Surgical Technique

Careful scrutiny of the CT scans is required preopera-tively to familiarize yourself with the anatomy of the skull base and the possible position of the artery (Fig. 14.23 a). The artery is usually seen as a funnel-like appearance passing medially through the upper-medial wall of the orbit (Fig. 14.23 b). The uncinate process is removed using 45° through-cutting forceps or a punch to nibble it away to its superior attachment. If there are small or no significant agger nasi air cells, then a 45° scope can be used to inspect the area medial to the ethmoid bulla and lateral to the middle turbinate. It is sometimes possible to see the anterior ethmoid artery in this area. If it is not visible there, then the ethmoid bulla can be removed to reveal the suprabullar recess that extends up into a supraorbital cell: the artery nor mally lies in the next undulation behind this. Once again the 45° scope is invaluable in visualizing this area.

The unipolar suction diathermy device is ideally shaped to cauterize the artery (Fig. 14.24a, b). If a clip is used, it should be applied gently because this is one of the thinner areas of the skull base and it is possible to inadvertently transect the ethmoid artery or go into the skull base. Normally, no packing is required.

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