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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4368_Библиотеки_им_академика_М_И_Перельмана
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Endoscopic Lateral Nasal Wall and Anterior and Posterior Ethmoid Sinus Dissection
https://t.me/med1917
MT
MT
i
BE
UP
ML
UP
ii
iii
Fig. 3.4a Performing an uncinectomy (i–iv). The uncinate process (UP) is palpated, medialized, and removed with Blakesley forceps
(anteroposterior uncinectomy) and free edge of the bone and the lateral nasal wall Identifi ed. BE, bulla ethmoidalis; ML, maxillary line;
MT, middle turbinate.
iv
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Endoscopic Lateral Nasal Wall and Anterior and Posterior Ethmoid Sinus Dissection
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UP
ML
ii
v
iii
vi
MT
i
iv
BE
vii
Fig. 3.4b Performing an uncinectomy (i–ix). The uncinate process (UP) is palpated, medialized, and removed with Blakesley forceps
(antegrade undnectomy) and free edge of the bone and the lateral nasal wall is identifi ed. BE, bulla ethmoidalis; ML, maxillary line;
MT, middle turbinate.
26
viii
ix
Endoscopic Lateral Nasal Wall and Anterior and Posterior Ethmoid Sinus Dissection
https://t.me/med1917
MT
NS
a
NS
c
Fig. 3.4c Performing an uncinectomy (i–iv). (i). The uncinate process (UP) is palpated and removed with Blakesley forceps
(posteroanterior uncinectomy). BE, bulla ethmoidalis; MT, middle turbinate; NS, nasal septum.
MT
UP
UP
NS
b
NS
d
MT
MT
BE
UP
UP
3.4 Middle Meatal Antrostomy
Once the most anterior-inferior aspect of the uncinate
has been removed, the natural ostium of the maxillary
sinus can be seen. There is no absolute need to enlarge it
for just inflammatory diseases.
3.4.1 Indications
• Chronic rhinosinusitis with and without nasal polyps
or with large retention cysts.
• Opening the sinus to improve nasal irrigation and the
removal of foreign material, for example, a dental root
in the maxillary sinus, aspergillosis, benign and malignant tumors, and foreign bodies.
• For extended approaches to the pterygopalatine and
infratemporal fossae and transpterygoid corridors.
3.4.2 Technique
After removal of the uncinate process, the ethmoid bulla
and maxillary ostium should be visible. The ostium lies
at the junction of the anterior and inferior walls of the
ethmoidal bulla.
Different instruments may be used for the enlargement of maxillary sinus ostium. These include side-biting
punches, straight and angled forceps, and microdebriders
(Figs. 3.5a and b).
Check for an accessory ostium along the posterior fontanelle. In such a case, both ostia need to be connected to
avoid mucous recirculation.
3.4.3 Complications
A common error is failure to expose the natural maxillary sinus ostium, instead creating a separate antral
27
Endoscopic Lateral Nasal Wall and Anterior and Posterior Ethmoid Sinus Dissection
https://t.me/med1917
BE
BE
PF
MS
i
Fig. 3.5a (i, ii) Endoscopic view of a left maxillary antrostomy (MS) with residual of the bulla ethmoidalis (BE) superiorly and
posterior fontanelle (PF).
fenestration in the posterior fontanelle
to mucous recirculation and accumulation within the sinus, as the ciliary beating continues to transport the mucous toward the natural ostium.
1,3,7,8
3.4.4 Tips and Tricks
• The antrostomy can be performed at any time of the
surgery. The advantage of doing it at the beginning of
the procedure is that it provides additional landmarks:
posterior wall of the maxillary sinus, which gives a
perspective of the depth, and the floor of the orbit,
which allows assessing the relation of the lamina
papyracea with the bulla and, later on, helps in the
orientation toward the sphenoid sinus. Maintaining the
bulla until then provides a landmark for the junction of
the medial and inferior orbital walls.
• If identification of the natural ostium is not possible
(e.g., scarring due to prior surgery), palpate the
fontanelle area with the tip of a curved suction tube
and enter smoothly into the sinus (check orbit from
inside and outside, particularly in revision surgery).
Penetration of the sinus should be performed pointing toward the floor of the sinus cavity while leaning
ii
that will lead
on the top of the inferior turbinate. Once the fontanelle is open, work yourself anteriorly with a
backbiter.
• Try to preserve the most anterior aspect of the natural
ostium.
• Do not engage too far anteriorly with the backbiting
forceps to prevent injury to the nasolacrimal duct.
• The extent of posterior enlargement can be controlled by
visualizing the posterior maxillary sinus wall. Avoid going
too far posteriorly toward the sphenopalatine ostium, as
branches of the sphenopalatine artery could be injured.
3.5 Dissection of the Anterior
Ethmoid (Partial Anterior
Ethmoidectomy)
The anterior ethmoid sinuses are cells that lie anterior
to the basal lamella (portion of the middle turbinate that
attaches to the lateral nasal wall). The anterior ethmoid
air cells consist of the ethmoid bulla, agger nasi cell, and
those cells that lie against the medial orbital wall anterior
to the basal lamellae (Fig. 3.6).
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Endoscopic Lateral Nasal Wall and Anterior and Posterior Ethmoid Sinus Dissection
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LP
LP
BE
MO
i
iv
ii
V
BE
MO
iii
MS
PWMS
vi
MSR
ION
PWMS
vii
Fig. 3.5b Endoscopic view of a left maxillary antrostomy (i-vii). Maxillary ostium (MO) with remnant of the bulla ethmoidalis (BE)
superiorly, lamina papyracea (LP), posterior wall of maxillary sinus (PWMS), maxillary sinus roof (MSR), and infraorbital nerve (ION)
MS, maxillary sinus.
3.5.1 Indications
• Chronic rhinosinusitis with and without nasal polyps.
• Closure of cerebrospinal fluid leak.
• Epistaxis from the anterior ethmoidal artery.
• Biopsy and excision of benign and malign tumors.
• Transcribriform approach. Other extended skull base
approaches.
• Frontal sinus sinusotomy (Draf I, II, and III).
3.5.2 Technique
The ethmoid bulla, located in the anterior ethmoid,
is the second lamella. Its boundaries are the lamina
papyracea laterally, posteriorly the vertical aspect of
the third basal lamella of the middle turbinate and the
retrobulbar recess, and anteriorly the ethmoid infundibulum and the vertical aspect of the uncinate process
(Figs. 3.7a and b).
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Endoscopic Lateral Nasal Wall and Anterior and Posterior Ethmoid Sinus Dissection
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a b
c
Fig. 3.6 Coronal (a), axial (b), and sagittal (c) CT scan showing the uncinate process, bulla ethmoidalis , maxillary sinuses, posterior
ethmoid cells, middle turbinate, lamina papyracea, and superior turbinate.
The area to enter the ethmoidal bulla, at a safe dis-
tance from the orbit, is medially and inferiorly. One may
use a J-curette or a straight-forward suction device to
do so. Inferior and medial walls are resected, while the
posterior wall is attempted to keep intact. Follow the anterior wall of the ethmoid bulla, and identify the frontal
recess, the roof of the ethmoid, and the anterior ethmoid
artery. The latter is usually located at the most superior
attachment of the anterior wall of the bulla at the roof or
right behind (see also Chapters 4 and 7 for more details).
Identify the lamina papyracea, which forms the lateral
wall of the ethmoidal bulla. If the middle meatal antrostomy has already been performed, the floor of the orbit
and the maxillary strut are helpful landmarks to identify
the papyracea.
Next, carefully perforate the posterior wall of the eth-
moidal bulla. The retrobulbar recess can be identified
just behind the bulla, and the skull base forms its superior limit. Please note that depending on the extension or
type of pneumatization or disease the posterior wall of
the bulla could be missing.
Carefully examine the basal lamellae of the middle
turbinate and check how it connects the middle
turbinate to the lamina papyracea in its more posterior
portion.
The agger nasi cells are the most anterior ethmoid sinus
cells, located superiorly to the lateral connection of uncinate process and positioned between the nasal bones,
the lacrimal bones, and the maxilla (ascending process of
the maxilla). Safe exenteration of agger nasi cells may be
accomplished with angled forceps and allow an extended
exposure of the frontal outflow tract.
3.5.3 Complications
The key structures at risk during this step of the surgery
are the orbit and the skull base and the anterior ethmoidal
artery. The risk of inadvertent entry into the orbit and
the risk of skull base and intracranial complications are
increased when an infraorbital cell is encountered and
well pneumatizaded.
8
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Endoscopic Lateral Nasal Wall and Anterior and Posterior Ethmoid Sinus Dissection
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AWBE
BE
MT
i
ii
AWBE
MT
iii
FE
AWBE
MT
v
vi
AWBE
AEA
iv
Fig. 3.7a Anterior ethmoidectomy (i-vi). AEA, anterior ethmoidal artery; AWBE, anterior wall of the bulla ethmoidalis; BE, bulla
ethmoidalis; FE, fovea ethmoidal; MT, middle turbinate.
3.5.4 Tips and Tricks
• The change in orientation of the middle turbinate is key
to understanding the ethmoid sinuses, as the middle
turbinate serves as both the posterior and the medial
boundary to the anterior ethmoid complex.
• Do not medialize (“in-fracture”) the middle turbinate
as it will become “floppy” and tend to lateralize later.
• Open the bulla at its inferior aspect to stay away from
the orbit.
• The dissection along the roof of the ethmoid bone is
most safely executed in a posteroanterior direction
(with a curved curette).
• The removal of the cells along the skull base and lam-
ina papyracea should preferably be performed with a
punch or through-cutting forceps to avoid stripping of
the mucosa that would leave the bone denuded.
• The Keros classification system may be helpful to assess
the dep
th of the olfactory fossa and the (the length and
depth of the) lateral lamella of the middle turbinate.
• The anterior ethmoidal artery is almost always located
behind the anterior wall of the bulla or at its superior
attachment.
3.6 Dissection of the Posterior
Ethmoid (Ethmoidectomy)
The basal lamella of the middle turbinate is opened in
this step. The posterior ethmoid air cells are those that lie
posterior to the third basal lamellae and anterior to the
sphenoid sinus. They are limited laterally by the orbital
apex and superiorly by the skull base (Fig. 3.8).
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Endoscopic Lateral Nasal Wall and Anterior and Posterior Ethmoid Sinus Dissection
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MT
i
MT
iv
BE
MT
BE
ii
FR
AN
AWBE
BL
FE
AEA
AER
v
iii
AWBR
FE
AEA
vi
AN
NS
MT
vii
Fig. 3.7b Anterior ethmoidectomy (i-vii). AEA, anterior ethmoidal artery; AER, anterior ethmoidal roof; AN, agger nasi; AWBE, anterior
wall of the bulla ethmoidalis; BE, bulla ethmoidalis; BL, basal lamellae; FE, fovea ethmoidal; FR, frontal recess; MT, middle turbinate;
NS, nasal septum.
3.6.1 Indications
• Transcribriform approach.
• Sphenoidotomy.
• Chronic rhinosinusitis with polyposis.
• Revision surgery for chronic rhinosinusitis.
• Disease in the posterior ethmoids and sphenoid sinus.
• Closure of cerebrospinal fluid fistulas along the anteri-
or skull base.
• Endoscopic orbital or optic nerve decompression.
• Endoscopic orbital surgery.
• Biopsy and excision of benign and malign tumors.
3.6.2 Technique
The boundaries of the posterior ethmoid complex are
the vertical portion of the basal lamella anteriorly, the
anterior wall of the sphenoid sinus posteriorly, the lamina
papyracea laterally, the superior turbinate medially, and
the skull base superiorly.
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Endoscopic Lateral Nasal Wall and Anterior and Posterior Ethmoid Sinus Dissection
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a
c
Fig. 3.8 Coronal (a, b) and axial (c) CT: anterior ethmoid air cells and the posterior ethmoid cells, middle turbinate basal lamellae
trajectory, lamina papyracea, and superior turbinate.
The lamella of the middle turbinate has a superior
vertical and an inferior horizontal portion. To access the
posterior ethmoid, the vertical aspect is removed. The
inferior (horizontal) is preserved to avoid lateralization of
the middle turbinate. Once in the posterior ethmoid, one
has to check whether there is a posterior pneumatization
of the ethmoid (sphenoethmoidal cell or former Onodi
cell) above the sphenoid sinus containing the optic strut
(Figs. 3.9a and b).
Identify the posterior ethmoid artery and nerve located
in the sphenoethmoidal recess, always in front and above
the anterior wall of the sphenoid sinus.
b
1–8
sphenoethmoidal cell.
the orbit, the skull base, and the sphenoid sinus contents.
Unrecognized entry into the sphenoid sinus increases the
risk to the optic nerves and the carotid arteries, especially
when anatomic variations such as anterior clinoid process
pneumatization lead to bony dehiscence over these
structures.
The other structures at risk are
3.6.4 Tips and Tricks (for Routine
Functional Endoscopic Sinus
Surgery)
3.6.3 Complications
There is a risk of inadvertent injury to the posterior
aspect of the lamina papyracea or the optic nerve in the
• Do not medialize the middle turbinate.
• Check the extension of the pneumatization before sur-
gery. A large posterior ethmoid cell formation will display a “window-like image” in a coronal section.
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Endoscopic Lateral Nasal Wall and Anterior and Posterior Ethmoid Sinus Dissection
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LP
BL
i
ER
PEA
ON
iv
Fig. 3.9a Posterior ethmoidectomy: removal of the basal lamellae (BL) (i–vi). View of Onodi cell (iv-vi). AWSS, anterior wall of the
sphenoidal sinus; ER, ethmoidal roof; LP, lamina papyracea; ON, optic nerve; PEA, posterior ethmoidal artery; SS, sphenoidal sinus.
ii
PEA
v
BL
ON
AWSS
LP
BL
iii
ON
vi
LP
LP
LP
LP
BL
BL
i
ER
PEA
ON
iv
Fig. 3.9b Posterior ethmoidectomy: removal of the basal lamellae (BL). Complete ethmoidectomy in endoscopic view (i-viii). AEA,
anterior ethmoidal artery; AWSS, anterior wall of the sphenoidal sinus; BE, bulla ethmoidalis; ER, ethmoidal roof; FE, fovea ethmoidal;
FR, frontal recess; FS, frontal sinus; LP, lamina papyracea; MT, middle turbinate; ON, optic nerve; PEA, posterior ethmoidal artery; SS,
sphenoidal sinus; ST, superior turbinate; STL, superior turbinate lamellae. (Continued)
ii
PEA
ON
AWSS
v
iii
vi
BL
ON
LP
LP
34
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