PNS RSO Lecture

8/18/2019 PNS RSO Lecture

1/40

Diagnostic imaging andImage-guided Interventions

Sinus SurgeryRAMON SANTOS-OCAMPO, MD


2/40

Cribriform !ate

Crista ga!i "sea

$atera! !ame!!

%ovea et&moida!is or't&moid roof

Nasa! setum

Midd!e turbinates

O!factory groov


3/40

Cribriform

Crista ga!

$atera! !a

%ovea et&moida!is

Midd!e turbinates


4/40

T&e Midd!e Turbinate

It is t&e (ey in understanding t&e re!ations&i of t&e nasa!structures

)asa! !ame!!a or ground !ame!!a

*ertica! anterior!y

+orionta! osterior!y

Demarcates t&e anterior and osterior et&moid air ce!!s


5/40

Midd!e turbinate sagitta!.


6/40

Anterior et&moid air ce!!s

Posterior et&moid air ce!!s

S&enoid sinus

Midd!e turbinate


7/40

Anterior et&moid air ce!!s

Midd!e turbinate


8/40

Posterior et&moid air ce!!s

Midd!e turbinate


9/40

Sinus drainage at&/ay

A!! t&e arasinuses drain into

t&e midd!e meatus, '0C'PTfor t&e osterior et&moid ands&enoid sinuses


10/40


11/40

%'SS

Preserve or restore norma! 5o/ of mucosa! secretions

C&ronic r&inosinusitis refractory to medica! treatment

• main c!inica! indication

Ot&ers

• e2cision of se!ected tumors

• CS% !ea( c!osure

• orbita! decomression

• in 6raves7 o&t&a!mo!egia

• otic nerve decomression

• dacryocystor&inostomy

• c&oana! atresia reair


12/40

'2ected 8ndings after %'SS

)asic comonents of %'SS inc!ude

seto!asty, /&ic& is erformed in about 9:; of atients uncinectomy

unroo8ng of t&e face of t&e et&moida! bu!!a

If ma2i!!ary sinus mucosa! disease is severe, a ma2i!!aryantrostomy can be erformed /&ere t&e natura! ostium is /idene

Ot&er comonents to /iden t&e anterior drainage at&/ay

midd!e turbinate resection

et&moidectomies


13/40

Postoerative c&anges

Status ost

seto!asty, rig&tuncinectomy and

unroo8ng of

et&moida! bu!!a


14/40

Com!ications of %'SS

Minor


15/40

Re!evant Anatomic Structures


16/40

Nasa! Setum

Describe and measure anyseta! deviation and sur

formation

• Measure deviation from a !ineconnecting t&e crista ga!!iand base of setum of t&e&ard a!ate and reort

Some atients may &ave tobe to!d a&ead of time t&at a

seto!asty may be re?uiredas t&e initia! art of t&e %'SSrocedure


17/40

Osteomeata! com!e2

Commondrainageat&/ay fort&e fronta!,ma2i!!aryand anterior

et&moidsinuses

E

U


18/40

Midd!e turbinate

Conc&a bu!!osa - neumatied

midd!e turbinate4 if $AR6'

or IN%$AM'D, can

contribute to obstruction


19/40

Parado2ica! turn of t&e midd!eturbinate

t&e fo!ding of t&e conc&a isreversed from norma!

T&is can cause uncinatedeviation and infundibu!arnarro/ing


20/40

1ncinate rocess insertion

$amina ayracea S(u!! base Midd!e turbinate

T&e anterior ortion of t&e uncusua!!y inserts !atera!!y onto t&or media! /a!! of an agger nasisinus drainage is media!!y direc


21/40

+a!!er ce!!

Infraorbita! air ce!! can contribute to

narro/ing of t&e et&moidinfundibu!um or ostium, esecia!!y if

diseased


22/40

Ma2i!!ary sinus

Accessory ostium of t&e rig&t

ma2i!!ary sinus, usua!!y !ocatedosterior to t&e norma! ostium

in 9:; of atients


23/40

%rontoet&moida! ce!!s

Imortant if surgeon is

!anning to /iden t&e fronta!recess

Agger nasi ce!!

most anterior et&moid airce!!

!ies >ust anterior to fronta!

recess

if !arge, may cause media!

dis!acement of t&emidd!e turbinate

causing narro/ing of t&efronta! recess

A


24/40

%rontoet&moida! ce!!s

Imortant if surgeon is

!anning to /iden t&e fronta!recess

Agger nasi ce!!

most anterior et&moid airce!!

!ies >ust anterior to fronta!

recess

if !arge, may cause media!

dis!acement of t&emidd!e turbinate

causing narro/ing of t&efronta! recess

A


25/40

@u&n C!assi8cation Sc&eme

Tye I Sing!e air ce!!

suerior to t&e agger nasi ce!!4Does not rotrude into t&e

fronta! sinus4

Tye II More t&an one airce!! suerior to t&e agger nasi

ce!!4 None rotrudes into t&efronta! sinus

Tye III Sing!e air ce!!suerior to t&e agger nasi t&atrotrudes ast t&e fronta!ostium or fronta! bea( into t&e

sinus roer

Tye I* Iso!ated air ce!!com!ete!y /it&in t&e sinus

roer4

TyType III


26/40

't&moida! bu!!a

$argest andmost constantanterior et&moidair ce!!

boundsuerior!y byt&e 5oor of t&eanterior crania!

fossa and!atera!!y by t&e!aminaayracea

Drains into t&einfundibu!um


27/40

Critica! Anatomic *ariants


28/40

“CLOSE”

Cribriform !ate &o/ !o/ or &o/ ta!! are t&e !atera! !ame!!aeB.

Lamina ayracea any de&iscence.

Onodi or Posterior et&moid ce!! resent or absent.

S&enoid sinus symmetric, e2tent of neumatiation, otic nervor interna! carotid artery bony coverings de&iscent.

Et&moid artery Is anterior et&moid artery resent on a mesenteror embedded in bone.

orma!d, 'ndoscoic Sinus Su:9E


29/40

C$OS' Cribriform @eros C!assi8cation

based on t&e det& of t&e o!factoryfossa

determined by measuring t&egreatest &eig&t of t&e !atera!!ame!!a in t&e corona! !ane4

T&e !atera! !ame!!a and cribriform!ate are t&in and rone to in>ury

during endoscoic surgery t&e greater t&e &eig&t of t&e

!ame!!a, t&e greater t&e c&ance ofin>ury

Keros Type 1

9-E mm

F;


30/40







Keros Type 2

G-H mm

HE;


31/40







Keros Type 3

-9F mm

9 ;


32/40

Asymmetry

Asymmetry in t&e &eig&ts oft&e fovea et&moida!is oret&moid sinus roof canredisose to enetration oft&e anterior s(u!! base if t&esinus surgeon is not a/are

may be asymmetric someasurements s&ou!d be

made for eac& side


33/40

Asymmetry

Asymmetry in t&e s!oes of t&e foveaet&moida!is or et&moid sinus roof canredisose to enetration of t&eanterior s(u!! base if t&e sinus surgeonis not a/are

t&e oerator cou!d mista(e t&e !o/,do/ns!oing side for an unoened,diseased et&moid air ce!!


34/40

CLOS' $amina ayracea Penetration into t&e

orbit may occur if t&esurgeon is not a/are ofany de&iscence in t&e!amina ayracea4

Microdebriders, /&ic&suction and removetissue raid!y, may !ead

to media! rectus in>uryin !ess e2erienced&ands


35/40

C$OS' Onodi ce!! Must be mentioned if resent

e2tends to t&e s&enoid sinus!ying media! to t&e otic nerveand dis!aces t&e s&enoid sinusmedia!!y and inferior!y

Potentia! damage to t&e oticnerve in


36/40

Divided by an intersinus setum /&ic& may be com!ete or

incom!ete4 Asymmetry bet/een t&e rig&t and !eft sinus andinsertion of t&e setum on t&e carotid cana! s&ou!d be reorted4

T/isting may &urt t&e vesse!

C$OS' S&enoid sinus


37/40

C$OS' S&enoid sinus Carotid cana! de&iscence

May !ead to increased ris( ofin>ury


38/40

C$OS' S&enoid sinus*idian cana!

Rig&t vidian cana! ise2osed as it traverses t&e

5oor of t&e s&enoid sinus,t&e vidian nerve and arteryare at ris(


39/40

C$OSE anterior 't&moida!artery T&e et&moida! arteries are embedded

in t&e bone of t&e anterior s(u!! base4Cone-s&aed divot at t&esueromedia! asect of t&e orbita!/a!! reresents t&e anterioret&moida! foramen4

In t&is case, t&e artery traverses t&eair-8!!ed sinuses be!o/ t&e s(u!! base

on a t&in mesentery, /&ic& increasest&e ris( of in>ury during %'SS4

Transection and retraction of t&eanterior et&moida! artery can ?uic(!yresu!t in signi8cant orbita!&emorr&age4

P ti CT


40/40

Preoerative CT

• Sinus neumatiation and symmetry

•Nasa! setum deviated, ?uantify

• '2tent and attern of sinus disease greatest measurement of

mucosa! t&ic(ening, air 5uid !eve!s or frot&y = bubb!y secretions

• Drainage at&/ay of fronta! sinuses Insertion of t&e uncinated

rocess

• Descrition of frontoet&moida! ce!!s @u&n c!assi8cation

• "C$OS'#

• Osseous sc!erosis or areas of de&iscence

• '2trasinus 8ndings denta! disease, orbita! abnorma!ities,

intracrania! mass !esions and ot&er at&o!ogy

PNS RSO Lecture

Documents

Transcript of PNS RSO Lecture