Archives of the Balkan Medical Union vol. 52, no. 3, pp.

333-337
Copyright © 2017 Balkan Medical Union September 2017

MINIREVIEW

ETHMOIDECTOMY – PROCEDURES AND COMPLICATIONS

Cristina Maria Goanță1,2, Daniela Cîrpaciu1,2, Andreea Sorică1,3, Mihail Tușaliu1,3, Vlad
Andrei Budu1,3
1
University of Medicine and Pharmacy „Carol Davila“, Bucharest, Romania
2
Clinical Emergency Hospital „Sf. Pantelimon“, Bucharest, Romania
3
Institute of Phonoaudiology and Functional ENT Surgery „Prof. Dr. D. Hociotă“, Bucharest, Romania

ABSTRACT RÉSUMÉ

Ethmoid sinusitis is one of the most complicated L’ethmoïdectomie: procédés et complications

pathologies in ear, nose, and throat (ENT) practice.
Because of its anatomical particularities, ethmoid La sinusite ethmoïdale est l’une des pathologies les plus
sinusitis can easily become a dangerous pathology, compliquées dans la pratique d’ORL. En raison de ses
difficult to treat. The first method of treatment is considérations anatomiques, la sinusite ethmoïdale peut
usually proper medication, but sometimes it can be facilement devenir une pathologie dangereuse qui peut
difficult to manage without surgery. Surgery may be être difficile à traiter. La première méthode de traite-
performed, the most used being the intranasal (endo- ment est généralement un médicament approprié, mais
scopic) ethmoidectomy. Other types of surgical inter- parfois la pathologie est difficile à gérer sans intervention
ventions are external ethmoidectomy and transantral chirurgicale. La chirurgie peut être effectuée, la plus uti-
ethmoidectomy. Each approach has advantages and lisée étant l’ethmoidectomie intranasale (endoscopique).
disadvantages. The potential complications of endo- D’autres types de chirurgie sont: l’ethmoidectomie ex-
scopic surgery are: orbital injury, blindness, orbital he- terne et l’ethmoidectomie transantrale. Chaque ap-
matoma, epiphora, and postoperative epistaxis. Skull proche présente des avantages et des inconvénients. Les
base injury and cerebrospinal fluid leak are very rare complications potentielles de la chirurgie endoscopique
complications that should be discussed with patients sont: les lésions orbitales, la cécité, l’hématome orbitaire,
undergoing endoscopic sinus surgery. Regardless of the l’épiphora et l’épistaxis postopératoire. Les blessures à la
approach used, the surgeon must be familiar with the base du la base du crâne et la fuite de liquide céphalo-ra-
anatomy and aware of all pertinent landmarks to re- chidien sont des complications très rares qui devraient
duce the risk of complications. Attention must be paid être discutées avec les patients soumis à une chirurgie
to avoid violating the cribriform plate or inadvertently endoscopique des sinus. Indépendamment de l’approche
entering the orbit. utilisée, le chirurgien doit connaître l’anatomie et tous
les repères pertinents pour réduire le risque de complica-
Key-words: ethmoid sinusitis, ethmoidectomy, orbital tions. Il faut veiller à ne pas violer la plaque cribriforme
injury, external ethmoidectomy. ou à entrer par inadvertance sur l’orbite.

Corresponding author: Mihail Tușaliu

Institute of Phonoaudiology and Functional ENT Surgery „Prof. Dr. D. Hociotă“, 21
Mihail Cioranu street, 5th District, Bucharest, Romania
Phone: +40729828480, e-mail: [email protected]
Ethmoidectomy – procedures and complications – GOANȚĂ et al

Mots-clés: sinusite ethmoïdale, ethmoidectomie, lé-

sion orbitale, ethmoidectomie externe.

ANATOMICAL CONSIDERATIONS When looking on a preoperative CT scan, atten-

tion should be payed to5:
The ethmoid sinuses develop during infancy and  The insertion of the uncinate process.
expand during the early childhood. The ethmoid si-  The dehiscence of lamina papyracea.
nuses are paired and they are divided into anterior  The dehiscence of the skull base.
and posterior ethmoid air cells. This division is pro-
vided by the basal lamella of the middle turbinate. SURGICAL CONTRAINDICATIONS
The ethmoid sinus in adults has an average length of
4-5 cm and a height of approximately 3 cm1. Surgical intervention for acute ethmoid sinusitis
The walls of the ethmoid sinus are composed is contraindicated in candidates who are unable to
of the maxillary, palatine, lacrimal, frontal and sphe- undergo the risks of anesthesia. Bleeding dyscrasias
noid bones. Medially to the sinus we find the lamina may also be a relative contraindication to surgery.
papyracea – the medial wall of the orbit and superior Lawson stated that patients with a defect in the lam-
the fovea ethmoidalis. The ultimate pathway for the ina papyracea, fovea ethmoidalis, or the cribriform
secretions from the anterior ethmoid air cells is the plate should not have an ethmoidectomy from the
osteomeatal complex, in the middle meatus. The pos- intranasal approach. However, not all surgeons agree
terior air cells drain into the superior meatus. The with this6.
infundibulum of the ethmoid represents a cleft that is
demarcated by the uncinate process on its medial side PREOPERATIVE STEPS
and the lamina papyracea on its lateral side2.
 Written consent should be obtained prior to any
INDICATIONS FOR SURGERY surgical procedure. The possible risks of this sur-
gery are: orbital injury, blindness, nasolacrimal
The main indication is reserved for patients duct injury, epiphora, epistaxis, cerebrospinal fluid
who have not responded to medical therapy of 3-6 leak, meningitis and brain abscess, and, of course,
weeks of antibiotics, nasal steroids, and nasal saline persistent rhinosinusitis.
irrigations. Ethmoid sinusitis can spread outside of  If an active infection is present, a preoperative
the borders of the sinus and cause an orbital celluli- antibiotic course may be administered during
tis, orbital subperiosteal abscess, orbital abscess, su- the weeks prior to surgery. A preoperative steroid
perior orbital fissure syndrome, or cavernous sinus course may be administered if significant edema or
thrombosis. This last condition can result in limited polyps are observed on clinical examination7.
ocular motility, proptosis, and loss of vision and can
be life threatening. If any of these complications ap- SURGICAL OPTIONS
pears, surgery is required. Intracranial complications
from sinusitis are fortunately rare, but can have high Ethmoidectomy
morbidity and mortality. These complications include An ethmoidectomy is performed using one of
meningitis, thrombophlebitis of the superior sagittal 3 major approaches: the external ethmoidectomy,
sinus, and abscess formation3. the intranasal (endoscopic) ethmoidectomy, and the
In order to perform surgery, confirmatory com- transantral ethmoidectomy. Each approach has its ad-
puted tomography (CT) scans are necessary. CT scans vantages and disadvantages. Usually, the decision on
should be obtained to determine the extent of the which method to be used is based on the surgeon’s
ethmoidectomy needed. The degree of surgery re- preference and the extent of the disease. Sometimes,
quired is determined by the extent of the disease. because of the extent of the disease, more than one
The use of image-guidance systems, that correlate the approach may be combined during the surgical inter-
intraoperative position of the instrumentation with vention8.
the CT-scan anatomy, may reduce complications in Regardless of the approach used, the surgeon
adjacent structures during the more posterior dissec- must be familiar with the anatomy and aware of all
tion4. Findings may include significant mucosal thick- pertinent landmarks to reduce the risk of complica-
ening, air-fluid levels, osteomeatal complex obstruc- tions. The most frequent complications are violating
tion, polyposis, or calcification suggestive of fungal the cribriform plate or inadvertently entering the
sinusitis. orbit. It is important to avoid injury of the septal

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mucosa, because bleeding would obscure the view. If uncinate process in front of the ethmoid bulla. The
bleeding appears, it must be controlled using cautery, uncinate process always lies posterior to the anterior
thrombin, Gelfilm, Gelfoam, Surgicel, or Merocel, aspect of the middle turbinate13. Do not confuse
or with packing containing cocaine, adrenaline, phe- the uncinate process with the maxillary line (fron-
nylephrine, or oxymetazoline9. tal process of maxilla). Insert a ball probe through
the hiatus semilunaris, behind this free edge. The
EXTERNAL APPROACH natural ostium of the maxillary sinus lies at the level
where the inferior edge ethmoid bulla intersects with
This surgery can be performed under monitored the free posterior edge of uncinate process. Gently
anesthesia sedation or general anesthesia. General elevate the uncinate process anteriorly, thus creating
anesthesia may be preferred, because manipulating some space behind it; the ball probe is now in the
the globe can be uncomfortable for the patient. An infundibulum. Take care not to overmanipulate or
incision approximately 2.5-3 cm long is made, in a overmedialise the middle turbinate, as fracturing the
curvilinear manner. It is positioned at the midpoint superior attachment of the middle turbinate at the
between the medial canthus and the middle of the lateral lamella of the cribriform plate may cause a
anterior nasal bone. The skin is incised, and the dis- CSF leak. Use a 45° backbiter / side-biter to com-
section is carried down to the periosteum. If the an- plete the uncinectomy. Insert a closed 45° backbiter
gular artery is transected, it is cauterized or ligated. up to face of ethmoid bulla in middle meatus. It is
Dissection is carried subperiosteally to the posterior important to resect the uncinate with all its three
lacrimal crest, avoiding damage to the lacrimal excre- layers (mucosa/bone/mucosa). After uncinate process
tory structures10. has been removed, the agger nasi, ethmoid bulla can
The medial canthal tendon may need to be re- be seen. The lateral attachment of the ethmoid bulla
leased, to allow an easier access to this area; if this is represents the 2nd lamella. The straight curette and
done, care must be taken to reposition it correctly. 45° Blakesley are the most important instruments for
The posterior crest may need to be removed. Care ethmoidectomy; the curette is used to break the bony
must be taken not to extend the dissection superiorly lamellae and the 45° Blakesley is used to remove the
to the frontoethmoid suture, as this demarcates the cells. First, open the bulla ethmoidalis by placing a
cranial fossa11. straight curette behind the ethmoid bulla, into the
retrobullar recess or into the bulla from below, and
Intranasal ethmoidectomy breaking the bulla down by moving the instrument
Achieve topical decongestion by inserting rib- towards yourself. Other anterior ethmoid air cells are
bon gauze or neurosurgical patties, soaked in 2 ml similarly opened. Once the cell walls are fractured,
of 1:1000 adrenaline, between the inferior turbinate remove them with a 45° Blakesley14. Remember never
and the nasal septum and in the middle meatus, if to pull on any tissue; the basal lamella of the middle
possible. Carefully inspect the nose with the endo- turbinate now comes into view. The lateral insertion
scope; this is an essential step before beginning any of the middle turbinate to the lamina papyracea is
procedure. Always examine the postnasal space for called the basal lamella. It is posterior to the bulla
lesions or adenoidal tissue. Pay careful attention to ethmoidalis and separates the anterior from posterior
the inferior and middle turbinates, including the ax- ethmoid air cells, and represents the 3rd lamella. An
illa of the middle turbinate (conchae, hypertrophy, Onodi cell is associated with an increased risk of op-
paradoxical turbinates), the nasal septum (deviation, tic nerve injury (15% dehiscent in Onodi cell) as it is
spurs which may impede surgical access to mid- often closely related to the optic nerve and care needs
dle meatus), uncinate process (may be everted) and to be taken not to injure the optic nerve within this
ethmoid bulla (most constant landmark)12. Inject cell. It is also associated with carotid artery injury
local anaesthetic and adrenaline, using a dental sy- (20% dehiscent in Onodi cell) or brain injury. Use a
ringe into the nasal septum (if septoplasty required) straight curette to break down the posterior ethmoid
middle turbinate, and inferior turbinate (very slow cells, working from posteriorly to anteriorly and away
injection into turbinates). In- and outfracture the in- from the skull base. Once the frontal recess area is
ferior turbinate, to improve access to the uncinate reached, care needs to be taken to avoid injury to the
process and middle meatus. Care must be taken not anterior ethmoid artery15.
to manipulate the middle turbinate too vigorously,
as this might cause a cerebrospinal fluid (CSF) leak. Transantral approach
It is important to mobilise the middle turbinate only This surgery can be performed under moni-
at its posterior aspect, where it is more mobile, and tored anesthesia sedation or general anesthesia. A
not anteriorly. Identify the free posterior edge of the Caldwell-Luc approach is used. Once the maxillary

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Ethmoidectomy – procedures and complications – GOANȚĂ et al

sinus has been entered, the medial and superior walls Endoscopic approach complications are22:
of the maxillary sinus are identified. At the midpoint  orbital hematoma and blindness;
of the medial wall, the bulla ethmoidalis may be seen  diplopia can occur if an extraocular muscle, usually
bulging into the maxillary sinus16. A curette is used to the medial rectus, is injured;
enter this area and this allows access to the anterior  blindness due to resection of the optic nerve;
cells, but the most anterior cells may be difficult to  synechia and ostial closure;
reach. The posterior cells of the ethmoid sinus can  CSF leaks.
also be reached. Most of these complications will solve with
conservative treatment; however, if a leak is exten-
Postoperative steps sive and noted at the time of surgery, it should be
The stomach and nasopharynx should be suc- addressed and repaired with dura, fat, mucosa, and/
tioned prior to extubation. After extubation, the pa- or fibrin glue.
tient is taken to the postoperative care unit for recov- Transantral approach complications are23:
ery. Once the patient is awake, he or she is examined,  damage to the dentition, oral-antral fistula forma-
to check extraocular motility and to look for evidence tion;
of excessive bleeding or proptosis. If the patient is  paresthesias in the distribution area of the infraor-
doing well, he may be discharged home, after all pos- bital nerve;
tanesthesia protocol parameters have been applied17.  paresthesias in the gingivobuccal sulcus and alveo-
lar ridge.
Postoperative follow-up
Postoperative care of the patient with chronic
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