functional endodontic sinus surgery project

a powerpoint presentation

1. FUNCTIONAL ENDOSCOPIC SINUS SURGERY TALAT MAHMUD NAIYA Final year , Roll : 18 Unv . Roll : Dept. of Oral and Maxillofacial Surgery

2. INDEX INTRODUCTION Ostio Meatal complex Indictions of FESS Strategic approach to FESS Post-operative care Complications

3. INTRODUCTION FESS- Functional Endoscopic Sinus Surgery is often a non-invasive / minimal invasive surgical procedure that discloses sinus air cells and sinus ostia by having an endoscope. It restores the paranasal sinus function by re-establishing the physiologic pattern of ventilation & mucocilliary clearance The term FESS was coined by Kennedy in 1985 Father of FESS is Prof Mesenklinger Hirschmann 1 st described use of primitive endoscope to examine the maxillary sinus through an oroantral fistula

4. FESS- The Functional Aspects: Preserving normal structure Removing only obstruction Preserving mucosa Restoration of function Advantage over Open Sinus Procedure Safe , minimally invasive, no cuts Doesn’t disturb healthy tissue Performed in less time with better management No visible signs that surgery has been performed Quick recovery

5. OSTIO MEATAL COMPLEX The ostiomeatal complex is the key anatomic area addressed by endoscopic sinus surgeons. Blockage of the ostiomeatal complex prevents effective mucociliary clearance, thus leading to a stagnation of secretions and therefore leading to recurrent or chronic sinusitis .

6. OSTIO MEATAL COMPLEX Maxillary sinus ostium ethmoid bulla frontal recess uncinate process infundibulum hiatus semilunaris middle meatus.

7. Landmarks in FESS Middle turbinate Uncinate Process Bulla E thmoidalis Sphenoid O stium Skull Base Maxillary sinus ostium

8. Indication of FESS: Chronic rhinosinusitis unresponsive to medical treatment Recurrent acute sinusitis Sinunasal polyposis Mucocoele Noninvasive fungal ball Invasive fungal rhinosinusitis CSF rhinorrohoea & anterior meningoencephalocele Sinonasal Tumour Severe Exopthalmus N LD obstruction

9. Patient selection: Pre-operative assessment History - Symptoms - Medical treatment - associated disease Examination of the Patient: (General & Local) - Anterior rhinoscopy - Septal deviation - Turbinate hypertrophy -Nasal airway Problem - Nasal Endoscopy - Character of mucosa & appearance of sinus drainage, anatomical variations, structural abnormalities

10. Radiological- Pre-operative X-rays, CT Scan(Gold Standard) Routine Blood Investigations Key Points to be reviewed on Pre-operative CT SCAN Disease: Extent and pattern & its clinical correlation Bony integrity- (Erosion, expansion ,dehiscence )- skull base, lamina papyracea , optic canal, carotid canal Skull Base- Height, symmetry, slope of cribriform plate & fovea ethmoidalis . Maxillary Sinus- location & attachment of uncinate process to medial orbital wall, pneumatisation & height Ethmoid Sinus – location of AEA,PEA, height of post.ethmoid cell Sphenoid Sinus- location of sphenoid ostium , septation & their relation to carotid canal Frontal Sinus- extent of pneumatisation, natural drainage pathway, presence of ager nasi & frontal cell

11. Strategic Approach to FESS Patient under general anaesthesia Local vasoconstriction of the nasal cavity Septoplasty and/or Rhinoplasty Management of Middle T urbinate Uncinectomy Maxillary Antrostomy Ethmoidectomy Frontal S inusotomy Sphenoidectomy Management of Inferior Turbinate

12. Nasal Preparation P reoperative oxymetazolline spray 3 times separated by 5-10min Once GA induced, nose is packed with topical epinephrine pledgets After draping , the nose is injected with a focus on MT in 3 loction - Over the axilla at the junction of the Turbinate & lateral wall - Inferomedially on the head of MT - Posteriorly along the inferior aspect of Turbinate

13. Nasal Septal Surgery If a DNS is present, obstructing the nasal cavity & limiting the nasal airway or access to the sinus cavities , a septoplsty is performed prior to beginning the sinus surgery B. Management of Middle Turbinate The anatomical variants of the middle turbinate may cause middle meatal obstruction like Choncha Bullosa where the head of MT is enlarged. Resection of CB is done by incising the inferior free border of MT along its length and carrying the incision up to the neck. The incision is further enlarged using microscisor & the lateral half of the concha is removed after elevating the mucosal flap from the lateral bony wall

14. C . Uncinectomy The MT is medialized using a Freer Elevator by applying firm pressure against the lateral aspect of the upper part of turbinate. Uncinectomy begins with an incision of the uncinate process at its anterior attachment. The incision is extended posteriorly and inferiorly , parallel to the upper of Hiatus Semilunaris & towards the natural ostium of maxillary sinus Uncinectomy exposes base of Infundibulum & anterior wall of Ethmoid bulla

15. D. Maxillary Antrostomy Initial identification of the natural ostium - anterior & inferior within the middle meatus. Ostium usually at the same level as the inferior margin of the middle turbinate,anterior to ethmoid bulla Opening is further enlarged posteriorly to the posterior fontanelle with backward-biting punch forceps & anteriorly with upturned Blakesley -Wilde ethmoid forceps Antrostomy should be placed just above the inferior turbinate & not more anterior than the anterior end of the middle turbinate Polypoid tissue, diseased mucosa , mucous plug should be removed

16. E. Ethmoidectomy Maxillary sinus is a single cavity with distinct ostium but the ethmoid sinus consists of multiple cavities of interconnected cells. The basal lamella of MT separates ethmoid labyrinth to two distinct anatomical and physiologic compartment. Anterior group of cells drains its secretion into infundibulum together with maxillary & frontal sinuses Posterior group of cells drains their mucus into superior meatus Main anatomical landmark for ethmoidectomy is identification of E thmoid Bulla Mucosa is dissected over the bony surface of Ethmoid Bulla The goal of anterior ethmoidectomy is complete exposure of anterior ethmoid cells

17. Posterior ethmoidectomy is done if involvement of posterior comaprtment . After dissecting the anterior ethmoid cells ,the basal lamella of the MT encountered. It is perforated medially & inferiorly. The posterior ethmoid cells are removed stepwise till the anterior wall of the sphenoid sinus is exposed. The posterior ethmoid artery can be seen & landmarks the anterior edge of most posterior ethmoid cells.

18. F. Frontal Sinusotomy Kuhn Classification of Frontal Recess & Frontal Sinus Cell Agger nasi cell Supraorbital ethmoid cell Frontal cell Type 1 – Single Frontal cell above agger nasi cell Type 2- Tier of cells in FR above agger nasi cell Type 3- Single massive cell pneumatising cephalad in to Frontal Sinus Type 4- Isolated cell in Frontal Sinus Frontal Bulla Cell Suprabullar cell Interfrontal sinus septal cell

19. Intranasal frontal sinusotomy is the potentially dangerous procedure as it is close to the Orbit & Skull base Imp. Landmark is anterior ethmoid artery which is posterior to frontal recess To visualise the frontal recess area, it is necessary to remove the ager nasi cells. Then the frontal recess is enlarged using sharp curette to break down anterior ethmoid cells, the spina nasalis frontalis ( nasofrontal ‘’beak”)

20. G . Sphenoidotomy The sphenoid sinus can be opened safely 10 mm above the choana just lateral to the midline septum at the rostrum of the sphenoid. After identification of ostium the opening enlarged in lateral & inferior direction. Initial opening is made with Straight Blakesley forceps. If the entire anterior wall of the sinus is thick & ostium is not visualised , an angulated hand piece with extra long diamond burr is used to make opening in ostium area Optic nerve & carotid artery located in lateral & posterior wall. Sella turcica situated medial & superior to the sinus & cavernous sinus located laterally Roof of sphenoid sinus is extremely thin- potential risk of a CSF leak

21. H. Management of inferior turbinate After taking care of septal deviation & parnasal sinus diease , last step is to treat IT hypertrophy Long nasal speculum is introduced along the IT & with endoscopic view the posterior third of turbinate is removed after being retracted medially with straight Blakesley forceps. The anterior & middle third of HIT treated with Radio Frequency Thermal Ablation

22. Post-operative Care Nasal packing : Packing used to control bleeding ,prevent adhesions Regular analgesia & vitals are carefully monitored Observe for epistaxis, headache, orbital swelling, diplopia, reduced visual acuity Remove nasal packing after 48 hours Post-operative Ambulatory Care Antibiotics are not routinely prescribed Instruct not to blow nose hard for at least 48 hours Commence topical decongestants for 5 days & saline spray for 6weeks Suction toilet of the nose Recommence long-term nasal steroids after 1 wk in nasal polyposis Decrust the nose with a rigid endoscope if necessary

23. Factors avoiding complications: Proper use of nasal endoscope True cut instrument Imaging Image guidance Through knowledge of anatomy Hypotensive anaesthesia Complications are common in: Revision FESS Surgery for nasal polyposis Type 3 kerio skull base Anatomical variants like asymmetrical low lying ethmoid roof