Endoscopic Sinus Views Video

Endoscopic Sinus Surgery
Ethmoidectomy & Frontal Sinusotomy

Endoscopic Sinus Surgery:  Right ethmoidectomy and frontal sinusotomy with the 30 and 70 degree telescope, image guidance and the powered dissector.

This patient has a history of chronic rhinosinusitis involving the ethmoid, maxillary, frontal and sphenoid sinuses.  She has been treated with multiple courses of antibiotics, allergy shots, nasal steroid and antihistamine sprays, a leukotriene modifier and a course of prednisone.  After symptoms failed to improve with the above therapy, a CT scan revealed thickening of the mucous membrane lining the frontal, ethmoid and maxillary sinuses bilaterally as well as the left sphenoid sinus.  After we discussed her treatment options and the risks and benefits of each type of therapy, she decided to have endoscopic sinus surgery.  Small polyps were found in the ethmoid cavities on both sides during the surgery.  Inflamed mucous membranes and thick mucous was encountered throughout the procedure. 

In this video, the right ethmoid sinus has been dissected.  The thin obstructing partitions of bone are fractured, cut and removed to convert the ethmoid cavity from a group of small cramped air cells to a larger open cavity which should drain efficiently and be less likely to become severely inflamed.  The partitions of bone obstructing the frontal sinus on the right side are also removed.    Portions of the procedure are performed with a powered dissector (suction tube with an opening containing a rotating blade.)  The powered dissector pulls (with a vacuum) diseased tissue into the opening and the rotating blade amputates the tissue within the tubing.  The tissue fragments are then collected in a container and sent to the pathology lab for analysis.  The cut tissue edges continuously ooze blood during the surgery.  Usually this oozing is minimized by injecting the mucous membranes with a solution which constricts blood vessels.  The initial injection is performed at the beginning of the procedure and repeated as needed at different points during the procedure.  Cotton sponges soaked in vasoconstricting medication are also used throughout the procedure to slow down the oozing.  On most occasions, the oozing slows down over the first 24-48 hours following surgery and most patients have no active bleeding after 24 hours.  Very rarely, sponge packing must be placed at the end of the sinus surgery to slow down or stop the oozing.  This packing is usually removed within two days in the office.

The endoscopic dissection is aided by use of the image guidance probe.  This is the silver colored tube with a small sphere at the tip.  The silver colored sphere or “BB” is detected by an electromagnetic field and shows up on our OR computer screen as cross-hairs.  The image guidance computer screen in the operating room serves as a road map, just like the geographic map on a car’s GPS navigation screen.  The cross-hairs representing the tip of the image guidance probe help in determining the location of the skull base, brain and orbit (eye socket) relative to the sinus cavities. At the end of the dissection, the camera on the 70 degree telescope is able to see to the roof of the frontal sinus.  The lining at the roof of the frontal sinus appears pale pink to white in color and healthier than the inflamed mucosal lining found lower in the frontal sinus and ethmoid cavity.

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