detail what surgery has been done.
Ask for fine cuts if indicated, e.g., in case of a CSF leak or
when sagittal reconstruction is needed.
Name the area you want examined, e.g., the frontal
recess.
If you suspect a tumor, say so and ask for a contrast
study.
Preoperative Check list
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5.
what should you do before operating?
Minimize the amount of surgical manipulation
required.
Preserve as much olfactory mucosa as possible.
Reduce peroperative bleeding to reduce the
likelihood of complications.
Work out the surgical anatomy in order to minimize
the chance of entering the orbit or skull base.
Set clear goals for yourself and your patient
The Preoperative Checklist
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3.
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6.
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8.
Confirm the diagnosis.
Review previous medical treatment.
Optimize the immediate preoperative condition.
Check that relevant investigations have been done ( Allergy
tests, Immune status, Hematological parameters, Olfaction,
Vision)
Review the relevant medical history, e.g., drug allergies,
medication.
Preoperative CT checklist.
Planning and staging the procedure.
Informed consent.
Vision
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Left enophthalmos due to silent sinus syndrome—
involution of the maxillary sinus with collapse of its
roof
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The loss of color discrimination, particularly of red,
is a worrying symptom of pressure on the optic
nerve, and this requires urgent treatment.
For any orbital surgery, e.g., orbital decompression,
an ophthalmological assessment is required.
It is alarming if a unilaterally enlarged is noticed
during or after surgery.
Preoperative CT Checklist
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Like an airline pilot before preparing for take-off,
you must go through a systematic check of the CT
scanvbefore surgery so as to avoid the surgical
equivalent ofva crash.
Step 1.
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When placing the scans on the viewing box,
orientate the scan sequence from anterior to
posterior and ensure that the sides are marked and
placed as though as you are looking at the patient.
Follow the cuts anterior to posterior; follow the
septum, note any deviation, and look for the size
and extent of the ethmoidal bulla, which is a
relatively consistent landmark.
A polyp arising from the lamella lateralis
Step 2.
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Examine the lamina papyracea, uncinate process,
and middle turbinate.
Variations of the position of the cribriform plate
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Localize the uncinate process (arrow) from its free
margin posteriorly and follow it anteriorly and
upward
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A key aspect of frontal recess surgery is to define
the insertion of the uncinate process as this may also
“guard” anterior access to the frontal recess by
forming a web if it attaches to the skull base or
middle turbinate
The uncinate process insertion
An absent middle turbinate
Hypoplasia of the maxillary sinuses
Left infraorbital cell
Step 3.
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Examine the area of the frontal recess. The frontal
recess lies anterior and superior to the ethmoid
bulla.
Bilateral bulla frontalis
Bulla frontalis and the start of agger nasi cells below
Bilateral suprabullar recesses and supraorbital
cells
Anterior ethmoid artery
Step 4.
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Determine the height of the skull base
Asymmetrical skull base
Step 5.
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Examine the sphenoid sinus
Dehiscent optic nerve (+) and carotid artery (*)
Informed Consent
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The following issues need to be addressed.
What are the options available to the patient?
Specifically what would happen if no surgery were
undertaken?
What is the patient’s prognosis with the various treatment
strategies?
What does the surgery involve?
What are the complications of surgery?
This should include complications occurring more
frequently than 1 in 100, and severe complications even if
they are rare.
Patient Consent and Information
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How much do we need to explain to our patients to
properly gain their consent?
The surgeon may feel that mentioning complications
to the patient will frighten them unnecessarily, but it
is possible to mention even serious complications in
the right context without causing alarm, and it is our
duty to do so.
Patients need to:
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Understand their diagnosis
Understand the context of their symptoms in the
light of their diagnosis
Understand the principles of the surgical procedure
Be informed about complications even if they are
rare
Be informed about what they can expect in the
postoperative period: the healing process, the
symptoms they can expect, the medical therapy
they should take, and the need for time off work
Time Off Work
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2.
3.
Rest:
After minor surgery, such as a limited anterior
ethmoidectomy: one week
If they work in dusty or smoky environment, this
should be extended by a further week
Patients who have had more extensive sinus
surgery are advised to take 2 weeks off work.
Advice about Flying
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2.
Fly :
Some authorities have advised that it is wise to
wait up to 6 weeks after surgery,
if patients are able to do a Valsalva maneuver
Complications
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Our aim is to inform the patient without alarming
them unnecessarily
We say that the reported risk of any moderate or
serious complication is approximately 0.5% to 1%
On reviewing the world literature on the prevalence
of complications associated with endoscopic sinus
surgery, it is worth mentioning that these are no
more common than with conventional surgery
Complications
Conventional technique
Endoscopic technique
Adhesions
2−8%
4−6%
Bleeding
0.9−2.65%
0.48−0.6%
Periorbital bruising
0.4−7%
0.4−1.3%
Nasolacrimal injury
0.1%
0−0.5%
CSF leak
0.1−0.6%
0.07−0.9%
Anosmia
0.1%
0.4%
Frontal mucocele
Unknown
0.08%
Retro-orbital hemorrhage
0.3−3.4%
0−0.4%
Extraocular muscle damage
0−0.4%
Unknown
Optic nerve injury
Unknown
0.007%
Pneumocephalus
Unknown
Unknown
Meningitis
0.1%
0.007%
Carotid artery injury
Unknown
Unknown
Specific Complications
External Incision
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When undertaking frontal recess surgery, and in
particular revision surgery, or when a median
drainage procedure is planned, it is worth
mentioning the possibility of the need for an
external incision
For vascular tumors of the lateral nasal wall, such as
an angiofibroma, it is important to mention that an
external approach such as a lateral rhinotomy or
midfacial degloving may be required.
Inverted Papilloma
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In the case of accompanied SCC; more radical
procedure may be required.
The surgeon should aim to remove all the diseased
mucosa there is an increased risk of stenosis,
particularly in the frontal recess.
The incidence of recurrent disease is as high as
30%.
Local Osteitis
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A rare complication is local osteitis caused by
exposure of bone.
It produces a dull, severe nagging ache that lasts
for 10 days before abating.
Major analgesics are required, and local treatment
appears to provide little help.
Infection
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Infection following surgery is rare and can be
minimized by giving perioperative antibiotics when
purulent disease is present.
Surgical emphysema
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Caused by air being forced through a defect in the
lamina papyracea, is avoided if the surgeon
advises the patient not to blow their nose or to stifle
sneezes for 4 days after surgery
Visual Complications
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If a patient has significant proptosis or displacement
of the axis of their pupils due to paranasal sinus
disease (e.g., a mucocele), they may have adapted
slowly to these changes over several weeks and not
have any diplopia.
Occasionally, patients may have some temporary
diplopia after surgery when this displacement is
suddenly corrected, and it is worth mentioning this
before surgery
Diplopia in orbital decompression
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Patients who undergo orbital decompression are
at an increased risk of diplopia, although
maintaining the medial−inferior strut of bone
between the medial wall and floor of the orbit
minimizes this risk.
Recurrent Polyposis
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When counseling a patient with nasal polyposis
associated with late-onset asthma or aspirin
sensitivity, it is wise to mention that, in spite of good
surgery and postoperative medical treatment, the
majority of patients will have a recurrence of their
polyps
Perioperative Aids
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Local anesthesia
General anesthesia
Operating room setup
Ancillary staff
Camera-guided surgery
Instruments
Computer-aided surgery
Local Anesthesia
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A day-stay procedure
Encouraging preservation of mucosa
There is less peroperative bleeding
It is possible to monitor vision
General Anesthesia
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It is possible to access areas that are not readily
anaesthetized with local anesthetic
The surgeon is freed from worrying about patient
feels discomfort
If bleeding is moderate or marked, it can be sucked
out as the patient is not distressed
In infected cases, local anesthetic works poorly
The patient is unaware of unpleasant sensations
Operating Room Setup
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Operating Table
Surgeon’s Seat
Position of the Anesthetist
Setup for One Surgeon
Setup for Two Surgeons
Video Stack/Cameras
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The screen should be positioned at a level that
makes the surgeon raise their head just a little, as
this will encourage good posture
Cables
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Cables can get in the way and their weight can tire
the surgeon.
The light cable and camera lead should be clipped
to the drapes so that their weight going to the stack
does not pull on the surgeon’s supporting hand
It is important that the scrub nurse gives and takes
each set of instruments so that they are kept
separate and do not become entangled.
Lighting
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For optimal viewing, the screen should have a
relatively dim background
Radiograph Screen
The CT scans must be
placed in order on a
screen for the surgeon
to inspect before and
during the procedure
Instruments
Endoscopes
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The majority of surgery is best done using a 0°
4mm endoscope, which allows good illumination.
Even in a child or a narrow nose it is easier to
operate with this than with a 2.7mm scope.
Most of the paranasal sinuses can be visualized with
a 0° scope, with the exception of the lateral,
medial, and inferior walls of the maxillary sinus.
It is best to do as much surgery as possible using the
0° scope.
Endoscopes
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Even the frontal recess can be approached using a
0° scope, but you need to remove the front of any
agger nasi air cells.
A 45° scope provides superior access and visibility
that helps conserve mucosa around the frontal
recess.
Camera Systems
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The three-chip camera gives a superlative image
that allows detailed surgery of the paranasal
sinuses.
A good camera and light source are required
because redness of bleeding from the rich blood
supply to the nose absorbs much of the light and it
is difficult to get definition and a sense of depth
with a poor image.
Point
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Operating with the naked eye down an endoscope
does provide a good image.
There is, however, a dear price to be paid for this,
and that is that the operator may develop neck
problems over time.
Suckers
Curved Olive-ended Suckers
Ball Probes
Curettes
Blakesley Forceps
Through-cutting Instruments
Rhinoforce Stammberger Antrum Punch
(“Back-biters”)
Hajek−Kofler (Rotating) Punch
Stammberger Cutting Mushroom Punch
Freer Elevator
Sickle Knife
Belluci and Zurich Scissors
Stammberger Side-biting Punch Forceps
Heuwieser Antrum Grasping Forceps
Giraffe forceps
Anterior-posterior
Side-grasping
Powered Shavers
Drill
Unipolar Suction Diathermy
Bipolar Suction Diathermy
Computer-aided Surgery