What is
Ethmoidectomy?
Septoplasty is an operation
that corrects any defects or deformities of the nasal
septum, which is the wall between the two nostrils.
The term "ethmoidectomy" describes a surgical
procedure during which ethmoid sinus cells are opened to
treat infection or sinus obstruction that has led to chronic
sinus problems.
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Effects
of Ethmoidectomy
The goal of the surgery is to straighten out
the nasal septum or to relieve obstructions
or other problems related to deviation of
the septum.
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Candidates
for Ethmoidectomy
The main conditions that call for nasal
surgery are:
·
Nasal
airway obstruction
·
Septal spur
headache
·
Uncontrollable
nosebleeds
·
Nasal septal deformity in the presence of other intranasal
surgery
Nasal airway obstruction is usually the result of a septal
deformity that causes breathing by mouth,
sleep apnea, or recurrent nasal
infections. A septal spur
headache
is defined as a headache secondary to
pressure from the nasal septum on the inside
the nose (septal impaction) that is relieved
by topical anesthesia (applied to a
localized area of the skin) on the septal
impaction.
Other intranasal surgeries that may be modified to include
septoplasty include the following:
·
Polypectomy (removal of a polyp)
·
Ethmoidectomy (operation on the ethmoid bone at the superior
part of the nasal cavity)
·
Turbinate surgery (operation on the concha nasalis)
·
Tumor removal
People who snort drugs such as cocaine in large quantities
for long periods of time may require this
surgery if drug use has damaged the septum.
The typical case of acute ethmoidal
sinusitis is treated with medical therapy.
Medical treatment can reduce the
inflammation and edema of the mucosa,
alleviate the pain, combat the infection,
open the ostia of the sinuses, and restore
normal mucociliary secretions. However,
surgery is indicated in the following
instances:
-
Sinusitis not responsive to medical management
-
Rapidly progressing sinusitis
-
Sinusitis that creates an abscess either in the
sinus or adjacent areas such as the
orbit or brain
-
Sinusitis that compromises the survival
of the patient
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Your
Consultation
-
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The Ethmoidectomy
Procedure
An incision is made internally on one side of the nasal
septum. Afterwards, the
mucous membrane is elevated away from
the cartilage and bone, obstructive parts
are removed, and
plastic
surgery is performed as
necessary. Then the mucous membrane is
returned to its original position. The
tissues covering the septum are maintained
in the midline by either sutures or packing.
Anatomically, the ethmoid sinuses are divided
into anterior and posterior regions each
with a variable number of sinus cells.
Typically the anterior cells are fewer in
number and more consistent in their size and
structure. The posterior ethmoid cells may
number from 1-5 and their size and structure
may be more variable. The posterior cells
are also associated with several important
structures; the orbit (eye), optic nerve,
and the sphenoid sinus. Dependent on the
extent of sinus disease, the surgeon may
elect to open only the anterior cells
(anterior ethmoidectomy) or may need to open
all the cells (total ethmoidectomy). After
opening these cells, drainage of infected
mucous and removal of inflamed tissue is
accomplished. Surgical treatment of the
ethmoid sinus cells is one of the more
common components of sinus surgery.
Medical therapy:
Medical therapy for acute ethmoid sinusitis
is geared toward eradicating the infection,
opening the ostium, restoring the
mucociliary function, and relief of pain.
Treatment is often empiric, with the use of antibacterial
agents most often directed against
gram-positive organisms. Antimicrobial
agents such as ampicillin, amoxicillin,
amoxicillin/clavulanate, erythromycin,
clarithromycin, cefaclor, cefuroxime, and
trimethoprim/sulfamethoxazole can be used,
usually for 10 days. If dental extraction is
implicated, consideration should be given to
using metronidazole. Decongesting of the
mucosa using topical oxymetazoline or oral
decongestants can be helpful in shrinking
the mucosa. Pain is managed as needed.
If the patient does not respond to treatment, the results of
cultures can be used to guide further
therapy. Investigations for atypical
pathogens or immunocompromised status must
be undertaken in an otherwise healthy
patient who develops ethmoiditis that is not
responsive to therapy and progresses. If
Pseudomonas or fungal sinusitis may be
present, it must be identified, and therapy
must be altered to treat the offending
agents.
Medical treatment may not be enough to resolve the
ethmoiditis. In those cases that resolve but
are not eradicated, chronic sinusitis may
develop. Further antibiotic treatment and
ultimately surgical therapy may be warranted
for chronic ethmoidal sinusitis, but such
matters are beyond the scope of this
article.
When acute ethmoidal sinusitis is rapidly progressing,
threatening to involve or involving
contiguous areas such as the orbit, and not
responding to aggressive antimicrobial
therapy, surgical intervention is warranted.
These patients are often hospitalized, and
medical treatment consists of broad
antibiotic coverage with more than one
agent. In addition to the agents mentioned
previously, these include ceftriaxone,
vancomycin, ticarcillin/clavulanate,
ampicillin/sulbactam, and ceftazidime. If
improvement is not observed within 24 hours,
surgical intervention is usually undertaken.
Surgical therapy:
An ethmoidectomy is performed using one of 3 major
approaches, the external ethmoidectomy, the
intranasal (endoscopic) ethmoidectomy, and
the transantral ethmoidectomy. Each approach
offers advantages and has disadvantages. The
ultimate decision of which approach to use
will depend on the surgeon's preference and
the extent of the disease. However, the
transantral approach is the least used for
isolated ethmoidal sinusitis. Depending on
the extent of the disease, more than one
approach may be combined during the surgical
intervention.
External approach
This surgery can be performed under monitored anesthesia care
or general anesthesia. General anesthesia
may be preferred because manipulating the
globe can be uncomfortable to the patient.
An incision is made in a curvilinear fashion
approximately 2.5-3 cm in length. It is
positioned at the midpoint between the
medial canthus and the middle of the
anterior nasal bone. The skin is incised,
and the dissection is carried down to the
periosteum. If the angular artery is
transected, it is cauterized or ligated.
Dissection is carried subperiosteally to the
posterior lacrimal crest, avoiding damage to
the lacrimal excretory structures.
The medial canthal tendon may need to be released to allow
for easier access to this area, and, if this
is done, care must be taken to reposition it
correctly. The posterior crest may need to
be removed. Care must be taken not to extend
the dissection superiorly to the
frontoethmoidal suture as this demarcates
the cranial fossa. The anterior ethmoidal
artery lies at the level of this suture 20
mm posterior to the posterior lacrimal
crest. The posterior ethmoidal artery is
also at this level another 10 mm posterior,
and the optic nerve is found 5 mm further
back from the posterior ethmoidal artery. If
needed, the anterior ethmoidal artery can be
ligated.
The anterior cells are removed. The posterior cells can also
be approached and treated as needed with
ligation of the posterior ethmoidal artery
if required. A drain is often placed and can
be used in the postoperative period for
lavage of the sinus. The medial canthal
tendon is repositioned if needed, the
periosteum can be closed or left open, and
the skin is closed in layers.
Intranasal approach
This surgery can be performed with the patient under
monitored anesthesia care or general
anesthesia. Pledgets soaked in 4% cocaine or
a combination of 4% lidocaine and 0.25%
oxymetazoline are passed into the nasal
cavity to anesthetize and decongest the
mucosa. A local anesthetic containing 1%
lidocaine and 1:100,000 epinephrine is
injected into the mucosa of the middle
turbinate, septum, and lateral wall. Hand
instruments or powered instrumentation is
used. If present, polyps are resected.
If the middle turbinate is obstructing the ostial area, such
as with a concha bullosa, it can be
partially resected. When manipulating the
middle turbinate, care must be taken not to
fracture the cribriform plate, which is just
medial to the attachment of the turbinate,
because this will cause a cerebrospinal
fluid (CSF) leak.
The uncinate process and infundibulum are approached. An
incision is made in the infundibulum and the
uncinate process is resected. The mucosa can
be incised with a sickle blade and removed
with forceps. A loop curette or other
noncutting instrument can be used to gently
break into the anterior cells of the sinus.
The cells are opened with biting
instruments. Posteriorly, the dissection
ends at the sphenoid sinus. Dissecting this
far posterior in isolated anterior disease
may not be necessary.
If the sphenoid sinus is involved, it must also be surgically
addressed. The frontoethmoidal suture lies
at approximately the level of the pupils,
but this can be less reliable with a patient
under general anesthesia. Complications from
improper dissection of the sphenoid sinus
can involve the optic nerve and carotid
artery with disastrous consequences.
Culture can be obtained and material sent for pathologic
examination as warranted. The nasal area is
then packed with antibiotic ointment–coated
gauze.
Transantral approach
This surgery can be performed under monitored anesthesia
sedation or general anesthesia. A
Caldwell-Luc approach is used. Once the
maxillary sinus has been entered, the medial
and superior walls of the maxillary sinus
are identified. At the midpoint of the
medial wall, the bulla ethmoidalis may be
seen bulging into the maxillary sinus. A
curette is used to enter this area, which is
enlarged with a Kerrison rongeur or other
bone cutting instruments. This allows access
to most of the anterior cells, but the most
anterior cells may be difficult to reach.
The posterior cells off the ethmoid sinus
can also be reached.
Preoperative details:
CT scans should be obtained to determine the extent of the
ethmoidectomy needed. The degree of surgery
required is determined by the extent of the
disease and not by a simple categorization
or technique, such as limiting the surgery
to only the anterior ethmoidal air cells as
in the Messerklinger technique or a complete
sphenoethmoidectomy as in the Wigand
approach (Swift, 1998).
Intraoperative details:
Regardless of the approach used, the surgeon must be familiar
with the anatomy and aware of all pertinent
landmarks to reduce the risk of
complications. Attention must be paid to
avoid violating the cribriform plate or
inadvertently entering the orbit. Avoiding
injury to the septal mucosa, especially if
the endoscopic approach is used, will
diminish bleeding that otherwise would
obscure the view. If bleeding is a problem
it must be controlled, with cautery;
thrombin; Gelfilm; Gelfoam; Surgicel;
Merocel; or packing containing cocaine,
adrenaline, phenylephrine, or oxymetazoline.
Postoperative details:
The postoperative course and care of the patient will to some
extent depend on the approach used. All
patients are maintained on antibiotic
therapy and pain medication. Culture results
can be used to adjust the antimicrobial
regime as needed. Once the prognosis is
improved, steroid usage can be considered.
Patients are instructed to avoid nose
blowing for up to 1 week.
In the external approach, the drain is usually removed in
48-72 hours. It can also be used to lavage
the sinus; however, the authors do not do
this. The skin sutures are removed in
approximately 7 days. Topical nasal
decongestants are used for 3 days after
surgery and then discontinued. The patient
then uses nasal saline mist for 1 week.
In the endoscopic approach, the packing is removed within
48-72 hours. Topical nasal decongestants are
used for 3 days after surgery and then
discontinued. The patient then uses nasal
saline mist for 1 week. Repeat nasal
endoscopic examination and debridement in
the postoperative period are usually
necessary.
In the transantral approach, the patient rinses with an
antiseptic mouthwash after each meal and at
bedtime to maintain the hygiene of the
mouth. The sutures are dissolvable. Topical
nasal decongestants are used for 3 days
after surgery and then discontinued. The
patient then uses nasal saline mist for 1
week.
Follow-up care:
All patients have a follow-up visit the first day after
surgery. Further follow-up visits are
scheduled according to the surgical approach
used and the degree of illness of the
patient.
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Recovery
To help the healing, it is recommended that
you avoid blowing the nose or performing any
Valsalva maneuver (for example, when you
hold your breath and tighten your muscles
while bearing down for a bowel movement) for
a few days after surgery. Ice packs on the
nose will enhance comfort.
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Risks
·
Infections
·
Excessive
bleeding
·
Relapse of the nasal obstruction may require revision surgery
Complications of sinusitis
Ethmoidal sinusitis can spread outside of
the borders of the sinus and cause an
orbital cellulitis, orbital subperiosteal
abscess, orbital abscess, superior orbital
fissure syndrome, or cavernous sinus
thrombosis. Cavernous sinus thrombosis can
be life threatening and result in limited
ocular motility, proptosis, and loss of
vision. Intracranial complications are
fortunately rare from sinusitis but can have
a high morbidity and mortality and include
meningitis, thrombophlebitis of the superior
sagittal sinus, and abscess formation.
Osteitis and osteomyelitis have also been
observed. Mucoceles and pyoceles can occur.
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Frequently Asked
Questions
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