The posterior wall of the maxillary sinus: An important landmarkin endoscopic sinus … ·...
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The posterior wall of the maxillary sinus: An important landmark The posterior wall of the maxillary sinus: An important landmark in endoscopic sinus surgery in endoscopic sinus surgery Jacques E. Jacques E. Gaudet Gaudet MD, Robert MD, Robert Peden Peden MD, Albert Alexander MD, Kevin McLaughlin MD, Daniel W. MD, Albert Alexander MD, Kevin McLaughlin MD, Daniel W. Nuss Nuss , MD , MD Department of Otolaryngology Department of Otolaryngology - - Head and Neck Surgery, Louisiana State University Health Science Head and Neck Surgery, Louisiana State University Health Science s Center, New Orleans, LA s Center, New Orleans, LA Abstract Objective: To determine the consistency of the relationship between the posterior wall of the maxillary sinus (PMW) and the face of the sphenoid sinus (FOS), thus providing a useful landmark for endoscopic sinus surgery (ESS). Setting: Tertiary care otolaryngology clinic Design: Retrospective review of computed tomography (CT) scans Population: 28 patients scheduled for image-guided ESS. Diagnoses included sinonasal tumors and chronic sinusitis. Patients were excluded if either previous surgery or active pathology altered normal anatomic relationships. Methods: Using Osirix software and 1mm axial CT scans, measurements were taken to document the position of the PMW and the FOS in an anterior-posterior dimension. For uniformity, the PMW was measured at the most postero-medial aspect of the maxillary sinus in the axial plane of the sphenopalatine foramen. The FOS was measured at the sphenoid ostia. Measurements were taken independently by two otolaryngologists. Results: The average anterior-posterior distance from the PMW to the FOS was 2.19 mm (range -3.56-7.77 mm) +/- 2.48 mm. The PMW was within 5 mm of the FOS in 89.3% (p < .001). The PMW was anterior to the FOS in 71.4% (chi 2 =.001). The Pearson coefficient for inter-rater reliability was 0.94. Conclusion: The PMW is a reliable indicator of the depth of the FOS. The fact that the PMW is a relatively unmistakable and concrete landmark makes this a useful tool for novice sinus surgeons and surgeons operating in difficult sinonasal cavities Since the inception of endoscopic sinus surgery (ESS), surgical and radiologic landmarks have been used to minimize complications and keep the surgery as safe as possible for the patient 1 . This is very important in ESS, as complications as severe as blindness, cerebrospinal fluid (CSF) leak, hemorrhage, and death can result form surgical misadventures during an elective procedure 2 . Newer technology has allowed the advent of image-guidance, providing the surgeon with knowledge of his/her location within the particular patient’s anatomy 3 . This technology, though, has its flaws, and objective visual landmarks are equally if not more important when endoscopically navigating the paranasal sinuses 3 . It has been the experience of the senior author that the posterior wall of the maxillary sinus provides a consistent and useful landmark for identifying the depth of the face of the sphenoid sinus. This is important because improper assessment of the depth of the sphenoid could result in an incomplete ESS (with residual ethmoid and/or sphenoid disease left untreated) or, more worrisome, over aggressive ESS putting the optic nerve, carotid artery, and other intracranial structures at risk while also increasing the risk of intra-operative or post-operative CSF leak. Introduction Discussion References Conclusion Results 1. Stammberger, H. Functional Endoscopic Sinus Surgery: The Messerklinger Technique. Philadelphia. BC Decker, 1991. 2. Stankiewicz, JA. Complications of Sinus Surgery. In Bailey BJ, Johnson JT eds. Otolaryngolology – Head and Neck Surgery. 4 th ed. Philadelphia PA: Lippincott, Williams, & Wilkins. 477-493. 3. Metson R. Image-guided sinus surgery: Lessons learned from the first 1000 cases. Otolaryngol Head Neck Surg 2003;128:8-13. 4. Plackett, R.L.(1983). "Karl Pearson and the Chi-Squared Test” International Statistical Review 51 (1): 59–72. 5. Elwany S. Yacout YM. Talaat M. El-Nahass M. Gunied A. Talaat M. Surgical anatomy of the sphenoid sinus. Journal of Laryngology & Otology. 97(3):227-41, 1983 Mar. 6. Elwany S. Elsaeid I. Thabet H. Endoscopic anatomy of the sphenoid sinus. Journal of Laryngology & Otology. 113(2):122-6, 1999 Feb. 7. Orlandi RR. Lanza DC. Bolger WE. Clerico DM. Kennedy DW. The forgotten turbinate: the role of the superior turbinate in endoscopic sinus surgery. American Journal of Rhinology. 13(4):251-9, 1999 Jul-Aug. 8. Metson R. Gliklich RE. Endoscopic treatment of sphenoid sinusitis. Otolaryngology - Head & Neck Surgery. 114(6):736-44, 1996 Jun. 9. Kim HU. Kim SS. Kang SS. Chung IH. Lee JG. Yoon JH. Surgical anatomy of the natural ostium of the sphenoid sinus. Laryngoscope. 111(9):1599-602, 2001 Sep. 10. Casiano RR. A stepwise surgical technique using the medial orbital floor as the key landmark in performing endoscopic sinus surgery. Laryngoscope. 111(6):964-74, 2001 Jun. 11. May M, Schaitkin B, Kay SL. Revision endoscopic sinus surgery: six friendly landmarks. Laryngoscope. 104: 766-7. 1994 Jun. The PMW is a reliable indicator of the depth of the FOS. The fact that the PMW is a relatively unmistakable and concrete landmark makes this a useful tool for endoscopic sinus surgery. ESS, as originally described by Messerklinger 1 , has truly revolutionized the approach to a multitude of pathologies, including chronic sinusitis, allergic fungal sinusitis, and sinonasal and skull base tumors. Early experience with ESS revealed the importance of reliable anatomic landmarks for safely navigating the paranasal sinuses, and revealed the significant consequences of errant dissection 1,2 . Recent advances in technology have brought image-guidance to the forefront of ESS 3 , but visible and reliable endoscopic landmarks are unequivocally vital in performing safe and effective ESS. Literature Review While much literature has been written with regards to sinonasal anatomy, especially in regards to ESS, less literature is available regarding specific anatomic relationships of the sphenoid sinus. Most of the anatomic literature regarding the sphenoid sinus is devoted to its role in neurosurgical approaches and pneumatization patterns, 5-6 as well as its relationship to the relation to the nasal sill 7 , posterior end of the superior turbinate 8-9 , and other intranasal landmarks. Casiano 10 and May 11 describe the use of the “antrostomy ridge”, a bony ridge of the medial orbital wall near the posterior end of a maxillary antrostomy as a useful landmark in ESS. Casiano performed endoscopic and direct measurements in cadaveric heads and determined that this “antrostomy ridge” was a useful and consistent landmark for multiple aspects of ESS, and showed a consistent relationship between this landmark and the anterior wall of the sphenoid sinus. This corroborates our data, as this “antrostomy ridge” and the posterior wall of the maxillary sinus as described in our protocol are in very close proximity. Relevance of the data Our data shows that the posterior maxillary wall is a reliable indicator of the depth of the sphenoid ostium. This information will prove useful to the sinus surgeon for several reasons. 1)The posterior wall of the maxillary sinus is a relatively unmistakable visible landmark that is relatively easily visualized during standard ESS, and is generally unaltered by even extensive disease-related or post-surgical changes. 2)Identification of the face of the sphenoid is a critical part of any complete ethmoidectomy or sphenoidotomy. 3)The use of the PMW as an indicator of the depth of the FOS should allow for a more confident and complete ethmoidectomy and sphenoidotomy 4)The addition of another visible “depth gauge” within the sinonasal cavity should help the sinus surgeon decrease risk to the carotid artery and optic nerve. Materials and Methods 1. Pearson T-test coefficient of 0.94, indicating very good inter-rater reliability. 2. The two independent reviewers agreed on 56/56 measurements (100%) with regards to which structure was anterior. 3. The PMW was anterior to the FOS in 40/56 sides (71.4%). p = 0.001 4. The mean distance from the PMW to FOS was = 2.19 mm (+/-2.48 mm) 5. The range was -3.56 to 7.77 mm. Negative distances indicate that the FOS was the anterior structure. 6. The PMW was within 5mm of the FOS in 50/56 sides (89.3%) (p < .001) and was within 10 mm of the FOS in 56/56 sides (100%). Inclusion/Exclusion Criteria Inclusion Criteria Patient underwent an image-guided endoscopic surgery with the senior author. Patient underwent thin cut (1mm) axial non-contrasted CT scan. Exclusion Criteria Patient’s anatomy is /was significantly altered by active or previous pathology or surgery. 1 millimeter axial CT scans of the paranasal sinuses were reviewed using Osirix TM software. Scans were reviewed by a neuroradiologist (AA) and interpreted by the junior author (JG) and a senior faculty member (RP). 1 millimeter axial CT scans of the paranasal sinuses were reviewed using Osirix TM software. Scans were reviewed by a neuroradiologist (AA) and interpreted by the junior author (JG) and a senior faculty member (RP). The sphenopalatine foramen was identified. If it was present in multiple images, the middle image was chosen. The Y-coordinate (location in anterior-posterior dimension) of the most postero-medial portion of the posterior maxillary wall present in this axial cut was recorded. The sphenopalatine foramen was identified. If it was present in multiple images, the middle image was chosen. The Y-coordinate (location in anterior-posterior dimension) of the most postero-medial portion of the posterior maxillary wall present in this axial cut was recorded. The sphenoid ostium was identified and its Y value was recorded. The sphenoid ostium was identified and its Y value was recorded. The anterior-posterior distance between the posterior maxillary wall (at the level of the sphenopalatine foramen) and the face of the sphenoid was calculated by subtracting the 2 corresponding y-values. The anterior-posterior distance between the posterior maxillary wall (at the level of the sphenopalatine foramen) and the face of the sphenoid was calculated by subtracting the 2 corresponding y-values. Figure 1: Axial non-contrasted CT scans of the paranasal sinuses. Green arrows indicate the sphenopalatine foramen. The most postero-medial portion of the posterior wall of the maxillary sinus present in this axial cut was marked (green dot), and the y-value was recorded. Figure 2: The red dots indicate the sphenoid ostia. The Y-coordinate of this point was recorded.
Transcript of The posterior wall of the maxillary sinus: An important landmarkin endoscopic sinus … ·...
The posterior wall of the maxillary sinus: An important landmarkThe posterior wall of the maxillary sinus: An important landmark in endoscopic sinus surgeryin endoscopic sinus surgeryJacques E. Jacques E. GaudetGaudet MD, Robert MD, Robert PedenPeden MD, Albert Alexander MD, Kevin McLaughlin MD, Daniel W. MD, Albert Alexander MD, Kevin McLaughlin MD, Daniel W. NussNuss, MD , MD Department of OtolaryngologyDepartment of Otolaryngology--Head and Neck Surgery, Louisiana State University Health ScienceHead and Neck Surgery, Louisiana State University Health Sciences Center, New Orleans, LAs Center, New Orleans, LA
AbstractObjective: To determine the consistency of the relationship between the posterior wall of the maxillary sinus (PMW) and the face of the sphenoid sinus (FOS), thus providing a useful landmark for endoscopic sinus surgery (ESS).
Setting: Tertiary care otolaryngology clinic
Design: Retrospective review of computed tomography (CT) scans
Population: 28 patients scheduled for image-guided ESS. Diagnoses included sinonasal tumors and chronic sinusitis. Patients were excluded if either previous surgery or active pathology altered normal anatomic relationships.
Methods: Using Osirix software and 1mm axial CT scans, measurements were taken to document the position of the PMW and the FOS in an anterior-posterior dimension. For uniformity, the PMW was measured at the most postero-medial aspect of the maxillary sinus in the axial plane of the sphenopalatine foramen. The FOS was measured at the sphenoid ostia. Measurements were taken independently by two otolaryngologists.
Results: The average anterior-posterior distance from the PMW to the FOS was 2.19 mm (range -3.56-7.77 mm) +/- 2.48 mm. The PMW was within 5 mm of the FOS in 89.3% (p < .001). The PMW was anterior to the FOS in 71.4% (chi2 =.001). The Pearson coefficient for inter-rater reliability was 0.94.
Conclusion: The PMW is a reliable indicator of the depth of the FOS. The fact that the PMW is a relatively unmistakable and concrete landmark makes this a useful tool for novice sinus surgeons and surgeons operating in difficult sinonasal cavities
Since the inception of endoscopic sinus surgery (ESS), surgical and radiologic landmarks have been used to minimize complications and keep the surgery as safe as possible for the patient1. This is very important in ESS, as complications as severe as blindness, cerebrospinal fluid (CSF) leak, hemorrhage, and death can result form surgical misadventures during an elective procedure2. Newer technology has allowed the advent of image-guidance, providing the surgeon with knowledge of his/her location within the particular patient’s anatomy3. This technology, though, has its flaws, and objective visual landmarks are equally if not more important when endoscopically navigating the paranasal sinuses3.
It has been the experience of the senior author that the posterior wall of the maxillary sinus provides a consistent and useful landmark for identifying the depth of the face of the sphenoid sinus. This is important because improper assessment of the depth of the sphenoid could result in an incomplete ESS (with residual ethmoid and/or sphenoid disease left untreated) or, more worrisome, over aggressive ESS putting the optic nerve, carotid artery, and other intracranial structures at risk while also increasing the risk of intra-operative or post-operative CSF leak.
Introduction
Discussion
References
Conclusion
Results
1. Stammberger, H. Functional Endoscopic Sinus Surgery: The Messerklinger Technique. Philadelphia. BC Decker, 1991.
2. Stankiewicz, JA. Complications of Sinus Surgery. In Bailey BJ, Johnson JT eds. Otolaryngolology – Head and Neck Surgery. 4th ed. Philadelphia PA: Lippincott, Williams, & Wilkins. 477-493.
3. Metson R. Image-guided sinus surgery: Lessons learned from the first 1000 cases. Otolaryngol Head Neck Surg 2003;128:8-13.
4. Plackett, R.L.(1983). "Karl Pearson and the Chi-Squared Test” International Statistical Review 51 (1): 59–72.
5. Elwany S. Yacout YM. Talaat M. El-Nahass M. Gunied A. Talaat M. Surgical anatomy of the sphenoid sinus. Journal of Laryngology & Otology. 97(3):227-41, 1983 Mar.
6. Elwany S. Elsaeid I. Thabet H. Endoscopic anatomy of the sphenoid sinus. Journal of Laryngology & Otology. 113(2):122-6, 1999 Feb.
7. Orlandi RR. Lanza DC. Bolger WE. Clerico DM. Kennedy DW. The forgotten turbinate: the role of the superior turbinate in endoscopic sinus surgery. American Journal of Rhinology. 13(4):251-9, 1999 Jul-Aug.
8. Metson R. Gliklich RE. Endoscopic treatment of sphenoid sinusitis. Otolaryngology - Head & Neck Surgery. 114(6):736-44, 1996 Jun.
9. Kim HU. Kim SS. Kang SS. Chung IH. Lee JG. Yoon JH. Surgical anatomy of the natural ostium of the sphenoid sinus. Laryngoscope. 111(9):1599-602, 2001 Sep.
10. Casiano RR. A stepwise surgical technique using the medial orbital floor as the key landmark in performing endoscopic sinus surgery. Laryngoscope. 111(6):964-74, 2001 Jun.
11. May M, Schaitkin B, Kay SL. Revision endoscopic sinus surgery: six friendly landmarks. Laryngoscope. 104: 766-7. 1994 Jun.
The PMW is a reliable indicator of the depth of the FOS. The fact that the PMW is a relatively unmistakable and concrete landmark makes this a useful tool for endoscopic sinus surgery.
ESS, as originally described by Messerklinger1, has truly revolutionized the approach to a multitude of pathologies, including chronic sinusitis, allergic fungal sinusitis, and sinonasal and skull base tumors. Early experience with ESS revealed the importance of reliable anatomic landmarks for safely navigating the paranasal sinuses, and revealed the significant consequences of errant dissection 1,2. Recent advances in technology have brought image-guidance to the forefront of ESS3, but visible and reliable endoscopic landmarks are unequivocally vital in performing safe and effective ESS.
Literature Review
While much literature has been written with regards to sinonasal anatomy, especially in regards to ESS, less literature is available regarding specific anatomic relationships of the sphenoid sinus. Most of the anatomic literature regarding the sphenoid sinus is devoted to its role in neurosurgical approaches and pneumatization patterns, 5-6 as well as its relationship to the relation to the nasal sill7, posterior end of the superior turbinate8-9, and other intranasal landmarks. Casiano 10 and May11 describe the use of the “antrostomy ridge”, a bony ridge of the medial orbital wall near the posterior end of a maxillary antrostomy as a useful landmark in ESS. Casiano performed endoscopic and direct measurements in cadaveric heads and determined that this “antrostomy ridge” was a useful and consistent landmark for multiple aspects of ESS, and showed a consistent relationship between this landmark and the anterior wall of the sphenoid sinus. This corroborates our data, as this “antrostomy ridge” and the posterior wall of the maxillary sinus as described in our protocol are in very close proximity.
Relevance of the data
Our data shows that the posterior maxillary wall is a reliable indicator of the depth of the sphenoid ostium. This information will prove useful to the sinus surgeon for several reasons.
1)The posterior wall of the maxillary sinus is a relatively unmistakable visible landmark that is relatively easily visualized during standard ESS, and is generally unaltered by even extensive disease-related or post-surgical changes.
2)Identification of the face of the sphenoid is a critical part of any complete ethmoidectomy or sphenoidotomy.
3)The use of the PMW as an indicator of the depth of the FOS should allow for a more confident and complete ethmoidectomy and sphenoidotomy
4)The addition of another visible “depth gauge” within the sinonasal cavity should help the sinus surgeon decrease risk to the carotid artery and optic nerve.
Materials and Methods1. Pearson T-test coefficient of 0.94, indicating very good inter-rater reliability.
2. The two independent reviewers agreed on 56/56 measurements (100%) with regards to which structure was anterior.
3. The PMW was anterior to the FOS in 40/56 sides (71.4%). p = 0.001
4. The mean distance from the PMW to FOS was = 2.19 mm (+/-2.48 mm)
5. The range was -3.56 to 7.77 mm. Negative distances indicate that the FOS was the anterior structure.
6. The PMW was within 5mm of the FOS in 50/56 sides (89.3%) (p < .001) and was within 10 mm of the FOS in 56/56 sides (100%).
Inclusion/Exclusion CriteriaInclusion Criteria
Patient underwent an image-guided endoscopic surgery with the senior author.
Patient underwent thin cut (1mm) axial non-contrasted CT scan.
Exclusion Criteria
Patient’s anatomy is /was significantly altered by active or previous pathology or surgery.
1 millimeter axial CT scans of the paranasal sinuses were reviewed using Osirix TM software. Scans were reviewed by a neuroradiologist (AA) and interpreted by the junior author (JG) and a senior faculty member (RP). 1 millimeter axial CT scans of the paranasal sinuses were reviewed using Osirix TM software. Scans were reviewed by a neuroradiologist (AA) and interpreted by the junior author (JG) and a senior faculty member (RP).
The sphenopalatine foramen was identified. If it was present in multiple images, the middle image was chosen. The Y-coordinate (location in anterior-posterior dimension) of the most postero-medial portion of the posterior maxillary wall present in this axial cut was recorded.
The sphenopalatine foramen was identified. If it was present in multiple images, the middle image was chosen. The Y-coordinate (location in anterior-posterior dimension) of the most postero-medial portion of the posterior maxillary wall present in this axial cut was recorded.
The sphenoid ostium was identified and its Y value was recorded.The sphenoid ostium was identified and its Y value was recorded.
The anterior-posterior distance between the posterior maxillary wall (at the level of the sphenopalatine foramen) and the face of the sphenoid was calculated by subtracting the 2 corresponding y-values. The anterior-posterior distance between the posterior maxillary wall (at the level of the sphenopalatine foramen) and the face of the sphenoid was calculated by subtracting the 2 corresponding y-values.
Figure 1: Axial non-contrasted CT scans of the paranasal sinuses. Green arrows indicate the sphenopalatine foramen. The most postero-medial portion of the posterior wall of the maxillary sinus present in this axial cut was marked (green dot), and the y-value was recorded.
Figure 2: The red dots indicate the sphenoid ostia. The Y-coordinate of this point was recorded.
