Total Sinusectomy

Because the chronic attack of sinusitis affects daily life, the total sinus resection is performed according to the condition. Indications: 1. Severe group of chronic sinusitis, ineffective by series of non-surgical treatment or local surgery. 2. Chronic group of sinusitis and multiple nasal polyps, those who are not treated conservatively. Treatment of diseases: suppurative sinusitis, paranasal sinusitis Indication 1. Severe group of chronic sinusitis, ineffective by series of non-surgical treatment or local surgery. 2. Chronic group of sinusitis and multiple nasal polyps, those who are not treated conservatively. Contraindications 1. The lesion is limited to some sinus or conservative treatment, and extensive surgery is prohibited. 2. Children should not undergo extensive sinus surgery. Preoperative preparation Regular use of antibiotics to prevent infection. Surgical procedure From front to back (1) Anesthesia: local anesthesia or general anesthesia. The optimal anesthesia for the patient is selected based on the patient's general and local conditions, taking into account the skill level of the surgeon. (2) Preoperative preparation 1 Patient preparation: The patient is supine, 4% chlorhexidine is routinely disinfected on the head and face, and a sterile surgical towel is placed. 2 nasal examination: after the use of vasoconstrictor, thoroughly examine the bilateral nasal cavity, and according to the CT scan of the sinus, focus on the anatomy and lesions of the middle nasal passage of the operation side and the important anatomical reference markers related to the operation. The patient's endoscopic findings were consistent with CT findings. (3) Basic steps 1 Resection of uncinate process: It is the initial step from the anterior to posterior procedure. Whether the uncinate resection is complete determines whether the field is spacious, whether the maxillary sinus can be exposed smoothly and whether the operation can be performed smoothly. The mucosa at the junction of the uncinate process and the outer wall of the nasal cavity is gently pressed by a blunt face of a stripper or a sickle knife to determine the approximate incision position. Use a sickle knife to insert from the anterior root of the middle turbinate hook, and along the attachment edge of the hook and the outer wall of the nasal cavity, the mucosa is opened from the front to the back and down to the lower edge of the uncinate process. The stripping protrusion is peeled inward along the slit so as to be in contact with the upper and lower ends and the outer side wall of the nasal cavity. Separate the upper and lower ends of the uncinate process from the outer wall of the nasal cavity with different angles of sinus sinus forceps and then bite off. 2 open/excision anterior ethmoid sinus: different angles of ethmoid sinus forceps open from front to back/excision before anterior ethmoid sinus as much as possible to avoid and avoid damage to the mucosa, after the middle nasal methyl plate, from the front to the back or from the back to the front Residual air chambers in the base of the cardboard and the middle turbinate. 3 open maxillary sinus Localization of the maxillary sinus natural hole: Find the natural hole of the maxillary sinus in the middle nasal passage with a 30° or 70° endoscope. The natural hole of the maxillary sinus is usually located behind the sieve funnel, corresponding to the middle 1/3 junction of the lower edge of the middle turbinate, and is covered by the uncinate tail. The uncinate process can be fully exposed after the uncinate process. Sometimes the hole can be covered by polyps or edema mucosa. turn up. At this point, a stripper or an angled aspirator, or a curved probe, may be used, and the groove formed by the outer sieve funnel along the outer edge of the uncinate cut edge slides down from the front to the back, or along the upper part of the inferior turbinate and the outer side wall of the nasal cavity, lightly pressed. The mucosa of the lateral wall of the nasal passage of the middle nasal passage can find a natural hole of the maxillary sinus which is narrow and funnel-shaped. Treatment of the maxillary sinus natural hole: If the natural hole of the maxillary sinus is open and there is no lesion in the sinus, the natural structure of the maxillary sinus hole is preserved. Otherwise, the 90° sinus sinus clamp can be used to explore and enlarge the natural hole, then use the anti-biting forceps to bite the front bony forward and forward, or use a straight forceps to back, bite the posterior bony, enlarge the natural hole of the maxillary sinus, and make the upper jaw The anteroposterior diameter of the sinus natural hole is 1 to 2 cm. 4 open/excision group ethmoid sinus: sinus tongs at different angles penetrate the middle and lower part of the middle nasal methyl plate, along the lateral side of the middle turbinate root, open the posterior sinus to the anterior wall of the sphenoid sinus, and then from front to back in order Or remove the residual air chamber of the cardboard and the middle turbinate root and the anterior wall of the sphenoid sinus from the posterior and posterior. 5 open sphenoid Transsphenoidal sinus natural hole open sphenoid sinus: the natural hole of the sphenoid sinus is located in the anterior wall of the sphenoid sinus 10~12mm from the upper edge of the posterior nostril, near the midline of the stenosis of the sphenoid sinus A relatively constant anatomical reference marker for positioning the natural sphenoid sinus is the upper turbinate. Excision of the posterior part of the upper turbinate helps to expose the natural sphenoid sinus. If the natural opening of the sphenoid sinus is good, there is no need to damage. Otherwise, the sphenoid sinus at different angles will expand the natural hole of the sphenoid sinus inward and forward. Transsphenoidal anterior wall open sphenoid sinus: When the lesion is extensive or local hyperplasia is obvious, the open posterior sieving can be performed to the anterior wall of the sphenoid sinus, follow the principle of the near midline, open the anterior wall of the sphenoid sinus, or in the middle of the sinus The posterior margin and the anterior wall of the sphenoid sinus in the nasal septum enter the hole. At this time, the CT scan of the sinus should be carefully referred to. 6 open frontal sinus: with 30 ° or 70 ° endoscope, with different angles of sinus sinus clamp (45 ° or 90 °) to clear the front end of the middle turbinate attachment edge, that is, the residual sieve room in front of the anterior ethmoid sinus reaches the frontal sinus floor, At this time, according to the CT scan, the attachment of the upper part of the uncinate process and the distribution of the crypt of the frontal crypt should be used to assist in positioning and opening the frontal sinus opening during the operation. (4) operative tamponade: the tamponade is mainly selected according to the bleeding condition of the operation cavity. For patients with less intraoperative blood loss and cleansing of the operation cavity, gelatin sponge, hemostatic fiber, soluble hemostatic gauze, etc. coated with antibiotic ointment (such as tetracycline cortisone ointment) can be used to fill the operation cavity; If there is still bleeding, patients need to add Vaseline oil gauze, grasp the tightness of the filling according to the bleeding activity, and strictly record the amount of stuffing, in case of postoperative cleanup of the operation cavity. 2. The method from the back to the front is characterized by the surgical direction from the back to the front. Apply to the posterior group of sinus lesions. Since the surgery starts with direct exposure to the anterior wall of the sphenoid sinus and has low requirements for the integrity of the anterior nasal anatomical landmark, it is particularly suitable for patients whose anatomical landmarks (such as the middle turbinate) have been destroyed due to previous surgery. At the same time, the surgical field is required to be relatively spacious, to ensure the smoothness of the posterior anterior approach, and for patients with severe nasal septum deviation and affecting the ventilatory function, nasal septum correction is required. (1) Anesthesia: local anesthesia and general anesthesia are acceptable. (2) Preoperative preparation: basically the same as before and after. Special attention should be paid to controlling intraoperative bleeding and not to flow back into the nasopharynx. (3) Basic steps 1 partial resection of the middle turbinate: depending on the size of the middle turbinate, cut the middle and back of the middle turbinate with the turbinate, and expose the anterior wall of the sphenoid sinus. 2 Exposing the natural hole of the sphenoid sinus: The position of the natural hole of the sphenoid sinus is about the level of the posterior and middle turbinate of the middle turbinate, about 7 cm from the anterior nasal spine, and about 30° from the nasal base. Properly open the posterior ethmoid sinus, or partially remove the upper turbinate to expose the anterior wall of the sphenoid sinus. If the sphenoid sinus natural hole is still not seen at this time, the sphenoid sinus anterior wall can be touched with an aspirator tube or probe to find the natural sphenoid sinus that may be covered by the diseased structure, which is generally successful. 3 exploration of the sphenoid sinus: use the rongeur to carefully expand the natural sphenoid sinus to the medial and / or below, to meet the needs of postoperative drainage. If the natural sinus sinus is locked and the condition needs to open the sphenoid sinus, make a hole in the inner and lower anterior wall of the sphenoid sinus. If necessary, use an osteotome or a bone drill. The nasal endoscope is inserted into the sphenoid sinus to observe the lesion performance, and remove or biopsy as appropriate. At the same time, the internal carotid artery and optic nerve caused by the external wall of the sphenoid sinus should be observed, and the general trend and relationship should be judged accordingly, which provides a basis for the degree of sphenoid sinus enlargement. 4 Open/excision anterior and posterior ethmoid sinus: the upper boundary of the sulcus is opened, and the anterior and posterior sinus air chambers are opened/removed from front to back, until the opening of the frontal nasal canal. 5 Open frontal sinus: The frontal sinus drainage channel is observed with an angled endoscopic sinus, that is, the anterior stenosis air chamber around the frontal crypt, which is sequentially opened, and the method from the anterior to the posterior, according to the frontal sinus drainage method indicated by CT Microscopically locate and open the natural opening of the frontal sinus. Care should also be taken to avoid damage to the cardboard. During the frontal sinus opening process, under the premise of clearing the frontal sinus floor lesions, the mucosa around the frontal and nasal gorges and its bone structure should not be damaged as much as possible to avoid the narrowing of the frontal sinus drainage channel caused by postoperative bone hyperplasia. If the open frontal sinus opening can be extended into a 4 mm diameter aspirator, stenosis usually does not occur after surgery. 6 open maxillary sinus: the basic method is the same as the aforementioned front-to-back method. This completes the open/resection of all sinuses on one side. 7 postoperative operative tamponade: see the aforementioned front-to-back method.