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Sphenoid Sinus
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RS
M
LS
LS
R
MT
a
Fig. 5.9 Transseptal sphenoidectomy in a cadaveric specimen, after performing the transnasal sphenoidotomy and a nasoseptal fl ap.
(a) Initial exposure of the rostrum. (b) After gently chiseling the rostrum sphenoidale, the whole sphenoid sinus can be seen.
The sphenoid sinus is wide open. C, choana; LS, left sphenoid; M, midline; MT, middle turbinate; R, rostrum; RS, right sphenoid;
S, sella turcica.
nasoseptal flap, which, otherwise, would have no bony
contact on its way to the clivus.
• The key of this approach is the removal of the sphenoid
rostrum with bone-cutting forceps (Kerrison) or powered instrumentation. A transnasal sphenoidotomy
may be performed previously.
• As lateralized intersinus septa tend to insert onto the
carotid (see Figs. 5.4 and 5.5), it is recommended to
remove them with burrs. Breaking them down with
forceps may lead to a lesion of the internal carotid
artery.
• Before lateral enlargement of the ostium is performed,
one should confirm its lateral pneumatization.
5.5 Case Examples
5.5.1 Case 1
A 79-year-old woman arrives at the emergency room
in a delirium. Lumbar puncture, CT scan, and MRI confirmed pneumococcal meningitis with full occupancy
of the right sphenoid sinus and a pneumoencephalus
(Fig. 5.10a). MRI displayed the presence of a skull base
defect and a CSF fistula to the sphenoid as the cause of
the meningitis. Once the meningitis was cured, intrathecal fluorescein injection was applied (Fig. 5.10b,c)
and the closure of the sphenoid fistula performed
with fascia underlay- overlay covered by a turbinal free
16
graft
(Fig. 5.10d). After 3 years of follow-up, the CSF
leak remains closed and the patient has not suffered
any further episode of bacterial meningitis.
5.5.2 Case 2
A 67-year-old woman was referred to the Rhinology
Unit presenting since 20 days a right, parietal-occipital
headache with ophthalmoplegia and third cranial nerve
involvement with mydriasis. Contrast-enhanced CT scan
demonstrated a sphenoid sinusitis, and a cavernous sinus
thrombosis was suspected (Fig. 5.11a,b). The patient was
C
b
immediately submitted to medical treatment without
proper response. A transethmoidal sphenoidectomy was
performed to drain the content of the sphenoid sinus (Fig.
5.11c). Purulent and hyphae material was extracted. The
results of the cultures showed exclusively Enterococcus
faecalis. Patient got immediate headache remission after
surgery and ophthalmoplegia was corrected within a few
months. This last symptom correlates well with current
literature findings.
revealed recurrence.
5.6 Complications
Complications can be avoided if the sphenoidotomy/
sphenoidectomy is carefully performed (Fig. 5.12a,b).
Before entering the sphenoid sinus, its ostium has to be
enlarged widely to obtain a better overview from within. For inflammatory diseases, a limited surgery at the
ostium has shown to be safe and effective to treat symptomatology.
18
5.7 Tips and Tricks
The following anatomic landmarks should be identified
during surgery:
• Laterally. The superolateral aspect of the most poste-
rior ethmoid cells (if pneumatized) or the sphenoid
covering the optic nerve. Dissection here should be
avoided. Below the infraoptic recess, the internal carotid artery is exposed.
a carotid bleeding is packing with muscle to stop the
bleeding and to proceed with an angiography without
extubating the patient.
• Superiorly. Creating a CSF leak during endonasal sur-
gery is not so infrequent. A meticulous landmark-oriented dissection reduces the risk.
• Inferiorly. Enlarging the sphenoidotomy inferiorly with
the sphenoid punch is associated with bleeding from
the posterior nasal artery, a branch from the sphenopalatine artery. Having at hand a bipolar forceps might
be very helpful.
C
17
Nasal endoscopy monitoring has not
19
The best method to cope with
20
MT
21
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Sphenoid Sinus
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a b
c d
Fig. 5.10 Case of meningococcal meningitis and sphenoid occupancy. (a) Sagittal MRI image evidencing great pneumoencephalus
and total sphenoid occupancy.
(b) Demonstration of CSF leak from the sphenoethmoidal recess to the nasopharynx after intrathecal fl uorescein injection
(c) Once the sphenoid is opened, the fi stula site is located at the bottom of the sinus. White arrow points at the fi stula site.
(d) The wall defect is meticulously closed using multilayer technique with fascia lata underlay-overlay, and then patching it with a free
mucosal graft from the middle turbinate.
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a b
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Sphenoid Sinus
c
Fig. 5.11 Cavernous sinus thrombosis after sphenoid sinusitis. (a) Coronal CT scan imaging evidencing sphenoid sinus occupancy
with presence of calcifi cation at the right sphenoid sinus. (b) Coronal T1-weighted MRI image that shows diff erent densities in the
right sphenoid sinus. (c) Endoscopic view after transethmoidal sphenoidectomy; please note the aspiration of detritus from the
bottom of the sphenoid cavity.
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Sphenoid Sinus
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ON
ON
OR
ICA
ICA
S
a
b
Fig. 5.12 (a) Areas of potential complications when performing a sphenoidotomy. Dotted lines refl ect the most frequent
complication seen at each area. Green, skull trauma or CSF leak; yellow, optic nerve damage; red, carotid lesion; blue, cavernous sinus
lesion; purple, sphenopalatine branches damage. (b) Areas of risk under higher magnifi cation. ICA, internal carotid artery; ON, optic
nerve; OR, lateral opticocarotid recess; S, sella turcica.
References
1. Wise S, Orlandi R, DelGaudio J. Sinonasal development and anatomy. In: Kennedy DW, Hwang PH, eds. Rhinology: Diseases of the
Nose, Sinuses and Skull Base. New York, NY: Thieme; 2012:1–20
2. Lang J, Bressel S, Pahnke J. The sphenoid sinus, clinical anatomy
of approaches to the pituitary region. Gegenbaurs Morphol Jahrb
1988;134(3):291–307
3. Keskin G, Ustündag E, Ciftçi E. Agenesis of sphenoid sinuses. Surg
Radiol Anat 2002;24(5):324–326
4. Hosemann W, Fanghänel J. A Dissection Course on Endoscopic
Endonasal Sinus Surgery. Greifswald: Endo-Press; 2006
5. Siedek V, Pilzweger E, Betz C, Berghaus A, Leunig A. Complications
in endonasal sinus surgery: a 5-year retrospective study of 2,596
patients. Eur Arch Otorhinolaryngol 2013;270(1):141–148
6. Gardner PA, Tormenti MJ, Pant H, Fernandez-Miranda JC, Snyderman CH, Horowitz MB. Carotid artery injury during endoscopic
endonasal skull base surgery: incidence and outcomes. Neurosurgery 2013;73(2, Suppl Operative):ons261–ons269, discussion
ons269–ons270
7. Becker SS, O’Malley BB. Evaluation of sinus computed tomography scans: a collaborative approach between radiology
and otolaryngology. Curr Opin Otolaryngol Head Neck Surg
2013;21(1):69–73
8. Al-Abri R, Bhargava D, Al-Bassam W, Al-Badaai Y, Sawhney S. Clinically significant anatomical variants of the paranasal sinuses.
Oman Med J 2014;29(2):110–113
9. Lu Y, Pan J, Qi S, Shi J, Zhang X, Wu K. Pneumatization of the
sphenoid sinus in Chinese: the differences from Caucasian and
its application in the extended transsphenoidal approach. J Anat
2011;219(2):132–142
10. Tomovic S, Esmaeili A, Chan NJ, et al. High-resolution computed
tomography analysis of the prevalence of Onodi cells. Laryngoscope 2012;122(7):1470–1473
11. Ryan WR, Ramachandra T, Hwang PH. Correlations between
symptoms, nasal endoscopy, and in-office computed tomography
in post-surgical chronic rhinosinusitis patients. Laryngoscope
2011;121(3):674–678
12. Fokkens WJ, Lund VJ, Mullol J, et al. EPOS 2012: European position
paper on rhinosinusitis and nasal polyps 2012. A summary for otorhinolaryngologists. Rhinology 2012;50(1):1–12
13. Lin HW, Bhattacharyya N. Diagnostic and staging accuracy of magnetic resonance imaging for the assessment of sinonasal disease.
Am J Rhinol Allergy 2009;23(1):36–39
14. Lee DH, Yoon TM, Lee JK, Joo YE, Park KH, Lim SC. Invasive fungal sinusitis of the sphenoid sinus. Clin Exp Otorhinolaryngol
2014;7(3):181–187
15. Thamboo A, Chang BA, Habib AR, et al. The effect of two sphenoidotomy approaches on the sense of smell: trans-ethmoidal versus
trans-sphenoethmoidal. Rhinology 2014;52(3):281–287
16. Malik MU, Aberle JC, Flitsch J. CSF fistulas after transsphenoidal
pituitary surgery-a solved problem? J Neurol Surg A Cent Eur Neurosurg 2012;73(5):275–280
17. Lizé F, Verillaud B, Vironneau P, et al. Septic cavernous sinus
thrombosis secondary to acute bacterial sinusitis: a retrospective
study of seven cases. Am J Rhinol Allergy 2015;29(1):e7–e12
18. Awad AJ, Mohyeldin A, El-Sayed IH, Aghi MK. Sinonasal morbidity
following endoscopic endonasal skull base surgery. Clin Neurol
Neurosurg 2015;130:162–167
19. Labib MA, Prevedello DM, Carrau R, et al. A road map to the internal carotid artery in expanded endoscopic endonasal approaches
to the ventral cranial base. Neurosurgery 2014;10(Suppl 3):448–
471, discussion 471
20. Cinar C, Bozkaya H, Parildar M, Oran I. Endovascular management
of vascular injury during transsphenoidal surgery. Interv Neuroradiol 2013;19(1):102–109
21. Castro MCM, Michel LMP, Denaro MM, Gontijo PAM, Sousa AA. Endoscopic transnasal approach for removing pituitary tumors. Arq
Neuropsiquiatr 2014;72(5):378–382
OR
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Chapter 6
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6.1 Indications 60
Medial Maxillectomy
6.2 Surgical Steps 60
6.3 Case Example 61
6.4 Complications 63
6.5 Tips and Tricks 63
Medial Maxillectomy
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6 Medial Maxillectomy
Christos Georgalas, Michael Tsounis
Introduction
Endoscopic medial maxillectomy is a versatile approach
to the maxillary sinus as well as to the pterygopalatine
and infratemporal fossa. It can be used to address either
recalcitrant inflammatory disease or neoplasias of the
area. It can be technically challenging, but it has the significant advantage that it can be tailored to the pathology
encountered, and can include the nasolacrimal duct or
the whole medial wall of the maxillary sinus as well as
the medial part of the anterior maxillary sinus wall.
6.1 Indications
• Extensive inverted papilloma or other benign tumors
broadly attached to the anterior, lateral, inferior, or
posterior maxillary wall.
• Creation of transmaxillary/transpterygoid access.
• Recalcitrant chronic inflammation of the maxillary
sinus (i.e., cystic fibrosis, primary ciliary dyskinesia).
1,2
3
4
6.2 Surgical Steps
6.2.1 Anatomic Landmarks
• Frontal process of maxilla (anterior lacrimal crest).
• Lacrimal “bulge.”
• Inferior turbinate.
• Uncinate process.
• Maxillary sinus floor.
• Vertical process of palatine bone.
maxillectomy (including the piriform aperture and part
of the anterior maxillary sinus wall, until the infraorbital
nerve is exposed; we call this “extensive, type 2 medial
maxillectomy”; Fig. 6.3).
Initially, the mucosa over the frontal process of the
maxilla and the anterior lacrimal crest is incised with a
45-degree ophthalmology slit/phaco knife, down to the
level of the nasal floor (Fig. 6.4). A no. 15 blade is then
used to continue the initial incision under the inferior
turbinate, up to the level of the posterior maxillary wall
(Fig. 6.5). The incised mucosa is then reflected over the
projected osteotomy sites with a Freer elevator (Fig. 6.6).
A 3-mm chisel is used to cut the bone following the route
of the initial mucosal incisions, always first anterior to
the nasolacrimal duct and then under the inferior turbinate (Fig. 6.7), all the way to the posterior wall of the
6.2.2 Description
The procedure starts by applying topical cocaine powder
in cotton buds soaked in 1 mg/mL epinephrine. Topical
cocaine is not allowed in some countries, so vasoconstriction solution could be used. The cotton buds should
be placed into the nasal cavity, where they stay until the
patient is draped and the surgical field is prepared. A solution of 1:80,000 adrenaline/lignocaine is subsequently
injected under the inferior turbinate and over the ridge of
the frontal process of the maxilla (Fig. 6.1).
The extent of the procedure is defined by the extension
of the tumor. For those limited to the medial wall of the
maxillary sinus, a wide middle meatal antrostomy with
inclusion of the tumor and the involved part of the wall
is usually enough. In the case that the tumor involves the
lateral or posterior wall of the maxillary sinus, a “conservative” medial maxillectomy with or without the excision
of nasolacrimal duct is performed (we call this “conservative, type 1 medial maxillectomy”; Fig. 6.2). If the tumor
involves the anterolateral wall and/or the inferior part of
the maxillary sinus, an endoscopic Denker is performed
(as described by Draf)—radical or extensive medial
60
Fig. 6.1 Injection of local anesthetic/vasoconstriction
solution submucosally under the inferior turbinate.
Fig. 6.2 Type 1 (conservative) medial maxillectomy, involving
only the medial maxillary wall.
Fig. 6.3 Type 2 (extensive) medial maxillectomy, with
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excision of the nasolacrimal duct and the medial/anterior wall
of the maxillary sinus.
Medial Maxillectomy
Fig. 6.4 Vertical incision of the lateral nasal wall mucosa
anterior to the nasolacrimal duct.
Fig. 6.5 Horizontal incision of the mucosa under the inferior
turbinate.
maxillary sinus (Fig. 6.8). The medial wall of the maxillary sinus is subsequently reflected medially en bloc with
the inferior turbinate. The nasolacrimal duct is identified
and resected horizontally with a sharp scissors to prevent
postoperative stenosis (Fig. 6.9). If necessary, the maxillectomy opening is further enlarged anteriorly, laterally, and inferiorly with a 15-degree diamond burr and
a Kerrison punch, aiming always to completely visualize
the anterior wall (including the lateral part of it) of the
sinus. The final margins of resection are the nasal floor
inferiorly, the orbital floor superiorly, the posterior wall
of the maxillary sinus posteriorly, and the (lateral part
of the) anterior wall of the maxillary sinus anteriorly. At
this stage, in cases of inverted papilloma or other benign
tumors, the whole attachment of the tumor in the maxillary sinus should be clearly visualized. We find that malleable suction elevators (Wormald set) are very helpful
for removing a 10-mm cuff of normal mucosa around the
attachment of the tumor. Before the tumor is removed,
Fig. 6.6 Refl ection of the incised mucosa.
the sphenopalatine artery is often ligated. The bony maxillary wall where the tumor was attached is drilled using a 70-degree diamond drill and the cavity is inspected
with a 30- or 45-degree endoscope.
We send all the specimens (including that in the
debrider trap) for histology, to avoid missing a synchronous malignant tumor.
5
1
6.3 Case Example
A 45-year-old man presented in our clinic with progressive right-sided nasal obstruction. On rigid endoscopy, a
large fleshy polyp was visualized extending through the
middle meatus, deflecting medially the middle turbinate,
and partly obstructing the nasal cavity (Fig. 6.10).
A biopsy taken in outpatients confirmed the clinical diagnosis of an inverted papilloma. The computed
tomography (CT) scan and magnetic resonance imaging
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Medial Maxillectomy
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Fig. 6.7 Anterior limit of
osteotomies performed.
(MRI) revealed that the tumor was occupying the whole
maxillary sinus (Figs. 6.11 and 6.12). Importantly, there
was evidence of localized hypertrophic bone formation
(osteitis sign) in the lateral part of the anterior wall of
the maxillary sinus (Fig. 6.11), suggesting that this was
the origin of the tumor. On the basis of the scans and
the histological report, a radical medial maxillectomy
( endoscopic Denker procedure) was planned.
After preparing the nasal cavity, we assessed the extent
of the tumor, specifically trying to identify the location
and extent of attachment. The intranasal part of the tumor
was debulked. The auto-antrostomy i.e. widening of the
Fig. 6.8 Posterior limit of osteotomy.
maxillary sinus osmium produced by the tumor itself was
further enlarged surgically. After significant tumor debulking within the maxillary sinus, the attachment at the anterolateral wall was visualized, on an area of osteitis, as
predicted by the CT scan (Fig. 6.13). An endoscopic Denker
(radical medial maxillectomy) was performed, including
the incision of the nasolacrimal duct. At the end of surgery,
all the remaining walls of the maxillary sinus were visualized and were free of tumor. The area around the attachment was drilled and the mucosa cauterized. At 2 years of
follow-up, the patient remains asymptomatic and the nasal
cavity is free of tumor (Fig. 6.14).
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Medial Maxillectomy
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Fig. 6.9 Clean resection of the
nasolacrimal duct—note the remaining
stump.
Fig. 6.10 Endoscopic view of the inverted papilloma fi lling
the right nasal cavity.
6.4 Complications
Acute hemorrhage may occur due to injury of the sphenopalatine artery or its branches and can be prevented by
prior artery ligation/clipping/bipolar coagulation. Epiphora due to stenosis of the lacrimal duct can be avoided by
resecting the duct horizontally with a sharp scissors. The
authors do not routinely stent the duct.
sible sequela after medial maxillectomy is paraesthesia
of the dental hemiarcade due to damage to intraosseous
nerve branches supplying the dental alveoli.
syndrome is relatively rare, whereas excessive crusting
can be prevented by as conservative removal of healthy
mucosa as possible.
1,6
Another pos-
7
Empty nose
6.5 Tips and Tricks
• Hypotensive, total intravenous anesthesia and ade-
quate local vasoconstriction are useful for a bloodless
field and adequate visualization during the operation.
• Always assess the lesion with both CT and MRI. The
bony detail included in the CT is important to recognize the presence of intrasinus septa, Haller’s cells, and
the relative depth of the orbit and the nasolacrimal
duct, while MRI (especially T2 with intravenous contrast) can differentiate between tumor and retained
secretions.
• It is increasingly recognized that the papilloma attach-
ment can be predicted with some degree of accuracy
from signs of osteitis: taking enough time to examine thin
(1 mm) cuts for signs of bony hyperostosis always pays.
• 30- and rarely 45-degree endoscopes are usually suffi-
cient for the whole procedure.
• Image guidance is seldom, if ever, necessary.
• Try to remove en bloc the medial maxillary wall togeth-
er with the tumor. Use a 3-mm chisel to perform the
inferior and anterior/medial osteotomies on the medial
maxillary sinus wall.
• Always aim to clearly visualize and sharply cut the
nasolacrimal duct. In our opinion, there is no indication
for the routine use of nasolacrimal duct stents.
• Be flexible and change shaver (straight, 12, 40, 60
degrees) and drill (15-degree 4-mm diamond DCR
drill, 40-degree 3-mm finesse drill, 70-degree 4-mm
diamond drill) according to the anatomy and the
pathology.
• A 70-degree diamond drill and curved suction diather-
my are important to completely remove any remnants
of the lesion as well as its attachments in the maxillary
sinus walls.
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Medial Maxillectomy
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Fig. 6.11 Papilloma fi lling the right
maxillary sinus—note the osteitis sign
(intraoperative navigation view).
Fig. 6.12 Same image as in Fig. 6.11,
MRI window in navigation fusion.
64
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