Basic Surgery in Acute-Chronic Rhinosinusitis Prof. Dr. Murat Ünal Mersin University School of Medicine Dept. of ORL, Turkey

Basic Techniques for Sinus Surgery Endoskopic sinus surgery (ESS) is the most commonly performed procedure for inflammatory and infectious sinus disease. Baloon sinoplasty has been recently developed alternative technique to ESS. External operations may be useful especially in cases with complications.

Indications for ESS Chronic sinusitis refractory to medical treatment Recurrent sinusitis Nasal polyposis Antrochoanal polyps Mucocele Excision of selected tumors Orbital decompression Optic nerve decompression Dacryocystorhinostomy Choanal atresia repair Foreign body removal Epistaxis control

Keynotes for the patient selection to ESS -History; Allergic rhinitis -Physical examination; septal deviation, turbinate hypertrophy, nasal valve problems, adenoid hypertrophy -Computed tomography scans; ostiomeatal complex evaluation -Appropriate medical treatment has failed -Expectations of the patient and surgeon

Keynotes for the ESS-I The target of the ESS is to remove the pathology of the ostiomeatal complex region to maintain a normal ventilating and drainage sinuses.

Keynotes for the ESS-II OMC

Surgical Steps in ESS Decongestion of the nose with cotton pledgets Infiltration of middle turbinate and OMC region with 1% lidocaine with 1:100.000 adrenaline solution (dental needle 27 gauge) Middle turbinate is gently medialized with Freer elevator Uncinectomy with sickle knife, Blakesley forcep or Freer elevator

Surgical Steps in ESS-II During uncinectomy, orbital injury could be happen, orbital palpation can be helpful for the location of lamina papyracea Lower 1/3 part of the uncinate resection is important for the visualization of the maxillary sinus ostium Maxillary sinus ostium can be enlarged with Blakesley or true cut forceps (a curved suction tube could be helpful). If there is a acessory ostium, it should be combined with the natural ostium.

Surgical Steps in ESS-III Anterior Ethmoidectomy; The ethmoidal bulla should be identified and opened (infero-medial aspect). J-shaped curette or aspirator may be used. Other ethmoid cells first uncap then remove carefully. Using a curette allows for tactile sensation and determinationof the thickness of bone.

Surgical Steps in ESS-IV Anterior ethmoid cells should be cleared to the skull base. When approaching to the ethmoid roof, surgeon should evaluate the surgical position and CT scans. Posterior ethmoidectomy; Begins with perforating the basal lamella just junction of the vertical and horizontal segments of the middle turbinate.

Surgical Steps in ESS-V Skull base typically slopes inferiorly at an approximately 30 degree angle from anterior to posterior. Also if Onodi cell is present, it must be carefully identified from the sphenoid sinus.

Surgical Steps in ESS-VI Sphenoid sinus osteotomy; A rough guide is that the face of the sphenoid sinus is approximately 7 cm from the nasal entrance at a 30 degree angle. Identifying the superior turbinate aids its position. Superior turbinate inserts on the anterior face of the sphenoid sinus. Also the natural ostium could be found via choana.

Surgical Steps in ESS-VII Sphenoid sinus is entered just medial and inferior to its natural ostium with J curette or a suction tube. Once the sinus is entered safely, the ostium can be enlarged using a mushroom punch forceps. Care must be taken not to aggressively enter the sinus due to the risk of carotid artery and optic nerve injury.

Surgical Steps in ESS-VIII Frontal sinusotomy; Frontal sinus work may be reserved for the end of the surgical procedure because manipulation may lead bleeding (anterior ethmoidal artery) and obscure the further areas. 45 degree telescopes are very useful. Typically an agger nasi or frontal cell is the cause of the obstruction. A frontal sinus curette could be passed above the cell and then pulled anteriorly.

In the frontal recess area, extra care must be necessary due to anatomical proximity to the skull base.

A Brief Overview on ESS A good visualization begins with good hemostatic control and hypotensive anesthesia Two dimensional approach into a three dimensional region (First try on cadaver dissection) A comprehensive anatomical evaluation and always check the position of the endoscope Go thorough medially and inferiorly (to avoid any skull base injury) Middle turbinate should be preserved as possible. If it is necessary, superior portion must be protected. Non-diseased mucosa should be left for better healing process Aggressive postoperative dressing should be avoided.