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ENDOSCOPIC SINUS SURGERY BY SEQUENTIAL REMOVAL OF 5 BASAL LAMELLAE
내시경 부비동수술시 사골기판을 전방으로부터 순서적으로 제거하는 전방접근법

아주대학교 의과대학 이비인후과학교실 서 경식

배경: 만성 부비동염에 있어서, 부비동의 병변을 제거하기 위한 내시경 수술 방법으로 주로 Messerklinger-Stammberger의 구상돌기절제술후 전방에서 후방으로 사골동의 하부2/3에 해당되는 부위를 순서적으로 제거한 후 비제봉소 및 전두와/전두동의 병변 제거를 후방에서 전방으로 접근하는 방법을 사용하거나, Wigand등의 방법으로 중비갑개 후하단을 절제하고, 접형동으로부터 사골동의 천정인 두개저를 따라 후방에서 전방으로 접근하는 방법등이 사용되고 있다. 이러한 방법이 전사골동맥이나, 안와내측벽의 손상의 위험을 줄이는 방법으로 알려져 있다. 그러나 이러한 경우0도 내시경을 사용하여 수술을 진행하다가, 전두와에 이르러서는 30도 내시경을 사용해야하는 경우가 번거로울 수 있으며, 술자에게 내시경하의 시야의 혼란을 초래하는 원인을 제공할 수도 있다고 사료된다.

목적: 이에 저자들은 전방으로부터 사골기판을 주로0도 내시경 시야하에서 전방으로부터 순서적으로 제1기판(구상돌기)절제->상악동자연공확인 및 개방->비제봉소제거 및 전두와개방->제2기판(사골포 및 사골판)절제->제3기판(중비갑개기판)절제->상비도를 통한 제4, 5기판(상비갑개기판 및 최상비갑개기판) 절제->접형동 개방의 순서로 수술을 시행하여 내시경 부비동수술시 전방접근법의 효용성과 안전성을 알아보았다.

재료 및 방법: 수술법은 비디오 모니터링 시스템을 이용하여 먼저0도 내시경하에서 구상돌기절제후 상악동자연공을 확인하여 필요시 개방하고, 비제봉소의 전벽을 구상돌기 절개선에서 외상방으로 중비갑개의 기시부의 직하부를 punch forceps을 사용하여 개방하고, 전두동 개구부의 후방이 관찰될 때까지 전두와 개방술을 시행하였다(제1기판을 절제한 후 제2기판을 그대로 둔 채로 전두동과 상악동을 개방). 그 다음으로 필요시 70도 내시경으로 전두동 입구부가 전체 시야에 들어오게 하여 추가로 병변을 제거하였다. 다음 단계로 사골포 및 사골판(제2기판)을 절제하여 측동을 개방하고, 전두개저가 노출될때까지 사골동 절제술을 시행하였으며, 전사골동맥은 이 때 제2기판과 제3기판의 사이로 지나가게 되므로 주의한다. 후사골동의 병변이 있으면, 중비갑개기판(제3기판)을 절제하고 후사골봉소를 정리한 다음 상비도를 통하여 상비갑개기판 및 최상비갑개기판(제4, 5기판) 주위를 정리하여 완전한 사골봉소의 제거를 시행하였다. 접형동은 수술의 맨 마지막 단계로 상비갑개와 비중격사이로 자연공 개구부를 확인하여 필요시 넓혀 주었다.

결론: 부비동 내시경 수술시0도 내시경을 주로 사용한 방법이 내시경의 방향과 기구의 진행방향이 일치하여, 수술이 용이하고, 일정한 수술 시야를 제공하여, 부비동 수술에 있어서 전방접근법은 해부학적인 지표인 기판을 사용하여 보다 쉽게 병변을 앞에서부터 차례로 제거 할 수 있는 안전한 접근법으로 사료되었다.

@. BEFORE THE DISSECTION

* The major procedure is performed under 0( endoscope.
* You should be accustomed with the uniform endoscopic view, which must be memorized by continuous self-training.
* Because you are viewing the ethmoid sinus in a 2-dimensional way and then you are reconstructing the ethmoid sinus in your brain as a 3-dimensional space, frequent changing the several angled endoscopes during the ESS can make you lost your way in the ethmoid sinus.

STEP 1. PERFORM COMPLETE UNCINECTOMY(UP=BL1)

* Initially identify the groove in the lateral wall which is an indicator of anterior and inferior edge of UP; The groove is just above the inferior turbinate(IT) horizontally and just below the insertion point of middle turbinate(MT) to the lateral nasal wall vertically.
* Just after complete uncinectomy, you can see MO and FO in the surgical field without any further procedure.
* UP is a part of ethmoid bone and holds MO laterally and AN superor-laterally.
* UP is attached with the lamina papyracea(LP) laterally, anterior skull base superiorly and inferior turbinate(IT) infero-posteriorly with the ethmoidal process of IT.
* The upper and lower attachments of UP can be removed with upward cup forceps with a rotatory fashion after sickle knife incision.
* In case of sclerotic UP, you can use fontanelle knife, backbiter or even chisel for removing the UP.
* I recommend you to cut the insertion point UP to the inferior turbinate(IT) first with cutting forceps after OUT-FRACTURING the UP to the MEDIAL DIRECTION by ANTERIOR FONTANELLOTOMY APPROACH.
* The ANTERIOR FONTANELLOTOMY is performed when the MO is expected not found or UP is sclerotic. But you can use it as a routine uncinectomy procedure if you are skillful. The procedure is performed by directly perforating the maxillary anterior fontanelle(MAF) with a curved sharp instrument(fontanelle knife, bent elevator or else that is sharp, long and curved). At this time the elevator is already in the maxillary sinus. The lower 2/3 of UP is out-fractured by pushing the elevator medially. After this, you can see the maxillary antrum directly under 0( endoscope. Then straight cutting forceps is used to cut the inferior margin of UP. After this you can see the antrum is already open. The upper portion of UP is also out-fractured by curette from posterior-to anterior direction, then cut with punch forceps. If it is done, you can enter the AN easier, later.
* Instruments - sickle knife, Freer elevator, fontanelle knife, backbiter, punch forceps, cutting forceps, ethmoid straight or upward forceps

STEP 2. FIND MAXILLARY OSTIUM(MO) AND ENLARGE MAXILLARY FONTANELLE (MAF/MPF)

* If the complete uncinectomy is performed, you can see the MO by 70(or even 30( endoscope. This opening is easily torn by maxillary sinus ostium seeker to the posterior direction to opening the maxillary posterior fontanelle(MFP).
* The anterior edge of MO should not be touched if possible, but in case of difficulty in finding MO due to severe edematous or polypoid ostium, the anterior edge of MO should be enlarged just anterior to the ascending process of maxilla covering lacrimal sac.
* Remember bulla ethmoidalis(BE) and bullar lamella(BL2) is the most important structure protecting the medio-inferior orbital wall and anterior skull base for safe dissection. Also BE and BL2 is used as surgical landmarks of MO and FO.
* MO is located just antero-inferior direction of BE.
* MO is covered with UP in every case.
* The infraorbital cell(IOC) is sometimes encountered, the opening of the IOC can be from anterior ethmoid sinus(AES) or posterior ethmoid sinus(PES).
* The maxillary anterior fontanelle(MAF) is a membranous wall devoid of bony structure and an opening between 3 bony structures of lateral nasal wall as a triangular space just posterior to the ascending process of maxilla, antero-inferior to the UP and superior to the IT insertion to the lateral nasal wall.
* The maxillary posterior fontanelle(MAP) is a membranous wall devoid of bony structure and an opening between 3 bony structures. The UP is anterior border, LP is superior border and ethmo-maxillary plate(EMP) and palatine bone are the posterior border.
* But before the STEP 5(removing walls of BE), the maxillary opening cannot be enlarged large enough. By removing BE, the maxillary opening can be enlarged further superiorly and posteriorly.
* The antral pathology is removed if bleeding is not expected such as simple polyp or antrochoanal polyp, etc. But in case of bleeding is expected such as removing the antral mucosa, which is considered as irreversible, the antral procedure is performed as a last step of the surgery.
* Instruments - maxillary sinus ostium seeker, angled spoon, backbiter, curette, fontanelle knife, cutting forceps, ethmoid straight or upward forceps, malleable curved suction

STEP 3. REMOVE AGGER NASI(AN)

* The lateral and medial walls of AN are LP and UP.
* The AN is the firstly removed cell among anterior ethmoid sinus(AES) cell groups. The removal of AN should be performed if you want to open the FR completely.
* The AN is the most frequent problem making ethmoid cell after ethmoidectomy.
* After successful removal of medial wall of AN(which is UP), you can see variable sized cell just supero-lateral portion if insertion point of MT to the lateral nasal wall. This is AN cell.
* AN is defined as a pneumatization of superior remnant of the 1st ethmoturbinal(ET1=BL1=terminal UP). AN cell is connected with ethmoidal infundibulum.
* You should not to be confused with the FALSE ROOF of FR(this is a roof of AN) as the frontal sinus(FS) roof.
* Instruments - ethmoid straight or upward forceps, punch forceps

STEP 4. APPROACH TO THE FRONTAL RECESS(FR): REMOVE ANY FRONTAL CELL(FC) & FIND FRONTAL SINUS OSIUM(FO)

* Use frontal ostium seeker to confirm the true FO. The FO is usually located between MT and UP which separates the upper portion of FR from AN.
* Pass the frontal ostium seeker between MT and UP without force.
* Sometimes one to a few cells are found in the FR: frontal cells(FC).
* The supraorbital cell(SOC) opening is usually located lateral to the FO, but due to the variation of pneumatization tract, SOC is located posterior to the FO.
* The posterior wall of FO is bulla lamella(BL2).
* If the bulla lamella is not extended to the anterior skull base, by simple opening the FR reveals a large FO and you can find that the FR is connected directly with the suprabullar recess(SBR) and retrobullar recess(RBR) posteriorly.
* Instruments - frontal ostium seeker, ethmoid straight or upward forceps, punch forceps, J-curette, malleable curved suction, cutting forceps

STEP 5. REMOVE BULLA ETHMOIDALIS(BE) AND BULLA LAMELLA(BL2)

* BE is a pneumatized 2nd ET. BL is a lamella that is connected with the anterior skull base.
* The anterior wall of BE is perforated with a sharp instrument and opened with punch forceps. Then the medial wall and lateral wall is removed. Before removing lateral wall of BE, caution is needed not to injure the roof of maxillary sinus(floor of orbit).
* The maxillary opening can be further enlarged to the level of basal lamella of middle turbinate(BL3 of MT) posteriorly and to the level of orbit superiorly(Cutting forceps are preferred to avoid unnecessary antral mucosal trauma). If done by cup forceps, mucosal tearing from posterior or superior wall of maxillary sinus is sometimes experienced.
* The upper BL is cut with punch forceps to the skull base. If it is successfully done, you can find anterior ethmoid dome(AED) and anterior ethmoid artery(AEA) between BL2(UP) & BL3(MT).
* The AEA usually runs in the skull base from orbit to the MT slightly from posterior-to anterior direction.
* The FO can be further enlarged after removing the BL2 in the posterior direction. The anterior wall of FO can be enlarged with J-curette.
* Connecting FO and SOC openings can be initiated by fracturing the septum between frontal sinus(FS) opening(FO) and SOC with curved suction or J-curette and then fractured bony particle is removed with giraffe forceps.
* Now you can see the entire anterior ethmoid roof including FS.
* The successful FO opening can be determined after STEP 5.
* The posterior wall of FS is looked as convex or bulged anteriorly.
* Instruments - ethmoid straight or upward forceps, cutting forceps, punch forceps, J-curette, frontal ostium seeker and curette, giraffe forceps, malleable curved suction

THIS IS THE END OF ANTERIOR ETHMOIDECTOMY

STEP 6. IDENTIFY AND REMOVE THE 3rd BASAL LAMELLA(BL3) OF MIDDLE TURBINATE(MT)

* You can find the basal lamella of MT(BL3) by following the mucosal continuation of lateral part of MT to the vertical part of BL3. The choana can be a good surgical landmark for tracing the horizontal part of BL3 from below. Large maxillary opening can be used as a surgical landmark to find vertical part of BL3.
* Due to the degree of pneumatization of AES, there is so much variation of the location of BL3.
* If BL3 is found, a sharp perforator is used to open the lamella. The point of perforation is located at 2/3 portion of vertical lamella of BL3 from above and not too medial to the MT because if you perforate too much close to the MT, the opening will lead to the olfactory fissure(OF) and unwanted trauma to the ST can be resulted.
* The perforated opening is enlarged simply rotating the sharp instrument. This rotating motion can fracture the lamella of BL3. Then the punch forceps are used to enlarge the opening and removing the lamella of BL3.
* Initially the vertical lamella of BL3 is only removed, but if you decide to remove the diseased PES mucosa or polyp completely, the horizontal lamella of BL3 can be also removed.
* If you are not certain that you have successfully opened the BL3, a curved elevator is employed to confirm. Through the OF, the curved elevator or fontanelle knife is inserted and see the instrument through the opening. If the instrument is not seen through the opening, the BL3 is not opened.
* Instruments - sharp Bayonet forceps, punch forceps, Freer elevator or fontanelle knife

STEP 7. PERFORM POSTERIOR ETHMOIDECTOMY

* Open posterior ethmoid sinus(PES) and find posterior ethmoid roof(PER). Usually the posterior ethmoid artery(PEA) lies in the posterior ethmoid roof just in front of anterior wall of sphenoid sinus.
* The posterior ethmoid cells are removed if diseased. Be careful not to injure the superior turbinate(ST) when removing the diseased mucosa or polyp along the MT. To avoid this unnecessary injury to the ST, you should find superior turbinate(ST) and supreme turbinate(SST) through OF.
* Instruments - ethmoid straight or upward forceps, cutting forceps, punch forceps

STEP 8. IDENTIFY & REMOVE BASAL LAMELLAE OF SUPERIOR TURBINATE AND SUPREME TURBINATE(BL4 & BL5)

* Through the olfactory fissure(OF), the ST and sometimes SST can be seen. If the BL4(basal lamella of ST) is seen, it is removed to open the superior meatus. There is almost no need of removing BL5, because there is almost no cell draining through supreme meatus.
* The ST is used as a surgical landmark finding sphenoid sinus(SS) opening(SO)
* Instruments - ethmoid straight or upward forceps, cutting forceps, punch forceps, malleable curved suction, Freer elevator

STEP 9. FIND SPHENOID SINUS OSTIUM(SO) & ENLARGE THE OSTIUM THROUGH SPHENOETHMOIDAL RECESS(SER)

* The sphenoid sinus opening(SO) is easily found with the curved blunt blade of Freer elevator by probing through sphenoethmoidal recess(SER).
* The SO lies 10mm from choana and 5mm lateral to the midline(nasal septum). This is the reason why I recommend you to use Freer elevator. With any small sized straight suction tip, the opening cannot be found easily.
* If the SO is patent and good drainage is expected, there is no further management needed.
* When you decide the SS to be opened, the inferior portion of SS is removed partially by cutting forceps. Then the SO is enlarged in superior and lateral direction. During this procedure, too much care is necessary to avoid any optic nerve(ON), internal carotid artery(ICA) or skull base injury. The mucosa inferior to the SO contains the septal branch of posterior nasal artery. When you dissect the inferior part of anterior wall of SS, mucosal elevation is needed prior to the bony removal.
* Instruments - Freer elevator, sphenoid punch forceps, small diameter straight suction, ethmoid straight or upward forceps, cutting forceps

STEP 10. MANAGEMENT OF MT & IT
(INCLUDING SEPTAL SURGERY)

* Any portion of MT or IT obstructing the normal drainage and/or ventilation should be removed.
* Any unnecessary removal of MT or IT cannot be justified.
* Any septal spur, hypertrophy or deviation should be corrected.
* Instruments - cutting forceps, ethmoid straight or upward forceps, Freer elevator, chisel with mallet, blade # 15

THIS IS THE END OF POSTERIOR ETHMOIDECTOMY.
THIS IS THE END OF DISSECTION.