Surgical Technique

The sphenoid ostium can be found at the level of the superior turbinate. It is often necessary to lateralize the middle and superior turbinate in order to visualize it (see Fig. 5.72 k). The ostium can then be enlarged as necessary.

If visibility is poor because of polyps or bleeding, the sphenoid sinus can safely be approached by staying close to the septum in the midline and palpating with the straight sucker up the posterior wall of the sphenoid (Fig. 5.84). At 1-1.5 cm above the posterior choana, the bone of the anterior wall of the sphenoid sinus is thin and it can be punctured by applying moderate pressure with a straight sucker (2-3 mm diameter). It may be necessary to gently lateralize the middle turbinate in order to obtain access to the sphenoeth-moid recess. Once the sphenoid sinus is located, it can be enlarged with a small 45° forceps while a Hajek-Kofler punch or a Stammberger circular cutting punch or "mushroom" punch is used to enlarge it. It is best to

< Fig. 5.84 The sphenoid ostium with mucus coming out of it. This is a type I sphenoidotomy where suction and inspection were done, but it was not enlarged.

Aspergiloza Sinusa
Fig. 5.85 a Aspergillosis of the sphenoid sinus. b The endoscopic appearance after a type II sphenoidotomy.
Sinus Endoscopy Dehiscent Carotid

b stay near the midline in order to avoid damaging a dehiscent carotid or optic nerve that may not be readily discernible on a CT scan if it is opaque with mucus retention or polyps.

It is advisable not to open the sphenoid ostium downward to a level lower than half the total height of the sinus, as a branch of the sphenopalatine artery runs along its anterior wall and if cut this can bleed briskly (see Fig.5.72k-t). Occasionally, the intersinus septum of the sphenoid is so oblique that one side can be very small. Care needs to be taken when removing the intersinus septum as it is oblique in over 75% of patients and can be based on the bone over the internal carotid artery. If the sphenoid is rudimentary or the bone around it is hyperostotic, then careful consideration needs to be given as to whether opening it serves any purpose. This is rarely the case (Fig. 5.85a, 5.86 a-c).

Dermoid Sinus Bilder

Fig. 5.86 a Axial CT scan and b axial MR image scans showing a dermoid in the sphenoid sinus extending laterally. c Postoperative appearance after a type III sphenoidotomy.

Fig. 5.86 a Axial CT scan and b axial MR image scans showing a dermoid in the sphenoid sinus extending laterally. c Postoperative appearance after a type III sphenoidotomy.

Puncture Anterior Wall Sphenoid Sinus
Fig. 5.87 a, b Appearance after a sphenoethmoidectomy. c, d Gentle lateralization of the middle turbinate to open up the olfactory cleft.

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