Fig. 5.1. Endoscopes available for endoscopic surgery with lenses of various angulation (0°, 30°, 45°, 70°)

Fig. 5.1. Endoscopes available for endoscopic surgery with lenses of various angulation (0°, 30°, 45°, 70°)

of the two techniques, a reasonable compromise, recognizing advantages and limitations inherent to each technique and suggesting that both techniques could be used in a combined fashion, has been found. This has led to the coining of the term "microendoscopic surgery" (Stamm and Draf 2000), which will be used in the present book.

The technique for systematic endoscopic evaluation of the lateral nasal wall developed by Messerklinger (1972) confirmed that most inflammatory diseases of the paranasal sinuses secondarily arise from an inflammatory process taking origin in one or more of the narrow spaces (called "pre-chambers") which collect the mucus drainage from the different sinuses. The ostiomeatal unit has a key role in the ventilation and drainage of the maxillary and frontal sinuses and of the anterior ethmoid cells, much like the spheno-ethmoid recess has for posterior ethmoid cells and sphenoid sinus. Any anatomic variant narrowing those spaces may impair the mucociliary clearance efficacy, predisposing to obstruction and contributing to the pathogenesis of sinusitis.

As a logical consequence of physiopathologic observations, a new concept of a selective, more conservative surgery has resulted. Messerklinger (1972) observed that surgical removal of the primary disease at the level of the lateral nasal wall by means of a limited procedure ("pre-chamber" surgery) resulted in the recovery of sinus diseased mucosa without resorting to any surgical aggressive procedure on the sinus itself. Endoscopic surgery was first described as a one-handed technique in which one of the surgeon's hands handles the endoscope, while the other manages different instruments using the shaft of the endoscope as a safe guide to advance in the nasal fossa, positioning it as far as possible behind the instrument. Having an experienced assistant who helps the surgeon with suction (so-called two-handed techniques) may be of some help in difficult situations such as massive bleeding.

The aim of this section is to briefly analyze the standard surgical steps of a microendoscopic dissection taking into account the differences in the management philosophy between inflammatory and neo-plastic lesions.

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