1. Endoscopic Sinus Surgery
Section 6 (قسمت ششم فایل)
Bakhshaee M, MD
Rhinologist, Assistant Prof. MUMS

2. Frontosphenoethmoidectomy

3. Frontosphenoethmoidectomy
This includes an anterior ethmoidectomy, posterior ethmoidectomy, sphenoid sinusotomy along with opening the frontal recess

4. This is mainly reserved for those with persistent symptoms after anterior ethmoid surgery.
In patients with severe recurrent polyposis, the best way to provide the patient with a longer symptom- free interval is to open up all the cells including the frontal recess

5. Sphenoid Sinusotomy (I, II, III)
Sphenoid sinusotomy I: Identifying the sphenoid ostium without further instrumentation.
Sphenoid sinusotomy II: Opening the sphenoid inferiorly to half its height and upward to the skull base.
Sphenoid sinusotomy III: The sphenoid sinusotomy is extended to the floor of the sinus and laterally to the vital structures

6. Isolated sphenoid sinus disease, e.g., Aspergillosis
Indications
Isolated sphenoid sinus disease, e.g.,
Aspergillosis
Purulent bacterial infection
Inverted papilloma
Mucocele
Biopsy of skull base lesions

7. Surgical Technique
The sphenoid ostium can be found at the level of the superior turbinate. It is often necessary to lateralize the middle and superior turbinate in order to visualize it

8. If visibility is poor because of polyps or bleeding, the sphenoid sinus can safely be approached by staying close to the septum in the midline and palpating with the straight sucker up the posterior wall of the sphenoid
At 1−1.5 cm above the posterior choana, the bone of the anterior wall of the sphenoid sinus is thin and it can be punctured by applying moderate pressure with a straight sucker

9. It is advisable not to open the sphenoid ostium downward to a level lower than half the total height of the sinus, as a branch of the sphenopalatine artery runs along its anterior wall and if cut this can bleed briskly.
Occasionally, the intersinus septum of the sphenoid is so oblique that one side can be very small.

10. Comment on the Management of the Middle and Superior Turbinates

11. By preserving “all” the mucosa in the olfactory area on the septum and the turbinates, as well as opening the olfactory cleft.
It is difficult to resist the temptation to remove or debulk polyps medial to the middle turbinate, but it is best to preserve this mucosa.
A course of preoperative steroids will help reduce the size of the polyps.
Only remove polyps that come from the posterior ethmoid cells under the superior turbinate and not polyps that are based on the septum or the middle turbinate.

12. If there is a concha bullosa, the lateral half of the turbinate can be resected.
This can be done by incising the anterior surface with a sickle knife and then removing the lateral portion by cutting it free with microscissors or with straight through-cutting forceps

13. The Endoscopic Tour

14. Step 1
involves advancing the endoscope along the inferior meatus

15. Step 2
involves coming forward a little and angling the endoscope upward to see the sphenoethmoid recess area

16. Step 3
is accomplished by gently rolling the endoscope under the middle turbinate to see whether mucopus is tracking under the ethmoid bulla from the maxillary sinus

17. Anatomical Variations

18. Agger Nasi Air Cells

19. Concha Bullosa

20. Paradoxical Middle Turbinate

21. Bifid Middle Turbinate

22. Polypoidal Anterior End of the Middle Turbinate

23. Paradoxical Uncinate Process

24. Pneumatized Uncinate Process

25. Accessory Ostium of the Maxillary Sinus

26. An Atlas of Specific Conditions

27. Allergy
Hypertrophied inferior turbinate
Edematous middle turbinate

28. Infection
Bacterial rhinosinusitis
Aspergillosis

29. Inflammatory Diseases
Pyogenic granuloma

30. Wegener granulomatosis

31. Sarcoidosis

32. Benign Tumors
Antrochoanal polyp
Inverted papilloma

33. Benign Tumors
Chondroma
Angiofibroma

34. Malignant Tumors
Olfactory neuroblastoma
Lymphoma

35. Malignant Tumors
Amelanotic melanoma
Adenocarcinoma

36. Hereditary hemorrhagic telangiectasia

37. The Place of Radiology

38. The Role of Conventional Radiology
Plain radiographs have a limited role in the modern management of paranasal sinus disease because they have so many false-positive and false-negative findings
In acute maxillary or frontal sinusitis, they can help confirm the diagnosis

39. The Role of Computed Tomography
This provides a map for endoscopic sinus surgery
Although CT has good sensitivity for diagnosing paranasal sinus disease, it has poor specificity; for example, there are many false-positive changes.

40. Important not to request a CT scan in the initial management if patients unless there are specific reasons to do so.
These include:
Suspected intracranial or intraorbital involvement as a complication of rhinosinusitis
Suspected atypical infection or malignancy
Specific pathology, e.g., mucoceles, benign tumors of the paranasal sinuses, where the extent of the lesion
Needs to be defined Prior to orbital or optic nerve decompression

41. When to Request CT
CT for rhinosinusitis is best reserved for patients who have not responded to maximum medical treatment

42. CT Parameters
Axial sections with coronal reconstruction will remove any dental artifacts; these can be excluded because they lie in the axial plane, and this produces better images with less artifact

43. Sagittal reconstructions
Helpful for frontal surgery, giving the surgeon a better understanding of the complex relationship between the anterior ethmoid sinuses and the frontal recess

44. Intravenous contrast
is only required for tumors, vascular lesions, and the orbital and intracranial complications of infection

45. Indications for MRI
The prevalence of incidental changes on MRI is so great that the technique is of little use in the diagnosis of rhinosinusitis
This is particularly helpful in defining the boundary of pathology in relation to the dura, orbital apex, or optic nerve.

46. A comparison between a T2-weighted image (fluid bright), a T1-weighted image (fluid dark), and a T1-weighted image with nonionic contrast provides useful information about soft-tissue lesions

47. MRI is complementary to CT
Where malignancy has reached the dura of the anterior skull base, the orbital apex, and the optic nerve

48. If there is intracranial or intraorbital involvement from an atypical infection or inflammatory process

49. In vascular tumors like a juvenile angiofibroma.

50. internal carotid artery aneurysm

51. Meningocele
In congenital midline lesions such as meningocele, meningoencephalocele, or sinonasal glioma