The Preoperative Sinus CT: Avoiding A "Close" Call With Surgical Complication

Journal Reading
THE PREOPERATIVE SINUS CT : AVOIDING A “CLOSE” CALL WITH

SURGICAL COMPLICATION
Prayudo Mahendra Putra
Supervisor :
dr. Atta Kuntara Sp. Rad (K)
OVERVIEW
 Paranasal sinusitis is a common clinical condition that affects

approximately 16% of adults in the United States each year
 Acute uncomplicated sinusitis is a clinical diagnosis that is often

succesfully treated medically with antibiotic therapy
 The surgical procedure for treating sinusitis have evolve

throughout the years to the minimally invasive endoscopic
surgeries used in modern day practice
OVERVIEW
 Preoperative Computed Tomography (CT) imaging has become

a mainstay in surgical planning prior to endoscopic surgery and
affords the opportunity to identify anatomica variants that
predispose patients to surgical complication
 This review article will highlight and ilusrate common anatomic

variants of the paranasal sinuses with an emphasis on those that
place patient at risk for surgical complications by utilizing the
mnemonic “CLOSE”
OVERVIEW OF PARANASAL SINUS ANATOMY
OVERVIEW OF PARANASAL SINUS ANATOMY
FUNCTIONAL ENDOSCOPIC SINUS SURGERY
 Standard of care for relieving obstructions associated with paranasal sinus

drainage pathways
 The goal of FESS in the setting of reccurent or refractory rhinosinusitis is to
open the normal paranasal sinus drainage pathways by alleviating
anatomic or pathologic obstructions
 The principal target of FESS is the OMC (Ostiomeatal Complex), which is
primary drainage pathway for the maxillary, anterior ethmoid, and frontal
sinuses.
 An additional important sinus drainage pathway that may be targeted with
FESS is the frontal recess
 Several common anatomic variants may adversely affect the
OMC and frontal recess in some patient, resulting in a
predisposition to reccurent or refractory rhinosinusitis
 In addition, these variants alter the surgical lanscape in the
region of the sinus outflow tracts
 The anatomic variants that affect the OMC include the Haller
cell, concha bullosa, paradoxical rotation of the middle
turbinate, and nasal sepatal deviation
 Anatomic anomalies that narrow the OMC tend to contribute to
reccurent acute sinusitis or limited chronic rhinosinusitis
Paradoxical rotation
of middle turbinate
Haller Cell Concha Bullosa

 During FESS, an endoscope is placed into the nasal cavity through the nostril and
advanced to the region of the OMC
 FESS often includes uncinectomy and maxillary antrostomy with opening of the
maxillary antrum and infundibulum, as well as any of the following additional
procedures: turbinectomy and/ turbinoplasty, ethmoidectomy, and frontal
sinusotomy
 Surgical complication associated with FESS are typically characterized as major or
minor. Major complications include arterial vascular injury, optic nerve injury,
orbital hematoma, cerebrospinal fluid leak, and nasolacrimal duct injury
PREOPERATIVE IMAGING
 CT imaging of the paranasal sinuses has become standard of care for
preoperative planning
 Imaging parameters for preoperative image-guidance studies include no gantry
tilt; reformats in all three planes at 2 mm or less (1 mm is typically used); and
inclusion of the ears, entire maxilla, tip of the nose, chin, and frontal sinuses
 Imaging is useful in evaluating the extent of disease, identifying anatomic
variants that narrow or obstruct sinus outflow tracts, evaluating for anatomic
variants that predispose patients to surgical complications, and for image
guidance during FESS
 Most important, the preoperative imaging examination affords the radiologist an
opportunity to identify danger areas for the otolaryngologist prospectively
PREOPERATIVE IMAGING REPORT
 The basic report structure includes evaluation of OMC and frontal recess patency on one
side, along with a description of the associated inflammatory disease of the maxillary,
anterior ethmoid, and frontal sinuses
 If anatomic variants are present that affect the OMC or frontal recess drainage pathways,
they are described along with the drainage pathway that is involved
 Patterns of inflammatory disease that are relevant to management include the presence of
polypoid or nonpolypoid mucosal thickening
 Secondary findings or complication of inflammatory sinus disease, such as central increased
attenuation (inspissated secretions and/or fungal colonization), osteitis, bony
demineralization, or bony dehiscence
 The final section of the preoperative imaging report includes an assessment of the
remainder of the visualized structures on the CT examination to include the orbits,
intracranial content, soft tissue of the upper neck, skull base and visualized portions of the
craniocervival junction and cervical spine
“CLOSE” MNEMONIC
Cribiform Plate
 Refers to the horizontal lamina cribrosa  located midline and separates the roof
of the nasal cavity from the anterior cranial fossa
 The vertical distance between the lamina cribrosa and the fovea ethmoidalis
represent the depth of the olfactory fossa, with the vertically oriented lateral
lamella as its lateral border
 Lateral lamella is the thinnest and most vulnerable bony portion of the skull base
in terms of intraoperative injury
 Direct communication between the intracranial compartment and the sinus cavity
substantially increase the risk of intracranial spread of infection and may lead
developmenmt of a pseudomeningocele or meningoencephalocele
KEROS CLASSIFICATION
Keros type I Keros type II Keros Type III

Lamina Papyracea
 Is a thin layer of the ethmoid bone that comprises the medial orbital
wall
 When dehiscent from a prior injury, the bony margin of the lamina
papyracea is displaced medially into the ethmoid sinus, along with
intraorbital fat and occasionally portion of the medial rectus muscle
 The lamina papyracea may also be at risk for injury-even when intact
 Direct injury to intraorbital structures, particularly the medial rectus
musculature, is less common but disastrous due to its irreparability.
Onodi Cell
 Onodi cell or sphenoethmoidal air cell is a variant posterior ethmoid air cell that
extends posteriorly along the superior and lateral aspect of the sphenoid sinus
 Onodi cell is an important variant to identify, as the optic nerve commonly
courses through the Onodi cell, with a thin margin of bone separating the optic
nerve from the underlying air cells  increase the risk optic nerve injury during
posterior ethmoidectomy
 Onodi cell is best visualized on coronal sequences by first locating an air cell above
the sphenoid sinus
Sphenoid Sinus
 It is important to evaluate the sphenoid sinus for the pattern of pneumatization,
as well as dehisence of the overlying bony plate of the carotid artery and optic
nerve
 Sphenoid sinus pneumatization characterized by conchal, presellar, and sellar
 The sellar variant is important to identify preoperatively, since it places the thin
posterior clival margin at risk for inadvertent perforation due to supine
positioning of the patient
 Excessive pneumatization of the sphenoid sinus into the skull base and anterior
clinoid processes may result in dehisence of the bony margin of the carotid and
optic nerve canals, rendering them susceptible to injury during FESS
Conchal Presellar Sellar
(Anterior) Ethmoidal Artery

 Is a branch of the opthalmic artery that supplies portions of the paranasal sinuses
and nasal cavity(ethmoid and frontal sinuses, anterior portion of the nasal
septum, and portion of the lateral nasal wall)
 The artery located on coronal CT images by identifying the anterior ethmoidal
notch along the medial orbital wall at the level of the anterior ethmoid sinus
 If the notch abuts the fovea ethmoidalis or lateral lamella, then the artery is
considered relatively protected during FESS
 The presence of supraorbital pneumatization of ethmoid air cells above the
anterior ethmoidal notch  places the artery at increased risk of injury during
FESS
CONCLUSION
 Although FESS is an effective means of treating patients with recurrent and

refractory sinusitis, the procedure is not without risk of complications, which can
be serious
 The routinr utilization of preoperative CT affords the opportunity to prospectively
identify important anatomic variants that predispose patients to surgical
complications
 The “CLOSE” mnemonic provides a simple menas of recalling critical variants that
can easily be incorporated into the preoperative imaging report
 This will prove beneficial to referring otolaryngologist, and more important help
reduce the risk of surgical complication
THANK YOU

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Journal Reading

THE PREOPERATIVE SINUS CT : AVOIDING A “CLOSE” CALL WITH

 Paranasal sinusitis is a common clinical condition that affects

 Acute uncomplicated sinusitis is a clinical diagnosis that is often

 The surgical procedure for treating sinusitis have evolve

 Preoperative Computed Tomography (CT) imaging has become

 This review article will highlight and ilusrate common anatomic

 Standard of care for relieving obstructions associated with paranasal sinus

Haller Cell Concha Bullosa

Keros type I Keros type II Keros Type III

(Anterior) Ethmoidal Artery

 Although FESS is an effective means of treating patients with recurrent and

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