Imaging for Endoscopic Sinus Surgery
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www.kenthospital s.com Imaging for Endoscopic Sinus Surgery Dr. Prahlada N.B M.S (PGIMER, Chandigarh) Karnataka ENT Hospital & Research Center, Chitradurga, Karnataka.
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Preface If not coincidence, at least it was in the same decade when endoscopic sinus surgery and computed tomography were introduced to Otolaryngologists, which have changed the approach to sinonasal problems dramatically. Probably, there are no such coincidences in the history of medicine where two new modalities of approaches appeared at the same time, to deal with the same problem and complement each other while doing so. The asset of improved visualization and magnification, available through endoscopes, has revolutionized the understanding of the pathophysiology of sinusitis, and resulted in better appreciation of the anatomy of the paranasal sinuses. However, non-invasive diagnostic endoscopy has its limits, and the deeper structures cannot be evaluated by endoscopy alone . Computed tomography, which has an ability to optimally display bone, soft tissue and air simultaneously, can not only complement endoscopic examination, it can provide a surgical road map delineating the anatomy, defining the obstructing lesions, and noting anatomic variations that may predispose to operative complications. Computed tomography has scored over plain radiographs and polytomographs as an imaging modality in this area. Even though surpassing CT's capacity to image soft tissue, MRI is less suitable as an imaging modality for evaluation of this area because of the similar signal intensities for bone and air. CT scanning has become imaging modality of choice and the cooperation required between the Radiologist and the Surgeon is mandatory for both evaluation and treatment of paranasal disorders. It is of paramount importance on the part of the Otolaryngologists to understand interpretation of CT films, Radiological anatomy of the paranasal sinuses, Anatomical variations and the pathology to complement the endoscopy findings for initial screening, surgical planning, reduce postoperative complications and to provide better results. This Presentations is prepared to help Otolaryngology colleagues to learn the Imaging/radiological aspects required for endoscopic sinus surgery.
Transcript of Imaging for Endoscopic Sinus Surgery
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Imaging for Endoscopic Sinus Surgery
Dr. Prahlada N.B M.S (PGIMER, Chandigarh)
Karnataka ENT Hospital & Research Center,Chitradurga, Karnataka.
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Imaging v/s Endoscopy
V/S
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Surgery done without imaging
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Imaging modalities
CT Scan is choice of Imaging
Plain X-Ray CT Scan MRI
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Patient Preparation
• Course of Antibiotics & Decongestants
• Sympathomimetic Nasal Spray 15 min before CT procedure
• Patient to blow the nose just before procedure
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Reading CT Films
• Coronal Images
• Mark R/L sides properly
• Read from Nasion to Sphenoid sinus
• Study following in all Sections- Nasal Septum- Lamina Papyracea- Skull Base
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Normal Anatomy
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Coronal Section : At Nasion
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Coronal Section : At Agger Nasi
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Frontal Recess
Sagittal Section Coronal Section
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Lacrimal Apparatus
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Coronal Section : At OMC
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Anterior Skull Base
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Ethmoid Infundibulum
Axial Section Coronal Section
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Middle turbinate attachements
I Part II Part III Part
Vertical Oblique Horizontal
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Lateral Recess
Coronal Section Sagittal Section
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Coronal Section : At Post. Ethmoid
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Posterior Ethmoid Cells (Onodi)
Axial Section Coronal Section
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Coronal Section : At Sphenoid
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Axial Section : At Frontal
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Axial Section : At Optic nerve
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Axial Section : At Maxillary sinus
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Anatomical Variations
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Variations : Frontal Sinus
Coronal Section Axial Section
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Variations : Frontal Sinus
Coronal Section Axial Section
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Variations : Frontal Sinus
Axial Section Coronal Section
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Variations : Frontal Cells
Type I
Type III
Type II
Type IV
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Variations : Agger Nasi Cells
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Variations : Agger Nasi Cells
Agger causing disease Large Agger Nasi cell
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Variations : Frontal Recess
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Variations : Anterior Skull Base
Type I Type II Type III
1 - 3 mm 4 - 7 mm 8 - 16 mm
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Variations : Uncinate process
Medially bent Pneumatized
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Variations : Bulla Ethmoidalis
Absent Bulla
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Variations : Ethmoid Sinus
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Variations : Haller’s Cells
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Variations : Middle turbinate
Concha Paradoxic MT Interlamellar
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Rostrum of the Sphenoid
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Sphenoid Pneumatization types
Conchal
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Sphenoid Pneumatization types
Presellar
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Sphenoid Pneumatization types
Sellar
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Variations : Sphenoid Sinus
Extensive pneumatization
Pterygoidpenumatization
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Variations : Sphenoid Sinus
Dehiscent nerves ACP penumatization
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Variations : Sphenoid Sinus
Dehiscent Optic Nerve Dehiscent Int. Carotid.a
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Variations : Sphenoid Sinus
Absent Septa Multiple Septae
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Variations : Sphenoid Sinus
Septa ending on Optic Septa ending on Carotid
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CT in Pathology
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Acute Sinusitis• Air Fluid level
• Mucosal thickening
• Complete opacification of the sinus
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Chronic Sinusitis
• Ethmoid sinus is commonly involved
• Mucosal thickening
• Bone remodeling due to osteitis
• Polyposis
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Fungal Sinusitis• Allergic fungal sinusitis
• Sinus mycetoma
• Acute invasive fungal sinusitis
• Chronic invasive fungal sinusitis
• Chronic granulomatous fungal sinusitis
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Allergic fungal sinusitis
• Complete opacification of multiple sinuses
• Sinus expansion & erosion of sinus wall
• High attenuation areas due to metals
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Sinus Mycetoma
• Focal area of increased attenuation that is created within a deseased sinus
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Acute invasive fungal sinusitis
• Aggressive bone erosion
• Extension of disease into adjacent soft tissues
• Intrasinus high attenuation may not be present
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Bening polyp
• Homogenous, well circumscribed hypodense/isodense mass
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AC Polyp
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Mucocoele
• Hypodense, non-enhancing mass that fills and expands the sinus cavity
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Mucocoele
Frontal Sphenoid
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Complications of FESS
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Complication : NLD injury
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Complication : ACF injury
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Complication : CSF Leak
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Complication : Orbital Haemorrhage
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Complication : Medical rectus injury
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Complication :Pneumo-encephaloceole
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Complication : Optic Nerve injury
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Complication : Haemorrhage
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Thank you
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