PNS RSO Lecture
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Transcript of PNS RSO Lecture
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Diagnostic imaging andImage-guided Interventions
Sinus SurgeryRAMON SANTOS-OCAMPO, MD
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Cribriform !ate
Crista ga!i "sea
$atera! !ame!!
%ovea et&moida!is or't&moid roof
Nasa! setum
Midd!e turbinates
O!factory groov
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Cribriform
Crista ga!
$atera! !a
%ovea et&moida!is
Midd!e turbinates
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T&e Midd!e Turbinate
It is t&e (ey in understanding t&e re!ations&i of t&e nasa!structures
)asa! !ame!!a or ground !ame!!a
*ertica! anterior!y
+orionta! osterior!y
Demarcates t&e anterior and osterior et&moid air ce!!s
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Midd!e turbinate sagitta!.
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Anterior et&moid air ce!!s
Posterior et&moid air ce!!s
S&enoid sinus
Midd!e turbinate
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Anterior et&moid air ce!!s
Midd!e turbinate
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Posterior et&moid air ce!!s
Midd!e turbinate
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Sinus drainage at&/ay
A!! t&e arasinuses drain into
t&e midd!e meatus, '0C'PTfor t&e osterior et&moid ands&enoid sinuses
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%'SS
Preserve or restore norma! 5o/ of mucosa! secretions
C&ronic r&inosinusitis refractory to medica! treatment
• main c!inica! indication
Ot&ers
• e2cision of se!ected tumors
• CS% !ea( c!osure
• orbita! decomression
• in 6raves7 o&t&a!mo!egia
• otic nerve decomression
• dacryocystor&inostomy
• c&oana! atresia reair
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'2ected 8ndings after %'SS
)asic comonents of %'SS inc!ude
seto!asty, /&ic& is erformed in about 9:; of atients uncinectomy
unroo8ng of t&e face of t&e et&moida! bu!!a
If ma2i!!ary sinus mucosa! disease is severe, a ma2i!!aryantrostomy can be erformed /&ere t&e natura! ostium is /idene
Ot&er comonents to /iden t&e anterior drainage at&/ay
midd!e turbinate resection
et&moidectomies
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Postoerative c&anges
Status ost
seto!asty, rig&tuncinectomy and
unroo8ng of
et&moida! bu!!a
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Com!ications of %'SS
Minor
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Re!evant Anatomic Structures
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Nasa! Setum
Describe and measure anyseta! deviation and sur
formation
• Measure deviation from a !ineconnecting t&e crista ga!!iand base of setum of t&e&ard a!ate and reort
Some atients may &ave tobe to!d a&ead of time t&at a
seto!asty may be re?uiredas t&e initia! art of t&e %'SSrocedure
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Osteomeata! com!e2
Commondrainageat&/ay fort&e fronta!,ma2i!!aryand anterior
et&moidsinuses
E
U
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Midd!e turbinate
Conc&a bu!!osa - neumatied
midd!e turbinate4 if $AR6'
or IN%$AM'D, can
contribute to obstruction
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Parado2ica! turn of t&e midd!eturbinate
t&e fo!ding of t&e conc&a isreversed from norma!
T&is can cause uncinatedeviation and infundibu!arnarro/ing
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1ncinate rocess insertion
$amina ayracea S(u!! base Midd!e turbinate
T&e anterior ortion of t&e uncusua!!y inserts !atera!!y onto t&or media! /a!! of an agger nasisinus drainage is media!!y direc
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+a!!er ce!!
Infraorbita! air ce!! can contribute to
narro/ing of t&e et&moidinfundibu!um or ostium, esecia!!y if
diseased
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Ma2i!!ary sinus
Accessory ostium of t&e rig&t
ma2i!!ary sinus, usua!!y !ocatedosterior to t&e norma! ostium
in 9:; of atients
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%rontoet&moida! ce!!s
Imortant if surgeon is
!anning to /iden t&e fronta!recess
Agger nasi ce!!
most anterior et&moid airce!!
!ies >ust anterior to fronta!
recess
if !arge, may cause media!
dis!acement of t&emidd!e turbinate
causing narro/ing of t&efronta! recess
A
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%rontoet&moida! ce!!s
Imortant if surgeon is
!anning to /iden t&e fronta!recess
Agger nasi ce!!
most anterior et&moid airce!!
!ies >ust anterior to fronta!
recess
if !arge, may cause media!
dis!acement of t&emidd!e turbinate
causing narro/ing of t&efronta! recess
A
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@u&n C!assi8cation Sc&eme
Tye I Sing!e air ce!!
suerior to t&e agger nasi ce!!4Does not rotrude into t&e
fronta! sinus4
Tye II More t&an one airce!! suerior to t&e agger nasi
ce!!4 None rotrudes into t&efronta! sinus
Tye III Sing!e air ce!!suerior to t&e agger nasi t&atrotrudes ast t&e fronta!ostium or fronta! bea( into t&e
sinus roer
Tye I* Iso!ated air ce!!com!ete!y /it&in t&e sinus
roer4
TyType III
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't&moida! bu!!a
$argest andmost constantanterior et&moidair ce!!
boundsuerior!y byt&e 5oor of t&eanterior crania!
fossa and!atera!!y by t&e!aminaayracea
Drains into t&einfundibu!um
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Critica! Anatomic *ariants
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“CLOSE”
Cribriform !ate &o/ !o/ or &o/ ta!! are t&e !atera! !ame!!aeB.
Lamina ayracea any de&iscence.
Onodi or Posterior et&moid ce!! resent or absent.
S&enoid sinus symmetric, e2tent of neumatiation, otic nervor interna! carotid artery bony coverings de&iscent.
Et&moid artery Is anterior et&moid artery resent on a mesenteror embedded in bone.
orma!d, 'ndoscoic Sinus Su:9E
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C$OS' Cribriform @eros C!assi8cation
based on t&e det& of t&e o!factoryfossa
determined by measuring t&egreatest &eig&t of t&e !atera!!ame!!a in t&e corona! !ane4
T&e !atera! !ame!!a and cribriform!ate are t&in and rone to in>ury
during endoscoic surgery t&e greater t&e &eig&t of t&e
!ame!!a, t&e greater t&e c&ance ofin>ury
Keros Type 1
9-E mm
F;
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C$OS' Cribriform @eros C!assi8cation
based on t&e det& of t&e o!factoryfossa
determined by measuring t&egreatest &eig&t of t&e !atera!!ame!!a in t&e corona! !ane4
T&e !atera! !ame!!a and cribriform!ate are t&in and rone to in>ury
during endoscoic surgery t&e greater t&e &eig&t of t&e
!ame!!a, t&e greater t&e c&ance ofin>ury
Keros Type 2
G-H mm
HE;
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C$OS' Cribriform @eros C!assi8cation
based on t&e det& of t&e o!factoryfossa
determined by measuring t&egreatest &eig&t of t&e !atera!!ame!!a in t&e corona! !ane4
T&e !atera! !ame!!a and cribriform!ate are t&in and rone to in>ury
during endoscoic surgery t&e greater t&e &eig&t of t&e
!ame!!a, t&e greater t&e c&ance ofin>ury
Keros Type 3
-9F mm
9 ;
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Asymmetry
Asymmetry in t&e &eig&ts oft&e fovea et&moida!is oret&moid sinus roof canredisose to enetration oft&e anterior s(u!! base if t&esinus surgeon is not a/are
may be asymmetric someasurements s&ou!d be
made for eac& side
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Asymmetry
Asymmetry in t&e s!oes of t&e foveaet&moida!is or et&moid sinus roof canredisose to enetration of t&eanterior s(u!! base if t&e sinus surgeonis not a/are
t&e oerator cou!d mista(e t&e !o/,do/ns!oing side for an unoened,diseased et&moid air ce!!
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CLOS' $amina ayracea Penetration into t&e
orbit may occur if t&esurgeon is not a/are ofany de&iscence in t&e!amina ayracea4
Microdebriders, /&ic&suction and removetissue raid!y, may !ead
to media! rectus in>uryin !ess e2erienced&ands
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C$OS' Onodi ce!! Must be mentioned if resent
e2tends to t&e s&enoid sinus!ying media! to t&e otic nerveand dis!aces t&e s&enoid sinusmedia!!y and inferior!y
Potentia! damage to t&e oticnerve in
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Divided by an intersinus setum /&ic& may be com!ete or
incom!ete4 Asymmetry bet/een t&e rig&t and !eft sinus andinsertion of t&e setum on t&e carotid cana! s&ou!d be reorted4
T/isting may &urt t&e vesse!
C$OS' S&enoid sinus
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C$OS' S&enoid sinus Carotid cana! de&iscence
May !ead to increased ris( ofin>ury
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C$OS' S&enoid sinus*idian cana!
Rig&t vidian cana! ise2osed as it traverses t&e
5oor of t&e s&enoid sinus,t&e vidian nerve and arteryare at ris(
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C$OSE anterior 't&moida!artery T&e et&moida! arteries are embedded
in t&e bone of t&e anterior s(u!! base4Cone-s&aed divot at t&esueromedia! asect of t&e orbita!/a!! reresents t&e anterioret&moida! foramen4
In t&is case, t&e artery traverses t&eair-8!!ed sinuses be!o/ t&e s(u!! base
on a t&in mesentery, /&ic& increasest&e ris( of in>ury during %'SS4
Transection and retraction of t&eanterior et&moida! artery can ?uic(!yresu!t in signi8cant orbita!&emorr&age4
P ti CT
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Preoerative CT
• Sinus neumatiation and symmetry
•Nasa! setum deviated, ?uantify
• '2tent and attern of sinus disease greatest measurement of
mucosa! t&ic(ening, air 5uid !eve!s or frot&y = bubb!y secretions
• Drainage at&/ay of fronta! sinuses Insertion of t&e uncinated
rocess
• Descrition of frontoet&moida! ce!!s @u&n c!assi8cation
• "C$OS'#
• Osseous sc!erosis or areas of de&iscence
• '2trasinus 8ndings denta! disease, orbita! abnorma!ities,
intracrania! mass !esions and ot&er at&o!ogy