27.1 Nasal Preparation

27.1.1 Options for Pre-operative Preparation and Perioperative Control

• Pre-operative steroids/antibiotics

• Xylometazoline (Otrivine)/other decongestants

• Moffat solution

• Cocaine paste

• Topical adrenaline

• Hypotensive anaesthesia (TIVA)

• Careful tissue handling

27.1.2 Multisystemic Effects of Cocaine

• Altered mental status

• New-onset seizures

• Hypertension

• Chest pain

• Myocardial ischemia or infarction

• Shortness of breath

• Intracranial hemorrhage

• Epistaxis

• Hyperthermia

27.1.3 Treatment of Cocaine Toxicity

• β-blockers (propranolol)—depress CO

• GTN and sodium bicarbonate may be required

• Benzodiazepines (lorazepam) for seizures

27.2 Pre-operative CT Checklist

• Nasal cavity roof—slope, height, thin and thick areas, Keros classification of cribriform plate

• Medial orbital wall—shape and integrity, optic nerve, infundibulum

• Maxillary sinus—Haller cells, retention cysts, dentigerous cysts

• Ethmoids—vertical height, anterior (and posterior) ethmoid arteries, basal lamella, size of bulla

• Sphenoid sinus—pneumatization, intersinus septum, carotids, Onodi cells

• Frontal recess—size, position of cells (Kuhn, ISSC, SOE, FBC), agger nasi

• Middle turbinates—paradoxical, resected, conchae bullosae

• Can you manage all the eventualities?

27.3 Four Constant Landmarks in Sinus Surgery

• Uncinate process

• Face of the bulla

• Basal lamella

• Face of the sphenoid sinus

27.4 A Stepwise Approach to Sinus Surgery

• Total uncinectomy—upper uncinate (0° scope) and lower uncinate (30° scope)

• Visualization of the natural maxillary sinus ostium with preservation of the outflow tract (infundibulum) (30° scope)

• Debridement or lavage of maxillary sinus contents (30° scope)

• Resection of bulla (0° scope)

• Penetration of basal lamella (0° scope)

• Posterior ethmoidectomy to sphenoid face (0° scope)

• Sphenoidotomy via Bolger/Lanza/transnasal approach ± lavage/debridement of contents (0° (± 30°) scope)

• Clearance of the skull base from sphenoid face to frontal recess (0° and 30° scope)

• Removal of the agger nasi cap (30° scope)

• Frontal sinusotomy including removal/opening of any frontal cells (Kuhn, etc.) (30° and 70° scope)

• Lavage/debridement of frontal sinus contents (70° scope)

27.5 Exceptions to the Rule

• Wide antrostomy performed when:

Tumour

AFRS

Cystic fibrosis

Conchae bullosa

Polypoid portions

Tumour

27.6 Sphenoid Approaches

• Superior turbinate attachment to sphenoid face (Parson ridge) critical in determining entry to sphenoid:

Type A: sup turbinate attachment in medial 1/3: 40%

Type B: sup turbinate attachment in middle 1/3: 40%

Type C: sup turbinate attachment in lateral 1/3: 19%

Type D: sup turbinate attachment to orbit: 1%

• 3 endoscopic approaches:

Transnasal (via sphenoethmoidal recess)

Bolger—parallelogram method (natural ostium not used)

Lanza—resection of inferior portion of Parson ridge to allow transethmoidal access to ostium

27.7 Frontal Recess (Kuhn) Cells

• Type I—one ethmoid cell in association with agger nasi

• Type II—stacked ethmoid cells in frontal recess

• Type III—single large ethmoid cell extending into frontal sinus

• Type IV—isolated ethmoid cell within frontal sinus without connection to frontal recess (probably an artifact of older CT imaging protocols)

27.8 Skull Base Configuration—Keros

• (A) Type I—olfactory fossa 1 to 3 mm deep

• (B) Type II—olfactory fossa 4 to 7 mm deep

• (C) Type III—olfactory fossa 8 to 16 mm deep

• (D) Asymmetric fossae

27.9 Frontal Sinus Surgery

27.9.1 Techniques—Endoscopic

• Balloon sinuplasty

• Draf type 1—dissection of frontal recess (uncapping the egg—Stammberger)