Open Sinus Surgery

Open Sinus Surgery

William Lawson

♦ Caldwell-Luc Procedure

The Caldwell-Luc procedure has evolved from a radical antrectomy to a minimally invasive procedure to reduce the associated operative morbidity. With chronic inflammatory disease, it is generally performed following intranasal endoscopic surgery that has been unsuccessful in eliminating chronic infection (granulomatous disease, mycotic disease, odontogenic disease). The more extensive traditional form is still used for tumor removal (inverted papilloma, angiofibroma), orbital decompression (Sewall-Walsh-Ogura procedure), and pterygopalatine fossa surgery.

Surgical Technique

A 3 cm incision is made in the maxillary vestibule in the premolar area above the line of the attached gingiva.

The soft tissues are divided, and limited elevation of the periosteum is performed. No attempt is made to expose the infraorbital foramen and nerve, which lie in the plane between the first and second premolars beneath the infraorbital rim. This is to avoid injury to the nerve from instrumentation or traction.

Entry into the sinus is through the canine fossa (distal to the canine tooth) with a small gouge. Limited bone removal (1 cm) is performed with a Kerrison rongeur. The lateral wall of the maxillary sinus is covered by branches of the superior alveolar nerve, which form an extensive alveolar plexus. Minimal bone removal reduces postoperative paresthesias. The point of entry into the sinus is above the tooth root apices (~2.5 cm from the crown–root junction). This places the bone defect above the mucosal incision, avoiding the formation of a direct fistula into the sinus.

The sinus is surveyed with endoscopes, and selective removal of disease is performed. If most of the lining is removed, the cavity should be stripped completely to prevent the formation of a secondary mucocele in the zygomatic recess from a band of fibrosis sequestering it postoperatively.
An antrostomy is created in the middle meatus by enlarging the natural ostium. Creation of an opening at another site in the medial antral wall will create circular movement of the secretions and promote stasis and continued infection. A small inferior meatus antrostomy may be made for temporary drainage in an essentially healthy sinus that has been entered for fracture reduction or foreign body removal. A large inferior meatus antrostomy is made for dependent drainage in a nonfunctional sinus lacking mucociliary clearance.
The incision is closed with interrupted resorbable sutures (3–0 chromic).

♦ External Frontoethmoidectomy

The external frontoethmoidectomy is a workhorse procedure for management of a wide variety of congenital, inflammatory, traumatic, and neoplastic disorders. It permits direct access to all the ipsilateral paranasal sinuses, anterior skull base, and posterior nasal cavity. Illumination is by headlight, which may be augmented by the adjunctive use of endoscopes placed transorbitally and transnasally for magnification and angular vision. It may also be combined with other procedures (degloving procedure, Denker procedure, septectomy, medial maxillectomy) to increase surgical access and resection. It may also be used for removal of osteomas and mucoceles, resection of encephaloceles, repair of cerebrospinal fluid (CSF) leaks (especially in the narrow nose), drainage of orbital infections, orbital decompression, and management of epistaxis from trauma, or as a complication of endoscopic sinus surgery.

Surgical Technique

A 2 to 3 cm incision is made between the eyebrow and the medial canthus, midway between the nasal dorsum and the canthus. This generally results in healing without producing a web.

The soft tissues are divided, and the angular blood vessels are controlled by electrocautery. Bovie and bipolar cautery may be used reliably.

The periosteum is incised, the medial canthal ligament is detached, and the lacrimal sac is elevated from its fossa and retracted laterally. Elevation and retraction of the sac do not result in dacryostenosis.

The periorbita is elevated, which exposes the frontoethmoidal suture line, and the anterior ethmoidal artery is identified. Measurements are critical in determining the location of the ethmoidal blood vessels. The average distance from the lacrimal fossa to the anterior ethmoidal foramen is 1.5 cm; from the anterior to the posterior foramen, 1 cm; and from the posterior foramen to the optic canal, 1.0 cm. When elevating the periorbita, which is relatively dense, the herniation of fat into the operative field signals that the anterior ethmoidal foramen has been reached and impending damage to the blood vessels is likely.

Hemostasis of the anterior ethmoidal artery is by electrocautery, which leaves a burn mark on the bone that will not wash away with bleeding (clips may become dislodged). It is imperative to clearly identify the frontoethmoidal suture line, as dissection below it will prevent intracranial injury.
The lamina papyracea is exposed, and entry into the ethmoid labyrinth is made with a small punch forceps.
Bone can be removed superiorly to the frontoethmoidal suture line, inferiorly as far as the junction of the medial and inferior orbital walls, posteriorly to the ethmoidal blood vessels, and anteriorly to the anterior lacrimal crest.
The ethmoidectomy is completed, and the nasal cavity is entered.
If the frontal sinus is to be entered, dissection is performed superiorly above the lacrimal fossa. Dissection above the plane of the frontoethmoidal suture line is safe only anteriorly. A probe should be placed into the nasofrontal duct to guide dissection. Determination by imaging studies of the size and shape of the frontal sinus and whether a supraorbital ethmoid air cell is present is essential to avoid entering a cul-de-sac created by it and not the frontal sinus. The amount of frontal sinus floor that needs to be removed is variable and dependent on the pathology.
When the frontal sinus is opened, a stent of rolled thin Silastic sheeting is inserted, which extends from the frontal sinus into the nasal cavity. The middle turbinate is resected to facilitate placement and postoperative management. The Silastic tube is anchored superiorly to the subcutaneous tissues with a 4–0 Vicryl suture. It can be readily removed in the office through the nose after 6 to 8 weeks.
The periorbita is carefully realigned and closed with 4–0 Vicryl interrupted sutures that reattach the trochlea and medial canthal ligament. Suturing the periorbita with slow-absorbing sutures is sufficient for reattachment, with wire fixation unnecessary.
The subcutaneous tissues and skin are sutured in layers.
The nose is left unpacked for drainage.

♦ Frontal Osteoplastic Flap

The frontal osteoplastic flap is the benchmark procedure for the management of chronic inflammatory disease of the frontal sinus following unsuccessful endonasal or external surgery. Creating an inferiorly based, hinged osteoperiosteal flap of the anterior table provides direct access to the sinus and all its extensions for instrumentation and obliteration. Other indications are for access to septate sinuses; removal of mucoceles, encephaloceles, osteomas, and other tumors; repair of complex fractures; and correction of pneumatoceles.

A major advantage of the procedure is that by isolating and obliterating the sinus, the need for maintaining drainage and ventilation through a patent nasofrontal outflow is eliminated—a factor limiting the success of other procedures. However, any retained epithelium in the sinus has the propensity to form a secondary mucocele. The viability of the bone flap is attested to by the absence of postoperative cosmetic deformity, although a small number of patients develop areas of resorption where periosteum has been lost, or flap enlargement (embossment) by a hyperostotic reaction.

Surgical Technique

A coronal or direct brow (gullwing) approach may be used depending on the position of the frontal hairline. The coronal approach is preferable and should be used whenever possible not only for purposes of scar camouflage but because it permits preservation of the supraorbital and supratrochlear nerves. Transecting these nerves not only causes numbness and paresthesia of the forehead but in some patients results in a chronic local pain syndrome minimizing recurrent disease.

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Open Sinus Surgery