External Approaches to the Paranasal Sinuses

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External Approaches to the Paranasal Sinuses

Surgical Procedures
Neoplasms
Rhinology
Author Credentials 

Kyle K. VanKoevering, MD
Resident
Mark A. Zacharek, MD
Associate Professor
Department of Otolaryngology, Head and Neck Surgery
University of Michigan
Ann Arbor, Michigan

Module Summary

External approaches to the paranasal sinuses have largely been replaced by less invasive endoscopic alternatives in today’s rhinologic practices. However, these approaches each maintain unique advantages in exposure and application over endoscopic approaches. There remain clinical conditions, including extensive frontal disease, bony tumors, trauma and other conditions in which the anatomical access requires more traditional external approaches. The concepts and techniques of these approaches remain paramount components of the competent rhinologist’s skillset.

Module Learning Objectives 
  1. Explain the key external approaches to the paranasal sinuses.
  2. Recognize the utility and limitations of these approaches.
  3. Describe clinical conditions that could utilize external approaches.
Frontal Sinus External Approaches

Objectives:

  1. Understand the anatomy of the frontal outflow.
  2. Variations in middle turbinate anatomy.
  3. Describe the mini-trephine frontal sinusotomy, indications and limitations.
  4. Describe the bicoronal incision for access to the frontal sinus.
  5. Layers of the frontal scalp.
  6. Location of frontal nerve.
  7. Describe how to identify the boundaries of the frontal sinus.
  8. Describe the osteoplastic bone flap.
  9. Differentiate frontal sinus obliteration and cranialization.
  10. Describe the indications for each.

References:

  1. Myers EN, Carrau RL. Chapter: External Approaches to the Frontal Sinus. In Operative otolaryngology: Head and neck surgery. Philadelphia: Saunders/Elsevier; 2008.
  2. Kountakis SE, Senior BA, Draf W. Chapter: Osteoplastic Frontal Sinusotomy and Reconstruction of Frontal Defects. In The Frontal Sinus. Berlin, Germany: Springer Berlin Heidelberg; 2005.

 

Maxillary Sinus External Approaches

Objectives:

  1. Understand the anatomic boundaries of the maxillary sinus.
  2. Including infraorbital nerve Canine fossa.
  3. Define the anatomic location of the Caldwell-Luc maxillary sinusotomy.
  4. Understand sublabial and Weber-Ferguson approaches to the maxilla.
  5. Describe the anatomic importance of the maxillary tooth roots in the approach.

References:

  1. Myers EN, Carrau RL. Chapter: Anterior Antrostomy: The Caldwell-Luc Operation. In Operative otolaryngology: Head and neck surgery. Philadelphia: Saunders/Elsevier; 2008. 
  2. Myers EN, Carrau RL. Chapter: Medial Maxillectomy. In Operative otolaryngology: Head and neck surgery. Philadelphia: Saunders/Elsevier; 2008. 
  3. Myers EN, Carrau RL. Chapter: Complete Maxillectomy. In Operative otolaryngology: Head and neck surgery. Philadelphia: Saunders/Elsevier; 2008. 
Ethmoid Sinus External Approaches

Objectives:

  1. Describe the Lynch incision and lateral rhinotomy.
  2. Know the anatomy of the maxilla, nasal bones, lacrimal and ethmoid bone.
  3. Know the anatomy of the medial canthus and lacrimal system, anterior and posterior ethmoid arteries.
  4. Understand the trans-orbital and trans-nasal external ethmoidectomies.
  5. Describe the subcranial approach.
  6. Differentiate the lamina papyracea, fovea ethmoidalis, lateral lamella and cribriform plate.

References:

  1. Myers EN, Carrau RL. Chapter: External Ethmoidectomy. In Operative otolaryngology: Head and neck surgery. Philadelphia: Saunders/Elsevier; 2008. 
  2. Shohet MR, et al. Advances in approaches to the cranial base: minimizing morbidity. Facial Plast Surg. 2008;24(1):129-134.
Sphenoid Sinus External Approaches

Objectives:

  1. Describe landmarks and techniques to identify the sphenoid ostium
  2. Describe the trans-septal approach to the sphenoid sinus
  3. Discuss the significance of an onodi cell
  4. Understand the anatomy of the medial opticocarotid recess and sella

References:

  1. Myers EN, Carrau RL. Chapter: Sphenoid Sinus. In Operative otolaryngology: Head and neck surgery. Philadelphia: Saunders/Elsevier; 2008. 
Case Studies
  1. A 57 yo M presents with complaints of 3 years of progressive frontal pressure and right orbital fullness. Examination shows subtle right proptosis with intact extraocular motility. A CT scan is performed and shown above. Discuss the likely pathology and planned surgical approach.

     

  1. A 23 yo F returns to your clinic 2 years after removal of an antrochoanal polyp from the right maxillary sinus. Her initial surgical approach was performed endonasally with a wide maxillary antrostomy and microdebrider resection. She now has recurrent symptoms and a CT scan as shown above. Describe external approaches that may be considered and the potential benefits of an external approach.

 

Complications

Recognize the following complications and risks and their management:

  1. CSF Leak
  2. Orbital penetration/injury
  3. Orbital hematoma
  4. Neurologic injury
    1. Frontal branch of facial nerve
    2. Supraorbital or supratrochlear nerves
  5. Sinocutaneous fistula
  6. Subcutaneous emphysema
Review Questions
  1. What is the most common sinus accessed via external approach?
  2. List at least 2 techniques for tracing the limits of the frontal sinus for an osteoplastic flap
  3. What are the anatomic boundaries of the canine fossa
  4. What is the spacing of the anterior and posterior ethmoid arteries from the lacrimal crest?
  5. Which bones articulate with the lacrimal bone?