Surgical Atlas of pediatric otolaryngology - part 5 pps

Endoscopic Ethmoidectomy and Antrostomy 333 Figure 13–16 Orbital preseptal cellulitis. Figure 13–17 Coronal view of orbital subperiosteal abscess. Inflammation in the ethmoid labyrinth penetrates the lamina papyracea and is trapped beneath the orbital periosteum. The medial rectus muscle is thickened from inflammation and the globe is displaced anteri- orly, producing proptosis. 334 Surgical Atlas of Pediatric Otolaryngology CYSTIC FIBROSIS Most children with cystic fibrosis have chronic sinusitis, though many are asymptomatic. Clinically important disease falls into two categories: (1) headache with chronic inflammatory changes, and (2) polyposis with or without mucocele formation. Before endoscopic techniques, intervention was restricted to children with massive polyposis and expansion of the nasal bones. In skilled hands, however, children with lesser degrees of sympto- matic disease can benefit from endoscopic polypectomy if the following pointers are observed: • Pulmonary function should be optimized before surgery. • Polyps usually fill the nasal cavity arising from the ethmoid cells and maxillary antra (Figure 13–18). Some of the anterior polyps must often be removed with a microdebrider before the uncinate process can be located. • The uncinate is often demineralized, floppy, and rotated into the nasal cavity by protruding maxillary polyps. A microdebrider is used to remove the uncinate process. • In contrast to the techniques above, ethmoidectomy is performed before antrostomy, because the maxillary sinus contents often bleed vigorously. Ethmoid polyps are removed in a controlled fashion with the microde- brider (Figure 13–19). Ethmoid mucoceles are occasionally encountered during polyp dissection; marsupialization into the nose is curative. • The natural ostium of the maxillary sinus is usually widely patent, but filled with polyps. A curved microdebrider tip is used to remove polyps at the mouth of the maxillary antrum, and to remove the soft tissue of the fontanelle (Figure 13–20). Figure 13–18 Polyps arise from the ethmoid air cells and maxil- lary antrum, and protrude into the nose. 336 Surgical Atlas of Pediatric Otolaryngology • The contents of the maxillary sinus are tenacious and cannot be suc- tioned out. To clean the sinus, the curve of the microdebrider tip must be increased to about 70˚ (Figure 13–21). A small aluminum pipe ben- der (available at most plumbing supply stores) is used to avoid kinking (Figure 13–22). • Thick secretions and hyperplastic mucosa are removed from the antrum using the 30˚ and 70˚ endoscopes for visualization (Figure 13–23). Oxymetazoline-impregnated pledgets are placed into the antrum to con- trol bleeding. If bleeding is excessive, expanding nasal sponges (Merocel) are left in the sinus cavities overnight and removed at the bedside. • For cystic fibrosis without polyps, surgery is performed as described pre- viously for chronic sinusitis. Of note, ethmoid partitions are often very thick secondary to chronic osteitis and must be removed with through- biting forceps instead of the J-curette to avoid injuring the ethmoid roof. Figure 13–21 Microdebrider tips. (A) Straight. (B) Curved. (C ) Curved reversed and augmented. 338 Surgical Atlas of Pediatric Otolaryngology DEDICATION I acknowledge Rodney P. Lusk, MD and David S. Parsons, MD who, in collaboration with other fine otolaryngologists, developed the techniques of pediatric endoscopic sinus surgery and taught them to the rest of us. REFERENCES 1. Parsons DS, Phillips SE. Functional endoscopic surgery in children: a retrospective analysis of results. Laryngoscope 1993;103:899–903. 2. Clement PA, Bluestone CD, Gordts F, et al. Management of rhinosinusitis in children. Int J Pediatr Otorhinolaryngol 1999;49 Suppl 1:S95–100. 3. Gentile VG, Isaacson G. Patterns of sinusitis in cystic fibrosis. Laryngoscope 1996;106:1005–9. 4. Alvarez RJ, Liu NJ, Isaacson G. Pediatric ethmoid mucoceles in cystic fibrosis: long-term fol- low-up of reported cases. Ear Nose Throat J 1997;76:538–9 and 543–6. 5. Arjmand EM, Lusk RP, Muntz HR. Pediatric sinusitis and subperiosteal orbital abscess forma- tion: diagnosis and treatment. Otolaryngol Head Neck Surg 1993;109:886–94. 6. Nishioka GJ, Barbero GJ, Konig P, et al. Symptom outcome after functional endoscopic sinus surgery in patients with cystic fibrosis: a prospective study. Otolaryngol Head Neck Surg 1995;113:440–5. 7. Madonna D, Isaacson G, Rosenfeld RM, Panitch H. Effect of sinus surgery on pulmonary func- tion in patients with cystic fibrosis. Laryngoscope 1997;107:328–31. 8. Lusk RP, Polmar SH, Muntz HR. Endoscopic ethmoidectomy and maxillary antrostomy in immunodeficient patients. Arch Otolaryngol Head Neck Surg 1991;117:60–3. 9. Parsons DS, Greene BA. A treatment for primary ciliary dyskinesia: efficacy of functional endo- scopic sinus surgery. Laryngoscope 1993;103:1269–72. 10. Blackwell KE, Ross DA, Kapur P, Calcaterra TC. Propofol for maintenance of general anesthe- sia: a technique to limit blood loss during endoscopic sinus surgery. Am J Otolaryngol 1993;4:262–6. 11. Riegle EV, Gunter JB, Lusk RP, et al. Comparison of vasoconstrictors for functional endoscop- ic sinus surgery in children. Laryngoscope 1992;102:820–3. 12. Lusk RP, Muntz HR. Endoscopic sinus surgery in children with chronic sinusitis: a pilot study. Laryngoscope 1990;100:654–8. 13. Stammberger H, Posawetz W. Functional endoscopic sinus surgery. Concept, indications and results of the Messerklinger technique. Eur Arch Otorhinolaryngol 1990;247:63–76. 14. Bolger WE, Parsons DS, Mair EA, Kuhn FA. Lacrimal drainage system injury in functional endoscopic sinus surgery. Incidence, analysis, and prevention. Arch Otolaryngol Head Neck Surg 1992;118:1179–84. CHAPTER 14 INFLAMMATORY SINONASAL DISEASE Andrew J. Hotaling, MD Kevin J. Hulett, MD DRAINAGE OF SEPTAL ABSCESS OR HEMATOMA Indications • The primary cause of a septal hematoma is trauma, often secondary to a nasal fracture. An undetected hematoma may progress to abscess formation. • A septal abscess or hematoma must be treated when detected because the blood supply to the septal cartilage is interrupted. Untreated abscess or hematoma may result in necrosis, perforation, or septal collapse with saddle nose appearance. Anesthetic Considerations • The procedure usually is performed under general anesthesia. • Neuropledgets moistened with 0.05% oxymetazoline solution are placed intranasally for topical decongestion. A variety of inflammatory nasal disorders in children may require surgery, but many are amenable to endoscopic management. The decision to use an external or intranasal approach depends on the amount of exposure needed and the surgeon’s training and expe- rience. The exposure gained by an external approach to the maxillary sinus may be helpful in removing a large cyst or tumor; however, an experienced surgeon can manage a subpe- riosteal orbital abscess endoscopically. 340 Surgical Atlas of Pediatric Otolaryngology Procedure • An incision is made over the abscess or hematoma, usually in the depen- dent portion to assist drainage. If pus is encountered, a culture may be taken (Figure 14–1). • After evacuating the abscess or hematoma, a light nasal pack is placed along the traumatized site to prevent a recurrence. • One-quarter-inch plain gauze with topical antibiotic ointment is used for packing. Postoperative Care • The pack is removed in the office after 2 or 3 days. • The site is re-inspected after 5 to 7 days to ensure that healing is satis- factory. • Normal saline solution (1 or 2 sprays or 2 to 4 drops) is placed in each naris every 4 hours while the patient is awake to keep the nasal cavity lubricated and to minimize crusting and scabbing. Figure 14–1 Drainage of a septal abscess. Inflammatory Sinonasal Disease 341 ANTRAL ASPIRATION AND LAVAGE Indications • Acute maxillary sinusitis unresponsive to medical management • Aspiration of culture specimen in immunocompromised patient with maxillary sinusitis Anesthetic Considerations • The procedure is performed under general anesthesia or topical anesthe- sia with intravenous sedation. Procedure • After induction of anesthesia, the nose is decongested. Two small cot- tonoids soaked in oxymetazoline are placed along and under the inferi- or turbinate. • The maxillary sinus is entered by one of several approaches: ♦ Inferior meatal approach. A trocar is inserted into the posterior half of the inferior meatus, posterior to the nasolacrimal duct. The trocar is aimed toward the ipsilateral lateral canthus (Figure 14–2). If the tro- car does not enter the sinus with moderate pressure, it is repositioned several millimeters posteriorly. The bone is often thinner posteriorly along the inferior meatus. Figure 14–2 Aspiration of the maxillary sinus with a trocar. The trocar is aimed toward the ipsilateral lateral canthus. 342 Surgical Atlas of Pediatric Otolaryngology ♦ Middle meatal approach. The middle meatus is identified with the 0° endoscope, and the natural ostium of the maxillary sinus in the pos- terior infundibulum is identified by a ball-tipped seeker. The seeker should “fall into” the opening with gentle probing. A curved antral suction cannula is then inserted into the ostium for irrigation. This may not be feasible if the uncinate process is large or the middle mea- tus is constricted. ♦ Canine fossa approach. This approach is not recommended in young children because the unerupted tooth buds will interfere with passage of the trocar. In older children care must be taken to avoid harming dentition. • Once entered, the contents of the sinus can be aspirated with a syringe attached to the trocar or suction cannula. If the contents cannot be aspi- rated, instillation of nonbacteriostatic saline into the sinus and subse- quent aspiration may be helpful. Aspirated material is sent for culture and sensitivity testing. • Antral irrigation is performed next, using a syringe attached to the tro- car or cannula by intravenous extension tubing. The ipsilateral globe and cheek should be palpated while irrigating. Displacement of the globe or soft tissue swelling indicates placement of the trocar within the orbit or into the soft tissues of the cheek. • After aspiration and washing, placement of a small dry piece of absorbable gelatin sponge under the inferior turbinate will assist in hemostasis. • If required a nasoantral window can be constructed using a rasp or a Cottle elevator. Postoperative Care • Normal saline solution (1 or 2 sprays or 2 to 4 drops) is placed in each naris every 4 hours while the patient is awake to keep the nasal cavity lubricated and to minimize crusting and scabbing. CALDWELL-LUC PROCEDURE Indications • Presence of a mass within the sinus, such as a cyst or a suspected neo- plasm • Recurrent antrochoanal polyp, refractory to endoscopic management • The operation is not recommended for chronic sinusitis; maxillary sinusitis usually improves following adequate medical or surgical treat- ment of ethmoid disease. Anesthetic Considerations • The procedure usually is performed under general anesthesia. • A 0.05% lidocaine solution with 1:200,000 epinephrine is injected into the gingivobuccal sulcus. • Neuropledgets moistened with 0.5% oxymetazoline solution are placed intranasally for topical decongestion. Inflammatory Sinonasal Disease 343 Procedure • The incision is placed above the secondary dentition. A plain sinus radi- ograph can be helpful in determining this level. • The periosteum is elevated until the infraorbital nerve is seen (Figure 14–3 A). • An osteotome is used to outline a window into the antrum. After the bony cuts are made, the window can be elevated with a Freer elevator. • A maxillary sinus culture is obtained through the antral window. • Once the limits of the sinus have been established by inspection and pal- pation, the window can be enlarged with Kerrison forceps, taking care to protect the infraorbital nerve and dentition. • The contents of the sinus are removed. If required the mucosal lining can be elevated and removed using ring curettes. • A nasoantral window is constructed using a curved hemostat to enter the sinus from the nose through the inferior meatus. The window is enlarged as necessary to provide adequate aeration (Figure 14–3 B). • The nose is packed with a folded sheet of Telfa gauze coated with antibiotic ointment. Alternatively a Foley catheter can be placed into the sinus through the nose via the nasoantral window and the balloon filled with saline. • The mucosal incision is closed with an absorbable suture. Figure 14–3 Caldwell-Luc procedure. A, An incision is made over the secondary dentition and the periosteum is elevated. B, Using a curved hemostat, a nasoantral window is created through the inferior meatus. A B [...]... to the anterolateral aspect of the sac with a 5- 0 chromic suture The nasal extent can be secured with a 5- 0 nylon suture • The anterior-based flaps are sutured together carefully using interrupted 4-0 chromic sutures (Figure 14–6C) • The skin and subcutaneous tissue are closed in two layers • The Silastic stent is removed after 7 to 10 days  350 Surgical Atlas of Pediatric Otolaryngology No 2 Endoscopic... infectious process They may be changed according to the results of intraoperative cultures 364 Surgical Atlas of Pediatric Otolaryngology REFERENCES 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Anon JB, Rontal M, Zinreich SJ Anatomy of the paranasal sinuses New York: Thieme; 1996 p 3–11, 25 8 Levine HL, May M, Rontal M, Rontal E Complex anatomy of the lateral nasal wall: simplified for the endoscopic... the role of the superior turbinate in endoscopic sinus surgery Am J Rhinol 1999;13: 251 –9 26 Sethi DS, Pillay PK Endoscopic management of lesions of the sella turcica J Laryngol Otol 19 95; 109: 956 –62 27 Har-El G The anterior wall of the sphenoid sinus Ear Nose Throat J 1994;73:446–8 C H A P T E R 16 S URGERY OF THE TONGUE Carlos Gonzalez, MD Oral tumors constitute approximately 3% of all tumor-like growths... Levine HL, May M, editors Endoscopic sinus surgery New York: Thieme; 1993 p 1 05 75 Muntz HR Diagnosis and management of chronic sinusitis In: Wetmore RF, Muntz HR, McGill TJ, editors Pediatric otolaryngology- principles and practice pathways New York: Thieme; 2000 p 4 75 85 Rosen FS, Sinha UK, Rice DH Endoscopic surgical management of sphenoid sinus disease Laryngoscope 1999;109:1601–6 Stankiewicz JA Sphenoid... the insertion of the superior turbinate to the skull base (Figure 15 4) Alternatively, the newer endoscopic coaxial bipolar instruments can be also used for this purpose 360 Surgical Atlas of Pediatric Otolaryngology • Next, endoscopic scissors are used to transect the superior turbinate superiorly, close to its skull base attachment, through the cauterized area (Figure 15 5) • The tip of the turbinate... nonrevision cases, however, imaging is usually not required  356 Surgical Atlas of Pediatric Otolaryngology • Measurements with a marked probe, or with color-coded instruments, will also assist the surgeon In a mature adolescent, the anterior sphenoid wall is about 7 cm from the anterior nasal spine, at about an angle of 30˚ from the nasal floor (Figure 15 1A) • The safest location to enter the sphenoid sinus... such as the Jennings or a bite block, is placed • A silk suture is placed in the midline of the tongue for retraction 370 Surgical Atlas of Pediatric Otolaryngology • Wedge resection of the tongue (Figure 16–2) can be fashioned in several forms, depending on the amount of tongue that needs to be excised One advantage of wedge resection is that more lateral tongue can be preserved, thus preserving taste... depending on the amount of tongue base dissected and reliability of the pharyngeal closure 376 Surgical Atlas of Pediatric Otolaryngology FRENULOPLASTY Restrictive ankyloglossia can contribute to feeding and speech problems in some children Surgical release, with or without tissue rearrangement, may be beneficial in appropriately selected cases Indications • Difficulty with breast-feeding in the neonate... surgeon may extend the sphenoidotomy laterally or medially 362 Surgical Atlas of Pediatric Otolaryngology • Lateral extension of the sphenoidotomy 1 Lateral exposure is achieved by performing limited posterior ethmoidectomy through the superior meatus This is followed by additional removal of anterior sphenoid wall in a lateral direction (Figure 15 9) 2 Before removing bone, it is safer to insert an upbiting... mucosal surfaces to avoid inadvertent laser burns 368 Surgical Atlas of Pediatric Otolaryngology Procedure • A mouth retractor, without a tongue blade, such as the Jennings or a bite block, is placed • A silk suture is placed in the midline of the tongue for retraction • The lesion and surrounding soft tissue are removed with a scalpel, a needle-tip monopolar cautery, or a laser When using the laser . Isaacson G. Pediatric ethmoid mucoceles in cystic fibrosis: long-term fol- low-up of reported cases. Ear Nose Throat J 1997;76 :53 8–9 and 54 3–6. 5. Arjmand EM, Lusk RP, Muntz HR. Pediatric sinusitis. nonrevision cases, however, imag- ing is usually not required. 356 Surgical Atlas of Pediatric Otolaryngology • Measurements with a marked probe, or with color-coded instruments, will also assist. soft tissue of the fontanelle (Figure 13–20). Figure 13–18 Polyps arise from the ethmoid air cells and maxil- lary antrum, and protrude into the nose. 336 Surgical Atlas of Pediatric Otolaryngology •