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Endoscopic Surgery of the Paranasal Sinuses and Anterior Skull Base (ISBN 9783137494027) © 2008 Georg Thieme Verlag

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Endoscopic Surgery of the Paranasal Sinuses and Anterior Skull Base (ISBN 9783137494027) © 2008 Georg Thieme Verlag 46 2 Endoscopic Anatomy of the Nose and Paranasal Sinuses a Fig. 2.39 Medial wall of the antrum in an anatomical dissection (Prof. Dr. J. Lang, Würzburg, Germany). The prelacrimal recess (∗ ) protrudes in an anterosuperior direction, in front of the bulge of the nasolacrimal canal. It is difficult to assess by intranasal endoscopy. A paper millimeter scale lies in the maxillary ostium, and the internal maxillary artery is marked in red (→ ). b Fig. 2.40a The natural primary antral ostium is usually not round but is split up and very variable in shape (straight telescope with a view through a left-sided anterior antral window). b Coronal CT projection demonstrating the true structure of the so-called primary maxillary ostia: narrow channels (arrows), not windows. On both Frontal sinus sides are paradoxically curved middle turbinates with a right concha within frontal bone bullosa. Middle nasal concha Left orbit recess. From this point a flat groove can be followed as it Nasal runs upward and medially to form the boundary between septum the posterior wall and roof of the antral cavity. The junc- Nasal cavity tion between the roof and anterior wall is usually smooth. The surgeon learns to recognize the typical contours, usu- Birth Inferior ally bilaterally symmetric, in order to preserve the thin turbinate 1 year wall of the orbit during sharp dissection. The anterior 4 years wall of the antral cavity slopes outward, and tapers infe- riorly (Fig. 2. 42 c ). Fig. 2 .42a–d 7 years Palate 12 years Maxillary sinus The bony canal of the infraorbital nerve may form a Adult Molar tooth within maxilla sagittal bulge running anteriorly in the roof of the antral cavity, providing a valuable landmark (Fig. 2. 42 b ). It must Fig. 2.41 Increase of the extent of the frontal and maxillary cavities not be confused with mucosal bands that often run from with age. Preoperative knowledge of their individual size is particu- the medial to the lateral walls of the antral cavity under larly important for endoscopic sinus surgery during childhood. its roof (Fig. 2. 43). Fig. 2 .43 aus: Wigand, Endoscopic Surgery of the Paranasal Sinuses and Anterior Skull Base (ISBN 9783137494027) © 2008 Georg Thieme Verlag Kap_02.indd 46 25.03.2008 14:35:54 Nasal and Paranasal Dissection of Specimens 47 ab cd Fig. 2.42a Endoscopic view of the left posterior wall of the antral tion of the three different colored regions. View with a 70 ° telescope cavity through an inferior meatal antrostomy. The zygomatic recess introduced through a window in the inferior meatus. d Alveolar re- lies on the right side ( ∗ ) (70 ° telescope). b Left antral roof with prom- cess of a left antral cavity with the root of a molar tooth ( ∗ ). The pos- inent canal of the infraorbital nerve ( ∗ ). View with a 70 ° telescope terior wall of the antrum is marked in blue, the anterior wall in yel- through an inferior meatal antrostomy. c The left anterior antral wall low. View with a 70 ° telescope through an inferior meatal antros- shown in yellow, bordering onto the roof shown in pink, and the pos- tomy. terior wall in blue. The zygomatic recess lies at the point of intersec- Fig. 2.43 Mucosal fold ( ∗ ) in a left antral cavity. View with a 70 ° Fig. 2.44 Abnormal extension of the ethmoids into the maxillary telescope through an inferior meatal antrostomy. sinus with protruding giant cells (coronal CT). aus: Wigand, Endoscopic Surgery of the Paranasal Sinuses and Anterior Skull Base (ISBN 9783137494027) © 2008 Georg Thieme Verlag Buch 1.indb 47 20.03.20020.03.200880 08:57:558:57:55 50 2 Endoscopic Anatomy of the Nose and Paranasal Sinuses a b Fig. 2.49 a, b Intranasal middle meatal antrostomy. b The punch is pushed in a strictly horizontal direction with the jaws a First step: application of a pointed 45 ° upward-cutting ethmoid slightly open. A small window is created by closing the forceps forceps immediately above the center of the inferior turbinate. and removing fragments that are grasped. Fig. 2.50 The left lateral nasal wall of an anatomical dissection with a small middle meatal antrostomy ( ∗ ) at the typical site above the center of the inferior turbinate, immediately above its upper edge, Fig. 2.51 A small middle meatal antrostomy ( ∗ ) seen through a directly under the posterior end of the uncinate process. The win- straight telescope from in front. The middle turbinate has been dow may be considerably widened above, anteriorly, and posteriorly pushed slightly medially and upward. The uncinate process and the from this point. ethmoid bulla are visible. Fig. 2.52 A large middle meatal antrostomy as seen through a 70 ° telescope, and the posterior wall of the antrum beyond it. The over- hanging middle turbinate conceals the uncinate process and the bulla. aus: Wigand, Endoscopic Surgery of the Paranasal Sinuses and Anterior Skull Base (ISBN 9783137494027) © 2008 Georg Thieme Verlag Buch 1.indb 50 20.03.2008 08:58:10 Nasal and Paranasal Dissection of Specimens 51 a b Fig. 2.53 Topography of the supraturbinate part of the lateral nasal wall in the plane of a proper fenestration, in a frontal section of a dissected specimen. The antral opening of the maxillary ostium lies very close to the floor of the orbit above a fold. If the nasal wall is al- ways perforated in a strictly horizontal direction above the dorsum of the turbinate bone, the orbit is always out of reach of the instru- ment. c Fig. 2.54 a–c Transoral fenestration of the maxillary cavity. a The sublabial skin incision in the upper oral vestibule. b Exposure of the translucent bone in the canine fossa. c Limited bone resection with a chisel has preserved the anterior mucosa. A small bony frame protects the infraorbital nerve ( arrow). ab Fig. 2.55 a, b Transcanine endoscopy of the maxillary cavity. b Cranial view of the inferior orbital wall. a Direct inspection (0 ° telescope) of the posterior wall bending down from the floor of the orbit with the primary ostium on its Fig. 2.55 c–e ୴ left side. aus: Wigand, Endoscopic Surgery of the Paranasal Sinuses and Anterior Skull Base (ISBN 9783137494027) © 2008 Georg Thieme Verlag Kap_02.indd 51 25.03.2008 14:43:51 114 6 Standard Operations for Acute and Chronic Sinusitis Seiden and Stankiewicz 1998; Lowry and Brennon 2002). Every defect in the anterior bony wall, however, implies the danger of ingrowing subcutaneous soft tissues. The following approaches are available: • Endoscopic, limited opening of the frontal sinus from below (widening of the frontoethmoidal junction zone). • Limited intracavitary manipulations controlled by an- gled- or fiber-optics, laser surgery. • Combined external–endonasal approaches utilizing the endoscope as monitor of remote manipulations in minimal-access surgery for trauma and tumor growth. • A limited external frontal sinus procedure using the Fig. 6.42 Posteroanterior ethmoidectomy (schematic drawing). endoscope and plastic repair of the small defect in the The upward-biting punch follows the skull base safely with its blunt anterior wall of the frontal sinus, with preservation of head. the bony framework. If necessary, a mucocele is mar- supialized and tumors are reduced in size within the cavity before removal. Treatment of infl ammatory The second principle is complete opening of the cells complications by such conservative surgery is still de- to guarantee healing of the chronic polypoid mucosal in- veloping, and demands intensive postoperative care. flammation. Remaining cells are often the point of origin of persistent disease. These two aspects therefore led us to develop complete ethmoidectomy, in which an entirely Operative Technique visible ethmoid compartment is created with no remain- ing narrow areas and no remaining cells. The resulting Preliminary Observations wide upper nose was a new and surprising experience, which did not lead to drying of the regenerating mucosa The restricted access to the often extensive and recessed or to the development of ozena. frontal sinus limits transnasal frontal sinus surgery. Whereas the view into all recesses may be satisfactory for diagnostic purposes, many therapeutic manipulations are ill-advised because the necessary instruments cannot Operations on the Frontal Sinus be monitored endoscopically. However, much can be achieved, contrary to what Indications might be expected, including the generous transnasal fenestration of the floor of the frontal sinus, which suf- • Recurrent empyema of the frontal sinus fices for the treatment of most cases of sinusitis when • Chronic frontal sinusitis combined with circumscribed dissection of the frontal • Auxiliary drainage of osteitic complications infundibulum. Many other problems such as stenosis, • Auxiliary endonasal aproach together with external foreign bodies, and occasionally mucopyoceles can be operations for frontal trauma or foreign bodies tackled if this procedure is combined with a small trans- • Biopsy and removal of small tumors, and tumorlike le- frontal portal to allow the introduction of an endoscope sions or instruments. When choosing between a transfacial or intranasal procedure, the safety of the patient is more important than avoiding a facial scar. Principles Recent developments of combined instruments for fi - ber-optic monitoring and laser delivery have opened new The goal of the endoscopic operation from below is the options. restoration of ventilation and drainage. For this purpose, a recanalization of the frontal sinus infundibulum is often Exposure of the Frontal Infundibulum sufficient, and provides mucosal recovery also in remote recesses. Preservation of mucosa and thus of mucociliary The prerequisite for endoscopic exposure of the frontal transport are preconditions, especially in the frontoeth- sinus from the nose is removal of the anterior part of the moidal transition as a bottleneck. Limited pathological ethmoid area as far as the base of the skull.
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