Учебники / Computer-Aided Otorhinolaryngology-Head and Neck Surgery Citardi 2002
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FIGURE 13.13 This intraoperative CAS screen capture was obtained during computeraided FESS in a patient who had previously undergone orbital decompression. In the endoscopic image, anterior ethmoid sinus polyps are seen adjacent to orbital fat. The relative position of the instrument tip is shown by the crosshairs on the CT images.
FIGURE 13.14 This coronal CT image depicts the absence of surgical landmarks as well as a large nasal septal perforation in patient who had previously undergone a Cald- well-Luc procedure as well as extensive transnasal endoscopic surgery. The left posterior ethmoid sinus is aerated and provides a reliable landmark early in the revision surgery.
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likely to be physiologically significant, it may obscure visualization, making the surgical procedure more difficult. It is important to remember that if visualization is poor and reasonable hemostasis cannot be achieved, the procedure should be terminated. FESS is largely performed on an elective basis for benign inflammatory disease, and major complications are difficult to justify.
In patients with allergic fungal sinusitis with diffuse polyposis, landmarks are difficult to identify because of the fungal debris, allergic mucin, and polypoid mucosa (Figure 13.15). With CAS, the surgeon can more readily localize the lamina papyracea and the skull base.
In some cases, revision ethmoid surgery is performed in the presence of new bone formation. Typically osteoneogenesis occurs adjacent to areas of inflammation. New bone may form to the extent of causing obstruction of outflow from the paranasal sinuses. Figure 13.16 shows new bone formation along the ethmoid roof bilaterally. Previously, the patient had undergone drainage of a right frontal sinus mucocele with an acute orbital abscess. After resolution of the acute inflammatory process, follow-up CT scanning showed bilateral frontal sinus opacification with anterior ethmoid sinus opacification. Using CAS, the new bone formation in the anterior ethmoid sinus and frontal recess was reduced
FIGURE 13.15 This coronal CT image shows many of the common features seen in allergic fungal sinusitis. Differing densities are notable in the right maxillary sinus. The ethmoid sinus is filled with soft tissue density, but no bony remnants are visible.
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FIGURE 13.16 This coronal CT image demonstrates osteoneogenesis (new bone formation) along the ethmoid roof bilaterally.
FIGURE 13.17 In this case, new bone formation has obstructed the left frontal sinus, causing a mucopyocele. The microdebrider was used to reduce new bone formation along the anterior ethmoid sinus roof as a means of decompressing the mucopyocele. The microdebrider tip’s position is indicated by the crosshairs on the CT images.
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and a large frontal sinus mucopyocele was decompressed on each side (Figure 13.17).
13.6CAS PITFALLS
Current CAS workstations do not provide real-time data that reflect changes that take place during the surgical procedure. This may not be problematic in a fixed, bony environment, such as the paranasal sinuses. However, as CAS indications broaden, significant limitations would exist when current technology is adapted for the resection of soft tissue tumors of the cranial base. In these procedures, simply exposing the posterior or lateral skull base and achieving initial vascular control would significantly alter the size and position of the tumor, making CAS navigation inaccurate. Fried et al. [29] published preliminary reports of performing cadaveric sinus surgery in an open MRI unit. The highly sophisticated operating suite and specialized surgical instrumentation required are currently cost-prohibitive, but it is conceivable that modifications will be made to enable real-time surgery using both CT and MRI.
Perhaps the most significant concern with CAS is that the technology tends to decrease the tendency for the surgeon to be a good anatomist. It is easy to have the expectation that the technology alone will prevent complications. Of course, such an attitude is false, since CAS is simply a guide. While this technology may enhance operator confidence, it is still incumbent upon the physician to become an expert surgical anatomist through multiple cadaver dissection and experience [20,22,23,27,30,31].
The use of CAS has been associated with an increase in operative time as reported by Metson et al. [27]. This increase in operative time was most notable during the surgeon’s early use of this new technology (15–30 min) and was found to improve with experience (5–15 min). Most new technologies are associated with a ‘‘learning curve’’ during which period an increase in surgery length is anticipated. However, as the surgeon and operating room personnel become more familiar with the new technology, the increase in operative time should decrease. Further, with improved anatomical localization and surgical precision available with CAS, an eventual overall decrease in surgery length may be achieved.
13.7CONCLUSION
Computer-aided revision functional endoscopic sinus surgery can be performed safely and effectively. Since CAS provides confirmatory localization of potentially obscured surgical landmarks, areas of recurrent or residual disease may be appropriately treated. At the same time, CAS assists in the identification of the
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ethmoid roof and lamina papyracea. In this way, CAS may reduce surgical morbidity and improve the surgical outcomes of revision FESS.
REFERENCES
1.JM King, DD Caldarelli, JB Pigato. A review of revision functional endoscopic sinus surgery. Laryngoscope 104:404–408, 1994.
2.DH Rice. Endoscopic sinus surgery: results at 2-year follow-up. Otolaryngol Head Neck Surg 101:476–479, 1989.
3.HL Levine. Functional endoscopic sinus surgery: evaluation, surgery, and followup of 250 patients. Laryngoscope 100:79–84, 1990.
4.M May, SJ Mester. Endoscopic Endonasal Sinus Surgery: Factors contributing to Failure. Presented at the First International Symposium on Contemporary Sinus Surgery, Pittsburgh, November 4–6, 1990.
5.BL Matthews, LE Smith, R Jones, et al. Endoscopic sinus surgery: outcome in 155 cases. Otolaryngol Head Neck Surg 104:244–246, 1991.
6.DW Kennedy. Prognostic factors, outcomes and staging in ethmoid sinus surgery. Laryngoscope 102 (suppl57):1–18, 1992.
7.JP Corey, RM Bumsted. Revision endoscopic ethmoidectomy for chronic rhinosinusitis. Otolaryngol Clin North Am 22:801–808, 1989.
8.GP Katsantonis, WH Friedman, MC Sivore. The role of computed tomography in revision sinus surgery. Laryngoscope 100:811–816, 1990.
9.WH Friedman, GP Katsantonis, BN Rosenblum, et al. Sphenoethmoidectomy: the case for ethmoid marsupialization. Laryngoscope 96:473–479,
10.VL Schramm, MZ Effron. Nasal polyps in children. Laryngoscope 90:1488–1495, 1980.
11.LF Smith, PC Brindley. Indications, evaluation, complications, and results of functional endoscopic sinus surgery in 200 patients. Otolaryngol Head Neck Surg 108(6): 688–696, 1993.
12.JA Stankiewicz . Complications of endoscopic intranasal ethmoidectomy. Laryngoscope 97:1270–1273, 1987.
13.JA Stankiewicz. Complications in endoscopic intranasal ethmoidectomy: an update. Laryngoscope 99:686–690, 1989.
14.M May , HL Levine , SJ Mester , B Schaitkin. Complications of Endoscopic sinus surgery: analysis of 2108 patients—incidence and prevention. Laryngoscope 104: 1080–1083, 1994.
15.AJ Maniglia. Fatal and other major complications of endoscopic sinus surgery. Laryngoscope 101:349–354, 1991.
16.SD Schaefer, S Manning, LG Close. Endoscopic paranasal sinus surgery: indications and considerations. Laryngoscope 99:1–5, 1989.
17.H Stammberger. Endoscopic endonasal surgery: concepts in treatment of recurring rhinosinusitis. Part I Anatomic and pathophysiologic considerations. Otolaryngol Head Neck Surg 94:143–146, 1986.
18.H Stammberger. Endoscopic endonasal surgery: concepts in treatment of recurring
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rhinosinusitis. Part II Surgical technique. Otolaryngol Head Neck Surg 94:147–156, 1986.
19.RH Lazar, RT Younis, TE Long, et al. Revision functional endonasal sinus surgery. Ear Nose Throat J 71:131–133, 1992.
20.AM Neumann Jr., K Pasquale-Niebles, T Bhuta , MJ Sillers. Image-guided transnasal endoscopic surgery of the paranasal sinuses and anterior skull base. Am J Rhinol 13(6):449–454, 1999.
21.DW Kennedy, SJ Zinreich, H Shaalan, et al. Endoscopic middle meatal antrostomy: theory, technique, and patency. Laryngoscope 97(43):1–9, 1987.
22.JB Anon, SP Lipman, D Oppenheim, RA Halt. Computer-assisted endoscopic sinus surgery. Laryngoscope 104:901–905, 1994.
23.J Claes, E Koekelkoren, L van den Hauwe, PH Van de Heyning. Computer assisted E. N. T. surgery, a preliminary report. Acta Oto-Rhino-Laryngol Belg 53:117–123, 1999.
24.MP Freid, J Kleefield, R Taylor. Drug/Device capsules. Otolaryngol Head Neck Surg 119(5):526–532, 1998.
25.R Mosges, L Klimek. Computer-assisted surgery of the paranasal sinuses. J Otolaryngol 22(2):69–71, 1993.
26.M Caversaccio, R Ba¨chler, K L La¨drach, G Schroth, L-P Nolte, R Ha¨usler. Frameless computer-aided surgery system for revision endoscopic sinus surgery. Otolaryngol Head Neck Surg 122(6):808–813, 2000.
27.RB Metson, MJ Cosenza, MJ Cunningham, GW Randolph. Physician experience with an optical image guidance system for sinus surgery. Laryngoscope 110:972– 976, 2000.
28.WJ Mann, G Kahaly, W Lieb, RG Amedee. Orbital decompression for endocrine ophthalmopathy: the endonasal approach. Am J Rhinol 8(3): 123–127, 1994.
29.MP Fried, L Hsu, GP Topulos, FA Jolesz. Image-guided surgery in a new magnetic resonance suite: preclinical considerations. Laryngoscope 106:411–417, 1996.
30.MP Fried, J Kleefield, H Gopal, E Reardon, BT Ho, FA Kuhn. Image-guided endoscopic surgery: results of accuracy and performance in a multicenter clinical study using an electromagnetic tracking system. Laryngoscope 107:594–601, 1997.
31.M Roth, D Lanza, et al. Advantages and disadvantages of three-dimensional computer tomography intraoperative localization for functional endoscopic sinus surgery. Laryngoscope 105:1279–1286, 1995.
14
Computer-Aided Frontal Sinus
Surgery
Frederick A. Kuhn, M.D., F.A.C.S.
Georgia Nasal & Sinus Institute, Savannah, Georgia
James N. Palmer, M.D.
University of Pennsylvania Health System, Philadelphia,
Pennsylvania
14.1INTRODUCTION
Chronic frontal sinusitis resistant to medical management has long posed a difficult problem for the otolaryngologist. Multiple surgical approaches for chronic frontal sinusitis have been advocated over the past century, suggesting that no single procedure yielded good reproducible results from patient to patient and from surgeon to surgeon. What has been needed is an organized, integrated approach to frontal sinus surgery (as outlined in this chapter).
Intranasal procedures were first proposed in the 1890s, and by 1917 multiple articles discussing the use of intranasal frontal sinusotomy in chronic disease had been published [1–3]. However, these procedures fell from favor and were replaced by a group of external procedures. We suspect that a high failure rate or complication rate associated with intranasal procedures caused them to disappear from the scene. Interestingly, the original articles, as well as the later works of Van Alyea and Mosher, pointed out the importance of the frontal recess in frontal sinus disease [4–7]. This concept of frontal recess disease as the cause of frontal sinusitis was apparently lost with the advent of external procedures and frontal sinus obliteration. Today, however, meticulous attention to endo-
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scopic frontal recess dissection and removal of frontal recess disease in endoscopic sinus surgery has become the hallmark of successful frontal sinus treatment (8).
Endoscopic sinus surgery has been a major advance in the surgical treatment of sinusitis and has brought with it a widespread increase in the understanding of nasal and sinus anatomy. However, even with our improved visualization and increased anatomical knowledge, we commonly have difficulty determining where we are in the sinuses. Stereotactic computer-assisted surgical navigation, or image-guided surgery, is another major advance that has greatly enhanced the ease and completeness of sinus surgery, particularly the endoscopic approach to frontal sinus and frontal recess surgery. Computer-aided surgery (CAS) allows the surgeon to understand the complex frontal recess anatomy and to treat more advanced frontal sinus disease, such as osteoma, mucocele, polyps, and tumor. Because of noticeable improvements in safety and completeness of the procedure, endoscopic frontal recess dissection combined with CAS is the procedure of choice for treatment of chronic frontal sinus disease.
In the first part of this chapter, we will cover frontal sinus mucociliary clearance, frontal recess anatomy, and several anatomical variants, which must be understood in order to perform frontal recess dissection successfully. The use of CAS clarifies these anatomical structures and improves frontal recess dissection. The second portion of the chapter will highlight the utility of CAS in more advanced endoscopic procedures, including treatment of lateral frontal sinus lesions, osteomas of the frontal sinus, mucoceles and even an osteoplastic frontal sinus obliteration. Taken as a group, the procedures outlined comprise an integrated approach to the frontal sinus that CAS can enhance. It is important to emphasize that these procedures (Table 14.1) are used with the least invasive first; progression to the more invasive techniques occurs in a graduated stepwise approach only as the patient’s disease dictates. Due to the added dimension of CAS, the least invasive procedures are often successfully applied in more advanced cases; in this way, CAS reduces the patients’ exposure to more invasive surgery and lessens the risks of complications associated with these more aggressive procedures.
TABLE 14.1 The Integrated Approach for Frontal Sinus Surgery
1.Endoscopic frontal sinusotomy
2.Above and below approach (endoscopic & trephine)
3.Frontal sinus rescue (FSR)
4.Modified endoscopic Lothrop (Draf drill out)
5.Above and below approach (endoscopic and osteoplastic)
6.Frontal sinus obliteration
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14.2FRONTAL SINUS PHYSIOLOGY AND ANATOMY
14.2.1 Frontal Sinus Mucociliary Clearance
Mucus transport in the frontal sinus is governed by its mucosal ciliary beat patterns. This pattern is up the interfrontal sinus septum, then laterally across the frontal sinus roof, and finally medially along the frontal sinus floor (orbital roof ) to the ostium. Approximately, 40–60% of the mucus recirculates up the interfrontal sinus septum and around the sinus again, while the other 60–40% is swept out the ostium and down the medial orbital wall. The recirculating mucus loop may actually extend down into the frontal recess, where it could possibly pick up bacteria or fungus, transporting them into the frontal sinus. The frontal recess cilia play a very active role in frontal sinus health; therefore, this mucosa and its attendant cilia must be carefully preserved. Since Moriyama et al. [9] demonstrated that cilia do not regenerate if mucosa is stripped from bone, it is obvious that drilling or leaving exposed bone in the frontal recess is counterphysiologic.
14.2.2 Frontal Recess Dissection
The express goal of endoscopic frontal recess dissection is to open the drainage pathway from the frontal sinus into the middle meatus by removing all air cells and attendant bony lamella from the boundaries of the frontal recess. The frontal recess boundaries are (1) posterior—skull base; (2) anterior—anterior wall of the agger nasi cell or the middle meatus; (3) lateral—lamina papyracea/superior medial orbital wall; and (4) medial—vertical attachment of middle turbinate to skull base. The frontal recess is a potential space frequently filled by air cells, known as frontal recess cells. Removal of these cells in frontal recess dissection will clear the frontal recess, ‘‘removing the cork from the bottle,’’ and thereby open the frontal sinus drainage pathway. The various frontal recess cells will be described and techniques will be suggested for their removal using image guidance.
Figure 14.1 is an endoscopic picture of a patient’s left frontal recess following endoscopic surgery, which resulted in frontal ostium stenosis. This photograph, combined with Figure 14.2, demonstrates the utility of CAS in endoscopic frontal recess dissection. The three depressions, from medial to lateral, are (1) a blind depression, (2) the stenosed frontal ostium, and (3) a supraorbital ethmoid cell. Using CAS and frontal recess dissection techniques, the frontal sinus was identified and opened, the mucocele drained from the frontal sinus, and the recurrent frontal sinus disease resolved. It should be mentioned that meticulous postoperative care is also required to achieve long-term successful results.
Knowledge of the individual patient’s frontal sinus drainage pathway is best determined preoperatively using the CAS computer to review the images sequentially. Once the drainage pathway is established and understood, resection of cell
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FIGURE 14.1 This endoscopic view of the left frontal recess shows with interfrontal sinus septal cell (1), supraorbital ethmoid cell (2), medial orbital wall (3), and scarred over frontal sinus ostium (4). No obvious frontal sinus drainage pathway is apparent.
FIGURE 14.2 This intraoperative CAS screen capture (InstaTrak, Visualization Technology, Lawrence, MA) shows that the left frontal sinus and supraorbital ethmoid cells have been opened into the left frontal recess. The localizing pointer is on the medial orbital wall in the supraorbital ethmoid cell. The preoperative view is shown in Figure 14.1.