Rhinosinusology

SURGICAL RHINOSINUSOLOGY—-DANIEL TODD, MDPARANASAL SINUSES FUNCTIONS: FROVIDE CONSTANT FLOW OF MUCOUS TO THE NASAL CAVITY ACT AS SHOCK ABSORBERS TO PROTECT THE CRANIAL VAULT FROM TRAUMA ACT AS SURGE TANKS TO PREVEN NASAL BAROTRAUMA (RETROGRADE INTRANASAL PRESSURE) LIGHTEN THE SKULL PROVIDE VOCAL RESONANCE ENHANCE OLFACTION AID IN HUMIDIFICATION INTERESTINGLY A PAUSITY OF NOCICEPTORS AND MUCOUS CELLS COMPARED TO THE NASAL VAULT—REQUIRES 230 MMHG PRESSURE OVER 1 ATMOSPHERE TO CAUSE FACIAL PAIN 3 EMBRYONIC STAGES PRESKELETAL STAGE (3-6 WEEKS) NASAL PLACODES(THE FOUNDATION ECTODERM AROUND WHICH THE NOSE DEVELOPES)–INITIATE A PROLIFERATION OF SURROUNDING MESENCHYME–NASAL PITS—SINK DEEPER CFORM LAT AND MEDIAL NASAL PROMINENCES—NASAL PLATES OF AHOCHSTETTER@–LATERAL TISSUE MASSES FORM THE ANASAL FINS@ CHONDROCRANIAL STAGE (6-12 WEEKS) MESENCHYME CONDENSES TO FORM PRIMITIVE NASAL CAPSULE MESETHMOID–NASAL SEPTUM, TURBINATES, ECTETHMOID–NASAL CAPSULE OSTEOGENEC STAGE (12 WEEKS–) SLOW PNEUMATIZATION OF THE PARANASAL SINUSES 2 TYPES OF BONE FORMATION INTRAMEMBRANOUS–BONES FORM WITHIN THE MESENCHYME–NOT CARTILAGE ENDOCHONDRAL(WITHIN THE CARTILAGE)—BEGIN AS OSSIFICATION CENTERS WITHIN THE NASAL CAPSULE—-5 BONES IN THE SKULL–POEMS–PETROUS, OCCIPITAL, ETHMOID, SPHENOID, ?INF NASAL CONCHA? NEONATE REALLY ONLY BORN WITH MAXILLARIES AND ETHMOID LABYRINTH SINUSES ARE NAMED BY THE MAIN BONES THE INVAGINATE INTO LINED WITH SCHNIEDERIAN (CILIATED PSEUDOSTRAT COLUMNAR) EPITHELIUM FRONTAL SINUS BEGINS DEV 4TH MONTH OF GESTATION AS A SUP EXTENSION OF THE ANT NASAL CAPSULE IN THE FRONTAL RECESS 80% EMPTY INTO FRONTAL RECESS FRONTAL SINUS—FRONTAL SINUS OSTIUM–FRONTAL RECESS—HIATUS SEMILUNARIS FRONTAL RECESS—ANT WALL=POST WALL OF THE AGGAR NASI AGGAR=BUMP IN THE NOSE—THE ANT MOST AE TAKE OFF THE SUP UNCINATE–PUTS YOU INTO THE AGGAR NASI MAY BE DIFFICULT TO FIND THE FRONTAL SINUS OPENING, VERY DIVERSE IN ITS SHAPE, OFTEN NO AGAR NASI—OFTEN THE ANT INSERTION OF THE MIDDLE TURB FORMS THE MEDIAL AND ANT WALL OF THE FRONTAL RECESS FRONTAL SINUS DUMPS VIA THE NASOFRONTAL DUCT INTO THE FRONTAL RECESS (MESSERKLINGER PRE-CHAMBER) =TRANSITIONAL SPACE—-CAN BE A PROBLEM AREA—CLASSIC TEACHING IS TO STAY OUT OF THIS AREA AS CICATRICIAL SCARRING CAN LEAD TO DEBILITATING Dz PNEUMATIZATION AFTER 1-2 KYEARS OF LIFE (RARELY RADIOGRAPHICALLY EVIDENT BEFORE AGE 2—USUALLY EVIDENT BY AGE 6) GROWS 1.5 MM/YR—-USUALLY COMPLETE BY AGE 20 INNERVATED BY V1—-OPHTHALMIC—-FRONTAL N.—-SUPRAORBITAL AND SUPRATROCHLEAR NERVE ETHMOIDS CAN ENCROACH ON NASOFRONTAL DUCTS TO FORM INF WALL CONVEXITY = BULLA FRONTALIS INTRASINUS SEPTUM COMMON 86% PTS HAVE B FRONTALS 30% HAVE A UNILAT HYPOPLASTIC SINUS 10% UNILAT AGENESIS 4% COMPLETE FRONTAL AGENESIS (ALMOST ALL PTS WITH CF) ANT TABLE OF FRONTAL = DIPLOIC BONE (OSTEO OR SUBPERIOSTEAL ABCESS OF ANT TABLE OF FRONTAL SINUS = POTT=S PUFFY TUMOR—PRIMARILY STAPH AUREUS POST TABLE(PLATE) = THIN COMPACT BONE WITH PITS AND TRABECULAE—-@CRYPTS OF BRESCHET@ WHICH CONTAIN VALVELESS DIPLOIC VEINS CONTIGUOUS WITH THE DURA—-POTENTIATE THE SPREAD OF INFXN OR TUMOR VIA RETROGRADE THROMBOPHLEBITIS—-GROWTH OF SINUSES —INCREASED VASCULARILTY (ANGIOGENESIS) AND PNEUMATIZATION LEAD TO AN INCREASED RISK OF INFXOUS COMPLICATIONS DURING ADOLESCENCE FRONTAL RECESS AN INVERTED FUNNEL ANT ETHMOID ARTERY AND POST LIMIT OF THE FRONTAL RECESS = THE ORIGIN OF THE BULLA LAMELLA NAMES IN THE HISTORY OF FRONTAL AND ETHMOID SINUS SURGERY RIEDEL–1898–REMOVAL OF THE ANT WALL AND FLOOR OF THE FRONTAL SINUSES MOSHER—ALSO REMOVED THE POST WALL—VERY DISFIGURING–PULSATILE FOREHEAD KILLIAN–1904–LEFT THE SUPRAORBITAL RIM INTACT
HOWARD AUGUSTUS LOTHROP–1912–UNIQUE PROCEDURE—-COMBINED INTERNAL AND EXT APPROACH—AT LEAST A UNILAT AND USUALLY A B ETHMOIDECTOMY, CONNECTION OF THE FRONTAL OUTFLOWS VIA INTRASINUS SEPTECTOMY AND HIGH NASAL SEPTECTOMY—ALSO TOOK THE MIDDLE TURBINATE ALBERT JANSEN—-JANSEN-MIDDLETON DOUBLE ACTION RONGEURS ROBERT CLYDE LYNCH–1920—LYNCH INCISION—EXT FRONTOETHMOIDECTOMY—CUT ABOUT 2 WAY INBETWEEN THE NASION AND THE LACRIMAL PUNCTUM OF THE MEDIAL CANTHUS–CUT PERPENDICULAR TO THE BONE—BEWARE OF EXTENDING TOO FAR LATERALLY TO TRANSECT THE TROCHLEA OR SUPRATROCHLEAR NEUROVASCULAR BUNDLE—ORIGINALLY TOOK THE MIDDLE TURB AND REMOVED THE FLOOR OF THE FRONTAL SINUS–ALL THE FRONTAL SINUS MUCOSA WAS ALSO REMOVED BY CURRETTE—FIRST LOCATE THE FRONTO-ETHMOID SUTURE LINE—-THIS IS ABOUT AT THE INTERPUPILLARY LINE AND APPROXIMATES THE CRANIAL BASE– AT THE LEVEL OF THE CRIBRIFORM PLATE—AS YOU GO BACK—(USE A SEWALD RETRACTOR) THE ANT ETHMOID IS 20-24 MM POST TO THE LACRIMAL CREST(CONGENITALLY ABSENT 14% UNILAT,2% BILAT, POST ETHMOID IS 10-12 MM POST TO THIS—OPTIC NERVE IS 5-6 MM POST TO THIS EDWARD C SEWALL—NOW USE HIS ORBITAL RETRACTOR MONTGOMERY –1960’S—OSTEOPLASTIC FLAP AND FRONTAL SINUS ABLATION DRAF-–1991–ENDONASAL FRONTAL SINUS FLOOR DRILL OUT IF IT AINT BROKEN DONT FIX IT—NEVER PROBE AN PRISTINE FRONTAL RECESS!—–EVEN IF THERE IS FRONTAL DZ—SHOULD CONFINE THE FIRST SURGERY TO THE OMC—-CHANCES ARE IT WILL CLEAR APPROACHES BICORONAL TRANSFACIAL: GULLWING (BROW); LYNCH TRANSANTRAL(CALDWELL-LUC) TRANSNASAL SELDINGER TECHNIQUE OF IDENTIFYING AND STENTING THE FRONTALS XOMED OR SETLIFF DRILL SET WITH PROBES AND DRILL GUIDES AND GUARDS GET 6 FOOT SCOUT FILM (CALDWELL VIEW) 11 BLADE STAB INCISION ATTEMPT TO AVOID SUPRATROCHLEAR NEUROVASCULAR BUNDLE—MIGHT DOPPLE THESE OUT CONSENT PT ABOUT BROW HYP-PARESTHSEISAS DRILL INTO SINUS—PLACE BLUNT PROBE IN SINUS—PLACE ENTRY CATHODER AROUND PROBE AND LOCK INTO SINUS ASPIRATE—AIR—CULTURE ECT… FLUSH WHILE VISUALIZING ENDOSCOPICALLY PASS 3.5 PEDIATRIC FEEDING TUBE INTO THE NOSE—GRASP WITH PEDIATRIC POLYP FORCEPS DO ANY FRONTAL RECESS WORK DEEMED NECESSARY SETLIFF TUCKS THE FEEDING TUBE UP INTO AN ETHMOID AND LEAVES IT FOR 6-8 WEEKS USE A 3-0 NYLON—SUTURE ONTO DISTAL END OF PEDIATRIC FEEDING TUBE—LEAVE ABOUT A 3 CM LINK OF ONLY SUTURE AND THEN TIE ONTO AN 8 OR 10 FR RED RUBBER CATHODER MARK THE CATHODER 3 CM FROM THE DISTAL END WITH A MARKER FEED THE CATHODER INTO THE FRONTAL DUCT AND PULL THE NYLON OUT FROM THE SUPERCILIARY RIDGE CUT OFF THE RED RUBBER CATHODERS AND SUTURE THEM TO THE SEPTUM CUT OFF THE NYLON STICHES AT THE SKIN—-MAY PUT A FAG OR STERISTRIP THE STAB INCISION LEAVE THE STENTS IN FOR ? OSTEOPLASTIC FRONTAL SINUSECTOMY AND FAT ABLATION 6 FOOT AP CALDWELL X-RAY (COIN FOR REFERENCE) TARSORRAPHY STICHES WIDOWS PEAK BICORONAL INCISION—PARALLEL THE HAIR FOLLICLES—MINIMIZE CAUTERY—-USE RAINEY CLIPS LEAVE PERIOSTEUM DOWN AND CUT THIS 1 CM OUTSIDE THE TEMPLATE CUT THROUGH THE BONE WITH THE SAGITTAL SAW BEVELLING IN —-MUST CUT THE INTERSINUS SEPTUM WITH THE OSTEOTOME FX IT DOWN AT THE LEVEL OF THE SUPRAORBITAL RIDGE—LEAVING THE PERIOSTEUM INTRACT REMOVE ALL THE MUCOSA CLOSE OVER 2 LAT JP DRAINS USE A MASOID TYPE COMPRESSION DSG KEEP ON ABX FOR 48 – 72 HOURS STAPLES OUT PO DAY #10 ETHMOIDS(ETHMOID LABYRINTH) THE MOST DEVELOPED IN THE NEONATE EXHIBITS THE MOST VARIATION AMONG THE PARANASAL SINUSES—ALSO THE MOST CONFUSION IN NOMENCLATURE 4-17 CELLS—DIVIDED INTO ANT AND POST CELLS BY THE SIGMOID SHAPED ATTACHMENT OF THE MIDDLE TURB (GROUND OR BASAL LAMELLA)—BASAL LEMELLA IS THE PREFERRED TERM! BASAL LAMELLA= THE THIRD BASAL LAMELLA OF THE ETHMOTURBINALS = THE INSERTION OF THE MIDDLE TURB—LIES IN 3 DEFFERENT PLANES WHICH RESULTS IN MIDDLE TURBINATES STABILITY THERE ARE NO MIDDLE ETHMOID CELLS! ENTIRE LABYRINTH IS IN A PYRAMIDAL SHAPE ROOF = FOVEA ETHMOIDALIS (FRONTAL BONE) JUST LAT AND 2-3 MM SUP TO THE CRIBRIFORM PLATE THERE ARE 3 CONFIGURATIONS TO THE ETHMOID ROOF FROM SHALLOW TO DEEP OLFACTORY FOSSA—THE DEEP IS THE MOST DANDEROUS—-THE LATERAL LAMELLA OF THE CRIBRIFORM PLATE ARE VERY THIN AND FRAGIL LAT WALL = LAMINA PAPYRECEA–OS PLANUM (ETHMOID BONE)—MOST CONSTANT STRUCTURE IN THE LABYRINTH
ANT ETHMOIDS—DIVIDED INTO THE FRONTAL RECESS CELLS (0-4)—INCLUDES AGGAR NASI CELL=@NASAL MOUND@=BUMP IN THE NOSE—THE MOST ANT AE–OF THE MAXILLARY BONE——10% PTS HAVE 2—-MAY ALSO HAVE BULLA FRONTALIS ROOF OF THE AGGAR = FLOOR OF THE FRONTAL SINUS POST WALL OF THE AGGAR = ANT WALL OF THE NASOFRONTAL DUCT SUP UNCINATE INSERTS INTO THE AGGAR--UNCINATE PROCESS = PROCESSUS UNCINATUS AHOOKED OUTGROWTH@—A REMNANT OF THE FIRST ETHMOTURBINAL INFUNDIBULAR CELLS (1-7) NATURAL OSTIUM—-INFUNDIBULUM—-HIATUS SEMILUNARIS—DIVIDED INTO A SUP AND INF PORTION DRAIN INTO THE OMC—-USUALLY THE ETIOLOGY OF RHINOSINUSITIS BULLAR CELLS (1-6)—DRAIN POST/SUP—-BULLA ETHMOIDALIS = ETHMOID BULLA–LIKE A BLEB ON THE LAMINA PAPYRACEA = IS THE MOST CONSTANT OF THE AE=S CONCHA BULLOSA = ANT ETHMOID CELL WITHIN THE TURBINATE HALLER CELL = MAXILLOETHMOIDAL CELL (DESCRIBED BY ALBERT VON HALLER)—REALLY A INFRAORBITAL ETHMOID CELL WHICH CAN RARELY OBSTRUCT THE OMC SINUS LATERALIS=SUPRABULLAR AND RETROBULLAR RECESS=@OF GRUNWALD OR MOURET@= THE MOST POST OF THE ANT ETHMOID CELLS—POST TO THE BULLA—DRAINS INTO THE HIATUS SEMILUNARIS SUPERIORIS—USUALLY EXTENDS SUPERIORLY OVER THE BULLA TO CONNECT WITH THE FRONTAL RECESS—-WHEN ABSENT THE POST WALL OF THE BULLA = THE BASAL LAMELLA POST ETHMOIDS (1-7) MAY DRAIN THROUGH THE ANT ETHMOIDS OR INDEPENDENTLY THROUGHT THE SUP MEATUS POST ETHMOID ARTERY ENTERS AT THE JUNCTION OF THE FRONTAL BONE AND THE LAMINA PAPYRECEA—3-8 MM ANT TO THE OPTIC NERVE MOST POST/LAT ETHMOID CELL =SHENOETHMOID CELL = ONODI CELL—EXTENDS POST TO THE SPHENOID ROSTRUM (CLOSE TO THE OPTIC NERVE) EXT ETHMOIDECTOMY BEGIN WITH A LYNCH INCISION JUST AS FOR ANT ETHMOID ARTERY LIGATION—-WILL NEED TO DEAL WITH THE ANGULAR VESSELS—CUT THROUGH THE PERIOSTEUM AND RAISE THE PERIORBITA WITH A FREER—-CAN TAKE THE ANT ETHMOID ARTERY—-RAISE THE LACRIMAL SAC OUT OF THE FOSSA AND RETRACT IT LAT WITH A SEWALD OR A MALLEABLE—ENTER THE NOSE POST TO OR THROUGH THE LACRIMAL FOSSA—STAY BELOW THE FRONTOETHMOID SUTURE LINE—–CAN TAKE THE ANT 2/3 OF THE LAMINA PAPYRECEA(USE ENDOSCOPES AS WELL) CAN DISSECT ANT WITH THE KERRISON RONGUERS AND WIDELY EXPOSE THE FRONTAL DUCT SPHENOID SPHENOPALATINE ARTERY (RHINOLOGISTS ARTERY) RUNS ACROSS THE FACE OF THE SHENOID ROSTRUM—MAY CAUSE SIGNIFICANT BLEEDING IF YOU GET INTO IT WITH YOUR KERRISON RONGUERS BE READY FOR A CAROTID BLEED WHEN OPERATING ON THE SHENOID—-BIG TIME PACKS ECT… 3 STAGES OF GROWTH—–NON-PNEUMATIC—PRE-SELLAR—-POST SELLAR 22% POSSES AN INTERSINUS SEPTUM POST/SUP SEPTUM SPLITS TO FORM ANT WALLS OF THE SPHENOID—-CAN LOOK LIKE PNEUMATIZATION OF THE SEPTUM OSTIUM (MID ROSTRUM)—7CM POST/SUP TO NASAL SPINE AT A 30 DEGREE ANGLE CAN HAVE A SH ENOETHMOID CELL OF ONODI MAY SEE THE OPTIC NERVE OR OPTIC NERVE TUBERLE PROBABLY IF YOU ARE GOING TO ADDRESS IT—DO IT EARLY IN THE CASE OR YOU WILL BLEED ON IT EASIEST TO GET TO VIA THE MEDIAL ROUTE ISOLATED SPHENOID LESIONS ARE OFTEN BAD NEWS MAXILLARY = ANTRUM OF HIGHMORE (AHIGHMORITIS@) 80% OF SINONASAL CA ORIGINATE HERE 2ND BICUSPID AND 1ST AND 2ND MOLAR IN CLOSE RELATION TO THE FLOOR INFRAORBITAL NERVE TRAVELS IN A GROOVE IN THE SUP MAX SINUS—-BONE CAN OFTEN BE DEHISSENT OVER IT AND INJURY CAN OCCUR NATURAL OSTIUM-—ANT/SUP MOST PORTION OF THE FONTENELLE—-ANGLED PLANE (OBLIQUE)—-OVOID SHAPED—-ALWAYS LOCATED WITHIN 1-2 MM OF ANT INSERTION OF THE UNCINATE NEVER VISIBLE WITH INTACT UNCINATE ACCESSORY OSTIA–OCCUR IN NASAL FONTANELLES (AREAS WITH OUT BONE) OMC@OSTEOMEATAL COMPLEX@ = FINAL COMMON PATHWAY—A BIT DIFFICULT TO DEFINE BUT IS THE TARGET OF A MINI-FESS ON CT THE HYPOPLASTIC MAXILLARY WILL APPEAR AS THE UNCINATE FUSED TO THE LAMINA PAPYRECEA STEPS AND ABNL IN REVIEWING CT SCANS MOST COMMON ABNL—–LAMINA PAPYRECEA LIES MEDIAL TO THE NATURAL OSTIUM——MAXILLARY SINUS HYPOPLASIA—-FOVEA ETHMOIDALIS ABNL (LOW LYING-(40%), DOWN SLOPING, OR ENCEPHALOCELE)—–LAMINA PAPYRECEA DEHISCENCE RESULTING IN ORBITAL HERNIATION——–SPHENOID SEPTATIONS ATTACHING TO THE POST WALL AND CAROTID OR OPTIC CANAL——-SPHENOETHMOID CELLS OF ONODI INTIMATELY ASSOC WITH THE OPTIC NERVE—-LOOK FOR HORIZONTAL SEPTUM IN THE SPHENOID CORONAL—-SLOPE OF FOVEA ETHMOIDALIS—-INTEGRITY OF LAMINA PAPYRECEA—LOOK FOR MAXILLARY HYPOPLASEA—-LOOK AT SPHENOID FOR ABNL AND ONODI CELLS AXIAL—-LOOK AT LAMINA PAPYRECEA FOR DEFECTS—-SPHENOETHMOID INTERFACE—-GENERAL DIMENSIONS OF SPHENOID
CAVEATES ANDDEFINITIONS: (ANATOMY – LATIN / PROCEDURES – GREEK)UNCINATE = HOOK LIKEBULLA (ETHMOIDALIS/LAMELLA) = BLISTER/BUBBLE/BLEBINFUNDIBULUM=FUNNEL SHAPED (TO POUR INTO)HIATUS = APERTUREUVULA = LITTLE GRAPETURBINATE = SCROLLEDCONCHA = SHELLCHOANAE = INFUNDIBULUMMEATUS = PASSAGEWAYCAVEATES: KEFLEX IS CONSIDERED A POOR CHOICE FOR BOTH H INF AND MCAT CONCHA BULLOSA CORRELATES 30% WITH CHRONIC RHINOSINUSITIS HALLER CELLS AND PARADOXICAL TURBS DO NOT CORRELATE WITH SINUSITIS KAUTMANN DOUBLE OR REDUPLICATED UNCINATE IS NOT UNCOMMON 10% INCIDENCE OF CAROTID DEHESCENCE IN THE SPHENOID DERMOID—LOOK FOR FAT IN THE INTRACRANIAL FALX CEREBRI MUCOUS RETENTION CYST= AN IDIOPATHIC PRIMARY CYST MUCOCELE= A SECONDARY ACAUSED@ MUCOUS RETENTION CYST MUCOPYOCELE= AN INFECTED MUCOCELE OR MUCOUS RETENTION CYST HIATUS SEMILUNARIS=CURVED APERTURE INFUNDIBULUM=FUNNEL CHILDREN SHOULD NOT HAVE POLYPS—THINK CF SPHENOIDAL CONCHA OR TURBINATE=BONE OF BERTIN RHINOLITH—USUALLY A F.B. NIDUS—CA++MG++ SALTS PEDS (< THAN 7 YEARS OLD)—REALLY ONLY MAXILLARY—AND ETHMOIDSINUSITIS AFTER 7-8 YEARS THEN GET SPHENOID AND FRONTALS IF YOU ARE GOING TO OPERATE—–PROBABLY DO AN ADENOIDECTOMY FIRST PEDS—CONSIDER–ALLERGY, CF, IMMUNE DEFIECEINCY (DO THEY RESPOND TO PNEUMMOVAX AND HIB VACCINE?), CILIARY DYSKINESIA(POST TURB OR TRACHEAL Bx), GERD—-(CONSIDER SCINTISCAN VS PH PROBE) SILENT SINUS SYNDROME—MAXILLARY ATELECTASIS RESULTING IN ENOPHALMOS—-MAY ALSO LEAD TO A CHRONIC PAIN SYNDROME HISTORY CURIES=—-RADIUM 1898 WATERS, CALDWELL, STENVERS, TOWNE—X-RAY VEIWS VALVASORRI–TOMOGRAPHY OIDENDORF AND HOUNDSFIELD–DENSITY LAUTEBUR—MRI AURTHOR WALTER PROETZ—SUCTION DISPLACEMENT TECHNIQUE GOTTSEINE–ADENOID CURRETTE SLUDER,BALLENGER,WAUGH,BOYLE,CROW,DAVIS–TONSILLECTOMY ASCH–FORCEPS FOR ACRUSH@ SEPTOPLASTY—-NOW CNR BALLENGER—SWIVEL KNIFE OGSTON—FATHER OF FRONTAL SINUS SURGERY SEIFFERT—IMA LIGATION GOODYEAR—ANT ETHMOID A LIGATION ANTON VON TROLTSCH—HEAD MIRROR BABBINGTON–HHT NATHANIAL HIGHMORE—MAXILLARY SINUS SURGICAL HURSCHMAN,REICHERT,HOPKINS,MESSERKLINGER,STAMMBERGER,WIGAND UNCINECTOMY MINI-FESS (A-E + MMA) MMA—-APPROACH IN A RETROGRADE FASHION(DAVID PARSONS)—-NOT MORE ANT THAN THE MIDDLE TURB—-A CM OVER THE INF TURB FESS—-MAY CONSIDER MMA + NASOANTRAL (INF MEATAL) WINDOW ABEER CAN EFFECT@—-PROBABLY NOT WORTH IT AND PROBABLY DOESN=T WORK CAN RESECT ANT 1/3-1/2 MIDDLE TURB TO PREVENT SCARRING—-SOME CONCERN (KEUN) OVER THIS LEADING TO SCARRIFICATION INTO THE FRONTAL RECESS DO THE SURGERY NECESSARY FOR THE DISEASE—DO NOT WORRY ABOUT ATROPHIC RHINITIS—MORE OF AN SYSTEMIC DZ OF THE PT—-BUT… INITIALLY DO OMC SURGERY—-THE ANT SINUSES DRAIN INTO TRANSITIONAL SPACES OR APRECHAMBERS@—WHERE AS THE POST SINUSES DRAIN DIRECTLY INTO THE NASAL CAVITY (AND ARE MORE RESISTANT TO DISEASE)—THE OBJECT OF OMC SURGERY (OR MINI-FESS) IS TO REMOVE TRANSITIONAL SPACES AND ALLOW THE ANT NASAL SINUSES DIRECT DRAINAGE INTO THE NOSE NASAL ENDOSCOPY ASTANDARD THREE PASS TECHNIQUE@ RETAIN INF STRUT OF BULLA ETHMOIDALIS AS SUPPORT FOR THE MIDDLE TURBINATE SETLIFF—MINIMALLY INVASIVE TECHNIQUE—LEAVE THE BIRTH MEMBRANE WHERE EVER POSIBLE—EVEN WHEN BADLY DISEASED USE THE 70 DEGREE ENDOSCOPE TO EXAMINE YOUR ETHMOID CAVITY
TRANSILLUMINATE THE FRONTAL RECESS TO SEE THE FRONTALS BE CONSERVATIVE—IT IT AINT BROKE—DONT FIX IT—PERIOD—YOU MAY EVEN OPERATE ON ONLY ONE SIDE NEVER PROBE A NL FRONTAL RECESS OR DUCT BETTER TO BAIL OUT EARLY THAN SUFFER A COMPLICATION—–CAN ALWAYS COME BACK USE THE J-CURRETTE AND PEDS POLYPS A LOT TO CLEAN OFF THE SKULL BASE–STAY LATERAL NASAL AIRWAY OBSTRUCTION >50% OF THE NASAL AIRWAY OBS IS FROM THE NASAL VALVE REGION NASAL VALVE=SEPTUM, JUNCTION BETWEEN UPPER AND LOWER LAT CARTILAGE, FLOOR OF THE NOSE (USUALLY PIRIFORM APERTURE) ADDRESS INT AND EXTERNAL VALVES—DO SPREADER GRAFTS THROUGH AN EXT APPROACH—ALSO DO INF TURBS SEPTOPLASTY/RHINOPLASTY 4 APPROCHES: HEMITRANSFIXTION (MEMBRANOUS COLUMELLA), COMPLETE TRANSFIXTION (WILL DEPROJECT AND DROP THE TIP), EXTERNAL COLUMELLAR (AINVERTED V@) OPEN STRUCTURE, KILLIAN (4-8 MM POST TO CAUDAL BORDER)—THE PREFFERRED APPROACH TO SIMPLY HARVEST CARTILAGE USED TO BE SAID 90% OF NSD TO THE L—-FROM LOA DELIVERIES LAFERRIERE—HEMITRANSFIXTION INCISION ON CONVEX SIDE AND MUCOPERICHONDRIAL FLAP ON THE CONCAVE SIDE—-DO A DIAMOND AFIGURE OF 8″ SUTURE REPAIR—-CONSERVE CARTILAGE MAXIMALLY BERMAN—-MULT CUTS—BUILDING BLOCK REPAIR CONSIDER O.S. RHINOPLASTY—-ESPECIALLY IMPORTANT FOR TIP WORK USE METHYLENE BLUE IN A TUBERCULIN SYRINGE TO INITIALLY MARK THE PROPOSED AREAS FOR LOWER LATERAL CEPHALIC TRIM—–BE CONSERVATIVE—-LEAVE TOO MUCH INSTEAD OF TOO LITTLE CONSIDER THE JOSEPH SAW FOR HUMP REMOVAL—-THEN A DOUBLE GUARDED STRAIGHT CINELLI CHISLE RASP THENGS SMOOTH CONSIDER A MODIFIED SILVER NOTCHED DOUBLE GUARDED OSTEOTOME—-MAKE UNEVEN OSTEOTOMIES TO CORRECT FOR DEVIATION INVERTED AV@ COLUMMELLAR—-PLUS A MARGINAL ELEVATE UP THE PERICHONDRIUM —- CAN EASILY ACCESS THE SEPTUM FROM THIS VANTAGE THEN PUTTING SPREADER GRAFTS IN—DISSECT UNDER THE SEPTAL MUCOPERICHONDRIUM TO AVOID GETTING INTO THE NOSE GREY LINE(VERNON GREY)—–CONNECTS NASAL SPINE WITH SPHENOID ROSTRUM—–ANT/ SUP—SEPTAL EXCISIONS ARE ORIENTED VERTICALLY, POST/INF—EXCISIONS ARE ORIENTED HORIZONTALLY—–SUCH AS A LONG SPUR RESECTION PRIMARY REASON FOR A SEPTAL PERF 30 YEARS AGO WAS SURGERY—–NOW PRIMARY REASON IS COCAINE MUST WAIT FOR PT TO BE OFF COCAINE FOR 2 YEARS BEFORE ATTEMTING REPAIR PLACE YOUR OSTEOTOMIES IN THE FACIAL-NASAL GROOVE–RATHER LOW DISSECT DOWN YOUR COLLUMELLA FOR A STRUT 6-0 NYLON TO CLOSE YOUR INCISION CONSIDER ELLIPTICAL SKIN EXCISIONS FOR AGED REDUNDANT OR RHINOPHYMATOUS SKIN (SOFT TISSUE ENVELOP TENDS NOT TO CONTRACT SO NICELY AFTER AGE 40) USE BENZOIN WITH 3 AND 2 INCH STERISTRIPS FOR THE AQUAPLAST DSG ENDOSCOPIC DCR STENOSIS SECONDARY TO TUMOR, INFXN, TRAUMA, CONG. ABNL PRIMARY Sx: EPIPHORA, INFXN ANAT: P.C.S.D. SUP AND INF PUNCTA IN LACRIMAL CANILICULI—8 MM—-DRAIN INTO COMMON LACRIMAL CANICULUS—-1.5 MM IN LENGTH—-DRAIN INTO LACRIMAL SAC—15 X 7 X 5 MM——DRAINS INTO THE NASOLACRIMAL DUCT—15-25 MM OBSTRUCTION DIVIDED ANATOMICALLY PRESACCULAR SACCULAR POST SACCULAR (BY FAR MOST COMMON) ETIOLOGICALLY CONG.—-POST SACCULAR HASNER=S FOLD BENEATH THE INF TURBINATE CONG DACRYOCELE LACRIMAL SAC FISTULA RARE CANICULI ATRESIA AQUIRED—-POST OP FESS EPIPHORA 0.7-14%——NEED FOR DCR = < 1% ENDOSCOPIC DCR IS A GOOD PROCEDURE UNCINECTOMY—ANT ETHMOIDECTOMY—?RESECT ANT 1/3 OF MID TURBINATE—-KEEP RESECTING POSTC REMOVE ENTIRE MEDIAL WALL OF THE LACRIMAL SAC
EASY WAY TO DO THIS PROCEDURE IS WITH A FIBEROPTIC LIGTH INSERTED THROUGH THE PUNCTA—-VIEW IT IN THE NOSE WITH THE ENDOSCOPE AND OPEN UP AROUND IT—–GENERALLY IF YOU ARE GOING TO STENT IT–LEAVE THE STENT IN FOR 6 MONTHS EPISTAXIS HX, FREQ, DURATION, SEVERITY, HX SUBSTANCE ABUSE, BLEEDING HX, WHICH SIDE (PT TO LEAN FORWARD) PMX—STROKE, TIA, HEMOPTYSIS FH—HHT, BLEEDING DISORDER MEDS—ASA, NSAIDS, COUMADIN PE–MULT MUCOSAL TELANGIECTASIAS—-HHT, SEPTAL DEVIATION OR PERF, GT CBC WITH INDICES, PT, PTT, BLEEDING TIME, CXR OPERATE EARLY—-CONSIDER EARLY ENDOSCOPIC COAGULATION OR PACK WITH SURGICEL AND A MEROCEL IMA LIGATION—–CONSIDER ENDOSCOPIC SP ARTERY CLIPPING OR EMBOLIZATION PRE-OP ABX PRE-OP AXIAL CT SCANS TO R/O HYPOPLASTIC SINUS THROAT PACK HEAD LIGHTS ROUTINE APPROACH (LEAVE SOME MUCOSA TO SEW TO)—NO NEED TO TRANSECT FRENULUM RAISE SOFT TISSUE OFF OF THE MAXILLA—-CAN USE JOSHEPH OR FREER—USE BIMANUAL TECHNIQUE WITH FINGER ON THE INFRA-ORBITAL RIM TO PROTECT THE GLOBE(VISUALIZE V2) ENTER ANT SINUS WITH OSTIOTOME—USE KEROSYN TO OPEN SITE LARGER THAN FINGER USE OSTIOTOME TO BREAK THROUGH POST SINUS WALL–CAREFULLY ELEVATE A BONEY WINDOW LEAVING THE PERIOSTEUM INTACT USE # 1 KNIFE TO OPEN PERIOSTEUM BRING IN SCOPE WITH 300 FOCAL LENGTH LENS DISSECT OUT BV=S—USE PENFIELD DISSECTOR—(IMA, DESC. PALATINE, S.P.) HOLD VESSELS WITH NERVE HOOK AND CLIP PUT GELFOAM WITH THROMBIN OVER MUCOSAL BLEEDING AND CLOSE WITH 3-0 BIOSYN (RUNNING/LOCKING) ETHMOID ARTERY LIGATION USE LYNCH INCISION (1/2 WAY BETWEEN THE NASION AND MEDIAL CANTHUS)—MID POINT OF LYNCH IS ABOUT LEVEL WITH SUP PUPIL) CUT DIRECTLY DOWN TO PERISTEUM—RAISE FLAPS WITH JOSEPH PLACE SUTURES ON PERIOSTEAL FLAPS TO FACILITATE EXPOSURE DISSECT UP PERIORBITA DEFINE LACRIMAL CREST ANT. ETHMOID IS 24 MM POST, 12MM TO POST. ETHMOID, 6MM TO OPTIC NERVE USE HEADLIGHT AND SEWELL RETRACTOR IDENTIFY BV—DISSECT UP PERIORBITA ALL AROUND BV—INCLUDING BEHIND IT CAN USE TELESCOPES CLIP AND BIPOLAR BV DEPENDING ON EXPOSURE MAY LOOK FOR POST ETHMOID—MAY JUST CLIP THIS ONE METICULOUSLY REPAIR PERIORBITA WITH 4-0 CHROMIC TO AVOID DIPLOPIA CSF RHINORRHEA HALO OR TARGET SIGN ON BEDDING OFTEN A RESERVOIR SIGN OF A SIG VOLUME OF CSF SPILLING OUT OF THE NOSE FROM NOCTURNAL POOLING HIGH GLUCOSE AND B TRANSFERRIN LEVELS MAY SEE WITH A DNE, OR CONTRAST CISTERNOGRAM—MAY NEED A NUC MED SCAN WITH PLEDGETTES IN THE NOSE GET A CT—1MM FINE CUTS—SEE PNEUMOCEPHALUS—–100% O2 HELPS RESOLVE PNEUMO ANYTHING—LAT SKULL FILM IS A QUICKAND EASY WAY TO MONITOR PNEUMOCEPHALUS Rx––BE CONSERVATIVE—HOB UP, LUMBAR DRAIN—VERY IMPORTANT, DIAMOX, STOOL SOFTENERS AND FOLEY ENDONASAL REPAIR WITH ONLAY GRAFT—TUCK TEMPORALIS FASCIA INTO DEFECT—–PUTON A LITTLE FIBRIN GLUE—–PUT ON A LARGE PEICE OF TEMPORALIS MUSCLE AND FOLD THE TURBINATE UP THERE—PACK THE NOSE-REPAIR VIA CRANIOTOMY HAS MORE MORBIDITY INCLUDING PERMANENT ANOSMIA TRANSEPTAL APPROACHES TO THE SHENOID/PITUITARY THREE WAYS TO GO—HEMITRANSFIXTION +/- ALOTOMY, SUBLABIAL, OR O.S. RHINO DO A UNILAT SUBMUCOPERICHONDRIAL DISSECTION TO THE B-C JUNCTION AND THEN GO ON BOTH SIDES WILL NEED TO DO A THOROUGH INF DISSECTION AND FRACTURE THE SEPTUM OFF OF THE CREST TO THE OTHER SIDE DISSECT OFF THE MUCOPERIOSTEUM TO DEFINE THE NATURAL OSTIA USE THE ZERO DEGREE ENDOSCOPE TO SEE IT BETTER—-BEST TO DO THIS WITH THE SCOPES (CAN ALSO USE THE 30 AND 70 DEGREE SCOPES TO HELP YOU) RESECT THE BONEY SEPTUM WITH A DOUBLE ACTION JANSEN MIDDLETON BE CAREFUL NOT TO TORQUE TO MUCH—MAY Fx INTO THE CAROTID ARTERY¬†

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