36 Nasal Surgical Anatomy • Surgeon typically stands on the right side of the patient (if right-handed). • Monitor and any intraoperative imaging devices are located facing the first surgeon. • Position: The patient is positioned supine. • Body: The body lines 20° from the horizontal in anti-Trendelenburg position. • Head: The head is flexed 30° and rotated in the direction of the first surgeon. • Face is draped in order to expose forehead, eyes, nose, and upper lip. • The left hand is used to keep the telescope. • Commercially available telescopes comprise zero-degree and angled view (30°, 45°, 70°, 120°). Zero-degree and 30°telescopes are the minimum equipment required for basic dissections. • The right hand keeps the surgical instruments: straight and angled forceps, back-biting and down-biting forceps, straight and angled suctions, Cottle periosteal elevator, ostium seeker, sphenoid and frontal punch. • Powered instruments (drill) can be useful for the sphenoid sinus dissection. • At the beginning of surgical dissection, the tip of the telescope must be positioned at the nasoseptal angle, retracting the nasal tip cranially. • The telescope is then directed toward the occipital area in order to progressively visualize ◦ Nasal floor. ◦ Inferior turbinate. ◦ Nasopharynx. • A 30° telescope is placed in the middle meatus and rotated to identify ◦ Uncinate process. ◦ Bulla ethmoidalis. ◦ Middle turbinate axilla. ◦ Frontal recess. Fig. 36.1 Setup of the operative theatre. • Zero-degree telescope is useful to identify the sphenoid ostium and the spheno-ethmoidal recess. • Before starting the surgical dissection, the surgeon must identify fundamental anatomical landmarks such as the inferior turbinate, the head of the middle turbinate and its attachment to the maxillary bone (axilla of the middle turbinate), the nasal septum, and the uncinate process. • The uncinate process is a C-shaped process of the ethmoid bone, which represents a small part of the medial wall of the maxillary sinus posteriorly to the lacrimal bone, and articulates with the axilla of the middle turbinate (Fig. 36.3). • The maxillary sinus ostium is found within the concavity designed by the uncinate process, using the ostium seeker. The natural ostium is sloped 45°on the axial plane, and it is perpendicular to the coronal plane. • The ostium must be enlarged using back-biting and down-biting forceps in order to remove the caudal part of the uncinate process (Fig. 36.4), taking care to preserve the cranial part as an important anatomical landmark for the frontal recess. The surgeon should avoid injuries to the lacrimal canal. If needed, the ostium can be enlarged posteriorly, using straight forceps (Fig. 36.4). • Thirty-degree and 45°telescopes allow the exploration of the maxillary sinus including the alveolar as well as infra-orbitary recess, which can be visualized in the roof of the maxillary sinus (Figs. 36.5, 36.6).
36.1 Operative Theater Setup (Fig. 36.1)
36.2 Patient Positioning
36.3 Endoscopic Instrument Employment (Fig. 36.2)
36.4 Exploration of Nasal Fossae
36.5 Opening of Maxillary Sinus
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