nasal septum ,lateral nasal wall anatomy

MAXILLECTOMY

1. Classification of medial maxillectomy Dr.hadi mohammed hamed mokarbesh Rhinology & Endoscopic Skull base Surgery Fellowship Otorhinolaryngology/ Head & Neck Surgery Consultant KING FAHAD CENTRAL HOSPITAL , JAZAN , KSA

2. anatomy of lateral wall  by bony ,cartilage & soft tissue (mucosa) Bony – uncinate Process Perpendicular plate of palatine bone Medial plate of pterygoid process of sphenoid bone Medial surfaces of lacrimal bones and maxillae Inferior conchae

3. anatomy of lateral wall  Turbinate Inferior (separate bone) middle superior + - supreme ethmoid bone

4. anatomy of lateral wall  Turbinate inferior, middle and superior turbinate +- supreme turbinate (the most superior) 60 to 70 % of the normal population <20 % of cases posterior ethmoid drain into the supreme meatus ( lateral to the supreme turbinate) if no supreme posterior ethmoid will drain into the superior meatus

5. anatomy of lateral wall  the superior meatus lateral to the superior turbinate the posterior ethmoid opens into the superior meatus sphenoethmoidal recess receives the opening of sphenoid sinus lies medial & superior the superior turbinate

6. anatomy of lateral wall  inferior turbinate Largest of all meatus inferior meatus opening of the nasolacrimal duct

7. anatomy of lateral wall  OSTIO MEATAL COMPLEX key for functional endoscopy sinus surgery The area in the middle meatus where the frontal sinus, the maxillary and anterior ethmoidal area sinuses drain

8. anatomy of lateral wall  OSTIO MEATAL COMPLEX Maxillary sinus ostium ethmoid bulla frontal recess uncinate process infundibulum hiatus semilunaris middle meatus

9. anatomy of lateral wall  Maxillary natural ostium reduced into a small natural ostium in life Anterior-superiorly by the lacrimal bone inferiorly by the inferior turbinate Posteriorly by the perpendicular palate of palatine bone superiorly by the ethmoid bulla & part of uncinate process The rest is covered by mucus membrane (membranous part)

10. anatomy of lateral wall  the uncinate process Crescent-like / sickle shaped structure inferior attachment is always into the inferior turbinate anterior attachment to the lacrimal bone the superior attachment. the lamina paprecyea of the orbit the middle turbinate the skull base

11. anatomy of lateral wall  the uncinate process uncinate process divides the membranous area into anterior & posterior anterior & posterior fontanelle (larger & most commonly accessory ostium ) accessory ostia 5-6 % of the normal population 25 % in chronic sinusitis

12. anatomy of lateral wall  ethmoid bulla the most constant and the largest anterior ethmoid cell Behind the uncinate process

13. anatomy of lateral wall  the hiatus Semilunaris space between this uncinate process & the ethmoid bulla the ethmoid infundibulum area between the uncinate process & the lamina paprecyea

14. anatomy of lateral wall  maxillary sinus is not directly opening into the middle meatus Natural ostium - ethmoid infundibulum -hiatus Semilunaris -the middle meatus frontal sinus drains into the most anterior part of the middle meatus anterior ethmoids cells drains into the middle meatus is through ethmoid bulla

15. anatomy of lateral wall  blood supply of the lateral wall Arteries By both from ICA & ECA the sphenopalatine artery : (main) to all turbinate the greater palatine artery (facial) anterior & posterior ethmoidal arteries venous system is more variable & complex parallel to the arterial supply pterygoid plexus & facial vein

16. classification of medial maxillectomy

17. classification of medial maxillectomy Types of maxillary sinusotomy: (SIMMENS CLASSIFICATION) Type.I : Ostium is opened posteriorly to a limited extent(<1cm in D) Type.II : Ostium is opened posteriorly & inferiorly (<2cm in diameter) Type.III : Wide exposure of opening of ostium in all direction anteriorly up to lacrimal crest, superiorly up to orbit, inferiorly to inferior turbinate, posteriorly to level of posterior wall of maxillary sinus

18. Transnasal endoscopic partial maxillectomy standard middle meatal antrostomy posteriorly enlarged TEPM - 1 removal of the medial maxillary wall with the inferior turbinate (partial or complete) connect the nasal floor with the maxillary sinus floor nasolacrimal duct PRESERVED TEPM - 2 Removal of the lacrimal bone & transection of nasolacrimal duct TEPM - 3A inferior turbinate displaced medially & sutured back nasolacrimal duct is mobilized & preserved (pre-Lacrimal approach) TEPM - 3A (modified) Removal of pyriform aperture (partial or complete) & drilling out the ascending branch of the maxillary bone TEPM - 3B Removal of the anterior wall as far as the zygomatic bone (+- infraorbital transposition) TEPM - 4 endoscopic endonasal anterior maxillotomy TEPM – 4 (modified)

19. Transnasal endoscopic partial maxillectomy standard middle meatal antrostomy posteriorly enlarged TEPM - 1 removal of the medial maxillary wall with the inferior turbinate (partial or complete) connect the nasal floor with the maxillary sinus floor nasolacrimal duct PRESERVED TEPM - 2 Removal of the lacrimal bone & transection of nasolacrimal duct TEPM - 3A inferior turbinate displaced medially & sutured back nasolacrimal duct is mobilized & preserved (pre-Lacrimal approach) TEPM - 3A (modified) Removal of pyriform aperture (partial or complete) & drilling out the ascending branch of the maxillary bone TEPM - 3B Removal of the anterior wall as far as the zygomatic bone (+- infraorbital transposition) TEPM - 4 endoscopic endonasal anterior maxillotomy TEPM – 4 (modified)

20. standard middle meatal antrostomy posteriorly enlarged TEPM - 1 removal of the medial maxillary wall with the inferior turbinate (partial or complete) connect the nasal floor with the maxillary sinus floor nasolacrimal duct PRESERVED TEPM - 2 Removal of the lacrimal bone & transection of nasolacrimal duct TEPM - 3A inferior turbinate displaced medially & sutured back nasolacrimal duct is mobilized & preserved (pre-Lacrimal approach) TEPM - 3A (modified) Removal of pyriform aperture (partial or complete) & drilling out the ascending branch of the maxillary bone TEPM - 3B Removal of the anterior wall as far as the zygomatic bone (+- infraorbital transposition) TEPM - 4 endoscopic endonasal anterior maxillotomy TEPM – 4 (modified) Transnasal endoscopic partial maxillectomy

21. Transnasal endoscopic partial maxillectomy standard middle meatal antrostomy posteriorly enlarged TEPM - 1 removal of the medial maxillary wall with the inferior turbinate (partial or complete) connect the nasal floor with the maxillary sinus floor nasolacrimal duct PRESERVED TEPM - 2 Removal of the lacrimal bone & transection of nasolacrimal duct TEPM - 3A inferior turbinate displaced medially & sutured back nasolacrimal duct is mobilized & preserved (pre-Lacrimal approach) TEPM - 3A (modified) Removal of pyriform aperture (partial or complete) & drilling out the ascending branch of the maxillary bone TEPM - 3B Removal of the anterior wall as far as the zygomatic bone (+- infraorbital transposition) TEPM - 4 endoscopic endonasal anterior maxillotomy TEPM – 4 (modified)

22. Transnasal endoscopic partial maxillectomy standard middle meatal antrostomy posteriorly enlarged TEPM - 1 removal of the medial maxillary wall with the inferior turbinate (partial or complete) connect the nasal floor with the maxillary sinus floor nasolacrimal duct PRESERVED TEPM - 2 Removal of the lacrimal bone & transection of nasolacrimal duct TEPM - 3A inferior turbinate displaced medially & sutured back nasolacrimal duct is mobilized & preserved (pre-Lacrimal approach) TEPM - 3A (modified) Removal of pyriform aperture (partial or complete) & drilling out the ascending branch of the maxillary bone TEPM - 3B Removal of the anterior wall as far as the zygomatic bone (+- infraorbital transposition) TEPM - 4 endoscopic endonasal anterior maxillotomy TEPM – 4 (modified)

23. standard middle meatal antrostomy posteriorly enlarged TEPM - 1 removal of the medial maxillary wall with the inferior turbinate (partial or complete) connect the nasal floor with the maxillary sinus floor nasolacrimal duct PRESERVED TEPM - 2 Removal of the lacrimal bone & transection of nasolacrimal duct TEPM - 3A inferior turbinate displaced medially & sutured back nasolacrimal duct is mobilized & preserved (pre-Lacrimal approach) TEPM - 3A (modified) Removal of pyriform aperture (partial or complete) & drilling out the ascending branch of the maxillary bone TEPM - 3B Removal of the anterior wall as far as the zygomatic bone (+- infraorbital transposition) TEPM - 4 endoscopic endonasal anterior maxillotomy TEPM – 4 (modified) Transnasal endoscopic partial maxillectomy

24. standard middle meatal antrostomy posteriorly enlarged TEPM - 1 removal of the medial maxillary wall with the inferior turbinate (partial or complete) connect the nasal floor with the maxillary sinus floor nasolacrimal duct PRESERVED TEPM - 2 Removal of the lacrimal bone & transection of nasolacrimal duct TEPM - 3A inferior turbinate displaced medially & sutured back nasolacrimal duct is mobilized & preserved (pre-Lacrimal approach) TEPM - 3A (modified) Removal of pyriform aperture (partial or complete) & drilling out the ascending branch of the maxillary bone TEPM - 3B Removal of the anterior wall as far as the zygomatic bone (+- infraorbital transposition) TEPM - 4 endoscopic endonasal anterior maxillotomy TEPM – 4 (modified) Transnasal endoscopic partial maxillectomy

25. Transnasal endoscopic partial maxillectomy

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