Find author-narrated surgical videos for Endoscopic Sinonasal Dissection Guide online at MediaCenter.thieme.com! Simply visit MediaCenter:thieme.com and, when prompted during the registration process, enter the scratch-off code below to get started today. This book cannot be returned once this panel has been scratched off. Surgical videos available online: 1. Basic Endoscopic Dissection 2. Medial Orbital Decompression, and Anterior and Posterior Ethmoid Arteries Exposure 3. Sphenopalatine Foramen 4. Endoscopic Draf Il: Modified Lothrop Procedure . Navigating without a Navigator during ESS: Anatomical Landmarks for Advanced Polyp Disease ‘The first four videos show dissections illustrated in the book, being performed by the senior author, pointing out the critical landmarks. The landmarks are used along with clinical pearls in the fifth video to demonstrate a typical complex surgical case. 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Library of Congress Cataloging-in-Publication Data Casiano, Roy R, 1956- Endoscopic sinonasal dissection guide / Roy R Casiano prem, Includes bibliographical references and index, ISBN 978-1-604C6-587-9 (alk. paper) 1. Paranasal sinuses—Endoscopic surgery. 1. Title [DNLM: 1, Paranasal Sinuses—surgery—Handbooks, 2. Dissection-methads—Handbooks. 3. Endoscopy— methods—Handbooks, 4. Paranasal Sinuses—anatomy & histology—Handbooks. WV 39] RF421.359 2011 617.5'230597—de22 2011010456 Copyright ©2012 by Thieme Medical Publishers, Inc. This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation without the publisher's consent is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing or duplication of any kind, translating, preparation of microfilms, and electronic data processing and storage. Important note: Medical knowledge is ever-changing, As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may be required. The authors and editors of the material herein have consulted sources believed to be reliable in their efforts to provide information that is complete and in accord with the standards accepted at the time of publication, However, in view of the Possibility of human error by the authors, editors, or publisher of the work herein or changes in medical knowledge, neither the authors, editors, nor publisher, nor any other party who has been involved in the preparation of this work, warrants that the information contained herein isin every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from use Of such information. Readers are encouraged to confirm the information contained herein with other sources, For example, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this publication is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recommendation is of particular importance in connection with new or infrequently used drugs, ‘Some of the product names, patents, and registered designs referred to in this book are infact registered traclemarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that itis in the public domain, Printed in China 54321 ISBN 978-1-60406-587-9Dedicated to all the residents and fellows at the University of Miami School of Medicine and throughout the country and the world, who represent our specialty’s future.Contents Foreword Preface... xi Acknowledgments xiii Contributors.. xv 1 Introduction to Endoscopic Sinonasal Surgery Roy R. Casiano 2. Instrumentation, Set-Up, and Patient Positioning, Roy R. Casiano 3. Anteroposterior Versus Posteroanterior Approach 9 Roy R. Casiano 4. The Use of Anatomical Landmarks... B Roy R.Casiano 5 Basic Endoscopic Sinonasal Dissection ..... 19 Roy R.Casiano, Islam R. Herzallah, Amy S. Anstead, Jean Anderson Eloy, ‘Adam Folbe, Lori Lemonnier, and Belachew Tessema 6 Advanced Endoscopic Sinonasal Dissection ; 59 Roy R. Casiano, Islam R. Herzallah, Amy S, Anstead, Jean Anderson Eloy, ‘Adam Folbe, Lori Lemonnier, and Belachew Tessema Index. 101Foreword Endoscopic sinus surgery was introduced in the United States in 1985 and became an accepted al- ternative technique in the surgical management of paranasal sinus disease. As instrumentation and optics improved, the endoscopic surgical techniques were taught in otolaryngology residency programs eventually became widespread. By the late 1990s, the need for a surgical dissection manual that would advance skills and could be used to train residents and fellows became clear. In 2001, Dr. Casiano’s first endoscopic sinus surgery dissection manual was published, illustrating a stepwise approach for learning to perform endoscopic sinus surgery. As discussions in the literature, in residency training programs, and at national meetings then centered on how to reach remote sinuses safely and effec- tively, it was refreshing that 40% of Dr. Casiano's manual feocused on advanced techniques, includ- ing anterior skull base resection. Many of us used it to guide residents and fellows on how to practice in the setting of the dissection laboratory and to teach them the logic of the stepwise technique of identi- fying and confirming surgical landmarks to avoid complications in the operating room. Dr. Casiano’s methodical way of thinking and his drive to always perform to the best of his ability at all times are reflected in all his publications. He adopts a stepwise, logical approach to investigating, learning, and teaching, with a complete and success- ful final delivery of the intended message. Combine Dr. Casiano’s natural ability to effectively transfer information with his 20-years of experience teach- ing residents and fellows, and this new dissection guide is nothing less than spectacular. The color pictures in the Endoscopic Sinonasal Dissection Guide immediately stand out as detailed diagrams that illustrate the appearance of the sur- gical cavity before and after a proposed resection. They illustrate the anatomic landmarks as they sequentially appear in the surgical field, thereby reinforcing the stepwise approach to effective sur- gery. Safe zones are identified for surgical sinus entry, while respecting paranasal sinus physiology and mucociliary pathways. Along the way, ana- tomic variants are illustrated to teach a general- ized surgical approach that can be used for all sur- gical cases but may also be tailored to the individual patient. The basic endoscopic techniques section is attractive to younger residents but can also serve as an excellent source for preparation and review by advanced residents and fellows. The advanced techniques are shown in spectacular illustrations of the anatomy that show endoscopic surgical techniques of the skull base and the orbit. In line with Dr. Casiano’s style of always driving the final message home, the online content associated with ixX Foreword Endoscopic Sinonasal Dissection Guide includes a video of a real surgical case that highlights the anat- omy and surgical steps reviewed in this book. This endoscopic sinonasal dissection guide will serve as an effective teaching tool for many years. Stilianos E, Kountakis, MD, PhD Professor and Chief of Rhinology-Sinus Surgery Georgia Health Sciences University Augusta, GeorgiaPreface This dissection manual is designed as a step-by- step pictorial reference guide, ideal for use during endoscopic surgical dissections in the cadaver labo- ratory. Chapters 1 to 4 provide a historical per spective on the quest to develop useful endoscopic anatomical landmarks since the first detailed de- scription of paranasal sinus anatomy in the early 1900s. This manual not only provides a unique per- spective of the author's 20 years of experience teaching endoscopic sinus surgical technique to residents and fellows, but also of all those before him who have provided their own surgical pearls. In the basic dissection chapter, the surgeon will be taught how to effectively use simple and consis- tent anatomical landmarks to safely navigate the nose and paranasal sinuses without the need for computer navigation. Paying close attention to the anatomical landmarks discussed in each section, the surgeon should be able to safely navigate through all the paranasal sinuses and also identify the closely related critical anatomical structures of the skull base and orbit, The reader is encouraged to identify all the anatomical structures in the order in which they are presented throughout this manual, progressing from the easier (basic) dissections to the more advanced ones. In the advanced dissection chapter, the surgeon will identify skull base and orbital structures that are critical to performing more advanced surgical techniques in these areas. This will require prior dissection and de-epithelialization of the sinus cav- ities and careful bone removal with osteotomes or with a cutting or diamond burr to fully visualize these structures. Sagittal and endoscopic pictures, along with ra- diologic correlations, are presented in each chapter to give the reader the best perspective of this very complex anatomy. Key anatomical landmarks will be repeatedly highlighted in each section throughout this manual to stress the significance of their impor- tance, Remember that practice and repetition are the keys to gaining surgical expertise and experience. xiAcknowledgments I thank Karl Storz Inc. and Olympus/Gyrus ENT for supplying the surgical instrumentation and video- recording equipment necessary for the preparation of this manual; Anspach Corporation for supplying the specimens and supplies; and Karl Storz Inc. and Entellus Medical for financial support for the illustrations.Contributors Amy S. Anstead, MD Director, Rhinology and Endoscopic Skull Base Surgery Department of Otolaryngology Virginia Mason Medical Center Seattle, Washington Roy R. Casiano, MD, FACS Professor and Vice Chairman Department of Otolaryngology, Head and Neck Surgery Director, Rhinology and Endoscopic Skull Base Program Miller School of Medicine University of Miami Miami, Florida Jean Anderson Eloy, MD, FACS Assistant Professor Department of Otolaryngology, Head and Neck Surgery University of Medicine and Dentistry of New Jersey New Jersey Medical School Vice Chairman and Director of Rhinology and Sinus Surgery Department of Otolaryngology, Head and Neck Surgery Neurological Institute of New Jersey Newark, New Jersey ‘Adam Folbe, MD, MS Assistant Professor Director, Rhinology and Endoscopic Skull Base Program Department of Otolaryngology, Head and Neck Surgery Wayne State University School of Medicine Detroit, Michigan Islam R. Herzallah, MD Lecturer Department of Otolaryngology, Head and Neck Surgery Faculty of Medicine Zagazig University Zagazig, Egypt Lori Lemonnier, MD Fellow, Rhinology and Endoscopic Skull Base Clinical Instructor Department of Otolaryngology, Head and Neck Surgery Miller School of Medicine University of Miami Miami, Florida Belachew Tessema, MD Assistant Clinical Professor Department of Surgery Division of Otolaryngology University of Connecticut School of Medicine Connecticut Sinus Institute Farmington, Connecticut xv1 Introduction to Endoscopic Sinonasal Surgery Roy R. Casiano Transnasal sinus surgery began in 1886, when Mic- ulicz reported on the endonasal fenestration of the maxillary sinus.’ A transnasal approach to perform- ing an ethmoidectomy was first in 1915 by Halle? Even then, it was immediately apparent that a trans- nasal ethmoidectomy posed significant inherent risks for the patient. Indeed, these risks were best paraphrased by Mosher in 1929, when he described intranasal ethmoidectomy as being "one of the easi- est operations to kill a patient."} Further reports have also shown the wide variability in distances and dimensions among virtually all the intranasal anatomical structures.4-1 Hirshman made the first attempt at nasal and sinus endoscopy in 1901 using a modified cysto- scope.!' In 1925, Maltz, a New York rhinologist, used the term sinoscopy and advocated the tech- nique for diagnosis."? However, endoscopic sinus surgery (ESS) was introduced in the European lit- erature in 1967Messerklinger,'? and was then fur- ther popularized by others.'*-2" In 1985, Kennedy introduced the technique of functional endoscopic sinus surgery (FESS) into the United States.” Since then, there has been an ongoing effort to refine and redefine ESS technique and to identify consistent anatomical landmarks to navigate within the eth- moid sinuses and facilitate safe entry into the max- illary, sphenoid, and frontal sinuses.2>? This has led to further refinement in transnasal endoscopic surgical technique beyond the confines of the sinus cavities to address complicated inflammatory and neoplastic processes of the skull base and orbit. Although exceptions do exist, nowadays most thinologists agree that ESS for chronic rhinosinus- itis should be a “disease-directed” and a mucosal- sparing operation, recognizing the principle of the potential for reestablishing drainage and mucosal recovery of the dependent sinuses." The ostio- meatal complex theory states that most inflam- matory conditions of the maxillary, ethmoid, and frontal sinuses arise from this common drainage pathway." Therefore, the surgical procedure, when combined with appropriate medical management, can be limited to an absolute minimum and correc- tion of ethmoid disease usually results in reestab- lishment of drainage and mucosal recovery of the larger (dependent) sinuses. In more advanced disease states (revision sinus surgery, significant polyp disease, or neoplastic dis- ease) mucosal preservation may not always be pos- sible, or even indicated. In such cases, severe distor- tion ofanatomy requiresan enhanced understanding2. CHAPTER 1 = Introduction to Endoscopic Sinonasal Surgery of critical anatomical landmarks as one navigates endoscopically through the nose and paranasal si- nuses along the orbit and skull base. Anatomical structures typically used in less diseased states may not be appropriately used or even dependable when applied to these types of cases. This dissec- tion manual defines time-tested, consistent, and reliable anatomical landmarks, which will keep the surgeon oriented as he or she proceeds antero- posteriorly through the nose, paranasal sinuses, skull base, and orbit. i REFERENCES 1. Miculitz JV. (1886) Zur operativen Behandlung des Empyems der Highmorshohle. Dtsch Arch Klin Med 1886;34:626-634 2. Halle M, Die intranasalen operationen bei eitrigen er- krankungen der nebenhohlen der nase. Arch Laryn- gol Rhinol 1915;29:73-112 3. Mosher HP. The surgical anatomy of the ethmoidal labyrinth, Ann Otol Rhinol Laryngol 1929;38:869- 901 4, Van Alyea OE. The ostium maxillare: anatomic study of its surgical accessibility. Arch Otolaryngol 1936; 24:553-569 5, Van Alyea OE, Ethmoid labyrinth: anatomic study, with consideration of the clinical significance of its structural characteristics. Arch Otolaryngol 1939; 29(6):881-902 6. Van Alyea OE. Sphenoid sinus: anatomic study, with consideration of the clinical significance of the struc- tural characteristics of the sphenoid sinus. Arch Oto- laryngol 1941;34:225~253 7. Van Alyea OE. Nasal Sinuses: An Anaiomic and Clinical Consideration. Baltimore: Williams & Wilkins; 1951 8. Myerson M. The natural orifice of the maxillary sinus. I. Anatomic studies. Arch Otolaryngol 1932;15:80-91 9. Hajek M, Pathologie und therapie der entzundlichen erkrankungen der nebenhohlen der nase. 5th ed. Leipzig: Deuticke; 1926. Neivert H. Surgical anatomy of the maxillary sinus. Laryngoscope 1930;40:1-4 11. Draf W. Endoscopy of the Paranasal Sinuses. New York: Springer-Verlag, 1983 . Maltz M, New instrument: the sinuscope. Laryngo- scope 1925;35:805-811 13, 14, 16. 17. 18. 19, 20. 21 22, 23. 24, 25, 26. Ni Messerklinger W. Uber die drainage der menschli- chen nasennebenholen unter normalen und patholo- gischen bendingungen Il: die stirnhole und ihr aus- fubrungssystem. Monatssch Ohrenheilkd 1967;101: 313-326 Messerklinger W. Endosckopiche diagnose und chirurgie der rezidivierenden sinusitis. In: Krajina 2, ed, Advances in Nose and Sinus Surgery. Zagreb, Yugo- slavia: Zagreb University; 1985 ann H. Pathologische anatomie der chronischen rhinitis und sinusitis. in: Proceedings VIII International Congress of Oto-Rhinolaryngology. Amsterdam, the Netherlands: Excerpta Medica; 1965:80 Stammberger H. Endoscopic endonasal surgery concepts in treatment of recurring rhinosinusitis. Part 1. Anatomic and pathophysiologic consider ations. Otolaryngol Head Neck Surg 1986;94(2) 143-147 Stammberger H. Endoscopic endonasal surgery— concepts in treatment of recurring rhinosinusitis. Part Il. Surgical technique. Otolaryngol Head Neck Surg 1986;94(2):147-156 Wigand ME, Steiner W, Jaumann MP. Endonasal sinus surgery with endoscopical control: from radical op- eration to rehabilitation of the mucosa. Endoscopy 1978;10(4):255-260 Wigand ME. Transnasal ethmoidectomy under endo- scopical control. Rhinology 1981;19(1):7-15 Wigand ME. Endoscopic surgery of the paranasal sinuses and anterior skull base. New York, NY: Thieme Medical Publishers, 1990 Draf W. Surgical treatment of the inflammatory dis- eases of the paranasal sinuses. Indication, surgical technique, risks, mismanagement and complications, revision surgery. Arch Otorhinolaryngol 1982;235(1) 133-305 Kennedy DW, Zinreich SJ, Rosenbaum AE, Johns ME. Functional endoscopic sinus surgery. Theory and di- agnostic evaluation. Arch Otolaryngol 1985;111(9): 576-582 Rice DH, Schaefer SD. Endoscopic paranasal sinus sur gery. New York NY: Raven Press, 1988 Rice DH. Basic surgical techniques and variations of endoscopic sinus surgery. Otolaryngol Clin North Am 1989;22(4):713-726 Schaefer SD. Endoscopic total sphenoethmoidectomy. Otolaryngol Clin North Am 1989;22(4):727-732 Schaefer SD. An anatomic approach to endoscopic intranasal ethmoidectomy. Laryngoscope 1998;108 (11 Pt 1):1628-163427. May M, Schaitkin B, Kay SL. Revision endoscopic sinus surgery: six friendly surgical landmarks. Laryn- goscope 1994;104(6 Pt 1):766-767 28. May M, Sobol SM, Korzec K. The location of the maxil- lary 0s and its importance to the endoscopic sinus sur- geon. Laryngoscope 1990;100(10 Pt 1):1037-1042 29, Parsons D, Bolger W, Boyd E. The "ridge"—a safer entry to the sphenoid sinus during functional en- doscopic sinus surgery in children, Oper Tech Oto- laryngol—Head Neck Surg 1994;5:43~44 CHAPTER 1 # Introduction to Endoscopic Sinonasal Surgery 3 30. 31 32. Bolger WE, Keyes AS, Lanza DC. Use of the superior meatus and superior turbinate in the endoscopic ap- proach to the sphenoid sinus. Otolaryngol Head Neck Surg 1999;120(3):308-313 Hosemann W, Gross R, Gode U, et al. The anterior sphenoid wall: relative anatomy forsphenoidotomy, ‘Am J Rhinol 1995;9:137-144 Stankiewicz JA. The endoscopic approach to the sphe- noid sinus. Laryngoscope 1989;99(2):218-221Instrumentation, Set-Up, and Patient Positioning Roy R. Casiano Very few instruments are actually required to per- form basic ESS in the laboratory (Fig. 2.1), As one gains more surgical experience with advanced procedures or proceeds with live cases, however, additional instrumentation may be needed depend- ing on the type of procedure or the surgeon's per- sonal preferences. In addition to a 30-degree tele- scope, the minimum instrumentation required for most of the basic dissections in this manual in- clude the following: w= 3.5-mm straight non-through-cut forceps (A) w= 3.5-mm straight through-cut forceps (B) = 3.5-mm upbiting non-through-cut forceps (C) m= 3.5-mm upbiting through-cut forceps (D) m Cottle periosteal elevator (E) = Ostium seeker or ball probe (F) m= 4-mm long curved suction (G) m Calibrated straight (Frazier) suction (H) 1 360-clegree sphenoid punch or forceps (1) 1 360-clegree backbiting forceps (J) Fig. 2.16 CHAPTER? ® Instrumentation, Set-Up, and Patient Positioning Powered instrumentation (microdebrider) with a 4-mm straight and/or 60° cannula can be used in ieu of forceps for most of the dissections For advanced procedures, a 70-degree telescope is useful to visualize lateral or supetior recesses of the frontal, maxillary, or sphenoid sinus. Curettes of various sizes are useful for removing thick bone, es- pecially around the frontal ostium or sphenoid ros- trum (Fig. 2.2A,B), Powered instrumentation with cutting or diamond burrs may also be necessary to carefully remove bone around critical structures, such as the lacrimal sac, skull base, optic nerve, or carotid artery. The surgeon should be sitting or standing com- fortably at the patient's side. A right-handed surgeon typically stands on the right side of the patient. If the surgeon chooses to sit, then a Mayo stand (cush- ioned with a pillow) is used to rest the arm holding the telescope at a comfortable height over the pa- tient’s head. The video tower and any intraopera- Fig. 2.20.8tive imaging devices are positioned at the head of the table, facing the surgeon. The surgeon's neck should be in a comfortable neutral position to avoid long-term strain on his/her Gspine, which can re- sult neck pain. In live patients, a clear adhesive dressing (eg., OpSite) is placed over the eyes for protection. This allows the surgeon to visualize and palpate the eyes during the surgical procedure. The patient's face is draped to expose only the forehead, eyes, nose, and upper lip. The mouth and endotracheal tube are typically draped unless a concomitant sublabial or oral procedure is planned. The manner in which the telescope is grasped or instrumentation introduced into the nose may vary depending on the surgeon's preference, the specific length and type of telescope and/or camera, and the specific anatomical area being addressed. Gener- ally, the surgeon determines which manner is best suited for his or her hand. A 30-degree telescope looking laterally is all that is typically necessary for most of the dissections CHAPTER 2 ™ Instrumentation, Set Up, and Patient Positioning 7 described in this manual. A zero-degree telescope may also be used, but it may limit adequate visual- ization of the lateral nasal structures (i.e., maxillary natural ostium, maxillary sinus, supraorbital eth- moidal cells, etc.). The axis of the telescope is di- rected toward the occipital area of the head. and the superior border of the inferior turbinate is kept in view during the initial part of the procedure until the medial orbital floor is identified through the antrostomy. This keeps the surgeon directed toward the choanal arch and superior nasopharynx. The telescope is positioned at the nasoseptal angle with gentle superior retraction of the nasal tip, and the surgical instrumentation is inserted inferior to the telescope (Fig. 2.3). A70-degree telescope can be used if further visu- alization is required into the superior or lateral re- cesses of the frontal, maxillary, or sphenoid sinus. The 30-legree or 70-clegree telescope is placed along the floor of the vestibule looking superiorly (as when working around the frontal ostium) or medi- ally (as when performing a septoplasty). In these Fig. 2.38 CHAPTER 2 ® Instrumentation, Set-Up, and Patient Positioning cases, the instruments are introdu: the telescope (Fig. 2.4). In some advanced skull base procedures, where drilling of bone or manipulating tissue around critical neurovascular structures is necessary, it d superior to is helpful to have the telescope fixed in place with the help of an assistant, or by utilizing a specially designed telescope holder, allowing the surgeon to operate with both hands simultane- ously (Fig. 2.5). Fig. 2.4 Fig. 2.5Anteroposterior Versus Posteroanterior Approach Roy R. Casiano Today, there are essentially two endoscopic ap- proaches available to.address inflammatory or neo- plastic disease of the ethmoid, maxillary, and sphe- noid sinuses: the anteroposterior (AP) approach and the posteroanterior (PA) approach,'~4 @ The Anteroposterior (AP) Approach Anteroposterior exenteration of the ethmoid sinuses is the technique most widely used in the United States.!? In this approach, the surgeon begins with an anterior ethmoidectomy by removing the unci- nate process, bullar cells, ager nasi cells, and occa~ sionally entering the frontal recess. The surgeon then proceeds as far posteriorly as needed to re- move the diseased ethmoid cells and polyps and to establish drainage to the dependent sinuses that are blocked. A limited maxillary antrostomy is typi- cally not performed until after most ethmoid cells have been addressed. If a sphenoidotomy is indi- cated, a transethmoidal operation through the com- mon wall of the sphenoid and posterior ethmoid sinus is performed. Proponents of the AP approach argue that this technique enables the surgeon to address anterior ethmoidal disease without the need for extensive surgery.'25 Not all surgeons share this view, how- ever, arguing that patients frequently have pansinus disease affecting not only the anterior ethmoid's dependent sinuses (maxillary and frontal) but also the sphenoethmoidal recess and surrounding ostia draining the posterior ethmoids and sphenoid si- nuses.° In the AP approach, the surgeon is taught to stay “inferomedially,” as the ethmoidectomy pro- ceeds posteriorly, to minimize the chances of in- advertently penetrating the orbital wall or the skull base. Yet the problem for the inexperienced sur- geon is that the anatomy is often distorted because of pathological conditions or prior surgery. In addi- tion, the inexperienced surgeon may face orienta- tion difficulties with respect to how far inferomedi- ally he or she has to go, which can cause inadvertent intracranial penetration through the posterior crib- riform plate. Furthermore, during the course of the surgical procedure, the nasal telescope and/or camera may become rotated within the nose. The unsuspecting surgeon may think that he or she is heading in an inferoposterior direction while in fact following a superior or lateral trajectory toward the skull base or orbit. In the absence of other consis- tent anatomical landmarks as internal reference10 CHAPTER3 Anteroposterior Versus Posteroanterior Approach points, the surgeon may fail to see that he or she is improperly oriented. Entering the sphenoid sinus through the poste- rior wall of the ethmoid sinus is advised through the inferomedial portion of this wall, just lateral to the superior turbinate, to avoid injury to the optic nerve and the internal carotid artery which lie be- hind the lateral portion of this common wall. How- ever significant problems remain with entering the sphenoid sinus through the AP approach. First, a transethmoidal sphenoidotomy does not offer an optimal access; the bone of the anterior wall of the sphenoid is thicker retroethmoidally than parame- dially adjacent to the nasal septum in the area of the natural sphenoid ostium,’ Second, because this procedure is performed relatively close to the optic nerve and the carotid artery, specific anatomical variations in these skull-base structures may lead to significant complications. Lastly, if the ostio- meatal complex theory also applies to the spheno- ethmoidal recess and the surrounding ostia to the posterior sinuses (posterior ostiomeatal complex), then whichever endoscopic surgical technique is selected must also address the natural drainage areas of these sinuses. In other words, the natural ostium of the sphenoid needs to be enlarged rather than a new one created through the common wall of the sphenoid and posterior ethmoid cells. It would therefore make sense to stay medial to the superior turbinate, rather than lateral to it, to access the natural ostium of the sphenoid. I The Posteroanterior (PA) Approach Recognizing the potential difficulties with the AP approach, especially with more extensive disease of the paranasal sinuses, Wigand described the PA ap- proach. In this approach, the surgeon initially opens the sphenoid sinus, beginning with a poste- rior partial resection of the middle turbinate. The posterior ethmoid sinus is opened by limited re- moval of the posterior free body of the middle tur- binate, The sphenoid is entered by using a suction tip or probe with gentle pressure 1-2 cm above the upper edge of the posterior nasal choanal arch. Wigand noted that his technique poses little danger of perforating the skull base because the rigid plate of the sphenoid planum will be encountered if the surgeon goes too high. Nevertheless, he advised against exposing the posterior ethmoid cells as far as the ethmoid roof at this point. Rather, he advo- cated first exposing and removing the anterior wall of the sphenoid sinus. Once the roof of the sphenoid and lateral wall are identified (as the superior and lateral limits of dissection, respectively), a retro grade dissection of the ethmoid cells is performed. Wigand described performing an antrostomy last through the posterior fontanelle since this is a con- sistent reference point for safely entering the max- illary sinus. According to Wigand, the PA approach gives a clear exposure of the surgical field, reducing the risk of serious complications and yielding reliable results without long-term crusting. This approach, however, is more extensive than the AP approach, irrespective of the extent of the dlisease. The tech- nique involves routine opening of the sphenoid, frontal, and maxillary sinuses (a pansinus opera- tion). It also requires a certain degree of precision and experience in determining the exact location of the sphenoid sinus ostium in the sphenoethmoidal recess. With advanced disease, the anatomy in this area may be significantly distorted and the superior and middle turbinate may be difficult to identify. Although the mean distance from the sphenoid os- tium to the skull base (posterior cribriform) is also 8 mm, there is still a range of 3 to 17 mm. Thus, the sphenoid ostium can be very close to the posterior cribriform, creating the potential for inadvertent intracranial penetration when attempting to enter the sphenoid too superiorly. @ REFERENCES 1, Messerklinger W, Endosckopiche diagnose und chirur- gie der rezidivierenden sinusitis. In: Krajina Z, ed. Ad- vances in Nose and Sinus Surgery. Zagreb, Yugoslavi Zagreb University; 1985 2, Stammberger H. Endoscopic endonasal surgery— concepts in treatment of recurring rhinosinusitis. PartCHAPTER 3 ™ Anteroposterior Versus Posteroanterior Approach 11 II, Surgical technique. Otolaryngol Head Neck Surg 1986;94(2):147-156 3. Wigand ME, Steiner W, Jaumann MP. Endonasal sinus surgery with endoscopical control: from radical oper- ation to rehabilitation of the mucosa. Endoscopy 1978; 10(4) 255-260 4, Wigand ME, Endoscopic surgery of the paranasal sinuses and anterior skull base. New York, NY: Thieme Medical Publishers, 1990 Kennedy DW, Zinreich S}, Rosenbaum AE, Johns ME. Functional endoscopic sinus surgery. Theory and diag- nostic evaluation, Arch Otolaryngol 1985;111(9):576- 582 6. Casiano RR. Correlation of clinical examination with ‘computer tomography in paranasal sinus disease. Am J Rhinol 1997;11(3):193-196 7. Hosemann W, Gross R, Gode U, et al. The anterior sphenoid wall: relative anatomy for sphenoidotomy. ‘Am J Rhinol 1995;9:137-144 8, Wigand ME, Transnasal ethmoidectomy under endo- scopical control. Rhinology 1981;19(1):7-15 9, Van Alyea OE. Sphenoid sinus: anatomic study, with consideration of the clinical significance of the struc- tural characteristics of the sphenoid sinus. Arch Oto- laryngol 1941;34:225~253The Use of Anatomical Landmarks Roy R. Casiano In 1994, May and colleagues introduced six friendly anatomical landmarks that are almost always pres- ent despite previous surgery’ 1. the arch (or convexity) formed by the posterior edge of the lacrimal bone, marking the lacri- mal duct at the anterior margin of the middle meatus 2. the anterior superior attachment of the middle turbinate (vertical lamella) 3. the middle meatal antrostomy and its bony “ridge,” along its superior border, formed by the junction of the floor of the orbit with the lamina papyracea and resected margin of the posterior fontanelle. 4. the lamina papyracea 5, the nasal septum 6. the arch of the posterior choana Using these landmarks, revision endoscopic sinus surgery (ESS) for recurrent or persistent disease in the maxillary, ethmoid, sphenoid, or frontal sinuses can be safely performed. May was one of the first to acknowledge that in advanced sinus disease ana- tomical landmarks, such as the uncinate process, basal lamella, and superior or middle turbinates are not always readily identifiable. He was also one of the first to point out that the floor of the orbit, as seen through an antrostomy, serves as a consis tent landmark from which other structures may be found. The bony “ridge” along the superior border of the antrostomy corresponds to the medial or- bital floor, which facilitates identification of the in ferior lamina papyracea prior to proceeding with an ethmoidectomy. The ridge is also useful in locating the posterior ethmoid and sphenoid sinuses (see Chapter 5). Despite prior reports that showed great inté subject variability, May and Stankiewicz reintro- duced the possible clinical efficacy of using stan- dard measurements from the columella to orient the surgeon during ESS? They based this proposal onanecdotal experience and prior anatomical stud- ies by others, noting that the distance from the area of the anterior nasal spine to the sphenoid ostium is 60 mm (range 47-70 mm).** If one more centi- meter is added for the length of the columellar base, the mean distance to the sphenoid ostium would be approximately 70 mm. For this reason, May advo- cated labeling instruments with colored tape to warn the surgeon when the anterior face of the sphenoid is reached (~7 cm). In fact, today, many instruments come premarked in centimeters markings from the tip to allow for 1314 CHAPTER 4 The Use of Anatomical Landmarks such measurements. However, there will likely be variability among surgeons’ measurements of these distances. In isolation, these measurements have not been shown to be clinically relizble. Schaefer was the first to described a “hybrid or combined technique” that blended the conserva- tion goals of the AP approach with the anatomical virtues of the PA approach,’ Surgery begins with identification and complete removal of the unci- nate process. If further surgery of the ethmoid sinus is warranted, the maxillary natural ostium is enlarged posteriorly or inferiorly, rather than anteriorly, to avoid injury to the lacrimal canal. Schaefer noted that this immediately exposes the level of the orbital floor. Like May, Schaefer recog- nized the importance of the medial orbital floor as a very important landmark to facilitate iden- tification of the inferior lamina papyracea prior to proceeding with an ethmoidectomy. He also advocated removal of the inferior two-thirds of the ethmoid cells in an AP direction using a zero- degree telescope. Often this involves removal of most, if not all, of the basal lamella of the middle turbinate to address the drainage area of the posterior sinuses and to fa- cilitate entry into the sphenoid sinus. If the ostium cannot be visualized or palpated, the sphenoidl is entered in the inferomedial quadrant of the ante- rior wall of the sinus, This approach ensures that the surgeon will maintain a safe distance from the skull base. Itis only after the sphenoid roof has been identified that a superior dissection of the sphenoid face or ethmoid cavity (if indicated) is performed, as with the PA approach. Schaefer’s approach, like May's, recognizes the importance of performing an antrostomy prior to an ethmoidectomy to identify the orbital floor and medial orbital wall, Schaefer was the first to note the importance of performing an inferior ethmoid- ectomy before proceeding posteriorly using the me- dial orbital floor as a reference point. As the sur geon proceeds posteriorly, it is the orbital wall that dictates the trajectory and not some ill-defined and often distorted lamella or turbinate structure, as advocated by proponents of the AP approach, Schaefer's study did not, however, define the ver- tical extent of the initial “inferior ethmoidectomy” from the level of the medial floor of the orbit. Mosher has shown that the height of the ethmoid labyrinth ranges from 2.5 to 3 cm®; however, this height may vary even more depending on whether itis measured anteriorly or posteriorly. Similarly, the distance of two thirds of the eth- moid cells, as described by Schaefer, can be quite variable, The maximum vertical distance permit- ted for an “inferior ethmoidectomy” as the surgeon proceeds posteriorly before critical skull base struc- tures are at risk remained not clear. Similarly, the distances to the critical structures in the posterior and lateral walls of the sphenoid sinus remain un- defined. In 2001, Casiano confirmed May's and Schaefer's observations on a series of human cadavers. In this study, two examiners, with varying experi- ence in endoscopic sinus surgery, performed en- doscopic and direct measurements from the colu- mella and medial orbital floor to critical orbital and skull-base structures. The distances to four critical skull-base or orbital structures (the carotid artery, optic nerve, mid-ethmoid roof, and ante rior ethmoid artery), and to the anterior and pos- terior walls of the sphenoid sinus, were measured (Fig. 4.1A,B). The mean, ranges, and standard de- viations for all measurements (endoscopic and direct) were calculated. In addition, the variability in measurements between examiners and be- tween the endoscopic and direct measurements was also determined. The mean and range of val- ues for each of the variables correlated well both between examiners and between endoscopic andCHAPTER 4 # The Use of Anatomical Landmarks 15 Posterior Fovea Anterior ethmoid artery ethmoidalis_ethmoid artery Optic nerve Cavernous internal carotid -f Sphenoid sinus, Fig. 4.1 A Distances from the columella and antrostomy Shaded area in B denotes the “safe zone" of inferior orbital ridge to crit al structures: 9 cm to the posterior sphenoid; dissection within 1 cm of the antrostomy ridge. Arrows in Fig- 7 cm to the anterior sphenoid or posterior wall of posterior ure B denote the key measurement points illustrated in Figure ethmoid: 5 cm to the anterior wall of the posterior ethmoids, 4.28.16 CHAPTER4 ® The Use of Anatomical Landmarks Mean,Min..Max. & SD for measurements from the columellar base (mm) .Max. & SD measurements from the antrostomy ridge (mm) Fig. 4.2 (A) Mean, minimum, maximum, and standard devia- tion for measurements from the columellar base (in millime- ters). (B) Mean, minimum, maximum, and standard deviation for measurements from the antrostomy ridge (in millimeters). PM, posterior maxillary sinus; AS, anterior sphenoid sinus; PS, posterior sphenoid sinus; ON, optic nerve at canuilicular por tion; CA, cavernous cartoid artery; AA, anterior ethmoidal ar- tery: E, ethmoid roof at the junction of the orbital wall. Colum- nellar measurements greater than 9 cm represent “extra-sinus* extension into the orbit or skull base or posterior sphenoidl wall (black dotted line in Figure 4.2A). Staying within 1 cm of the antrostomy ridge along the inferior orbital wall maintains the surgeon away from most critical neurovascular structures (white solid line in Figure 4.28).direct measurements. The columellar measure- ments appeared to be very consistent between ex- aminers and between endoscopic and direct mea- surements (Fig. 4.2A,B). When the antrostomy ridge and adjacent medial orbital floor was used, there was some slight vari- ability between the individual measurements of the examiners and between endoscopic and direct measurements. However, the differences in mea- surements were no more than a few millimeters and did not appear to affect the overall clinical utility of these values. Casiano concluded that the bony ridge of the antrostomy and adjacent medial orbital floor, when combined with the use of colu- mellar measurements, are easily identifiable, and consistent, anatomical landmarks that provide even the most inexperienced surgeon with very reliable information to navigate through even the most distorted paranasal sinus cavities. For exam- ple, staying within 1cm of the antrostomy ridge, along the medial orbital wall and anterolateral sphenoid sinus, keeps the surgeon well away from critical skull base structures (Figures 4.1B and 4,28). This is particularly important for advanced cases with distorted anatomy of the paranasal si- nuses, due to prior surgery or significant inflam- matory disease (i.e., polyps). This, as well as other critical anatomical landmarks, will be reviewed throughout the course of this dissection manual, illustrating their practical use during endoscopic CHAPTER 4 # The Use of Anatomical Landmarks 17 sinus surgery, and maintaining the surgeon ori- ented within this complex anatomical area. @ REFERENCES 1. May M, Schaitkin B, Kay SL. Revision endoscopic sinus surgery: six friendly surgical landmarks. Laryngo- scope 1994;104(6 Pt 1):766-767 2, May M, Sobol SM, Korzec K. The location of the maxi lary os and its importance to the endoscopic sinus sur- geon, Laryngoscopebib_year 1990;100(10 Pt 1):1037- 1042 3, Stankiewicz JA. The endoscopic approach to the sphe- noid sinus. Laryngoscope 1989;99(2):218-221 4, Van Alyea OE. Sphenoid sinus: anatomic study, with consideration of the clinical significance of the struc tural characteristics of the sphenoid sinus. Arch Oto- laryngol 1941;34:225-253 5, Lang J. Clinical Anatomy of the Nose, Nasal Cavity and the Paranasal Sinuses. New York: Thieme Medical Pub- lishers, 1989 6. Calhoun KH, Rotzler WH, Stiernberg CM. Surgical anatomy of the lateral nasal wall. Otolaryngol Head. Neck Surg 1990;102(2):156-160 7. SchaeferSD. An anatomic approach to endoscopicintra- nasal ethmoidectomy. Laryngoscope 1998;108(11 Pt 1): 1628-1634 8, Mosher HP. The surgical anatomy of the ethmoidal labyrinth, Ann Otol Rhinol Laryngol 1929;38:869-901 9. Casiano RR. A stepwise surgical technique using the medial orbital floor as the key landmark in performing endoscopic sinus surgery. Laryngoscope 2001;111 (6):964-9745 Basic Endoscopic Sinonasal Dissection Roy R. Casiano, Islam R. Herzallah, Amy S. Anstead, Jean Anderson Eloy, Adam Folbe, Lori Lemonnier, and Belachew Tessema i Intranasal Examination Ethmoid bulla Uncinate process Key Landmarks (Fig. 5.1) @ Inferior and middle turbinates 1m Nasal septum '@ Posterior choanal arch 1m Eustachian tube opening Nasolacrimal convexity Middle turbinate Fig. 5.120 CHAPTER 5 = Basic Endoscopic Sinonasal Dissection Vertical lamella Vertical lamella of — Cribriform plate superior turbinate middle turbinate Nasolacrimal sac Vertical lamella supreme turbinate “ SS Nasolacrimal Sphenoid Bt Neat sinus Nasolacrimal convexity ‘Supreme turbinate Superior torus tubarius and eustacian ‘ibe opening Superior turbinate Middle turbinate Inferior turbinate Middle turbinate Inferior turbinate B Fig, 5.2 (A.B)The surgeon starts examining the nasal fossa by passing a 30-degree telescope posteriorly (looking laterally) along the junction of the inferior and mid- dle turbinates and adjacent to the nasal septum (Fig. 5.2A,B). The structures at the posterior nasal choana (ie., the posterior nasopharyngeal wall, eu- stachian tube opening and torus tubarius, posterior choanal arch, posterior septum, and posterior ends of the middle and inferior turbinates) are routinely identified before proceeding with endoscopic sur- ‘Arch of the posterior choana Torus tubarius Nasopharynx Eustachian tube orifice CHAPTER 5 ¥ Basic Endoscopic Sinonasal Dissection 21 gery of the paranasal sinuses (Fig. 5.3). Early identi- fication of these structures establishes the antero- posterior dimensions of the nasal airway, provides a drainage route for blood into the nasopharynx, and facilitates the introduction of endoscopic surgi- cal instrumentation and telescopes. The anterior ostiomeatal complex (ethmoid bulla, uncinate, and surrounding recesses and drainage outflow track for the maxillary, frontal, and suprabullar ethmoid air cells), can be seen by gentle medial displacement Soft palate22 CHAPTER 5 m Basic Endoscopic Sinonasal Dissection ‘Suprasphenoid (Onodi) Posterior ethmoid cell outflow tract colls outflow tract, (supreme meatus) (Superior meatus) Ethmoid bulla Middle turbinate Fig. 5.4 (A,B) Maxillary sinus accessory ostium the posterior fontanelle area Lacrimal apparatus outfow Maxillary / frontal / anterior ethmoid calls outflow tract (middle meatus) Uncinate process Nasolacrimal SS convexityof the middle turbinate, toward the nasal septum (Fig. 5.4A,B). During live surgery, hemostasis and adequate nasal exposure and evacuation of blood are imperative, For this reason, the nose is topically decongested and infiltrated with vasoconstrictive agents. Hyper- trophied turbinates, and/or septal spurs or devia- tion obstructing the nasal airway, are addressed prior to proceeding with any sinus work, to gain the greatest exposure possible, as well as to improve the patient's nasal airway. A separate contralateral suction may be used for the continuous evacuation of accumulated blood and debris from the nasopharynx. When bilateral polyp disease is present, a bilateral nasal polypectomy is performed first, to reestablish the anteroposterior dimensions of the nose, as well as to facilitate the placement of a contralateral nasopharyngeal suction. Suction-irrigation is performed as necessary. Monopolar or bipolar suction cautery is helpful, if discrete bleeding vessels are encountered during surgery, However, excessive cauterization should be avoided to minimize crusting and prolonged heal- ing in these areas. Wi Inferior Turbinoplasty and Submucous Resection of the Inferior Turbinate Key Landmarks (Fig. 5.5) 1m Inferior turbinate “scroll” area '™ Middle turbinate anterior and posterior (tail) attachment m Lamellar attachment to the lateral nasal wall ‘An endoscopic inferior turbinoplasty andjor sub- mucous resection bone may be indicated when there CHAPTER 5 # Basic Endoscopic Sinonasal Dissection 23 is poor endoscopic visualization of the nasal and posterior choanal structures, or symptomatic nasal obstruction due to turbinate hypertrophy." Frequently, inferior turbinate bone enlargement may contribute to the turbinate hypertrophy and resultant nasal obstruction resistant to medical treatment3 Using a 30-degree telescope, a microdebrider is used to perform an inferolateral incision along the inferior edge of the inferior turbinate, Alternatively, this incision can be performed with a sickle knife or a cutting forceps. Mucosal flaps are then raised on the medial and lateral surfaces of the inferior turbi- nate, and the turbinate bone is partially removed in a Paradoxical middle turbinates Scroll area in the posterior inferior meatal 1/2 of the inferior turbinate Fig. 5.524 CHAPTERS = Basic Endoscopic Sinonasal Dissection Submucosal resection ofthe inferior turbinate {arrows denote a superiorly-based mucoperiosteal lap temporarily raised to allow bone removal) Fig. 5.6 Superiorly based Anterior inferior turbinate attachment mucoperiosteal of inferior flap turbinate (nasal valve area) Inferior turbinate bone Lateral mucoperiosteal flap and vascular redicle Fig. 5.7piecemeal fashion (Figs. 5.6 and 5.7). To minimize the chance of secondary maxillary sinusitis, care should be taken to avoid fracturing the inferior tur- binate lamellar attachment to the lateral nasal wall, adjacent to the maxillary natural ostium. For ad- ditional airway space, the lateral mucosal flap in the inferior meatus and “scroll” area (if present) is trimmed as needed to remove redundant mucosa (Fig. 5.5). At the completion of the procedure, the medial and lateral mucosal flaps of the inferior tur binate are reposed along the entire anteroposterior extent of the inferior turbinate. This minimizes the chance of prolonged crusting due to exposed bone (osteitis) or de-epithelialized surfaces. @ Septoplasty Key Landmarks (Fig. 5.8) m Perpendicular plate of the ethmoid bone @ Anterior nasal spine 1 Cartilaginous septum = Rhinion icant septal spur or deviation may pre~ clude adequate endoscopic visualization or adversely affect nasal airway patency. In these cases, an endo- scopic septoplasty may be indicated.>® Using a 30-degree telescope looking slightly superomedi- ally, an ipsilateral L-shaped or T-shaped incision is performed in the septal mucosa. The vertical por- tion of this incision (‘A’ in Fig. 5.9) is performed im- mediately anterior to the deviated area to facilitate cartilage or bone removal. The horizontal portion of the incision ‘B’ in Fig. 5.9) is made perpendicular to the vertical incision at the junction of the floor and nasal septum or just slightly superior to this point, depending on the extent of the deviation. The incision should be made only through the mucosa on the ipsilateral side (Fig. 5.9). Through this CHAPTER 5 = Basic Endoscopic Sinonasal Dissection 25, Perpendicular Plate of the Rosum fethmoid bone ‘Sphenoid sinus Cartilaginous ‘septum tube orice Crest of the palatine bone Crest of the maxilary bone Fig. 5.8 Vertical (A) and horizontal (B) portions of an L-shaped septoplasty incision and creation of a posterosuperiorly based septal flap.26 CHAPTERS = Basic Endoscopic Sinonasal Dissection, incision, a posterosuperiorly based mucoperiochon- drial flap is elevated on the ipsilateral side. The inci- sion is then carefully advanced (with a periosteal elevator) through the septal cartilage where the contralateral mucoperichodrium is identified, ele- vated, and preserved to avoid the chance of a per- manent septal perforation (Fig. 5.10). The septal spur or deviated portion of the nasal septum is then removed. Occasionally, it is necessary to remove a strip of the perpendicular plate bone just posterior to the coronal plane of the rhinion to free up a caudal deflection and break the cartilage “spring” caudal to this area, Nevertheless, dorsal and caudal struts of septal cartilage are always preserved to avoid the chance of septal collapse and saddle-nose deformity. Periodic transillumination should reveal a bright light posterosuperior to the rhinion, where it is safe to remove cartilage or bone without the Septal cartilage Mucosal flap Contralateral mucoperiosteum Fig. 5.10 risk of dorsal collapse (Fig. 5.11). Transillumina- tion caudal to the rhinion implies that the surgeon is removing cartilage too close to the dorsal strut with impending loss of dorsal support (Fig. 5.118). The mucoperichondrial flaps are then returned to their normal position. At the conclusion of the procedure, the vertical septal incision may be su- tured, although this is usually not necessary unless the flap interferes with the introduction of the tele- scope or instruments. Through and through basting sutures with absorbable sutures may be used for this purpose. Otherwise, blood is allowed to drain through the horizontal incision to minimize the chance of hematoma formation. A light, gentle pres- sure dressing or packing is generally not required unless the septal incisions are completely sutured. This minimizes the chance of septal hematoma formation.Endoscopic septoplast Incorrect level of transillumination caudal to the thinion, risking dorsal collapse. CHAPTER 5 ¥ Basic Endoscopic Sinonasal Dissection 27 Endoscopic septoplast Correct level of transillumination behind the nasal bone and superior to the rhinion. Fig. 5.11 (A) Endoscopic septoplasty: incorrect level of transillumination caudal to the rhinion, risking dorsal collapse, {B) Endoscopic septoplasty: correct level of transillumination behind the nasal bone and superior to the rhinion. I Middle Turbinoplasty Key Landmarks m Middle turbinate anterior attachment and “axilla” m Posterior attachment or tail im Vertical lamella Basal or ground lamella When the middle turbinate is enlarged, a middle turbinoplasty may be indicated.2"° Middle turbi nate enlargement may be due to mucosal hyper- trophy or a concha bullosa, Middle turbinate reduc- tion may be indicated to improve access to the mid- dle meatal structures, sphenoethmoidal recess and sphenoid ostium. Although controversial, it may be also indicated to relieve headache caused by con- tact between the enlarged middle turbinate and the septum. A conservative reduction of the middle turbinate head can be performed whereby visualization of the middle or superior meatal structures is im- proved without adversely affecting olfaction, ostial drainage from the anterior ethmoids or frontal si- nuses, or the patient's airway.'"2 The procedure is performed using a tru-cut biting forceps starting anteriorly and moving posteriorly toward the tail of the middle turbinate. The posterior attachment of the resected portion of the middle turbinate is usually freed with a microdebrider and cauterized. Care is taken to sharply resect the middle turbinate head while avoiding fracturing or de-epithelializing28 CHAPTERS Basic Endoscopic Sinonasal Dissection, Middle turbinate “head” removal without fracturing its vertical lamella Fig. 5.12 Medial edge of the basal (ground) lamella of the middle turbinate Vertical lamella of. after head removal the middle turbinate Ethmoid bulla Uncinate process. and hiatus semilunaris Maxillary sinus accessor ostium Fig. 5.13the vertical lamella of the turbinate adjacent to the olfactory cleft (Fig. 5.12). In case of a concha bullosa, reduction of lateral portion of the middle turbinate can be also performed using powered instrumentation. However, the oscillations of the microdebrider may inadvertently fracture the ver- tical lamella of the middle turbinate, rendering it unstable. In the absence of a stable basal lamella (discussed in later sections), this may result in lat- eralization of the middle turbinate with maxillary, ethmoid air cells, or frontal sinus obstruction. If this occurs, the ethmoid cavity can be temporarily lightly packed with resorbable or nonresorbable packing, to keep the middle turbinate from lateral- izing, Alternatively, an absorbable suture may be placed between the middle turbinate and nasal septum. The mucosal membranes on the medial as- pect of the middle turbinate as well as around its “axilla” are preserved to avoid scarring around the Ethmoid bulla Maxillary sinus Maxillary natural ostium Fig. 5.14 CHAPTER 5 # Basic Endoscopic Sinonasal Dissection 29 olfactory cleft or frontal recess/orbital wall, respec- tively (Fig. 5.13). @ Maxillary Sinusotomy Key Landmarks (Fig. 5.14) ®@ Uncinate process inferior attachment 1 Medial orbital floor (MOF) = Horizontal, transitional, and vertical antrostomy ridge 1 Posterior fontanelle area and posterior third of the inferior turbinate Using an angled probe, the uncinate process, hia- tus semilunaris, and infundibulum are identified. The uncinate process is gently back-fractured with Medial orbital floor and horizontal antrostomy ridge area Uncinate process30 CHAPTERS ® Basic Endoscopic Sinonasal Dissection, Fig. 5.15 (A, B) Anterior fontanelle area Natural ostium osterolateral the inferior uncinate process Accessory ostium in the posterior fontanelle area Posterior fontanelle area Cut edge of, middle turbinate Uncinate vertical lamella process: (head removed) Nasolacrimal » convexity y Ethmoid bulla Probe reflecting uncinate process anteriorly to identity maxillary natural ostiumthe angled probe and carefully removed with a back- biting forceps or powered instrumentation to ex- pose the lateral (orbital) wall of the infundibulum and the maxillary sinus natural ostium (Fig. 5.15, BC). Care is taken to conserve the mucosal mem- branes of the lateral infundibular wall. The tail or CHAPTER 5 # Basic Endoscopic Sinonasal Dissection 31 posteroinferior remnant of the uncinate may oc- clude the natural ostium. Thus, this remnant must be identified and removed to clearly see the natural ostium of the maxillary sinus, The superior border of the natural ostium demarcates the junction of the medial orbital floor (MOF) with the lamina Transantral view looking medially (left side) Nasolacrimal convexity, Uncinate process Fig. 5.15 (C) Transantral view looking medially (left side). Maxillary natural ostium Medial orbital floor Posterior fontanelle32. CHAPTERS = Basic Endoscopic Sinonasal Dissection, ‘Sphenoid sinus natural ostium Fig. 5.16 papyracea (i.e, the junction of the floor and the me- dial wall of the orbit) (Figs. 5.16 and 5.17). For limited disease of the anterior ostiomeatal complex, an uncinectomy, exposure of the maxil- lary natural ostium, and a limited antrostomy may Ethrroid bulla Middle turbinate vertical lamella Maxillary sinus accessory ostium Transitional antrostomy ridge Vertical antrostomy ridge Maxillary sinus natural ostium Fig. 5.17 Ethmoid bulla Medial orbital floor level (dotted line) Maxillary. sinus ostium be all that is necessary. However, if there is sig- nificant sinus disease, then the MOF should be iden- tified through a wide middle meatal antrostomy prior to proceeding with an ethmoidectomy. As the surgeon gains more experience, identification of Cut edge of the inferior 1/3td. ‘of the uncinate process Horizontal antrostomy ridge and medial floor of orbitthe MOF may merely require visualizing the supe- rior margin of the maxillary sinus natural ostium, obviating the need for a wider antrostomy. In patients with advanced sinonasal disease and/ or anatomical distortion due to prior surgery, a wide antrostomy is may be indicated.!?-18 As the wide an- trostomy is created, the surgeon should be able to CHAPTER 5 # Basic Endoscopic Sinonasal Dissection 33 identify the MOF along the horizontal bony ridge of the antrostomy, and the posterior wall of the maxil- lary sinus along the vertical bony ridge of the antros- tomy. The MOF helps in maintaining the surgeon ori- ented in the correct anteroposterior trajectory as he/ she proceeds with the ethmoidectomy toward the sphenoid sinus (Figs. 5.18 and 5.19A,B). Medial (cut edge) of the middle turbinate basal lamella (horizontal portion) Sphenoid sinus. natural ostium ‘Transitional antrostomy ridge Ethmoid bulla Horizontal antrostomy ridge and adjacent medial otbital floor Vertical antrostomy ridge Fig. 5.1834 CHAPTER'S = Basic Endoscopic Sinonasal Dissection, Ethmoid bulla Middle turbinate ¥ Cut edge of the vertical lamella inferior 1/3rd of the uncinate process, Horizontal antrostomy ridge Middle ‘Transitional meatal antrostomy antrostomy ridge Vertical antrostomy ridge Maxillary sinus A natural ostium area ‘Transantral view looking medially (eft side) Nasolacrirral Medial convexity orbital floor Ethmoid bulla Fig. 5.19 (A,B) Transantral view looking medially (left side.In the absence of any “normal” ostiomeatal com- plex landmarks, or when there is difficulty identi- fying the natural ostium of the maxillary sinus, the maxillary sinus should be entered through the pos- terior fontanelle, superior to the posterior one-third of the inferior turbinate, This approach will ensure that the surgeon remains in a safe distance below the orbit floor which rises superiorly as one pro- ceeds anteroposteriorly (Fig. 5.20). The surgeon should be aware that the MOF rises in a superior direction, as one proceeds posteriorly, and that the orbit floor is higher medially than laterally. The posterior wall of the maxillary sinus demarcates the relative level of the anterior wall of the sphe- noid sinus, medially adjacent to the nasal septum. When performing the antrostomy through the pos- terior fontanelle area, care must be taken that the nasal, as well as the medial maxillary sinus mucosa, are penetrated. Failure to do so may result in lateral elevation of the medial maxillary sinus mucosa and subsequent formation of a maxillary sinus cyst, or mucocele. A curved frontal curette with a sharp edge may be used for this endeavor. CHAPTER 5 # Basic Endoscopic Sinonasal Dissection 35 Once the posterior wall of the maxillary sinus and MOF have been identified through the poste- rior fontanel opening, a wider antrostomy is cre- ated by removing most of the posterior fontanelle as well as by moving anteriorly toward the maxil- lary natural ostium. During posterior enlargement of the antrostomy through the fontanelle area, it is important not to take down the posterior or vertical ridge of the antrostomy too flush with the coronal plane of the posterior wall of the maxillary sinus, to avoid injury of the greater palatine nerve which de- scends in its canal within this ridge (vertical plate of the palatine bone), at the junction of the medial and posterior walls of the maxillary sinus. Anteriorly, the site of the natural ostium is incor- porated into the maxillary antrostomy to reduce the chances of circular mucus flow. When the natural ostium is not clearly visible, this is best achieved by removing tissue in a retrograde fashion following the MOF, and the horizontal portion of the antrostomy ridge, to a point just behind the convexity of the na~ solacrimal duct. At this point, the MOF, being lower anteriorly, appears to be approximating the lamellar ‘Superior inclination of the orbital floor as one proceeds towards the sphenoid ostium ostium at the level of the posterior medial orbital floor Fig. 5.20 "Zone" of safe entry into the maxillary sinus through the posterior fontanelle area staying a greater distance from the orbital floor36 CHAPTERS ® Basic Endoscopic Sinonasal Dissection attachment of the inferior turbinate to the lateral nasal wall. The MOF must always be kept in view and be constantly referred to throughout the surgery. Failure to visualize the superior margin of the an- trostomy (and the corresponding MOF) may cause the surgeon to proceed in a more superior direction toward the skull base (Fig. 5.21). The camera alignment on the monitor screen must also be periodically checked to ensure that the camera has not been inadvertently rotated. The en- donasal anatomy is aligned so that the upper border of the monitor screen corresponds to anatomically superior. The opening of the antrostomy should al- ways face medially in the sagittal plane (parallel to the nasal septum), with the horizontal portion of the antrostomy ridge and adjacent MOF projecting in an anteroposterior direction toward the orbital apex. The posterior wall of the maxillary sinus, as seen through the antrostomy, demarcates the ap- proximate level of the anterior wall of the sphenoid sinus or posterior wall of the posterior ethmoid, in the coronal plane (Fig. 5.22A,B). Incorrect AP trajectory {not visualizing the orbital floor) Correct AP trajectory (staying at the level of the orbital floor) Fig. 5.21CHAPTER 5 © Basle Endoscopi inonasal Dissection 37 n Middle White arrow points to petite anatomically superior Inferior turbinate Inadvertent camera rotation tothe loft Red arrow denotes incorrect trajectory leading to inadvertent orbital penetration (left side) Middle White arrow turbinate points to anatomically superior Inferior turbinate Fig. 5.22 (A,B)38 CHAPTERS m Basic Endoscopic Sinonasal Dissection @ Anterior Ethmoidectomy The anterior ethmoid air cells are located medial to the horizontal antrostomy ridge. The ethmoid bulla is the inferior-most anterior ethmoid air cell, Key Landmarks adjacent and superomedial to this ridge (Fig. 5.23). mene reeineynine In advanced disease or distorted cavities, the sur Nor geon first performs an inferior ethmoidectomy (anterior andjor posterior, depending on the extent of disease) to identify the inferior portion of the 1m Medial orbital wall Anteromedial wall of the ‘ethmoid bulla Inferomedial orbital wall Horizontal antrostomy ridge Transitional antrostomy ridge Vertical antrostomy ridge Fig. 5.23medial orbital wall and its junction with the MOF." At this point, the surgeon must begin to regularly palpate the eye prior to removing any ad- ditional ethmoidal cells. By looking for movement in the orbital wall, bony dehiscence may be identi- fied. A good exercise is to fracture or remove a small piece of bone from the lamina papyracea in the cadaveric dissection to illustrate this movement ‘Suprabuller cells Middle turbinate vertical lamella Middle meatal antrostomy connected with natura ostium (removal of posterior fontanelle) Fig. 5.24 CHAPTER 5 & Basic Endoscopic Sinonasal Dissection 39 while palpating the eye. This will also be reviewed during the advanced section, under “orbital dissec- tion” (Fig. 5.24). The medial orbital wall, once identified, repre- sents the lateral limits of one's dissection. Further posterior dissection along the inferior portion of the medial orbital wall is then performed. This al- lows dissection of the inferior posterior ethmoid Inferomedial orbital wall Cut lateral edge of inferior uncinate process Maxillary natural ostium Coronal ridge/septation along medial orbital floor40 CHAPTER'S m Basic Endoscopic Sinonasal Dissection Posterior ‘ethmoid artery Optic nerve Cavernous internal carotid Fig. 5.25 air cells and identification of the sphenoid, prior to dissection of the more superior ethmoid air cells, In advanced disease with anatomical distor- tion, the surgeon should initially remain within a safe distance of ~10 mm above the level of the horizontal antrostomy ridge (shaded area in Fig. 5.25) as one proceeds dissecting the posterior ethmoid air cells, toward the sphenoid sinus, in an anteroposterior direction.'® This corresponds to the approximate size of a large upbiting forceps. The tip of the forceps, or opening of the microde- brider cannula, should always be pointed supero- medially, parallel and adjacent to the medial or bital wall, to avoid inadvertent orbital penetration (Fig. 5.25). Anterior ethmoid artery i Posterior Ethmoidectomy Key Landmarks (Fig. 5.26) 1 Transitional antrostomy ridge 1 Middle turbinate basal or ground lamella 5 cm from the columella ‘& Horizontal line from the posterior MOF to the posterior nasal septum Ethmoid roof (fovea ethmoidalis) The posterior ethmoid air cells may be entered safely through the most horizontal portion of the middle turbinate basal or ground lamella (Fig. 5.27).CHAPTER 5 = Basic Endoscopic Sinonasal Dissection 41 Horizontal line denoting level of the MOF and horizontal antrostomy ridge Posterior ‘ethmoids Maxillary sinus. Horizontal portion of basal or ground lamella of the middle turbinate Fig. 5.26 — ———rr = a Vertical portion of the em basal (ground) Iamelia , separating the suprabular cells from the superior posterior ethmoid cells Horizontal portion of the basal (ground) lamella of the middle turbinate "Zone" of safe entry into the inferior posterior ethmoidal cells through the middle turbinate basal lamella at the orbital floor level and 5 om from the columnella Fig. 5.2742 CHAPTER'S m Basic Endoscopic Sinonasal Dissection ‘Suprabullar ethmoidal cells Horizontal (inferior) portion of basal (ground) lamella of the middle turbinate “Safe zone” Medial orbital of entry into floor (posteriorly) the sphenoid sinus at 7 cm from the columnella / Posterior Middle maxillary turbinate sinus vertical wall lamella ‘Safe zone" of entry > * “Transitional” area into the inferior posterior ethmoid cell at § cm from of the antrosiony ree A the columnetia Trensantral view of completed middle meatal antrostomy looking medially (left side) Nasal Middle Basal lamella of the Horizontal ridge septum ——_turbinate le turbinate of the antrostomy Inferior turbinats Transitional ridge Vertical ridge insertion of the antrostomy of the antrostomy Fig. 5.28 (A) (B) Transantral view of completed middle meatal antrostomy looking medially (left side).Endoscopically, the area of safe entry into these air cells is inferiorly at the level of an imaginary hori- zontal line drawn parallel to the nasal floor from the level of the posterior MOF to the nasal septum (Fig. 5.28A,B). At its midpoint, this line demarcates the zone of safe entry into the inferior aspect of the posterior ethmoid air cells (i.e, through the horizon- tal portion of the middle turbinate’s basal lamella).'° By using this landmark, the surgeon consistently enters the inferior-most posterior ethmoid air cells, adjacent to the transitional ridge of the middle me- atal antrostomy. Unlike the sphenoid sinus floor, which lies significantly inferior to the ostium, and is not readily visible upon its initial opening, the posterior ethmoid floor is immediately identified at or slightly inferior to the level of the posterior MOF without difficulty (Fig. 5.29). Once the lateral (orbital) wall of the posterior ethmoid has been identified, the surgeon may pro- ceed with further dissection of the superior cell(s) of the posterior and anterior ethmoid cavity, in~ ‘Suprabullar ethmoidal cells, Vertical (superior) portion of basal (ground) lamella of the middle turbinate Middle turbinate vertical lamella “Safe zone” of entry into the inferior posterior cathmoid cell at 8 cm from the columnella, Posterior cethmoid floor seen at or slightly below the medial orbital floor level. Fig. 5.29 CHAPTER 5 # Basic Endoscopic Sinonasal Dissection 43 cluding the suprabullar area, thus completing the total ethmoidectomy. In advanced disease, where a sphenoid sinusotomy may already be planned, it is safer to postpone further ethmoid dissection supe- riorly until a sphenoidotomy is performed, and the sphenoid roof and lateral wall are identified, as the superior and lateral limits of dissection, respec- tively. This allows safer identification of the poste- rior ethmoid roof and posteromedial orbital wall, by following the sphenoid roof and lateral wall in a retrograde (posteroanterior) direction as describe in the Wigand approach in Chapter 1. Superior ethmoid dissection is carefully per- formed in a posteroanterior and superoinferior di- rection. Initially, the surgeon restricts the dissection to an area adjacent to the orbital wall and lateral eth- moid roof where the bone is thickest. Additional passes along the medial ethmoid roof are then per- formed to open up more medially located cells, once the roof of the ethmoid is identified laterally. The surgeon should observe that the roof of the anterior Inferior posterior ethmoid air coll Medial orbital floor (posteriorly) Posterior maxillary sinus wall ransitional” area of the antrostomy ridge44 CHAPTERS ® Basic Endoscopic Sinonasil Dissection, ethmoid roof slopes medially by as much as 45 de- grees. Bone tends to be thicker in areas where there is bony septation perpendicularly attached to a bony wall. For example, in the case of the ethmoid roof, the bone is thicker laterally close to the orbitand thinner medially, adjacent to the middle turbinate vertical lamella insertion into the skull base, lateral to the cribriform plate. This degree of thinning at the level of the olfactory fossa has been classified by Keros, if only to bring awareness to the surgeon as to the variability of bony thinning in this area, where the surgeon has to exhibit the highest degree of cau- tion, so as to minimize inadvertent intracranial pen- etration.!” The Keros classified the olfactory fossa depth as follows: type 1: olfactory fossa 1-3 mm deep; type Il: olfactory fossa 4~7 mm deep; type Ill: olfactory fossa 8-16 mm deep. In type Ill olfactory fossae, the surgical risk of intracranial entry during endoscopic sinonasal surgery increases if one is not careful (Fig. 5.30). Whenever possible, the mucosa along the orbital wall and ethmoid roof is left undisturbed to avoid granulations, osteitis, prolonged healing, osteoneo- genesis, and fibrosis, Only the mucosa overlying the septations is removed. This can be facilitated by the use of cutting forceps or powered instrumentation. § Sphenoid Sinusotomy Key Landmarks (Fig. 5.31) 1 Superior turbinate tail and basal lamella and adjacent nasal septum, ~7 cm from the columella 1 Horizontal ine from the posterior MOF to the posterior nasal septum ® Posterior choanal arch i= Sphenoid roof and lateral roof ® Posteromedial sphenoid wall ‘The fovea ethmoidalis or roof ofthe ethmoid air cells slopes inferomedially towards the skull base attachment Of the middle and superior turbinate vertical lamellae. Its bone is thicker adjacent to the orbit, Measurement points for the olfactory fossa depth under the Keros Classification Middle turbinates Fig. 5.30Foramen ‘Sphenoid rotundum sinus Vidian ‘Sphenold foramen rostrum Fig. 5.31 The sphenoid ostium is located medial to the tail of the superior and supreme turbinate and adjacent CHAPTER 5 = Basic Endoscopic Sinonasal Dissection 45 Anterior Optic clinoid process nerves Base of the pterygoid bone Lateral pterygoid plate Medial pterygoid plate Pharyngeal or palatovaginal tana (artery) angle of the columella." The area of the sphenoid natural ostium in the anterior wall of the sinus usu- to the nasal septum, ~1.5 to 2. cm above the arch of _ ally lies at the middle third of the sphenoid sinus’ the posterior choana and 7 cm from the nasolabial Sphenoid natural ostium 7om from the columnella at 30° from the nasal floor Fig. 5.32 vertical height (Fig. 5.32). Variable degrees of sphe-4G CHAPTER'S m Basic Endoscoplc Sinonasal Dissection noid sinus pneumatization may exist, sometimes extending into the greater wing of the sphenoid bone, to create a prominent lateral sphenoid recess (Fig. 5.33). A direct transnasal sphenoid sinusotomy may be performed without performing an ethmoidectomy or antrostomy, via the sphenoethmoidal recess, me- dial to the middle turbinate. The superior turbinate is exposed endoscopically by reducing the middle turbinate head (as previously described). In a well- pneumatized sphenoid, its posterior wall measures ~9 cm from the base of the columella. The sphenoid is initially identified adjacent to the nasal septum and superomedial to the tail of the superior turbi- nate with a straight ball probe or periosteal eleva- tor, palpating its posteromedial wall, and away from any critical structures located in the lateral wall of the sphenoid sinus (Fig. 5.34A,B). The sphenoid os- tium is enlarged laterally by resecting the posterior one-third of the superior turbinate and its basal la~ mela, The latter forms the common wall between the inferior posterior ethmoid cells and the sphe- noid sinus. A sphenoid punch, or powered instru- mentation, may be used only after confirming an air-containing space behind its common wall with the posterior ethmoid air cells. Blind removal, with- out confirming an air-containing space, can result in inadvertent injury to the sphenoid internal carotid artery (ICA), When significant anatomical distortion exists in the area of the sphenoethmoidal recess, and the posterior insertion of the superior turbinate is not clearly visible, then the MOF is used to determine the approach into the sphenoid sinus. In these sit- uations, the sphenoid sinus is entered and identi- fied medially adjacent to the nasal septum, ~7 cm from the base of the columella, at the level of the posterior MOF. When the posterior MOF is used as a reference point, the sphenoid sinus will be en- tered consistently in its middle third, adjacent to the nasal septum. In most cases, this area also corresponds to the location of the sphenoid os- Left sphenoid sinus ‘Sphenoid rostrum Fig. 5.33 2nd Division ofthe trigeminal nerve (V2) Lateral sphenoid recess Posterior nasal septumCHAPTER'S 1 Basic Endoscopic Sinonasal Dissection 47 Middle turbinate (tail) Septal branches of the Posterior sphenopalatine A choanal artery arch ‘Superior turbinate tail Middle turbinate Sphenoid sus Septal branch of the sphenopalatine artery Fig. 5.34 (A.B)48 CHAPTER 5 = Basic Endoscopic Sinonasal Dissection, ‘Suprabullar ethmoidal cells. Vertical (superior) portion Inferior posterior of basal (ground) lamella ‘ethmoid air cell of the middle turbinate “Safe zone" of entry into the sphenoid sinus at 7 cm from the columnelia Posterior i Middle ae {urinate P wall vertical lamella “Transitional” area of the antrostomy ridge Fig. 5.35 ‘Superior posterior ethmoid cell Posterolateral 4 vertical lamella Inferior posterior of superior ‘ethmoid cell turbinate a orbital \ 7 wall ‘Sphenoid (posteriorly) sinus, Medial orbital floor Maxillary sinus Posterior wall Fig. 5.36tium (Fig. 5.35). Once the common wall between the sphenoid and posterior ethmoid sinuses are re- moved. One can appreciate that most of the sphe- noid sinus cavity lies below the level of the MOF, and conversely, most of the posterior ethmoid cells lie above the MOF (Fig. 5.36). Also, the surgeon may also use the natural curvature of the maxil- lary middle meatal antrostomy to direct him/her Posterolateral vertical lamella of superior turbinate ‘Sphenoid sinus Inferomedial trajectory as one proceeds towards, the sphenoid sinus 11cm superior and parallel to the antrostomy ridge Fig. 5.37 CHAPTER 5 1 Basic Endoscopic Sinonasal Dissection 49. toward the sphenoid sinus in an inferomedial di- rection as he/she proceeds posteriorly (Fig. 5.37). If the maxillary natural ostium (or anterior antros- tomy ridge) is used as a reference point, then the sphenoid will be entered slightly more inferiorly, where thicker bone may be encountered, necessi- tating a bone curette or cutting burr to facilitate removal. ‘Superior posterior ethmoid cell Inferior posterior ‘ethmoid cell “Transitional area of the antrostomy ridge Maxillary sinus posterior wall50 CHAPTERS = Basic Endoscopic Sinonasal Dissecti Correct trajectory into the sphenoid sinus adjacent to the nasal septum, at the level of the sphenoid sinus natural ostium Transethmoida tajector into the sphenoid sinus, risking inadvertent penetration into the carotid artery A Carotid artery Superior posterior . Superior (cut edge) sitvnotd col , : = Nasolacrimal ie Nasolacrimal duct Nasolacrimal convexity Nasolacrimal convexity inferior turbinateprominent convexity in the lateral wall of the nose running adjacent to the anterior middle meatal margin. The bony wall may be very thin posteriorly, adjacent to the uncinate process or maxillary natu- Fig. 6.3 (A,B) Nasolacrimal sac Middle turbinate anterior attachment Uncinate process CHAPTER 6 ® Advanced Endoscopic Sinonasal Dissectio 61 ral ostium. Superiorly, the lacrimal sac receives the opening of the common canaliculus; the common outflow tract into the nose from the superior and inferior canaliculus (Fig. 6.3A,B). Lacrimal sac area Lacrimal duct area Nasolacrimal duet62 CHAPTER 6 = Advanced Endoscopic Sinonasal Dissection The membranous nasolacrimal duct is located in the inferior meatus and consists of a membranous medial wall and a bony lateral wall. The membra- nous medial wall collapses into the lumen and func- tions as a one-way valve (Hasner's valve) to minimize retrograde flow of secretions or air into the nasolac rimal duct and sac. Hasner’s valve may be seen tra- versing the anterior third of inferior meatal wall. Inferior meatus: inferior turbinate lamella Fig. 6.4 With a small probe, a mucosal canal or trench can be followed superiorly to identify Hasner’s valve and the lacrimal ostium (Fig. 6.4). Occasionally, Hasner’s valve is absent, In these cases a patulous opening looking into the bony nasolacrimal duct may be seen in the superior recess of the inferior meatus adjacent to the inferior turbinate lamellar insertion into the lateral nasal wall (Fig. 6.5). Probe elevating Hasner's Valve Mucosal “trough” or depressionInferior meatus: inferior turbinate vertical lamella insertion into the medial wall of the maxilla Fig. 6.5 @ Anterior and Posterior Ethmoid Arteries Key Landmarks 1 Ethmoid roof (fovea ethmoidalis) 1 Superomedial orbital wall 1 Cribriform plate and olfactory cleft medial to the middle and superior turbinates vertical lamellae Endoscopic ligation or cauterization of the ante- rior ethmoid artery has been advocated in select CHAPTER 6 ® Advanced Endoscopic Sinonasal Dissectio 63 Patulous lacrimal duct devoid of Hasner's Valve cases with anterior epistaxis"? The anterior and posterior ethmoid arteries are branches of the oph- thalmic artery which arises from the internal ca~ rotid artery and enters the orbit via the optic fora- men, together with the optic nerve. The ophthalmic artery then runs on the medial wall of the orbit be- neath the lower border of the superior oblique muscle. The artery gives off both the anterior and posterior ethmoid arteries, which can be seen pen- etrating the periorbita into their respective bony canals, coursing through the roof of the ethmoid sinus." Occasionally, the anterior ethmoid artery courses within a mucosal fold up to several milli- meters below the level of the bony ethmoid roof.64 CHAPTER6 ® Advanced Endoscopic Sinonasal Dissection Additionally, branching of these arteries may occur and posterior to the cribriform plate area, respec- within the ethmoid roof, The ethmoid arteries then tively. Both arteries give off a meningeal branch to enter the cranial cavity medially, in the anterior the dura as they enter intracranially (Fig. 6.6A,B), Posterior ‘Superior posterior Anterior Suprabulla ethmoid artery _ethmoid cells ethmoid artery ethmoid cells Frontal sinus. infundibulum, Carotid artery ie Ethmoid bulla Inferior posterior A ethmoid cell Olfactory cleft (blue outline) Vertical lamella of the middle Frontal sinus turbinate infundibulum Anterior ethmoid artery Posterior ethmoid fond (ans Vertical lamella of branches) Fig. 6.6 (A,B)@ Orbital Decompression Key Landmarks Inferior orbital nerve m= MOF @ Horizontal antrostomy ridge 1 Lamina papyracea @ Medial rectus muscle 1@ Frontal sinus infundibulum Fig. 6.7 (A,B) CHAPTER 6 # Advanced Endoscopic Sinonasal Dissectio. 65 Orbital decompression may be indicated for a pa- tient with an orbital abscess, periorbital or orbital he- matoma, or severe Graves’ ophthalmopathy with ex- posure keratitis and threatened visual loss.!?-22 When a subperiosteal abscess is present, only the lamina papyracea needs partial or complete removal to en- sure aclequate drainage of the abscess loculations into the nose, This may require exposing the periorbita over the superomedial or inferomedial orbital walls to ensure adequate drainage of all potential abscess loc- ulations. Nasal packing is usually avoided. The peri- orbita is left intact without any incisions (Fig. 6.7A,B). Medial wall of orbit (lamina Maxillary natural ostium area Lamina Papyracea elevated (exposing periorbita) Sphenoid sinus66 CHAPTER 6 = Advanced Endoscopic Sinonasal Dissection Lamina papyrecea removed: Approximate level of medial Approximate level of the medial _ periorbital incisions for medial rectus muscle (white circle) orbital decompression in "Graves" Periorbital Incision Miegial rectus muscle area (white circle) Periorbital incision B —Sphenoid sinus posterior wall Fig. 6.8 (A,B)For patients with Graves’ ophthalmopathy, the lamina papyracea and MOF are removed medial to the infraorbital nerve through a wide antrostomy. Postoperative diplopia is possible, but may be mini- mized by preserving the horizontal ridge of the an- trostomy, and placing the periorbital incisions paral- lel to the superior and inferior borders of the medial rectus muscle (see above), at its junction with the superior oblique and inferior rectus muscle, respec- tively2? The periorbita is incised to allow herniation of orbital fat into the ethmoid and maxillary sinus cavities, while minimizing significant muscular her- niation of the medial rectus especially (Fig. 6.8A,B). Medial and inferior orbital decompression allows for ~4-5 mm proptosis reduction. This may have to be combined with a lateral orbital decompression through an external approach. Care is taken not to occlude the maxillary, frontal, or sphenoid ostia with orbital fat, as this may result in secondary ostial ob- struction and rhinosinusitis2*25 In these situations an extended middle meatal, frontal, and/or sphenoid sinusotomy may be prudent. @ Optic Nerve Decompression key Landmarks = Canalicular portion of the optic nerve 1 Opticocarotid recess @ Orbital apex 1 Optic nerve sheath In patients with worsening visual acuity due to traumatic neuropathy or neoplastic compression, an CHAPTER 6 ® Advanced Endoscopic Sinonasal Dissectio 67 optic nerve decompression may be indicated.25-29 The orbital apex may be found by following a verti- cal line, parallel and at the coronal plane of the su- perior vertical ridge of the antrostomy and adjacent posterior wall of the maxillary sinus, toward the junction of the posterior ethmoid sinus roof with the superomedial orbital wall. The orbital apex is located ~7 cm from the columella. The canalicular portion of the optic nerve is identified as it takes an abrupt turn medially at this point, coursing toward the optic chiasm (Fig. 6.9). The thicker bone in this area is carefully thinned with a diamond bur and removed with a periosteal elevator. In the cadaver laboratory this can be carefully performed utilizing a bone curette, The length of the canalicular por- tion is ~8-12 mm. The optic nerve sheath is con- Posterior ethmoid artery Cavernous internal ‘carotid Maxillary sinus \ Vertical line at the coronal plane of the posterior maxillary sinus wall delineates the approximate level of the orbital apex Fig. 6.9