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Principles of Functional Endoscopic Sinus Surgery

Principles of Functional Endoscopic Sinus Surgery

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Principles of Functional Endoscopic Sinus Surgery

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  1. Principles of Functional Endoscopic Sinus Surgery ShahinBastaninejad, MD Assistant Prof. of ORL-HNS TUMS Amir’Alam Hospital

  2. Outline • Definition • Anatomy • Patient evaluation • FESS Concepts of Surgery

  3. Definition

  4. Functional Endoscopic Sinus Surgery • Replaced old practice of obliterating sinuses and removing mucosa. Concept of irreversibly diseased mucosa refuted. • Functional aspect refers to: • Preserving normal structures • Removing only obstruction • Preserving mucosa • Attempt to restore function

  5. Anatomy

  6. Ethmoid anatomy is complex: Labyrinth Lamellae 1st - Uncinate 2nd - Ethmoid bulla 3rd - Basal lamella of middle turbinate 4th - Superior turbinate Ethmoid anatomy

  7. Drainage • Frontal, anterior ethmoid & maxillary – OMC • Posterior Ethmoids – Superior meatus • Sphenoid sinus – Sphenoid-ethmoidal recess

  8. Middle Turbinate • Three components • First – Anterior, oriented in a sagittal plane and attached to skull base • Second – Middle, oriented in a Vertical plane and attached to lamina papyracea (basal lamella and separates ant from post ethmoids) • Third – Posterior, oriented in a horizontal plane and attaches to perpendicular plate of palate (forms roof of middle meatus, anterior to sphenopalatine foramen)

  9. Middle Turbinate

  10. Ostiomeatal Complex (OMC) • Common drainage for frontal, maxillary and anterior ethmoid sinuses.

  11. OMC

  12. OMC • Infundibulum – funnel shaped area whereby the maxillary, ant ethmoid and frontal sinuses drains • Uncinate process– Sickle shaped bony ethmoidal structure • Hiatus Semilunaris– Half-moon shape opening of infundibulum

  13. Uncinate Process • Attaches to the following structures: • Inf & far post. – To ethmoid process of inf. Turb

  14. Uncinate Process • Ant & far sup. – To lamina papyracea, skull base or mid turb

  15. Laterally – Lamina papyracea and fontanelle area

  16. Uncinate Process 52%

  17. Bulla Ethmoidalis • The greatest anterior ethmoid air cell, attached to lamina papyrcea and usually open into lateral sinus

  18. Sinus Lateralis = Suprabullar recess and retrobullar recess

  19. Middle turbinate: Horizontal and vertical basal lamella SBR Sinus Lateralis RBR

  20. Sphenoid Ostium • Medial to posterior sup. turbinate • Located between nasal septum and inferior aspect of sup. turbinate • Located at the same level as the roof of the maxillary sinus • Located 4 microdebrider/suction tip breaths above the choanae • Located 7cm from nasal crest at 30°

  21. Sphenoid Ostium

  22. Sphenoid Sinus • Relationships of important structures: • Optic nerve – superior-lateral • Carotid artery/cav sinus – mid-lateral • Vidian nerve and maxillary nerve – inferior-lateral

  23. Square – ant clinoid process, Circles – optic canals, triangle – vidian nerve Asterisk – pneumatization of pterygoid process

  24. Sphenoid Classification

  25. Presellar Sellar Conchal Post sellar

  26. Onodi Cells or Sphenoethmoid cells

  27. Optic Canal in Onodi Cells

  28. anatomic keyhole in SBS

  29. LOCR

  30. Cribriform plate Keros classification 1-3mm 3-7mm 7-16mm

  31. Keros Classification • Type I • 1-3mm • Type II • 3-7mm • Type III • 7-16mm

  32. Fovea and Ethmoidal arteries

  33. Lens 70 degree – End of surgery

  34. Kuhn Cells Frontal Cells

  35. Frontal Recess • Anatomic Boundries: • Ant – unicate process & aggernasi • Post – bulla ethmoidalis and suprabullar lamella • Lateral – lamina papyracea • Medially – hiatus semilunaris or middle turb • Inf – Ethmoidinfundibulum • Sup – Fovea ethmoidalis, supraorbital air cell, anterior ethmoid artery and frontal ostium

  36. Draf IIA Draf I

  37. Draf III Draf

  38. Frontal Sinus – Mucociliary Pattern  Save Mucosal Layer in Lateral part while performing Draf III opertation

  39. Patient evaluation

  40. Pre-op CT Evaluation • CLOSE Technique • C – Cribriform • L – Lamina Papyracea • O – Orbits, onodi cell, Optic Nerve • S – Sphenoid, Skull Base • E – Ethmoid Arteries

  41. C - Cribriform • Assess the Keros type • Look for assymetry

  42. L – Lamina Papyracea • Check for dehiscence or pathologic fractures

  43. O – Orbit, Optic Nerve, Onodi Cells • Check for dehiscence • Assess for onodi cells (superior-lateral to sphenoid) • Orbital slope

  44. S – Sphenoid, Skull base • Assess for Carotid dehiscence and aeration patterns • Conchal, Pre-sellar, & Sellar (thickness of clivus)

  45. Skull base • Assess slope of skull base • Assess if roof of sphenoid is level with skull base

  46. E – Ethmoid Artery

  47. FESS Concepts of surgery