Alternative Surgical Techniques

Occasionally, in a very narrow nose, where access is restricted by a narrow pyriform aperture, finding the maxillary ostia can be difficult, particularly if there is active purulent disease and a great deal of bleeding with any instrumentation in the middle meatus. While a c e

Attachment Middle Turbinate

Fig. 5.19 a Zurich scissors or through-cutting forceps are used process. d A line diagram of c. e Blakesley forceps can be used to divide any remaining superior attachment of the uncinate to grasp the uncinate and rotate it laterally to free any remain-

process. b A line diagram of a. c Zurich scissors are used to ing attachment. f A line diagram of e.

divide any remaining inferior attachment of the uncinate Fig. 5.19g, h >

Fig. 5.19 a Zurich scissors or through-cutting forceps are used process. d A line diagram of c. e Blakesley forceps can be used to divide any remaining superior attachment of the uncinate to grasp the uncinate and rotate it laterally to free any remain-

process. b A line diagram of a. c Zurich scissors are used to ing attachment. f A line diagram of e.

divide any remaining inferior attachment of the uncinate Fig. 5.19g, h >

Left Maxillary Ostium
Fig. 5.19 g The natural maxillary ostium is exposed and a small part of the uncinate process is left attached both superiorly and in-feriorly. h A line diagram of g.
Steps Middle Meatal Antrostomy

Fig. 5.20a-f The ball probe is used to palpate in order to locate the position of the natural ostium. Only use it as a probe and direct it downward away from the orbit. Fig.5.20e, f >

Fig. 5.20a-f The ball probe is used to palpate in order to locate the position of the natural ostium. Only use it as a probe and direct it downward away from the orbit. Fig.5.20e, f >

Middle Turbinate

Fig. 5.20e, f the surgeon is advised not to continue if they cannot see adequately, it is unusual not to be able to gain sufficient control with local vasoconstrictors to make it possible to undertake a middle meatal antrostomy.

The "lazy" way of undertaking a middle meatal an-trostomy is reserved for difficult situations when the natural ostium cannot be identified. A right-angled, olive-ended sucker not attached to the suction is used to palpate the posterior fontanelle. This area has no bone and the mucosa "gives" easily with little pressure. It is important to palpate where the inferior turbinate comes off the lateral wall and to point the curved sucker downward and laterally at 45° from the horizontal plane. When the area of the posterior fontanelle is identified, the sucker can be used to enter the maxillary sinus. This is best done relatively abruptly (as long as there is no evidence of a hypoplastic maxillary antrum on CT) so that mucosa on the medial wall of the maxillary sinus is punctured neatly and not torn off the medial bony wall of the antrum.

The sucker is then pushed and pulled forward a little to open a false ostium that is akin to a posterior fontanelle. A back-biter is inserted in this hole, having been introduced posterior to its position, and its jaws are opened widely so as to engage both the lining of the medial wall of the maxillary sinus and the mucosa of the lateral wall of the nose. Multiple bites are then taken to widen this and to come forward and join up the maxillary ostium. The uncinate process can be taken up with these bites and, as this is a crude way of undertaking an uncinectomy along with a middle meatal antrostomy, it can salvage a difficult situation.

It is important not to come too far anteriorly, in order to avoid the nasolacrimal system, but it is important to remove the uncinate process, because to leave most of it in position above the maxillary ostium encourages the formation of polyps in this crevice.

In a minority of revision cases there is so much thick osteitic bone that an anterior approach is best. This involves making an incision just anterior to the lacrimal crest and raising the mucosa posteriorly to reveal the uncinate process as it joins the lacrimal crest. The most medial lip of the lacrimal crest needs to be drilled away in order to improve visibility and access (Fig. 5.21 a, b).

Maxillary Sinusotomy (I, II, III)

First of all, the natural ostium is identified. In a type I sinusotomy (Fig. 5.22a, b), it is opened posteriorly to a limited extent (< 1cm diameter) with through-cutting instruments. In a type II, it is opened further posteriorly and inferiorly (< 2 cm diameter) (Fig. 5.23a, b).

A type III involves wide exposure opening of the ostium in all directions. It is possible to open it: anteriorly to the lacrimal crest; inferiorly to the base of the inferior turbinate; superiorly to the orbit; and posteriorly, level with the posterior wall of the maxillary sinus (Fig. 5.24a,b). If the sinusotomy extends to within 0.5 cm of the posterior wall, a branch of the sphenopalatine artery often requires cautery.

When opening the maxillary ostium it is important not to grab and pull on any loose pieces of mucosa that line the maxillary sinus as this often leads to the whole lining starting to strip off its wall like a pig's bladder. These loose tags are best left alone or sheared with through-cutting forceps or a shaver. The most useful instruments for opening a maxillary ostium are the straight, through-cutting forceps; the movable jaw of the forceps is placed in the antrum and the bone can be nibbled away in a controlled fashion (Fig. 5.25 a, b).

Anteriorly, back-biters should be used carefully in order to avoid damaging the nasolacrimal sac. If any resistance is felt, the operator should stop, as it is likely f e a

Lacrimal Pig

Fig. 5.21 a In a revision case where the landmarks for the uncinate process have been lost, the hard white bone of the lacrimal

Fig. 5.21 a In a revision case where the landmarks for the uncinate process have been lost, the hard white bone of the lacrimal crest is exposed. bThe lacrimal crest is reduced with a coarse diamond burr to help expose and define the uncinate process.

Fig. 5.22a, b A type I sinusotomy can be opened posteriorly to a limited extent with through-cutting instruments.

Fig. 5.22a, b A type I sinusotomy can be opened posteriorly to a limited extent with through-cutting instruments.

Revision Maxillary AntrostomyRevision Maxillary AntrostomyNatural Ostium
Fig. 5.25 a Endoscopic view and b line diagram of the natural ostium being joined to a posterior accessory ostium using through-cutting forceps.

that the nasolacrimal apparatus will be damaged. Superiorly, there may be a low anterior ethmoidal air cell based on the lamina papyracea or roof of the maxillary sinus. The extent of this should be estimated from the CT scan and if a large antrostomy is to be undertaken this can be palpated with a curved sucker and opened using the side of 45° Blakesley forceps while the assistant is observing the eye.

Essentials of Human Physiology

Essentials of Human Physiology

This ebook provides an introductory explanation of the workings of the human body, with an effort to draw connections between the body systems and explain their interdependencies. A framework for the book is homeostasis and how the body maintains balance within each system. This is intended as a first introduction to physiology for a college-level course.

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