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Treatment of
Sinusitis
Dr. Vishal Sharma
Maxillary Sinusitis
Surgical Treatment Methods:
1. Antral Washout
2. Intra-nasal Inferior meatal antrostomy (INA)
3. Caldwell - Luc surgery
4. Middle meatal antrostomy
5. Functional Endoscopic Sinus Surgery (FESS)
Antral Washout
(proof puncture,
antral lavage)
Indications
Diagnosis & treatment of chronic maxillary sinusitis
not responding to conservative medications
Cytology/culture sensitivity of antral contents
Contraindications
Age < 3 yrs
Hypoplastic maxilla with thick bony walls
Acute maxillary sinusitis untreated by antibiotics
Trauma to maxillary sinus or Fracture of orbital floor
Drainage of maxillary antral hematoma
Higginson Syringe
Antral irrigation
Anesthesia: L.A. for adults. G.A. for children & uncooperative pt. Position: Sitting / supine.
Technique: Puncture lateral wall of inferior meatus
with Tilley-Litchwitz antral trocar & cannula, just
anterior to turbinate genu, trocar directed towards
tragus of ipsilateral ear, with gentle boring action.
Advance till it hits posterior wall, then withdraw
slightly. Remove trocar & wash sinus with saline at 370
C with pt leaning forwards & saying k k. Wash till clear
fluid comes. Remove cannula.
Complications
1. Hemorrhage ( Lateral Sphenopalatine artery)
2. Pain & swelling of cheek (breach of anterior wall)
3. Orbital damage (perforation of orbital floor)
4. Perforation of posterior wall (maxillary artery injury)
5. Vasovagal attack
6. Fatal air embolism
Indications
Chronic refractory maxillary sinusitis
Oro-antral fistula closure
Foreign body removal from maxillary antrum
Fungal maxillary sinusitis
Elevation of orbital floor fractures
Ethmoidectomy (trans-antral)
Biopsy of suspicious neoplasm of maxillary antrum
Orbital floor decompression
Antrochoanal polyp (recurrent)
Route to pterygo-palatine fossa (Vidian nerve, Max Artery)
Dental / dentigerous cyst (maxillary antrum) removal
Incision
4 cm long, sub-labial,
horizontal incision made
3 mm above & parallel to
the gingival margin,
from lateral incisor to
2nd molar tooth.
Incision closed
Complications
Facial: Cheek edema, ecchymosis, subcutaneous
emphysema, infraorbital n. paresthesia
Orbital: Hematoma, extraocular muscle trauma,
diplopia, globe trauma, blindness
Oral: Trauma to teeth roots, Superior alveolar nerve
damage, Dental anesthesia, Oroantral fistula
Vascular: Internal maxillary artery injury
Ethmoid Sinusitis
Surgical Treatment Methods:
1. Intra-nasal microscopic ethmoidectomy
2. Extra-nasal Ethmoidectomy
a. Lynch Howarth procedure
b. Patterson trans-orbital procedure
c. Trans-antral (Jansen Horgan procedure)
3. Functional Endoscopic Sinus Surgery
Patterson ethmoidectomy
Trans-antral ethmoidectomy
Caldwell Luc
surgery done to
reach maxillary
antrum
Ethmoid cells
approached via
postero-superomedial angle of
maxillary antrum
Frontal Sinusitis
Surgical Treatment Methods:
1. Trephination of frontal sinus
2. Modified Lothrop procedure
3. Osteoplastic Flap surgery
4. Functional Endoscopic Sinus Surgery
Lothrop Procedure
Removal of frontal sinus (inferior septum +
floor) + superior part of nasal septum
Lothrop Procedure
Sphenoid sinus
Surgical Treatment Methods:
1. Trans-nasal trans-septal approach
2. Sublabial trans-septal approach
3. External ethmoidectomy approach
4. Endoscopic intra-nasal approach
5. Functional Endoscopic Sinus Surgery
Endoscopic approach
Functional
Endoscopic Sinus
Surgery
F.E.S.S.
Steps of F.E.S.S.
1. Uncinectomy (Infundibulotomy)
2. Anterior ethmoidectomy
3. Middle meatal antrostomy
4. Perforation of basal lamella
5. Posterior ethmoidectomy
6. Sphenoid sinus exploration
7. Skull base disease clearance
8. Frontal recess exploration
Steps of F.E.S.S.
Incision completed
Surgical Navigation
Complications
Major (1%)
Major epistaxis
Orbital hematoma
Diplopia
Blindness or ed visual acuity
Internal carotid injury
Intracranial hemorrhage
CSF leak / Meningitis
Pneumocephalus
Anosmia
Nasolacrimal duct trauma
Minor (7%)
Minor epistaxis
Hyposmia
Adhesions (synechiae)
Headache
Periorbital echhymosis
Periorbital hematoma
Dental / facial pain
Thank You