endoscopic ethmoidectomy

The purpose of ethmoid sinus resection is to open all sinus sinus air chambers, open the nasal frontal tube, remove all polyp and polypoid tissue and infection, and make it communicate with the nasal cavity. However, as many mucous membranes as possible should be retained, especially the mucosa of the sinus sinus wall must be retained to regenerate the mucosa and restore ventilation and drainage of the ethmoid sinus. In the functional ethmoid sinus surgery, the nasal passage is the aisle that receives the ventilatory drainage of the antral sinus, and is called the "ostio-meatal area". It is currently believed that the underlying cause of obstruction of the middle nasal passage is the anterior ethmoid deformity and the mid-nasal polyps. Polyps are often produced in the exposed parts of the middle nasal passages, such as the uncinate process, the middle turbinate, the surface of the sinus and the maxillary sinus. Reconstruction of the sinus of the frontal sinus, maxillary sinus, and anterior ethmoid sinus is the basic principle of sinus nasal passage. Therefore, it is advocated to preserve the normal mucosa in the middle turbinate and ethmoid sinus. The scope of surgery is limited to the anterior group ethmoid sinus or sinus nasal passage area to drain the frontal sinus and maxillary sinus. Treatment of diseases: chronic ethmoid sinusitis Indication 1. Chronic recurrent ethmoid sinusitis, ineffective after conservative treatment. 2. Nasal polyps with chronic ethmoid sinusitis. 3. Decompression drainage of sinus sinus mucus cyst. 4. Localized ethmoid sinus tumors. Contraindications 1. Abnormal blood coagulation mechanism. 2. The general condition is poor, and the vital organs such as heart and lung are insufficiency. Preoperative preparation 1. Identify diagnostic and surgical indications and eliminate contraindications. 2. Read the film carefully to determine the surgical plan. 3. Conventional preoperative examination (blood routine, platelet, liver and kidney function, coagulation function, electrocardiogram and chest radiograph). 4. Pre-operative signature. 5. Use antibiotics 1 to 3 days before surgery. 6. Cut nose hair 1d before surgery. 7. Intramuscular hemostatic drugs 30 min before surgery. 8. General anesthesia according to general anesthesia routine. Surgical procedure 1. Cut the uncinate process (screen funnel cut) Method 1: Insert the occipital blade from the back and forward with the anti-bite forceps, hook the crochet body forward, bite the crochet body according to the size of the uncinate process, and then use the different angles of the sinus occlusion pliers from the hook. The notch of the protrusion bites the hook head and the tail part forward and backward, respectively. Or use a suction head to separate the uncinate residue. Method 2: Using a sickle knife or a triangular double-edged sharp knife, the bone is pierced against the outer wall of the nasal cavity in front of the uncinate process, and the tip of the blade has a "falling feeling", which penetrates the entire hook into the semilunar or sieve funnel, and then From the original incision, the incision is extended from the front to the upper to the forehead, and the blade is then pressed down to the bone wall to cut the tail of the uncinate. Note that the tip should be parallel to the inner wall of the crucible to avoid damage to the paper template. Use a sickle knife or a small peeler to separate the uncinate process to the inside. Use a straight sinus occlusion forceps to clamp the upper part of the uncinate process, gently twist, separate the upper part of the uncinate process from the outer side wall of the nasal cavity, and bite with a bite clamp. Contact the front end, then use the sinus sinus clamp to clamp the back of the uncinate process, gently twist, and completely remove the uncinate process. It should be noted that cutting forward first, if the back end is free, lack of support, it is more difficult to cut forward. If the tail is too thick, the knife is not transparent, and the cutting must be cut again to ensure that the back end is completely cut off. The uncinate process may lack bone texture due to inflammatory erosion, or hypertrophy and hyperplasia. When the skeletal hypertrophy is hypertrophy and displaced to the lateral side, it is difficult to remove the uncinate process. At this time, the uncinate bone piece should be fully separated with a sickle knife or a small peeling piece, and then clamped and taken out. After the uncinate process is removed, the sieve funnel has been opened (the hook is the inner wall of the sieve funnel), and the half moon split and the sieve funnel are exposed to the field of view. A semi-circular bulge anterior wall can be seen in the middle nasal passage. The natural opening of the maxillary sinus can usually be seen with a 25° endoscope. Whether to do the middle nasal maxillary sinus or frontal sinus surgery should be determined according to the extent of the lesion. 2. If CT confirms that the ethmoid sinus has lesions, or the sputum is too large, the sinus should be removed and the ethmoid sinus should be opened Use a straight sinus bite forceps to bite the anterior wall of the sinus sinus and enter the sinus sinus air chamber. When opening the sieving capsule, as close as possible to the middle turbinate side, open the sieving bubble inside and below the sieve, and enter the anterior group sinus air chamber. In order to avoid inadvertent damage to the paper template. According to the condition of the lesion, open the anterior sinus air chamber one by one. The ethmoid sinus septum and the diseased mucosa were removed using an ethmoid sinus forceps or a cutting drill. The degree of gasification of the ethmoid sinus varies, the size and number of the screening room, and the degree of the lesion vary from person to person. The CT can be analyzed at any time according to the patient's CT analysis. Carefully clean the sinus air chamber from front to back under the endoscope. It should be removed sharply during surgery, and it should not be forcibly pulled. During the operation, attention should be paid to identify important anatomical landmarks and do not damage the ethmoid paper template. When cleaning the top wall of the ethmoid sinus, be careful not to damage the anterior stenosis The paper template is a vertical bone plate with a thin bone partition attached to the sinus air chamber. According to this feature, the position of the paper template can be judged. The color of the ethmoid sinus is slightly yellowish compared to the sinus ventricle and is sensitive to pain. The anterior ethmoid artery traverses the bone tube formed by the apical bone and is an important marker of the ethmoid sinus. After the completion of the anterior ethmoidectomy, the middle of the surgical field is the middle turbinate, the outer side is the paper plate, the upper wall is the sinus sinus, and the posterior part is the middle nasal methyl plate. The position of the mid-nasal methyl plate can usually be identified under the endoscope. However, due to anatomical variations and pathological lesions, it is sometimes difficult to identify the middle nasal methyl plate. The middle nasal methyl plate is not a smooth bone plate. The posterior group sinus air chamber can make the middle nasal methyl plate bulge forward. The anterior group sinus air chamber can also make the middle nasal methyl plate sag backward. If the posterior ethmoid sinus has no lesions, there is no need to open the middle nasal methyl plate. If the frontal sinus and maxillary sinus have lesions, this can be done with frontal sinus enlargement and middle nasal maxillary sinus. 3. If there is a lesion in the posterior ethmoid sinus, the middle nasal methyl plate should be bitten open, and the ethmoid sinus should be opened and cleaned. The position of the open middle nasal methyl plate should be as close as possible to the inside and the bottom. Use a straight sinus bite forceps to gently press the middle nasal methyl plate, and when there is a gas chamber behind the middle nasal methyl plate, then gradually open the posterior sinus. After entering the posterior ethmoid sinus, the operator should change the angle of the endoscope. When the sieve funnel is opened, the angle of the 0° endoscope and the hard palate is 45°. When reaching the front wall of the middle nasal methyl plate, the angle of the 0° endoscope and the hard palate should be about 30°. When reaching the anterior wall of the sphenoid sinus, the 0° endoscope The angle with the hard cymbal is between 15 ° and 25 °. The angle of the endoscope should be adjusted in time during surgery to avoid damage to the skull base. The extent of the posterior sinus ventricle should be determined according to the condition of the lesion. At this point, it should be noted that the outer wall of the gasified sinus sinus air chamber is closely related to the optic nerve. When cleaning the Onodi air chamber, be careful not to damage the optic nerve, the internal carotid artery and other important structures. 4. Carefully clean the diseased mucosa of the anterior and posterior sinus ventricles and the thin bone partition. The upper boundary reveals the ethmoid sinus and frontal sinus opening. The outside is the ethmoid paper template. The inner boundary is the outer side of the middle turbinate and the lower boundary is the lower The upper edge of the turbinate. Non-neoplastic lesions for the purpose of establishing unobstructed drainage should preserve the healthy mucosa or the lighter mucosa in the ethmoid sinus as much as possible to facilitate the recovery of postoperative sinus function. According to the lesion, the following operations can be performed on this basis. : 1 enlarge the natural opening of the maxillary sinus in the middle nasal passage; 2 open the posterior wall of the sinus sinus and enter the sphenoid sinus; 3 enlarge the frontal sinus opening. If the tumor is a tumor, the middle turbinate should be removed, all the sieve rooms should be removed, and the mucosa in the sieve room should be scraped off. If necessary, the surrounding tissues such as the lateral wall of the nasal cavity and the anterior wall of the sphenoid sinus are removed to expand the lesion. complication The incidence of complications of endoscopic surgery varies from 0.4% to 6.4%. The main reason is that the operation is unskilled and unfamiliar with the anatomy, and the anatomical variation is not fully understood, resulting in damage to important anatomical structures and various complications. The most common ones are: Eye complication (1) periosteal injury: injury to the tarsal plate and iliac fascia integrity generally does not occur intraorbital complications; if accompanied by fascia fascia injury, there are formation of ecchymosis, intraorbital hematoma, eyeball protrusion, eye movement disorders, diplopia Subcutaneous emphysema, intraorbital infection and the possibility of visual acuity caused by optic neuritis may cause blindness. (2) Visual impairment: the posterior ethmoid sinus and the external wall of the sphenoid sinus with good gasification are closely related to the optic nerve. After treatment, the ethmoid sinus and sphenoid sinus can easily damage the optic canal or the optic nerve. Can also be due to post-ball hematoma, increased intraocular pressure, resulting in retinal vascular occlusion and ischemia, visual loss, or even blindness. In addition, there are also ophthalmic arterial spasm caused by local anesthetic drugs leading to blindness. (3) tears caused by nasolacrimal duct injury: the bone wall of the nasolacrimal duct is relatively hard, which is one of the characteristics. When expanding the maxillary sinus opening forward, be careful not to damage the nasolacrimal duct. When opening the nasal cavity, be careful not to damage the lacrimal sac. 2. Intracranial complications (1) Cerebrospinal fluid rhinorrhea: The color of the top of the sieve is yellowish compared with other parts of the ethmoid sinus. At local anesthesia, the top of the sieve is sensitive to pain and is an important feature for identifying the top of the sieve. Multiple polyps or cysts in the ethmoid sinus tend to be thin and defective, and it is easy to damage the sieve plate and the dura mater to cause leakage of cerebrospinal fluid. (2) intracranial hematoma: caused by intraoperative injury of the internal carotid artery and anterior cerebral artery. (3) Intracranial infection: multiple complications of late skull base injury. (4) Intracranial nerve tissue damage: occurs mostly in meningeal brain swelling, skull base tumor surgery. There are reports in the literature that endoscopic surgery causes serious complications such as meningitis, intracranial hemorrhage or direct brain injury. 3. Nasal complications (1) Bleeding: Injury to the anterior ethmoid artery during surgery can cause more severe bleeding. The proximal end of the anterior ethmoid artery is retracted into the eyelid and can cause hemorrhage in the orbit. Therefore, attention should be paid to the identification of the anterior ethmoid artery during surgery, and should not be damaged. The violent bleeding in the treatment of sphenoid sinus lesions should be considered as rupture of the internal carotid artery. (2) nasal adhesions: the most common middle turbinate front and outer side walls and the adhesion between the lower turbinate and the nasal septum. Due to nasal stenosis, mucosal injury, and excessive tissue retention during surgery, especially in the case of mucosal reactive swelling in the middle turbinate, it is easy to cause the adhesion of the wound mucosa to cause adhesion, and the adhesion site is in the olfactory or middle nasal passage.

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