Intranasal ethmoidectomy. The surgery intranasal of the ethmoid is quite effective when indicated, although it has been neglected by many otolaryngologists.
Chronic ethmoiditis, with or without nasal polyps , is a positive indication for this method, being the eradication of chronic ethmoid infection sufficient to achieve the cure of a chronic frontal and sphenoid infection .
Although it is recognized that external ethmoidectomy is a safer and more effective method to reach the entire ethmoidal labyrinth, carefully performed intranasal ethmoidectomy is capable of achieving perfect resolution of the aforementioned conditions.
Summary
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- 1 Surgical anatomy
- 2 Preparation for surgery
- 3 Operation technique
- 4 Sources
Surgical anatomy
The ethmoidal labyrinth has a pyramidal shape, being wider behind than in front, and also wider above than below. The anterior width of the ethmoid is 0.5 to 1 cm; the posterior is approximately 1.5 cm. The anteroposterior diameter or length of the labyrinth is 3 to 4 cm; height, from 2 to 2.5 cm. The internal wall of the ethmoid is formed by the upper half of the lateral nasal wall. The lower half is the inner wall of the club.
While the cribriform lamina is the ceiling of the olfactory cleft in the anterosuperior nasal cavity, a prolongation of the orbital lamina of the frontal bone forms the ceiling of the ethmoidal labyrinth. The insertion of the middle turbinate separates the anterior and posterior ethmoidal cells from each other, and constitutes the most important surgical reference point when performing an intranasal ethmoidectomy. The lacrimal bone constitutes the lateral wall of the anterior ethmoidal cells and the flat bone forms the lateral wall of the posterior ethmoidal cells.
As a general rule, the outer half of the anterior aspect of the sphenoid sinus is the posterior limit of the ethmoid labyrinth. The most important connections of the anterior ethmoid cells are the lacrimal bone, the frontal sinus floor and the semilunar hiatus; and those of the posterior ethmoid cells are the posterior half of the inner wall of the orbit, the optic nerve, and the outer half of the anterior wall of the sphenoid sinus. The plane of the cribriform plate corresponds approximately to a horizontal line at the level of the pupils . The number of ethmoid cells ranges from four to eight.
Preparation for surgery
The procedure is easy due to the use of general anesthesia. An endotracheal intubation cannula with pharyngeal protection is required. The entire face is prepared with antiseptic solution. Cotton soaked in antiseptic solution is introduced into the nasal cavities. The patient’s face is covered in such a way that the nose , eyes and lower forehead remain exposed .
The head is placed on a rubber sponge cushion to take the proper position. The upper portion of the face remains uncovered so that external reference points can be used. The patient’s head needs to be extended when the anterior ethmoid cells are reached.
Operation technique
Submucosal resection of the nasal septum facilitates intranasal ethmoidectomy, and many surgeons perform it as a routine phase of the procedure. This phase, however, is not absolutely necessary as long as the partition is rectilinear.
Anesthetic solution soaked cotton is removed and replaced with cotton impregnated with a 1 / 1,000 adrenaline solution , which remains in place while the patient’s head is in extension to visualize the anterior ethmoidal region. After five minutes, the adrenaline-soaked cotton is removed.
With the patient’s head extended, the area of the blister can be visualized. A cutting teaspoon is used to penetrate the anterior ethmoid cells of this area (i.e. nasoturbinal and periinfundibular). Angled cutting edge teaspoons are used to remove the anterior ethmoid cells. If aspiration bleeding cannot be easily controlled in an instant , the anterior ethmoid maze is plugged with gauze strips soaked in adrenaline.
Since intranasal ethmoidectomy is often a bilateral procedure, the surgeon can now act on the anterior ethmoid cells on the contralateral side. After performing this maneuver, he returns to the original side, removes the adrenaline tamponade and returns the patient’s head from the extension position in which it was in the neutral position. The next phase is the removal of one or two anterior thirds of the middle turbinate. With a turbinate scissor (if this type of scissor is not available, a straight one can be used). The cornet body is then sectioned transversely with the cold handle or with curved scissors. The bleeding at this point is usually not profuse, but if it is somewhat bothersome, the tamponade is inserted and the operation is continued on the opposite side.
This reference point may be masked by the disease process, but its relative position is judged fairly well immediately after the anterior portion of the turbinate has been removed. A teaspoon is inserted into the posterior ethmoid cells. By gentle curettage and with adequate knowledge of the approximate dimensions of the area, the boundaries of the posterior ethmoid can be easily followed. The remains (bones, polyps, etc.) are removed with tweezers such as Greene’s or Takahashi’s. Bleeding can be very profuse at any time. It should be remembered that it can be controlled by tamponade and with a little patience. The posterior boundary of the ethmoid labyrinth is the anterior wall of the sphenoid sinus. If indicated,
Bleeding is an occasional complication of intranasal ethmoid surgery. A postoperative tamponade should not be used, except in cases where there is bleeding and, if necessary, it will remain applied for no more than 24 hours.
The tamponade should consist of Vaseline iodoformic gauze or gauze impregnated with an antibiotic ointment. After edmoidectomy, a general antibiotic therapy is usually instituted, which should be performed, whenever possible, according to the specific data provided by the antibiogram. Although local therapeutic action is required, the patient should be closely monitored for two weeks. It is not advisable to carry out any maneuver in the intranasal spaces during the first week, except practicing a gentle cleaning by aspiration or with tweezers.
Oily nasal spray can sometimes be used to soften the crusts that form. One week or ten days after the surgical act, synechiae can be observed, the section of which is very important and, if there is a tendency to new formation, the application of a piece of gauze for a few days will solve the problem. It may also be necessary to remove small fragments of polypoid tissue and bone spicules during the immediate postoperative period.
For a few weeks after the operation, the patient will complain of dryness and repeated crusting; If you are informed of this possibility, you will surely accept contingency as a normal healing process
