investing papilloma maxillary sinus anatomy
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Investing papilloma maxillary sinus anatomy

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If anesthetic techniques fail to provide a clear view of the surgical field, temporary application of cotton plugs soaked with adrenaline is useful. As described above the surgeon should first analyze the superior attachment and the anatomic variations of the uncinate process. Using a zero-degree scope, the uncinectomy or infundibulotomy is started by gentle medialization of the middle turbinate Fig. The next step consists of resection of the uncinate process and exposure of the ethmoid bulla.

The uncinectomy can be performed in a posterior-to-anterior direction with a backbiter, or in an anterior-to-posterior direction with a sickle knife Figs. The most cranial part of the uncinate process should be left intact preventing any mucosa damage and scar tissue formation around the frontal recess. The uncinate process is very thin and its incision should not be deeper than 1 mm to avoid any damage to the lamina papyracea.

Once the uncinate process is incised and mobile Figs. Remnants of the uncinate process can be removed with a backbiter anteriorly until the thick lacrimal crest is approached. Unlike the uncinate process, this bone usually is thick and there is a remarkable resistance. At this point, one should not go further anteriorly to avoid damage to the nasolacrimal duct see Videos Overall, the uncinectomy can be regarded as the first step for exposure of the ethmoid bulla and the ethmoid sinuses Fig.

The frontal sinus drains medially into the middle meatus. B Insertion into the skull base, or C insertion into the middle turbinate. In both these cases, the frontal sinus drains laterally into the ethmoidal infundibulum. EB, ethmoid bulla; UP, uncinate process. A,B Incision of the uncinate process UP with a sickle knife in anterior to posterior technique arrow.

C Medialization of the uncinate process with a sickle knife. F Endoscopic view into the maxillary sinus MS after uncinectomy. MT, middle turbinate. B After removal of ethmoid bulla, anatomic orientation by identification of middle turbinate and lamina papyracea. In the case of concha bullosa, the head of the middle turbinate is incised with a sickle knife and the lateral portion removed with a through-cutting straight forceps. One should definitely preserve the medial portion and the superior attachment of the middle turbinate to prevent a floppy middle turbinate.

In cases of septal deviation with limited access to the ostiomeatal complex OMC , we first perform a septoplasty. If the middle nasal meatus is filled with polyps, we first remove the polyps to expose the uncinate process. This step can be performed with soft tissue shavers. In experienced hands, the uncinectomy can also be done with the shaver.

Oscillation of the blade is realized by continuous suction, which permanently removes soft tissue, blood, and debris from the operative area. The soft tissue shavers are available in various sizes and shapes and have an oscillate speed of at least rpm. The maxillary sinus ostium can usually be visualized after the uncinate process has been removed. The ostium can be identified with a thin curved suction cannula.

For further steps the degree telescope is preferred. Enlargement of the natural ostium is managed posteriorly and inferiorly by extending its border to the posterior fontanel Fig. This step can be performed with a through-cutting and side-biting punch forceps. Dissections extended too far posteriorly may lead to arterial bleeding from the branches of the sphenopalatine artery. This bleeding can be managed with electrocautery.

Extending dissections too far anteriorly should be avoided because this may cause damage to the nasolacrimal duct. With the help of the and degree telescope the maxillary sinus is examined and treated, when necessary. In cases of huge polyposis of the maxillary sinus, we prefer to remove polyps with a curved soft tissue shaver. In case of intense bleeding with poor visualization of the operative field, the middle meatus is temporarily packed with cotton plugs as described above.

With the help of the degree telescope, the inferior and far lateral areas of the sinus can be inspected. Also, endoscopic maxillary sinus surgery is performed usually as the first step in different pansinus operations. In cases of massive or recurrent polyposis with opacification of all sinuses pansinusitis , we first perform a middle meatal antrostomy and proceed to a frontal sinus surgery type I, II, or III after Draf, 21 , 22 depending upon the pathology see Videos Nowadays the indication for inferior meatal antrostomy is rare.

Usually, we first perform a gentle conchotomy, corresponding to the planed window in the inferior medial wall of the maxillary sinus. It is useful to incise the inferior turbinate with a septal scissor parallel to the inferior margin in a way that a posteriorly pedicled flap is created. The length of this flap depends on the length of the planed window. The pedicle is cut with a cutting snare to reduce the bleeding to a minimum.

Bipolar coagulation helps to provide meticulous hemostasis. Doing so, the result achieved is similar to those designed already by Claoue. The inferior portion of the medial maxillary sinus wall is opened with a degree curved Blakesley. This primary window can be enlarged with a backbiter anteriorly Fig. With the popularity of FESS, the indication for an inferior antrostomy has decreased considerably.

In our opinion, this type of surgery is indicated only in persistent or recurrent isolated maxillary sinusitis with cysts, polyps, or mycetomas due to dental pathology in the alveolar recess of the maxillary sinus. Endoscopic endonasal medial maxillectomy can be regarded as an extended endonasal approach to the maxillary sinus for resection of benign and, in special circumstances, malignant tumors.

It was later called the endonasal Denker operation. Interestingly enough, the nasolacrimal sac is not mentioned in either of the early publications. Recently, several authors reported on their experience with medial maxillectomy for removal of inverted papilloma see below. If indicated, the posterior maxillary sinus wall also can be removed. Usually, we first perform a wide middle meatal antrostomy with removing the medial maxillary wall cranially up to the level of the orbital floor.

B Resection of the medial parts of the maxillary bone including the medial maxillary sinus wall and parts of the middle and inferior turbinate with preservation of the nasolacrimal duct. Resection can be widened including the nasolacrimal duct and a little area of the piriform aperture.

In the next step, depending on the tumor extension, the medial wall is resected until the posterior margin of the tumor is reached. Bleeding from branches of the sphenopalatine artery can be stopped with electrocautery. Then, the medial maxillary sinus wall is resected anteriorly. In large tumors, the anterior dissection includes the lacrimal bone with the nasolacrimal duct.

In this case, an endonasal endoscopic dacryocystorhinostomy is performed at the end of the medial maxillectomy. With this extended approach, the tumor margins can be visualized sufficiently to achieve a total removal. Diseased bone should be freed of pathology with a diamond burr. In this case, the medial maxillectomy is combined with the resection of the medial portion of the anterior wall including the piriform crest. An endonasal Denker operation 25 is the result.

Figure Mucoceles are slowly expanding epithelial-lined lesions containing mucus and have been found in all paranasal sinuses. They show an expanding behavior and can lead to pressure atrophy of the bone with extra sinonasal growth into the orbit and endocranium. Most cases of maxillary sinus mucoceles can be treated with an endonasal endoscopic approach. Usually the frontal wall of the mucocele sack is dissected and marsupialized see Video For mucoceles located too far lateral of the maxillary sinus, we prefer an osteoplastic maxillary sinus approach Fig.

Seventy-two patients had a mucocele of the maxillary sinus. In 42 mucoceles the etiology was previous surgery, most commonly a Caldwell—Luc operation. The majority of the mucoceles The long-term results of this and other studies show that endonasal endoscopic surgery is an effective and safe approach for the majority of this type of pathology. Traditionally, lateral rhinotomy or mid-facial degloving with en bloc tumor resection in combination with medial maxillectomy were used and are standard approaches today.

For IP of the maxillary sinus, the kind of operation varies in relation to the site of origin and the extent of the lesion. To choose the best surgical approach i. In the assessment of sinonasal expansile lesions, CT scan is generally considered the examination of choice. However, CT scanning cannot differentiate between retained secretion of inflamed mucosa and IP. In unilateral maxillary sinus opacification, preoperative MRI can be very helpful for further surgical planning and better informed consent Fig.

Basically, we use a completely endonasal endoscopic resection or an endonasal procedure combined with an osteoplastic maxillary sinus OMS technique as described by Feldmann. All medially localized tumors are resected via an endonasal endoscopic procedure, which includes the medial maxillectomy or enlarged maxillary sinus technique indicated as an endonasal Denker operation.

In the next step, the soft tissue is prepared in the subperiosteal plane and the anterior wall of maxillary sinus exposed. The infraorbital nerve is identified to prevent its damage during the bone dissection work. After that, the bone window is created with a special saw 43 through the osteoplastic approach.

An 8-hole plate, which is lightly curved, is put in place for drilling the burr holes. After this, the bony graft is removed and the lateral region of the maxillary sinus is bluntly freed from tumor using a surgical pad. The dissection work is continued until all tumor parts are removed from the maxillary sinus. In the final step, the bone graft that was temporarily taken out is replaced and fixed with two screws.

If feasible, lesions are removed en bloc, but in large tumors the nasal portion of the mass is first debulked to focus subsequently on the most critical lateral areas, where dissection is always performed in the subperiosteal plane. Then drilling of the diseased-underlying bone is accomplished and frozen sections from surgical bed margins are taken to ensure surgical radicality and complete tumor removal.

In a few cases, the additional use of the microscope can be helpful see Video During the last years, several series have been published reporting on the endonasal endoscopic management of IP; increasingly, this has been accepted as the surgical modality of choice for most IP.

Fifty-three percent of the IPs could be removed via an endonasal approach. During the follow-up period, ranging from 12 to months median 74 months four recurrences 8. Three tumors had been reoperated via a combined approach with one endonasal surgery. Hence, the recurrence rate for endonasal surgery was 2. The mean recurrence interval after endonasal surgery was 24 months in contrast to months after combined approach.

A Horizontal incision in the canine fossa. C Fixation of a curved eight-hole plate to the bony window and marking of outer burr holes for later reattachment. D Temporary removal of the bone graft. Bone graft and blunt dissection E of the tumor with a surgical pad. F Refixation of the bone graft with two outer screws.

Antrochoanal polyps ACP are benign lesions that are most commonly seen in children. This isolated polyp has its origin from the mucosa of the maxillary sinus and grows through the natural or accessory maxillary sinus ostium into the nasal cavity and can extend into choana and nasopharynx Fig.

The major symptom is a unilateral nasal obstruction. Treatment of choice is primary endoscopic removal with resection of the basis in the maxillary sinus see Video B Postoperative short tau inversion recovery STIR sequences after tumor resection via a combined technique including an osteoplastic maxillary sinus approach and endonasal medial maxillectomy 6 years postoperatively.

No sign of recurrence. A,B Coronal T2-weighted magnetic resonance imaging MRI scan shows complete opacification of the right maxillary sinus and the middle meatus with extension into the nasopharynx. The polyp is hyperintense on T2-weighted MRI scans. In the preoperative phase, a study with CBCT scan is suggested, in order to identify intraosseous arterial course, patency variability and the distance from alveolar ridge.

Furthermore, it is strongly recommended the use of piezosurgery, to preserve vascular structures and soft tissues. A modified Lundgren technique can be useful to avoid the use of round bur and thus reduce the risk of perforation of the underlying structures. Keywords: sinus lift; antral artery; modified Lundgren technique. Alveolar Antral Artery: does its diameter correlate with maxillary lateral wall thickness in dentate patients?

Iran J Otorhinolaryngol Jul; 26 76 —7. Blood supply to the maxillary sinus relevant to sinus floor elevation procedures. Clin Oral Implants Res Feb; 10 1 — Alveolar antral artery isolation during sinus lift procedure with the double window technique. Open Dent J May 30; — Bone reformation with sinus membrane elevation: a new surgical technique for maxillary sinus floor augmentation. Clin Implant Dent Relat Res ; 6 3 — Valente NA. Distance of the alveolar antral artery from the alveolar crest.

Related factors and surgical considerations in sinus floor elevation. The piezoelectric bony window osteotomy and sinus membrane elevation: introduction of a new technique for simplification of the sinus augmentation procedure.

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Papilloma maxillary sinus anatomy investing forex technical analysis

Inverting Papilloma or Squamous Cell Carcinoma?

OSP occurs exclusively on the lateral nasal wall or in the sinuses, usually the maxillary or ethmoid, and presents as a fleshy pink, tan, red-. The maxillary sinus is the most commonly involved. Ethmoid, frontal, and sphenoid sinuses are affected less often. Etiology and pathogenesis. Non-invasive FRS. MR imaging–based texture analysis has the potential to differentiate squamous cell carcinoma from inverted papilloma and may, in the future, provide incremental.