Surgical Technique

It is best to assess the endoscopic findings and coronal CT images together in order to work out the position and insertion of the uncinate process before starting surgery. We recommend using a 0° endoscope for almost every procedure outside the frontal sinus. The optics of the 0° endoscope give minimal distortion and this reduces the likelihood of the surgeon losing their orientation. Check that the maxillary sinus is not hy-poplastic and whether there is a large infraorbital cell (Haller cell) present, as this may alter your approach. An infraorbital cell is an inferiorly placed anterior ethmoidal air cell that is attached to the floor of the orbit in the roof of the maxillary sinus.

With a hypoplastic maxillary sinus you must stay low toward the base of the inferior turbinate in order to avoid entering the orbit. With an infraorbital cell you need to particularly check, when undertaking a middle meatal antrostomy, that you have opened the maxillary ostium widely, and not simply entered the infraorbital cell. Occasionally the lateral wall is dehiscent and then the orbit is easily entered. Under these circumstances, it is particularly helpful to ballotte the closed eye while endoscopically inspecting the area to see whether the orbital contents prolapse into the nasal airway. It is important to do this at the beginning of surgery if there has been previous surgery.

The uncinate process is defined endoscopically by palpating it laterally with the side of a Freer's elevator or a ball probe (Fig. 5.13 a-c). It is mobile, unlike the rigid anterior lacrimal crest. A curved seeker can be used to gently palpate the posterior edge of the unci-nate process and then be passed around its inferior edge anteriorly to feel the site of the natural ostium.

There are several ways to do an uncinectomy. For the inexperienced surgeon, a retrograde approach is safer and runs less risk of inadvertently entering the orbit. A closed Rhinoforce Stammberger antrum punch (back-biter) is advanced into the middle meatus behind the posterior edge of the uncinate process and then rotated so that the "finger" of the back-biter opens upward. This finger can then be fed into the in-fundibulum and the back-biter rotated so that it lies horizontally (Fig. 5.14a-d).

Rotating Backbiter
Fig. 5.15a, b The backbiter can be used to reduce the uncinate process, with multiple segments being removed.
Lacrimal Crest Middle Turbinate

Fig. 5.16a-c A Hajek punch being used to remove the unci-nate process.

Fig. 5.16a-c A Hajek punch being used to remove the unci-nate process.

Hajek Punch

It is best to take the first bite as low as possible near the base of the uncinate process. When the back-biters are closed they should not meet any significant bony resistance as the uncinate process is thin. If anything more than minimal resistance is met, then the backbiters should not be closed as the nasolacrimal duct may be damaged. Back-biters can take more than one bite at a time without having to be cleaned. The backbiters can then be fed upward to take a bite higher up (Fig. 5.15 a, b), thus creating a "door" of the uncinate process that can be opened or folded forward on its anterior hinge. The door of the uncinate process can then be removed using through cutters, a Hajek punch or one of the microdebriders that can "digest" bone (Fig. 5.16a-c).

An alternative is to remove just the inferior strip with the back-biters and then use the 45° through cutters to nibble away upward at the uncinate process incrementally. If an infundibulectomy is all that is indicated, there is no need to follow it up to the middle turbinate or skull base if it is attached there.

The more experienced surgeon may perform an uncinectomy by palpating the lateral wall in order to define the position of the anterior lacrimal crest, which is totally rigid unlike the uncinate process, which gives way to some extent. A sickle knife or a Freer's elevator is used to incise the uncinate process near its top edge and then to run it down in a sagittal plane, being careful not to go through it more than 1 mm, and then extend the incision inferiorly (Fig. 5.17a, b).

On the patient's right side a "C" shape of mucosa and uncinate is incised, and on the other side the shape is reversed. While the incision is being made, the shoulder of the sickle knife can be used to mobilize the uncinate process medially. The initial incision can be started half way up and then extended in either direction (Fig. 5.18a-d). The sickle knife is used to me-dialize the uncinate process in order to reveal the in-fundibulum; the natural ostium may also be seen. The line diagrams illustrate one way of making this incision. The remaining superior attachment can be cut with Zurich scissors or Rhinoforce Blakesley (through-cutting) forceps and the same is done at its inferior attachment (Fig. 5.19 a-h). With this maneuver, this segment of the uncinate process can be removed without tearing any mucosa.

Often there are tags of mucosa that need to be trimmed with through-cutting forceps or a microde-brider. If the sickle knife comes up against hard bone then this is likely to be the anterior lacrimal crest, meaning that the incision has been started too far anteriorly. Whichever method is used, as soon as the sickle knife has gone through the uncinate process, it should be medialized so that the operator can check the position of the uncinate process and the depth of the incision. It is best to use through-cutting forceps or scissors to cut mucosal tags, as to grasp them with forceps and pull runs the risk of tearing the mucosa off the lateral wall. When this happens, it can come off the lateral wall like steamed wallpaper being pulled. This would run the risk of causing stenosis of the fron-tonasal recess. If forceps are the only instrument available, then they should be rotated laterally toward the lateral wall in order to minimize the chance of peeling the mucosa off the lateral nasal wall.

Remember that while the uncinate process inserts into the lamina papyracea or lateral nasal wall in 70% of patients, in the other 30% of patients it is attached to the skull base or middle turbinate, and under these circumstances it will extend up to the "armpit" where the middle turbinate attaches to the lateral nasal wall and guards the frontal recess. It is unnecessary to remove the uncinate process this high up in these circumstances, unless there is good reason for operating in the frontal recess area.

Whichever method is used, there is usually a small "stub" of uncinate process remaining at its inferior at

Inferior Meatal Antrostomy

Fig. 5.17a, b The sickle knife is used with caution, incising only 1 mm—which is all that is needed to go through the uncinate process—and is kept in the sagittal plane as much as possible.

Fig. 5.17a, b The sickle knife is used with caution, incising only 1 mm—which is all that is needed to go through the uncinate process—and is kept in the sagittal plane as much as possible.

tachment just medial to and below the natural maxillary ostia (Fig. 5.19g, h). This little piece of bone is best dissected out with the end of a fine ball probe and the mucosal remnants shaved off or trimmed with side-biting forceps.

The natural ostium can usually be visualized, but if not it can be palpated gently with a ball probe, a curette, or an olive-ended right-angled sucker unattached to the suction tube (Fig. 5.20 a-f). When this is done, minimal pressure should be required and it is important to direct the end of the seeker downward and laterally and to search for it from the level of the attachment of the inferior turbinate so as to minimize the chance of inadvertently entering the orbit. If the maxillary ostium cannot be seen it is likely that an insufficient amount of uncinate process has been removed; this can be a b

UncinectomyRight Inferior Turbinate
b

Fig. 5.18 a A right uncinectomy with the uncinate process medialized to reveal the natural maxillary ostium. b One method for doing an uncinectomy is to initially incise downward with a sickle knife. c Next turn the sickle knife around and incise in the opposite direction. d The uncinate process is then medialized to help define its remaining superior or inferior attachments.

Uncinectomy

Fig. 5.18 a A right uncinectomy with the uncinate process medialized to reveal the natural maxillary ostium. b One method for doing an uncinectomy is to initially incise downward with a sickle knife. c Next turn the sickle knife around and incise in the opposite direction. d The uncinate process is then medialized to help define its remaining superior or inferior attachments.

trimmed either with back-biting forceps or with side-biting forceps until it is visible. Sometimes palpating the lateral nasal wall will produce a bubble out of the ostium that will locate its position.

In an infundibulotomy, where there is no reason to enlarge the natural ostium, it is important not to scuff the mucosa on the posteroinferior aspect of the natural maxillary ostium, as mucociliary clearance passes around this aspect along the lateral wall of the nose under the ethmoid bulla. Unless there are good reasons for opening the maxillary ostium it is best left alone as opening it runs the risk of causing scar tissue around its margin that may interfere with mucociliary clearance. ¡T/î» 6, 7, 8

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Responses

  • karolin
    Do you have to remove the uncinate process to get to maxillary sinus?
    8 years ago
  • Thomas
    Do i need surgery for hypoplastic maxillary sinus?
    7 years ago

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