Requirements of nasal sinus surgery:
1. Nasal endoscope or operating microscope (with objective lens 300mm)
2. Good illumination: head light.
3. Suction: using Zoellner sucker.
4. Haemostasis.
5. Instrumentationt: using the right instruments is very useful in surgery.
Intranasal (inferior meatal) antrostomy
Principle: Creation of an opening in the in inferior meatus for better drainage of the maxillary sinus, since the mucociliary drainage is always towards the natural ostium, the mucous will bypass the antrostomy opening and retained at the natural ostium, so the operation is now not used for treatment of sinusitis.
Indication:
To take a biopsy from a suspected neoplasm.
Contraindications:
- Acute sinusitis.
- Hemorrhagic blood disease.
Complication:
- Epistaxis from injury of sphenopalatine artery.
- Nasolacrimal duct damage.
- Damage to the infra-orbital nerve.
- Early closure of the antrostomy.
Puncture and lavage of the Maxillary sinus
Indication:
Rarely performed nowadays, Used in the past for:
- Treatment of chronic sinusitis and get a material for culture and sensitivity.
- The washout is used for cytological examination in tumors.
Complications:
- Complications of surface anesthesia.
- False passage leading to swelling of check or orbit.
- Hemorrhage from nasal mucosal injury.
Radical Antrostomy operation (Caldwell-Luc)
Indications:
- Removal of intra-sinus foreign body (tooth root, bullet).
- Closure of oroantral fistula.
- Removal of recurrent antrochoanal polyp.
- Removal and biopsy of sinus cysts and maxillary tumors.
- As an approach for treatment of fracture maxilla.
- Chronic sinusitis: removal of hypertrophic mucosal lining of the maxillary sinus, if various methods of treatment failed, this is now a rare indication.
Complications:
- Cheek anesthesia from damage of intra-orbital nerve.
- Damage to dental roots with subsequent loosening of teeth.
- Oroantral fistula.
- Epistaxis from sphenopalatine artery.
- Damage to nasolacrimal duct.
External frontoethmoidectomy
Indications:
- Chronic frontal sinusitis with obstruction of the nasofrontal duct.
- Chronic ethmoiditis with irreversible mucosal disease.
- Acute ethmoidal abscess.
- Ligation of ethmoidal arteries in epistaxis.
- Osteoma.
- Mucocele.
N.B: Most of these indications are done now using endoscopic sinus surgery (ESS).
Complications:
- Orbital hematoma.
- Diplopia.
- Discomfort from the indwelling tube.
- Persistence of symptoms.
Submucous resection (SMR) of the septum
Definition: Removal of the deviated portion of the septal cartilage and bone.
Indications:
- Deviated septum causing symptoms. e.g.: nasal obstruction, headache at the same side of deviation, recurrent epistaxis.
- During trans-septal hypophysectomy.
Contraindications:
Before the age of 18, as nasal cartilage removal interferes with development of the face.
Septoplasty
Definition: Straightening of the septal cartilage without total resection of the cartilage.
Only the deviated part of cartilage and/or bone is removed. It can be done before age 18.
Indications:
- Septal deviation causing symptoms, e.g. nasal obstruction, headache, recurrent epistaxis.
- Anterior septal dislocation.
Complications:
- Anaesthetic complications.
- Post operative bleeding.
- Hematoma between mucosal septal flaps, which may get infected causing septal abscess.
- Perforation of the septum (in SMR only).
- Supratip deformity (in SMR only).
- CSF rhinorrhea, if cribriform plate is injured.
Inferior turbinate reduction by using submucous diathermy
Principle: Creation of Submucosal fibrosis to cause shrinkage of the enlarged inferior turbinate.
Indications:
- Chronic hypertrophic rhinitis.
- Allergic and vasomotor rhinitis.
Complications:
- Intranasal adhesion.
- Epistaxis.
- Recurrence of symptoms.
Turbinectomy
Principle: Resection of the inferior turbinate to reduce its bulk.
Indications: Hypertrophy of inferior turbinates causing nasal obstruction.
Complications:
Atrophic rhinitis.
Postoperative bleeding.
Recently: to avoid the complication of turbinectomy, other methods may be used for turbinate reduction using submucous diathermy, laser, coblation, radiofrequency or shavers.
Rhinoplasty
Principle: Correction of nasal deformity with or without special correction.
Indications:
- Bony and cartilaginous deformity.
- Tip deformity.
Contraindication: Psychic patient or unreasonable expectations.
Complications:
- Patient’s unsatisfaction.
- Anesthetic complications.
- Bleeding.
- Persistence of deformity.
- Marked edema for long time.
- Intranasal adhesions.