endoscopic_ana_of_nose__PNS in otolaryngology .ppt

Ent and head neck surgery

1. Endoscopic Anatomy of the
Nose and the Paranasal
Sinuses
Dr. Shankar Shah
MS( ORL-HNS)
2
nd
year
GMS Memorial Academy of ENT-H & N Studies
IOM, TU

2. History
►First attempted by Hirshmanin 1901, using a
modified Cystoscope
►In 1925, Maltz, a New York rhinologist, used the
term sinoscopy& described techniques
►ESS introduced in the European literature in
1967, by Messerklinger

3. ►1978 Messerklinger’s collection of images &
experience published –major reference workfor
endoscopic diagnosis
►Stammberger, Messerklinger’s former resident
began teaching ESS outside Germany & Austria
►1985, Kennedyintroduced the technique FESS into
the US

4. EQUIPMENT
►4 mm 0, 30, and 70
degree nasal telescopes
for adults
►2.7 mm 0 and 30 degree
nasal telescopes for
children, a flexible
fiberscope and a light
source
►a video camera, color
monitor, and video
recording system

5. ►0-degree : majority of
dissection
►30-degree : exam &
manipulation of
maxillary sinus ostium,
frontal recess
►70-degree : viewing
the antrum & anterior
frontal sinus

6. Paired images from 0-degree (left) and 70-degree (right)
endoscopes. If the surgeon used only a 0-degree endoscope,
the adhesion allowing recirculation of mucus in the maxillary
sinus would not be identified.

7. Technique
►Explanation
►Ant. Rhinoscopy –
assess nasal mucosa ,
secretions or
ulcerations
►Spray LA & topical
decongestants

8. General principles
►Telescope in left hand using thumb & 2
fingers
►Direct visualization
►Clues to excessive pressure or potential
trauma to mucosa
-collection of mucus on the edge
-blanching of mucus membrane
-grey or black meniscus along periphery

9. Nasal Endoscopy
►Three steps to
examine the nasal
airway and conduits
of the paranasal
sinuses

10. Step 1 examines these areas

11. ►Along floor of nose
►Initial impression
-Sinonasal mucosa
-Overall Sinonasal anatomy
►Inferior turbinate
►Inferior Meatus & opening of Nasolacrimal duct
►ET orifice
►Torus Tubaris
►Fossa of rosenmuller
►Adenoids
►Nasopharynx

12. Anterior endoscopic view of the right nasal cavity showing the
nasal septum, the anterior end of the inferior turbinate, and
the floor of the nasal cavity. (A) Sagital schematic view, (B)
endoscopic view, (C) schematic view

13. Endoscopic view of the right inferior turbinate and part of the
inferior meatus as a 0 degree telescope is passed along the
floor of the nasal cavity

14. Hasner’s valve lies 1 cm behind the anterior end of
the inferior turbinate

15. Posterior endoscopic view of the right choana revealing the
nasopharynx with the torus tubarius, and the eustachian tube
orifice. 0 degree telescope is placed between the inferior
turbinate and the septum along the floor of the nasal cavity

16. Step 2 examines the sphenoethmoid recess and the
anterior wall of the sphenoid

17. ►Endoscope reinserted into middle meatus
-Inferior portion of middle turbinate & middle meatus
-Fontanelles & accessory Maxillary Ostia (Natural ostium
is hidden)
-Sphenoethmoid recess
-Sphenoid ostium
-Superior Turbinate

18. ►The initial view of the
sphenoethmoid recess and
view of the upper part of
the sphenoethmoid recess
showing the sphenoid
ostium that is sometimes
possible

19. Posterosuperior endoscopic view of the right nasal cavity
revealing the anterior wall of the sphenoid sinus. (A) sagital
schematic view, (B) endoscopic view of the anterior wall of
the sphenoid sinus, (C) schematic view

20. The areas examined in step 3: the middle meatus,
the ethmoid bulla, the hiatus semilunaris,
Infundibular entrance and the uncinate

21. ►An accessory ostium of the right maxillary sinus with clear
mucus filling it.
►The posterior edge of the uncinate process and the
bulla ethmoidalis with an accessory ostium in the posterior
fontanelle

22. Endoscopic view of the middle meatus presenting the middle
turbinate, the uncinate process, and the ethmoid bulla. A:
sagital schematic view. B: endoscopic view of right middle
meatus showing uncinate process and ethmoid bulla. C:
Schematic view

23. Endoscopic view of the anterior insertion of the middle
turbinate also exhibiting the smooth swelling of the agger
nasi cells in front of the neck of the middle turbinate. A:
sagital schematic view. B: endoscopic view of anterior
aspect of right middle turbinate. C: schematic view

24. Landmarks in FESS
The four lamellae
1.Uncinateprocess
2.Bulla ethmoidalis
3.Basal lamella
4.Sphenoid sinus

25. Ostiomeatal complex
►Naumann, 1965
►Functional unit
►Collectively to
-uncinate process
-infundibulum
-ant. ethmoid cells
►Also contain the ostia of the ant. ethmoid,
maxillary & frontal sinuses

26. OMC

27. Uncinate process
►Sickle-shaped, sagitally
oriented
►3-4 mm x 1.5-2 cm length
►Attachment:
Postero-inferiorly : Inf.
Turbinate
Posteriorly -superiorly:
perpendicular process of
palatine bone
Anterior ascending convex
margin contacts lateral nasal
wall up to lacrimal bone

28. Uncinateprocess

29. Sagittal (a) and endoscopic (b) views illustrating the degree
of uncinate resection (dotted line) just behind the convexity
of the NL duct. The small circle denotes the approximate
location of the maxillary sinus natural ostium behind the
uncinate process

30. Sagittal (a) and endoscopic (b) views after uncinate
resection, illustrating the maxillary sinus natural ostium (M),
the lateral (orbital) wall of the infundibulum (I), ethmoid bulla
(B), and posterior fontanelle (PF) area

31. Bulla Ethmoidalis
►Largest & most consistent
ant.ethmoid air cell
►Behind uncinate ,front of
ground lamella
►may extend up to skull
base & form posterior limit
of frontal recess
►Lateral wall –medial wall
of orbit
Drawing showing entrance into
the medial and inferior aspect of
the ethmoid bulla, where it is
safe to avoid injury to the
lamina papyracea and/or fovea
ethmoidalis

32. Hiatus semilunaris
►sagittal cleft between posterior
border of the uncinate process
& anterior surface of ethmoid
bulla.
►middle meatus communicates
with the infundibulum through
this area ( hiatus semilunaris
inferior )
►hiatus semilunaris superior is
cleft formed between the
posterior wall of ethmoid bulla
& ground lamellae of middle
turbinate.

33. Ethmoid infundibulum
►funnel-shaped, 3-D space
in the ant. ethmoidal
region
►Boundaries :
medially : uncinate
laterally : lamina
papyracea.
anterior-superior:
frontal process of the
maxilla & lacrimal bone
posterior border :
portion of the anterior
ethmoid bulla
►communicates with the
middle meatus through the
hiatus semilunaris

34. Middle turbinate, basal lamella
PartSite Direction Attachment
1
st
part(anterior) Vertical Skull base
2
nd
part(middle) Oblique Lamina
papyracea
3
rd
part(posterior) Transverse Perpendicular
plate
of palatine bone

35. Anatomical variations of the middle turbinate. (A)
Normal. (B) Paradoxical turbinate. (C) Normal turbinate
with partial pneumatization. (D) Paradoxical turbinate
with partial pneumatization. (E) Concha bullosa

36. ►Dissection never be medial to the superior aspect of the
middle turbinate -risk of penetrating the cribriform plate or
the fovea ethmoidalis.
►Attachment of MT carefully preserved during ESS.
Disruption lead to destabilization, cause the turbinate to
scar in a lateral position.
►Lateralized middle turbinates cause postoperative
obstruction of the sinus drainage pathways, persistent
inflammation and infection, a common finding during
revision surgery

37. Dissection should be avoided along the medial aspect of the
middle turbinate because the roof of the ethmoid may lie
higher than the cribriform plate

38. Sinus lateralis
►Behind & above the
ethmoid bulla.
►also called the suprabullar
and retrobullar recesses.
►Borders
superiorly –ethmoid roof
laterally –lamina papyracea
inferiorly and anteriorly –
ethmoid bulla roof and
posterior wall
Posteriorly –ground lamella
of the middle turbinate
►ethmoid bulla often opens
into the sinus lateralis

39. Ostiomeatal complex : OMC
Suprabullar recess
Frontal ostium
Lateral sinus Frontal recess
Retrobullar recess HSS
HSI
Maxillary ostium Infundibulum

40. Sinus Lateralis = Suprabullar
recess and retrobullar recess

41. Frontal recess and sinus
►Complex anatomic area
leading from ant. Ethmoids
to frontal ostium
►drains into the ostiomeatal
unit through frontal recess
►shaped like a funnel with
its narrow end toward the
duct ostium.

42. Frontal Recess
►Anatomic Boundaries:
Ant –unicate process & agger
nasi
Post –bulla ethmoidalis and
suprabullar lamella
Lateral –lamina papyracea
Medially –hiatus semilunaris
or middle turb
Inf –Ethmoid infundibulum
Sup –Fovea ethmoidalis,
supraorbital air cell, anterior
ethmoid artery and frontal
ostium

43. Agger nasi
►means nasal eminence
►just anterior to the
middle turbinate’s
insertion into the lateral
nasal wall
►When the agger nasi is
pneumatized , it forms
an agger nasi cell.
►It arises from the
superior aspect of the
infundibulum or the
frontal recess.

44. Aggar Nasi Cell
►A well-pneumatized
agger nasi cell
producing a
bulge in the lateral
nasal wall near the
origin of the middle
turbinate and the
corresponding CT
image

45. Basal lamella and ethmoids
►Basal lamella:
Anterior ethmoids
Posterior ethmoids

46. Posterior ethmoids
►collection of one to five cells
►drain into the superior (supreme meati if present)
►Boundaries:
anteriorly: ground lamella of the middle turbinate
posteriorly: anterior wall of the sphenoid sinus
laterally : lamina papyracea
medially : superior and supreme turbinates
superiorly : ethmoid roof
►The meati are located along the medial surface

47. The posterior ethmoid cells may be entered safely through
the most horizontal portion of the middle turbinate

48. Onodi cell
►most posterior cells of the
posterior ethmoidal sinus
►can extend posteriorly
along the lamina
papyracea into the anterior
wall of the sphenoid sinus
►the optic nerve may be
adjacent
►To avoid injury, dissection
should be medial and
inferior.
►internal carotid artery may
also impinge the lateral
wall of the posterior
ethmoidal cells

49. Onodi Cells or Sphenoethmoid cells

50. Maxillary sinus ostium
►The natural ostium is located in the superior
aspect of the medial wall of the sinus and drains
into the hiatus semilunaris;
►elliptical structure
►measuring 1 mm -20 mm diameter
►behind the lower attachment of the uncinate
process
►above the superior portion of the anterior superior
aspect of the inferior turbinate

51. Anatomic variations
►Haller cells: also known as Intraorbital ethmoid
cells
the most common anatomic variation
arise from the anterior ethmoid in 88% of individuals or
from the posterior ethmoid in 12%
develop into the floor of the orbit above the natural
ostium of the maxillary sinus.
When diseased, the natural ostium of the maxillary
sinus may become obstructed

52. ►Another variation is hypoplasia or atelectasis of
the maxillary sinus
►Uncinectomy is difficult in these cases because of
the risk of orbital injury from lateral displacement
of the uncinate.
►Accessory maxillary sinus ostia
occur in 20% to 50% of patients
located in the infundibulum or the membranous meatus
inferior to the uncinate but above the insertion of the
inferior turbinate

53. Recirculation

54. Anterior accessory ostium and its
appearance on CT

55. Landmarks for Sphenoid Sinus
►Medial to superior
turbinate & lateral to
posterior nasal septum
►About 1.5 cm superior to
posterior choana
►On a posterior inclination
of 30 degree about 7cm
from ant. Nasal spine.
►Posterior Ethmoidal
neurovascular bundle

56. A calibrated probe can be useful to identify the anterior wall
of the sphenoid sinus. In the average adult, it is
approximately 7 cm from the nasal sill at a 30-degree angle

57. Sphenoid Sinus
►Relationships of important structures:
Optic nerve –superior-lateral
Carotid artery/cavernous sinus –mid-lateral
Vidian nerve and maxillary nerve –inferior-
lateral

58. Skull base: anterior ethmoids & AEA
►Crista galli
►Septum
►Middle turbinate
►Cribriform plate
►Lateral lamella
►Fovea ethmoidalis

59. Fovea ethmoidalis
►frontal bone extends from the orbital plate to form
the ethmoid roof
►medial aspect of ethmoid roof formed by the
lateral lamellae of the cribriform plate, also known
as the lamina lateralis of the lamina cribrosa

60. ►Mean thickness of 0.5 mm. lateral lamella only 0.2
mm in thickness -perforation can easily occur.
►Relationship of the anterior ethmoid artery
important as it leaves the orbit & enters the
anterior cranial fossa
►Ethmoidal sulcus, a groove in the lateral lamella
containing the anterior ethmoidal artery, only 0.05
mm in thickness

61. Skull base: anterior ethmoids

62. ►Lateral lamella contributes significantly to the
ethmoid roof and makes this the most hazardous
configuration
►By staying lateral to the insertion of the middle
turbinate, the surgeon can avoid perforating the
lamina cribrosa

63. II-Anatomical Variations
►Concha bullosa
►Paradoxically bent middle turbinate
►Medially bent uncinate process
►Large bulla ethmoidalis
►Haller cell
►Sphenoethmoidal air cell

64. ►A concha bullosa with
the corresponding CT
image

65. ►Endoscopic
appearance and CT
image of a right
paradoxical middle
turbinate

66. ►A right bifid middle
turbinate and its
appearance on CT

67. ►Posterior bifidity of the
middle turbinate

68. ►A paradoxical uncinate
process (*) and its
appearance on CT

69. ►A paradoxical and
pneumatized uncinate
process (*) and its
appearance on CT.

70. Anterior accessory ostium and its
appearance on CT

71. ►An endoscopic view of
a right posterior
accessory ostium and
its appearance on CT

72. Image-guided Triplanar
Localization Sinus Surgery
►more rapid and
accurate intraoperative
anatomical localization
►Prior to surgery, a
helical CT scan
obtained with a special
headset
►scan data are either
transmitted
electronically to a
workstation in the OT

73. ►In the OT, the same
headset is placed on the
patient after asleep &
headset is linked to a CT
workstation.
►The headset is registered
via the computer
workstation software so
that the computer is aware
of the anatomical
structures.

74. ►Straight and angulated
suction aspirators are also
linked to the computer
workstation.
►When these are placed
within the nasal or sinus
cavity the tip of the
aspirator can be located on
the screen of the
workstation with 3 mm
accuracy and seen on axial,
coronal, and sagittal views.

75. Computer-aided surgical navigation
Indications for image-guidance in sinus surgery :
1.Revision sinus surgery
2.Distorted sinus anatomy of development,
postoperative, or traumatic origin
3.Extensive sino-nasal polyposis
4.Pathologic conditions involving the frontal, posterior
ethmoid, and sphenoid sinuses
5.Disease abutting the skull base, orbit, optic nerve, or
carotid artery
6.Cerebrospinal fluid rhinorrhea or conditions where
there is a skull-base defect
7.Benign and malignant sino-nasal neoplasms

76. Minimally Invasive Functional
Endoscopic Sinus Surgery
►Many patients present with minimal CT-proven sinus
disease and minimal changes on nasal endoscopy but
with recurrent acute and subacute rhinosinusitis.
►Most of these patients have anatomical abnormalities such as
paradoxically bent middle turbinate, concha bullosa etc
►these deformities can be corrected with a minimally
invasive functional endoscopic sinus procedure.
►Microendoscopic sinus instruments are used along with
miniature powered instruments to remove small bits of
tissue, correct the abnormality, preserve normal mucosa & restore
function.
►Healing is rapid because surgical trauma is limited to the areas of
pathology