ENDOSCOPIC DIAGNOSIS AND SURGERY OF THE PARANASAL SINUSES AND ANTERIOR SKULL BASE The MESSERKLINGER Technique and Advanced Applications from the Graz School el ma are 1-0c0 4 University Ear, Nose and Throat Hospital Graz, AustriaF.E.S.S. ENDOSCOPIC DIAGNOSIS AND SURGERY OF THE PARANASAL SINUSES AND ANTERIOR SKULL BASE The MESSERKLINGER Technique and Advanced Applications from the Graz School Prof. Heinz STAMMBERGER, M.D. University Ear, Nose and Throat Hospital Graz, AustriaEndoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Bas FESS - Endoscopic Diagnosis and ‘Surgery of the Paranasal Sinuses and Anterior Skull Base ‘The Messerklinger Technique ‘and Advanced Applications from the Graz Schoo! Prof. Heinz STAMMBERGER, M. D. Prof. and Head, Department of General ENT, Head and Neck Surgery University Medical School, Graz, Austria ‘Auenbruggerplatz 20 ‘8-8036 Graz, Austria Fax: +49/316/385-3425 Copyright: pp. 3-59, Prof. H. Stammberger, M. D. © Verlag Endo-Press, Tuttlingen, 2001 pp. 60-81, ISBN 3-89756-014-3. Printed in Germany P.O. Box, D-78503 Tuttlingen, Germany Phone: +49 (0) 7461/14590 Fax: +49 (0) 7461/708-529 Other foreign language editions are available on request. For additional information please apply to the above- mentioned address of Endo-Pret publisher, Tutllingen, Germany. Printed by: Braun-Druck GmbH, D-78532 Tuttingen, Germany Several ofthe ilustrations printed here are taken from the following books: STAMMBERGER, H. Functional Endoscopic Sinus Surgery Editions B. C. Dacker, Philadelphia, 1991 BENJAMIN, 8., BINGHAM, B., HAWKE, M., STAMMBERGER, H.: ‘A Color Atias of Otorhinolaryngology Editions Martin Dunitz, London, 1996 ‘STAMMBERGER, H., HAWKE, M. Practical Endoscopy of the Nose, Sinuses and Anterior Skull Base Editions Martin Dunitz, London, 1996 ‘Al rights reserved. No part of this publicatio may be ttansiated, reprinted or reproduce Itansmitted in any form or by any means, elec tronic o mechanical now Known or hereafte invented, insluding photocopying and recor ing, of utitzed in any information storage ‘ettoval system without the prior permission | ‘wing from the copyright holder. If not othernise indicated, all anatomical drawings and schematics are by Ms. Astrid Hambrosch, Anatomical Institut of the Karl-Franzens-University Graz, Austra, (Chairman: Prof. F Anderhuber, M.D.)Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base Imprint 4.9 Introduction 20. Pathophysiological Basics — Endoscopic Diagnosis. ‘Technique of Diagnostic Nasal Endoscopy. ‘Systematic Endoscopic Examination of the Nose ~ Three Stops Tips and Tricks. Instruments for Endoscopic Diagnosis Examination of the Lateral Nasal Wall - Anatomical Variations. 3.0. Maxillary Sinus Endoscopy - Technique of Maxillary Sinus Endoscopy. S.4. Blue Light Endoscopy 4.9. Surgical Techniques. 4.1. Preparation for Surgery ‘Surgical Techniques ~ Practica OR Positioning Individual Surgical Steps, Frontal Sinus Drains 4.5. FESS and Septum Deviations. 4.8. Conclusion of Surgical Procedure 4.7. Selecting Telescopes and instruments. 48. Bleeding curing Surgery 4.9. Extended Applications 5.0. Diffuse Eosinophil-dominated Polyposis, 5.1. KARL STORZ Paranasal Sinus Shaver System 5.2. Mucoceles 5.3. Mycoses of the Paranasal Sinuses, 5.3.1. Foreign Bodies. Decompression of the Orbit and of the Optic Nerve. CSF Fistulae/Meningoencephaioceles Choanal Atresia, Dacryocystorhinostomies. |. Complications of Acute Sinusitis Tumors. Postoperative Endoscopic Treatment. Limitations of Endoscopic Techniques Complications. Summary, Bo6 Recommended Telescopes, Instruments and Units for Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base, Diagnosis ~ Nasal Endoscopy. Diagnosis ~ Maxillary Sinus Endoscopy Operating Techniques ~ GRINS) Telescopes and Accessories Operating Techniques ~ Standard Instrument Set ‘Operating Techniques - Extended Instrument Set. Operating Techniques - Pediatric Instrument Set Postoperative Endoscopic Treatment. Light Sources and Imaging Systems for Photo-Video-Documentation a7 et 2 18 14 16 16-18 19-20 a 22-28 24 25 25-26 27-34 35 36 36 37 40-41 42-43 43 44-45 47-48 49 50 50 51 52-83 54-65 87 58-59 60-79 60-61 62-63 4-65 66-69 70-73 74-75 76-77 78-79~ Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base 3 1.0 Introduction he teciriquo for systematic endoscople exploration ofthe lateral nasal wal, Goveloped by Prot Mosserkingor inthe late 1060s/oary 1970s, impresswely onto cincal experiance that most dooages of tho lage paranesal sinuses, Such 29 the roal and mailer sinuses, are rhinogentc. As he was able 0 Gomonstate, most Infections spread fom the nose tothe sinuses. Even ifthe Smmptoms cf a dsoased frontal and/or maxilay sins are cincaly inthe fSrepround, the underng changes were nat for the most pat inthe sinus fst, but lay rater e_procoong oetts ane narrow Spaces of mo Teer ‘asel wal Those areas ofthe osiomeatal unit which by thet nature ae exter Gy narow, play 2 key olen the normal and pathophysiiogy ofthe sinuses, | , They roprocent procharbors loading tothe onal anc manilary einueos, provi : bhp ventaton and dranage foc em. Embryology, he fora as wol as SAM) manilay sus wore fred fom the anteror enol sins, to which they remain connected via extremely complex “clefts” A number of anatomical Fs. Variants con adationely narrow these prechambers inthe lateral nasal wal, ,blcel Light Conductor by Pin Causing a precispositon to constantly recurring diseases. The exact clagnosis of tote changes which uncer an auto or recur sinus, he bass for the technique prsonted here. Fig. 2 Emil Zuckerkandl, Graz/Vienna, who published his fundamental work (Ghown in Fig 3 in 1882. Fig. 3 Emil Zuckerkand, “Anatomy of the Nasal Cavity and its Pneumatic Appendices.” First action, 1882, Fig. 4 jw ofthe auditorium ofthe University Ear, Nose and Throat Hospital in Graz, Austria4 Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Bas Endoscopic diagnostic examinations in conjunction with modern imagin ‘methods, particularly computed tomography (CT), have proven to be an ide combination in recent years and are already accepted as the “Standard « Care" in many parts of the world for sinus diseases. ‘As a logical consequence of diagnostic findings, an endoscopic-surgical con cept has resulted which is directed at the diseased areas in key positions of th lateral nasal wall. It was fascinating to see how, after relatively localized inter vention in these key positions, even massive changes in the mucosa of th adjoining large sinuses regressed, even without being actually touched. Thu using lass traumatic interventions which preserve the mucosa, a cure was pos sible In the majority of all cases of chronic sinusitis, without having to resort t the more radical surgical methods - either endonasally or from the exterior that have been implemented up to now. Fig. 5 Le middle nasal meatus with concha bullosa ina paradoxeally curved mide ‘urbinate as a variant (of te norm). Pronounced tuberculum sept, Tis patient had no complaints, Fig. 6 Fig.7 Fight middle nasal metus: edematous _D- Walter Messerktinger, Professor and Chairman Emeritus ofthe sgweling wth incipient polyp formation ENT University Hospital, Graz, during an endoscopic examination, in 1980. from the anterior surface ofthe ethmaldal bulla. The hiatus semiunaris betwoon te latter and the uncinate process is thereby blackedEndoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base 6 Thus today, routine radical sinus operations or *-ectomies” take place very ‘rarely. The exact diagnostics allow intervention to be tailored to the respective ‘ndividual pathology with a very broad spectrum of indications. In the extreme case, if technically a total sphenoethmoidectomy is quite possible, the real ‘sdvantage nevertheless lies in the fact that, due to the preceding diagnostics, Such interventions are becoming far less necessary. Even then, these interven- ‘ions can take place mostly with preservation of anatomical landmarks such as the midele turbinate, and preservation of the parietal mucosa. For chronic sinusitis today, we can say that interventions which used to be irected at the large sinuses, are targeted today at their prechambers in the lateral nasal wall; the ostiomeatal unit with the narrow infundibulum of the thmoid and the frontal recess as key positions. In the hands of a skilled surgeon, the “Messerklinger Technique”, (MT/FESS. technique) demonstrates extremely few complications and a low morbidity FEO an nasal meatus ie. Sold portion of an antrachoanal polyp which extends, through an accessory Ostium inthe postarorfontanalia, al the ‘way tothe flr ofthe nose and the haan Fig. 8 Fig. 9 Paranasal sinus CT with anatomical variants (concha bullosa bilaterally, Halles Cel Fight mile nasal meatus: Pronounced on the right with infundibulum blockage and consequent sweling ofthe mucosa inthe concha bullosa of the middle turbinate. ‘manilary sinus), Note the protrusion ofthe lamina papyracea into the ethmoid sins.Le 6 Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base ‘As with any surgical procedure, the technique described here also has its problems, limits and clear contraindications. t entails the typical risks of any type of endonasal ethmoid sinus and skull base surgery, and must therefore be carefully learned. Serious complications are nevertheless extremely rare when the technique is correctly performed. ‘The mechanical concept of stenoses and contact areas in the lateral nasal wall is, of course, not able to explain all pathological phenomena. But even in ‘complex disease processes such as diffuse polyposis, the first changes mani- {fest themselves primarily in this area. Today the method of choice seems to be ‘a combination of surgery and medical therapy for the aforementioned syn~ ‘drome, the complex nature of which we are only gradually beginning to under- stand through basic research in the last years. A more radical surgical proced- Ure alone only rarely leads to healing. Diffuse, enosinophilic-dominated nasal polyposis is therefore a domain of endoscopic surgery in combination with ‘medical therapy (see page 40), usually by topical corticosteroids. Fig. 11 .Zuckerkancl, 1882: Drawing of an axial section through the ethmoid sinus. Fig.t2 CCT, 19965: axial cut atthe same evel.Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base 7 ‘Stee introduction of the endoscopic technique, the spectrum of indications thas widened considerably. Not only cases of chronic and polypoid rhnosinus- Ss can be controlled today, but also Imminent complications of acute sinusitis. ‘rer conditions appropriate for an endoscopic approach ara: Mucoceles of all Smuses ~ even with considerable intracranial extension; lesions of the anterior ‘skal base (including cerebrospinal fuid fistulae) and meningoencephaloceles ‘pericularly of the sphenoidal sinus. Decompressions of the orbit as well as of Septic nerve. dacryocystorhinostomies or choanal atresia can also be treat- fe¢ endoscopically. Under certain conditions, benign tumors such as inverted feeptiomas, mycoses and localized malignancies are also particularly suitable fer endonasal, endoscopic resection. With the development of new instru- sents and techniques, resections can also be performed on pituitary tumors, ‘296 in special cases even on juvenile nasopharyngeal angiofibromas. fe spite ofall these fascinating possibilities, it should not be forgotten that the ‘sctual domain of rigid endoscopy within the field of the paranasal sinuses is Fig. 15 ‘Gagnos's. Early recognition of disease can therefore alow medical therapy to MAlot an extensive cholestrol cyst of es therefore alow medical therapy 0 the schenoid bone and of the mide ‘be sufficient in many cases. Cranial fossa, The lesion was removed endoscopically witrout any problem. Endoscopy should therefore primarily help in avoiding un- necessary operations and unnecessarily radical surgery! aw a) Fig. 19 (OF situation during intervention unde local anesthesia Fruiting head of aspergilus fumigatus in a ‘case of maxilary sinus mycosisFig. 16 Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base 2.0 Pathophysiological Basics — Endoscopic Diagnosis The frontal and maxillary sinuses are connected to the nose via a complicated system of clefts and stenotic areas, through which their drainage and venta tion occur. These narrow passageways - the frontal recess in the case of the frontal sinus, and the ethmoid infundibulum in the case of the maxilary sinus ~ are part of the anterior ethmoid sinus and could be described as the precham- bers of the respective large paranasal sinuses. They are components of the ‘ostiomeatal unit. As long as these clefts are healthy, they play a significant role in the maintenance of the physiological conditions of the large paranacal sinus- ‘85. In the clefts, often only millimeters wide, mucosal surfaces with a respirat- ‘ory epithelium directly face one another, often over several centimeters. in these bottlenecks, ciliary beat can act from both sides on thickened or other- ‘wise pathologically changed secretion and therefore facilitate evacuation. In an, ‘Schematic drawing of the active secretion ostium, the cilia can even act circularly on the mucus. transport in and out ofthe frontal sinuses OStUM. the cla can evan act circularly on the through the frontal recess. Fig. 17 Secretion transpor from a maxilary sinus (igh, Schematic drawing ot potential 18 Cth pronounced ethmold cisease and consequent opacification of the maxilary sinus. ‘obstructions In the ostiomeatal unt (tt.Endoscoy lf however — for whatever reason ~ close contact of facing mucosal surfaces occurs in these narrow clefts, ciliary activity can be greatly inhibited and limit- ed, or even completely blocked. Mucus between the contact areas is no longer evacuated. Through adhesion of exogenic noxae, localized infections can ‘occur which may remain clinically quiescent for a long period. One of the first ‘symptoms of such a lesion ~ not recognizable via rhinoscopy and general x-ray — can however be subjectively felt 2s a significant pressure between the eyes, Cr impaired nasal respiration. According to our clinical experience in the past, many an innocent, slightly deviatert nasal septum has surgirally “fallen victim” to this phenomenon, Fig. 19 Evacuation ofa blood clot through the narrowed maxilary sinus ostium 5 days after an ial oor fracture Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base Fig. 200 Hypoplastic maxillary sinus (ype Uncinate process is attached ' lamina ppapyracea and obstructs ethmoil Irtundtoutum. Fig. 20 Blood traces mark the star-shaped path ‘of ative mucus transport tothe natural Ostium. Fight maxilary sinus.10 Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base If the human organism alone cannot cope with such a lesion, or a medical therapy is not effective, disease may spread under certain circumstances in a sort of “snowball effect,” particularly affecting the subsidiary large sinuses. Even relatively lcalized lesions, i they occur in the ethmoid infundibulum and in the frontal recess, can significant affect the ostium of the respective sinus. ‘Aresuit of this could be secretion retention and impaired ventlltion of the large sinus, creating ideal concitions for the growth of pathogenic bacteria and fur- ther expansion of inflammation. During inspiration, the main current of air is directed through the nasal valve in the direction of the anterior attachment of the middle turbinate. With this, par- ticles may be deposited on the head of the middla tirhinate ar on the uncinate process, the ethmoidal bulla and other frontally positioned bone-mucosa sur- faces. Normally, rapid removal of toxic substances occurs via mucociliary transportation. When contact areas occur, made more likely by anatomic vari- Fig. 21 ations or by epithelial lesions after viral infections, particles can remain longer Polyp development on the contact area, on the mucosa, and harmful activity occur either of bacterial, viral, toxic, en the uncinate process and middle turbinate on alt side. Dueto pressure €'zY™atic, allergic or immunological nature, from the polyps. the mice turbinates posted against the septum, Fig. 22 ‘Through an accessory ostium in the posterior fontanelle (280), viscous Secretion is transported from the nose into the left maxilary sinus and evacuated ‘through the natural ostium (above). The secretion “croulates” and can therefore ‘wansport pathogens into the maxillary Fig. 23 Purulent secretion trom acute sinusitis passes medially and latealy ofthe tubal otic, but also directly over the already blocked tubal ostium,Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base n ‘The hiatus semilunaris can become diseased as a result of a contact area be- ‘ween the uncinate process and the middle turbinate. This in turn can affect the ‘ethmoid infundibulum and/or the frontal recess or other ethmoid clefts, which ‘can cause disease of the maxllary or frontal sinus. The disease processes can ‘encroach upon the posterior ethmoid bone and the sphenoidal sinus, or even Endoscopic diagnosis is designed to recognize chronic and acute inflamma tion or possible underlying anatomical variations and other predisposing factors In the lateral nasal wall, and allow an early (medica) treatment. Further, tho effect of a therapy can endoscopically be controlled and, if necessary, a surgi cal procedure may be indicated. Fig. 24 Fig. 25 ‘MUcus transport out ofthe paranasal sinuses and through lateral nasal wall with Mucus transport out ofthe paranasal pathological route via the tubal esti, ‘sinuses and through lateral nasal wall. Under physiological conditions, the ‘tubal orice is bypassed.2 Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Bas Technique of Diagnostic Nasal Endoscopy ‘The examination is performad on a patient in the recumbent position preferat ly after applying topical anesthesia combined with a mild vasoconstrictor. F difficult cases with children, general anesthesia may be required. The telescopes best suited for endoscopic diagnostics are: 1. 90° direction of view, 4.0. mm diameter 2. 30° direction of view, 2.7 mm diameter 3. 70° direction of view, 2.7 mm diameter “The 20" telescopes offer suicient straight forward viewing to be inttoduc Under rect vison, without making contact witha mucosa srlace.Troug longitudinal rotation (not noticeable to the patient), they allow an overview o Fig. 26 for example, the entire epipharynx of a patient from one side of the nose. F< Pion tthe examinesurgeon dng narow anatomical conditions or corresponding pathology, the 2.7 mm ik poneniaa nine ‘scopes are used. Moraaver, the 70° telescope is intended for special problem (frontal recess, postoperative inspection of the sinuses through the ostia). Fig. 27 Fig. 28 Twoshanded guiding of the 30 telescope Correct single-handed hold ofthe 20° telescope with atached round handle, during diagnostic endoscopy.Endoscopic Diagnosis and Surgary of the Paranasal Sinuses and Anterior Skull B 13 Systematic Endoscopic Examination of the Nose is Divided into Three Steps: 41. General overview for orientation and then passage along the floor of the nose up to the choana. Examination of the tubal orifice, Rosenmillers recess, 2s well as the nasopharynx with significant structures (e.g. the adenoids) ‘When retracting the telescopa, the orifice of the nasolacrimal duct can be iden- tified in the inferior nasal meatus. for which purpose a 2.7 mm 30° telescope is, ‘tated beneath the turbinate. 2. For the second step of examination, the 30° telescope is guided past the middle turbinate to the upper edge of the choana and from here upward into ‘the sphenoethmoidal recess. The superior turbinate and possibly a supreme ‘turbinate with their corresponding nasal meatus are visible. The sphenoidal sinus ostium can be seen in certain cases, depending upon the pathology "ig. 4 ‘Schematic drawing of the 3 examination ‘3. The third examination step leads the 30° telescope into the middle nasal “™SP®/or agnost nasal endoscopy. ‘meatus itself. The middle turbinate is carefully pushed medially with an lova- ‘or (Freer), without fracturing it. Depending on the anatomical proportions and prevailing pathology, one can identify the uncinate process, the hiatus semiluneris, the ethmoidal bulla, as well as the clefts behind and above the latter. In an antero-superior direction, a view of the frontal recess is achieved. Due to numerous anatomical variants, extremely difficult anatomical situations ‘may prevent here. The natural maxillary sinus ostium is normally *hidden” in ‘the ethmoidal infundibulum, and is not visible even with the telescope. Often, ‘one finds accessory ostia in the posterior, and more rarely in the anterior, fonta~ ‘alles. Sometimes one can lock through these into the maxillary sinus itself. When pulling back the telescope, ¢ look can then be taken into the olfactory fissure. Fig. 29 Fig. 90 Correct positioning ofthe telescope and instrument. This basic position apples to both Schematic drawing of retrograde examina ‘Stes ofthe nose. ‘ion ofthe mile nasal meatus. The insert shows, ia frontal section, now the feo Scope ls "roled” under the middle tubinate.14 Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base Tips and Tricks The topical anesthetic with vasoconstrictor should be given a few minutes tims to take effect. For areas upon which pressure is likely from the telescope or an instrument (septal ridges or spurs), a topical anesthetic should be direct) applied with a cotton applicator. The telescope should always be guided under direct vision, in order to avoid Injuries, bleeding and pain of the very sensitive mucosa. The endoscopic ‘examination technique is an ideal opportunity to learn the correct handling o' telescopes and instruments. This is an indispensable prerequisite for atrauma: tic surgery In order to identity the orifice of the nasolacrimal canal, it may be useful t gently massage the patient's lacrimal sac with a finger. This will cause either Fig. 92 tear fluid to appear or the mucosa will buige over Hasner’s vaive. Overview ofthe common nasal meatus neal “) and entry into the middle nasal meatus on the right Fig. 83. Hatsne's valve (orice of the nasolacrimal lucy}, inthe Inferior nasal meatus on the Fight. Fig. 94 View into the middle nasal meatus onthe ight. From lateral, the uncinate process is. Cleary recognizable, and behind I, partially obscured, the front surface of the ethmoidal Dalla Medialy the lateral surface ofthe middle turbinate,Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base 15 itis not possible to enter the middle nasal meatus directly from the front, one can also move the telescope in the direction of the posterior end of the turbin- ate and then rotate it under the turbinate. The middle nasal meatus is usually wider here than anteriorly. The examination then proceeds retrograde from back to front (Fig. 20), ‘The goal of any diagnostic examination should also be to rule out hidden mall- ghanicies, Precise Uucumentation of findings is strongly recommended as part Of the case history. This can be of medico-legal significance especially in pa- tients who have had previous surgery elsewhere. Instruments for Endoscopic Diagnosis Besides the telescopes mentioned, we use an atomizer with rubber bulb to Fig. 38 soray the topical anesthetic, a nasal speculum and, according to need, a Freer elevator, cotton applicators, angled dressing forceps, as well as a suction system. If necessary, appropriate biopsy forceps and punches should be on hand. (ilustration of instrument set, see page 60) Postoperative healing process. Crust formation eround a wide maniliary sinus ‘cetum in the miscle nasal meatus on the Fight, 8 days postoporativay. Fig. 35 Fig. 26 Fight sphenoethmoidal recess. The Fight nose. A ver large septum ridge in. Apa spur protrudes into th lateral sphenoidal sinus ostium is clearly Close contact withthe midle turbinate. nasal wal ust below the lft middle, ‘recognisable, Lateraly from this, turbnate rugimentary supreme troinateEndoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base 15 itis not possible to enter the middle nasal meatus directly from the front, one can also move the telescope in the direction of the posterior end of the turbin- ate and then rotate it under the turbinate. The middle nasal meatus is usually wider here than anteriorly. The examination then proceeds retrograde from back to front (Fig. 20), ‘The goal of any diagnostic examination should also be to rule out hidden mall- ghanicies, Precise Uucumentation of findings is strongly recommended as part Of the case history. This can be of medico-legal significance especially in pa- tients who have had previous surgery elsewhere. Instruments for Endoscopic Diagnosis Besides the telescopes mentioned, we use an atomizer with rubber bulb to Fig. 38 soray the topical anesthetic, a nasal speculum and, according to need, a Freer elevator, cotton applicators, angled dressing forceps, as well as a suction system. If necessary, appropriate biopsy forceps and punches should be on hand. (ilustration of instrument set, see page 60) Postoperative healing process. Crust formation eround a wide maniliary sinus ‘cetum in the miscle nasal meatus on the Fight, 8 days postoporativay. Fig. 35 Fig. 26 Fight sphenoethmoidal recess. The Fight nose. A ver large septum ridge in. Apa spur protrudes into th lateral sphenoidal sinus ostium is clearly Close contact withthe midle turbinate. nasal wal ust below the lft middle, ‘recognisable, Lateraly from this, turbnate rugimentary supreme troinate16 Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Bast Examination of the Lateral Nasal Wall. ‘Anatomical Variations. Numerous anatomical variations can additional complicate the anatomy of the lateral nasal wall and the conditions of the ‘ostiomeatal unit. It must be remembered that none of the listed variations is pathological process per se, le., the simple presence of an anatomica variation must not automatically be interpreted as an indication for a surgica procedure. However, such variations may considerably constrict the narroy lets of the ostiomeatal unit, especially if multiple variations occur in combina tion, bringing facing mucosal surfaces into contact, Therefore (from a certair degree of development) we must view these variations as factors which pre dispose to more rapid and frequant appearance and persistence of acute anc chronic inflammations. Differentiation between an anatomical variation as ‘coincidental finding and as a causal factor for sinusitis can be very diffcutt i incividual cases, The most frequent variations are summarized in the followin. Fig. 39 table. With 2 rif look into this let mide nasal meatus, there only appears to be a smal ‘rust. When approached withthe tee ‘Scope, it however demonstrates, Frequent anatomical variations which can predispose to acute and recurrent sinusitis or impaired nasal breathing: Variations: Clinical significance: Septum deviations, ridges, spurs Contact points, potential narrowing ofall nacal meatus, pain ‘Aggor nasi cals Depending on degree of preumatzation, constriction of tho frontal recess, deeasbe of he lacrimal system Uneinate process Laterally curved, contact with the lamina DPapyracea and resulting atelectatic invun- ‘libulum (ypieal for the 3 degrees of hypoplastic maxilary sinus) medialy cuived, curved mectaly and towards the front (doubled mile turonate' rack tres, pneumatizad: all types of contact vith trbinate Fig. 40 32 perforation in the uncinate process with inristation and granulating mucooa incioa ting an inflammatory process in the ethmoid infundibulum Preuratizaion concha bulosa), parado- cally curved, contact with uncinate pro- {ees andlor septum. Extreme size due to proumatization; fl pert middle nasal meatus; contact points with mide turinate: overlapping the hiatus sernlunaris: constction of the frontal recess, pressing the middle turbin- ate against the septum o* growing out of ‘the midole nasal meatus towards the front. peo CConstricion of tha ethmoidalintuncibul- lum and/or maxllary sinus ostium, dale turbinate Ethmoidal bulla Fig. 1 Lat mice nasal meatus with uneinate process folded foward mecialy. The ree ‘mergin ofthe process touches the middle {urorate. A the contact point, mucosal ‘edema and incipient polyp formation, ]The best known and most frequent variations affect the course of the uncinate process. For one, it can be bent in such a way medially that it contacts the turbinate and blocks the path into the middle nasal meatus lke a frontal plate. It can be curved so that it projects out of the middle nasal meatus like a 1nd middle turbinate. This condition is known as the “doubled middle turbi * (Fig. 43). Perforations in the uncinate process can arise from inflamma: s behind this, ie., in the ethmoicel infundibulum. All mucosal changes of the medial surface of the uncinate process can be clues to changes which le erin the middle nasal meatus and must be carefully evaluated (Fig. 40). osal polyps very frequently result from contact points between the uncin roves and the middle turbinate, as well as to the ethmoicial bulla (Fig. 42). pneumatization of the middle (possibly also superior) nasal turbinate is called ‘concha bullosa”. These can be so pronounced that the turbinate is pressed the lateral nasal wall and medially touches the septum. Simply by their pre- ce, they can considerably impair breathing. In their interiors (the “turbinate cei"), pathological mucosal changes, edemas, mucopyoceles, mycoses and lesions can be found. Fig. 42 Left midale nasal meatus. Between the uncinate process lateral, the ethmoidal bulla srsally, and the middle turinate medially, a sof mucosal polyp has developed which 58 form a Contact poin between the bulla and uncinate process. joscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base Fig. 43 ‘Anluncinate process oxtramely folded ‘madally and toward the front ona ght Side, The unciate process tnereoy appears like a second (‘doubied") mice trbinate,18 Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base The middle turbinate can also be paradoxically curved, i.o., its convexity pointing laterally, and thus significantly constrict the entry to the middle nasal ‘meatus. The ethmofdal bulla can be extremely pronounced and then greatly constrict the hiatus semilunaris from behind. From contact areas on the un- cinate process and on the middle turbinate, edemas and polyps may result Agger nasi cells result ifthe agger nasi is preumatized from the frontal recess. Even a non-diseased large ager nasi cell can considerably constrict the fron- tal recess and therefore cause a predisposition to recurrent, frontal sinusitis (Fig. 45). Haller’s cells develop at the floor of the orbit in’ the area of the ethmoid infundibulum, considerably constricting it trom above and behind, and can even completely block it. They are frequently the reason for recurrent, otherwise therapy-resistant diseases of the maxillary sinus (Fig. 46) Fig. 44 Paradslally curved and simultaneously jpnoumatiznd mise tuoinato on the ft Fig. 45 Fig. 46 A protrusion in the area ofthe aggernasi_ CT with pronounced Halles cal, bilaterally, These are practically using up the ethmoid Just above and before the attachment of __infurcibUlum and are touching the uncinate process. the middle tuinate ean indicate a pna matizaton. Definite proof is only possile byer.Endoscopic Diagnosis and Surgery of 3.0 Maxillary Sinus Endoscopy ‘We see much less indications for maxilary sinus endoscopy today than only @ ‘few years ago. Basically tis required only to clarity suspicious lesions affect- “eg the maxilary sinus, for instance, tumors. Foreign bodies can also be _femoved endoscopically. Inlammatory processes which affect the maxilary ‘oday are treated mostly by transethmoidal routes via the middle nasal ‘meatus. - ‘Technique of Maxillary Sinus Endoscopy: ~ ‘We perform endoscopy almost exclusively via the canine fossa. After injection ‘ofa jocal anesthetic under the mucosa, the anterior wall of the canine fossa is ‘perforated with the maxillary sinus trocar using a regular to and fro rotating ‘movement. Incision of the mucosa is not required. One should never attempt to “punch through” the anterior wall of the maxillary sinus using the trocar without ‘tating. One very clearly feels the perforation of the mucosa of the oral vesti- ‘bule, as well as the “boring through” of the anterior wall of the maxillary sinus. “The advantage of this approach is in the large rotation radius which the maxil- ‘ary sinus trocar offers for direct vision and manipulation (see Figs. 47 and 48). the trocar into the maxilary sinus through the canine fossa with rotating Fig. 48 Schematic drawing ofthe rotation radius ofthe trocar sleave20 Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base Fig. 49 Right maxilary sinus, a foreign body (root canal filing) Blocks the natural ostium. Fig. 50 Aspergilus mycosis of « maxillary sinus. ‘The fungal concretion is recognizable. Further dorsally, purulant secretion with fungal spores © evacuated through the Biopsies from the maxillary sinus can be done with optical biopsy forceps or also “blindly”. To do this, the 0° telescope is used to direct the trocar sleeve to the point to be biopsied, the telescope removed and the trocar sleeve is held in position. Then a straight biopsy forceps is guided in, Tissue Is removed and then the telescope is used to inspect the area again. Cysts can also be remov- ed in this manner. This approach is also well suited for studying the secretion transport in the maxillary sinus. When correctly performed (perforation is normally high between the roots of teeth 3 and 4 and as laterally as possible in the canine fossa), problems such as lasting dysesthesia or paresthesia are ‘extremely rare. The trocar sleeve is removed at the end of the examination ‘end/or menipulation with the seme careful rotating movement. A suture is not required. The patiants are instructed to avoid blowing their nose for 2-3 days. For children, maxillary sinus endoscopy is very rarely indicated. In this case the path of approach must be chosen depending on the status of development of the maxillary sinus. (Detailed information about use of the technique on child- ren can be found in the book “Functional Endoscopic Sinus Surgery”, H. Stammberger, page 232) 35 oot canal filing was found atthe base ofthis ral guta-percha pin, reaching fealy into the lumen, maxillary sinus surrounding @cExdoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base 21 3.1. Blue Light Endoscopy Sue light endoscopy i utllzed to demonstrat and localize cerebrospinal flo Setulze and for thot surgical closure. To doth, we administer 0.2 to 0.5 ml of 25% soclum fiorescan solution intalumbaty before the examination/opera Seon. After injection, the patient is positioned with the head down fora variable boron of time inorder to alow the sodium furesceln tobe astbuted nthe Serbrospinal fig, Dependent upon the sia ofthe defector the inensty of swalquorthea, neon yellow-green marked CSF appears out ofthe nose, With ‘Pe eiescape, important information concerning the focaton ofa detest can be Gautier. The application of blue ight witha certain wavelangth in conjunction sen. complementary titer (see below) then activates the fucrescence. Under ese concitons, ven minimal CSF traces appear glowing yelow-green. Thus, many cases, detection of iquorthea ls successful, where radisotopes and citer techniques have fale. Areas can also be recognized were there Is no freo flow of CSF, but stil an inauficiont scar (e.g. mucosa-arachnoidea) 6-52 a prevents the escape of CSF, but not an ascending bacterial infection. Often in waescein marked CSF dipping om ‘ese cases, the deposition of fluorescein Inthe mucosa or the scars the only ue toa weak pont inthe anterior skull base and thus allows a solctve sug cal procedure. must again be emphasized that only very specific prepara = ‘Sons of sodium fluorescein in avery specitic concentration may be used. these recommendations are folowed, the intrathecal fuorescaln technique becomes a method of examination with extremely few complications and cl= cally very helpul Details 2s to the exact proparaton ofthe Nuorescoin solution with reference sources fan be found in: European Archives of OTO-RHINO-LARYNGOLOGY, Verhanglungs Bericht 1993 der a. Ges. fUr HNO-Heikunde Tol | Reate), Ve Fig. 53 Diagnostic endoscopy with bluo light. Fig. 84 Fig. 55 Fig. 56 Fight rma olfactoria. Some yellowish ‘Sbservation under bie lght allows the BY combining a barter fiter withthe blue green secretion is visible on the skull “ecretion” tobe olealyidentifed as light, only the ight from the excited Base. fluorescein marked cerebrospinal fuid, fluorescein le alowed through, Thus even the smallest waces of marked CSF can be aiscovered22 Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base 4.0 Surgical Techniques The basic techniques for the surgical intervention itself have already been described in detail in various publications and need only be described here in a brief overview. It should however be emphasized again, that surgical techniques must ‘only then be used when a selective and balanced medical therapy has not brought about any improvement in complaints, or incipient complications, ‘make an immediate operation necessary. Tho basic principle of the Messerklinger technique is to selectively clean up only the diseased key positions after an exact preliminary diagnosis. The nat- tral drainage and ventilation paths should be restored, the anatomy changed. as litte as possible, and the mucosa preserved to the greatest extent. These Fig. 57 principles may also be applied during the performance of a total sphenoeth- Unde conan creunetarces ort maidectomy. Shorter perocs of healing rapid epithelial regeneration anda iow Rear eee eee, tendency to incrustation are the cistintive features of this procedure. Larger cally without surgery amounts of diseased mucosa are removed only in cases of marked mucosal changes, such as diffuse polyposis nasi with eosinophilic dominance and bronchial asthma or fungal allergic sinusitis. In the maxillary sinus itself, the ‘bone should never be exposed nor the mucosa completely removed. This, is reserved for radical surgery in cases of tumorous changes. Fig. 52 Fig. 50 Endoscopically the middle nasal meatus _In this CT, a homogenous opactiction of the ethmoid and the maxillary sinus on the left Is blocked, the uncinate process pressed are seen against the midoleturbinate. There is no ‘escape of pus.Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anteri ‘The frontal recess represents the most complicated anatomical region. Even’ for experienced surgeons it can be very difficult to find the route to the frontal sinus, e.g. through the scars and polyps after previous operations, without performing radical surgery. With appropriate experience and practice, care and patience, this can, however, almost always be achieved. Opening a diseased frontal sinus transnasally with the dril, as well as the creation of socalled "median drainages” have become a rarity for us due to these techniques. It has ‘also become evident that itis exactly these surgically induced lesions caused bya routine use of too aggressive procedures which bring the patiant discom- fort due to scar formations, synechia and ostial stenosis. The Messerkiinger technique alms to perform surgery which is individually Suited to the respective pathologic process. It proves to’be advantageous that, ue to the graduated procedure moving from front to back, the surgeon is able fo respond to situations encountered during the operation by expanding or reducing the surgical intervention, Therefore routine radical operations can be avoided for the most part. The tissue-preserving surgical technique and the relatively minor bleeding associat- ed with it mean that @ postoperative tamponade can almost always be dispensed with. This contributes significantly to more rapid patient recovery. However, it must constantly be remembered that telescopes are only auailiary optical instruments. Endoscopic surgery has many indications, but also defin- te limits and contraindications. The risks and possibilities of complication are the same as for any type of endonasal ethmoid surgery. This technique must therefore be carefully learned and taught. Easily attached endocameras provide: ‘excellent learning and demonstration possiblities for students as well as for OR personnel Fig. 60 Applators with 2% pantocaine + adrenaline 1:1,000 were placed inthe mid Salus under endossone guidance and let or 20 minutea. Upon removal, pus began jo flow and the symptoms improved. Skull Base 23 Under cominuing antilotc therapy anc repeated endoscopic insertion of decon- {gesting applicators, complete recovery Securred without surgical intervention ang without maxilary sinus eigaton.24 Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base Fig. 62 Preparation of anesthetizing and econgesting applicators, soaked with 2% pantocain and adrenaline ¥:1,000 (oe text 4.1. Preparation for Surgery Regardless of whether the patient is to be operated on under local anesthesia after premedication, or under general anesthesia, the nasal mucosa must be suitably prepared, The aim is good vasoconstriction and anesthesia. For patients under local anesthesia we use cotton applicators (Fig. 62) which have been soaked in a mixture of 4 to 5 parts 2% pantocain and 1 part adrenaline (1:1,000) and excess solution removed. These applicators are inserted under direct vision into the middle nasal meatus, as far as the pathology allows. The applicators are then also applied around the middle turbinate on all ‘mucosal surfaces, if possible also to the end of the middle turbinate near the ssphenopalatine foramen. Moving toward the front, the common nasal cavity is, loosely filed with applicators. For patients being operated on under general anesthesia, we use applicators soaked in adrenaline (1:1,000) only. Again itis emphasized that excess solution must be well squeezed out before applica- tion. ‘The applicators remain for at least 10 minutes in situ and are then removed (see Fig. 62 and 63). Then an additional local anesthetic is applied which is normally injected under the mucosa of the uncinate process. An injoction ‘appears to be important at the attachment of the middle turbinate, since in this, ‘way the anterior ethmoidal vessels and nerve fibers can be blocked. In most ‘cases, 1 to 1.5 mi of this submucosal infitration are sufficient, for which we generally use the customary 1% lidocaine (Xylocaine) with epinephrine 4:200,000. Fig. 63 ‘After a waiting period of atleast 10 minutes (fr interventions under local ‘nesthesia) the applicators are removed ‘and additonal infiraton anesthesa 'e ‘administered. Fig. 64 ‘Schematic drawing of the most important injection points forthe local infitraton ‘anesthesia, (Drawing: W. SCHROCKENFUCHS, M.D)Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base 25 _ 4.2. Surgical Technique — Practice |The following surgical steps shown are not routinely performed during every Jntervention and in this exact sequence. They rather represent the possibilities. ‘fa surgical procedure as they may become necessary in individual cases. The basic principle of the technique is always an individualized surgical procedure ‘appropriate to the respective situation of the patient in question. Of course a {otal sphenoethmoidectomy with openina of the maxillary and frontal sinuses. ‘can be performed. We, however, see the advantage of the technique precisely In the fact that euch interventions can be avoided in the majority of cases as routine measures. 4.3. OR Positioning Fig. 66 shows the standard positioning during endoscopic intervention: the ‘surgeon sits at the right side of the patient, with the knees under the patient's, ‘shoulders. The OR nurse stands across from him. The monitor is at the head ‘end of the patient, the anesthesiologist standing preferably at the left side of the patient next to the OR nurse or on the right side behind the surgeon. ‘Support for the surgeon’s arms is important to avoid fatigue and aid in precise ‘manipulation. During individual steps of the operation, the same caution and ‘care should be applied as during middle ear interventions. In our opinion, itis hardly possible for a surgeon to stand and work “free hand” with as much pre- cision as a seated surgeon with supported arms, Its neither necessary to use ‘Specula nor cut the hair in the nasal vestibule. (OF situation during intervention under Jocal anesthesia wlita - Fig. 65 Fig. 85 OF situation, general anesthesia: the surgeon operates under direct vision trough the Schematic drawing ofthe OR arrango- telescope, Observers can follow the procedure on monitors. ‘ment during interventions under general sresthesia.26 Endoscopic Diagn is and Surgery of the Parana: | Sinuses and Anterior Skull Base With some practice and care, it is easy to guide instruments and telescopes in and out through the nostrils more efficiently than with the use of self-support- Ing specula. The elasticity and distensibility of the nostrils can thus be exploit fed in order to reach remote corners of the nose and sinuses. We perform all interventions, from the first to the last step, under endoscopic Vision. Using a magnitying lens or a headlight to remove anterior polyp masses. Under direct vision has not proven successful in our experience. Important structures in the area of the middle meatus can thus be destroyed or so damag- ed that bleeding results. This will impair the telescopic view and render the remaining procedure more difficult. Cspecially for massive polyps, experience ‘shows that with the first surgical step ~ usually the removal of the uncinate process - the bulk of this polyp mass is also removed since it also arises from the uncinate process or its immediate surroundings. Fig. 68 Extreme care should be utilized with every manipulation: mucosal injuries “Signal pop between uncinate process. should not occu, nelther when introducing the applicators nor when guiding in ° the instruments and telescopes. Even the tiniest bleeding mucosal lesion in front of the middle nasal meatus can greatly complicate the remaining pro- cedure Our recommendation is therefore never to operate via the monitor image. The surgeon's eye should always be on the telescope and he should always. move with it. In our experience, a better spatial foo! is attained and uninten- tional injuries are avoided to the greatest extent when guiding in the telescope and instruments. Further, the anatomic orientation of the surgeon is therefore always immediate and direct, which means (possibly unnoticed) rotations of the attached camera in relationship to the telescope do not influence the orientation of the surgeon; however, such movements can more easily lead to orientation problems on the monitor. Fig. 8 ‘Small polyp from contact area on the middle turbinate: uncinate process on the lft Fig. 70 Fig. 71 Fig. 72 Patient from Fig. 68, view of edematous Lage polyp trom etmold infundibulum Telescope and instrument hanaling during bulge on anterior surace of ethmoidal on the left. surgical manpulavons, bullndoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base ar ? 4.4. Individual Surgical Steps : Sinc® in the majority of cases the pathological changes are to be found in key areas of the anterior ethmoid, the first surgical step usually is resection of the ncinate process. This resection, also known as “infundibulotomy,” removes "e medial wall of the ethmoid infundibulum and thereby opens it. But the Sinfundibulotomy” is in no way synonymous with the “Messerklinger Technique.” it only represents a small ~ usually the frst ~ surgical step in an entire spectrum of further possibilities. With a sickle knife, the uncinate process is carefully punctured 2 to 3 mm posteriorly to its attachment on the lateral nasal wall. The knife must thereby y penetrate 1 to 2 mm into the ethmoidal infundibulum and then immedi ‘ely be positioned parallel to the lateral nasal wall. In this way, one can a event making the incision too deeply, e., through the lamina papyracea into the orbit especially on a flat or alm ic ethmoid infundibulum. In an Fig. 73 S it especially on a flat or almost atlectatio ethmoid infundibulum. In an 0.78. in. vewinto aright mide ‘nasal meatus, O° flescope. n interiorly convex line, the incision is then extended posteriorly-inferiorly and n anteriorly-superiorly and the uncinate process is thereby peritomized (Fig. 74), Should the attachment point ofthe uncinate process not be clearly identifiable, tis better to resect the uncinate process “in strips” from back to front, in order 9 prevent unnecessary bleeding of mucosal injuries at the entrance to the . middle nasal meatus. Fig. 74 - Afr piercing the uncinete pr Sickle leita must be guided par lator nasa wall (ower arrow Fig. 76 Fig. 75 , © uncinale process has been removed, _Sitvation from Fig. 75 on an anatomical _Luxation of the uncinate process medial © viow info the middle nasal meatus. specimen. View into the infundibulum and onto the anterior surface ofthe bull,SUS 28 Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base ‘Then the uncinate process is luxated medially (Fig. 75) and permits a view into the ethmoid infundibulum with its corresponding pathology. Dorsally, this chamber is limited by the anterior face of the ethmoidal bulla. When removing the uncinate process at the top and bottom, care must be taken that the resec- tion edges are smooth and the mucosa does not tear any further superiorly toward the middle turbinate or inferiorly towards the inferior turbinate, thus causing unnecessary raw surfaces. Its best to carefully twist off the uncinate process with Blakesley grasping forceps. “Pulling” movements towards an- teriorly should absolutely be avoided After removal of the uncinate process, view of the ethmoidal bulla is unob- structed. Between its madial walls and the middle turbinate, very frequently polyps arise or disease processes develop (Fig. 78). In case of frontal recess diseases without involvement of the ethmoidal bulla (which is relatively rare), ‘one could now simply change to a 30° telescope and select an upward path Fig. 78 through the frontal recess into the frontal sinus. If there are, however, changes Tavemove the niraides bom which require surgery on the posterior ethmoid and/or sphenoid sinus, we recommend taking care of these first and, as a last step in the intervention, ‘moving to the frontal recess. To resect the ethmoidal bulla (Fig. 79), It should be pressed in with a grasping forceps at its lower medial aspect and its lumen identified. If necessary, the bulla Is completely removed ensuring that the medial bulla lamella, sometimes. hidden by the middle turbinate, is also removed. Fig. 79 Ris pressed in at its lower medial edge, ifs lumen identined and then resected Fig. 20 Fig. 1 View of large ethmoidal bulla inthe right Schematic outine ofthe uncinate process (dotted in red), the hiatus semilunars, as ‘mice nasal meatus, wallas the thmoidal bul (green) below the middie turbinate,llustrated in yellow is the hourglass shaped" contourin sagittal section of the transition from the frontal sinus to the frontal recess.Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base 29 Above the bulla there can be, according to the anatomic situation, a corres- eondinaly large suprabullar recess, and dorsal of the bulla a retrobullar recess. The upper limit of the former is the skull base, the dorsal limit of the letter is the basal lamella of the middle turbinate (Fig, 81/82). In order to reach the posterior ethmoid sinus via a transethmoidal route, this basal lamella of the ‘middle turbinate must then be perforated in its middle, frontally oriented third. must be remembered that this lamella is not necessarily an ideal frontally run= fring bone surface, but rather can be indented by a large supra/tetrobullar recess. (This corresponds to the “sinus lateralis” according to Gruenwald, ‘extending far posteriorly) In an extreme case, this recess ~ belonging to the terior ethmoid ~ can reach all the way to the anterior surface of the sphenoid Sus. In the roof of the ethmoid above the bulla, the anterior ethmoidal artery an be recognized in many cases {in 40%, its bony canal downwardly dehis- cent) (Fig. 84), Jo perforate the basal lamella, one finds the correct position as folows: ater F985 fest identiying the horizontal section of the basal lamella (which forms the root Senate drawing ofthe tho oot of the dorsal thi of the middle nasal meatus) one then moves from back toward the front in ordar to identity the transition between tis horizontal pat of the basal lamala and middle, frontal oriented par (Fig. €2). Fig. 84 ‘An anterior ethmoidal artery in an ana tomical specimen, = | Big. 82 Fig. 8 Schematic drawing of perforation ofthe basal lamella to enter posterior ethmoid or Depiction of both anterior thmoidal Superior nasal meatus. ateres in a CT (arrows) 2 iceally-even basal lamella in its frontal course. The perforation is mado 3 to 4 mm ‘above the transition tothe horizontal par In the dorsal thir ofthe basal lamella, ) Basal lamela with recess caused by superior meatus bulging anterior, and downward ©) Basal lamella bulging posteriorly due to large supra/retrobullar recess,30 Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base - Fig. Sata | CT with the basal alia: ‘uncinate lamella; 2 = Bulla lamel; 35 basal emefla of he me rate: 44 basal lamella ofthe superior turbinat. Notice the “hourglass shape” ofthe fron= ‘ei sinustrontal eves transition Fig. Possible relationship ofthe optic nerve to the posterior ethmold and spheroidal Fig. 08 Longitudinal section through the sphen- da sinus with superimposed Onodi cal Which has a close relationship tothe optic foramen. (Original lustration from Onod's text Book, 1908) 3 to 4 mm eranially from this bend, the basal lamella Is now perforated with, closed Blakesley grasping forceps, opening up the route depending on the anatomical situation into the cells of the posterior ethmoid or into the superior nasal meatus. Depending on the pathology, polyps, eic., could now be re- moved from the posterior ethmoid. It must be remembered that the lateral limit Of this cavity, the dorsal third ofthe lamina papyracea of the orbit, is extremely thin here and may even be dehiscent. If posterior ethmoid cells extend far posteriorly, the optic nerve tubercle, ar even the optic nerve canal itself may be ‘prominent here. Such Onodi cells present to the surgeon as pyramid shaped cells, the base of which is facing the surgeon. These cells can extensively develop laterally beside or even superiorly above the sphenoid bone. In some cases, even the internal carotid artery can be prominent in such an Onodi cell (ig. 90). The surgeon should always remember that when Onodi cells are present, the anterior wall of the sphenoidal sinus must be looked for medially, and inferiorly curing transethmoidal approaches (Fig. £1) Opening of the sphenoidal sinus is possible in two ways: either by extending the previously described transethmoidal route or by direct route e.g. in cases of isolated diseases of the sphenoid sinus through the sphenosthmoidal recess. To do this, a path is chosen between the nasal septum and the nasal turbinates. With the transethmoidal route, the anterior wall of the sphenoidal sinus is carefully pressed in as medially and inferiorly as possible. This is best done with a small oval curette (Fig. 91). Under no circumstances should sharp cutting instruments be used for this. After identifying the lumen of the sphen= Old sinus, the perforation in the anterior wall can be extended if the sphenoid pathology requires this, and the natural ostium in particular can be included in Fig. 9 Fig. 00 Conventional sagital tomogram of an Prominent apt: nerve and internal carats ‘analogous situation on a patient. aniry in an Onodl cal ofthe right postee- ior ethmold. Notice the obliquely running anterior wall ofthe sphenoidal sinus (ght.Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Baso ‘is perforation. To do this, we use the circular punches shown in Fig. 95, which are Ideal for cutting in all directions without rotating the instrument handle and therefore without hampering the surgeon. Due to the blunt design cf the top part which is inserted into the sphenoidal sinus, unintentional injuries ae practically eliminated with correct handling Especially within the sphenoidal sinus, no cutting or punching instrument of any sort should be used if possible. Always keep in mind the great spectrum of variation and possibilty of dehiscences ‘in the optic nerve and the carotid canal All the steps described so far do not require full or partial resection of the middle or superior nasal turbinates. Thus, functional anatomy can remain preserved in most cases. Should it be necessary, the surgeon can now move on to the skull base and contal recess. To do this, one again identifies the attachment of the basal jamella of the midcle turbinate to the skull base and dissects along this from Fig. back to front. Attention must be paid to the anterior ethmoidal artery which at A “Tansethmoidal opsning othe sphenoid sinus with the cuette toward mechally and may run through an osseous channel several millimeters beneath the skull irenctly, base. It should not be injured if at all possible. Fig ing 92 View into sphencidal sinus demonstrat the course of opi nerve and internal Fig. 94 carole artery. é Fig. 95 Fig. 9 h the circular punch, the anterior wal ofthe sphenoldal sinus can be widened, or View intraoperative into a right sphencidal wen hin oss80us septa of the ethmold bone can be resected. Oue to the ckcular sinus after aspiration of congested secre iting mechanism, no rotating movements ofthe instument handle are necessary, tion.Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base Fig. 96 Schematic drawing ofa terminal recess ofthe ethmoid infundibulum, combined ‘wth an ethmoidal bulla (dotted line) which reaches far forward and superiorly. Fig. 97 High terminal recess ofthe ethmoidin- fundioulum, pronounced constriction of tha frontal recess Fig. 08 Constiction ofthe frontal recess by an ‘ager nasi cell dotted outing) Interventions in the area of the frontal recess present the greatest challenge by far to anatomical knowledge and surgical dexterity. There are essentially 3 ‘actors which can constrict the frontal recess and hence the route to the frontal sinus, and can predispose to recurrent inflammations of this area and of the frontal sinus: ‘The uncinate process, the ethmoidal bulla and ager nasi cells. In particu lar, combinations of anatomical variations of these structures, combined with a Paradoxically curved middle turbinate or a conche bullosa, can represent @ major technical challenge. It frequently occurs that a well developed agger nasi call ~ which is usually peumatized from the frontal recess Itself - grows posteriorly and superior into the frontal recess, closina this off with its upper half ike the top of an egg. The same situation presents when the ethmoidal bulla develops into the frontal recess from inferiorly and behind. The uncinate process may develop @ pronounced terminal recess. The uncinate then bulges out with this “blind sack" up into the frontal recess and inserts laterally con the lamina papyracea. ‘The surgeon must be familiar with these variations if he wishes to avoid un- necessarily radical procedures and subsequent traumatization of the frontal recess and the frontal sinus ostium. In the overwhelming majority of cases, it is possible to remove these andtomical structures with the correct instruments under direct vision of a 30° telescope without using a drill and thus open the path to the frontal sinus without removing any noticeable amount of parietal | Fig. 99 Highly schematic drawing of possible constrictions ofthe frontal recess. The route to the frontal sinus can be constrictad by an “egg-shaped” projection of aggernasi cols. (Give), variations of te uncinate process (red), as well as pneumatization ofthe bull (oreer) toward the front and top. Notioe the “hourglass” configuration of the transition from fontal sinus to frontal recess in this sagital section, The “waist is level withthe stm of the frontal sinus.Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base 33 Particularly well suited for this is Kuhn's frontal sinus curette (Fig. 103). If, after removal of the uncinate process and perhaps the bulla, no view is possible fhrough the frontal recess to the ostium of the frontal sinus, one must attempt fo very carefully remove the remaining bone cap with its diseased mucosa ‘rom the recess using the curved spoon. In case of a large agger nasi call, this, must proceed dorsally, i.e., entering between the skull base and bone cap, ‘breaking the latter away toward the front and downwards. In case of an en- ‘erged ethmoidal bulla or other cells coming from inferiorly and posteriorly, the ‘eat to the ostium of the frontal sinus opens up between the respective bone ‘cap and middle turbinate. This also applies to the terminal recess of the ‘ethmoid infundibulum which bulges superiorly. All of these manipulations must ‘be carried out with great care in order to avoid lesions of the lateral lamella of, ‘the cnibriform plate and of the ethmoid roof. ‘with 2 suitably curved, small forceps (Fig. 102), bone fragments can be careful- ly removed with precision under direct vision, and these instruments also permit the surgeon to reach into the frontal sinus. However, it is generally recommended that the ostium of the frontal sinus be extended toward the front ‘fnecessary and by no means remove the entire mucosa within the circum- ference of the ostium. This would inevitably lead to scar formation and steno- ses. The 65° upturned circular cutting punch was specifically designed for frontal recess. Without taking off mucosa (surgery), nearly horizontally lined up bony ‘amellar structures can be removed and the passage between frontal recess, and frontal sinus be cleared. Fig. 103 ‘Schematic drawing of removal ofthe terminal recess dome withthe curved curete, ‘© order to expose the ostium of the frontal sinus. led = uncinate process after “nfundbultomy. Fig. 100 Impeession ofa “flee celing." The domed remainder of tha uneinste process or Fig. 101 ‘of an aqger nasi cell can simulate the root of the ethmoid or of the frontal recess, The route Fig. 102 to the ostium ofthe frontal sinus and ihe sinus teal i, however, only exposed ater careful oval of this “egg eap'-lke ‘sseous lamela—— reer 34 Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base Fig. 104 Locking forthe ostium ofthe maxillary ‘Sinus nith the curette belveen the resect fed edge of the uneinate process and the ‘ethmoidal Bula, ‘Widening of a maxilary snus ostium moving forward with tne backbiting punch, Fig. 106 Gulding inthe sidebiting punch to enlarge the ostium ofthe maxilary sinus down: wards and posterior Widening of the natural ostium of the maxillary sinus in the middle nasal ‘meatus is no routine step for every endoscopic intervention. Only when corres- ponding pathological circumstances in the maxillary sinus are present, is the ?atural ostium widened in individual cases. The ostium is often concealed by a ‘small remaining lower part of the uncinate process, as if by a door. Iti there- fore important to identify this uncinate part. This is usually quite easy. After ‘medial and anterior luxation of this piece of bone, the ostium of the maxillary sinus is quite visible. Ideally, the ostium should not be touched further. If widening is necessary, this can be done with a backward biting punch (Fig 105) moving forward, at the expense of the anterior nasal fontanele, or with a sidebiting punch forceps (Fig. 106) moving down and back, possibly at the expense of the posterior fontanelie. If there are accessory ostia in the fontanel- les, these should definitly be connected with the natural ostia in order to prevent “circular transportation” of secretion in the postoperative phase. With such a widened ostium, it is now quite possible to remove any patholo gical processes such as cysts, polyps, foreign bodies, fungal growths, etc, via the middle nasal meatus with suitable instruments. if aconcha bullosa of the middle turbinate is present and is itself diseased or contributing to the pathological process, its lateral lamella is resected. To do. this, @ local anesthetic with vasoconstrictor is injacted under the mucosa as: described for the lateral nasal wall on page 24 and in Fig. 64. Then the turbinate coll is opened with the sickle knife from the front or from below, making certain that the pressure applied Is not strong enough to fracture the attachment of the turbinate. With a small scissors, the lumen of the turbinate cells then entirely opened and the lamella facing the lateral nasal wall is removed with grasping forceps. Under extremely pneumatized conditions toward the dorsal turbinate ‘end, beware of the proximity of vessels from the sphenopalatine artary. The lateral lamella of a concha bullosa should always be resected in such a way that the starting point of the pneumatization, i.e., the “ostium” of the cell is included in the resection. Fig. 108 Postoperative “crcular movement" of thickened secretion: Out of the natural maxily sinus ostium (not visio into the Imidale nasal meatus, trough an acces ory ostium in the posterior fontanelia and maxillary sinusse | Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base al Frontal sinus drains 5 ne | For endonasal surgery of the frontal recess and frontal sinus, we normally do '@ | getuse any spacing devices and/or drainage tubes. These are only used when @- | entering externally, particularly in case of trauma, with and without CSF fistulae er. | and tumors in this area, ifthe frontal sinus is to remain as an aerated cavity. In ry Sur experience, it has been an important criterion that the drain used is not Ii Sted tightly into the ostium of the frontal sinus but instead has enough 9 ‘@earance to allow growth of mucosa without risk of decubital necroses. This, a | marks best with a “self-nolding” frontal sinus drain,-which we construct as he | escribed in Fig. 108b. A 6 to 10 om long section is taken from a polyethylene el |g silcone tube (e.g, infusion tube), cuts are made into one end for approxim= to | tly 1 cm in such a way that a fan with numerous fingers results. This tube is, f ‘pulled over a steel “nail’, so that the nail head spreads apart the leaves of the hag jo- fen. The fan is then heated over a mirror heater unti all of the leaves bagin to. jia fun up. By sudden cooling in ice water, the fan is fixed in this shape. Finally, Fig. 108 se “nail is removed and the tube can be placed from within the frontal sinus, Set-holding frontal sinus drain ying in ‘The fans stiff enough to prevent the tube from slipping out, but is soft enough or five way during transnasal removal of the tube, passing through the ostium do ithout causing injury. In this way a loosely placed tube can be kept in situ for as several months without any problem. te in he aly ng te he ay Fo. 1080 ‘Beestnicton ofa sel-holcing frontal sinus drain, For details, see text. “Deswng: M. SCHROCKENFUCHS, M.D).96 Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base 4.5. FESS and Septum Deviations Septum ridges and spurs, which are significant to pathology and impair the endoscopic procedure, can be Weated without diffcully during the same tendoscopic session. After an inion of the mucosa and ereaton of sub faps, ridges and spurs are removed respectively and the mucosa laps are folded back. Then folows the scheduled intervention inthe lateral nasal wal itis only rarely necessary to perorm complete septoplasties. In our exper- ence, the signticance ofa slightly deviated septum has bosn overrated in sinus pathology, As long as the mile nasal meatus can be reached with a 4 mm telescope andthe necessary Istument, me do not perform any manipulations nthe septum. Atogether, the fequency of septoplasies performed in coniunc- ttn with endoscopic sinus interventions i ess than 5% among OU" patients The argument of performing a septoplasty routinely for almost every endonacal sinus operation in order to a) be able to use more voluminous Instruments Fig. 109 andor b) have “more room or postoperative care, we do not consider to be Inration offal anesthetic underthe Very gound. if an extensive septum deviation, e.g, a massive polyposis re- quires correction, we use the folowing procedure. The endoscopic intervention fst proceeds on the wider side, ‘nan the septum corecion Is performed {fom ths side va'a hemitransfion incision, followed by the endoscopic intr- vention onthe previously narrower side 4.6. Conclusion of Surgical Procedure We almost never use packings when finishing a surgical intervention. Usually, the oozing hemorrhage of the mucosa, which is minimal anyway, has stopped. at the end of the operation. If necessary, loose inserts of highly absorbent material, e.g., Sorbacel” can be used which do not need to be removed. In some cases we insert Merocel* or Sugi* sponges in the middle nasal meatus. These are secured with a holding thread, taped to the patient's cheek, to pre- vent slipping (aspiration!) A diluted cortisone solution is dripped onto these sponges which are normally left in the nose for no longer than 24 hours. Fig. 110 Opened concha bullosa with ol, thickened empyema Fig. 111 Septum ridge and spur on the left. Such findings can easly bo treated endoscopic. aly,Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base 37 4.7. Selecting Telescopes and Instruments Mest of the operation is performed using the 4 mm 0° telescope. This is the ‘eniy telescope which provides a direct, unlimited, straight forward view. This is f significance particularly for “endoscopic beginners”, since the instrument Sbaft actually points in the direction in which the surgeon is viewing. Working jean angled telescopes requires considerable practice. Until important land~ ‘arks have been identified, e.a.. on the transethmoidal route to the sphenoidal fone, the 0° telescope should be used exclusively for our technique. After ‘Sentification of landmarks, a 30° (or very rarely a 70°) telescope can be used fr work on the skull base or in sinuses such as the sphenoidal or maxillary sSrus. The 30° telescope Is indispensable, particularly for work in the area of Se maxillary sinus ostium and in the frontal recess. The forward oblique 30° fetescope with left side light connection and upturned Blakesley forceps with ‘side-angled jaws are especially sulted for manipulations in the frontal recess. This provides an improved action radius forthe telescope and grasping forceps fd avoids possible interference with the patient's chin and/or the intubation fube, which otherwise can considerably limit access to the frontal recess for ‘e telescope and instrument. ‘The 2.7 mm telescope is as excellently suited for diagnosis as it is limited in use for surgical procedures. It is used with corresponding handle for specially arrow circumstances, particularly when treating children (see below). The sespective instruments, grasping forceps in particular, should always be select- fed in such a way that the smallest possible model is used. By no means should ‘e instruments be so large that they cause lesions on the lateral nasal wall or fsasal turbinates when being inserted into the middle nasal meatus. Only in very ere cases, when treating adults, do we use a cifferent Blakesley size than size 4. For some cases of diffuse polyposis associated with considerable bleeding, Siakesley grasping forceps with integrated suction channel have proven to be helpful. We use these instruments selectively in such cases, but not routinely for every intervention, ‘Cutting forceps are a oreat help for special indications, particulary if after fprevious operations, compact scars or rather hard bone splinters must be Separated or removed. By no means, however, should these instruments be sed exclusively for routine application during a standard first intervention. ‘Their use should be reserved for experienced surgeons. Only they should use ‘aating instruments in the area of the spheroidal sinus or on the ethmoid roof wih extreme care. Fig. 112 Mile nasal meatus, et, postoperatively. Only ator moving closer with th toto scope. Fig. 113 "do2s one recognize thatthe ethmoid ‘nus hes boon completely opecated and iS well neaied. The maxillary sus ostium Is unafiected ¢ - im Fig. 114 CCT contol of conction after endoscople revision ofthe left sc,Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base 4.8. Bleeding during Surgery Of course, before surgery, any possible coagulopathies must be ruled out and/or corrected. If necessary, high blood pressure must be stabilized, although high systolic blood pressure in particular is rarely a reason for an increased tendency to hemorrhage during surgery It appears extremely impor- tant to instruct patients to refrain from taking aspirin and similar medications approximately 10 days before surgery, due to the well-known effects upon coagulation. Only exceptionally do we have the anesthetist use controlled, hypotension during interventions. Bothersome, diffuse oozing hemerhage of the mucosa can usually be control- led by repeated applications of cottonoids with 1:1,000 adrenaline. To do this, cotton swabs are sosked in adrenaline, pressed cut well and applied to the ‘corresponding locations. After 1-2 minutes, surgery can be continued in a rela tively bloodless area under good vision. Other possibilities include the applica- Fig. 115 tion of 2-3% HO, (hydrogen peroxide). Its foaming also leads to good ise eaccceneremarenaceican| hemostasis. Should spurting vessels appear, these can either be compressed, ‘as described above or treated with bipolar coagulation. Particularly suitable for this are bipolar suction-coagulation forceps. ‘There are four typical locations at which spurting vessels can appear: the an- terior ethmoidal artery during work on the ethmoid roof, particulary in the casa of a dehiscent channel. Second, branches of the sphenopalatine artery near the posterior end of the middle turbinate. Particularly in the case of middle ‘urbinate pneumatization which reaches far posteriorly, hemorrhages. can ‘occur here. Third, bleeding on the loner edge of the sphenoidal sinus window, also from branches of the sphenopalatine artery. Fourth, in case of expansion of the maxillary sinus ostium towards inferiorly, relatively massive bleeding ccan occur at the attachment of the inferior turbinate. Fig. 116 $e well controled withthe suction system, Fig. 117 ‘Tipofa bipolar suction-coaguation forceps. Fig. 117 ‘Spurting vessels can be stopped with atrenaline applicators or coagulated Fig. 1178 ‘View into the sphenoidal sinus after ‘coagulation ofa spurting vessel at the Tower edge ofthe perforation,4.9. Extended Applications J Athough the Messerklinger technique was originally developed for treatment ] ef chronic recurrent sinusitis with or without polyposis, new and rather fascina- n Sa application possibilities have arisen through the course of the years due to ereasing experience and familiarity with endoscopic surgery. Though the emnciples of functional endoscopic sinus surgery ("FESS") are applied for n ‘eesinophil-dominated, diffuse polyposis, this disease in fact represents. a d ‘ansition to extended applications in which well-known, standard and often Sescribed surgical techniques are performed under endoscopic view. This will eereesingly help avoid the previously used external and more traumatic ap- proaches, being at least equally effective. Here endoscopic surgery does not fepresent a new “concept” of treatment for a group of diseases such as : Shronic sinusitis, but rather a now, less traumatizing path of approach. The ; folowing can be treated endoscopically: mucoceles in all paranasal sinuses, in 4 some cases with considerable intracranial extension; mycoses of all sinuses; 4 removal of foreign bodies; small osteomas; benign or in certain cases even r malignant tumors; decompression of the orbit and optic nerve; the treatment of cerebrospinal fluid fistulae and meningoencephaloceles, and of choanal atresia and dacryocystorhinostomies. Even some pituitary tumors, or also juvenile acopharyngeal angiofibromas and other tumors in the area of the skull base an be operated on endoscopically. Fig. 122 OF situation during treatment of a Siateralchoanal aftesa n'a newborn. Fig. 121 Small meningoencephalocele, medially the middle turbinate ina patent with sthmoid polyposis, onthe right. e Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base 39 Fig. 118 Endoscopic aspect of a mucocele on the fight anterior emo anus, Fig. 119 Inthe CT, one can ave that there are two mucocele. Fig. 120 Fadiopaque concretion in the anterior ethmoid sinus ina typical aspergilus fumigatus mycosis,40 Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base 5.0. Diffuse, Eosinophil-dominated Polyposis Difuse polyposis is being recognized more and mote as an independent clin= ical entity, probably with an immunological background. The polyps here are an expression of underlying disease and not the disease itself. Their surgical removal alone ~no matter what technique or instrument is used - i insufficient in many eases. Only in combination with medical thocapy can the reappoar- ance of polypous mucosal sweling be prevented. Medical therapy is, according to tho current state of knowledge, primarly by topical and/or eystoratic cor Colds or In the future possibly By leucotrene antagonists or receptor blockers, for achesion molecule antagonists. The high incidence of arway hyperactivity, including asthma, points to a close correlation and possibly the same mecha- nism of origin. Light microscopy reveals that the mucosa and polyps of this patient group are characterized by a dense accumulation of eosinophils, the Eptpaxs mucosal edema inthe ariior majority of which are activated and degranulated. The mediators and harmful substances which thereby enter into the #ssue, support the infection, epithelial «damage, polyp formation and possibly even asthma in a sort of vious circle. Pationts with aspirin intolerance also appear to belong to this group, as do those with sinusitis caused by fungal allergy clinically characterized by more or less pronounced asthma, diffuse polypous rinosinopathy with the involvement. of all paranasal sinuses, and the formation of an extremely viscous, mucous secretion Fig. 127). In the CT, the paranasal sinus affections can be clearly divided into stages, the worst case being a so-called “white ou", in which practically no air-filed cavities are recognizable Fig. 125) Fig. 128 Tot Fig. 129. Fig. 127 Fungal allergic rhinosinueitis. ituse poly: posi, decalefication and disintegration of fssedus structures (skull base, wth no Fig. 125 "White out” during dice polyposie (fungal alergc hinosinustis), Fig. 126 Endcecopie finding in a patient with Subronchial syndrome» Exdoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior The therapy for these diseases is twofold: the first step must always be to tempt to improve minimal fincings entirely, massive findings partially by medical therapy (topical corticosteroids). Surgical therapy is directed at semoving the polypous mucosal masses as completely as possible and Sereby also the eosinophils and other cells with the harmful substances which : Sey contain. Here too, the principles of FESS can be applied: in most cases ! fe basic anatomical structures such as the middle and superior turbinates are preserved. It is, however, necessary to remove polypous mucosal membrane nanges from the sphenoidal bone, maxilary sinus and possibly the frontal Sus in far greater amounts than for a “simple” chronic sinusitis. However, ssucosa should never be removed so radically that bone is exposed. This feads to increased problems during the healing phase, such as granulations, esteits, formation of secretion and incrustation, etc. Postoperatively, treatment ust be extremely specific for eosinophil-dominated, diffuse polyposis. in the most favorable case, a topical corticoid therapy given at variable intervals is ssfcient to prevent the reappearance of mucosal thickening and, finally, polyps. Some patients require continuous therapy with topical corticoids, stil hers need adcitional systematic corticoids given at intervals. If, in these 1585, good patient compliance is achieved, the necessity of repeated opera: Sens is very small according to our previous experience. The reappearance of polyps in such casas does not therefore represent a true recurrence in the Stict sense, but is rather an expression of a not suitably or constantly treated persistent basic disease. To what extent the re-appearance of polyps is correlated or dependent on increased release of certain mediators (adhesion molecules, interleukin IL5, etc.) will hopefully be seen in future research results, Fig. 122 Gatstinous-edematous mucosa, post eperatve polyp reformation in case of Sse polyposis. Using topical cortiooi eran, the change rogressen Fig. 131 View into a frontal recess after surgery on an extensive chronic hinasinusts Fig. 128 ‘Artrochaanal polyp which extends though an acbessory ostium in the posterior fontaneli Fig. 129 Tnto the common nasal meatus. The ncinate process Is already pertomzed m4 5 Hulu Fig. 190 Solid portion ofthe above-shown polyp after removala2 Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Antorior Skull Bast Fig. 193 ‘The Peranasal Sinus Shaver in use suctioning in and. Fig. 138 Cutting of polyps from the middle iiasal meatus. 5.1. Powered Instrumentation — The KARL STORZ Paranasal Sinus Shaver System The KARL STORZ Paranasal Sinus Shaver System is an ideal instrument fo removing massive amounts of polyps. The principle is well-known from arth roscopy: a hollow knife, rotating in a suction channel which is open at its tip cots off the mucosa or polyp masses with an oscillating movement, which have been sucked into the channel. The material removed in this way can be caugh ina suction basket and histologically examined. Larger polyps can be cut a ‘thelr attachment point and removed win grasping forceps and thus subjecto to histological examination. Depending on the knife and shaver head used relatively thin bone segments can also be remioved, such as the uncinate pro ‘cess. The instrument is particularly sulted for removing polyps and disease mucosa, e.g., from the middle turbinate or medial orbit wall, without removing the basal membrane of the mucosa and exposing the bone. Since only tissu which has been suctioned in is cut off, unintentional injury of vital structures is easily avoided given correct application. Working with constant suctior simultaneously provides removal of blood and helps avold frequent changin of instruments. The opening of the suction and cutting channel can be infinitel rotated by 360° during the operation and endoscopically monitored. Withou changing the position of the instrument handle, tissue 360° around the shaft axis can be removed and suctioned. Due to this gentle work method bleeding can be minimized and, in many cases, the operating time can also be shortened. The rounded-off shatt tip allows one to press in cell septa, whils the strictly laterally directed cutting mechanism prevents lesions in the direction of work, such as can occur during use of cutting forceps. Due t the possiblity of using burrs without oscilation, the new Paranasal Sinus Shaver System can be called a true multipurpose instrument, also fitting fo driling procedures in the course of endonasal dacryocystorhinostomies, optic nerve decompression, and other situations. Fig. 135 Components ofthe KARL STORZ Paranasal Sinus Shaver System wth ts 90° angled ergonomic handpiece and the blades for suction, cutting and diilingery of the Paranasal Sinuses and Anterior Skull Base pic Diagnosis and S\ Working “around the corner" is nevertheless only possible to a very limited ‘extent, and the removal of more extensive bone septa is in many cases inad- equate. Therefore, work with the sinus shaver is by no means to be regarded 485.2 substitute for endonasal paranasal sinus surgery. Especially forthe frontal secess and work on the skull base, in the sphenoid sinus and maxilary sinus, precise instrumental procedure is indispensable. However, in many cases of Suse polyps, the paranasal sinus shaver proves to be a welcome accessory ad aid to surgery. Also for post-operative treatment, e.g., for reappearing or ‘eeipient polyps, the shaver can be used to advantage. 5.2. Mucoceles : Mucoceles of all paranasal sinuses are an Ideal indication for endoscopic pro- e-edures: even those with considerable intracranial extension can be operated pon successfully with the telescope. It is often enough to generously remove Se separating wall to the paranasal sinus system. The mucosal lining corres- fponds in most cases to the parietal mucosa of the affected sinus. Mucoceles =n, however, also clearly demonstrate the limits of endoscopic possibilities. In Se frontal sinus, for example, mucoceles positioned far laterally, or septate lsteral sections can be just as dificult to reach endoscopically as, for example, feterally located mucoceles in a maxillary sinus, particularly after previous Seerations. In these cases the indication for external intervention remains) wenanged 43 136 Fi Endonasal protrusion ofa large mucooal. 9, 137 of th lft ethmold as well asthe frontal ms Fo 140 Fig. 130 Fig. 138 Eeoscopic aspect of a maxilary sinus 27 years after a Galdwel-Luc operation. Condon after resection of the unciat mucoce! process with immediate empiying oft purulent mucocele contents44 Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base Fig. 141 Aspergillus furnigatus mycosis ofthe left ‘maxillary sinus with aberrant root canal 5.3. Mycoses of the Paranasal Sinuses The most common form of mycoses in Europe is the noninvasive, saprophytic. maxillary sinus mycosis. Numerous clues point toward a connection between. root canal filings and the frequent occurrence of maxillary sinus mycoses. Mostly asperaillus species settle on injured mucosa and/or on ctystalization cores ~ such as the root canal material - and can grow to considerable size. They can entirely fil a maxilary sinus, but only become invasive in the rarest cases. On the other hand, osseous sections of the lateral nasal wall can be decalcified and thus, in a CT, a malignant process may be suspected (Fig. 141). Noninvasive mycoace ean also appear in all other paranasal sinuses. They: require thorough surgical removal, whereby attention must be paid to good ‘ventilation of the affected paranasal sinus. Medical treatment is not requited. In the case of the maxilary sinuses, the masses can be removed with upbiting ‘forceps, malleable forceps, cursttes, curved spoons and with a suction system. after suitable widening of the natural ostium. I is important to get a good over- view of the maxillary sinus, e.g., with a 70° telescope. Relapses after mycoses. fing matelal forming the pont ofeyetal- almost always represent reinfection caused by fungal material left behind (Fig 143) Fig. 142 Endoscopicaly, a gutta-percha pin was. found (center of picture) around which ‘ungal masses had settled, Fig. 143 Pes-sized “fungus bal” in a maxillary ‘sinug, in a patient without aymptoms Fig. 144 Fig. 144 “Typical onion-skn layering of fungal Fruithead of aspergilus fumigatus with masses (HE sian. surrounding spores and hyphae (PAS. star)32 | Exdoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base 45 evasive mycoses require radical surgical therapy. Addit Sestomic antimycotic therapy may be indicated in these cases, particularly if Se kul base or even the endocranium is affected, Fungal allergic sinusitis is generally represented by diffuse polyposis. in CT, ech and low density areas” may be recognizable. The bone of the skull base an be decalcified and destroyed, exposing the cura during surgery. Here Seeropriate medical therapy with corticoids and antihistamines is necessary se 2 thorough surgical removal of polyps, viscous mucous and fungal mater- © There is no unanimous opinion about the necessity of antimycotic therapy. 2 > Fis 1480 which are sometimes hard to remove se the suction systom. Fig. 148 Between the polyps, viscous, almost ‘bor lke mucous masses are constant. ly found, nally, a massive Fig. 145, Ethmod and frontal sinus mucoceles with secondary fungal infestation. The dura was elovated but not infitrate Fig. 146 Fungal allergic sinusis with typical CT changes. Fig. 147 e Massive polyposis in case of fungal ater ie rhinosnuatis. There is considerable Fyperelorism. a... .:~COC~S*#48 Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base Fig. 149 Dentist's dil in aright maxillary sinus; the alveolus has bean packed Fig. 150 Dil after endoscopic removal Fig. 151 “Metal splinter which tad entered trans- crbitaly and remained stuck inthe posterior etm bone i the optic canal Fig. 152 ‘Metal pins ofa dental implant inthe inferior nasal meatus. Due to the hardness ofthe materia, endoscopic removal was rot possible. 5.3.1. Foreign Bodies Since all paranasal sinuses can be reached endoscopically, this presents an ideal opportunity to remove all types of foreign bodies from this area with ‘exception of the lateral portion of the frontal sinus. For the maxillary sinus as ‘well as for the frontal sinus, itis additionally possible to use a double-sided procedure: via trephination of the anterior wall of the frontal sinus, an adgi- tional telescope and/or instrument can be guided in, thus permitting examination, finsing and manipulation from the outside and via the frontal recess. For the ‘maxillary sinus, itis also possible to perform additional endoscopy via the canine fossa, which also - as described in the maxllary sinus endoscopy chapter (page 19) - allows two-sided manipulation via the middle nasal meatus and the canine fossa. Also wedged-in foreign bodies or hard fungal masses ‘can be removed with great safety by this route, and this technique can also be sed for small osteomas. Fig. 153 “Two-sided” procedure: view through dll hole inthe anterior wall of the frontal sis {9 the frontal sinus fundus, The insertion ‘ofa curete through a tough sear pate ‘San be contrllad inthis way.5.4. Decompression of the Orbit and of the Optic Nerve Exconasal decompression of the orbit may be indicated for various diseases, ech 5 endocrine orbitopathy, but also in case of hemorrhage, trauma and ‘sescesses, In case of endocrine orbitopathy, the procedure includes removing Jeena papyracea and the orbit floor (unto the infraorbital nerve) and silting the ‘Perorbita, so that the orbital contents can expand medially (into the ethmoic) ‘S66 downward (into the maxillary sinus). Thus in many cases, the eye bulb can em Dack > to & mm. Inis also means tnat the optic nerve and/or its suopIY Sesseis are relieved, and thus can contribute to the stabilization or even improve~ Spent of an already limited field of vision and/or acuity of vision. If for cosmetic Sessons, o.g., in the caso of extreme exophthalmus, further retraction of the ‘eye bulb is intended, the intervention can be combined with a lateral orbito- Sey and corresponding lipectomy. In principle, an endoscopic sphenoethmoid- S=tomy is performed with preservation of the middle and superior turbinate. Pee optic tubercle should be identified, as well as the frontal sinus ostium. The Seandlary sinus ostium is enlarged to the maximum, and the orbit floor removed ‘Seerally up to the intraorbital nerve. An extremely thick, osseous orbit floor can ean & limitation on the endoscopic procedure. With an elevator or finer instru- Speets, the thin bone of the lamina papyracea is removed and the periorbita is eosed. The latter is incised with a sickie knife, first longitudinally then Serena times crosswise, 80 that the orbital contents sink forward into the s@moid and toward the maxilary sinus. In order to prevent a secondary muco- Gee formation, care must be taken that neither the frontal recess with the route Se frontal sinus, nor the maxillary sinus ostium are completely obstructed. Excoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base az Fig. 154 Endocrine orbitopathy wit stretched ‘optical nerve and protruding eye bul. Fig. 155 Condition after endoscopic decom- pression. Tha route to the frontal sinus fe maxilary sinus isnot blockod, Fig. 156 Detall view: open route to the maxilary sinus in order to prevent ‘mucocele formationFig. 187 (CTof a patient with a sku base fracture ‘and compression of the optic earl with Subsequent bindness onthe let. Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base It necessary, this intervention can be combined with a Decompression of the Optic Nerve. ‘This intervention may be indicated in cases of traumatic andor inflammatory comoression or damage tothe optic nerve in the area of the apex ofthe orbit, the optic canal or is course in the wal ofthe posterior ethmoid bone and the sphenoical sinus. The indication must be decided upon together with the oph- thaimologist and/or neurosurgeon. After a sphenoethmoidectomy with preser- vation ofthe nasal tuoinates, the course ofthe optic nerve andthe prominence bitin terpelcsicantnreree iid the pherokial sr (2). Tarte optical tuberele Is visualized, Approximately one centimeter before this anterior, the lamina papyracea Ie caretuly lifed off rom front to back and Gissected between th's and the periorbita up to te optical tubercle (b). Usually one already sees the crculary running fibers ofZinn's corona here With a spe- cial diamond grinder, the bone above the optical tubercie anc further along the optic canal is now caretuly thinned out from medial to the point that can be removed completely with suitable instruments (c + d). No pressure should Occur toward lataral on the nerve curing these manipulations. In the case of fractures (which are mostly transverse) through the canal, the bone shoud always be removed 9-4 mm beyond these fracture points, In this way the opti herve and is sheath can be exposed medially almost to 180°. ‘Ihe slitting of the optical nerve sheath in the exposed area has been the subject of very controversial discussion in the literature. We perform this in special cases after consultation with the ophthaimologst. Todo this, 2 fine Sickle krfe plerces into the upper aspect of the exposed nerve sheath, opening this from back to front until just past the fibers of Zinn's corona (e). incisions on the lower edge ofthe crcumference of te exposed nerve should be avoided, in order to avoid risk ofa lesion to the ophthalmic artery # the later’ course fs unusual far medially. When the optio nerve sheath pl, wwe cover this incision immediately with fibrin glue in order to avoid a liquor fistula. We do not use any sort of tamponades etter forthe optical nerve decompression or orbit decompression, We have not observed any infections orether complications from these interventions up to now Fig. 1586Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base 5.5. CSF Fistulae/Meningoencephaloceles Through the intrathecal application of 596 sodium fluorescein, usually even the smallest iquor fistulae can be detected endoscopically, particularly under blue light. In recent years, the endoscopic technique has proven to be an excellent ‘method for closing defects in the area of the anterior skull base and especially inthe sphenoidal sinus. By their nature, lesions which extend into the posterior wall of the frontal sinus or affect the transition from here to the roof of the an- terior ethmoid usually cannot be treated endoscopically. The techniques cor- respond to those known for many decades in rhinosurgery; underiay as well as, the overlay techniques are used. As an underlay, various endogenic materials. (temporalis fascia, fascia lata, auricular cartilage etc} as well as exogenic ‘materials (freeze-dried dura, Goretex* patches) are used. It may also be sufti- cient, for very small defects, to rotate a muco-periosteal flap over the defect, secure it with fibrin glue and pack it (e.., in cases of minimal liquorrhea from offactory fers). For larger defects orn localizations where an underiay tachni- FI 458 us xed tamponade is sible (2.9, proxi i Resale tom eae ue and/or a fixed tamponade is not possible (e.g., proximity to carotid artery usvalion of an underay teobniaue; ‘and optic nerve), use of “composite grafts” from the nasal turbinates have {¢mall rows) proven effective. From a suitably large part of a turbinatee, a (ree) muco-perio- ‘steal flap or muco-periosteal bone fap is formed. In the latter, a suitably large piece of bone, for example, remains on the periosteum and is applied to the corresponding defect with the bone-periosteum side and glued into place. In the case of the sphenoidal sinus, we use several layers of slowly resorbable ‘material (e.g., Oxicell, = Tabotamp® ) which have been soaked with fibrin glue. ‘The final tamponade with, e.0., iadoform gauze, rarely requires more than a 10, to15.cm|ong, 1 em wide stip. In this way, most patients can breathe relatively well postoperatively through the affected haif of the nose. Fig. 1596 “as wal as here during an overiay tech- Figue. The resorbable tamponade materi- al Tabotamp) Is depicted as white, Fig. 159d the fibrin glue applied in between iS biue, and the non-resorbable gauze tamponade is greyeee Fig. 160 Endoscopic aspect of choanal stenosis, {hough which tne adenoids protrude into the nasal lumen, Fig. 161 Osceous and connective tissue atresia plate, laterally, in a newborn ‘] Fig. 162 Condition after endoscopic perforation of the nght atresia pata, 50 Endoscopic Diagnosis and Surgery of the Paranas: Sinuses and Anterior Skull Base 5.6 Choanal Atresia For endoscopic treatment of choanal atresia, the circular punch described on page 31 has proven to be very helpful. We were successful in creating suffi- lent openings for nasal breathing in all emergency situations in newborns. For newborns, intervention must occur using 2.7 mm telescopes, which naturally in conjunction with the narrow space available, can be technically very dificult. It may also be necessary in individual cases to enlarge the choanal opening again after some months or years (since it does not grow with the patient) In al of our previous cases. the endoscopic procedure has proven to be a quick. safe, successful and scarcely traumatic intervention, 5.7 Dacryocystorhinostomies The technique of the endonasal dacryocystorhinostomy has changed litle since its first description by West at the beginning of the 20th century. Of course, these interventions can also be performed endoscopically. After formation of a ‘mucosal flap, the medial nasolacrimal duct wall is driled away and the lacrimal ‘sac exposed. According to the anatomy, it may in certain cases be necessary to resect the uncinate process and/or open agger nasi cells. Optical light pro: bes inserted through the lacrimal punctum are of great help. After insertion of the probes, the telescope light is turned down or shut off completely so that the light of the probes clearly illuminates the localization of the sac and/or nnasolacrimal duct. According to individual pathology or the ophthaimologist's need, indwaling catheters can be placed, Fig. 163 Fig. 164 ‘and after maximum enlargement ofthe Aehild directly after the operation with Same 'ypcal scone tubes n situ to maintain patency.Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base 5 5.7.1 Complications of Acute Sinusitis ‘Above all, endoscopic techniques can be successfully implemented for sub- periosteal abscesses. However, because the borderline between subperiosteal and intraorbital infitrates and abscesses can be indistinct, the indication re- quires a great amount of experience and caution. If there are extensive osteitic, osteoistic, or even osteomyeltic processes, particulary ofthe frontal bone, the affected sinus must in many cases be opened from the outside and the dis- teased or even sequestered bone removed with it. Also processes that affect ‘the posterior wall of the frontal sinus and accompany subdural or epidural ab- soesses should not be approached by endonasal surgical techniques alone. Fig. 166 ‘Typical aspect of a patient with orbital compicaton of an acute sisi. i | | | | a b Fig. 165a-¢ Hote isa schematic representation of the steps for drainage of a subperiosteal abscess. After opening the infundibulum and removing ‘he ethmoidal bulla, tre bone ofthe lana papyracea is careful ifted up and removed inthe area in question, and the abscess is, drained ito the midele nasal meatus.———_—_— SS 52 Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base Fig. 167 Endoscopic diagnosis. Adenocarcinoma ‘ofthe right anterior etheaid Bone, with ‘secondary fungal infection, | Fig. 1680 ‘and after endoscopic resection. The anterior ethmoidal artery was endoscopi- aly clipped. 5.8 Tumors ‘At the beginning of the “endoscopic era”, endoscopic approaches to tumors of ‘the paranasal sinus were basically imited to diagnosis and biopsy. Today a great number of lesions are also being operated on endoscopically, e.., in- verted papillomas, even i greatly extended. Of course, malignancies with extensive infitration present clear contra-indications to a purely endoscopic procedure. Here the principles of oncological radical surgery must apply. But also protrusion into the lateral sections of the frontal sinus can be a definite tation for an endoscopic procedure. However, it is also entirely possible technically to carry out radical operations endoscopically, ¢.g. removing all the turbinates, and also the mucosa with the exception of large frontal sinuses, Particularly for tumors that affect the anterior skull base, such as esthesioneu- roblastoma, but also for other malignant lesions, an endoscopic procedure in ‘cooperation with the neurosurgeon can be very productive. The endonasal portion of a tumor is removed by the rhinosurgeon, and in certain circum stances, the corresponding dural section is also ‘resected and covered. ‘According to the extent of the tumor, a craniotomy can in individual cases be performed by the neurosurgeon in the same session. In our experience it is important that, after such combined interventions, the rhinosurgeon should protect the dural covering with @ mucosal flap at the conclusion ofthe interven- tion, in order to avoid dry necroses particularly during subsequent irradiation. In individual cases, unusual lesions, such as localized rhabdomyosarcomas, can also be removed. Particularly in the group of early recognized, relatively localized malignant lesions, we have obtained good results up to now with endoscopic procedures and subsequent gamma knife irradiation, Fig. 169a+0 Conaition after a combined endoscopic-endonasal and neurosurgcaltranscranial procedure on an esthesioneuroblasioma and subsequent gamma-krife radiation.Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base 53 Also some juvenile nasopharyngeal angiofibromas have been operated on endoscopicaly by us. n our cases, we considered it a prerequisite that they be Group ikl lesions according to Fisch; they must be capable of complete ‘embolization and may not demonstrate any intracranial expansion. Previously operated and/or recurrent nasopharyngeal fibroma are less suitable for a purely endoscopic procedure. The surpical procedure takes place ideally on the frst or second day after emoolzaton: frst the tumor Is endoscopically separated from its supply vessel, usually the sohenopalatine artary, by tho transnasal route, Also cones ofthe angiofioroma which reach into the choanae, the noe, the manllary einue or portions adhering to the vomor ean be removed in this way. The intervention proceeds simultaneously via the mouth: the soft palate is pullad forward over a velotractor, making It possibie to remove the lesion completely from the nasopharynx with 30" and 70° telescopes. In all our cases operated on inthis way, blood loss was minimal and no postoperative tamponade was requited Some pituitary tumors can also be operated on endoscopically, either with Fig. 170 the telescope alone or as an addtional endoscopic step, e.g. to remove para- S20 MR of an extensive raso- sellar tumor sections with the 30° telescope after transseptal resection under ~ microscopic guidance. Fig. 1720-4 Fig. 171 Video sequence rgery of a nasopharyngeal angio fibroma Coronal MRI on the same patient with a) Aspect of the tumor in the cnoana through the common nasal meatus, right representation of Inramanilry extent of 1) Transoral view under te elevated sof palate into the nasopharynx, the lesion, ©} Removal ofthe tumor masses via ine nasopharyr Condition 10 days postoperatively. LULL——EE 54 Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base Fig. 173 Corton ane week after endoscopic fthmold surgery. Aer removing inerusta tion at the entrance tothe middle nasal Fig. 174 "hore are further inerustations in tho postenor ethmotd tone and inthe maxillary sinus ostium. After removing these and suctioning off secretion Fig. 175 the middle nasal meatus is already Considerably normalized after 10 days. 6.0. Postoperative Endoscopic Treatment The postoperative treatment presents an ideal opportunity to learn the hand- ling of the telescope and corresponding instruments. To learn endoscopic techniques, many centers recommend first continuing surgical interventions using previously learned techniques, but to use the telescope in order to clean, maintain and care for the surgical cavities. Only after a high degree of profi- clency and practice has been attained, should one then begin adjusting to surgical techniques using the telescope. Individual postoperative treatment schemes vary greatly. It has proven to be ‘advantageous to perform a thorough endoscopic postexamination approxima: tely 1 week after an endoscopic paranasal sinus intervention: under topical anesthesia, Incrustation which normally has begun to loosen after this period can therefore be removed less traumatically and thickened secretion suctioned out, e.g., from the maxillary sinus. In contrast to earlier years, we no longer perform dally cleansing in the first postoperative days, but limit ourselves to suctioning out the nostrils and the nasal floor. During the control examination cone week later, it can usually be very clearly determined whether a “problem case” Is developing which requires further frequent and short term control, whether and what type of medication should be administered for how long, and when the patient should be called back for the next postoperative control ‘There are essentially two situations in which careful long-term postoperative care is required: it extensive surgery was performed in the frontal recess and the frontal sinus ostium was, for example imbedded in heavy scars after previous operations, and/or considerable masses of mucosa were removed. In this case, thorough postoperative care at short intervals is indicated in order to prevent residual stenoses. Fig. 177 the mucosa appears to be healthy ‘everywhere, and anspor from the maxitry sinus ostium is unimpaired Fig. 176 ‘ter 6 weeks, normal mucosal concitions prevall (ew without decongestants)Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Antarior Skull Base 55 For postoperative treatment of diffuse polypous rhinosinopathy with eosino- phil domination and/or bronchial asthma, regular endoscopic examination Serves to recognize changes in the mucosa which require renewed therapy and/or increase in dosage of a topical corticoid application before appearance of clinical symptoms. The “cobble stone aspect” of the mucosa and increasing impairment of the sense of smell are very fine criteria which precede the re- appearance of polypous changes. With suitable adjustment of medical therapy, a reappearance of polyps which require surgery can nevertheless be prevented in most cases, (of compliant patients) Packing Due to the generally low tendency toward hemorrhage during endoscopic interventions according to the Messerklinger school, the use of tamponades is an absolute rarity among our patients. For maderate, diffuse cozing the appli- Cation or insertion of quickly absorbable materials, such as Sorbacel”, have proven helpful. Spacing devices are not used. In our experience, the best guarantee against the appearance of synechiae is careful atraumatic surgery, which particularly avoids the creation of wounded surfaces facing one another in the entrance to the middle nasal meatus. Fractures of the middie turbinate should be just as carefully avoided. Fig. 181 Corton ater local treatment later Fig. 178 Instifciont surgical technique: remains of the unoinate prosecs and the dleaased sain ecards toto Fig. 179 Hote t00, pats ofthe diseased bulla have not b90n removed! the diseased othmold Sinus was not opened the frontal recess for the most part Backed by polyps and sears. 6 Fig. 180 ‘Cobble-stone” aspect in the frontal recess, 4 weeks after surgery for an ‘expansive diffuse polyposs,56 Endoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base FF | fo Fig. 182 Frontal sinusitis on the right, with orbital complication and lateral sequostrum formation Fig. 188 Aspect ofthe patient from Fig Fig. 184 Acute ethmoidal and frontal sinusts wth ‘subdural epidural abscess. 7.0. Limitations of Endoscopic Techniques The limitations and contraindications of a (purely) endoscopic procedure be- ‘come evident on the one hand in case of malignant or other invasive (mycoses) lesions for which the criteria of radical oncological treatment are required. But also for processes which appear far laterally, e.., in the frontal or maxillary sinus, primarily after external operations, the limits of the endoscopic process. could be reached. For one thina. it may be Impossible from the anale of vision to be able to look sufficiently into recesses which lie obstructed far laterally. Second, the special endoscopic instrument set does not allow reliable treat- ‘ment of such lesions. This especially applies to septate mucoceles, mucoceles which lie far laterally behind scars and/or bone walls, niches closed off after previous operations, especially following Caldwel-Luc or other external inter- ventions. Extremely strong scariication in the area of the frontal recess with and without neoformation of bone as appears especially after osteitic proces- ses may require an external surgical approach as a much safer and more direct path, especially if there is also inadequate scope for anatomic orientation. As already pointed out, in traumatology the limits of endoscopic care are lateral lesions on the posterior wall ofthe frontal sinus or the transition from here into the ethmoid bone root. a Fig. 185 Fig. 188 Conventional tomography: condition ater Extensive itragene, bilateral (lesion Caldwell-Lue operation with formation of of the ethmold roo, which requied treat- 8 far lateral uated, obstructed recess. ‘Tis could not be reached endoscopically ment by subtrontal routeEndoscopic Diagnosis and Surgery of the Paranasal Sinuses and Anterior Skull Base 8.0. Complications Endoscopic techniques are subject to all the risks and possible complications of any type of paranasal sinus surgery. Serious complications are fortunately very rare; however, when they do appear, they can be dramatic. This primarily includes lesions of the orbit and its contents, of the optic nerve, of the dura at the anterior skull base and of the adjoining endocranium, the Internal carotid artery and other carebral blood vessels. Intraorbital hemorrhages caused by retraction of a separated anterior ethmoidal artery in the orbit can lead to threatening exophthalmus and displacement with compression and possible ischemia, which could result in loss of vision. As with any type of paranasal sinus and skull base surgery, endoscopic techniques should only be used after suitable training anc careful learning of anatomic relationships and their varia- tions. As a “solo” surgeon, one should either be capable of mastering comp cations which may occur or be near to, and have contact with, a center where this is possible. In all cases, the defect could be repaired, no permanent injuries or complicati- ‘ons appeared. There has been no damage to the optic nerve, no impairment of eye motity and no cases of death in connection with endoscopic interventi- ‘ons. Alter intial restrictions, every resident today is introduced to endoscopic surgery in his fourth year of training; endoscopic diagnostics belong to the fun-

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