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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4416_Библиотеки_им_академика_М_И_Перельмана
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Section 2 Inammatory Nasal Conditions122
Contd...
RT LT
5. Bone expansion (mention site) A A
6. Bone erosion (mention site) A A
7. Bone sclerosis (mention site) A A
8. Nasal septum—deviated/midline Deviated to left
9. Middle turbinate anatomy
(normal/abnormal)
10. Uncinate process insertion Lamina papyracea Lamina papyracea
11. Osteomeatal complex Obstructed Obstructed
12. Frontal nasal duct pathway Obstructed Obstructed
13. Sphenoethmoidal recess Obstructed Patent
14. Inferior turbinate Hypertrophied Hypertrophied
15. Infraorbital ethmoidal (Haller) cell Absent Absent
16. Sphenoethmoidal (Onodi cell) Absent Absent
17. Anterior clinoid process
pneumatization
18. Lamina papyracea integrity Intact Intact
19. Cribriform plate anatomy (Keros
classicationI/II/III)
20. Ethmoid skull base integrity Intact Intact
21. Optic nerve anatomy (covered by
bone or not)
22. Internal carotid artery (ICA) anatomy
(covered by bone or not)
23. Orbit N N
24. Nasopharynx N N
25. Visualized brain parenchyma N N
26. Additional ndings Nil Nil
Impression:
• Mucoperiosteal thickening in bilateral, frontal, ethmoid and right sphenoid sinus, partial.
• Opacicationofleft maxillary sinus, bilateralobstructedosteomeatalcomplex (OMC)
and deviated nasal septum (DNS) to left with B/L inferior turbinate hypertrophy
suggestive of pansinusitis.
• Noanatomicalvariantsuggestiveofposingsurgicalriskidentied.
N N
Absent Absent
II II
Yes Yes
Yes Yes
123Chapter 9 Pre- and Post-Functional Endoscopic Sinus Surgery Imaging
A
C
B
D
E
Figs. 9.1A to F: Example of structured reporting format.
F
Section 2 Inammatory Nasal Conditions124
Table 9.3: Anatomical variants having surgical relevance.
Anatomic variants posing surgical risk Modication of technique required
Deviated nasal septum Septoplasty may be required to improve
access
Uncinate process—acute angle of lamina
papyracea attachment
Maxillary sinus hypoplasia Orbital injury due to close approximation of
Smallbullaethmoidalis→medial
projection of LP (torus lateralis)
LP defects (especially in posterior part
due to less orbital fat)
Medially placed LP [compared with
osteomeatal complex (OMC)—usually in
same plane]
Dehiscent infraorbital nerve (along
maxillary roof)
Frontal cell Anterior skull base penetration
Decreased vertical distance between
maxillary sinus roof and anterior skull
base
Areas of dehiscence in posterior wall of
frontal sinuses
Hypopneumatization of frontal sinus Anterior skull base injury especially if
Onodi cells Optic nerve injury
Hyperpneumatization of sphenoid sinus
Focal dehiscence may be seen lateral wall
Supaorbital ethmoidal cells Mistaken for frontal sinus
Pneumatized basal lamella Mistaken for posterior ethmoidal cells
Type III Keros anterior skull base
conguration
Decientbonycanalofanteriorethmoidal
artery
Orbital injury more likely
medial walls of the sinus and orbit
Orbital injury
Orbital injury
Orbital injury
Risk of nerve injury
Anterior skull base injury
Risk of meningitis (as sinus washes done
during procedure)
external approach planned [done for
disease in lateral part of frontal sinuses
(FS)] as trephination is done
Internal carotid artery (ICA), optic nerve,
V2 in foramen rotundum, vidian artery in
vidian canal
Anterior ethmoidal artery also displaced
posteriorly
Intracranial penetration
125Chapter 9 Pre- and Post-Functional Endoscopic Sinus Surgery Imaging
A
C
B
D
E
Figs. 9.2A to F: Anatomic variants posing surgical risk. (A) Hypopneumatization of RT
frontal sinus; (B) Type 3 frontal cell (asterisk) projecting above the frontal beak (solid arrow).
Agger nasi is shown by thin arrow; (C) Asymmetric depth of olfactory fossa. Lateral lamella
is vertical on left and oblique on right side. LT concha bullosa (asterisk) and asymmetric
aeration of ethmoid sinuses; (D) Bilateral concha bullosa with mucosal thickening left side
(arrow). LT Haller cells with mucosal thickening (asterisk); (E) Pneumatized anterior clinoid
processes (thin arrows) and lateral recess of sphenoid sinus (thick arrow) with foramen
rotundum (arrowhead) projecting into the roof of the aerated lateral recess; and (F) Laterally
deviated sphenoid sinus septum (arrow) going toward carotid canal.
F
Section 2 Inammatory Nasal Conditions126
Table 9.4: Anatomic variants associated with residual/recurrent disease.
Anatomic variants Residual/recurrent disease
Accessory maxillary ostium (behind the
natural ostium)
Hyperpneumatization of maxillary sinus Dental caries and resultant procedures can
Anterior and posterior components of
maxillary sinus
Anterior→middlemeatus
Smallposterior→superiormeatus
Basal attaches to maxillary sinus instead
of LP (missed basal lamella)
Sinusitis in lateral recess of sphenoid
sinus lateral part of FS
Recurrent sinusitis if both the ostia are not
joined during surgery
cause recurrent infections
Highrestoforoantralstula
Incomplete clearance/residual disease
Incomplete clearance/residual disease
Recurrence
POSTFUNCTIONAL ENDOSCOPIC SINUS
SURGERY POSTFESS APPEARANCE
■ Post-FESS, an early MDCT may be required if there is suspicion of a
surgical complication.
■ Contrast administration is needed if orbital or cranial complications are
suspected.
■ Computed tomography (CT) is performed in the late phase if there is
persistence or recurrence of symptoms.
■ Familiarity with normal post-FESS appearance is necessary while
evaluating for complications/disease recurrence (Figs. 9.3 to 9.6).
■ Table 9.5 delineates the explanation of the FESS procedures and the
normal expected postoperative appearance.
Specic Conditions
Mucocele
■ Entails opening up of the drainage pathways with clearing of the sinus
contents.
■ Stent/packing material may be visualized postoperatively.
■ Post-drainage remineralization of the sinus walls is expected over time.
■ CT/MRI also helps to identify residual/recurrent mucocele.
Sinonasal debridement for fungal sinusitis:
■ Postoperative imaging is challenging as dierentiation of residual fungal
disease versus postoperative changes (hemorrhage/packing material) is
dicult.
■ CT and MRI need to be co-evaluated.
127Chapter 9 Pre- and Post-Functional Endoscopic Sinus Surgery Imaging
mm)
• Widened “neoinfundibulum” on coronal CT
In ethmoidectomy:
• Medial bowing of lamina papyracea (1–3
• Middle meatal antrostomy/fenestration
• Middle turbinectomy
• Ethmoidectomy
inferior antrostomy
seen for evaluation of these structures
• Globe may appear deviated
• Defect in the region of inferior turbinate in
• Coronal and sagittal sections need to be
• Inferior antrostomy (uncommon)
Draf classication:
1. Resection of anterior ethmoid cells and uncinate process
Table 9.5: Post-functional endoscopic sinus surgery (FESS) imaging.
• Position of stent to be assessed
Axial + sagittal reformats
around the frontal recess
to lamina papyracea)
(modied)
2. 1+resectionofpartoftheooroffrontalsinus(nasalseptum
3. Entire frontal sinus oor + superior part of nasal septum
• Lothrop procedure
• ± stenting (if neo-ostium <5 mm)
• Widening of the natural ostium
not seen at all
period
Coronal sections
• Creating new opening through posterior ethmoid
• ± ethmoidectomy
Mucosal volume reduction (RFA/laser ablation/coblation)
Submucosal resection of inferior turbinate
• Nasal septum appears “straightened”
• Previously seen spurs may be reduced or
• Silicone stents/tubes in early postoperative
Type of endoscopic surgery/indications Procedures Postoperative appearance
Osteomeatal unit ESS for blocked OMU • Uncinotomy/uncinectomy
Frontal sinusotomy:
Done for persistent sinonasal disease
in spite of infundibular/anterior ethmoid
procedures
Sphenoidotomy ± sphenoid
marsupialization (exteriorizing the sinus)
for sphenoid sinus obstruction
Inferior turbinate reduction
Turbinoplasty or lateralization of the
inferior turbinate (out-fracture):
Hypertrophy of inferior turbinate (allergic
rhinitis)
Septoplasty or septorhinoplasty:
Deviated nasal septum worsening the
nasal obstruction or cosmetic
(ESS: Endoscopic sinus surgery; OMU: Osteomeatal unit; CT: Computed tomography; RFA: Radiofrequency ablation).
Section 2 Inammatory Nasal Conditions128
A
Figs. 9.3A and B: Post-FESS appearance and disease recurrence. Bilateral middle
turbinates are not seen and there are no septations in RT ethmoid sinus, suggesting bilateral
middle turbinectomies and RT ethmoidectomy; Recurrent mucosal thickening seen in RT
frontal drainage pathway (asterisk).
A
Figs. 9.4A and B: Post-FESS patient with recurrent left sinusitis and anatomic variant
posing surgical risk. LT maxillary antrostomy (wide maxillary ostium after uncinectomy
andmiddleturbinectomy).RecurrentLTethmoidsinusitis(asterisk).Adhesions/broticband
at the site of LT uncinate (arrow) may again obstruct the maxillary ostium. Note anatomic
variant posing surgical risk—Keros type III (bilateral deep olfactory fossae).
B
B
A
Figs. 9.5A and B: Post-FESS polyp recurrence. Recurrent antrochoanal polyp (asterisk)
after RT maxillary antrostomy.
B
129Chapter 9 Pre- and Post-Functional Endoscopic Sinus Surgery Imaging
A
Figs. 9.6A and B: Post-FESS contralateral disease recurrence. RT maxillary antrostomy
seen. Contralateral recurrence of allergic fungal sinusitis showing hyperdensity and causing
expansion of LT nasal cavity and maxillary sinus (asterisks). Here recurrence is due to nature
of disease and affects contralateral side.
B
COMPLICATIONS OF FESS
Table 9.6 enumerates the complications which may be associated with FESS
(Figs. 9.7A to F).
Immediate/Early Complications
ese complications often result from direct trauma during surgery due to
penetrating injury by surgical instruments.
Cerebrospinal Fluid Rhinorrhea
■ Occurs as a consequence of disruption of the ASB.
■ It may be associated with intracranial hemorrhage or parenchymal
injury, and later with recurrent meningitis/intracranial abscess.
■ Anterior skull base defects may even result in formation of cephaloceles.
■ A combination of thin section NCCT and contrast-enhanced magnetic
resonance (MR) is required for complete delineation of these injuries.
Orbital Complications
■ Lamina papyracea (LP) is the most common site of injury. Inferior orbital
wall may also be disrupted.
■ Resultant orbital hemorrhage appears as fat stranding of the orbital fat.
■ Extraocular muscles appear thickened with irregular margins. Associated
motility disturbances are seen.
■ Optic nerve injury is associated with visual loss. e optic nerve appears
thickened with irregular contours. MRI may reveal altered signal intensity
within the nerve itself.
■ Disruption of the nasolacrimal causes dacryocystitis and epiphora.
Section 2 Inammatory Nasal Conditions130
Nasal Septum
■ Particularly susceptible during septoplasty.
■ Hematoma within a closed space (perichondrium) results in ischemic
necrosis of the cartilage.
■ Patients are usually symptomatic with nasal obstruction, epistaxis,
recurrent crushing, secondary infections or “whistling”.
Vascular Complications
■ Arteries which may be injured include (anterior to posterior): anterior
ethmoidal, anterior cerebral, sphenopalatine, and internal carotid
arteries.
■ Patient presents with epistaxis in the postoperative period.
■ Imaging reveals extravasation of contrast/pseudoaneurysm.
■ CT angiography delineates the defect and injury. Digital subtraction
angiography (DSA) with embolization is the treatment of choice.
Table 9.6: Potential complications of endoscopic sinus surgery.
Skull base complications:
• CerebrospinaluidCSFleakage(rhinorrhea)orherniation(encephalocele)
• Infection
Intracranial injuries:
• Cerebral parenchymal injury
• Intracranial hemorrhage
• Infection
Ophthalmic injuries:
• Extraocular muscle injury
• Intraorbital hemorrhage
• Optic nerve injury
• Disruption of lacrimal drainage system
• Periorbital lipogranuloma
Sinonasal complications:
• Recurrent rhinosinusitis and polyposis
• Retained septations
• Neo-osteogenesis
• Adhesions
• Mucus recirculation phenomenon
• Mucocele
• Nasal septal perforation
• Empty nose syndrome
Miscellaneous:
• Gossypiboma
• Vascular injury (pseudoaneurysm)
131Chapter 9 Pre- and Post-Functional Endoscopic Sinus Surgery Imaging
A
C
B
D
E
Figs. 9.7A to F: Post-FESS complications. (A to C) Show nasal septal perforation (arrow) in
a patient who had undergone LT middle turbinectomy. There is recurrent mucosal thickening
in all the visualized sinuses; (D and E) Another patient who had undergone bilateral
middle turbinectomy and left uncinectomy showing recurrent mucoperiosteal thickening
with neo-osteogenesis (arrowhead). There was also extensive osteomyelitis of frontal and
maxillary bones with sequestrum formation (asterisks); and (F) Post RT maxillary antrostomy
patient with osteomyelitis of RT maxillary bone in a diabetic patient with sequestrum formation
(asterisk). There is bony remodeling of both maxillary sinuses.
F
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