SURGICAL ANATOMY OF LATERAL WALL OF NOSE & FESS

Presented by Dr. Praveen Kumar JR-III

DEPARTMENT OF OTORHINOLARYNGOLO AND HEAD & NECK SURGERYMLB MEDICAL COLLEGE, JHANSI (U.P.)

Nasal cavities• Begin at the piriform aperture• End at the posterior choanae• Boundaries :

– Roof– Floor– Septal wall– Lateral wall

Nasal cavitiesRoof• Nasal bones• Nasal spine of the frontal bone• Floor of the frontal sinus• Cribriform plate of ethmoid boneFloor• 3/4 : palatal process of maxillary bone• 1/4 : horizontal process of palatine bone

Nasal cavities

Nasal septum• Vomer• Perpendicular plate of ethmoid bone• Quadrilateral cartilage• Nasal crest, anterior nasal spine• Membranous septum and columella

Nasal septum

Lateral Wall

Lateral wall• Nasal surface of maxilla, superior, middle and inferior

conchae, perpendicular plate of palatine boneBony structure• Ethmoid bone ; Superior & Middle concha,Uncinate

process, Cribiform plate• Inferior concha bones• Maxilla bone; Palatine & Alveolar & Frontal process• Palatine bone; Perpendicular & Horizontal plate• Lacrimal bone• Sphenoid bone; Medial pterygoid plate• Nasal bone

Lateral wallConchal bone• Supreme • Superior • Middle • InferiorMeatus• Superior • Middle • Inferior• sphenoethmoidal recess

Lateral wallSuperior meatus• Superior to SM Sphenoethmoidal recess Sphenoidal sinus drainage• Inferior to SM Opening of posterior ethmoidal air cellsMiddle meatus• Uncinate process; hook shape bone• Hiatus semilunaris; posteroinferior• Maxillary sinus opens • Ethmoidal infundibulum

– Fronto-nasal recess • Frontal sinus opening

– Anterior• Anterior ethmoidal air cells opening• Ethmoid bulla

– Opening of middle ethmoid air cell

Lateral wall

Inferior meatus• Nasolacrimal duct opening• Sphenopalatine foramen • Posterior end of MT• Neurovascular bundle• Leading into pterygopalatine fossa

Lateral wall

Lateral Wall

I Part II Part III Part

Vertical Oblique Horizontal

Types of Attachment of Middle turbinate

ATTACHMENT OF MIDDLE TURBINATE

segment Bone of insertion Plane of insertion Site of insertion

Anterior 1/3 ethmoid Saggital

(vertical)

Lalateral lamella of

lamina cribosa

Middle 1/3 ethmoid Frontal

(oblique)

Lamina papyracea

Posterior 1/3 Ethmoid,

maxilla,

palatine

horizontal Post part of lateral

nasal wall

I. Unciate process II. Bulla ethmoidalis III. Horizontal part of middle turbinate IV. Superior turbinate V. Supreme turbinate

Types of Unciate attachment

Type – I Type – II Type – III

Lamina papyracea

Fovea ethmoidalis

Middle turbinate

Attach to

Bulla Ethmoidalis•Anterior ethmoid air cells attached to lamina papyrcea and usually open into lateral sinus

Bulla Ethmoidalis

TYPES OF FRONTAL CELL

Type I

Type III

Type II

Type IV

a single air cell above agger nasi

series of air cells above agger nasi but below the orbital roof

cells extends into the frontal sinus but is contiguous with agger nasi cell

Cells lies completely within the frontal sinus

Types of Sphenoid Sinus on basis of pneumatization

Complications of FESS

Complication : NLD injury

Complication : ACF injury

Complication : CSF Leak

Complication : Orbital Haemorrhage

Complication : Medial rectus injury

Complication :Pneumo-encephaloceole

Complication : Medial rectus injury

Complication :Pneumo-encephaloceole

Complication : Optic Nerve injury

Complication : Haemorrhage

BALLOON SINOPLASTY

• 31 million Americans suffer from chronic sinusitis

• Surgical treatment for chronic sinusitis has evolved tremendously since its inception

Inclusion & Exclusion criteria• Inclusion criteria :

– Adult > age of 18 years – Chronic sinusitis unresponsive to medical

management

• Exclusion criteria: – Extensive sinonasal polyps, cystic fibrosis– Extensive previous sinonasal surgery– Extensive sinonasal osteoneogenesis– Sinonasal tumors,– History of facial trauma – Ciliary dysfunction– Pregnancy

Sino Nasal Outcome Test (SNOT-20)

• 0 = Not present/no problem

• 1 = Very mild problem

• 2 = Mild or slight problem

• 3 = Moderate problem

• 4 = Severe problem

• 5 = Problem as “bad as it can be”

Lund- Mackay scores

• CLinical Evaluation to confirm sAfety and efficacy of sinuplasty in the paRanasal sinuses(CLEAR STUDY)

• Multi-center prospective non-randomized study– Bolger et al. (2007): 10 centers (24-week , 109

patients)– Kuhn et al. (2008): 7 centers (1 year f/u, 66 patients)

Luma Sinus Illumination System (Luma light)

Friedman M.Laryngoscope. 2009 Jul;119(7):1399-402.

Schematics of Balloon Sinuplasty

Measurement of success in balloon sinuplasty

• SNOT-20

• CT sinus

• Lund-Mackay CT score

• Nasal endoscopy to look for ostia patency

Thank you