LESSON 1: Eye, Ear, Nose, and Throat (EENT) Surgery

Section IIi: nose SURGERY

1-31

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1-31. OTHER NASAL OPERATIONS

The specialist assigned to scrub or circulate for the operations duties are similar to those described for submucous resection. The specialist is to check local policy carefully concerning instruments, sutures, and other items in the setup for the operation to be performed.

a. Excision of Nasal Polyps. Polyps are soft, benign tumors of the nasal mucosa caused by chronic nasal allergy (see figure 1-10).

Figure 1-10. Nasal polyps.

(1) Operation. Polyps that arise from the border of the middle turbinate may be removed by means of a submucous resection setup, using a nasal snare. Polyps that arise above this level may involve a sinus cavity, thus necessitating surgery of the sinus. In this event, the instruments and other setup are determined by the specific sinus cavity involved.

 

(2) Indications. The pressure exerted by nasal polyps results in obstruction to the passage of air through the nostrils. The obstruction may lead to a condition of chronic infection of the nose and give rise to frequent attacks of nasopharyngitis. The infection may extend also into the nasal sinuses, thus obstructing drainage from the affected sinus. The patient suffers pain in the region of the sinus involved. Treatment of the condition is excision of the polyps.

b. Turbinectomy. Turbinectomy is the surgical removal of hypertrophied portion of a turbinate bone.

(1) Hypertrophy of the turbinate prevents adequate breathing and drainage through the nose and produces painful pressure against the floor of the nose. Treatment is the removal of the hypertrophied turbinate.

 

(2) Excision of the hypertrophied portion of the turbinate is done using a setup as described for removal of nasal polyps.

c. Intranasal Antrostomy (Antral window).

(1) General. This procedure involves making an opening in the lateral wall of the nose under the inferior turbinate. It is done to relieve headaches, edema, infection, or swelling of the membranes lining the sinuses.

 

(2) Operative procedure. After prep and anesthesia, a postnasal plug is inserted. The inferior turbinate is elevated superiorly by means of a large elevator or tonsil dissector. An opening is made into the maxillary sinus beneath the inferior turbinate by means of a gouge, perforator, or antrum cannulae. The opening is enlarged with cutting forceps and antrum punches. Accessory polyps and degenerate mucosa are removed with a snare, septum forceps, and suction. The sinus is irrigated with saline solution by means of a Thornwald irrigator and suction apparatus; the sinus is packed with petrolatum impregnated iodoform gauze, and the face is cleaned and dried.

d. Radical Antrostomy (Caldwell-Luc Operation).

(1) General. This procedure involves an incision into the canine fossa of the upper jaw and exposure of the antrum for removal of bony diseased portions of the antral wall and contents of the sinus, or establishment of drainage by means of a counteropening into the nose through the inferior meatus.

 

(2) Operative procedure.

(a) The upper lip is elevated with a retractor, and a transverse incision is made in the gingivolabial sulcus just above the teeth; the incision is carried down to the underlying bone. Periosteum and soft tissue are elevated with dissectors and periosteal elevators.

 

(b) The thin bony plate is perforated with a gouge, the antrum is entered, and its opening is enlarged with nasal rongeurs. The anterior angle of the sinus may be opened by enlarging the window with Jansen-Middleton septum-cutting forceps, double-action rongeurs, and Kerrison forceps.

 

(c) The mucous membrane of the antrum is removed with Coakley or Myles angled currettes.

 

(d) Nasoantral drainage may be established by removal of a portion of the nasoantral wall below the inferior turbinate by means of cutting forceps and rasps.

 

(e) The antrum is packed with petrolatum gauze.

 

(f) The labial incision may or may not be sutured. The face of the patient is cleaned and dried.

e. Frontal Sinus Operation.

(1) General. This procedure involves making an incision through the eyebrow of the affected side and through the anterior wall and floor of the frontal sinus for removal of the diseased tissue, cleansing of the sinus cavity, and drainage. It may be made necessary in acute frontal sinusitis with persistent headaches and edema of the upper lid when other modes of therapy have failed.

 

(2) Operative procedure.

(a) An incision is made over the affected frontal sinus, extending from the base of the nose through the eyebrow as far as the supraorbital notch. A self-retaining retractor, hook retractor, knife, sponges, fine hemostats, fine ligatures, and suction set are needed.

 

(b) Either the anterior wall of the frontal sinus or the floor of the sinus is opened by means of dental burrs, chisel, mallet, gouges, septum-cutting forceps, curettes, and nasal forceps. Drainage is established by either the nasofrontal duct or the insertion of drains.

 

(c) An ethmoidal incision is made behind the nasal process of the superior maxillary bone with a chisel and mallet. The lacrimal duct is identified and preserved. Ethmoid cells are curetted.

 

(d) A Penrose drain is introduced; the external wound is approximated with fine silk sutures and dressing applied. The patient's face is cleaned and dried.

f. Ethmoidectomy.

(1) General. This is for removal of the diseased portion of the middle turbinate, opening and removal of ethmoid cells, and removal of diseased tissue in the nasal fossa through a nasal approach or external approach. It reduces the many celled ethmoid labyrinth into one large cavity to ensure adequate drainage and aeration.

 

(2) Operative procedure. For the nasal route, the procedure is similar to intranasal antrostomy described previously. For the external route, the procedure is similar to the frontal sinus operation.

g. Sphenoidectomy.

(1) General. This involves making an opening into one or both of the sphenoid sinuses by the intranasal or external ethmoidectomy approach. It is difficult to visualize the cavity of the sphenoid sinus because of its depth. Surgery of the sphenoid sinus is usually done intranasally or through an external ethmoidectomy approach.

 

(2) Operative procedure. This is the same as for intranasal antrostomy.

h. Fracture of the Nose.

(1) General. This procedure involves the manipulation and mobilization of fractured nasal bones and cartilages. Early reduction is important.

 

(2) Operative procedure. A rubber-covered narrow forceps is inserted into the nostril; the nasal bones are elevated and molded into place by external manipulation.

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