Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_30_библиотеки_им_акад_М_И_Перельмана
.pdf
1 Endoscopic Anatomy andSurgery
https://t.me/medicina_free
17
Fig. 1.14 Diagnostic nasal endoscopy is showing right
polypoidal uncinate process with polyp in middle meatus
passed into the middle meatus, the adjacent lateral nasal wall. The structures studied are middle
turbinate, uncinate process, ethmoid bulla,
ground lamella, and any variations or pathological process [17]. Wigand approach (posterior to
anterior) is the diagnostic technique in revision
surgery. It starts from choana then the identication of sphenoid ostia and follows skull base in
retrograde fashion.
1.4.2 FESS Techniques andSteps
The classication of ESS based on the extent of
surgery (Japanese Rhinologic Society, 2013)
• Type I removal of the ostiomeatal complex;
• Type II single-sinus procedure
• Type III polysinus procedure
• Type IV pansinus procedure
• Type V the extended procedure beyond the
sinus wall
Uncinectomy is the rst step in FESS. The
technique of doing uncinectomy by various
methods depends on surgeons' training and personal preference [18].
is visible after removal of polyps (Courtesy—Dr. Hitesh
Verma, Associate Professor, AIIMS, New Delhi, India)
1. Traditional Method/Anterior to Posterior
It was rst described by Messerklinger. It
starts with identication of the anterior attachment of the uncinate. It is rst incised off the
lateral wall using sickle knife/freer’s elevator,
then incision is extended to release it from its
anterior attachment to the lacrimal bone
(Fig.1.15). It can be dangerous by injuring to
lamina papyracea resulting in prolapse of
orbital fat. To overcome complications of
orbital injury in lateralized/contracted UP in
traditional method and NLD injury in swing
door approach, two more approaches are
futher introduced.
(a) Uncinectomy Through the Anterior Nasal
Fontanelle
Anterior fontanelle is membranous structure located between the lower and middle concha. It separates the maxillary
sinus and the nasal cavity only by the
mucosa. This approach allows complication free maxillary sinus exposure in
selected cases.
(b) Uncinectomy Through Posterior Fontanelle
The posterior fontanelle is located between
the tails of the middle and inferior turbinate, behind the hiatus semilunaris, and
18
https://t.me/medicina_free
Fig. 1.15 Freer’s elevator is used for antero-posterior uncinectomy. Ethmoid infundibulum is opened and fungal muck
is visible through maxillary sinus ostia (Courtesy—Dr. Hitesh Verma, Associate Professor, AIIMS, New Delhi, India)
H. Verma et al.
under the ethmoid bulla. It is mainly composed of soft tissue as a part of the medial
wall of the maxillary sinus. It is identied,
as an iatrogenic opening. The wide antrostomy is performed by combining uncinectomy and removal of medilal wall of
maxillary sinus.
2. Swing Door Technique (retrograde
uncinectomy)
Retrograde uncinectomy is initiated by identifying the posterior edge of uncinate process
(Fig.1.16). The retrograde uncinate window is
made with small backbiting forceps. The uncinate process is removed inferiorly. The uncinate is swung forward using the ball probe and
then removed with blakesley forceps. The
advantage is less risk of injury to orbit but it
can damage nasolacrimal duct when it runs in
the free medial wall of the maxilla.
Middle meatal antrostomy is performed by the
identication of maxillary sinus ostium, at the
same level of inferior edge of the middle turbinate. The opening is widened posteriorly and
inferiorly by removing mucosa [19]. If accessory
ostia have previously been identied, surgical
window and accessory ostium should be interconnected to avoid a subsequent recirculation
phenomenon.
Maxillary sinusotomy is of four types
(Fig.1.17):
1. Infundibulotomy (uncinectomy): Removal of
the uncinate process, preserving the mucosa
of the natural maxillary ostium. The superior
attachment of the uncinate can be left intact.
2. Type I—Enlarging the natural maxillary
ostium posteriorly by less than 1cm.
3. Type II—Antrostomy is opened 2cm posteriorly and inferiorly.
4. Type III—Antrostomy is opened up to the
posterior wall of maxillary antrum. anteriorly
to the lacrimal sac, and inferiorly to the base
of the inferior turbinate.
The natural ostium of bulla ethmoidalis lies
postero-medial to the anterior face. It can be
located using ball probe or curette. Anterior ethmoidectomy is initiated at antero- inferior part
of bulla to avoid orbital and anterior ethmoid
artery injury [20]. Bullectomy can be done by
placing J curette in retrobullar recess followed
by anterior fracture of bulla (Fig.1.18). Anterior
ethmoid artery generally runs intracranially but
in 10% of cases, it can be found in suprabullar
recess so one has to be careful using microdebrider to avoid injury to artery (Fig.1.5). The
anterior ethmoid artery is 1–2mm posterior to
1 Endoscopic Anatomy andSurgery
https://t.me/medicina_free
19
a
MT
Uncinate
process
c
b
d
Uncinate
flap
Fig. 1.16 (a) and (b) is showing site of lower cut in pos-
terior to anterior technique. (c) is showing site of upper
cut which can be vary in the relationship of exposure
the superior limit of the anterior wall of the
bulla ethmoidalis. The distance between the
artery and the middle turbinate axilla is
17–20mm. Mini-ESS is performed by uncinectomy and opening of the bulla with preservation
of 3 or 4mm of the anterior and inferior edge of
the bulla. If a posterior ethmoidectomy is
required. Complete anterior ethmoidectomy
should be done.
For post ethmoidectomy, ground lamella is
perforated in infero-medial quadrant (Fig.1.19).
It minimizes the risk of injury to the skull base or
lamina papyracea.
needed. (d) is showing uncinate ap generated after both
cuts (Courtesy—Dr. Hitesh Verma, Associate Professor,
AIIMS, New Delhi, India)
The preservation of vertical sagittal and horizontal lateral attachment is required to maintain
the stability of middle turbinate. Few situations
where partial or total resection of the middle
turbinate is necessary are
• Concha Bullosa
• Polypoidal middle turbinate
• Lateralized Atrophic Middle Turbinate
• Lateral displacement of the middle turbinate
with narrowing of the frontal recess to create
the wide exposure in extended endoscopic
appraoches
20
ab
cd
https://t.me/medicina_free
Type 1
H. Verma et al.
Type 2
Fig. 1.17 (a) is representing view after complete unci-
nectomy. (b) is showing visibility of maxillary sinus after
type 1 enlargement. Figure (d) is showing inside view of
the maxillary sinus after type 3 enlargement (Courtesy—
Dr. Hitesh Verma, Associate Professor, AIIMS, New
Delhi, India)
The detail study of preopertive radiology
helps in mapping the anatomy of posterior ethmoid sinus, presence of Onodi cell, and course of
optic nerve.
Surgery of Frontal Sinus—Three distinct philosophies for surgical management of chronic
rhinosinusitis affecting the frontal sinus and frontal recess is proposed by P J Wormald [21].
refactory anterior ethmoid disease. Inferior
uncinectomy and anterior ethmoidectomy is
performed to clear the frontal recess.
Clearance of disease in the ostiomeatal complex allows resolution of disease in the frontal sinus and frontal recess.
2. Frontal sinusitis is formed due to frontal
recess involvement. Complete uncinectomy,
anterior ethmoidectomy with removal of agar
1. Minimal Invasive Sinus Technique (MIST)—
Frontal sinusitis is developed secondary to
nasi and frontoethmoid cells is performed to
clear the outow tract of frontal sinus.
Maxillary
sinus
ab
1 Endoscopic Anatomy andSurgery
https://t.me/medicina_free
Fig. 1.18 The instrument is indicating site of entry in bulla ethmoidalis. J curette is placed in retrobullar recess for
postero-anterior bullectomy (Courtesy—Dr. Hitesh Verma, Associate Professor, AIIMS, New Delhi, India)
1. HRCT (nose and paranasal sinuses)- 1 mm cuts
are prepared to assess the antero-posterior (AP)
diameter of frontal recess, type of frontoethmoidal cells, degree of pneumatization frontal
sinus. Bony remodeling and scarring of frontal
outow tract in revision surgery needs mapping
Ground
lamella
Lamina
papyrecea
and scarring created by previous surgery in
Middle
turbinate
frontal recess. Two-dimensional CT Scans in
coronal, parasagittal, and axial planes are used
to create a three-dimensional picture of the
anatomy of the frontal recess.
2. Angled endoscopes are required to see the
frontal sinus.
3. Axillary ap technique—It starts by removal
of the anterior wall of the agger nasi cell. The
ap is created by making incision 8mm above
the axilla of middle turbinate and brings 8mm
Fig. 1.19 The suction tip is indicating site of entry in
posterior ethmoid after anterior ethmoidectomy in the left
nasal cavity (Courtesy—Dr. Hitesh Verma, Associate
Professor, AIIMS, New Delhi, India)
forward, turned down vertically 1–1.5cm, and
turned back under the axilla on to the roof of
the middle turbinate. The mucosal ap is
based medially on middle turbinate and is
replaced at the end of the procedure to cover
3. Complete exteriorization of cells of osteomeatal complex with wide frontal sinusotomy is
indicated in refractory frontal sinusitis.
the raw exposed bone to prevent granulation
and brosis formation. Direct examination of
frontal sinus is possible after the removal of
frontal beak.
Instruments and techniques require viewing of
frontal Sinus are listed here.
4. Frontal sinus mini-trephination (mentioned in
the chapter on frontal sinus).
21
22
https://t.me/medicina_free
5. Computer-aided surgery (CAS, or image
guidance surgery), radiological probing (C
arm) are helpful inlocalizing frontal sinus in
difcult cases.
1. Extensive nasal polyposis
2. Revision surgery
3. Distorted endoscopic anatomy
4. Extended endoscopic or open procedures
Endoscopic management of frontal sinus dis-
eases is classied by Draf into three types [22].
• Type-1 is Simple Drainage (DRAF1)—It is
characterized by complete removal of the
anterior ethmoid cells and uncinate process
and obstructive frontal cells inferior to frontal
ostium. The indication is limited frontal sinusitis with intractable ethmoid sinusitis.
• Type-2 Extended Drainage (DRAF 2)—It is
subdivided into type IIa and IIb approaches. In
type 2a, complete removal of the oor of frontal sinus from lamina papyracea to middle turbinate is performed. In type 2b, frontal sinus
oor is removed from the lamina papyracea till
the nasal septum. The indications are complicated frontal sinusitis, muco or pyocele, and
benign tumour extending into the frontal sinus.
• Type-3 Endonasal median Drainage (DRAF
3)—Entire oor of both side of frontal sinus is
removed. The limit is from one side lamina
papyracea to the other side (Fig. 1.20). The
indications are revision surgery, intractable
frontal sinusitis and polyposis in ciliary dysfunction syndromes (Kartagener’s syndrome,
mucoviscidosis, etc.) and benign and malignant tumour.
H. Verma et al.
Frontal sinus
Lamina
payrecea
Lamina
papyrecea
Fig. 1.20 The postoperative cavity after DRAF 3 procedure (Courtesy—Dr. Hitesh Verma, Associate Professor,
AIIMS, New Delhi, India)
Sphenoid ostia
Septum
Retracted
middle and
superior
turbinate
Sphenoid sinus is the posterior-most sinus and
the landmarks for sphenoid sinus ostium and
sphenoid sinus are (Fig.1.21):
1. Ten–fteen millimetre above the upper end of
bony posterior choanae.
2. Maxillary ridge is an imaginary line between
the medial and inferior wall of the orbit and it
extends backwards from the upper border of
the maxillary ostium. Sphenoid sinus is lying
below it and ethmoid cell above it.
Fig. 1.21 The gure is depicting sphenoid ostia in the
left nasal cavity after lateralization of middle and superior
turbinate (Courtesy—Dr. Hitesh Verma, Associate
Professor, AIIMS, New Delhi, India)
3. Seven centimeter from anterior nasal spine at
30° angle superiorly.
4. Four–ve millimetre lateral to septum.
5. Sphenoid sinus oor is not visible whereas
posterior ethmoid sinus oor is always in
view.
1 Endoscopic Anatomy andSurgery
https://t.me/medicina_free
23
The sphenoid sinus can be accessed by
medial route (medila to middle turbinate) and
lateral route (lateral to middle turbinate) after
ethmoidectomy transethmoid approach. In
intermediate approach, the lower half of superior turbinate is removed to get access in the
sinus. The sinus ostium is lies half the distance
between the superior and inferior border on the
anterior wall of the sphenoid. Sinus ostium is
gently widened in infero-medial direction in
the intial step of widening to examine the
spehnoid sinus lateral wall structures and to
prevent inadvertent injury to perisinus structures. Posterior nasal branch of sphenopalatine
artery may injure during inferior widening
which can be prevented by pushing mucosa
inferiorly before removing the bony wall.
Caution to be taken for the posterior attachment
of intersphenoid septa and accessory septa.
Natural dehiscence of the optic nerve and internal carotid artery is always keep in mind while
removing disease and violating septas. Onodi
cell is the posterior extension of posterior ethmoid cells over the sphenoid sinus and the optic
nerve may be seen in its lateral wall [23]. Onodi
cell is present above the imaginory line passes
from the roof of maxillary sinus.
landmarks. The location of these instruments is
tracked by the machine with tted navigation
probe. The machine displayed images in all
planes corresponding to the pateints anatomy
prepared from prefeeded radiology (CT and/or
MRI) in the system. The Indications are
1. Revision sinus surgery
2. Distorted surgical anatomy
3. Extensive nasal polyposis
4. Pathology involving the skull base
1.4.3 NASAL POLYP andFESS
• Functional endoscopic sinus suergery (FESS)
is indicated for complicated sinusitis and
chronic sinusitis with or without nasal polyposis, failed maximum medical management.
FESS aims to improve sinus ventilation and
drainage as well as removing polyps. The
extent of surgery varies with the extent of disease, the surgeon’s individual practice, and
available technology.
1.4.4 AFRS andFESS
Robot-Assisted Surgery (RAS)
The robotic guidance system facilitates manipulation in the surgical eld and full visualization
of the face of the anterior skull base. It is handsfree semi-automated endoscope guidance for
advanced applications in surgery of the paranasal
sinuses and the anterior skull base [24]. The literature is emerging on it.
Simulation/Three-Dimensional Tracking
It has been used for surgical training but the lack
of practicality and haptic feedback limits widespread use. Three-dimensional printing has revolutionized simulation, providing high-resolution
models for patient-specic anatomy [25].
Navigation and Image-Guided Surgery
The system uses computerized tracking devices
to monitor the position of endoscopic instruments in conjuction to the patient’s anatomical
• Surgery is usually the rst-line treatment for
the management of AFRS.The goal of surgery
is wide opened sinus ostium with complete
removal of fungal muck and allergic mucin.
1.4.5 ESS inPediatric Age Group
The Role of ESS is limited in pediatric chronic
rhinosinusitis. It should be considered after a
period of medical management (and/or adenoidectomy) and after exclusion of underlying pathologies. If required, ESS should be limited to up to
disease extent.
Absolute indications for ESS in children
• Complicated sinusitis
• Nasal polyposis
• Mucocoeles or mucopyocoeles
• Fungal rhinosinusitis
24
https://t.me/medicina_free
H. Verma et al.
1.4.6 Balloon Sinuplasty
Balloon Sinuplasty technology uses a exible,
balloon catheter to open up the blocked sinus
ostium, by ination with a calibrated pressure
gauge. When the sinus balloon is inated optimally, it gently restructures the sinus ostium by
inducing micro-fractures and bony displacement
around the occluded ostium, thus circumferentially widening the walls of the ostium, while
maintaining the integrity of the sinus mucosal
lining around the ostium. The indication is
chronic sinusitis limited mostly to ostial obstruction of the frontal, maxillary, and sphenoidal
sinuses, with near-normal middle meatal integrity [26]. The advantages are
1. Preservation of the normal anatomy of the
vital ostiomeatal complex, while precisely
focusing on the occluded sinus ostium and the
diseased sinus cavity beyond it.
2. Reduction in the invasiveness of the intervention, hospital stay, recovery time, postoperative debridement, postoperative medications,
and ofce follow-up visits.
1.4.7 Conclusion
• Endoscopic sinus surgery is a remarkably safe
and effective procedure. The knowledge of
three-dimensional anatomies of sinuses, anatomical landmarks, and its variations is essential for the successful outcome.
minimize complications and in patient admission.
Nasal bleeds can be either anterior or posterior.
Mostly anterior bleeds can be managed with cauterization of the bleeding point after identication
using either a headlight or an endoscope.
Cauterization can be done either using silver
nitrate (chemical cautery) or bipolar diathermy
(electrical cautery). Traditionally nasal packing
has been used in the emergency setting for control
of bleeding, though with the availability of endoscopes which allows better visualization of bleeding point, it is less preferred. Hemostatic nasal
packing is rarely required for anterior bleeds
unless the bleeding and coagulation prole of the
patient is deranged [
posterior nasal bleeds is not easily identiable in
an emergency setting and may require nasal packing for emergent control of bleeding. Packing of
the nose and para nasal sinuses may also be
required in postoperative setting. Availability of
various packing materials has made nasal packing
less traumatic and unpleasant. Also use of some
newer materials prevents nasal synechiae, hence
preferred in the postoperative setting [28]. Other
conditions requiring nasal packing include endoscopic sinus surgery, septal surgery, turbinate
reduction, and reduction of nasal fractures. Though
signicant hemorrhage post-surgery is rare, small
quantity of blood oozing out from the surgical site
can cause signicant anxiety to the patient.
The aim of this chapter is to introduce the
reader to various such materials available and
guide them about their utility and usage.
27]. Whereas the source of
1.5 Part E: Packing Materials
forNose andParanasal
Sinuses
Nasal mucosa has a rich vascular supply deriving
branches both from the internal and external
carotid artery system. Epistaxis is one of the commonest presentations in the accident and emergency room. It is seen in all age groups including
the elderly patients who often have other co-morbid conditions. A non-specialist may be required
to do the initial management, therefore a stepwise
algorithm should be available in emergency to
1.5.1 Uses ofNasal Packing
• Provision of hemostasis in cases of nasal surgery or epistaxis
• Intranasal support to bony or cartilaginous
dorsum, nasal septum, middle turbinate, or
mucosal surfaces
• Prevention of mucosal adhesions
• Induces hemostasis
• Tamponade effect
• Provision of moist environment for mucosal
healing
• Steroid or antibiotic impregnation may
achieve better surgical outcomes
1 Endoscopic Anatomy andSurgery
https://t.me/medicina_free
Fig. 1.22 Anterior and
posterior nasal pack
preparation
Fig. 1.23 Posterior nasal pack
1.5.2 Types ofNasal Packing
Material
Traditional nasal packing is prepared from ribbon
gauge. The anterior and posterior nasal packs are
prepared differently for control of bleeding.
Anterior packing consists of ribbon gauze of
around a meter length soaked in antibiotic ointment or bismuth iodine parafn paste (BIPP) and
placed in the nasal cavity in layers.
25
Figure
1.22 shows the preparation required for
placing ribbon gauze in the anterior nasal cavity.
Posterior nasal packs are prepared using roller
gauze to which tapes (or threads) are attached.
Two rubber catheters are inserted through the
right and left nasal cavities. The tapes on the posterior nasal pack are tied to the loose end of the
rubber catheter. The pack is then pulled through
the oropharynx in the posterior nasal cavity by
withdrawing the rubber catheters through the
nasal cavities. The tapes are then tied to each
other over the columella over a small strip of
gauze piece placed in between to prevent pressure necrosis. Though uncomfortable and
requires experience for placement, it achieves
good control of posterior epistaxis (Fig.
1.23).
In unexperienced hands, it can cause more
traumas to the delicate nasal mucosa and aggravate bleeding especially in patients with coagulopathy. Choice of packing material used depends
upon the inherent practice of the surgeon, cost,
and availability. Both absorbable and nonabsorbable materials are available.
1.5.3 Non-Absorbable Nasal Packs
Hydroxylated Polyvinyl Acetate Packs
(PVA) Commonly used is Merocel which is
26
https://t.me/medicina_free
Fig. 1.24 Polyvinyl
acetate nasal pack
(Merocel)
available both with and without an external
polyethylene coating (Fig. 1.24). Other PVA
packs are Netcell packs. These compressed,
dehydrated sponges are undergo expansion due
to in situ rehydration with blood and nasal uids and achieve hemostasis through tamponade. Increased localization of clotting factors
is achieved which facilitates coagulation.
Merocel packs laminated with polyethylene
lm are less adhesive to the surrounding nasal
mucosa and thus less traumatic and painful
during removal [29].
H. Verma et al.
Rapid Rhino Device
Nasal device consisting of
inatable polyvinylchloride nasal balloon with a
carboxymethyl cellulose (CMC) infused hemostatic exterior to which an inatable pilot cuff is
attached (Fig.1.25). Moist CMC forms a hydrocolloid gel and upon ination with air conforms
itself to the nasal cavity. It facilitates coagulation
and provides a moist environment for the healing
of traumatized nasal tissues. The pilot cuff is
used to maintain a steady intranasal pressure to
achieve compression for hemostasis and intranasal separation of tissues. It provides high volume
and low-pressure tamponade on the nasal mucosa.
Device models both with and without airway are
available for control of unilateral and bilateral
epistaxis and vary from 4.5cm to 9cm in length.
Fig. 1.25 Rapid Rhino device for bilateral nasal packing
Pain and bleeding during removal are minimized
as hydrocolloid gel formed on the exterior makes
only gentle contact with the nasal tissues without
any adherence.
Соседние файлы в папке Библиотека им академика М.И. Перельмана