Surgical Technique

Once an uncinectomy has been done and the natural ostium has been identified, the ethmoid sinuses may be opened. It is safe to remove the sinuses that lie in a sagittal plane medial to the medial wall of the maxillary sinus (N.B.: The orbits are not two cones with their long axes in the sagittal plane, but they face slightly laterally with their medial walls lying parallel to the sagittal plane (see Fig. 12.6).). The bulla can be punctured with straight forceps, and as they are withdrawn their jaws can be opened to help visualize the inside of the bulla (Fig. 5.34a-d). The bulla can then be opened with through-cutting forceps of various angles, but it is important to leave, and define, the top of its anterior wall as a landmark (Fig. 5.35 a-d). The ethmoid bulla is resected until the retrobullar space and basal lamella are clearly defined (Fig. 5.36a, b). There should be a few remaining anterior ethmoid cells left in an anterior ethmoidectomy if the frontal recess is to avoid instru-

Bulla Etmoidal Lamela Basal
Fig. 5.33 A coronal CT scan showing a right inferior orbital or Haller cell.
Haller Cells Sinus

Fig. 5.34a-d Straight Blakesley forceps are used to enter the bulla, being careful not to angle it laterally toward the orbit.

The forceps are opened before withdrawing them to help expose the inside of the bulla.

Fig. 5.34a-d Straight Blakesley forceps are used to enter the bulla, being careful not to angle it laterally toward the orbit.

The forceps are opened before withdrawing them to help expose the inside of the bulla.

Ethmoid Bulla

Fig.5.35a-d A Hajek punch or through-cutting forceps are to leave its upper limit as this is a useful landmark to help local-used to open the ethmoid bulla more widely, but it is important ize the frontal recess.

Fig.5.35a-d A Hajek punch or through-cutting forceps are to leave its upper limit as this is a useful landmark to help local-used to open the ethmoid bulla more widely, but it is important ize the frontal recess.

b a d c mentation. These air cells lie on the lamina papyracea, and surgically it is safest to stay in a plane medial to the sinusotomy when looking for them. Check the CT before operating in this area. If there is any doubt, ask your assistant to observe the eye for any movement that would indicate that the orbit has been entered.

Hajek forceps are a good instrument for opening air cells because they can only be used if there is space for the posterior beak of the instrument to be inserted. Hajeks are precise and also minimize tearing of tissue. If 45° forceps are used to remove ethmoidal air cells on the lamina papyracea, it is best to use the side of the forceps for opening and removing them to limit the possibility of going into the orbit with the sharp ends of the forceps. A blunt, unattached olive-ended sucker is a useful probe to gently palpate for the presence of residual cells. As mentioned for an anterior eth-moidectomy, the frontal recess should not be instru mented unless there is a good reason for doing so. It is often tempting, as part of an "anatomical exercise," to continue to find the frontal recess; but it may be the worst thing you do for the patient as you then run the risk of causing stenosis. Dealing surgically with ethmoid disease along with medical treatment is usually enough to lead to an improvement in frontal sinus disease (see Fig. 5.37). tJVD 7, 8

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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