Paranasal Sinuses

Question 1

When performing an external ethmoidectomy, where is the anterior ethmoid artery found?

Answer 1

2.5 em posterior to the lacrimal crest in the frontoethmoid suture line.

Question 2

What is the reduction in proptosis after endoscopic medial orbital decompression?

Answer 2

3.5 mm.

Question 3

What is the reduction in proptosis after endoscopic medial decompression and external lateral decompression?

Answer 3

3-4 mm.

Question 4

Where is the posterior ethmoid artery in relation to the optic nerve?

Answer 4

5 mm anterior.

Question 5

What percent of patients with rhinogenic headaches secondary to septal impaction experience relief after surgery?

Answer 5

50%.

Question 6

How long can the retina tolerate high intraocular pressures?

Answer 6

6o-go minutes; 15-30 minutes in the presence of an arterial bleed.

Question 7

What is the optimal graft material for sealing the sphenoid cavity?

Answer 7

Abdominal fat.

Question 8

What are the relative contraindications to the transsphenoidal approach to the pituitary gland (TSAP)?

Answer 8

Active sinus infection, limited air cell development, septal perforation, and giant pituitary tumor or vascular tumor that would require wide exposure.

Question 9

What procedure maximizes visualization of the frontal recess?

Answer 9

Agger nasi punch out procedure (POP).

Question 10

When attempting to remove a suprabullar cell, care should be taken to look for what structure?

Answer 10

Anterior ethmoid artery.

Question 11

Where does one enter the posterior ethmoids endoscopically?

Answer 11

At the junction of the oblique and horizontal portions of the basal lamella.

Question 12

If eye changes occur during surgery, what should be done?

Answer 12

Awaken patient, massage eye, and administer IV mannitol, +/- steroids; if pressure is not reduced, perform lateral canthotomy and cantholysis. Next, perform medial orbital decompression by Lynch external ethmoidectomy. Lastly, periorbital incisions can be made.

Question 13

Where does this most commonly occur?

Answer 13

Between the middle turbinate and lateral nasal wall.

Question 14

What is the most common intraoperative complication ofFESS?

Answer 14

Bleeding.

Question 15

What are the indications for osteoplastic flap and frontal sinus obliteration?

Answer 15

Chronic frontal sinusitis refractory to endoscopic surgery; mucopyocele; severe trauma with fractures involving the drainage pathways; after resection of large frontal tumors near the frontal recess.

Question 16

What should be done for a severe arterial hemorrhage during FESS that cannot be controlled with packing?

Answer 16

Compress carotid artery, induce hypotension under general anesthesia, have blood ready for transfusion, call neurosurgery, perform arteriogram with balloon occlusion test; if balloon occlusion is normal, ligate carotid artery. If changes occur, insert Swan-Ganz catheter, administer Hespan, and repeat occlusion test. If still abnormal, carotid bypass or barbiturate coma is indicated.

Question 17

What is the treatment for a CSF fistula detected postoperatively?

Answer 17

Conservative management initially-if still present after 2-3 weeks, surgical closure.

Question 18

What disease should be considered in an adult patient who underwent sinus surgery prior to 18 years of age?

Answer 18

Cystic fibrosis.

Question 19

How can a cerebrospinal fluid (CSF) fistula be detected intraoperatively?

Answer 19

Diluted fluorescein injected intrathecally can be detected intranasally after 20-30 minutes.

Question 20

What is the name of the procedure where the floor of the frontal sinus is removed but the superior nasal septum is left intact?

Answer 20

Draf II.

Question 21

What problem does an accessory maxillary sinus ostium create?

Answer 21

Enables mucous to recirculate back into the sinus.

Question 22

What are the most common complications of middle meatal antrostomy?

Answer 22

Epiphora secondary to nasolacrimal duct injury, synechiae.

Question 23

What is the safest direction to follow when resecting cells from the frontal recess?

Answer 23

From posterior to anterior, avoiding the skull base.

Question 24

Where do most osteoplastic flaps for frontal sinus obliteration fail?

Answer 24

Frontal recess and upper anterior ethmoids.

Question 25

What factors predispose to complications from ethmoidectomy?

Answer 25

General anesthesia, multiple previous surgeries, advanced disease, long-term chronic or fungal disease, intraoperative hemorrhage, right-handed right-sided surgery, endoscopic right-handed left-sided surgery, surgeon inexperience.

Question 26

What are the most common complications of osteoplastic frontal sinus surgery?

Answer 26

Hypoesthesia in the region of the supraorbital nerve, wound infection.

Question 27

What is the basic principle of the Messerklinger approach for functional endoscopic sinus surgery (FESS)?

Answer 27

Identify the skull base first then follow it in a posterior to anterior direction.

Question 28

Why is this preferred over muscle?

Answer 28

Improved take rate, less atrophy, increased resistance to infection, better sealing, and less donor site morbidity.

Question 29

What are the complications from excessive orbital decompression?

Answer 29

Intractable strabismus and hypoglobus.

Question 30

What are the three most important surgical landmarks during endoscopic ethmoidectomy?

Answer 30

Lamina papyracea, fovea ethmoidalis, and anterior ethmoid artery.

Question 31

What is the primary advantage of the inferior orbital decompression technique?

Answer 31

Large volume for decompression.

Question 32

What external structure serves as a landmark for the fovea ethmoidalis?

Answer 32

Medial canthus.

Question 33

What are the three transpalatal approaches to the sphenoid sinus?

Answer 33

Midline palatal split, U-shaped incision, S-shaped incision.

Question 34

What are the complications of transsphenoidal approach to the pituitary gland (TSAP)?

Answer 34

Numbness of teeth and gums, nasal septal perforation, short-term crusting/dryness of nasal mucosa, and CSF leak.

Question 35

What is the treatment for subcutaneous emphysema after FESS?

Answer 35

Observation and reassurance-usually resolves in 7-10 days.

Question 36

What are the indications for orbital decompression?

Answer 36

Optic neuropathy, severe proptosis (in excess of 24 mm), exposure keratopathy, acute deterioration in orbital status not responsive to short-term corticosteroids.

Question 37

Orbital hemorrhage occurs most frequently from trauma to which vessels?

Answer 37

Orbital veins lining the lamina papyracea and anterior ethmoid artery.

Question 38

If orbital fat is exposed during the operation, why should the nose not be overly packed?

Answer 38

Packing may press into the periorbita and posterior chamber, increasing pressure and causing proptosis.

Question 39

For which patients are gravity-dependent inferior antrostomies required?

Answer 39

Patients with dysfunctional cilia (immotile cilia, cystic fibrosis).

Question 40

What are the indications for endoscopic frontal sinus drillout?

Answer 40

Patients with mucoceles or severe frontal sinusitis in whom previous surgery has failed.

Question 41

Which area of the orbital floor should be preserved during endoscopic orbital decompression?

Answer 41

Portion lateral to the infraorbital nerve canal to prevent vertical subluxation.

Question 42

What is the landmark for the posterior extent of bone resection during medial orbital decompression?

Answer 42

Posterior ethmoid artery.

Question 43

Is an orbital hematoma a pre- or postseptal injury?

Answer 43

Postseptal.

Question 44

How can one differentiate between pre- and postseptal orbital bleeding?

Answer 44

Preseptal hematoma is darker, more diffuse with more lid edema; proptosis, chemosis, and mydriasis are characteristic of postseptal hematomas.

Question 45

Why is suprasellar tumor extension not a contraindication to transsphenoidal approach to the pituitary gland (TSAP)?

Answer 45

Resection is facilitated by auto decompression of the tumor into the sphenoid cavity.

Question 46

What complication after orbital decompression is most threatening to the vision?

Answer 46

Retinal artery occlusion.

Question 47

What adjuvant to endoscopic sinus surgery has been shown to decrease the need for subsequent surgery in patients with cystic fibrosis?

Answer 47

Serial antibiotic lavage.

Question 48

What factors increase the likelihood of requiring revision sinus surgery?

Answer 48

Smoking, severe diffuse disease preoperatively.

Question 49

Which two eye muscles are most prone to damage during FESS?

Answer 49

Superior oblique and medial rectus muscles.

Question 50

What is the most common postoperative complication of FESS?

Answer 50

Synechiae.

Question 51

What is bulgarization?

Answer 51

Technique to incite synechiae formation between the middle turbinate and septum to prevent the middle turbinate from collapsing and obstructing the osteomeatal complex postoperatively.

Question 52

Why must all mucosae be removed during frontal sinus obliteration?

Answer 52

To prevent mucocele formation.

Question 53

Which type of frontoethmoid cells are more likely to necessitate both an above (via trephination) and below (endoscopic) approach for adequate resection?

Answer 53

Type III and IV.

Question 54

What are the indications for surgical intervention in patients with sinusitis?

Answer 54

Well-documented history, failure of medical management, significant quality-of-life issues; history confirmed with CT scan and nasal endoscopy.

Question 55

If there is no evidence of a CSF leak intraoperatively, is a fat graft still used?

Answer 55

Yes, if a thin, bulging diaphragma sella is left, the fat will help prevent secondary empty sella syndrome and the potential for delayed CSF leak.