External Approaches for Sinus Surgery

Abstract

Sinus surgery by endoscopy is a surgical procedure that is safe and effective. Nowadays, procedures using external methods are rarely performed and are used only in specific circumstances. These procedures are considered if the complication is hard to reach by endoscopy or if the patient has undergone previous multiple failed procedures. In this chapter, we discuss the most commonly used external sinus approaches in the context of current endoscopic sinus surgery methods. Maxillary sinus access using endoscopy, including the most inferior, lateral, and anterior regions, requires special instruments, and success may not be possible in all cases. In those cases, external procedures can be useful. These external approaches can provide the sinus surgeon with the ability to surgically remove diseased tissue or neoplastic processes that cannot be reached even by extended approaches. The Caldwell–Luc procedure is the most common external approach that is used to access the maxillary sinus. The ethmoid sinus can be accessed via the nose, the maxillary sinus, or externally. Currently, the latter is rarely used in chronic rhinosinusitis patients, but can be used to access the medial orbit. When inflammation and edema limit endoscopic visualization, transcutaneous procedures are used to increase the exposure to the ethmoid, and the patient can be treated by external ethmoidectomy. In frontal sinus procedures, numerous past open methods have been described for treatment, including selective tumors, trauma cases, and sinusitis. Riedel, Kilian, Lothroph and Lynch’s procedures have been previously described the accessibility of frontal recess and sinus with the addition external ethmoidectomy to frontal sinusotomy. The osteoplastic frontal sinus flap in the presence or absence of obliteration and trephination have been described for access to the frontal sinus directly. Transseptal and transethmoid approaches to the sphenoid may be performed with a headlamp or a microscope but are now usually carried out using endoscopic guidance. The chapter is organized according to the anatomic sites and descriptions of the techniques, indications, contraindications, and complications are discussed.