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Image-guided Interventions
Sinus Surgery
Fovea ethmoidalis or
Ethmoid roof
Nasal septum
Cribriform plates
Middle turbinates
Lateral lamella
Olfactory grooves
Fovea ethmoidalis
Crista gali
Cribriform plates
Middle turbinates
Lateral lamella
Vertical anteriorly
Horizontal posteriorly
Middle turbinate
Sphenoid sinus
Middle turbinate
Middle turbinate
Diagnostic Imaging
Multislice CT still the mainstay imaging modality. Cone Beam CT
PURPOSE
FESS
Others
excision of selected tumors
CSF leak closure
orbital decompression
in Graves ophthalmoplegia
optic nerve decompression
dacryocystorhinostomy
choanal atresia repair
uncinectomy
ethmoidectomies
Postoperative changes
Status post
septoplasty, right
uncinectomy and
unroofing of
ethmoidal bulla
Complications of FESS
Minor (5%)
Major (5%)
Mucosal hemorrhage
Anosmia / hyposmia
Nasal Septum
Osteomeatal complex
Common
drainage
pathway for
the frontal,
maxillary
and anterior
ethmoid
sinuses
E
U
Middle turbinate
Concha bullosa - pneumatized
middle turbinate. if LARGE
or INFLAMED, can
contribute to obstruction
Skull base
Middle turbinate
Haller cell
Maxillary sinus
Frontoethmoidal cells
Important if surgeon is
planning to widen the frontal
recess
cell
lies just anterior to frontal
recess
if large, may cause medial
displacement of the
middle turbinate
causing
narrowing of the
frontal
recess
A
A
Frontoethmoidal cells
Important if surgeon is
planning to widen the frontal
recess
cell
lies just anterior to frontal
recess
if large, may cause medial
displacement of the
middle turbinate
causing
narrowing of the
frontal
recess
Type
Type
Type
Type III
Type IV
Ethmoidal bulla
Largest and
most constant
anterior ethmoid
air cell
bound
superiorly by
the floor of the
anterior cranial
fossa and
laterally by the
lamina
papyracea
CLOSE
Cribriform plate (how low or how tall are the lateral lamellae?)
CLOSE:
Cribriform
Keros Classification:
based on the depth of the olfactory
fossa
Keros Type 1
1-3 mm
26%
CLOSE:
Cribriform
Keros Classification:
based on the depth of the olfactory
fossa
Keros Type 2
4-7 mm
73%
CLOSE:
Cribriform
Keros Classification:
based on the depth of the olfactory
fossa
Keros Type 3
8-16 mm
1%
Asymmetry
may be asymmetric so
measurements should be
made for each side
Asymmetry
CLOSE:
Lamina papyracea
Microdebriders, which
suction and remove
tissue rapidly, may lead
to medial rectus injury
in less experienced
hands
CLOSE:
Onodi cell
CLOSE:
Sphenoid sinus
CLOSE:
Sphenoid sinus
CLOSE:
Sphenoid sinus
Vidian canal
anterior Ethmoidal
artery
CLOSE:
Preoperative CT
CLOSE
Osseous sclerosis or areas of dehiscence
Extrasinus findings: dental disease, orbital abnormalities,
intracranial mass lesions and other pathology