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SECTION X — Operative Surgery
THIRD PASS (EXAMINATION OF THE
MIDDLE MEATUS IN DETAIL)
Endoscope is passed from the front into the middle meatus. Sometimes middle turbinate needs to be displaced
medially or 2.7 mm 30° endoscope has to be used. Examine uncinate process, bulla ethmoidalis, hiatus semilunaris, sinus of the turbinate (cavity on lateral side of
middle turbinate) and the frontal recess.
Sometimes middle meatus is better entered from
behind where the space is wider than from the front
and structures are seen from behind forward, e.g. basal lamina, bulla ethmoidalis, hiatus semilunaris, sinus
of the turbinate, and uncinate process and the frontal
recess.
COMPLICATIONS
Occasionally bleeding can occur due to suction or manipulation of instruments. It is usually mild and easily
controlled by vasoconstrictor nasal drops.
Chapter 90
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Endoscopic Sinus Surgery
Endoscopic surgery has made a great contribution towards management of sinus disease. Indications for
conventional operations like those of Caldwell–Luc, frontal sinus operations and external ethmoidectomy have
greatly reduced. Endoscopic surgery is minimally invasive
surgery and does not require skin incisions or removal
of intervening bone to access the disease. In the sinuses,
ventilation and drainage of the sinuses is established preserving the nasal and sinus mucosa and its function of
mucociliary clearance. Advances in endoscopic surgery
have been possible due to:
1. Development of better optics.
2. Improved brighter illumination.
3. Development of microsurgical instruments to work
with the endoscopes and precise removal of tissue with
sharp cuts without stripping the mucosa.
4. Concomitant developments in imaging techniques like
CT and MRI to precisely define the area of pathology.
5. Introduction of powered instrumentation in the form
of soft-tissue shavers also called microdebriders (to remove nasal polyps, soft-tissue masses or mucosa) help
reduce bleeding to a great extent while bone-cutting
drills help endoscopic surgery of frontal sinus, lacrimal
sac, etc. to remove bony obstruction.
6. The latest advancement has been the computer-assisted image-guided navigational surgery in difficult cases
or revisional surgery when landmarks are not easy to
identify.
6. Optic nerve decompression.
7. Orbital decompression for Graves’ disease.
8. Control of posterior epistaxis (endoscopic clipping of
sphenopalatine artery).
9. Choanal atresia.
CONTRAINDICATIONS
1. Inexperience and lack of proper instrumentation.
2. Disease inaccessible by endoscopic procedures, e.g. lateral frontal sinus disease and stenosis of internal opening of frontal sinus.
3. Osteomyelitis.
4. Threatened intracranial or intraorbital complication.
ANAESTHESIA
General anaesthesia is preferred by most of the surgeons.
Local anaesthesia with i.v. sedation can be used in adults
when limited work is to be done.
POSITION
Patient lies flat in supine position with head resting on a
ring or head rest. Some also prefer to raise it by 15°.
INDICATIONS
1. Chronic bacterial sinusitis unresponsive to adequate
medical treatment.
2. Recurrent acute bacterial sinusitis.
3. Polypoid rhinosinusitis (diffuse nasal polyposis).
4. Fungal sinusitis with fungal ball or nasal polypi.
5. Antrochoanal polyp.
6. Mucocele of frontoethmoid or sphenoid sinus.
7. Control of epistaxis by endoscopic cautery.
8. Removal of foreign body from the nose or sinus.
9. Endoscopic septoplasty.
ADVANCED NASAL ENDOSCOPIC
TECHNIQUES
1. Removal of benign tumours, e.g. inverted papillomas
or angiofibromas.
2. Orbital abscess or cellulitis management.
3. Dacryocystorhinostomy.
4. Repair of CSF leak.
5. Pituitary surgery.
TECHNIQUES (FIGURE 90.1)
Two surgical techniques are followed:
1. Anterior to posterior (Stammberger’s technique). In
this technique surgery proceeds from uncinate process
backward to sphenoid sinus. Advantage of this technique is to tailor the extent of surgery to the extent of
disease.
2. Posterior to anterior (Wigand’s technique). Surgery
starts at the sphenoid sinus and proceeds anteriorly
along the base of skull and medial orbital wall. This
is mostly done in extensive polyposis or in revisional
sinus surgery.
STEPS OF OPERATION
1. Remove the pledgets of cotton kept for nasal decongestion and topical anaesthesia.
2. Inspect the nose with 4 mm 0° endoscope or do complete nasal endoscopy if not already done.
3. Inject submucosally 1% lignocaine with 1:100,000
adrenaline under endoscopic control (Figure 90.2):
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Figure 90.1. Endoscopic surgery in progress. Endoscope and other surgical instruments are passed through the nose and surgery
performed by looking at the monitor.
Figure 90.2. Sites of injection (indicated by stars) just anterior to
uncinate process on the lateral wall of right side of nose.
SECTION X — Operative Surgery
(a) On the lateral wall, near the upper end of middle
turbinate.
(b) On the lateral wall, just below the first injection.
(c) On the lateral wall, just above the inferior turbinate.
(d) In the middle turbinate, posterior aspect.
(e) Posterior aspect of nasal septum.
4. Replace cotton pledgets and repeat injections on the
opposite side if bilateral functional endoscopic sinus
surgery (FESS) is to be done.
Medialize the middle turbinate and identify the unci-
nate process and bulla ethmoidalis. If middle turbinate is
large, partial or total turbinectomy is performed. In case
of concha bullosa, lateral lamella is removed. Definitive
surgical steps include:
1. Uncinectomy. Uncinate process is incised with sickle
knife and removed with Blakesley forceps.
2. Identification and enlargement of maxillary
ostium. Maxillary ostium lies above the inferior turbinate and posterior to lower third of uncinate process.
Once localized, it is enlarged anteriorly with a backbiting forceps or posteriorly with a through cut-straight
forceps.
3. Bullectomy. Bulla ethmoidalis is penetrated with cu-
rette or Blakesley forceps and removed. Avoid injury
to medial orbital wall, skull base or anterior ethmoidal
artery.
4. Penetration of basal lamella and removal of poste-
rior ethmoid cells. Basal lamella is the dividing thin
bony septum between anterior and posterior ethmoid
cells. It is penetrated in the lower and medial part with
a small curette and then removed with Blakesley forceps. Posterior ethmoid cells are exenterated. Optic
nerve is at risk if Onodi cell is present. Onodi cell is
a posterior ethmoid cell which extends into the sphenoid bone lateral and superior to the sphenoid sinus.
5. Clearance of frontal recess and frontal sinusotomy.
If frontal sinus is clear on CT scan and patient also
does not suffer from frontal headaches, nothing need
to be done. In the event of frontal sinus disease, frontal
recess is cleared and frontal sinus drainage established.
Opening of frontal sinus is situated lateral to attach-
ment of middle turbinate, medial to medial orbital
wall, anterior to anterior ethmoidal artery and posterior to agger nasi cell(s). Surgery in the area of frontal
recess is challenging as any disrespect to the mucosa in
this area would lead to stenosis of frontal sinus opening
with mucocele formation or recurrent frontal sinusitis.
6. Sphenoidotomy. This step is done after clearance of
posterior ethmoid cells or after frontal sinusotomy. It
is omitted if sinus is healthy. In this procedure anterior
wall of sphenoid sinus is removed, and pus and inspissated material from within the sinus removed. There
are two ways to remove the anterior sinus wall:
(a) By entering the sphenoid sinus anterior and in-
ferior to the ethmoid cavity created by the above
steps.
(b) By enlarging the opening of sphenoid sinus with
Blakesley forceps or J-curette. Sinus opening is
identified after removal of the posterior-inferior
portion of superior turbinate near the nasal septum
and about 1.0 cm above the upper border of posterior choana.
7. Nasal packs. Finally the nasal packs are applied, if septal surgery has also been done with FESS or to stop any
bleeding from the nasal cavity.
POSTOPERATIVE CARE
It is individualized according to the extent of surgery
done.
1. Removal of nasal packs. Nasal packs, if kept, are removed at the time of discharge 24 h after the operation.
2. Antibiotics. An intraoperative intravenous antibiotic
(amoxiclav, cephalosporin or quinolone) is administered and then continued for 7–10 days by oral route.
3. Antihistaminics. For allergic patients.
4. Analgesics. For relief of postoperative pain.
5. Nasal irrigations. Saline irrigations are started after
1 week postoperatively to remove blood clots, crusts and
secretions and continued once or twice a day for 1 week.
6. Steroid nasal sprays. Required in cases of nasal allergy
or those operated for nasal polyps.
7. Endoscopic toilet. Blood clots, crusts and debris are
removed by suction and forceps from the ethmoid area
lateral to middle turbinate. Any adhesion formation
Chapter 90 — Endoscopic Sinus Surgery
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479
in the nose is divided with suction. Healthy mucosa
should not be disturbed. Suction can be done from
within the maxillary sinus with a curved cannula. Since
the endoscopic clearance is a painful process, topical
nasal anaesthetic with a decongestant is sprayed before
the procedure.
Patient pays weekly visits for inspection of the cavity
for 4 weeks and thereafter as required till mucosalization
of the cavity is complete.
COMPLICATIONS
They are similar to conventional surgery of ethmoid complex and can be divided into major and minor. Mostly
they involve orbit or skull base, or are of general nature
(see Table 90.1). Many of the complications are preventable by careful surgical technique.
TABLE 90.1 MAJOR AND MINOR COMPLICATIONS
OF ENDOSCOPIC SINUS SURGERY
Major Minor
1. Orbital haemorrhage
2. Loss of vision/blindness
3. Diplopia
4. CSF leak
5. Meningitis
6. Brain abscess
7. Massive haemorrhage
requiring blood transfusion
8. Intracranial haemorrhage
and direct brain trauma
9. Anosmia
10. Injury to internal carotid
artery in sphenoid sinus
11. Injury to nasolacrimal duct
and epiphora
12. Death
1. Periorbital ecchymosis
2. Periorbital emphysema
3. Postoperative epistaxis
4. Postoperative infection:
rhinitis or sinusitis
5. Adhesions
6. Stenosis of maxillary or
frontal sinus opening
7. Exacerbation of asthma
8. Hyposmia
9. Dental pain
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Chapter 91
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Direct Laryngoscopy
It is direct visualization of larynx and hypopharynx.
INDICATIONS
A. DIAGNOSTIC
1. When indirect laryngoscopy is not possible as in infants and young children, and the symptomatology
points to larynx and/or hypopharynx, e.g. hoarseness,
dyspnoea, stridor and dysphagia.
2. When indirect laryngoscopy has not been successful,
e.g. due to excessive gag reflex or overhanging epiglottis obscuring a part or complete view of the larynx.
3. To examine hidden areas of:
(a) Hypopharynx. Base of tongue, valleculae and lower
part of pyriform fossa.
(b) Larynx. Infrahyoid epiglottis, anterior commissure,
ventricles and subglottic region.
4. To find the extent of growth and take a biopsy.
B. THERAPEUTIC
1. Removal of benign lesions of larynx, e.g. papilloma,
fibroma, vocal nodule, polyp or cyst.
2. Removal of foreign bodies from larynx and hypo pharynx.
3. Dilatation of laryngeal strictures.
CONTRAINDICATIONS
PROCEDURE
1. A piece of gauze is placed on the upper teeth to protect
them against trauma.
2. Laryngoscope is lubricated with a little autoclaved liquid paraffin or jelly.
3. Laryngoscope is held by the handle in the left hand.
Right hand is used to retract the lips and guide the
laryngoscope and to handle suction and instruments.
4. Laryngoscope is introduced by one side of the tongue
which is pushed to the opposite side till posterior third
of tongue is reached. It is then moved to the midline
and lifted forward to bring the epiglottis in view.
5. Laryngoscope is now advanced behind the epiglottis
and lifted forward without levering it on the upper teeth or
jaw (Figure 91.1). This gives good view of the interior
of the larynx.
6. If anterior commissure laryngoscope is being used, its
tip can be advanced further between the ventricular
bands to examine the ventricles and anterior commissure. It can be passed between the vocal cords to examine the subglottic region.
7. Following structures are examined serially: Base of
tongue, right and left valleculae, epiglottis, (its tip,
lingual and laryngeal surfaces), right and left pyriform
sinuses, aryepiglottic folds, arytenoids, postcricoid region, both false cords, anterior and posterior commissure, right and left ventricles, right and left vocal cords
and subglottic area. Mobility of vocal cords should also
be observed.
1. Diseases or injuries of cervical spine.
2. Moderate or marked respiratory obstruction unless the
airway has been provided by tracheostomy.
3. Recent coronary occlusion or cardiac decompensation.
ANAESTHESIA
General anaesthesia is preferred though this procedure
can be performed under local anaesthesia. In infants and
young children, no anaesthesia may be required if procedure is for diagnostic purpose.
POSITION
Patient lies supine. Head is elevated by 10–15 cm by
placing a pillow under the occiput or by raising head
flap of the operation table. Neck is flexed on thorax and
the head extended on atlanto-occipital joint (barking-dog
position).
Figure 91.1. Direct laryngoscopy.
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SECTION X — Operative Surgery
A right-angled telescope can be used to see the undersurface of vocal cords and the walls of the subglottis. After
the procedure is completed, laryngoscope is withdrawn
and lips and teeth examined for any injury.
POSTOPERATIVE CARE
1. Patient is kept in coma position to prevent aspiration
of blood or secretions.
2. Patient’s respiration should be watched for any laryn-
geal spasm and cyanosis.
3. Trauma to larynx, especially if repeated attempts at la-
ryngoscopy have been made. It may lead to laryngeal
oedema and respiratory distress.
4. Bleeding may occur from the operative site. Patient
may spit blood. Care should be taken to prevent
aspiration.
COMPLICATIONS
1. Injury to lips and tongue if they are nipped between
the teeth and the laryngoscope.
2. Injury to teeth. They may get dislodged and fall into
pharynx.
3. Bleeding.
4. Laryngeal oedema.
Chapter 92
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Bronchoscopy
Bronchoscopy is of two types:
1. Rigid.
2. Flexible fibreoptic.
RIGID BRONCHOSCOPY
INDICATIONS
Diagnostic
1. To find out the cause for wheezing, haemoptysis or unexplained cough persisting for more than 4 weeks.
2. When X-ray chest shows:
(a) Atelectasis of a segment, lobe or entire lung.
(b) Opacity localized to a segment or lobe of lung.
(c) Obstructive emphysema—to exclude foreign body.
(d) Hilar or mediastinal shadows.
3. Vocal cord palsy.
4. Collection of bronchial secretions for culture and sensitivity tests, acid fast bacilli, fungus and malignant
cells.
Therapeutic
1. Removal of foreign bodies.
2. Removal of retained secretions or mucus plug in cases
of head injuries, chest trauma, thoracic or abdominal
surgery, or comatosed patients.
ANAESTHESIA
General anaesthesia with no endotracheal tube or with
only a small bore catheter is often preferred. It can also be
done under topical surface anaesthesia.
POSITION
Same as for direct laryngoscopy.
DETAILS OF TECHNIQUE
1. A piece of gauze or a dental guard is placed on the upper teeth for their protection against injury.
2. Proper-sized bronchoscope is lubricated with a swab
of autoclaved liquid paraffin or jelly. It is held by the
shaft in surgeon’s right hand in a pen-like fashion. Fingers of the left hand are used to retract the upper lip
and guide the bronchoscope.
3. Now looking through the scope, tip of epiglottis is
identified first and the scope passed behind it and the
epiglottis lifted forward to expose the glottis. Now
bronchoscope is rotated 90° clockwise so that its bevelled tip is in the axis of glottis to ease its entry into the
trachea. Once trachea is entered, scope is rotated back
to the original position.
4. Bronchoscope is gradually advanced and the entire
tracheobronchial tree examined. Axis of bronchoscope
should be made to correspond with axes of the trachea
and bronchi. To achieve this, head and neck are flexed
to the left when examining the right bronchial tree
and vice versa.
Openings of all the segmental bronchi in both the
lungs are examined in seriatim.
5. Direct vision, right angled and retrograde telescopes can
be used for magnification and detailed examination.
6. Biopsy of the lesion of suspicious area can be taken.
7. Secretions can be collected for exfoliative cytology, or
bacteriologic examination.
POSTOPERATIVE CARE
1. Keep the patient in humid atmosphere.
2. Watch for respiratory distress. This could be due to laryngeal spasm or subglottic oedema if the procedure
had been unduly prolonged or the bronchoscope introduced repeatedly. Inspiratory stridor and suprasternal retraction will indicate need for tracheostomy.
TECHNIQUE
There are two methods to introduce bronchoscope:
1. Direct method. Here bronchoscope is introduced directly through the glottis.
2. Through laryngoscope. Here glottis is first exposed
with the help of a spatular type laryngoscope and then
the bronchoscope is introduced through the laryngoscope into the trachea. Laryngoscope is then withdrawn. This method is useful in infants and young
children, and in adults who have short neck and thick
tongue.
COMPLICATIONS
1. Injury to teeth and lips.
2. Haemorrhage from the biopsy site.
3. Hypoxia and cardiac arrest.
4. Laryngeal oedema.
PRECAUTIONS DURING BRONCHOSCOPY
1. Select proper size of bronchoscope according to patient’s age (see Table A1 in Appendix II).
2. Do not force bronchoscope through closed glottis.
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SECTION X — Operative Surgery
TABLE 92.1 COMPARATIVE ADVANTAGES AND DISADVANTAGES OF FLEXIBLE AND RIGID BRONCHOSCOPY
Flexible bronchoscopy Rigid bronchoscopy
1. Anaesthesia Topical General
2. Route Nasal or through endotracheal tube Oral only
3. Structures seen • Nasalcavity
• Undistortedviewofsupraglotticandglottic
areas
• Segmentalandevensubsegmentalbronchi
4. Bedside exam Possible Not possible
5. Ventilation Poor control of ventilation especially in
children. Airway is compromised by scope
6. Foreign body removal • Difcult
• Contraindicatedinchildren
7. Biopsy Only small piece can be taken Larger piece can be taken
8. Jaw and neck abnormalities
or injuries
9. Control of haemorrhage Difficult • Bettercontrol
10. Cost of procedure Less More, require operation theatre facilities with costs of
Useful Technically difficult procedure
• Nosenotseen
• Supraglotticareaisdifculttoevaluate
• Onlysegmentalbronchicanbereached
Better control of ventilation especially in children
• Easy
• Ventilationcanbedonethroughscope
• Idealforforeignbodyremovalinchildrenandadults
• Usefulinmassivehaemoptysis
• Tipofbronchoscopecanbeusedtopressthe
bleeding area
operation theatre and anaesthesia
3. Repeated removal and introduction of bronchoscope
should be avoided.
4. Procedure should not be prolonged beyond 20 min in
infants and children, otherwise it may cause subglottic
oedema in postoperative period.
FLEXIBLE FIBREOPTIC BRONCHOSCOPY
These days flexible fibreoptic bronchoscopy has replaced
rigid bronchoscopy for diagnostic procedures particularly
in adults. It provides magnification and better illumination, and because of the smaller size of scope permits
examination of subsegmental bronchi. It is also easy to
use in patients with neck or jaw abnormalities and injuries where rigid bronchoscopy may almost be impossible
technically. This procedure can be performed under topical anaesthesia and is very useful for bedside examination
of the critically ill patients. The suction/biopsy channel
provided in the fibrescope helps to remove secretions,
inspissated plugs of mucus or even small foreign bodies.
Flexible bronchoscope can also be easily passed through
endotracheal tube or the tracheostomy opening. However, it has limited utility in children because of the problems of ventilation.
Table 92.1 gives the comparative advantages and dis-
advantages of flexible and rigid bronchoscopy.
Chapter 93
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Oesophagoscopy
Oesophagoscopy is of three types:
1. Rigid oesophagoscopy.
2. Flexible fibreoptic oesophagoscopy.
3. Transnasal oesophagoscopy.
RIGID OESOPHAGOSCOPY
INDICATIONS
Diagnostic
1. To investigate cause for dysphagia, e.g. cancer oesophagus, cardiac achalasia, strictures, oesophagitis, diverticulae, etc.
2. To find cause for retrosternal burning, e.g. reflux oesophagitis or hiatus hernia.
3. To find cause for haematemesis, e.g. oesophageal
varices.
4. Secondaries neck with unknown primary (as a part of
panendoscopy).
Therapeutic
1. Removal of a foreign body.
2. Dilatation in case of oesophageal strictures or cardiac
achalasia.
3. Endoscopic removal of benign lesions, e.g. fibroma,
papilloma, cysts, etc.
4. Insertion of Souttar’s or Mousseau-Barbin tube in palliative treatment of oesophageal carcinoma.
5. Injection of oesophageal varices.
CONTRAINDICATIONS
1. Trismus-makes the procedure technically difficult.
2. Disease of cervical spine, e.g. cervical trauma, spondylosis, tuberculous spine, osteophytes and kyphosis.
They make rigid oesophagoscopy technically difficult.
Flexible fibreoptic oesophagoscopy is performed in
these cases.
3. Receding mandible.
4. Aneurysm of aorta for fear of rupture and fatal haemorrhage.
5. Advanced heart, liver or kidney disease may be a relative contraindication.
ANAESTHESIA
General anaesthesia with orotracheal intubation with
tube in the left corner of the mouth. It can be performed
under local anaesthesia in selected individuals.
POSITION
Same as for direct laryngoscopy. Patient lies supine, head
is elevated by 10-15 cm, neck flexed on chest and head
extended at atlanto-occipital joint. The purpose of this
position is to attain the axes of mouth, pharynx and oesophagus in a straight line to pass the rigid tube easily.
This position can be achieved with the help of an assistant or a special head rest.
TECHNIQUE
1. A piece of gauze is placed over the upper teeth to protect them or a dental guard.
2. Oesophagoscope is lubricated with a swab of autoclaved liquid paraffin or jelly.
3. The oesophagoscope is held by its proximal end in a
pen-like fashion and introduced into the mouth by the
right side of the tongue and then towards the middle
of its dorsum.
Now there are four basic steps:
1. Identification of arytenoids. Once oesophagoscope
has been introduced to the back of tongue, it is advanced gently by the left thumb and index finger. Epiglottis is first seen, then the endotracheal tube and a
little further down arytenoids can be identified.
2. Passing the cricopharyngeal sphincter. Keeping the
tip of oesophagoscope strictly in the midline, behind
the larynx, it is lifted with movements of left thumb
to open the hypopharynx. With slow but sustained
pressure, the sphincter will open and then the tip of
oesophagoscope can be guided easily into the oesophagus. Never apply force to open the sphincter. Sometimes, a fine bougie can be used to find the lumen. An
additional dose of muscle relaxant may be required if
sphincter does not open. Once oesophagus has been
entered, it is easier to advance the scope, provided oesophageal lumen is kept constantly in view.
3. Crossing the aortic arch and left bronchus. In an
adult, this natural narrowing lies about 25 cm from
the incisors. Aortic pulsation can be seen. When
crossing this area, head of the patient is slightly lowered so that oesophageal lumen is in line with that of
the scope.
4. Passing the cardia Head and shoulders remain below
the level of the table, head being slightly higher than
the shoulders and moved slightly to the right. At this
stage, the oesophagoscope points to the left anteriorsuperior iliac spine. Cardia is identified by its redder
and more velvety or rugose mucosa.
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