Endoscopic sphenoid sinus surgery

The position of the sphenoid sinus is deep, adjacent to the important anatomical structure of the skull base, and the operation is difficult. With the wide clinical application of CT, MRI and endoscopy, the diagnosis and treatment of sphenoid sinus disease has made great progress. The advantage of endoscopic sphenoid sinus surgery is that the surgical approach is simple and the damage is small; the facial incision through the nasal sinus sinus is avoided. Compared with the previous surgery through the nasal cavity to the anterior wall of the sphenoid sinus, it has good illumination and safety. Treatment of diseases: sphenoid sin Indication 1. Isolated sphenoid sinusitis. 2. Sphenoid sinus mucinous cyst. 3. Sphenoid sinus mycosis. 4. Sphenoid sinus cerebrospinal fluid leakage. Preoperative preparation 1. Nasal endoscopy to see if there is abnormal nasal cavity. 2. Coronary and horizontal CT scans to determine the nature and extent of sphenoid sinus lesions. Surgical procedure For example, isolated sphenoid sinusitis, no ethmoid sinus lesions, or those with posterior stenosis lesions often use nasal approach. If accompanied by ethmoid sinus lesions, you can use the ethmoid sinus approach or direct transsphenoidal sinus natural and stenosis combined approach. 1. Sphenoid sinus natural mouth approach (1) Use the adrenaline patch to fully contract the olfactory fissure, and use a stripper or a suction head to shift the middle turbinate to the lateral fracture. If the back end of the middle turbinate is too large, it is feasible to remove the back end of the middle turbinate. If accompanied by a posterior stenosis lesion, the sifting chamber can be further removed and the lesion removed. A 4 mm 30° endoscope was inserted between the medial turbinate and the nasal septum to find the upper turbinate. In order to fully reveal the sphenoid sinus opening, the turbinate scissors and the ethmoid sinus forceps were used to remove the posterior turbinate to enlarge the surgical field. Accurate positioning of the anterior sphenoid sinus is the key to surgery. The sphenoid sinus opening is located in the stencil of the butterfly screen between the upper turbinate and the nasal septum, about 1 to 1.5 cm above the upper edge of the posterior nostril, about 7 cm from the anterior nasal spine, and 30° to the anterior nasal spine. (2) The posterior turbinate can be used as a marker to find the natural opening of the sphenoid sinus. The sphenoid sinus opening is usually located in a narrow gap between the upper turbinate stump and the nasal septum. The sphenoid sinus opening can be probed with a small suction tube or a small curette, and the secretion can be aspirated into the sinus. From the front nasal spine to the posterior wall of the sphenoid sinus, about 9cm. (3) After exploration into the sphenoid sinus, the sphenoid sinus occlusal forceps can be used to bite the anterior wall of the sphenoid sinus inward and downward, and the sphenoid sinus opening is enlarged to a left and right diameter of 5 to 8 mm. If necessary, the bone of the nasal septum can be bitten off. quality. The upper and lower diameters are up to 10mm to reduce the possibility of reocclusion. Care should be taken when expanding upwards to avoid opening the upper wall of the sphenoid sinus and causing cerebrospinal fluid leakage. As long as it is operated inside the upper turbinate stump, the risk of damage to the optic nerve and internal carotid artery is minimal. You can insert a 70° lens to observe the lateral wall of the sphenoid sinus or use a sphenoid sinus to detect the presence or absence of a ridge on the lateral side of the sphenoid sinus. Care should be taken not to damage the optic nerve and internal carotid artery. (4) In order to prevent the sinus ostium from shrinking, before the anterior wall of the sphenoid sinus is bitten down, the longitudinal incision is made on both sides of the lower edge of the sinus ostium, and the visceral bone under the sinus is separated into a butterfly. The osseous bone flap of the inferior anterior sinus. The bone below the anterior wall opening of the sphenoid sinus was bitten, and the bone was sinused into the sinus after surgery to cover the bone margin. (5) If it is sphenoid sinusitis, fully open the anterior wall of the sphenoid sinus, do not need to remove the sinus mucosa; if it is a mucous cyst, open the anterior wall of the sphenoid sinus and the cyst wall, fully drain the cyst, remove the cyst wall as much as possible, but It is not necessary to remove all cyst walls. The diseased tissue in the sinus cavity was thoroughly cleaned, and the polyps, fungal masses, pus, and cyst fluid were cleaned up. However, care should be taken when peeling the outer side wall to prevent damage to the internal carotid artery exposed on the wall. (6) Properly stop bleeding and fill the nasal cavity as appropriate. 2. After the ethmoid sinus approach to the anterior and posterior ethmoid sinus resection, the anterior wall of the sphenoid sinus can be reached. However, the ethmoid sinus approach usually does not directly reach the natural opening of the anterior wall of the sphenoid sinus, but is slightly above and out. The sphenoethmoid angle (the part of the posterior ethmoid sinus that intersects with the sphenoid sinus at 90°) is identifiable. The anterior wall of the sphenoid sinus is usually pale blue, suggesting that there is an air gap behind the bone wall. The inner surface of the posterior ethmoid sinus has a dura mater, usually pale yellow or white. When opening the anterior wall of the sphenoid sinus, it should be as far as possible inside and below. After finding the sphenoid sinus cavity, the anterior wall of the sphenoid If the anterior wall of the sphenoid sinus is not easily identifiable, the natural opening of the sphenoid sinus can be found in the anterior end of the middle turbinate, and the sphenoid sinus can be found in the sphenoid sinus. 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.