1 There has been a significant shift from external and headlight sinus surgery to endoscopic sinus surgery (ESS) in the past quarter-century. This dramatic change was initiated by the pioneering studies of Messerklinger in which he demonstrated that each sinus has a predetermined mucociliary clearance pattern draining toward its natural ostium irrespective of additional openings that may have been created into the sinuses.1 This philosophy of opening the natural ostium of the diseased sinus was then popularized by Stammberger2 and Kennedy.3 ESS is now accepted as the surgical management of choice for chronic sinusitis. In addition, as our knowledge of the anatomy of the sinuses has improved, other ancillary techniques such as endoscopic lacrimal surgery4 and orbital decompression5 have been developed. The development of specialized instruments has facilitated the endoscopic management of benign endonasal tumors6,7 and, more recently, the endoscopic management of malignant tumors8 of the nose and sinuses. ESS, ancillary nasal and sinus procedures, and, more recently, endoscopic transnasal intracranial surgery require a broad range of specially designed endoscopic surgical instruments. Disclaimer: Several instruments that are discussed in this book are manufactured and sold by Medtronic ENT. Those that are identified by an asterisk here and in subsequent chapters have been designed by the author; a royalty is received from the sale of these instruments. There are no undeclared financial incentives associated with any of the instruments discussed that do not bear the identifying asterisk. A complete list of the ESS instruments used by the author is presented in Table 1.1. In this table and here, the manufacturer is named if the particular instrument is produced by only that company, but if the instrument is produced by several companies then no manufacturer is named. The following instruments are the most important for basic sinus surgery: Powered microdebriders now form an essential part of the instrumentation required to perform ESS. These instruments allow the surgeon to remove blood from the operating field with the gate open and then the tissue can be cut with considerable precision by the rotating inner blade of the microdebrider. This precise cutting of mucosa minimizes the potential for stripping of the mucosa and helps to achieve maximum mucosal preservation which should improve postoperative healing and, consequently, the results of the surgery. These instruments are very effective at removing tissue and, if placed in the wrong area, such as the orbit, can create significant damage to the orbital contents in a very short space of time.9,10 Due to its soft consistency, orbital fat can be sucked into the blade opening and cut by the rotating inner blade at a frightening rate. If the surgeon is unaware of having penetrated the orbital periosteum with the microde-brider, significant damage can occur within a few seconds. There are numerous case reports in the literature in which powered microdebriders have caused inadvertent injury to the orbital contents and to the medial rectus muscle.9,10 Table 1.1 Full List of Operating Instruments and Equipment*
Setup and Ergonomics of Endoscopic
Sinus Surgery
Instruments
Small rotating backbiting forceps
Sickle knife
Small (2.5 mm) straight and 45-degree upturned Blakesley forceps
Small (2.5 mm) straight and 45-degree upturned through-biting (cutting) Blakesley forceps
Endoscopic scissors
Double right-angled ball probe
Forceps: 45- and 90-degree giraffe cup forceps, 45- and 90-degree through-biting giraffe forceps
Hajek Koffler forward-biting punch
Suction Freer elevator
Curettes (straight, 45- and 90-degree curette)
Malleable suction Freer elevator* (Medtronic ENT, Jacksonville, FL)
Malleable suction curette* (Medtronic ENT)
Malleable frontal sinus probe* (Medtronic ENT)
Powered Microdebriders
General Instruments Jacobson angled 7-inch needle holder 6-inch fine needle holder Small Luc forceps Angled Heyman turbinectomy scissors Tilley Henkel forceps Tilley packing forceps Mosquito curved artery clips Backhaus towel clips Sponge holder McIndoe forceps Adson toothed OR Adson Brown forceps Adson plain OR tungsten tip forceps Suture scissors Iris curved scissors No. 7 scalpel blade handle Freer dissector Frazier 9-French gauge sucker and stilette Frazier 10-French gauge sucker and stilette Dental syringe Heath mallet Small Killian speculum Medium Killian speculum Large Killian speculum |
Sinoscopy Instruments Medium straight Blakesley forceps Medium upturned Blakesley forceps Blakesley forceps straight through cut Blakesley forceps upturned through cut Right ostrum punch downcut Left ostrum punch downcut Sinus short sucker Sinus long sucker Sickle knife Freer dissector Double-ended probe Kuhn Bolger frontal ostium seeker Kuhn Bolger frontal sinus curette, 55 degrees Antrum curette 90-degree curette Suction Freer and stilette Rotating microbite backbiter Hajek Kofler sphenoid punch upcut forward |
Special Instruments Sinoscopy scissors, straight Sinoscopy scissors, curved left Sinoscopy scissors, curved right Kuhn Bolger giraffe forceps, horizontal Kuhn Bolger giraffe forceps, vertical Kuhn Bolger forceps, 60 degrees Kuhn Bolger forceps, 90 degrees Kuhn Bolger forceps, 90 degrees right angled Kuhn Bolger forceps, 90 degrees left angled Ligature clip carrier |
Branded Instrument Sets |
Wormald Sucker Bipolar* (Medtronic ENT) Wormald suction bipolar forceps, straight* Wormald suction bipolar forceps, upturned* Sterilization case Bipolar cable |
Medtronic ENT Frontal Trephine Set Medtronic frontal trephine set Drill guide Drill pin Irrigation cannula (reusable; keep six in stock) Sterilizing tray |
Wormald’s Malleable Frontal Sinus Instruments* (Medtronic ENT) Wormald malleable frontal sinus probe Wormald malleable frontal sinus sucker Wormald malleable elevator blunt Wormald malleable frontal sinus curette Sterilization tray |
Wormald Dacryocystorhinostomy Set* (Medtronic ENT) Sickle knife Spear knife Lusk MicroBite forceps |
Wormald MicroFrance Anterior Skull Base and Pituitary Instrument Set* (Medtronic ENT) 5-mm fine scissors: left, right, and straight 5-mm fine scissors: up 8-mm fine scissors: left, right, and straight 8-mm fine scissors: up 1-mm forceps straight and 45-degrees Malleable probe, straight Malleable probe, right angled hook Malleable suction dissector Malleable suction Malleable suction cage Malleable small and large 45-degree ring curettes Malleable small and large 90-degree ring curettes Bending tool |
MicroFrance Wormald Medtronic Hemorrhage Control Set* Clamp, straight rotatable Clamp, curved small Clamp, curved long Clamp, 45-degress straight Clamp, 45-degress curved small Clamp, 45-degress curved long Clip, applying forceps rotatable straight Clip, applying forceps rotatable 45-degress Needle holder, rotatable |
Camera System STORZ IMAGE 1 digital camera 0-degree endoscope (4 × 11 mm Hopkins) 30-degree endoscope 45-degree endoscope 70-degree endoscope |
Lens Washer Medtronic EndoScrub II |
Consumables 0-degree EndoScrub II sheath 30-degree EndoScrub sheath |
Microdebrider Medtronic IPC (Integrated Power Console) M4 handpiece Midas Rex stylus handpiece Skull base burrs |
Topical Solutions Cocaine solution (10%, 2 mL) Adrenaline (1:1000 × 1 mL) Normal saline (0.9 × 3 mL) |
*Instruments identified by an asterisk were designed by the author.
Fig. 1.1 (A) The blade is open and (B) tissue is sucked into the blade prior to rotation of the inner blade and severing of the tissue.
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