Surgery

Contents
Preface - 8
About the author - 9
Introduction - 10
Historical aspects of otolaryngological surgery - 15
History of mastoid surgery - 20
Role of microdebriders in otolaryngology - 23
Otology - 29
Mastoidectomy an introduction - 29
Tympanomastoidectomy - 46
Approaches & mastoidectomies - 47
Modified radical mastoidectomy - 56
Drilling tips - 60
Canalplasty - 61
Otoendoscopy - 64
Endoscopic myringoplasty - 66
Classic myringoplasty - 72
Tympanoplasty - 74
Grommet insertion - 88
Stapedectomy - 94
Ear lobe repair - 98
Surgical techniques in Otolaryngology
2
Preauricular sinus excision - 104
Labyrinthectomy - 111
Meatoplasty - 116
Retrolabyrinthine approach to petrous apex - 122
Middle cranial fossa approach to petrous apex - 126
Rhinology - 132
History - 132
Antral puncture & Lavage - 138
Maxillectomy - 142
SMR & Septoplasty - 154
Caldwell-Luc Surgery - 160
Endoscopic inferior meatal antrostomy - 168
Vidian neurectomy - 172
Transpalatal vidian neurectomy - 178
Endoscopic posterior nasal neurectomy - 182
Approaches to frontal sinus - 185
Endoscopic frontal sinus surgery - 188
Draf Procedure - 189
Frontal sinus rescue - 196
Sewall-Boyden flap usage in external frontal sinusotomy - 198
Diagnostic nasal endoscopy - 202
Bicoronal approach to frontal sinus - 206
FESS - 209
Anatomy of uncinate process - 210

Uncinectomy - 212
Maxillary antrostomy - 222
Anterior ethmoidectomy - 222
Posterior ethmoidectomy - 222
External ethmoidectomy - 226
Endoscopic management of fronto ethmoidal mucocele - 228
TESPAL - 230
Endoscopic Transnasal optic nerve decompression - 232
Fracture nasal bones reduction - 238
Classification of fracture zygoma - 248
Zygomatic complex fractures - 253
Blow out fracture of orbit - 255
Surgical approaches to orbit - 262
Use of Foley’s catheter in the management of fracture anterior wall of maxilla - 278
Leefort classification of maxillary fractures - 278
Endoscopic orbital decompression - 284
Endoscopic medial wall decompression - 286
Lateral orbitotomy - 288
Endoscopic DCR - 290
Hadad-Bassagasteguy flap - 304
Endoscopic Hypophysectomy - 306
Management of CSF Rhinorrhoea - 312
Intracranial repair of CSF leak - 317
Extracranial repair of CSF leak - 317

Bath plug technique for closing CSF leak - 320
Lateral rhinotomy - 322
Surgical approaches to nasopharynx - 324
Maxillary swing approach - 324
Mandibular swing approach - 325
Midfacial degloving approach - 326
Transpalatal approach to nasopharynx - 329
Surgical approaches to anterior skull base - 330
Laryngology - 338
Tonsillectomy - 338
Coblation tonsillectomy - 340
Adenoidectomy - 344
Quinsy drainage - 348
Tongue tie release - 352
Tracheostomy - 354
Types of cricothyroidotomy - 372
Percutaneous cricothyroidotomy - 374
Total laryngectomy - 381
Conservative laryngectomy - 390
Lingual thyroid and its management - 408
Elongated styloid process excision - 418
Classification of neck dissection - 426
Mandibular swing approach - 436
Diagnostic & therapeutic sialendoscopy - 440

Voice rehabilitation following total laryngectomy - 450
Submandibular salivary gland excision - 471
Kashima surgery - 477
Laryngeal framework surgeries - 484
Relaxation thyroplasty - 496
Equipment used in otolaryngology surgery - 498
Diathermy - 499
Operating microscope - 502
Lasers - 508
Coblation in otolaryngology - 523
Coblation tonsillectomy - 544
Coblation kashima procedure - 552
Endoscopic cordectomy - 558
Role of coblation in benign laryngeal lesions - 566
Coblation lingual tonsillectomy - 573
Coblation in tongue base reduction - 576
Coblation in UPPV - 580
Malignant tumor oropharynx ablation using coblation - 584
Rhinophyma excision using coblation - 588
Coblation in oropharyngeal hemanigoma - 592
Diathermy - 596
Suture materials - 600

Preface
Otolaryngology is a highly specialized field in Medicine.

The learning curve is also pretty steep. The text books available are found to be woefully inadequate
in imparting practical knowledge as far as operative techniques are concerned. This book has been
authored with the intention of imparting practical knowledge and skills from the field of operative
otolaryngology.
This book contains various topics including basic surgical techniques. The author has ensured that
recent surgical techniques are discussed in a detailed manner. Otolaryngology surgery is very de-
manding and instrument intensive. Major novelties as far as surgical instruments are concerned had
taken place in the field of otolaryngology. These instruments are discussed in detailed manner in
this book.
The topics are organized under the following heads:

Otology
Rhinology
Laryngology
This book will help in training the post graduates not only the basic surgical skills but also in ad-
vanced surgical techniques in otolaryngology.
8
About the Author
Professor Dr Balasubramanian Thiagarajan was formerly professor and Head Department of Oto-
laryngology Stanley Medical College, Registrar The Tamilnadu Dr MGR Medical University. He is
a devoted teacher with rich academic experience. He has authored many books in otolaryngology.
He is also running websites for the benefit of students of otolaryngology.
Android apps for the benefit of students have been developed by him.
Websites of the author:

1. www.drtbalu.com
2. www.drtbalu.co.in
3. www.drtbalu.in
Android apps:
1. drtbalu’s ENT (Post graduate resource) can be downloaded from android app store.
2. Imaging in Rhinology
3. ENT Instruments
4. ENT Resources
The author can be contacted at E mail.
Prof Dr Balasubramanian Thiagarajan

Introduction
Otolaryngology which was one of the sub spe- lentil bean.

cialties of General Surgery became a specialty In the 11th century the Arabian scholar Ibn al
of its own during the early 20th century. This Haitham1 first discovered the ability of a convex
happened because of the fact that otolaryn- lens to produce a magnified image of an object.
gological surgical skills had a steep learning The method of combining lenses to obtain an
curve and an aspiring student needed to spend enlarged image was conceived during the end of
a number of years practicing his / her skills the 16th century.
before they can become a complete otolaryngol- Seneca2 described that a globe of water mag-
ogist. It was the otologist who first paved the nifies letters. He used as reading glass. It was
way for separation of this specialty from general during 16th century that optical instruments
surgery. Surgeons of the 20th century bravely were designed by combining a series of convex
performed otological and laryngeal surgeries lenses. There is a lot of confusion regarding the
under primitive anesthesia with virtually no invention of compound microscope. If only a
antibiotics. Majority of their success could be single lens is used, (as in reading glass, or the
attributed to the excellent vascularity and heal- magnifier used by watch maker) it is termed as
ing capacity of these areas. a simple microscope. When two or more lenses
are used (ocular and objective lenses) then it is
The two world wars brought about a technolog- termed as the compound microscope.
ical revolution in the field of medicine. Better
equipment, anesthetic drugs, and discovery of The compound microscope was invented by
potent antibiotics tilted the balance in the favor the Dutch spectacle maker Zacharias and Hans
of surgeon. Discovery of antibiotics put an Janssen of Middelburg. The ocular lens mag-
end to an era of acute mastoiditis which could nifies the ‘real’ image formed by the objective
lead on to intra cranial complications a rarity. lens.
The number of tonsillectomies performed also
underwent a drastic reduction. The discovery
of microscope really transformed the field of
otology. Use of operating microscope helped
the surgeon to perform safe ear surgeries with
very minimal complications.
History of Operating Microscope:
For nearly 2000 years man knew that glass

bends light. In the second century BC Claudius
Ptolemy2 described that a stick appears to bend
in a pool of water. He also accurately recorded
the angles to within half a degree. He was the
first to calculate the refraction constant of water.
Early lenses were called as magnifiers / burning
glasses. The word lens is derived from the Latin
word Lentil, because it resembled the shape of
10
The early compound microscopes were very the observer’s eye. The body of the case can be
inefficient and the quality of the image was very used as a live box for storing specimen.
poor. During the first decade of the 17th centu-
ry large compound microscopes were designed. 18th century was a period of mechanical de-
The term microscope was used by Giovanni velopment of microscope. A screw barrel was
Faber4 of Germany. He was a botanist and art added to the basic design to improve focusing
collector. and superior magnification. The final form of
the microscope was established design wise.
Leeuwenhoek’s simple microscope: One basic problem existed in these microscopes
(chromatic aberration). This occurred because
Dutch surveyor Antoni van Leeuwenhoek in of different wavelengths making up the white
1673 used molten glass balls to form lenses light. Light waves of differing wave lengths are
and build crude simple microscopes that could bent at different angles by the convex lens to
magnify up to 275 times. One of the first things form this aberration. This aberration results
he examined under his new microscope was the in the formation of a series of strongly colored
scab from his own nose. fringe rings. This was overcome by design
modifications and by increasing the working
distance from the specimen.
Lister designed the first achromatic lens. It was

used by Dolland to set a standard in micros-
copy. In 1846, a German Carl Zeiss started a
microscope factory in Jena, Germany. Ernst
Abbe a physicist working with Zeiss developed
newer mathematical formulas and theories that
revolutionized lens making.
Early otological microscopes:
Three surgeons are associated with monocular

microscope. Kessel (1872), Weber-Liel (1876)
and Czapski (1888). Carl Olof Nylen was the
first to recognize the need for magnification in
ear surgery. He was responsible for developing
Image showing the Leeuwenhoek simple micro- the first monocular microscope. Emilio Rossi
scope has been quoted as the first to use a binocular
microscope in 1869. His earliest magnification
system had only a one lens system. This system
Flea glasses:
was replaced by another model developed by
Persson. One year later a binocular microscope
These glasses were used by entomologists to
developed by Zeiss factory (which had magni-
study insects. The lens is placed beneath the
fication of 6-10) was used for the first time by
acorn shaped lid. This lens is kept very close to

Gunnar Holmgren.
First microscope 1700. (courtesy of Zu-

rich University Medical Museum)
Image showing Nylen’s monocular microscope
12
Zeiss OPMI 1 Model (1951):
In 1951, Hans Littmann of Zeiss company de-

veloped a new binocular dissecting microscope.
This was used with great success since 1953.
This microscope had the combined advantage of
a good working distance and good illumination.
This development was done in collaboration
with Horst Wullstein and Zollner.
Image showing Binocular microscope used by

Holmgren
Technical problems of earlier binocular micro-

scope:
1. The field of view was limited to 6-12

mm
2. Working distance was only 7.5 cm Image showing Opmi 1 Zeiss microscope
3. Lack of maneuverability
4. Poor Illumination Howard House of Los Angeles summarized the
importance of microscope in ear surgery. He
Maurice Sourdille did not use the binocular said “It appears that our breakthrough is nearly
microscope, instead he preferred magnifying complete in the area of middle ear”.
spectacles. Other otologists like George Sham-
baugh, Simon Hall, Tullio and Cawthorne start- Otologists were the first surgeons to regularly
ed using microscope and continued to do so. use microscope for surgical purposes. They
were later followed by ophthalmologists and
other surgeons.
Progress in lens system and illumination pro-

vided good condition for otological surgeries.
Conditions for good microscope include:

1. Binocular vision
2. Magnification between 6 and 16x
3. Ability to modify magnification without
changing the working distance (20 cm)
4. Visual field of 20 mm
5. Coaxial illumination system
6. Good stability with total mobility in all
axes
Increasing stability of the microscope allowed for

attachment of accessory equipment like photo-
graphic cameras / other documentation systems.
Stereoscopic 3 D vision:
This is rather important for the surgeon engaged

in training students. This need gave birth to
3D video microscope. In order to produce 3
D image, two cameras are used to record the
microscopic image that can be transmitted to
the central module (the monitor). The monitor
turns the signals received from the cameras into
a double image. This requires special eye glasses
to be used. 3D image can also be produced by
image reconstruction algorithm.
14
Historical aspects of Otolaryngological Surgery
History of Paranasal sinus surgery: At this point it is worth narrating an interest-

ing story about an English anatomist who was
Introduction: consulted by a patient who had a continuous
flow of pus after extraction of upper canine
The Latin word “sinus” represents the geograph- teeth. The patient attempted to insert a pencil
ic term indicating a creek or a bay. The medical into the extraction cavity, it went in for about an
resources of Ancient Egypt (3700 and 1500 BC) inch. Anatomist then consulted Highmore who
indicated that the anatomy of nasal sinuses were explained to him the anatomical relationship of
known at that time. This resource also described antral cavity with that of dentition.
details of various treatments available at that
time. This deep knowledge of anatomy of nose Improvement of anatomical knowledge led to
and sinuses according to Edwin Smith’s papy- evolution of surgical approaches to sinus cavities.
rus was attributed to the fact that during the In 1743 Montpellier, Louis Lamorier gained ac-
mummification rituals the brain of the dead was cess to maxillary sinus cavity via the oral cavity.
remove via the nostrils, presumably by passing This approach was later published in 1768. Den-
via the ethmoid cells. tal surgeon by name Anselme L.B.B.Jourdain in
1816 treated suppurative maxillary sinusitis with
In the Hippocratic Corpus (460-377 BC) there saline irrigations via the natural ostium. But this
were indications for the therapy of rhinosinusal procedure unfortunately did not meet with the
polyposis. Aulus Cornelius Celsus (14 BC) desired success.
described paranasal sinus anatomy with a great
degree of accuracy. The first accepted reference material for normal
and pathological anatomy of nose and sinuses
In the 16th century, Sansovino described para- was published by Emil Zukerkandl in 1882. In
nasal sinuses as “cloaca cerebri”, i.e. the cavities this work the nose was considered to be part of
responsible for the drainage of “corrupted spirits” the surrounding sinuses.
from the head. In 1452 - 1509 Leornodo da Vin-
ci recognized the relationship between maxillary Origins of paranasal sinus surgeries:
sinus and the teeth. He documented it in his
drawings and paintings. Ludwig Grunwald narrated how acute and
chronic inflammations were the basis of sinusitis.
The clearest idea of anatomy of nose and sinuses Historic medical literature reveals that during
was provided by the great anatomist Berengario the 1st century in Pompei, speculum shaped
da Carpi. Andrea Vesalio in his important doc- nasal dilators were used for visualization of nasal
ument “De Humani corporis Fabrica” described cavities.
maxillary, frontal and sphenoid sinuses. He also
claimed that these spaces were filled with air. The chance of surgical drainage of nasal sinuses
More accurate studies were performed by Giulio was considered only from 17th century. Towards
Cesare Casseri. He named the maxillary sinus as the 19th century several surgeons considered
“antrum Casserii”. explorative puncture of maxillary sinus. Johann
von Mickulicz-Radecki 1905 suggested that max-

illary sinus antrum can be reached via the middle wide that the patient was able to perform antral
meatus. He was in fact the first surgeon to intro- irrigations.
duce the concept of antrostomy for drainage of
maxillary sinus. One year later Hermann Krause Kubo and Gerber expressed their preference
a German surgeon modified that technique by for antrostomy executed via the middle meatus.
adding a drainage tube to the antrostomy. They used a perforated designed by Onodi in
1902. Several techniques were used to access the
Karl K.H. Ziem described how the pathology of maxillary sinus cavity. Hall stated that inferior
maxillary sinus could be resolved through alve- meatus approach to maxillary sinus was the most
olar surgical access. Three years after him, Ernst correct one, on the other hand Lavelle and Harri-
G.F. Kuster proposed the validity of sublabial son found a higher rate of healing and lower in-
approach in drainage of maxillary sinus cavity. cidence of complications in patients with chronic
He usually created an opening in the canine fossa sinusitis treated by opening the middle meatus.
area, of the size of little finger. He used to oc- He suggested that physiologic pathway of drain-
clude the opening with rubber plug after washing age should be widened for optimal results. Mck-
its contents out. enzie described a combination of middle and
inferior meatal antrostomies. Sluder practiced
In 1893 George Walter Caldwell suggested the a more drastic surgery wherein he removed the
possibility of creating a window in the lateral entire medial wall of maxillary sinus preserving
wall of the inferior meatus via the canine fossa. only the inferior turbinate.
This approach was performed for the first time
in Europe in 1896 by Georg Boenninghaus. An Harris Peyton Mosher of Harvard University after
absolutely identical procedure was described by his detailed study of anatomy of paranasal sinus-
Robert H.S. Spicer and Henry Paul Luc in Lon- es by dissecting a number of cadaver specimen
don. A combination of procedures advocated said: “If it were placed in any part of the body it
by these surgeons was evolved where in a count- would be an insignificant and harmless collec-
er-opening of maxillary sinus was made via the tion of bony cells. In the place where nature has
inferior meatus in addition to the canine fossa put it, it has major relationships so that diseases
opening. and surgery of the labyrinth often lead to trage-
dy. Any surgery in this region should be rather
Gustav Killian described the resection of the simple, but it has proven to be one of the easiest
uncinate process with enlargement of nearby ways to kill a patient”. In 1912 he used intranasal
ostium. Halle was the first author to claim a large ethmoidectomy for the treatment of chronic eth-
personal experience on intranasal ethmoidecto- moiditis. Subtotal resection of middle turbinate
my, and frontal and sphenoid sinusotomies. He provided a better control of the sphenoidal region
stressed the importance of uniting all the cells of and posterior ethmoidal space making the sur-
ethmoid into a single common cavity. gery safer. This very same technique was adopted
by Yankauer, Lederer, and Weille.
In 1909, Dahmer performed an inferior meatal
antrostomy by cutting the anterior part of the Freedman and Kern emphasized the importance
inferior turbinate. The resulting opening was so of middle turbinate’s preservation for the preven-
16
tion of mucosal dryness due to enlargement of improve the drainage. In 1898 Riedel performed
the volume of nasal cavity. obliteration of frontal sinus. He advocated com-
Hence the term “ethmoidectomy” indicated an plete removal of anterior table and floor of frontal
opening restricted to few ethmoidal cells while sinus with stripping of mucosa. He performed
the term “total ethmoidectomy” included open- this procedure in a patient with osteomyelitis of
ing off sphenoid and maxillary sinuses as well. frontal bone. This procedure caused an unsight-
ly deformity of skull. Killian in 1903 advocated
The first approach to frontal sinus was derived retention of 1 cm bar of supraorbital rim. Killian
from ophthalmology. Alexander Ogston a Scot- was able to avoid deformity by retaining this bar
tish ophthalmologist managed to reach frontal si- of bone. Killian also advocated ethmoidectomy
nus via a horizontal incision performed under the combined with rotation of mucosal flap to cover
eyebrow and drilling the bone thereby creating the frontal recess area. Killian’s procedure was
a breach sufficiently wide to allow the opening fraught with complications like Restenosis, supra-
of both frontal sinuses. This technique was then orbital rim necrosis, post op meningitis, muco-
described in 1894 by Luc, who used it to insert a cele formation etc.
drainage tube into the frontal sinus. This surgery
was known as Ogston-Luc procedure. Era of conservative procedures (1905):
Major advantage of conservative procedure is

avoidance of cosmetic defects. Conservative
procedures involved intranasal approach to fron-
tal sinus. It was Knapp in 1908 who performed
external Fronto ethmoid surgery. He approached
the frontal sinus through its floor, removed the
diseased mucosa and stented the Fronto nasal
duct to prevent Restenosis.
In 1908 Halle chiseled out the frontal process of

maxilla and used a burr to remove the floor of
frontal sinus.
In 1914 Lothrop enlarged the frontal sinus

Alexander Ogston drainage pathway using intranasal approach. He
combined intranasal ethmoidectomy with exter-
Era of radical ablation procedures (1895): nal ethmoidal approach. He managed to create a
common frontal nasal communication by remov-
Kuhnt in 1895 described a procedure wherein ing the frontal sinus floor, intersinus septum and
he removed the anterior wall of frontal sinus in the superior portion of nasal septum. He also
an attempt to clear the frontal sinus of the dis- said that resection of medial orbital wall caused
eased mucosa. He stripped the mucosa up to the prolapse of orbital contents into the ethmoid area
frontal recess and stented the frontonasal duct to causing obstruction to frontal sinus drainage.

technology in order to design this device. He
External fronto ethmoidectomy 1897 – 1921: did this by devising a system of double alumi-
In 1897 Jenson performed the first external num tubes equipped with strategically angled
Fronto ethmoidectomy in Germany. Lynch mirrors (flat, concave and convex) that were
and Howarth in 1921 popularized resection of positioned in such a way as to bring the image
floor of the frontal sinus with dilatation of the back to his eye while simultaneously conveying
frontal sinus outlet via external approach. This the distally placed candle light into the interior
approach is hence known as Lynch Howarth body.
procedure. A curvilinear incision is made just
below the medial end of eyebrow. It is curved Endoscopic intranasal approach:
medial to the medial canthus. The frontal
process of maxilla and lamina papyracea is re- With the advent of nasal endoscopes (angled)
moved. Frontal sinus is entered via its floor and approach to the frontal sinus outflow tract has
the lining mucosa is curetted. A stent is placed become easy.
in the frontal sinus ostium to prevent stenosis.
The stent is left in place for a period of 4 weeks. History of Endoscopic Sinus Surgery
Boyden used silicone tube to prevent stenosis.
The first recorded instance of endoscope be-

Osteoplastic anterior wall approach (1958): ing used for visualization of nasal cavity was
by Hirschmann of Berlin in 1901. Alfred
This procedure became popular during 1960’s. Hirschmann was in the occupation of designing
Backer introduced radiographic plate to outline medical instruments. He modified a cystoscope
the frontal sinus. This procedure was fraught and used it to view the insides of nasal cavity.
with the risk of hemorrhage. In 1903 he published a paper titled “Endoscopy
of nose and its accessory sinuses”. In 1910, M
Zukerkandl studied sphenoid sinus drainage Reichart performed the first endoscopic si-
pathway, and he stated that it was possible to nus surgery using a 7mm endoscope. In 1925
reach this area via nasal cavities. His studies Maxwell Maltz created the term “sinuscopy” for
represent the basis for the trans-nasal-sphenoid the first time referring to the endoscopic meth-
surgery of pitutary gland. od of visualizing the sinuses. He was the one
to first encourage routine use of endoscopy as
Light source: a diagnostic tool in examination of nose and its
sinuses.
Bozzini was the first to describe an ante litteram
light source. He used his physics knowledge Walter Messerklinger working in the city of
to create a Lichtleiter (light conductor) which Graz, Austria performed basic research on mu-
allowed him to explore and examine the external cosal transport mechanism. He developed the
auditory canal, the nasal cavities and orophar- surgical principles in the management of chron-
ynx. Bozzini was the first to adopt existing lens ic sinusitis. His techniques later became popular
18
as the Messerklinger’s technique of endoscopic He developed the concept of major sinuses like
sinus surgery. frontal and maxillary sinuses were dependent
sinuses. Their drainage depended on a clear
anterior ethmoid cell structures in the middle
meatus. This zone was later christened as the
‘Osteomeatal unit’ by Naumann. This concept
was further popularized by David Kennedy of
United States.
Walter Messerklinger
In 1950’s and 1960’s Messerklinger mapped the

mucous transport routes in the nose on ca-
davers. In cadavers’ cilia continues to beat for
48 hours after death, hence they provided an
excellent model for the study. He placed Indian
ink particles inside the maxillary sinus cavity
and identified that maxillary sinus mucosal flow
was always towards the natural ostium, and then Heinz Stamberger
backwards through the middle meatus into the
postnasal space. This explained the failure of Surgeons from other European centers like
traditional Caldwell-Luc procedures and maxil- Malte Wigand of Erlangen and Wolfgang Draf
lary sinus punctures, because they depended on of Fulda Germany were also working on the
gravity for drainage of mucous secretions. concept of endoscopic sinus surgery. Draf used
a combination of rigid telescopes and operating
Messerklinger in 1960’s used a modified cys- microscope to drill out frontal sinus in recalci-
toscope and performed sinus surgeries under trant cases. Malte Wigand used an alternative
local anesthesia. He tailored the surgical proce- approach to manage sinus drainage problems.
dure according to the cause of obstruction. The He used a combination of headlight and suc-
surgery was minimalist in nature and concept. tion endoscopy in a gun like instrument with a

handle. He opened up the sphenoid sinus and his left hand.
then proceeded to dissect anteriorly. This poste-
rior to anterior dissection of sinuses goes under History of mastoid surgery:
his name “Wigand technique”. In this technique
the disease was pursued and removed rather than Introduction: “One who ignores history would
being left to resolve spontaneously unlike the do so at his peril, to be condemned to repeat the
Messerklinger ventilation concept. same mistakes”. A study of history of mastoid
surgery and its instrumentation is important in a
Path breaking developments that opened up new sense that they are the tombstones to our success
vistas in endoscopic sinus surgery: today. Eighteenth century is characterized by
advancement in instrument designs and steril-
Development of miniaturized telescopes at Read- ization techniques. Heat resistant metals were
ing University UK 1951 and development of CT used to manufacture surgical instruments as they
scan by Godfrey Hounsfield of Hayes London had to withstand extremely high sterilization
opened up new vistas in endoscopic sinus sur- temperatures. Our forefathers of 18th century
gery. were great innovators and to their credit even
now majority of mastoid instruments in use were
Endoscopic sinus surgery was not popular conceived and designed by them.
among British surgeons because Messerklinger
who is the father of endoscopic sinus surgery did Mastoidectomy during different eras:
not speak English and he delivered all his lectures
in his native tongue German. It was left to his The art and craft of Mastoidectomy has evolved
assistant Heinz Stamberger who spoke fluent En- during the past 200 years. The process of this
glish to popularize the technique among English evolution can be studied under three different
speaking surgeons. eras i.e.:
David Kennedy (ENT Resident) at Johns Hop- 1. Era of trepan (18th century)
kins Medical School Baltimore was asked to
review the paper published by Messerklinger 2. Era of chisel & gouge (Early 19th century)
titled “ Endoscopy of the nose”. He became so
enthused that he made it a point to learn the 3. Era of electrical drill (20th century)
technique himself. David Kennedy along with
Stamberger popularized Messerklinger technique Era of Trepan:
all over the English-speaking world.
Trephination was performed to let out pus. This
Endoscopic sinus surgery initially was performed was extensively practiced during the 18th century
with a Wittosmer side arm attached to a beam to let out pus from skull bones. The first success-
splitter placed on the eyepiece of the telescope ful trephination of mastoid cavity was performed
so that the observer could view the surgery. The by Ambroise Pare during 16th century. Young-
observer usually stood on the opposite side of the er during 17th century devised a hand Trepan
table and would support the bulky side arm with which he used extensively to perform this pro-
20
cedure. A handheld trepan was commonly used
during this period. The cutting head of trepan Modern mastoid surgery was pioneered by the
used could be circular (to cut a circular piece of German otologist Scwartze during 1873. He and
bone), exfoliative head (to shed the superficial his assistant Adolf Eysell abandoned the use of
layer of bone), and perforative head (used to Trepan in favor of chisel and gouge. He popu-
make a hole in the bone). In 1736 Jean Louis larized Chisel and gouge as he was convinced
Petit performed the first mastoid opening for a that it was the safest way to open up the mastoid
patient with mastoid abscess. Pus His main aim antrum. His assistant had drawn up detailed
was to create a hole through which pus from the illustrations of the various types of chisel and
mastoid cavity can drain. While using a Trepan gouges used in this procedure. Buck introduced
it should be dipped in cold water often to reduce the small curette that could be used to widen the
heat generated during the procedure. aditus. He also advocated continuous chiseling
of the hard mastoid cortex till the soft bone is
In 1776 Jasser used a trocar to open up the reached which could be curetted out rather easily
mastoid cavity. He used the nozzle of a syringe using curettes of varying sizes.
to aspirate the contents from the mastoid cavity.
This surgical procedure hence was aptly named Initially Volkmann sharp edged spoons were
as “Jasser procedure”. The term “trocar” has its used as curette. Samuel Kopetzky, American
origin in French language. “Toris – quarts” is otologist advised that one should become dex-
a French word to describe an instrument with terous and elegant with the use of a set of instru-
three cutting sides used to make a hole. Amer- ments. Newer instruments (design wise) should
ican otologist Fredreik White described this era be introduced only when they have distinct
of mastoid surgery as an experimental one. This advantages over the tried out older ones. This
experimental era proved that the concept of observation holds good even today.
opening up the mastoid cavity and draining the
secretions is a possibility. The instrumentation Electrically driven drill period: “Modern era
was of course woefully inadequate. The first Mastoidectomy”
catalogue of surgical instruments published in
1860’s mentioned the various surgical and dental Electrically driven drills were used to manage
instruments in use. Mastoid instrumentation of dental caries even way back in 1882. It was
course did not find a place in that catalogue. William McEwen who drew the attention of the
world to this unique device. He believed that
Chisel & Gouge period: the safest instrument that can be used to drill the
mastoid antrum is the rotating burr. It had better
This period was characterized by the introduc- control and uniform rotator cutting ability. The
tion of general anesthesia which facilitated a size of the burr bits can vary according to the
surgeon to operate leisurely on a patient. It was area of surgery. It was Julius Lempert in 1922
Amedee Forget a French surgeon who used a who really popularized the use of electrically
mallet and gouge to open the mastoid cavity and driven drill in ear surgeries. William House
drain the accumulated pus. He performed this introduced the suction irrigation system and
surgery during 1860. retractors in mastoid surgery. He observed that

while performing ear surgeries a surgeon needs
to keep both hands useful.
Holmgren introduced the operating microscope

which really made Mastoidectomy totally a safe
procedure.
22
Role of Microdebriders in Otolaryngology
Introduction:
The originally patented Vacuum dissector was
Microdebrider should be considered to be next cylindrical, electrically powered shaver system
only to an endoscope in rhinological surgical which is supplied with continuous suction. The
procedures. It is hence considered to be the most basic design which was patented has a hollow
important innovations in shaft with a rotating / oscillating inner cannula.
the field of rhinology and endoscopic sinus sur- The suction applied draws the soft tissue in-
gery. In recent times this instrument is becoming wards and is trapped there. This trapped tissue
really popular thereby reducing the reliance on is sheared off by the rotating blade between the
traditional non powered inner and outer cannulas.
sinus instruments like curettes and forceps. The slower the rotating speed of the blade larger
is the tissue bite, at higher speed rates the instru-
Advantages of Microdebrider include: ment becomes less aggressive. The sheared bits of
tissue are sucked by the suction effect. Irrigation
1. It spares the adjacent mucosa (Mucosal spar- via a side portal is performed in a continuous
ing) basis.
2. It is precise
3. Removes tissue real fast Irrigation helps in preventing the bits of tissue
4. Visualization is really good from blocking the suction portal of the hand
5. Since the blade comes in different angles it can piece. The bits of tissue sheared by debrider blade
be used to cut tissues from can be collected and sent for histopathological
even inaccessible areas inside the nose examination also.
6. The suction applied to the blade sucks and
holds the tissue for better cutting Hand piece design:
effect
All the commonly used debrider hand-pieces still
History: maintain the cylindrical design of the original
patent of Urban. The cylindrical design permits
Originally the concept and design of Microde- the surgeon to hold the hand piece as if it were a
brider was patented by Urban in 1969. scalpel.
In his patent application he called the equipment
“Vacuum rotatory dissector”. This equipment was The Diego Microdebrider provides a pistol grip
originally used by the House group to remove hand-piece. Some surgeons find this comfortable.
acoustic neuroma during 1970’s. Orthopedic sur-
geons started using it for arthroscopic surgeries With the image guidance systems becoming
from the year 1975. common hand-piece manufacturers have made
hand pieces that can be easily coupled with image
It was only from the year 1994 Setliff and Parsons guidance system.
started using this equipment for nasal surgeries.
Improvements to this original vacuum dissector
started taking place by leaps and bounds.

Debrider blades:
These blades are disposable. They come in var-

ious configurations. Their edges can be straight
or serrated. Straight edged blades are less trau-
matic and has more tissue sparing effect, whereas
serrated ones allow for better gripping of tissue.
It has an inner and outer cannula. The inner
cannula’s edge happens to be the blade. The outer
cannula serves as a conduit for suction, irrigation
and the inner cannula.
Depending on the relative angles of the inner and

outer cannulas the cutting action of the debrider
blade could either be guillotine or scissors. Most
of the debrider blades has a scissors like cutting
action with an angle between the openings of
the inner and outer cannulas hence the shearing
Image of Microdebrider hand piece force is applied only to a small tissue area at a
given time. In debrider blades with a guillotine
cutting mechanism the apertures of the two can-
nulas run parallel to one another hence it shears
off the entire bit of tissue.
Figure showing pistol grip hand-piece
Figure showing the two basic types of debrider

blades
24
These blades can either be set to oscillate or Tonsillectomy blades:
rotate. Oscillation usually runs at a slow speed
(5000 rpm) and is useful for soft tissue resection. These blades are used to perform extra capsular
At slower speeds the port remains open longer tonsillectomy. These blades are wider with low
allowing more soft tissue to be drawn into the angles to enable it to function as a guillotine.
aperture before the cut could be made. This adds These blades usually come in 4mm diameters.
to the efficiency of soft tissue resection.
Adenoidectomy blades:
Forward and reverse rotations are faster (up
to 15,000 rpm) and has a drill like action and These blades are curved and hence can be intro-
hence could be used to drill bony structures as duced through the nasal cavities. The curvature
in endoscopic dcr, reduction of bony septal spur of these blades mimics the curvature of the nasal
etc. Since the speed is too low for drilling bony cavity.
structures when compared to the mastoid micro-
drills, it takes a long time to drill bony structures
using a Microdebrider. Recent innovations in
Microdebrider blades is the availability of blades
which are prebent to suit the various angulations
of resection inside the nasal cavity.
Figure showing the debrider blade used for ade-

noidectomy
Image showing the prebent Microdebrider

blades
Special Microdebrider blades:
These blades are made to perform specific tasks.

Figure showing debrider blade used in tonsillec-
tomy
Figure showing turbinectomy blade
Turbinectomy blades:
Role of debriders in clearing up the operating
These blades are used to perform inferior turbi- field:
nectomy. These blades are small diameter blades
(2-2.8 mm). It has a beveled guard at the back Clearing the operating field of blood and other
which protects the turbinate mucosa while the secretions is a must for better visibility during
vascular erectile tissue is being dissected. This nasal endoscopic sinus surgery. Even small
mucosal protection causes lower incidence of amounts of bleeding can significantly impair
osteitis of the inferior concha. visibility during endoscopic surgeries. Debriders
have the ability to continuously suck blood and
Turbinectomy blades: dissected tissues out of the surgical field is a great
advantage.
These blades are used to perform inferior turbi-
nectomy. These blades are small diameter blades Recent modifications in debrider technology
(2-2.8 mm). It has a beveled guard at the back have managed to add the ability to cauterize
which protects the turbinate mucosa while the bleeders using bipolar cautery delivered via the
vascular erectile tissue is being dissected. This end of the blade. These blades themselves are sur-
mucosal protection causes lower incidence of rounded by layers of insulation causing a sand-
osteitis of the inferior concha. wiching of the inner and outer electrodes. These
instruments can be set to cauterize bleeders in
three settings:
1. Low – 10 Watts
2. Medium – 20 Watts
3. High – 40 Watts
26
The only drawback of these blades is that only a Where do you use Microdebrider drill bits?
small zone of bipolar cautery is present.
1. In Endoscopic DCR
Microdebrider drills: 2. In frontal sinus surgeries
3. In trans sphenoid pituitary surgeries
Even though Microdebriders are not suited for 4. In Endoscopic skull base surgeries
drilling bone, the thin ethmoidal bones
can easily be drilled using drill bits in place of de- Limitations of Microdebrider:
brider blades. These drill bits are commonly used
in endoscopic dacryocystorhinostomy proce- 1. Slow rotation rates – Debrider rotate at slow
dures. These drill bits are diamond drill bits (2.5 rates (15,000 rpm) as compared to that of micro-
mm) size. The number of grooves in the drill bit drills (80,000 rpm) thus making it inefficient to
determines the speed of drilling. Fewer grooves drill bony structures.
result in faster and aggressive drilling of bone. 2. Tactile feedback is less while operating with
This always comes with a price (poor control). As Microdebriders when compared to that of con-
the number of grooves in the drill bits increas- ventional instruments
es, the bone take down rate slows down but the 3. It should be used carefully in confined spaces
control is much better. Diamond burrs cause less close to vital structures in order to avoid damage
aggressive drilling than normal burrs. to them
4. Initial cost of equipment and recurring ex-
penses incurred towards purchase of blades
increase the cost of surgery.
Various components of Microdebrider:
A debrider contains three components.

1. The console which helps in controlling the
speed of rotation/direction of rotation. These
parameters can easily be changed with the help of
an attached foot pedal.
2. The blade: This is a tubular metal structure
with serrated edge / smooth edge. The cutting
edge is present only on one side only, while
the smooth opposite surface does not cut. It is
usually connected to a suction tube. These blades
come in various sizes and configurations. This
Figure showing sheathed Microdebrider drill blade allows for simultaneous cutting and remov-
bits al of cut tissue by suction.
3. Hand piece: Which is a portable micro motor.
It derives its power supply from the console. The

blade is attached to the shaft of the hand piece.
Image showing console of Microdebrider
Image showing debrider in action
28
Otology
2. Modified radical mastoidectomy

Mastoidectomy An Introduction
3. Open technique
Introduction: 4. Front to back mastoidectomy
Mastoid surgeries are performed to eradicate 5. Attico antrostomy

middle ear disease. A number of vital structures
are in close proximity / located inside the tem- 6. Open mastoidoepitympanectomy
poral bone. A thorough knowledge of temporal
bone anatomy is a must for all otologists. Sur- Aims of Mastoid surgery:
geon who attempts this surgery without ana-
tomical knowledge is sure to fall into the pit of 1. Eradication of mastoid and middle ear disease
complications. Anatomy of the temporal bone is and prevention of residual disease
highly variable. The surgeon should be aware of
all these variations. The mastoid portion of the 2. Improving middle ear ventilation and preven-
temporal bone has varying thickness of corti- tion of recurrent disease
cal osseous covering. This is filled with air cells
which are Septated. This is similar in appearance 3. To create a dry and self-cleansing cavity
to ethmoidal sinuses.
4. Reconstruction of hearing mechanism. The
Types of Mastoidectomy: terms open and closed mastoidectomy are com-
monly used these days. Common to both open
Various types of mastoidectomies are performed. and closed mastoidoepitympanectomy is the
They include: bony work involving the mastoid cavity. It in-
volves identification of the important landmarks
Canal wall up mastoidectomy: (this implies that skeletonizing a thin shelf of
bone covering the important structure) before
1. Combined approach attempting to remove the disease and creating
maximum exposure for complete exenteration of
2. Intact canal mastoidectomy the disease.
3. Close technique Canal wall down mastoidec- Closed technique:

tomy
In this technique the posterior canal wall is kept
1. Radical mastoidectomy - The classical radical in place and dissection is performed trans canal
mastoidectomy is not performed for eradication after a proper Canalplasty. It can be performed
of inflammatory pathology as it results in a large via Transmastoid approach also (post auricular
cavity that frequently discharges. This procedure incision).
is reserved only for middle ear malignancies.

Open Mastoidoepitympanectomy: temporomandibular joint which lies anteriorly.
This is achieved by drilling the bony portion of
This involves complete exenteration of the the external auditory canal. Drilling is focused
mastoid air cell system and the epitympanum. on the posterior wall, superior wall and inferior
This includes removal of incus and mastoid wall of the bony external auditory canal. Before
head, exenteration of the supralabyrinthine and drilling the skin lining of the external canal
supratubal cells. This procedure is indicated in should be reflected to expose the bony portion
poorly pneumatized and ventilated ears with of the external canal.
limited access and exposure. In this procedure
the the facial nerve is skeletonized along its Epitympanotomy:
mastoid segment. This is done by lowering the
posterior canal wall up to the level of the facial This involves removal of outer attic wall to ex-
nerve. A thin layer of bone is left over the facial pose the head of the malleus and incus and the
nerve. The mastoid area behind the facial nerve soft tissue pathology in the attic area is removed.
is obliterated with a muscle flap to keep the final In order to remove the soft tissue pathology
volume of the mastoid cavity low to prevent from the anterior epitympanum the head of the
discharging ear. malleus need to be clipped to get access to that
area.
The other method open mastoidectomy could
be performed (canal wall down) is front to back Epitympanectomy:
mastoidectomy. This approach can be selected
when a prior decision has been made in advance In this procedure after removing the outer
to bring down the posterior canal wall and the attic wall the incus and head of the malleus are
mastoid is sclerotic. The only draw back of this removed to get access to the entire attic. This
procedure is difficulty in removing all mastoid procedure also exenteration of the supralabyrin-
air cells. Leaving behind some cells would result thine cell tracts.
in a discharging cavity. Some of the terminol-
ogies used in mastoid surgeries: Cortical Mas- Posterior tympanotomy:
toidectomy: This is also known as the simple
mastoidectomy involves opening of the mastoid This is also known as Facial recess approach.
cortex and identification of the aditus ad an- This approach was initially used to approach the
trum. The aditus is widened as much as possible. hypotympanum air cells. Currently this ap-
The intention of this surgical procedure is to proach is used for cochlear implant procedures.
reventilate the middle ear cavity. A fully ventilat- In this procedure a window is opened from the
ed middle ear cavity is free of disease. mastoid to the middle ear between the facial
nerve and the chorda tympani. This is created
Canalplasty: after performing cortical mastoidectomy.
This surgery attempts to enlarge the external

auditory canal without causing injury to the
30
riorizing the surgical cavity. The posterior canal
Indications: wall is lowered up to the level of the facial nerve
canal. In order to reduce the size of the cavity,
1. Performed as a part of closed mastoidoepi- the mastoid tip is removed and a myosubcutane-
tympanectomy (combined approach) in order to ous occipital flap is created to reduce the size of
remove cholesteatoma from the hypotympanum the cavity. Meatoplasty is routinely performed.
Age is not a limitation for open mastoid proce-
2. To remove pus from the region of the round dures it can be performed with good effect even
window in acute bacterial / viral otitis media in children.
with sensorineural hearing loss
3. To provide access to promontory & round

window in cochlear implant surgery Indications for open mastoidectomy:
4. To access the incus / round window with 1. Large cholesteatoma

insertion of the vibrant sound bridge
2. Labyrinthine fistula
Closed mastoidoepitympanectomy with tym- 3. Cholesteatoma with complications

panoplasty:
4. Recurrent cholesteatoma after previous closed
This process includes: mastoidectomy
Canalplasty 5. Poorly pneumatized mastoid
Mastoidectomy 6. Extensive granulation tissue in the middle ear

cavity
Epitympanectomy
7. If the patient is not reliable for follow up
Posterior tympanotomy
Indications for closed mastoidectomy:
Tympanoplasty
1. Limited disease
The external bony canal is preserved. The only
drawback of this procedure is the view to the 2. If pneumatization is normal and space is
anterior epitympanum is very limited. Sinus sufficient
tympani view is also rather limited. Open mas-
toidoepitympanectomy with cavity obliteration: 3. If ventilation is normal in middle ear and
This procedure involves radical exenteration of mastoid air cells
the tympanomastoid air cell tracts thereby exte-

4. If the patient would come for regular follow Canalplasty needs to be done by drilling the an-
up terior wall which could be close to the temporo-
mandibular joint. Close to the posterior wall
Investigations: mastoid air cells are present. These should not
be breached while performing a Canalplasty.
1. Pneumatic otoscopy should be performed to
determine the presence of labyrinthine fistula. A 4. Size and presence of mastoid emissary vein. A
positive response will always indicate the pres- large mastoid emissary vein can cause trouble-
ence of a fistula while a negative test does not some bleeding if it is not anticipated.
exclude it.
5. Sigmoid sinus and its relation in the mastoid
2. Pure tone audiometry to assess the hearing cavity should be studied. In children the sigmoid
levels may lie close to the lateral surface of the mas-
toid, hence can be easily injured while drilling in
3. HRCT temporal bone: All patients undergo- this area. In adults sigmoid sinus malformation
ing mastoid surgery should have a preop HRCT may be appreciated in the preop CT scan. If the
imaging (1/2 mm cuts). The following should be sigmoid sinus lies very anteriorly in the mastoid
looked out for in HRCT: cavity it may be difficult to perform posterior
tympanotomy due to the limited space available.
1. Extend of pneumatization of temporal bone. In the case of revision surgery, CT image will
It will reveal whether pneumatization is normal, reveal whether sigmoid sinus has been exposed
poor or the mastoid is sclerotic. This gives an during the previous surgery or if there is any
important input about the eustachean tube func- bony covering left. If the sigmoid sinus was
tion during the first 4 years of the patient’s life exposed during the previous surgery then scar
was like. Poor ventilation and pneumatization formation in that area will make it difficult to
needs open cavity procedure. elevate tissue in that area without breaching the
sigmoid sinus. This can very well happen when
2. To assess ventilation. This can be done by the periosteal flap is elevated.
assessing the aeration of the middle ear and
mastoid air cells which could be clearly seen in 6. Jugular bulb. CT image should be studied for
the CT images. Opacification of the middle ear high riding position. If it is dehiscent it will also
or mastoid air cells would suggest poor ventila- be evident in the scan.
tion of middle ear cleft. Poor ventilation in the
already impaired pneumatized cell tracts would 7. Carotid artery. Images should be studied to
favor an open cavity procedure. look out for dehiscence at the level of the eusta-
chean tube.
3. Study of the bony external auditory canal.
Thickness of the bony portion of the external 8. Tegmen tympani. The shape of the tegmen
auditory canal both anteriorly and posteriorly should be studied. The following details should
should be assessed. This is important when a be looked into: Is the tegmen flat, or does it
32
slope upwards with air cells lying medial to it or the area and also serves to reduce immediate
whether it is low lying. Tegmen should also be post op pain.
looked out for dehiscence. A bony defect in the
tegmen tympani or anterior wall of the epitym- Incision: Post aural incision of William Wilde
panum should raise the suspicion of an encepha- is used. A curved incision is made about 1.5 cm
locele / cholesteatoma extending into the middle behind the post auricular sulcus with a 15 blade
cranial fossa. If dehiscence is present, then MRI knife. The incision begins from just above the
should be performed to glean more details. linea temporalis and extends up to the mastoid
tip. Care must be taken not to place the incision
9. Facial nerve. The tympanic segment may be over the post auricular sulus as it would enter
dehiscent, this is common in children. In the into the external auditory canal.
presence of cholesteatoma, the tympanic seg-
ment of facial nerve can be exposed due to bone Elevation of periosteal flap: Anteriorly based
erosion. In the case of revision surgery a prior periosteal flap is developed about 1.5 cm in
knowledge of exposed facial nerve will prevent length. Periosteal elevator is used to elevate
its inadvertent damage during elevation of tym- the flap from the bone until the spine of Hen-
panomeatal flap. le’s spine is visualized and the entrance of the
external auditory canal comes into view. A
10. Presence of fistula over lateral canal can be roller gauze is inserted through the flap and the
visualized flap is pushed anteriorly and held away from
the surgical field exposing the external audito-
11. Extent of the disease can be assessed. ry canal. Self-retaining retractors are used to
retract the flap. Retractor exposes the field to
12. Status of the ossicular chain can be studied the surgeon allowing the surgeon to have both
the hands free. Retraction also reduces bleeding
Mastoidectomy can be performed under both from the area. If there are any bony overhangs a
Local anesthesia and General anesthesia. Canalplasty needs to be performed. It is always
ideal to perform this procedure always as it de-
fines the anterior limit of the surgery. The entire
Positioning: The patient is positioned supine annulus should be visible.
with head rotated away from the surgeon. Over
extension of neck should be avoided specifically Tympanomeatal flap:
in children as it could cause atlantoaxial sublux- The posterior meatal skin flap is elevated to-
ation. wards the annulus. Cotton ball soaked in adren-
aline is used to push the flap in order to reduce
Infiltration: Post auricular skin incision area is bleeding. Suction is avoided over the flap. The
infiltrated with 2% xylocaine with 1 in 200,000 annulus should be elevated from the sulcus
adrenaline. Infiltration serves to elevate the skin exposing the middle ear mucosa. The middle ear
and periosteum in that area. It also serves to mucosa is incised with an angled picked thereby
reduce bleeding during surgery. It anesthetizes entering into the middle ear cavity. The entire

middle ear cavity can be inspected and disease plate is followed posteriorly up to the sinodural
inside the middle ear can be removed. angle which is actually the area between the
sigmoid sinus and the dura. The dural plate can
Antrostomy and mastoidectomy: be identified by the change in color of the bone
This should always be performed. The prin- and the change in the pitch of the burr. The
cipal surgical landmarks are linea temporalis sigmoid sinus is skeletonized. A thin covering
superiorly, bony ear canal and spine of Henle of bone should be left over the sinus. The lateral
anteriorly and the mastoid tip posteriorly. These and posterior semicircular canals are identified
surgical landmarks should be identified and and the retrolabyrinthine cells are exenterated.
exposed. While elevating the periosteum pos- The facial nerve should be identified next. The
teriorly one can encounter mastoid emissary superior landmark for the mastoid segment of
vein inferior to the mastoid tip. The same if the facial nerve are the lateral canal (the nerve
exposed can be cauterized. Maceven’s triangle is runs 2.5 mm anterior to it). The best way to
identified. Aditus is supposed to lie just under identify the facial nerve is along the digastric
it about 1.5 cms deep. Drilling is begun in the ridge. When searching for mastoid segment of
area of Maceven’s triangle using a 8 mm cut- facial nerve a large diamond burr 5 mm should
ting burr. Large burr is always preferred in this be used. Ample irrigation should be used to
step. A very common mistake is to search for reduce thermal damage to the underlying nerve.
the antrum very low thereby endangering the Digastric ridge: This is the distal landmark of
facial nerve. The safest way to find the antrum is the mastoid segment of the facial nerve. It is a
to follow the dura. The tegmen tympani marks smooth convex bone found close to the mas-
the superior extent of the dissection. Drilling is toid tip. This ridge is difficult to find in a poorly
always begun above linea temporalis. The teg- pneumatized mastoid while it is easier to identi-
men tympani is exposed. It can be identified by fy in a well pneumatized one. Once the sigmoid
a change in the color of the bone and the change sinus has been skeletonized the digastric ridge
in the pitch of the burr. The dura should always is found by drilling inferior to the sinus close
be skeletonized till the middle cranial fossa dura to its mastoid tip from laterally to medially in a
is exposed and is seen shining through a thin horizontal direction. The periosteal fibers run
layer of bone. The dural plate is followed in an anteriorly from the digastric ridge in a perpen-
anteromedial direction. The lateral semicircular dicular plane to the ridge. The facial nerve can
canal is encountered next. As soon as the later- be located proximal to the stylomastoid foramen
al canal is visualized the direction of drilling is by drilling the last of these periosteal fibers. The
changed to a medial to lateral action in order surgeon could encounter the sensory branch of
to avoid touching the ossicles. If ossicles are the facial nerve which innervates the posterior
touched by the rotating burr then it would cause canal wall just above the stylomastoid foramen.
sensorineural hearing loss. The body and short The nerve is skeletonized by drilling in a wide
process of incus are identified next. The incus plane between the lateral canal proximally and
is often seen by its refraction in the irrigation the stylomastoid foramen distally working from
fluid. Medial to the incus the tympanic segment anterior to posteriorly. Drilling is always done
of the facial nerve is identified. The sinodural parallel to the course of the facial nerve. Lots of
34
irrigation should be done. Drilling should be while drilling in this area. The tympanic and
performed along the lateral aspect of the nerve. labyrinthine segments including geniculum lie
Drilling should not be done behind and medial in this area. The tympanic segment lies in the
to the fallopian canal. Once the facial nerve is floor of the anterior epitympanic recess. Nerve is
identified the retrofacial cells can be exenterat- supposed to lie above the cochleariform process
ed. Posterior tympanotomy: The facial nerve is which is a reliable landmark. The cog which is
skeletonized leaving a thin shelf of bone overly- a bony process in the anterior epitympanum
ing the nerve. It is followed proximally towards which extends from the tegmen tympani points
its pyramidal segment, just inferior to the lateral to the location of the facial nerve.
canal. The facial recess is approached by drilling
away the bone situated between the pyramidal
segment of the nerve posteriorly, the chorda Modified radical Mastoidectomy:
tympani and the fossa incudis superiorly. In the
absence of disease, the facial recess and stapes This procedure is performed in patients with
suprastructure is visible through the tympa- extensive cholesteatoma and in whom follow up
notomy. For removal of cholesteatoma in facial is suspected not to be regular. Hence given the
recess one has to work from both sides of the only chance to tackle the disease the surgeon
intact posterior canal wall. Epitympanotomy: should perform complete removal of the disease
If cholesteatoma does not extend significantly in the first chance itself. The procedure is the
into the attic then atticotomy is performed. This same for atticotomy. The difference being the
involves exposure of the head of the malleus and posterior canal wall is lowered up to the level of
the incus to remove soft tissue from attic. The the facial canal. The aditus, antrum and the en-
outer attic wall is removed, by drilling using a tire middle ear cavity is exteriorized as a single
diamond burr. While drilling in this area care large cavity. A meatoplasty should be performed
should be taken to ensure that the burr does not in these patients. The meatoplasty creates a large
touch the ossicles. The tegmen plate should not opening in the external ear that would commu-
be breached. nicate with the operated cavity.
Epitympanectomy: The operated cavity and the meatoplasty are

packed with ointment gauze. The wound is
This procedure is indicated when cholesteatoma closed in layers.
extends medial to the ossicles or overlies the
lateral canal. If ossicles are involved by choleste- Drilling tips:
atoma then the ossicles need to be removed. The
incus is removed by mobilizing it with a 45-de- 1. It is better to set the magnification of the mi-
gree hook without injuring the underlying facial croscope between 4 - 6X as this will give a more
nerve. The malleus head is severed with a mal- complete orientation of the drilling area. Higher
leus clipper. The head of the malleus is removed magnification levels are necessary to appreciate
leaving the tensor tympani tendon intact. Facial the minute details.
nerve lies in this area. It should not be damaged

2. It is best to choose the largest possible burr bit as it will prevent damage to the structure even if
for initial drilling as this will cause less damage. the hand piece slips.
Using small burrs is always dangerous.
13. Canalplasty should be performed whenever a
3. The length of the cutting burr is adjusted bony overhang obscures complete visualization
according to the depth of the area to be drilled. of the ear drum.
Shorter the burr length better is the control.
14. while drilling care should be taken not to
4. Majority of bone drilling should be performed touch the ossicular chain.
by using cutting burrs. Diamond burrs can be
used when drilling is to be performed over facial 15. Middle cranial fossa dural plate should not
nerve area, dura, sigmoid sinus or sometimes to be drilled as this could cause CSF Otorrhoea.
obtain hemostasis over bleeding from bone.
Mastoidectomy Various Types
5. The hand piece should be held like a pen.
Different types of Mastoidectomy procedures
6. Drilling should be performed in a tangential have been described in the
direction as the cutting surface of the burr is literature. In this article we are making every
present in its sides. effort to clear the air and put to rest the con-
fusion which has been reigning so for. Several
7. The tip of the burr bit should not be used for basic terms, such as atticotomy, attico antrosto-
drilling. my, simple Mastoidectomy, conservative radical
operation, classic radical operation and tympa-
8. Only minimal pressure should be exerted over nomastoidectomy have often been described.
burr bits during drilling.
Atticotomy:
9. For fine drilling the head of the patient should
always be supported. Otherwise also known as Epitympanotomy,
denotes opening of the attic, performed through
10. The direction of rotation of burr should the transmeatal route. In this procedure the
always be away when drilling over important lateral wall of the attic is drilled away and the
structures. (Reverse). lateral attic is exposed.
11. Liberal irrigation should be performed

during the whole of the drilling process. This is
more important when drilling is performed over
facial nerve area / labyrinth.
12. It will be prudent to place the suction tip

between the burr bit and an important structure
36
Image showing atticotomy with preservation of Image showing Atticotomy with total removal
outer attic wall / bony bridge of bony bridge
Atticotomy can be performed in several ways, 2. Total removal of the bony bridge together
leading on to various modifications: with the lateral attic wall up to the level of teg-
men tympani, exposing the lateral attic, the ossi-
cles and the ligaments as shown in fig 2. In cases
of resorption of the ossicles or removal of the
1. Preservation of the bony bridge, by drilling remnants of the ossicles, the atticotomy can be
superior to the bony annulus and widening it further extended and the medial attic exposed.
towards the tegmen tympani. This is shown in 3. In cases of resorption of the ossicles or remov-
the illustration above. al of the remnants of the ossicles, the atticotomy
can be further extended and the medial attic
exposed.

Image showing atticotomy with a partially
Image showing medial attic wall exposed due removed bony bridge
to erosion of head of the malleus and body of
incus. 5. The bridge can be removed or be resorbed in
the middle as shown in the figure above.
4. Partial removal of the bony bridge. This situ-

ation can be caused by spontaneous resorption
of the bony annulus by cholesteatoma; or by
drilling in cases in which there are difficulties in
removing cholesteatoma at a particular point; or
lastly in cases with fixation of malleus.
Image showing Atticotomy with removal of

anterior part of bony ridge
38
superolaterally than the original bridge. This
6. In attic cholesteatoma there is often resorp- type of displacement of the bridge occurs after
tion of the bone in the region of Sharpnells’s performing an anterior attico-tympanotomy in
membrane (the scutum), and the bridge cannot order to remove the tensor tympani fold and the
remain intact in its middle or anterior part. bony plate in the anterior attic to improve the
ventilation through it.
7. In sinus cholesteatoma, starting with a pos-
terosuperior retraction of pars tensa, the poste-
rior part of the bridge can be resorbed, or may
have been removed to gain better access to this
region.
Image showing Atticotomy with superolateral

displacement of an intact bridge
Even though methods involving removal of the

bridge have been popular it is always better to
preserve varying amounts of bridge in order to
Image showing Atticotomy with removal of maintain the middle ear space. Of course, sacri-
posterior part of bony bridge ficing the bridge saves lot of time during surgery.
8. Displacement of the intact bridge - In cas- Attico antrostomy:

es with attic cholesteatoma and spontaneous
resorption of the bridge, or in cases requiring Is nothing but an extension of the atticotomy
drilling of the bony annulus in order to provide in a posterior direction through the transme-
better exposure of the mesotympanum, part atal route. The lateral attic and aditus walls are
of the superior bony annulus (the scutum) is removed, and the antrum is entered. The pos-
drilled away, displacing it superiorly. After the terosuperior bony can wall is removed, and the
atticotomy, the new bridge is positioned more access to the antrum is gradually widened. In

cases with poor pneumatization, a small antrum,
and a sclerotic mastoid process, an attico antros- Bondy’s Operation:
tomy results in a small cavity with smooth walls.
In a large cell system, the attico antrostomy This is nothing but attico antrostomy without
results in a large cavity. entering the tympanic cavity. The lateral part of
the cholesteatoma matrix is removed; the medial
part is left in place marsupializing the cholestea-
toma. If the tympanic cavity is entered the oper-
ation is not described as Bondy’s operation, but
as an attico antrostomy or conservative radical
operation.
In classic Bondy’s operation attico antrostomy

removal of the posterosuperior bony meatal
wall is performed exposing the cholesteatoma
sac involving the attic and antrum. The sac is
then incised, a suction tube is placed in the sac,
and the cholesteatoma mass is sucked away. The
lateral part of the matrix is then cut off.
If the tympanic cavity is opened and the choles-

teatoma marsupialized with the
Image showing a large attico antrostomy matrix being left in place in the attic, the fascia
has to be placed under the matrix in order to
prevent in growth of the cholesteatoma into
the tympanic cavity. The keratinized squamous
epithelium of the matrix and the epithelium of
the replaced drum remnant and the canal skin
gets integrated.
Image showing a small attico antrostomy
40
Image showing Bondy’s operation
If there is no need for hearing improvement Image showing attico antrostomy, or conserva-
and ossiculoplasty, the tympanic cavity is not tive radical operation, with marsupialization
opened in Bondy’s operation, whereas in conser- of an attic cholesteatoma extending into the
vative attico antrostomy a tympanoplasty is also tympanic cavity, which is open. The sac is in-
performed, either to prevent in growth of the cised, and the cholesteatoma is sucked out. The
cholesteatoma into the tympanic cavity or as a tympanic cavity is entered, with the tympano-
part of ossiculoplasty. meatal flap being elevated posteriorly.
In the treatment of attic cholesteatoma, a grad-

ual transition from an atticotomy with removal
of the bony bridge to Bondy’s operation can be
seen. In fact, it is only the extent of bone remov-
al from the posterosuperior ear canal wall and
the adherence of the cholesteatoma membrane
to the lateral semicircular canal, with blockage
of the ventilation through the tympanic isth-
mus that distinguishes a large atticotomy from
a small Bondy’s operation. In both types, the
medial part of the cholesteatoma sac is left in

place covering the intact Ossicular chain, or the
medial wall of the aditus ad antrum with the
lateral semicircular canal and the medial wall of
the antrum.
Image showing incus interposition between the

stapes and the malleus handle, after placement
of the fascia under the epithelial edges and un-
der the drum, and after replacement of the skin
flaps, the conservative operation is completed.
Image after removal of the partly eroded incus,

and after resection of the head of the malleus,
the medial part of the cholesteatoma matrix is
left in place. The cholesteatoma is marsupial-
ized in the attic and antrum regions but re-
moved from the tympanic cavity.
Image showing the side view of an atticotomy

with removal of the scutum and the bony bridge
(hatched area)
42
In cases with a small attic cholesteatoma, good
hearing, and no significant discharge, and in
which the bottom of the cholesteatoma cannot
be seen, an atticotomy can be performed by
removing the scutum until the bottom is visi-
ble. The lateral wall of the cholesteatoma sac is
removed, and the medial wall is left in place,
improving access to the cholesteatoma sac and
facilitating migration of the keratin from the sac.
In an attic cholesteatoma involving the aditus ad
antrum, a large part of the postero superior bony
canal must be drilled in order to perform a large
atticotomy and marsupialize the cholesteatoma.
Ventilation of the antrum still occurs through
the tympanic isthmus under the body of incus
and the head of the malleus and under the medi-
al part of the cholesteatoma matrix, which is not
yet adherent to the lateral semicircular canal.
The adherence of cholesteatoma membrane to Image showing side view of a large atticotomy
the lateral semicircular canal is probably the or a small Bondy’s operation in an attic choles-
most reliable sign differentiating the atticoto- teatoma involving the aditus ad antrum, ad-
my from the Bondy’s operation in cases of attic herent to the lateral canal closing the isthmus,
cholesteatoma. In cases with adherence of the blocking the ventilation of the antrum. Even
cholesteatoma membrane to the lateral canal the after removal of the large part of the superior
aditus ad antrum is involved in the cholesteato- bony canal wall (hatched area) and the lateral
ma, and ventilation of the antrum cannot take membrane of the cholesteatoma sac (dashed
place through the tympanic isthmus. Extensive line) with good exposure of the medial choles-
removal of bone is necessary to visualize the teatoma wall, progression of the cholesteatoma
cholesteatoma sac, and the result resembles a is possible towards the antrum indicated by the
small open attico antrostomy cavity – a Bondy’s arrow.
operation.

Image showing side view of a Bondy’s operation
in a case with large attic cholesteatoma. All
bone from the postero superior canal wall up
to the middle fossa dura is removed (hatched
area), together with the lateral membrane of the
cholesteatoma sac. The cholesteatoma is mar-
supialized, with wide access to the small open
cavity. The Ossicular chain is intact, and the
medial cholesteatoma membrane is adherent to
the medial aditus and antrum walls.
operation. The only difference between this

Cortical Mastoidectomy (Schwartz Mastoid- and the attico antrostomy is the extent of bone
ectomy) removal. In the radical operation, the exenter-
ation of the air cells is more radical than in an
This is a transcortical opening of the mastoid attico antrostomy. Also, marsupialization of
cells and the antrum. It is the initial stage of any the cholesteatoma and leaving intact the medi-
Transmastoid surgery of the middle ear, inner al part of the cholesteatoma membrane is not
ear, facial nerve, endolymphatic sac, labyrinth, included in conservative radical operation.
internal acoustic meatus, and various proce-
dures on the skull base for removing skull base DEFINITIONS:
tumors.
BRIDGE: is a part of bony postero superior
Conservative Radical Operation meatal wall lateral to aditus ad antrum.
Facial Ridge: It is a bony posterior meatal wall
Conservative radical Mastoidectomy, conser- that lies lateral to vertical portion of facial
vative radical operation, or modified radical nerve. Anterior Buttress: is that part of the bone
operation is a canal wall down procedure, where the posterior canal wall meets the teg-
denoting a Mastoidectomy with opening of men.
the antrum and attic, removal of the postero Posterior Buttress: is that part of the bone
superior bony canal wall, either drilling away of where posterior canal wall meets the floor of
the bony bridge and lowering of the facial ridge the external auditory canal lateral to the facial
or preserving the thinned down bony ridge. nerve.
The structures within the tympanic cavity are
preserved, hence the term conservative radical
44
Image showing simple cortical Mastoidectomy in a retro auricular approach. The antrum and
the mastoid cells are opened. The bony meatal wall is intact but thick, because the small cells
of the ear canal have not been removed. The lateral canal, the malleus, and the incus are just
visible. The outer attic wall is not opened.
tympanic cavity, an attempt to close the tympan-

Classical Radical Operation: ic cavity is performed to achieve faster healing,
or sometimes even to reventilate the tympanic
Classical radical Mastoidectomy or classical rad- cavity, or at least a part of it.
ical operation is a canal down Mastoidectomy
and includes the same bone work in the mastoid
process as the conservative radical operation.
However, the structures within the tympanic
cavity are removed, e.g. the remnants of the in-
cus and malleus, and the drum remnant with the
fibrous annulus and sometimes even the bony
annulus. In a classical radical operation closure
of the eustachean tube is performed. Today even
after radical removal of all structures from the

Tympanomastoidectomy:
Transmastoid tympanoplasty, tympanomastoid-

ectomy, combined approach tympanoplasty or
cortical Mastoidectomy, are terms denoting an
intact canal wall or canal wall up Mastoidectomy
where the posterior canal wall is preserved. The
procedure is based on retro auricular approach.
Several methods of Mastoidectomy are used:
1. classic intact canal wall

2. Modifications of intact canal wall procedures,
3. Temporary displacement or removal of bony
Image showing the Bridge ear canal.
Approaches and Routes:
The term approach means the method of access

to the middle ear through soft tissues: the term
route means the method of access to the mid-
dle ear through the bone. The approaches can
be Endaural, or retro auricular, and superior
or anterior. The routes can be transcortical or
transmeatal.
Transcortical route:
The transcortical route for drilling starts on

the surface of the cortical bone of the mastoid
process, behind the bony ear canal, which can
Image showing the situation in the tympanic remain intact either temporarily or permanent-
cavity after a classical radical Mastoidectomy ly. This route is also described as the outside
with removal of the fibrous annulus and all os- in route, because the initial drilling is always
sicles. The cavity is large, the facial ridge is low. outside.
46
Transmeatal route:
Approaches and mastoidectomies:
The transmeatal (trans canal) route for drilling
starts in the bone of the ear canal, either later- In Mastoidectomy, both the Endaural and the
ally or medially. This route is also described as retro auricular approaches have various advan-
the inside out route, because the initial drilling tages and disadvantages.
is from within the ear canal, e.g., with an atti- 1. The view into the attic in the retro auricu-
cotomy followed by antrostomy and retrograde lar approach is oblique, in the posteroanterior
Mastoidectomy. Through this Endaural route, an direction. In the Endaural approach, the view
atticotomy alone without Mastoidectomy can be is direct, lateromedially, and the distance to the
performed. The Mastoidectomy can start in the attic is shorter than in the retro auricular ap-
ear canal, as in the transcortical route. proach.
2. The view into the Eustachian tube orifice is
good in both approaches, but somewhat better
in the retro auricular approach.
3. The view into the posterior tympanum and
sinus tympani is better in the Endaural than in
the retro auricular approach.
4. Mastoidectomy can easily be extended in the
retro auricular approach, whereas extension
is difficult or even impossible in the Endaural
approach.
5. Cavity obliteration with muscle flaps, espe-
cially using the anterior based Palva flap and the
inferiorly pedicled Guilford flap are only possi-
ble in the retro auricular approach
The retro auricular approach is increasingly

Image showing transcortical and transmeatal dominating mastoid surgery, partly because of
routes for a Mastoidectomy in the retro auric- the ease of cavity obliteration and better access it
ular approach. The ear canal skin is pushed provides.
anteriorly, and its superior part is elevated. The
bone work can be performed by a transcortical Routes and approaches:
(outside - in) route or a transmeatal one (inside
- out). The transcortical TC and transmeatal Using the retro auricular approach, both the
TM routes are indicated as well as the transme- transcortical and the transmeatal routes to the
atal routes for atticotomy A, attico antrostomy mastoid for canal wall up Mastoidectomy, attico
AA and Mastoidectomy M. The dark dotted antrostomy, and canal wall down Mastoidecto-
area is the sigmoid sinus. my can be used. In fact, the transmeatal route
can be employed as easily as the transcortical

route. With the Endaural approach, the Trans-
meatal route is the route of choice.
An atticotomy usually starts with drilling of the

lateral attic wall, and a transmeatal attico an-
trostomy follows the atticotomy through further
drilling of the ear canal wall. Mastoidectomy
or a conservative radical operation can then be
performed as a retrograde extension of the attico
antrostomy. The cavities produced using the
retro auricular approach, either by transcortical
or the transmeatal route, are generally larger
than the cavities produced using the Endaural
approach.
Image showing the cavity usually achieved in

an end aural approach with less extensive drill-
ing of the cortical bone at the mastoid plane.
Canal wall up and canal wall down mastoidec-

tomies:
The terms canal wall up and canal wall down

have become popular. Mastoidectomies are
classified exclusively based on whether the canal
wall is removed or remains intact. The fact that
the bony ear canal wall sometimes remains only
partly intact, e.g., after spontaneous erosion, or
is deliberately partly removed, results in sever-
al variations or modifications of the canal wall
Image showing side view of the mastoid cavity Mastoidectomy techniques.
obtained in a retro auricular approach with ex-
tensive drilling of the cortical bone at the mas- Sub-classification of, or synonyms for canal wall
toid plane. Medially, the lateral semicircular down Mastoidectomy techniques are: atticoto-
canal, facial nerve, stapes and malleus handle, my, Bondy’s operation, attico antrostomy, classi-
with the anterior aspect of the drum are shown. cal radical operation, retrograde Mastoidectomy.
48
The subclassifications of canal wall up tech- several so called intact canal wall methods, the
niques are simple Mastoidectomy, cortical bony ear canal is not intact at all, partly because
Mastoidectomy, classic intact canal wall Mas- of the extensive drilling of the medial ear canal
toidectomy, CAT. The other features of the wall, and partly because of the spontaneous
classification are the obliteration of the cavity or resorption of the lateral attic wall.
reconstruction of the ear canal or both.
Modifications of intact canal wall Mastoidec-
Open technique: tomy:
In canal wall down Mastoidectomy, the cavity 1. Atticotomy with preservation of the intact
may remain open, neither obliterated nor with bony bridge
the ear canal reconstructed. The exposed bone is 2. Atticotomy with preservation of a partly re-
simply covered with fascia or skin or not cov- sorbed bony bridge
ered at all. This type of cavity is lined by granula- 3. Atticotomy with removal of the bridge
tions and later re epithelialized. 4. Widening of the ear canal Atticotomy open-
ings of various sizes with preservation of the
Closed technique: intact non resorbed bony bridge: The goal of
this atticotomy is to obtain a good view into the
The canal wall down Mastoidectomy cavity anterior attic. The bridge remains in its normal
can be partly or totally obliterated, and the ear position.
canal partly or totally reconstructed. A partly or
totally reconstructed canal wall down cavity is Atticotomy openings of various sizes with
defined as the closed technique. preservation of a partly resorbed bony bridge:
Classic canal wall up Mastoidectomy: In cases in which there is spontaneous re-

sorption of the lateral attic wall due to choles-
Also known as classic intact canal wall Mastoid- teatoma, an atticotomy has to be performed
ectomy or CAT is defined as a Mastoidectomy superiorly to the resorbed bridge, resulting in
with an entirely preserved, but thinned, bony ear displacement of the new bridge superiorly and
canal wall. The disease from the attic is removed laterally. Sometimes, resorption of the lateral
through careful drilling of all the bone between wall can be more extensive, so that the atticoto-
the ear canal and the tegmen tympani and hence my has to be performed further laterally, and the
enlarging access to the attic. Access to the tym- bony bridge in such cases is displaced further
panic cavity is achieved by a so called posterior superolaterally.
tympanotomy otherwise also known as poste-
rior attico-tympanotomy. The goal of the intact Atticotomy openings of various sizes with
canal wall Mastoidectomy is to re pneumatized removal of bony bridge:
the mastoid cavity.
Several modifications of intact canal wall Mas- Removal of the lateral attic wall is known as
toidectomy have been described and used, but in anterior tympanotomy. In cases with resorption

of the lateral attic wall, only limited removal of
the bridge is necessary. After extensive removal
of the lateral attic wall and a large atticotomy,
only the lateral half of the ear canal wall is intact.
Widening of the ear canal: By drilling the lateral
part of the canal, better access to the tympanic
cavity can be achieved. The superior wall of the
ear canal can be drilled away, exposing the later-
al attic, the tegmen antri, and the tegmen tym-
pani. With continued drilling of the ear canal,
an attico antrostomy can be performed resulting
in the entire canal wall being displaced posteri-
orly in relation to its normal position, with the
attic being exposed. The bridge can be preserved
or removed. Usually the Ossicular chain is not
intact.
Canal wall down Mastoidectomy:
The canal wall down mastoidectomies include Image showing Canal wall down Mastoidec-
attico antrostomy, Bondy’s operation and con- tomy with preservation of the bridge in a case
servative and classic radical mastoidectomies with spontaneous erosion of the lateral attic
with total removal of bony bridge. Modifications wall, resulting in the bridge being displaced
of canal wall down Mastoidectomy: Modifica- laterally and posteriorly.
tions are related to the preservation or partial
preservation of the bony bridge, resulting in in-
tact bridge techniques. In cases with resorption
of the lateral attic wall, the bridge can be pre-
served, but is displaced laterally and posteriorly.
The bridge may be partly resorbed, or surgi-
cally removed either posteriorly or anteriorly.
In combination with various degrees of Ossic-
ular deficiency (e.g., missing incus but present
malleus, or missing incus and malleus head)
and various types of partial bridge removal have
been described.
50
Image showing Canal wall down Mastoidec-
tomy with preservation of the bridge, which is Image of the ear canal with atticotomy and
displaced laterally and posteriorly in relation to Mastoidectomy, without bridge preservation.
the incus and malleus.
Cortical Mastoidectomy
Introduction:
This procedure is also known as simple mastoid-

ectomy / complete mastoidectomy. This proce-
dure consists of opening the mastoid cortex and
identifying the aditus and antrum. A complete
mastoidectomy involves removal of mastoid air
cells along tegmen, sigmoid sinus, presigmoid
dural plate, and posterior wall of the external
auditory canal. In this procedure the posteri-
or wall of the bony external auditory canal is
preserved. It is only thinned out in order to get
Image showing Canal wall down Mastoidecto- better access to all these air cells.
my with partial preservation of the bridge in a Successful and complication free mastoid sur-
case with partial preservation of the bridge in a gery is only possible if the following critical
case with spontaneous resorption of the bridge. structures are identified. These identified vital

structures should not be fully exposed and a
thin layer of cortical bone should be allowed to Position:
cover them. Allowing a thin bony covering over
them prevents complications from occurring The patient is placed in supine position with the
due to injury of these structures. To identify head turned to the opposite side. The face is
these structures adequate magnification is a supported by keeping a small sandbag under the
must. Hence operating microscope is a necessi- face on the opposite side.
ty for all mastoid surgical procedures.
Incision:
Indication:
Post aural incision of William Wilde is used.
1. Chronic otitis media not responding to con-
ventional medical management 2. Chronic otitis
media with cholesteatoma. Mastoidectomy
provides access to remove cholesteatoma matrix
from areas that are difficult to visualize through
the external auditory canal. These areas include:
Supra tubal recess, epitympanum, facial recess,
peri labyrinthine air cells, retrofacial air cells. 3.
Mastoidectomy is an initial step for cochlear im-
plant procedures 4. Mastoidectomy is the initial
step in removal of lateral skull base neoplasms
like vestibular schwannomas, meningiomas,
glomus tumors and epidermoids.
Contraindications:
1. If the patient is medically unfit to undergo the Image showing post aural incision of William
surgery Wilde
2. Patients with poorly pneumatized mastoid
may make the procedure a little complex as the Sir William Wilde who popularized this inci-
vital landmarks are difficult to identify. sion as a treatment of mastoiditis is the father of
Oscar wilde. He was the first to teach otology
Anesthesia: in the United Kingdom. This incision is used
for exposing the mastoid process. It follows the
Ideally mastoidectomy is performed under post aural fold. It begins just above the upper
general anesthesia. Endotracheal tube is used to attachment of auricle, and it extends downwards
maintain the airway and to administer anesthet- to the tip of the mastoid.
ic gases and oxygen. The mastoid process in infants is not fully devel-
oped, the usual incision could injure the facial
52
nerve. In this age group the incision should be
placed more horizontally.
A – Adult post aural incision

B – Post aural incision in a child
Diagram representing Endaural incision
Advantages of post aural incision:
This incision provides wide and open exposure.

This facilitates thorough exenteration of mastoid
air cells. It also provides an access for unexpect-
ed extension of disease process and also helps in
dealing with complications of mastoiditis.
Endaural incision of Lempert:
The incision is made in the cartilage free area

filled with fibrous tissue (incisura terminalis).
The incision is extended upwards parallel to the
helix. The lower part of the incision is made at
the bony cartilaginous junction and is curved Image showing Lempert’s speculum being used
from 3 - o clock position in the canal through to expose incisura terminalis area
the 12-o clock position to reach the floor of the
canal at 6 - o clock position. The incision is
deepened through the periosteum which is sepa-
rated upwards and backwards exposing the bony
mastoid cortex.

This incision provides direct access to the exter-
nal osseous canal, ear drum and tympanic cavity.
Since the exposure is limited this incision can be
used in limited middle ear disease.
Infiltration:
The post aural area is infiltrated with 1% xy-

locaine with 1 in 100,000 adrenaline. This
infiltration ensures that skin and is lifted away
from the mastoid bone. Presence of adrenaline
reduces bleeding during surgery.
The operating microscope with 200-250 mm ob-

Image showing incision given in the incisura jective is used for the entire procedure. Cutting
terminalis area and diamond burrs of various sizes are used.
A curvilinear post aural incision starting from

the linea temporalis up to the level of mastoid
tip. The incision should be sited 5-10 mm poste-
rior to the post aural sulcus. Incision should
avoid post aural sulcus as it would enter the ex-
ternal auditory canal. 15 blade knife is used for
making the incision. The skin and subcutane-
ous tissue is elevated off the periosteal lining of
the mastoid bone until the bony portion of the
external auditory canal can be palpated through
the periosteum.
After exposing the periosteum an incision is

made along the linea temporalis from the root
Image showing Incisura terminalis incision of the zygoma to the occipito mastoid suture
seen being deepened line. A perpendicular periosteal incision is
made from the linea temporalis to the mastoid
tip. The periosteum is elevated off the mastoid
cortex up to the bony portion of the external
auditory canal. This is an anterior based perios-
teal flap. A retractor is used to hold the auricle
forward.
54
found centered over the cribriform area of the
mastoid cortex which is just located posterior
and superior to the osseous external meatus.
Image showing mastoid cortex after periosteum

is elevated Image showing the direction of initial bone cuts
Operating microscope with a 200-250 mm

focal lens is used during bone drilling. Drilling
should commence at the level of and parallel
to the linea temporalis. Largest sized burr bit
5/8mm is used for this purpose. Copious irriga-
tion of saline should be given to prevent thermal
injury to the underlying structures. Drilling is
continued till the temporal lobe dura (tegmen)
is covered only by a thin osseous lining. Next
the burr is used to drill curvilinearly from the
sinodural angle to the mastoid tip. The sigmoid
sinus should be identified while drilling from
the mastoid tip area to the posterior aspect of
the tegmen. The sigmoid sinus can be seen as Image showing the mastoid bowl after initial
a blue tinge. A thin bony lining should be left phase of drilling
over the sigmoid sinus in order to protect the
sinus. Air cells along the posterior aspect of the
external auditory canal are removed until the
cortical bone is identified. The aditus would be

Image showing the anatomy after complete
mastoidectomy
Image showing mastoid air cells
The perifacial cells are drilled and opened out.

This drilling creates a mastoid bowl. The pos- Aditus is widened.
terior canal wall should be drilled in such a way This procedure ensures that the mastoid air cells
that it loses its curvature and becomes straight. are exenterated and the middle ear ventilated.
It should be thinned progressively till the instru- The aditus block is removed by widening the
ment placed in the external canal is seen as a aditus.
shadow from the mastoid bowl. Aditus anatom- The external canal is packed with ointment im-
ically lies 1.5 cm underneath the Henle’s spine. pregnated gauze.
Entry into the aditus will be revealed by the The wound is closed in layers and mastoid dress-
change in the sound of the drilling burr bit. The ing is applied.
lateral canal is identified along the medial sur-
face of the aditus ad antrum. The otic capsule
bone covering the lumen of semicircular canal is
yellow and is always of different color from that
of the adjacent bone. The lateral semicircular
canal is a critical landmark in mastoid surgery
because since the second genu of facial nerve is
always inferior to the midpoint of the canal.
56
3. Micro ear instruments
Modified radical mastoidectomy
Anesthesia:
This is the operative technique used to manage
cholesteatoma. In this procedure all diseased This surgery can be performed either under
tympanomastoid air cells are removed, exenter- local / General anesthesia
ated and exteriorized to the external auditory
canal. The middle ear transformer mechanism Anatomical landmarks:
is reconstructed.
1. Temporal line
Indications:
2. Henle spine
1. Cholesteatoma
3. Mastoid tip
2. CSOM with extensive middle ear granulation
4. External auditory canal
Steps of modified radical mastoidectomy:
MacEven’s triangle:
1. Drilling the mastoid cortex
This triangle contains the spine of Henle. It also
2. Exenterating mastoid air cells serves as an important landmark for mastoid an-
trum as it lies 1.2 - 1.5 mm deep to this triangle.
3. Identification of aditus
Boundaries:
4. Widening the aditus
Superior - Temporal line
5. Removal of outer attic wall (bridge)
Anterior - Postero-superior margin of bony por-
6. Lowering the facial ridge up to the level of the tion of external auditory canal
lateral canal
Posterior - Is formed by a tangential line draw to
7. Performing a meatoplasty mid point of posterior wall of external canal
Equipment needed:
1. Operating microscope with 200-250 mm ob-

jective is used for the entire duration
2. Otological drill with burr bits of different sizes

the incision is being made.
The skin and subcutaneous flap is elevated until

the bony portion of the external canal can be
palpated through the periosteum. Once the
periosteum is exposed, an incision is made along
the linea temporalis from the root of the zygoma
to the occipito mastoid suture. Another perpen-
dicular periosteal incison is made from the linea
temporalis to the tip of the mastoid process. The
periosteum is elevated off the mastoid cortex up
to the level of the external auditory canal using a
periosteal elevator. A retractor is then placed to
hold the auricle forward.
An operating microscope with 200-250 mm

focal length lens is used from now on. Ideally
Image showing McEven’s triangle drilling should be done under microscopic vi-
sion. The microscope provides good magnified
visualization at the expense of a narrower field
Positioning: of vision. Drilling commences at the level and
parallel to linea temporalis. Copious suction
Patient is placed in a supine position with the irrigation should be performed to remove bone
head rotated about 30-45 degrees away from the dust. Irrigation also prevents thermal injury to
surgeon. The patient’s head should be placed as the bone and underlying structures. Identifica-
close to the edge of the table as possible. tion of temporal lobe dura (tegmen) leaving a
very thin bone covering over it is the initial step
Incision: of mastoid surgery. After identification of dura
is made, the sigmoid sinus can be identified and
Post auricular area is infiltrated with 2% xylo- exposed by drilling from the mastoid tip area to
caine with 1 in 100,000 adrenaline. Infiltration the posterior aspect of tegmen. The sigmoid si-
helps in reduction of bleeding and also in flap nus can be identified by its characteristic bluish
elevation. Post aural incision of William Wilde tinge.
is used. This is a curvilinear starting from linea
temporalis superiorly to the mastoid tip. This Air cells along the posterior aspect of the ex-
incision should be as close to the post aural ternal auditory canal are removed until cortical
sulcus as possible. Caution should be exercised, bone is identified. The aditus ad antrum situ-
and the incision should not enter the external ated just under the cribriform area of mastoid
auditory canal. This can be avoided by placing cortex should be entered. As the aditus is wid-
the left index finger over the external canal while ened the dome of lateral canal comes into view.
58
It can be seen as whitish part of bone. Lateral performed.
canal is the critical landmark in mastoid surgery.
The second genu of the facial nerve lies inferior
to the midpoint of the lateral canal. Mastoid
portion of facial nerve can be skeletonized once
the lateral canal has been identified. The facial
nerve typically courses in a more lateral and an-
terior portion in its course from the second genu
to the stylomastoid foramen. The zygomatic
root cells lying superior to the osseous external
canal, adjacent to the glenoid fossa are opened
in patients with extensive cholesteatoma in the
epitympanum / supratubal recess.
The middle ear can be visualized by opening the

facial recess. The facial recess is defined by the
mastoid portion of facial nerve, chorda tympani
nerve and incus buttress. The incus buttress is
a bridge of bone connecting the lateral canal to Image showing facial recess
the medial aspect of the osseous posterior supe-
rior external auditory canal. The short process
of incus is attached to the incus buttress with
a small ligament. Opening of the facial recess
provides excellent visualization of the oval and
round windows. The anterior aspect of the sinus
tympani, hypotympanum and protympanum
can also be visualized. Facial recess is opened
usually during cochlear implant surgery. Open-
ing up this recess is beneficial in cholesteatoma
surgery as it allows the surgeon to remove dis-
ease from the region under direct visualization.
In modified radical mastoidectomy, the posteri-

or canal wall is thinned out. Outer attic wall is
removed, the anterior and posterior buttresses
are also removed. Facial ridge is reduced till Image showing cholesteatoma in MRM cavity
the level of lateral canal is reached. This results
in a single cavity that includes mastoid cavity,
aditus, antrum and middle ear cavity. They are
made into a single cavity. A large meatoplasty is

Drilling tips:
1. It is better to set the magnification of the mi-

croscope between 4 - 6X as this will give a more
complete orientation of the drilling area. Higher
magnification levels are necessary to appreciate
the minute details.
2. It is best to choose the largest possible burr

bit for initial drilling as this will cause less dam-
age. Using small burrs is always dangerous.
3. The length of the cutting burr is adjusted

according to the depth of the area to be drilled.
Shorter the burr length better is the control.
4. Majority of bone drilling should be per-

formed by using cutting burrs. Diamond burrs
Image showing Cholesteatoma sac being re- can be used when drilling is to be performed
moved from attic area over facial nerve area, dura, sigmoid sinus or
sometimes to obtain hemostasis over bleeding
from bone.
Burr bits:
5. The hand piece should be held like a pen.
Burr bits comes in various sizes. A cutting burr
is made up of multiple blades more or less close 6. Drilling should be performed in a tangential
to each other. The greater the number of blades, direction as the cutting surface of the burr is
the more stable is the burr. More stable the burr, present in its sides.
the less well it cuts.
7. The tip of the burr bit should not be used for
Diamond burrs function by saucerising and drilling.
thinning the bone in contact. This burr is used
in proximity to or in contact with soft tissues 8. Only minimal pressure should be exerted
(dura, sigmoid sinus, and facial nerve). over burr bits during drilling.
Reverse cutting can be used to reduce the 9. For fine drilling the head of the patient
cutting power and also to avoid uncontrolled should always be supported.
movements that could make the burr to hit at
vital structures. 10. The direction of rotation of burr should
always be away when drilling over important
60
structures. (Reverse). nous (1/3) and medial bony (2/3) portions.
The medial bony portion of the external canal
11. Liberal irrigation should be performed consists of the tympanic bone which is a ringed
during the whole of the drilling process. This is lateral projection of temporal bone. There is a
more important when drilling is performed over notch in the superior portion of the tympanic
facial nerve area / labyrinth. bone known as the notch of Rivinus which is lo-
cated at the junction of tympanosquamous and
12. It will be prudent to place the suction tip tympanomastoid suture lines.
between the burr bit and an important structure
as it will prevent damage to the structure even if Sensory innervation of external auditory
the hand piece slips. canal:
13. Canalplasty should be performed whenever a 1. Auriculotemporal nerve (from the mandib-
bony overhang obscures complete visualization ular branch of the trigeminal nerve) provides
of the ear drum. sensory innervation to anterior, posterior walls
and the roof of external canal.
14. while drilling care should be taken not to 2. The posterior wall and floor of the canal is
touch the ossicular chain. supplied by the auricular branch of vagus (Ar-
nold nerve)
15. Middle cranial fossa dural plate should not 3. The tympanic plexus also supplies some areas
be drilled as this could cause CSF Otorrhoea. Blood supply:
1. Posterior auricular artery
Canalplasty 2. Deep auricular branch of the maxillary artery
3. Superficial temporal artery
Introduction:
Important anatomic relations that should be
A Canalplasty is usually performed to widen a borne in mind during surgery:
narrowed external auditory canal either due to Anterior to the bony portion of external audito-
congenital / acquired causes. The reasons for ry canal lie the temporomandibular joint and the
performing this procedure are as follows: parotid gland. During Canalplasty care should
1. To improve access to middle ear and mastoid be taken not to injure these structures. Posterior
cavities during mastoid surgeries and inferior to the bony external canal lies the
2. To remove bony / soft tissue growths / scar mastoid portion of the temporal bone and it
tissue occluding the external canal contains the facial nerve.
3. To treat aural atresia
Facial nerve courses usually lateral to the annu-
Anatomy: lus in the posteroinferior quadrant of the tym-
panic membrane.
The adult external auditory canal is about 2.5
cms long and is composed of lateral cartilagi- Function of external canal:

away from the anesthesiology team to allow
1. It serves as efficient conduit for transmission proper positioning of the microscope.
of sound from the environment to the ear drum
2. Protects the middle ear and inner ear from Approaches:
environmental insults
Indications: The following approaches are possible:
1. Hearing loss due to the presence of osteoma 1. Endo meatal
2. To improve self-cleansing mechanism of ex- 2. Post aural
ternal canal in the presence of exostosis 3. Endo meatal Typically a post aural approach
3. To improve visualization of ear drum while combined with Endaural incision is used to
performing tympanoplasty remove exostosis and medial canal fibrosis.
Contraindications:
1. Presence of acute infections in the external Endaural / endo meatal incision may be pre-
auditory canal ferred for osteoma as they often have a stalk
that facilitates easy removal. Endaural incision
Planning: is made in the external canal as far medial as
possible. A laterally based vascular strip is devel-
If otitis externa is present, then the patient oped in the external auditory canal skin. After
should be treated for the same by administration completion of this step the post aural incision is
of topical antibiotic ear drops. A combination of given. It is usually given 7 mm behind the post
antibiotic and steroid ear drops would actually aural sulcus. The incision is continued through
help. the auricularis posterior muscle down to tem-
poralis fascia. Periosteum over the mastoid is
Anesthesia: incised and elevated anteriorly to the external
canal. The Endaural incision is found from
This surgery is ideally performed under general the post aural approach, and the two incisions
anesthesia. In congenital external canal atresia are joined. The external auditory canal skin is
facial nerve monitoring is used and hence long carefully elevated off the bony external canal
acting paralytics should not be used. Xylocaine and then retracted forward with the auricle.
1% mixed with 1 in 100,000 adrenaline is used In external canal exostosis, the skin over the
to infiltrate the external canal. Infiltration is exostosis is elevated with a round knife and
usually given in the cartilaginous, hair bearing elevated toward the ear drum. The exostosis is
portion of the external canal. This is done to drilled down using a cutting / diamond burrs in
reduce bleeding during the procedure. a lateral to medial direction. Curettes can also
be used to dissect bony edges. Canalplasty for
Patient positioning: acquired external canal stenosis needs drilling of
the anterior bony canal. When drill is used care
The patient is ideally positioned supine on the should be taken to avoid contact with the ossic-
Operating table with the head turned away from ular chain as it could cause conductive hearing
the surgeon. The table is turned 180 degrees loss. While drilling anteriorly care should be
62
taken to avoid penetration into the TM joint.
This can be prevented by drilling away bone
superior and inferior to the temporomandibular
joint first, before carefully removing the buttress
of bone overlying the joint. After canaplasty
the skin flap is repositioned, and the wound is
closed in layers. Ideally a stent may be placed to
assist adherence of the external canal skin to the
external canal.
Image showing canalplasty being performed

Otoendoscopy
Introduction:
Advent of endoscopes have revolutionized

diagnosis and treatment of various disorders.
Otology is no exception to it. Otoendoscopes
are rigid endoscopes which have been used for
diagnostic purposes in the field of otology. This
procedure of Otoendoscopy was first described
by Mer et al.
Commonly used Otoendoscopes include:
1. 1.7 mm 0-degree Otoendoscope

2. 1.7 mm 30 degrees Otoendoscope Author pre-
fers to use the nasal endoscope itself for otolog- Image showing retracted ear drum
ical diagnostic purposes. The advantages being
the obvious optimization of instrument usage.
Advantages of using rigid endoscopes to per-
form otological examinations:
1. The entire ear drum can be clearly visualized
with minimal manipulation
2. The image produced is of excellent resolu-
tion hence photographing these images provide
excellent results.
3. Fluid levels in middle ear cavity due to otitis
media with effusion is clearly seen in Otoendos-
copy than in routine otoscopy.
4. Every nook and corner of external auditory
canal and middle ear cavity if tympanic mem-
brane perforation is present can easily be exam- Image showing glomus jugulare
ined with minimal manipulation of the endo-
scope.
5. It is easy to clear the debris from the external
auditory canal under visualization with an Oto-
endoscope.
64
Image showing otoendoscopic view of attic
perforation Image showing otoendoscopic view of otomyco-
sis
Image showing otoendoscopic view of acute

otitis media
Image showing otoendoscopic view of attic
cholesteatoma

According to the author’s experience the follow- Endoscopic Myringoplasty
ing minor procedures can be easily performed
using Otoendoscopy:
Introduction:
1. Removal of epithelial debris from external
auditory canal Myringoplasty is a surgical procedure performed
2. Removal of cerumen to close tympanic membrane perforations.
3. Removal of otomycotic flakes The advent of operating microscope results of
4. Removal of maggots / foreign bodies myringoplasty started showing dramatic im-
5. Removal of aural polyp provements. This is attributed to the accuracy of
6. Suction clearance surgical technique. Major disadvantage of oper-
All these procedures can be commonly per- ating microscope is that it provides a magnified
formed as outpatient / day care procedures. image along a straight line. Success of myringo-
plasty should be assessed both subjectively and
objectively.
Subjective indicators include:
1. Improvement in hearing acuity

2. Absence of ear discharge
3. Absence of tinnitus
Objective indicators are:
1. Healed perforation as seen in Otoendoscopy
2. Improvement in hearing threshold demon-
strated by performing Puretone audiometry.
Image showing microscopic line of magnifica-

tion
66
tone average)
4. Results of this procedure was compared to
that of published results of microscopic myrin-
goplasty Puretone audiometry was performed
for all these patients. All of them had 30 – 40 dB
conductive hearing loss
Success rate of endoscopic procedure was com-
pared with that of various studies performed
using microscopic approach. Internet survey
revealed a success rate of 71% - 80% success
rates in patients undergoing microscopic my-
ringoplasty. This highly variable success rate was
attributed to the different locations of perfo-
rations. Posterior perforations carried the best
success rates i.e. 90%.
Image showing endoscopic line of magnification Procedure:
Temporalis fascia graft is harvested under local

Advantages of endoscope: anesthesia conventionally and allowed to dry.
The external auditory canal is then anesthetized
1. It provides an excellent magnified image with using 2 % xylocaine mixed with 1 in 10,000
a good resolution adrenaline injection. About 1/2 cc is infiltrated
2. With minimal effort it can be used to visualize at 3 - o clock, 6 - o clock, 9 - o clock, and 12 - o
the nook and corners of middle ear cavity clock positions about 3mm from the annulus.
3. Magnification can be achieved by just getting The patient is premedicated with
the endoscope closer to the surgical field intramuscular injections of 1 ampule fortwin
4. Antero inferior recess of external auditory and 1 ampule phenergan.
canal can be visualized using an endoscope
5. Middle ear cavity can be visualized easily Step I: Freshening the margins of perforation
using an endoscope. Even difficult areas to visu- - In this step the margins of the perforation is
alize under microscopy like sinus tympani can freshened using a sickle knife of an angled pick.
easily be examined using an endoscope. This step is very important because it breaks the
Methodology: Inclusion criteria: adhesions formed between the squamous mar-
1. Patients in the age group of 20 -40 were in- gin of the ear drum (outer layer)
cluded in the study with that of the middle ear mucosa. These adhe-
2. All these patients had dry central perforation sions if left undisturbed will hinder the take up
of ear drum of the neo tympanic graft. This procedure will in
3. Patients with demonstrable degree of con- fact widen the already present perforation. There
ductive deafness was chosen (at least 30 dB pure is nothing to be alarmed about it.

viated tip portion of the handle can be clipped.
Step II: This step is otherwise known as eleva- The handle of the malleus is freshened and
tion of tympano meatal flap. Using a drum knife stripped of its mucosal covering.
a curvilinear incision is made about 3 mm lat-
eral to the annulus. This incision ideally extends Step V: Placement of graft (underlay technique).
between the 12 - o clock, 3 - o clock, and 6 - o Now a properly dried temporalis fascia graft of
clock positions in the left ear, and 12 - o clock, appropriate size is introduced through the ear
9 - o clock and 6 - o clock positions in the right canal. The graft is gently pushed under the tym-
ear. The skin is slowly elevated away from the pano meatal flap which has been elevated. The
bone of the external canal. Pressure should be graft is insinuated under the handle of malleus.
applied to the bone while elevation. The tympano meatal flap is repositioned in such
a way that it covers the free edge of the graft
This serves two purposes: which has been introduced. Bits of gelfoam are
placed around the edges of the raised flap. One
1. It prevents excessive bleeding gel foam bit is placed over the sealed perfora-
2. It prevents tearing of the flap. tion. This
This step ends when the skin flap is raised up to gelfoam has a specific role to play. Due to the
the level of the annulus. suction effect created it pulls the graft against
the edges of the perforation thus preventing
Step III: Elevation of the annulus and incising medialisation of the graft material.
the middle ear mucosa. In this step the annulus
is gradually lifted from its rim. As soon as the
annulus is elevated a sickle knife is used to incise
the middle ear mucosal attachment with the
tympano meatal flap. This is a
very important step because the inner layer of
the remnant ear drum is continuous with the
middle ear mucosa. As soon as the middle ear
mucosa is raised, the flap is pushed anteriorly till
the handle of the malleus becomes visible.
Step IV: Freeing the tympano meatal flap from

the handle of malleus. In this step the tympano
meatal flap is freed from the handle of malleus
by sharp dissection of the middle ear mucosa.
Sometimes the handle of the malleus may be
turned inwards hitching against the promontory.
In this scenario, an attempt is made to lateralise Image showing a subtotal perforation. Rim of
the handle of the malleus. If it is not possible to the perforation indicated by the dark line
lateralise the handle of the malleus, the small de-
68
Image showing tympanomeatal flap being
Image showing the rim of the perforation being elevated. The incision is indicated by red line.
freshened with an angled pick Drum knife is seen in action.
Image showing the rim of the perforation being

removed using micro alligator forceps Image showing the flap being freed from its
superior attachment.

Image showing tympanomeatal flap being Image showing the view of chorda tympani
elevated from the bony portion of the external nerve (Yellow color).
auditory canal. Bone is clearly visible after
elevation of the flap.
Image showing anterior pocket being created

for insertion and stabilization of the graft
Image showing middle ear being entered. Mid-

dle ear mucosa is indicated by yellow dots.
70
Image showing handle of the malleus being Image showing temporalis fascia being harvest-
skeletonized. ed
Image showing graft being inserted into the

canal Image showing graft being inserted under the
handle of malleus. This step adds stability to
the graft material

4. Its thickness is more or less similar to that of
tympanic membrane
There are two available methods of performing

myringoplasty:
Overlay technique
Under lay technique
Overlay technique:
This is a difficult technique to master. Here the

graft material is inserted under the squamous
(skin layer) of the ear drum. It is a difficult
task peeling only the skin layer away from the
tympanic membrane, placing the graft over the
Image showing graft in situ perforation and redraping the skin layer.
Classic myringoplasty Underlay technique:
Myringoplasty is a procedure used to seal a This is a simpler and commonly used technique.
perforated tympanic membrane using a graft Here the graft is placed under the tympano
material. meatal flap which has been elevated hence the
name under lay. The major advantage of this
Temporalis fascia is the commonly used graft procedure is that it is easy to perform with a
material because: good success rate.
1. It is an autograft with excellent chance of take

Indications of Myringoplasty
2. It is available close to the site of operation
making its harvest easier 1. Central perforation which has been dry at
least for a period of 6 weeks.
3. It has a low basal metabolic rate, brightening
2. As a follow up to mastoidectomy procedure to
its success rate
recreate the hearing mechanism
72
Prerequisites for myringoplasty
Step II:
1. Central perforation which has been dry for at
least 6 weeks This step is otherwise known as elevation of
tympano meatal flap. Using a drum knife a
2. Normal middle ear mucosa curvilinear incision is made about 3 mm later-
al to the annulus. This incision ideally extends
3. Intact ossicular chain between the 12 - o clock, 3 - o clock, and 6 - o
clock positions in the left ear, and 12 - o clock,
4. Good cochlear reserve 9 - o clock and 6 - o clock positions in the right
ear. The skin is slowly elevated away from the
Procedure: bone of the external canal. Pressure should be
applied to the bone while elevation. This serves
Firstly a temporalis fascia of adequate site must two purposes:
be harvested and allowed to dry. The surgery is
performed under local anesthesia. Temporalis 1. It prevents excessive bleeding
fascia graft is harvested under local anesthesia
conventionally and allowed to dry. The external 2. It prevents tearing of the flap
auditory canal is then anesthetised using 2 %
xylocaine mixed with 1 in 10,000 adrenaline in- This step ends when the skin flap is raised up to
jection. About 1/2 cc is infiltrated at 3 - o clock, the level of the annulus.
6 - o clock, 9 - o clock, and 12 - o clock positions
about 3mm from the annulus. The patient is Step III:
premedicated with intramuscular injections of 1
ampule fortwin and 1 ampule phenergan. Elevation of the annulus and incising the middle
ear mucosa. In this step the annulus is gradu-
Step I: ally lifted from its rim. As soon as the annulus
is elevated a sickle knife is used to incise the
Freshening the margins of perforation - In this middle ear mucosal attachment with the tym-
step the margins of the perforation is freshened pano meatal flap. This is a very important step
using a sickle knife of an angled pick. This step is because the inner layer of the remnant ear drum
very important because it breaks the adhesions is continuous with the middle ear mucosa. As
formed between the squamous margin of the ear soon as the middle ear mucosa is raised, the flap
drum (outer layer) with that of the middle ear is pushed anteriorly till the handle of the malle-
mucosa. These adhesions if left undisturbed will us becomes visible.
hinder the take up of the neo tympanic graft.
This procedure will in fact widen the already Step IV:
present perforation. There is nothing to be
alarmed about it. Freeing the tympano meatal flap from the han-

dle of malleus. In this step the tympano meatal
flap is freed from the handle of malleus by sharp Tympanoplasty
dissection of the middle ear mucosa. Sometimes
the handle of the malleus may be turned inwards The fundamental principles of Tympanoplasty
hitching against the promontory. In this scenar- were introduced by Zollner and Wullstein. These
io, an attempt is made to lateralise the handle principles were directed towards restoration of
of the malleus. If it is not possible to lateralise middle ear function as well as ensured trouble
the handle of the malleus, the small deviated tip free and stabilized ear.
portion of the handle can be clipped. The handle
of the malleus is freshened and stripped of its Wullstein and Zollner classified Tympanoplasty
mucosal covering. according to the type of ossicular reconstruction
needed. Five types of Tympanoplasty have been
Step V: classified.
Placement of graft (underlay technique). Now a Type I Tympanoplasty:
properly dried temporalis fascia graft of appro-
priate size is introduced through the ear canal. This is indicated in patients with presence of all
The graft is gently pushed under the tympano the middle ear ossicles with normal mobility.
meatal flap which has been elevated. The graft Ossicular chain reconstruction is not needed in
is insinuated under the handle of malleus. The these patients. Efforts are made to close the per-
tympano meatal flap is repositioned in such forated ear drum using temporalis fascia graft
a way that it covers the free edge of the graft (Hong Kong flap). This procedure is also known
which has been introduced. Bits of gelfoam is as myringoplasty.
placed around the edges of the raised flap. One
gel foam bit is placed over the sealed perfora- Advantages of using temporalis fascia as graft
tion. This gelfoam has a specific role to play. Due material
to the suction effect created it pulls the graft
against the edges of the perforation thus pre- 1. It is an autograft with excellent chance of take
venting medialisation of the graft material. 2. It is available close to the site of operation
making its harvest easier
3. It has a low basal metabolic rate, brightening
its success rate
4. Its thickness is more or less similar to that of
tympanic membrane
74
Indications of Myringoplasty:
1. Central perforation which has been dry at

least for a period of 6 weeks.
2. As a follow up to mastoidectomy procedure to
recreate the hearing mechanism
Prerequisites for myringoplasty:
1. Central perforation which has been dry for at

least 6 weeks
2. Presence of normal middle ear mucosa
3. Intact ossicular chain
4. Good cochlear reserve
Procedure: Firstly a temporalis fascia of ade-

Image showing Type I tympanoplasty quate site must be harvested and allowed to dry.
The surgery is performed under local anesthesia.
Temporalis fascia graft is harvested under local
There are two available techniques for perform- anesthesia conventionally and allowed to dry.
ing myringoplasty / type I Tympanoplasty. The external auditory canal is
1. Overlay technique then anesthetized using 2 % xylocaine mixed
2. Under lay technique with 1 in 10,000 adrenaline injection.
Overlay technique: This is a difficult technique About 1/2 cc is infiltrated at 3 - o clock, 6 - o

to master. Here the graft material is inserted un- clock, 9 - o clock, and 12 - o clock positions
der the squamous (skin layer) of the ear drum. about 3mm from the annulus. The patient is
It is a difficult task peeling only the skin layer premedicated with intramuscular injections of 1
away from the tympanic membrane, placing the ampoule fortwin and 1 ampoule phenergan.
graft over the perforation and redraping the skin
layer. Step I: Freshening the margins of perforation
- In this step the margins of the perforation is
Underlay technique: This is a simpler and com- freshened using a sickle knife of an angled pick.
monly used technique. Here the graft is placed This step is very important because it breaks the
under the tympano meatal flap which has been adhesions formed between the squamous mar-
elevated hence the name underlay. The major gin of the ear drum (outer layer)
advantage of this procedure is that it is easy to with that of the middle ear mucosa. These adhe-
perform with a good success rate. sions if left undisturbed will hinder the take up
of the neo tympanic graft. This procedure will in

fact widen the already present perforation. There In this scenario, an attempt is made to lateralize
is nothing to be alarmed about it. the handle of the malleus. If it is not possible to
lateralize the handle of the malleus, the small
Step II: This step is otherwise known as eleva- deviated
tion of tympano meatal flap. Using a drum knife tip portion of the handle can be clipped. The
a curvilinear incision is made about 3 mm lat- handle of the malleus is freshened and stripped
eral to the annulus. This incision ideally extends of its mucosal covering.
between the 12 - o clock, 3 - o clock, and 6 - o
clock positions in the left ear, and 12 - o clock, Step V: Placement of graft (underlay technique).
9 - o clock and 6 - o clock positions in the right Now a properly dried temporalis fascia graft of
ear. The skin is slowly elevated away from the appropriate size is introduced through the ear
bone of the external canal. Pressure should be canal. The graft is gently pushed under the tym-
applied to pano meatal flap which has been elevated. The
the bone while elevation. This serves two pur- graft is insinuated under the handle of malleus.
poses: The tympano meatal flap is repositioned in such
a way that it covers the free edge of the graft
1. It prevents excessive bleeding which has been introduced. Bits of gelfoam are
2. It prevents tearing of the flap. placed around the edges of the raised flap. One
gel foam bit is placed over the sealed perfora-
This step ends when the skin flap is raised up to tion. This gelfoam has a specific role to play. Due
the level of the annulus. to the suction effect created it pulls the graft
against the edges of the perforation thus pre-
Step III: Elevation of the annulus and incising venting medialisation of the graft material.
the middle ear mucosa. In this step the annulus
is gradually lifted from its rim. As soon as the Type II Tympanoplasty: In this procedure the
annulus is elevated a sickle knife is used to incise tympanic membrane is grafted to the intact
the middle ear mucosal attachment with the incus and stapes. This procedure is very rarely
tympano meatal flap. This is used, since it is very rare for erosion of the han-
a very important step because the inner layer of dle of malleus to be present alone without the
the remnant ear drum is continuous with the involvement of other ossicles. The
middle ear mucosa. As soon as the middle ear neotympanum created is draped over the exist-
mucosa is raised, the flap is pushed anteriorly till ing incus and stapes. There is a certain amount
the handle of the malleus becomes visible. of obliteration of middle ear space.
Step IV: Freeing the tympano meatal flap from Since the ossicular chain lever ratio is not nor-
the handle of malleus. In this step the tympano mally maintained in these patients, they
meatal flap is freed from the handle of malleus tend to have at least 30 dB hearing loss even
by sharp dissection of the middle ear mucosa. after a successful surgery.
Sometimes the handle of the malleus may be
turned inwards hitching against the promontory.
76
grafted ear drum virtually drapes the promon-
tory.
Even after successful surgery these patients

would still have about 40 – 50 dB hearing loss.
Image showing Type II tympanoplasty
Type III Tympanoplasty: This technique is used

only when a mobile suprastructure of stapes
alone is present. In this surgical procedure the Image showing Type III tympanoplasty
tympanic membrane graft is draped over the
mobile suprastructure of stapes. This is also
known as Columella effect. This type of middle
ear is commonly seen in birds.
The middle ear space is really non existent. Even

after successful surgery these patients still man-
ifest with 30 – 40 dB hearing loss. This surgical
procedure is useful in patients without malleus
and incus. Incus has the most precarious blood
supply among the three ossicles.
Type IV Tympanoplasty: This surgical procedure

is performed in patients only with mobile foot Image showing Type IV tympanoplasty
plate of stapes. The grafted ear drum is draped
over the mobile foot plate. In these patients
there is virtually no middle ear space at all. The

In this surgical procedure the round window is Austin in 1971 classified the anatomical defects
protected from the incoming sound waves. This found in the ossicular chain due to chronic sup-
helps in preserving the round window baffle purative otitis media. Isolated losses of handle
effect. of malleus and stapes suprastructure were not
included in this classification due to their rarity.
Type V Tympanoplasty: In this surgical proce-
dure a third window is created over the lateral Type I – Normal = M+I+S
semicircular canal. (Fenestra over lateral canal). Type II – M+S – Absent incus – Good prognosis
This surgical procedure is outdated these days. Type III – Malleus + Foot plate of stapes – poor
prognosis.
Belluci’s prognostic classification: Belluci used
the status of middle ear cavity in determining The forerunner of partial and total ossicular
the prognostic features of Tympanoplasty. He replacement prosthesis was Dr. Austin’s polyeth-
grouped those under 4 heads. ylene malleus to foot plate strut. He designed the
“sunflower Columella”
Group I: Patients with a dry ear for a period of at designed out of Teflon. Teflon and polyethylene
least 6 months fall in this category. has the advantage of excellent air bone closure.
Group II: Patients with occasionally draining ear
was included in this group. The following are the various categories of
Group III: Patients with persistent ear drainage bio-materials used in ossiculoplasty:
associated with mastoiditis were included
in this group. 1. Polyethylene tubing
Group IV: Patients with persistent ear discharge 2. Polytetrafluoroethylene (Teflon)
associated with palatal malformations (cleft pal- 3. Gelatin foam (Gelfoam)
ate) were included in this group. 4. Silastic (Dimethyl silicone polymer)
5. Platinum – This material is very ductile, non
Ossicular grafts have revolutionized Tympano- magnetic and bio-compatible.
plasty procedure these days. These grafts help in 6. Titanium alloy
the preservation of middle ear space, as well as 7. Polycel and plastipore
produces excellent improvement in hearing. 8. Capcel – Hydroxyapatite
9. Otocel – Clear bioactive bioglass (ceramic
Implants used for ossiculoplasty should satisfy material)
four basic requirements:
1. They should be bio-compatible and should

not extrude / cause severe tissue reaction
2. They should improve / maintain hearing
3. They should be technically easy to use
4. They should maintain results over time
78
Stapes to malleus reconstruction:
Selection of prosthesis:
When malleus is present, it can be used to help
Factors to be considered while selecting an opti- to stabilize thee prosthesis and reduce the possi-
mal prosthetic design are: bility of extrusion. The malleus is never directly
1. Status of ear drum aligned to the underlying stapes (M-S offset). A
2. Status of residual ossicles variety of implants have been designed to take
3. Severity of Eustachian tube dysfunction advantage of the stabilizing effect of malleus.
4. Stability of prosthesis
5. Ease of placement Incus interposition: Guilford transposed the
6. Sound conductivity residual incus autograft on to its side so that it
lies on the stapes capitulum and beneath the
manubrium. Hearing results could be excellent

if the middle ear anatomy is favorable. The incus
remnants could be too short
or long. Too long a incus prosthesis could lead
to ankylosis. Revision surgery is difficult in such
patients owing to the fixation of the prosthesis to
the stapes and fallopian canal.
Zollner’s sculpted incus: Zollner popularized the

sculpturing of Autologous incus. This helps in
obtaining a better fit. It also reduces the inci-
dence of subsequent ankylosis.
Weher’s refined this technique to include ho-

mograft ossicles. This technique could be time
consuming. Remnant Autologous incus could
harbor cholesteatoma. Image showing Grote prosthesis
Grote Hydroxyapatite assembly: Grote devel-

oped the first commercial Hydroxyapatite pros-
thesis. Its configuration attempted to accom-
modate the M-S offset. This prosthesis should
be placed lateral to the malleus necessitating
dissection of the ear drum away from the malle-
us. There is also the associated risk of iatrogenic
perforation of the ear drum.
Wehr’s Hydroxyapatite prosthesis: Wehr’s ad-

vocated sculpted homograft for incus interpo-
sition. He also developed Hydroxyapatite incus
prosthesis in order to reduce the preparation
time inside the operation theatre during ossic-
uloplasty procedures. This prosthesis had an
anterior extension which was created to cradle Image showing the Wehr’s prosthesis. The ante-
the malleus. Biocompatibility of this material rior cradle supports the malleus.
was really superior.
80
Image showing Weher’s prosthesis
Image showing stapes replacement prosthesis
There are two types of Weher’s prosthesis: Kartush Hydroxyapatite struts: These struts were
designed to function as either a TORP or PORP.
1. Incus replacement prosthesis Hydroxyapatite was used. This prosthesis has a
2. Incus – Stapes replacement prosthesis self locking mechanism. It has very low displace-
ment and extrusion rates.
Image showing incus replacement prosthesis

Image showing Kartush prosthesis

Incus interposition ossiculoplasty: Incus due to frequency function at the expense of low fre-
its precarious blood supply commonly under- quencies.
goes necrosis, especially its long process. Homo- 5. Prosthesis that connects malleus to stapes
graft incus was shaped and placed between the appears to have no acoustic advantage over pros-
malleus and stapes head. A notch was created thesis that connects the ear drum to the stapes.
in the short process of the incus that fit under 6. If the ear drum is conical, prosthesis with
the malleus handle. This is done to stabilize the the head angulated at about 30° appears to be
ossicles. If the stapes suprastructure was intact beneficial because the angulation increases the
in the patient, the long process of incus was am- surface area in contact with
putated. A small cup was made in the amputated the ear drum.
long process of incus. The head of the stapes fits
into this cup. The notch prevented the prosthesis These prostheses may be used to reconstruct
from being displaced anteriorly / posteriorly. the ossicular chain during Tympanoplasty, in
The spring in the patient’s malleus would keep patients in whom erosion and discontinuity
the prosthesis from being displaced inferiorly. of ossicular chain has occurred. Long process
Superiorly its position is maintained by the con- of incus gets frequently eroded because of its
traction of tensor tympani tendon. precarious blood supply. In these cases the
lenticular process of incus is still attached to
When the stapes superstructure is absent, the the head of stapes. The incudo stapedial joint in
long process of incus could be placed over the these patients should be separated and the long
foot plate of stapes. process of incus removed. This is done because
squamous debris could still be attached to the
Pitfalls: With AID’s being common these days, incus fragment. It is also preferable to remove
incus homograft has given way to artificially the body of the incus, because it could also have
designed prosthesis. Hydroxyapatite was com- squamous ingrowth. It can also have scar tissue
monly used to design these prosthetic incus blocking the antrum.
replacements.
Surgical procedure:
Factors that should be taken into consideration
before designing the optimal prosthesis: The prosthesis is laid on its side on the promon-
tory. The cup of the prosthesis is near the stapes
1. Proper tension is very important. A prosthe- and its notched portion close to the tip of the
sis that makes tension adjustment easy for the handle of malleus. With the help of right-angle
surgeon should be advantageous. pick held in the surgeon’s left hand, the malleus
2. Prosthesis with masses less than 40mg is best is elevated, and with a gently curved pick in the
for overall acoustic performance. surgeon’s right hand, the prosthesis is brought
3. For improved high frequency performance, up under the manubrium of the malleus. As it is
rigid low mass prosthesis (less than 10g) is the brought to an upright position, the cup engages
best choice. the head of stapes.
4. Longer prosthesis produces excellent high
82
Image showing the prosthesis laid on its side on
the promontory
Image showing prosthesis in final position
Ossicular reconstruction with prosthesis of

Hydroxyapatite should not be attempted in cases
of acute trauma / traumatic perforation of ear
drum. It should be performed only after the
drum has healed and stabilized.
Complications:
Owing to the biocompatibility of this prosthesis,

the incidence of complications is rare.
Image showing the prosthesis being positioned 1. Extrusion of the prosthesis.
2. Too short / Too long prosthesis could lead to
increased extrusion rates
3. Failure to improve hearing
The success or failure of ossiculoplasty proce-

dure could be assessed by calculating the Middle
Ear Risk (MER) Index. In this index a value is
assigned for each risk factor, and these values are
added to determine the MER index.
The success or failure of ossiculoplasty proce-

dure could be assessed by calculating the Middle
Ear Risk (MER) Index. In this index a value is
assigned for each risk factor, and these values are
added to determine the MER index.
Ossiculoplasty using presculptured banked

cartilage:
Homologous cartilage can be sculptured prior to

surgery into TORP / PORP configuration. They
can easily be stored by a tissue bank for use at
a later date. It is configured in a self stabilizing
manner with a disk shaped upper surface.
Donors should be screened serologically for

Hepatitis and HIV antigens. Costal cartilage
is ideal for this purpose. Graft material is har-
vested from the costochondral cartilages. These
cartilages are fashioned into TORP type im-
plants. The classic TORP configuration is about
8 mm long. It has a disk like head of about 4 mm
diameter. The diameter of the shaft should be 2
mm in diameter.
According to MER:
0 – Best prognosis
2 – Mild risk
84
5 – Moderate risk tion in the absence of stapes suprastructure is
7 – Severe risk technically more demanding. Cartilaginous
12 – Worst prognosis homografts are effective if the patient has a wide
oval window niche. Measurements are taken as
described for PORP configuration.
The length of the shaft should be trimmed and

contoured as per requirements. If there is a per-
foration in the tympanic membrane that corre-
sponds with the location of
the disk shaped head of the reconstruction pros-
thesis, the head of the prosthesis itself can be
used as a graft for the perforation. The surface of
the TORP readily epithelializes.
Image showing PORP configuration to be used Advantages of presculptured homograft cartilage

when malleus is absent as prosthesis:
1. The incidence of graft extrusion is rare

2. Contact of the implant with adjacent bony
walls of middle ear can be consistent with
excellent hearing results, because the cartilage
remains flexible.
3. Hearing improvement is excellent
4. Operating technique is less demanding when
presculptured cartilage homograft is
used.
Ossiculoplasty with composite prosthesis:

PORP’s and TORP’s designed out of composite
Image showing PORP configuration to be used materials was first popularized by Sheehy and
when malleus is present Shea. Major advantage of using
synthetic graft is there is no fear of transmission
The disk like top of the implant can be placed in of diseases like HIV and Hepatitis.
contact with the posterior bony annulus for add-
ed stabilization. It is better to thin the cartilage Composite prosthesis has two distinct por-
in the area of contact with the annulus, thereby tions: a Hydroxyapatite head and a plastipore or
minimizing the potential for dense adhesions. fluoroplastic shaft. The Hydroxyapatite head is a
universal design, and no modification or intra-
TORP configuration: Ossicular reconstruc- operative reshaping is required. The plastipore

shaft is manufactured in such a way
that it can be precisely trimmed to within a 0.5
mm variance on the basis of intraoperative mea-
surements.
The type of Hydroxyapatite head that should

be used in the prosthesis depends upon wheth-
er malleus is present or absent. In cases where
malleus is present, the head of the prosthesis
used should be in the form of a delicate hook. It
is designed in such a way that the hook is po-
sitioned under the handle of the malleus. The
Hydroxyapatite head to be when the malleus is
absent has a flat, egg shaped design, with gently
rounded edges.
This design facilitates easy insertion under the
ear drum without the need for cartilage inter-
position. This prosthesis is best used when the Image showing the types of composite prosthesis
middle ear is healthy and free of in use
disease.
The plastipore shaft is of two types:

Contraindications for composite prosthesis:
1. Type I: The shaft has a hollow sleeve to ac-
commodate the head of stapes
2. Type II: The shaft is more slender, wire rein- 1. Should not be used in patients with severe
forced. This design helps the shaft to rest directly Eustachian tube function.
on the foot plate of stapes / oval window. 2. Should not be used in patients with an obliter-
ated middle ear space.
There are 4 types of composite prosthesis de- 3. Middle ear mucosa should be healthy and free
signed to solve the four basic problems encoun- of any disease.
tered during ossicular reconstruction. These
situations include:
• Malleus present, stapes present

• Malleus present, stapes absent
• Malleus absent, stapes present
• Malleus absent, stapes absent
86
Spandrel: This is a type of TORP. It has a wide
head which can be slid under the ear drum and
a narrow shaft. The length of the shaft can be re-
duced by cutting it. The shaft rests over the foot
plate of stapes.
Parts of spandrel: It has a perforated shoe to

allow protrusion of the wire core. It has a thin
flange on the prosthesis head to avoid possible
damage induced by a sharp edge of the Polycel
Image showing standard TORP configuration disk.
Cartilage harvested from rib is cut into 8 mm

sections. They are then placed over sterile hard
surface. Using a 4mm disposable dermal punch
cylinders of cartilage are created each with 4
mm diameter and 8 mm long. From these cylin-
drical grafts, appropriately shaped TORP’s can
be prepared. Cartilage material can be placed in
sterile saline and put in glass specimen sterile
bottles and sealed with a plastic seal.
PORP configuration: When stapes is present and

mobile, a measurement is taken from the lateral
most part of the capitulum of the stapes to the
ear drum. 1 mm should be
added to this value, and the TORP blank car-
tilage is trimmed to this measurement. A de-
pression is made in the end of the shaft of the Image showing a Spandrel.
trimmed blank to accommodate the head of the
stapes. The depth of this indentation could be Before assembling the prosthesis, air is removed
about 0.5 – 1 mm. The 4 mm disk of the top of from the Polycel casing by connecting the
the implant should be in complete contact with prosthesis and its shoe to a syringe containing
the ear drum. If an intact malleus handle is pres- Ringer’s solution and antibiotic.
ent, the anterior most portion of the head of the This prosthesis ensures better closure of air bone
implant can be trimmed to fit the handle. If the gap.
malleus handle is absent, a more flat configura-
tion can be used.

patient doesn’t have middle ear effusion. Symp-
toms are usually fluctuating (disequilibrium,
Grommet Insertion tinnitus, vertigo, auto phony and severe retrac-
tion pocket).
Introduction:
6. Otitis barotrauma in order to prevent recur-
Myringotomy with grommet insertion was rent episodes.
introduced by Poltizer of Vienna in 1868. He
used this procedure to manage “Otitis media ca- 7. To administer intratympanic medications
tarrhalis”. Soon it became the common surgical
procedure performed in children. Problems with Grommet insertion:
Indications: This procedure is not without its attendant prob-

lems.
Bluestone and Klein (2004) came out with re-
vised indications for grommet insertion which Common problems include:
took into consideration the prevailing antibiotic
spectrum. 1. Segmental atrophy of tympanic membrane
Tympanosclerosis
1. Chronic otitis media with effusion not re-
sponding to antibiotic medication and has 2. Persistent perforation syndrome (rare) Before
persisted for more than 3 months when bilateral treating patients with otitis media with effusion
or 6 months when unilateral. the following factors should be borne in mind.
Pneumatic otoscopy should be used to differen-
2. Recurrent acute otitis media especially when tiate otitis media with effusion from acute otitis
antibiotic prophylaxis fails. The minimum epi- media. Duration of symptoms should be careful-
sode frequency should be 3/4 during previous 6 ly documented. Children with risk for learning /
months / 4 or more attacks during previous year. speech problems should be carefully identified.
Hearing should be evaluated in all children who
3. Recurrent episodes of otitis media with effu- have persistent effusion for more than 3 months.
sion in which duration of each episode does not Grommet insertion can be performed under
meet the criteria given for chronic otitis media local anesthesia. Incision is made in the antero
but the cumulative duration is considered to be inferior quadrant of ear drum. The incision is
excessive (6 episodes in the previous year) given along the direction of radial fibers of the
middle layer of ear drum. This causes minimal
4. Suppurative complication is present / sus- damage to the radial fibers. It also enables these
pected. It can be identified if myringotomy is fibers to hug the grommet in position.
performed.
5. Eustachean tube dysfunction even if the
88
Image showing the site of incision in the ear Image showing glue flowing out after the inci-
drum sion
Image showing grommet being introduced

Image showing incision being given using sickle
knife

He also suggested that this condition could be
relieved by incising the eardrum. The first myr-
ingotomy was reported in 1649 by Jean Riolan
a French anatomist who described an improve-
ment in hearing following intentional laceration
of the tympanic membrane with a ear spoon.
He also hypothesized that artificial perforations
of the ear drum could be a cure for congenital
deafness.
Image showing grommet being pushed into the During 17th and 18th centuries, many famous
perforation surgeons attempted to explain the relationship
between the ear drum and hearing. William
Cheselden completed animal studies by per-
forming myringotomy. He wanted to conduct
human trials which was prevented. In 1748,
Julius Busson became the first person to rec-
ommend perforating the ear drum if pus was
present medial to it. Peter Degraers performed
myringotomy in Edinburgh. Sir Astley Paston
Cooper, a surgeon to Guy’s hospital can be con-
sidered the first to outline clear indications for
myringotomy.
Home was the first to describe the radial fibers

Image showing grommet in situ of the ear drum. He used a trocar concealed
within a cannula to create a perforation in the
History: ear drum. This trocar and cannula was designed
by Ashey Cooper. The procedure performed
The term Grommet is derived from the French was really blind, and his only indication for this
word gourmer (“to curb”). procedure was deafness due to eustachean tube
obstruction. He also insisted that bone conduc-
The first era of myringotomy tion should be intact in these patients.
Otitis media with effusion is an age old problem In 1804 Christian Michalis a professor of anat-
affecting young children and infants. The term omy from marburg performed tympanic mem-
“glue ear” was first coined in the year 1960. This brane perforations in 63 patients. Cooper’s strict
condition was first described by Hippocrates indication of having good bone conduction
and Aristotle. In 400 BC, Hippocrates described before performing myringotomy was ignored by
how the middle ear become filled with mucous. subsequent surgeons at their own peril.
90
tempt to liquefy the middle ear fluid facilitating
removal. Adam Politzer was actually credited
with the first use of suction to remove fluid. It
was noted by him that one of the drawbacks of
myringotomy was that the site of incision healed
spontaneously and very quickly.
Earliest attempts to prevent rapid healing was

described by Antoine Saissy in 1829. He used an
oiled catgut string to keep the perforation open.
In Italy during the 18th century Monteggio
attempted to maintain the opening with cautery.
About the same time the German Ophthalmol-
ogist Himly devised a larger trocar for the same
reason.
Image showing Ashey Cooper trocar and can-
nula The focus of this phase is the search for success-
ful method of maintaining the ear drum perfo-
Second Era ration open. Essentially the focus was divided
into two schools of approach. The first one was
In the mid-19th century few surgeons were still led by Philippeaux and Gruber who removed
performing myringotomy. Toynbee of St Mary’s sections of the ear drum, progressing from larg-
hospital happens to be one among them and his er myringotomies to wedge-shaped excisions.
assistant James Hilton was the other. Toyenbee Though this approach left a reasonably large
was the first to document insertion of a tube in opening in the ear drum for a reasonable period
the myringotomy performed to keep the middle of time, this was not a dependable one always.
ear ventilation going for long period of time. In some cases the annulus portion of the ear
In Dublin Sir William Wilde was using a sickle drum was also removed.
knife to incise the antero inferior quadrant of
the ear drum and followed it up with silver ni- The second school of surgeons headed by
trate cautery of the edges to keep the perforation Politzer searched for a foreign body that would
open. sit within the perforation and keep it open.
They also found that Saissy’s catgut insertion /
Myringotomy was reintroduced into otologi- insertion of a lead wire / whale bone insertion
cal practice in the latter half of 19th century by did not work reliably to keep the perforation
Schwarte and Politzer. They advised this proce- open. In 1845 it was Martel Frank who de-
dure only for fluid collections in the middle ear scribed the use of a small gold tube to keep the
cavity. Schwartze and his contemporaries tried ear drum perforation open by inserting it into
instilling medications via eustachean tube, as the middle ear cavity via the perforation. This
well as via the external auditory canal in an at- method had a reasonable degree of success de-

spite its temporary nature. Politzer described a from occurring. The prevalence of secretory
rubber grommet in 1868, which had three flang- otitis media increased rather dramatically in
es and 2 grooves to allow it to sit across the ear this era. In 1954, American surgeon Beverley
drum as well as a silk thread to prevent it falling Armstrong used insertion of ventilation tube as
into the middle ear cavity. This resembled the a new treatment modality in managing patients
currently available grommets. This grommet with secretory otitis media. He first introduced
was adopted by Dalby, but it remained in place the concept of modern grommet and used plas-
only for a few months before extruding. He also tic grommets. He also recommended removal
observed that sometimes it would be necessary of the grommet after 4 weeks in order to allow
to insert a fresh grommet to keep the perfora- perforation to close. It was found to remain
tion open. Voltolini developed a gold ring in in situ for much longer if left alone. He in his
1874, and later modified it with aluminum. He writings related the success of grommet inser-
incised the anterior and posterior to the malleus tion to a beveled end which acts to secure the
and placed the ring around the handle. This also tube within the opening. In 1959, he designed
was not useful. the first flanged tube molded of polypropylene.
In 1965 he designed a Teflon tube with a slop-
Added to these problems surgeons encountered ing flange which was easier to insert through a
other complications like post operative infec- smaller incision. He patented the “Armstrong
tion, and foreign body reaction. Since this hap- V” in 1981. This tube was designed for easy,
pened to be the preanitbiotic era surgeons really precise insertion and to accommodate the anat-
found it hard to manage infections following the omy. The flange was supposed to have an entry
procedure. They then started to focus on ade- tab for easy insertion via the myringotomy and
noid and tonsil removal. Adenotonsillectomy comes complete with a stainless steel insertion
surgery became a panacea of all illness during instrument that fits onto a tab on the lateral end
the later part of the second era. of the tube. Armstrong the original designer to
the tube advised myringotomy to be made in
Third era the anterosuperior quadrant of the drum imme-
diately adjacent to the fibrous annulus. He also
The third era of myringotomy and grommet in- believed that incision at any other site will lead
sertion followed the second world war. The first to a premature extrusion of the tube, on the oth-
set of antibiotics had arrived and post operative er hand the right tube in the right place would
infections became treatable. Introduction of remain in situ for two years and above.
antibiotics ensured that acute otitis media could
be treated and the incidence of acute mastoid- Myringotomy became a standard treatment for
itis decreased dramatically. This reduced the glue ear with or without adenoidectomy. 91%
number of cortical mastoidectomies and otolo- of American otolaryngologists found ventilating
gists had time and energy to manage less serious tubes to be more effective than antibiotics in
conditions. During the first half of the 20th preventing acute otitis media. Radio-frequency
century, the otologists were treating the sequel assisted myringotomy is known to delay closure.
of serous otitis rather than preventing the sequel Closure can still be delayed if mitomycin C is
92
applied to the perforation edges. obstructing the vision then it must also be re-
moved.
Applied anatomy
An incision is given along the the anteroinferior
The tympanic membrane is an oval, thin, quadrant of the ear drum along the direction of
semi-transparent membrane separating the the radial fibers of the ear drum. The incision
external and middle ear cavity. The tympanic should be approximately 3-5 mm in length.
membrane is divided into 2 parts: Grommet is inserted into the opening and the
Pars flaccida and pars tensa. The manubrium radial fibers hold the grommet in position keep-
of the malleus is attached to the medial tym- ing the perforation open.
panic membrane; where the manubrium draws
the tympanic membrane medially, a concavity
is formed. The apex of the concavity is called
the umbo. The area of tympanic membrane
superior to umbo is termed as pars flaccida; the
remainder of the ear drum is known as the pars
tensa.
Procedure
Myringotomy is usually performed as an outpa-

tient procedure in adults and local anesthesia is
used. In children and infants general anesthesia
is preferred.
Equipment needed:
Pneumatic otoscope
Speculum
Myringotomy knife
Grommets
The head of the patient is tilted slightly towards

the opposite ear. Thee operative microscope
is brought into the field and focused on the
external auditory canal. If cerumen is found

4. Patient with tinnitus and vertigo
Stapedectomy
5. Presence of active otosclerotic foci (otospon-
This surgical procedure is performed to treat giosis) as evidenced by a positive flemmingo
deafness due to otosclerosis. Otosclerosis is sign. Since a patient with otosclerosis is also an
caused by fixation of the foot plate of stapes ideal candidate for hearing aid and surgery, the
which prevents efficient sound transmission to patient must be properly counseled regarding
the oval window. The deafness caused is conduc- the advantages and disadvantages of both.
tive in nature. The surgical procedure is per-
formed under local anesthesia. The position of the patient is made so that the
surgeon can see directly down the ear canal
Advantages of performing this surgery under from a sitting position.
local anesthesia are:
Anesthesia:
1. Improvement in hearing can be ascertained
on the table. Xylocaine with adrenaline mixed in concentra-
tion of 1:1000 is used to infiltrate the external
2. Bleeding is minimal under local anesthesia. auditory canal. 0.25 ml of the solution is infil-
trated using a 27 gauge needle. Infiltration is
Indications for stapedectomy: given as illustrated in the diagram.
Exposure:
1. Conductive deafness due to fixation of stapes.
A large speculum is used to straighten the
2. Air bone gap of at least 40 dB. external auditory canal. A curved or triangu-
lar incision is made in the external canal skin
3. Presence of Carhart’s notch in the audiogram beginning at 2mm away from the annulus. The
of a patient with conductive deafness. incision extends from 11 o clock position to 6
o clock position as viewed in the right ear. The
4. Good cochlear reserve as assessed by the pres- tympano meatal flap is elevated up to the an-
ence of good speech discrimination. nulus. Using a sharp pick the annulus is slowly
lifted from its groove, the middle ear mucosa is
Contraindications for stapedectomy: excised and the middle ear proper is entered.
1. Poor general condition of the patient. The chorda tympani nerve will come into view
immediately on entering the middle ear cavity.
2. Only hearing ear.
In most patients the posterior superior bony
3. Poor cochlear reserve as shown by poor overhang must be curetted using a curette (de-
speech discrimination scores signed by House). The long process comes into
view. Curetting is continued till the base of the
94
pyramidal process is visualised. Oval window 8. Perilymph fistula
is visualised. At this point round window reflex
is tested by moving the handle of malleus and 9. Labyrinthitis
looking for movement of round window mem-
brane. In otosclerosis this reflex is absent.
Using a hand burr a small fenestra about 0.6mm

in diameter is made over the foot plate. The
stability of the incus is left intact because the sta-
pedial tendon is not cut at this point. From now
on the steps may vary according to the surgeon’s
viewpoint. Some surgeons would like to insert
the piston at this stage without disturbing the
stability of the incus. The distance between the
long process of incus and the foot plate is mea-
sured using a measuring rod. Appropriate size
Teflon piston is introduced and hung over the
long process of the incus and is crimped after
ascertaining whether its lower end is inside the
fenestra. The stapedial tendon is cut at this point Image showing the site of incision in stapedec-
and the supra structure of the stapes is disartic- tomy
ulated and removed. The Tympanomeatal flap is
repositioned.
Complications of stapedectomy:
1. Facial palsy
2. Vertigo in the immediate post op period
3. Vomiting
4. Peri lymph gush
5. Floating foot plate Image showing tympanomeatal flap being

elevated
6. Tympanic membrane tear
7. Dead labyrinth

Image showing bony overhang being curetted
Image showing middle ear cavity being en-

tered. Middle ear mucosa is indicated by the
yellow arrow
Image showing chorda tympani nerve pushed Image showing stapedial tendon being cut
anteriorly
96
Image showing suprastructure of stapes being
sectioned Image showing piston being introduced
Image showing Piston introduction complete.

Image showing foot plate being fenestrated Could be seen hanging from the long process
of incus and entering the fenestra

Ear lobe repair
Incision:
Ear lobe repair is the most common request in
cosmetic surgery. Torn ear lobes result from vari- Common incisional modalities include scar
ous forms of trauma, which include: excision with scalpel / scissors. Incision should be
performed in a pressure less manner. Radio-fre-
1. Babies pulling ear rings quency cautery has also been used for this pur-
pose. It offers precision, and simultaneous cutting
2. Entanglement in telephone cords and coagulation. The frequency used is 4.0 MHz.
Some authors also prefer using CO2 laser. Small
3. Hair brushes tears involving the upper two thirds of ear lobe
can just be incised. The enlarged fistula can be
4. Caught in the clothing repaired by approximating the lateral and medial
surfaces. It is not mandatory for converting these
5. Spousal abuse tears into a full one. Some authors prefer using
elliptical biopsy punch forceps. 6-0 silk is ideal.
6. Heavy ear rings Some of the ear lobe tears Some authors use 6-0 chromic catgut which need
occur over years of constant weight of heavy, not be removed. Incomplete tears that are at or
pendulous ear rings. Patients fail to seek immedi- below the junction of the lower third of the ear
ate care when the ear lobe is acutely torn causing lobe should be converted into a full tear. Failure
the torn edges of the lobe becoming epithelialized to include the inferior border of the lobe mar-
thus forming a fistula or cleft. gin can result in bunching and elongation of the
earlobe. When repairing full thickness ear lobe
All the currently available methods of earlobe tear a single buried 5-0 absorbable suture is used.
repair concerns the removal of the scar tissue and This reduces the dead space and diminishes the
some type of approximation of the fresh edges. tension on the skin sutures. The lateral surface
Ear lobe repair is usually performed under local of the ear lobe is sutured first, this will enable
anesthesia. 2% xylocaine with 1 in 100,000 units a minor irregularity to be hidden behind the
adrenaline is used as the local anesthetic. About earlobe. Re-piercing ear lobe: This can be done
0.5 ml of this drug is injected at the root of the immediately. This is viable because the patient
ear lobe to anesthetize the area. Since the ear can leave the OT with an ear ring which can be
lobe is the most fleshy and mobile areas of the worn throughout the healing period.
body it should be controlled and stabilized before
attempting the repair. Common stabilization mo-
dalities include the use of skin hooks, chalazion Complications:
clamps and sterile tongue blades (wooden straight
ones). 1. Depressed linear scar. This can be treated by
resurfacing with Co2 laser.
2. Inferior notching of the lobe. This is due to im-

proper alignment of the inferior lobe or from scar
98
retraction. Everting the closure and placing a key
suture will reduce the incidence of this complica-
tion.
Prevention of ear lobe tears:
1. Avoid wearing heavy ear rings for long periods

of time
Image showing Chalazion clamp
2. The ear rings can be removed while using the
phone
3. Ear rings to be removed when in saloon
4. Children should not be allowed to wear small

loop or dangling ear rings
5. Ear rings are ideally removed before taking off

the upper clothing.
Image showing earlobe tear

Image showing scar in the lobule removed
Image showing lateral surface of the ear lobule

wound sutured.
100
Canalplasty 2. The posterior wall and floor of the canal is
supplied by the auricular branch of vagus (Arnold
nerve)
Introduction:
3. The tympanic plexus also supplies some areas
A canalplasty is usually performed to widen a
Blood supply:
narrowed external auditory canal either due to
congenital / acquired causes. The reasons for per-
1. Posterior auricular artery
forming this procedure are as follows:
2. Deep auricular branch of the maxillary artery
1. To improve access to middle ear and mastoid
cavities during mastoid surgeries
3. Superficial temporal artery
2. To remove bony / soft tissue growths / scar
tissue occluding the external canal
Important anatomic relations that should be
3. To treat aural atresia
borne in mind during surgery:
Anterior to the bony portion of external auditory

canal lie the temporomandibular joint and the
Anatomy:
parotid gland. During canalplasty care should be
taken not to injure these structures. Posterior and
The adult external auditory canal is about 2.5
inferior to the bony external canal lies the mas-
cms long and is composed of lateral cartilaginous
toid portion of the temporal bone and it contains
(1/3) and medial bony (2/3) portions.
the facial nerve. Facial nerve courses usually
lateral to the annulus in the posteroinferior quad-
The medial bony portion of the external canal
rant of the tympanic membrane.
consists of the tympanic bone which is a ringed
lateral projection of temporal bone. There is a
Function of external canal:
notch in the superior portion of the tympanic
bone known as the notch of Rivinus which is
1. It serves as efficient conduit for transmission of
located at the junction of tympanosquamous and
sound from the environment to the ear drum
tympanomastoid suture lines.
2. Protects the middle ear and inner ear from
Sensory innervation of external auditory canal:
environmental insults
1. Auriculotemporal nerve (from the mandibular
Indications:
branch of the trigeminal nerve) provides sensory
innervation to anterior, posterior walls and the
1. Hearing loss due to the presence of osteoma
roof of external canal.

Approaches:
2. To improve self cleansing mechanism of exter-
nal canal in the presence of exostosis The following approaches are possible:
3. To improve visualization of ear drum while 1. Endomeatal

performing tympanoplasty
2. Post aural
Contraindications:
3. Endomeatal Typically a postaural approach
1. Presence of acute infections in the external combined with endaural incision is used to re-
auditory canal move exostosis and medial canal fibrosis.
Endaural / endomeatal incision may be preferred

for osteoma as they often have a stalk that facil-
Planning: itates easy removal. Endaural incision is made
in the external canal as far medial as possible. A
If otitis externa is present then the patient should laterally based vascular strip is developed in the
be treated for the same by administration of topi- external auditory canal skin. After completion
cal antibiotic ear drops. A combination of antibi- of this step the post aural incision is given. It is
otic and steroid ear drops would actually help. usually given 7 mm behind the post aural sulcus.
The incision is continued through the auricularis
Anesthesia: posterior muscle down to temporalis fascia. Peri-
osteum over the mastoid is incised and elevated
This surgery is ideally performed under general anteriorly to the external canal. The endaural
anesthesia. In congenital external canal atresia incision is found from the post aural approach,
facial nerve monitoring is used and hence long and the two incisions are joined. The external au-
acting paralytics should not be used. Xylocaine ditory canal skin is carefully elevated off the bony
1% mixed with 1 in 100,000 adrenaline is used to external canal and then retracted forward with
infiltrate the external canal. Infiltration is usually the auricle. In external canal exostosis, the skin
given in the cartilaginous, hair bearing portion of over the exostosis is elevated with a round knife
the external canal. This is done to reduce bleeding and elevated toward the ear drum. The exostosis
during the procedure. is drilled down using a cutting / diamond burrs
in a lateral to medial direction. Curettes can also
Patient positioning: be used to dissect bony edges. Canalplasty for
acquired external canal stenosis needs drilling of
The patient is ideally positioned supine on the the anterior bony canal. When drill is used care
Operating table with the head turned away from should be taken to avoid contact with the ossic-
the surgeon. The table is turned 180 degrees away ular chain as it could cause conductive hearing
from the anesthesiology team to allow proper loss. While drilling anteriorly care should be
positioning of the microscope. taken to avoid penetration into the TM joint. This
can be prevented by drilling away bone superior
102
and inferior to the temporomandibular joint first,
before carefully removing the buttress of bone
overlying the joint. After canaplasty the skin flap
is repositioned and the wound is closed in layers.
Ideally a stent may be placed to assist adherence
of the external canal skin to the external canal.
Image showing canalplasty being performed

These 6 hillocks eventually fuse to form the full
Preauricular sinus and its management fledged pinna.
Theories or preauricular sinus formation:

Introduction: Embryological fusion theory: This commonly
This condition was first described by Van He- accepted theory attributes the development of
usinger in 1864. He also rightly postulated it to preauricular sinus due to incomplete or defective
be congenital in nature. Most of these patients are fusion of these
symptomatic. Hillocks.
Common symptoms include infections, celluli-
tis, and abscess formation in-front of the pinna. Ectodermal infolding theory: This theory attri-
Some of these patients may have recurrent infec- butes isolated ectodermal folding during auric-
tions leading on to ular development. This theory has virtually no
embarassing discharge from the sinus. In most takers.
patients this condition is identified during routine
examination involving ear, nose and throat. Incomplete closure of dorsal part of first pharyn-
geal groove: This theory suggests that branchial
Synonyms: fistula are formed due to incomplete closure of
Various terminologies have been used to describe the dorsal part of first pharyngeal groove. This
this condition. They include preauricular pit, pre- theory assumes that preauricular sinuses form
auricular fistula, preauricular tract, helical fistulae part of branchiogenic malformations.
or preauricular cyst.
Preauricular sinus should not be confused with
Incidence:
branchial cleft anomalies. These branchial cleft
The estimated incidence as reported by studies in
anomalies are intimately related to the external
US puts the incidence somewhere between 0.1 –
auditory canal / ear
0.9%. Studies in Africa put a slightly higher figure
drum / angle of the mandible whereas the preau-
(4 – 5%).
ricular sinus are not. It has also been shown that
the preauricular sinus does not involve the facial
Embryology:
nerve or its branches, of course surgical removal
Since this condition is an embryological aberra-
of preauricular sinus may put the facial nerve at
tion, a study of development of Pinna wont be out
risk.
of place here. Studies have shown that the forma-
tion of preauricular
sinus is closely associated with the development
of pinna which occurs during the 6th week of
gestation. Auricle develops from 6 mesenchmal
hillocks known as Hillocks
of His. Three of these hillocks arise from the
caudal border of the first arch, and the other three
arise from the cephalic border of the second arch.
104
lateral cervical fistulae, preauricular sinus, and
nasolacrimal duct stenosis and fistula.
2. Branchio oto urethral syndrome – These pa-
tients have sensorineural hearing loss, preauric-
ular sinus, renal anomalies like bifid ureters and
bifid renal pelvis.
3. Branchio otic syndrome – This is a variant of
BOR syndrome. These patients
have branchial anomalies, preauricular sinus,
branchial fistula (unilateral) with no renal dyspla-
sia
4. Branchio oto costal syndrome – These patients
have conductive deafness, preauricular sinus,
bilateral commissural lip, unilateral branchial
fistula and rib anomalies
5. Cat eye syndrome – Coloboma of iris, Preau-
ricular sinus, imperforate anus and down slanting
of palpebral fissures
6. Trisomy 22 – These patients have bilateral pre-
Image showing development of Pinna auricular sinus, anti mongoloid palpebral fissures,
macroglossia, cleft palate, enlarged sub lingual
Mode of inheritance: glands and short lower limbs
Preauricular sinus occurs either sporadically or Clinical features:

may be inherited. In about half the number of Preauricular sinus is seen as a small pit usually at
patients it occurs in a sporadic manner and com- the anterior margin of the ascending limb of the
monly on the right side. helix. In some patients this opening may also be
Bilateral cases are commonly genetically inherit- seen along the
ed. Studies have shown that inheritance is auto- postero superior margin of helix. Rarely it may be
somal dominant with varying degrees of penetra- seen close to the tragus or lobule.
tion (about 85% penetration). Studies in China
has shown chromosome 8q11 to be site of abnor- In almost all patients part of the tract blends with
mal gene which transmits preauricular sinus. the perichondrium of the auricular cartilage.
The sinus tract may follow a tortuous course.
Preauricular sinus has been described as a part of The sinus tract is usually superior and lateral to
number of syndromes. These syndromes include: the facial nerve and parotid gland. This feature
differentiates it from branchial cleft anomalies.
1. BOR syndrome (Branchio oto renal syndrome) Sometimes the preauricular sinus may lead to the
– defects in these patients include outer, middle formation of subcutaneous cyst that is intimately
and inner ear deformities with conductive deaf- related to the tragal cartilage and the
ness. These patients also have renal anomalies, crus of helix.

Patients usually present with discharge from the
preauricular sinus pit. Discharge could be due
to desquamating epithelial debris or infection.
Studies have shown that the common pathogens
causing infection in the preauricular sinus in-
clude staphylococcus, Proteus, streptococcus and
peptococcus.
It is always better to rule out syndromes associ-

ated with preauricular sinus. Almost majority of
these syndromes involve kidney. There is intense
debate raging whether ultrasound examination
should be performed as a routine in all patients
with preauricular sinus. Considering the com-
monality of the lesion and the cost and time
involved routine ultrasound in these patients are Image of a child with preauricular sinus
not indicated. Wang et al of California came out
with a set of indications when ultrasound abdo-
men should be performed in these patients.
Complications of preauricular sinus:
Wang’s criteria in performing ultrasound exam-
ination in patients with preauricular sinus: Infection is the predominant complication. In the
acute phase of infection (cellulitis stage) man-
1. Presence of another malformation / dysmor- agement is by prescribing appropriate antibiotics
phic feature in adequate doses. Since the common infecting
2. Family history of deafness organism is staphylococcus aureus the drug of
3. Malformations involving pinna choice is a combination of amoxycillin and clavu-
4. Maternal history of gestational diabetes lanic acid.
Pure tone audiometry: Abscess formation:

This is another investigation that should routinely
be performed in all patients with preauricular Abscess in this area should always be drained.
sinuses. Incision and drainage using a scalpel would cause
extensive fibrosis causing difficulty in complete
surgical clearance of the area at a later date.
Precisely for this reason Coatesworth et al de-
scribed a drainage procedure using lacrimal
probe. This probe negates the need for incision in
this area and thus causes very little disturbance
to the underlying preauricular sinus tissue. In
106
this technique of drainage the overlying skin is
anesthetized using 2% xylocaine infiltration. The
blunt end of the lacrimal probe is inserted into
the sinus through the pit. This allows drainage to
occur via the normal opening which is usually
present in front of the ascending limb of the helix.
If preauricular abscess does not drain when this
technique is used then conventional incision and
drainage should be performed. Recurrent infec-
tions involving the preauricular sinus should be
managed by complete surgical resection of the
sinus tract completely during the stage of quies-
cence.
Image showing common sites of preauricular

sinus involvement
1. Anterior margin of ascending limb of helix
(most common)
2. Superior to auricle
3. Along the posterior surface of cymba concha
4. Lobule
5. Posterior to auricle
Image showing lacrimal probe which is used to Surgical excision of preauricular sinus:
drain preauricular abscess
While surgically excising the sinus tract care
should be taken to completely remove it. Incom-
plete removal of sinus tract is the commonest
cause for recurrence. The recurrence rate ranges
between 1 – 45% depending on the procedure
followed.

Simple sincectomy:
This is the commonly used standard procedure

for excising preauricular sinus. An ellipse of skin
surrounding the preauricular sinus tract is ex-
cised and dissected out
along with the tract. The tract can simply be iden-
tified by its glistening white color, or methylene
blue dye can be injected through the opening to
facilitate easy identification of the tract. Most of
these fistulae follow the external auditory canal.
This procedure can be performed under local or

general anesthesia. While operating on children
general anesthesia is preferred.
Jensma technique:
This technique was popularised by Jensma in
1970. It is actually a modification of the classic Image showing the incision marked around the
sinusotomy procedure. This technique is also preauricular sinus opening.
known as inside out technique.
Procedure:
A small skin incision around the sinus is made.
Stay sutures are placed to allow retraction of the

tract to facilitate surgical extirpation. The sinus is
opened with a sharp scissors.
Under magnification the glistening lining which

is inside and the outer wall of the tract are dis-
sected free from the surrounding tissue.
Image showing sinus opened with a sharp scis-

sors
108
The main advantage of this procedure is that
the sinus can be viewed and followed from both
inside and outside. The classic procedure allows
visualization of the sinus from only outside. All
the tracts are opened and followed until the dead
end is reached. A lacrimal duct probe can be used
to establish the direction of small tracts.
It should be borne in mind that one of the tracts
could be closely adherent to the perichondrium
of the root of the helix / tragus. This piece of
perichondrium along with a small bit of under-
lying cartilage should be resected along with the
specimen.
The medial limit of dissection is always the

temporalis fascia. Before closure the wound bed
should be carefully examined for evidence of
residual tracts.
Causes of recurrence:
1. Major cause of recurrence is inadequate remov-

al of the mass.
2. Performing the surgery without magnification
aids
3. Skill of the operating surgeon. This is rather
important because surgeons consider this case to
be a minor procedure and hence pass it on either
to a novice or junior surgeon who may not be
experienced enough in performing this type of
surgery.
Supra auricular approach:
This is a more radical approach. Major advantage

of this approach is that it gives excellent exposure
and hence removal of the sinus tract is nearly
complete. This procedure has the lowest recur-
rence rate among all other surgical procedures for
preauricular sinus removal.

This procedure involves a post auricular exten-
sion of the elliptical incision around the preau-
ricular sinus opening. The incision is deepened
till the temporalis fascia comes into view. This is
supposedly the medial limit for resection in this
procedure. All the tissue superficial to the tem-
poralis fascia is removed together with the pre-
auricular sinus. A portion of the cartilage along
the base of the preauricular sinus should also be
excised. The dead space should be closed in layers
and compression dressing should be applied. A
drain need not be placed here.
Image showing the bed after excision of preau-

ricular sinus. Note the cartilage of helix after
removal of the preauricular sinus.
Image showing incision for supra auricular

approach
Image showing closure of wound after preauric-

ular sinus excision.
110
Labyrinthectomy Trans canal labyrinthectomy:
This is an effective option for the management of

Introduction:
poorly compensated unilateral peripheral vestib-
ular dysfunction in the presence of ipsilateral pro-
Labyrinthectomy is an effective surgery for
found sensorineural hearing loss. This technique
managing poorly compensated unilateral pe-
was first introduced in 1950’s by Schuknecht and
ripheral vestibular dysfunction in the presence of
Cawthrone.
non-serviceable hearing ear. Relief from vertigo is
achieved at the expense of residual hearing in the
Advantages of trans canal labyrinthectomy:
ear operated. This procedure is strictly reserved
for patients with non-serviceable hearing.
1. It is less invasive than transmastoid labyrin-
thectomy
Principle:
2. It provides direct approach to vestibular end
organ
The principle is to open all the three semicir-
3. The operating time is shorter when compared
cular canals and vestibule with preservation of
to that of transmastoid labyrinthectomy
landmarks till the end of the procedure. After
4. It has lesser morbidity than transmastoid ap-
exposure of all the ampullae of the semicircular
proach
canals and vestibules the five individual groups of
The main disadvantage of this approach is that
sensory epithelia are excised under direct vision.
the exposure is highly unlimited.
This procedure eliminates abnormal vestibular
input from the affected ear.
There is significant incidence of incomplete lab-
yrinthectomy if the surgeon is not experienced.
Indications:
Reaching the ampulla of the posterior canal is dif-
ficult because it is performed with blind probing.
1. In order to approach internal acoustic meatus
in acoustic schwannoma surgery
It should be stressed at this point that vestibular
2. Unilateral vestibular dysfunction with non-ser-
disorders should be given appropriate medical
viceable hearing
treatment and reconditioning exercised before
3. Severe and intractable Meniere’s disease
embarking on labyrinthectomy.
Techniques:
In patients with bilateral vestibulocochlear disor-
ders alternate techniques of labyrinthine destruc-
Two techniques can be used for labyrinthectomy.
tion should be considered before surgery.
1. Trans canal labyrinthectomy
2. Trans labyrinthine labyrinthectomy

Indications for transmastoid labyrinthectomy: Trans canal approach:
1. Delayed onset vertigo syndrome In this procedure an anteriorly based tympano-

2. Unilateral severe Meniere’s syndrome meatal flap is elevated and the posterior aspect of
3. Trans canal labyrinthectomy failures the tympanic annulus is curetted to visualize the
foot plate of stapes. Curetting of the tympanic
Contraindications for labyrinthectomy: annulus should be continued till the horizontal
segment of facial nerve; stapes foot plate and
1. If the affected ear is the only hearing ear round window area should be fully visible.
2. If the patient has serviceable hearing
3. Patients with poor surgical risk
Anesthesia:
This procedure is ideally performed under gener-

al anesthesia. Local anesthesia is not advisable
because of violent reactions that could accom-
pany vestibular ablation. Of course revision
labyrinthectomy in an ear with minimal residual
vestibular function can be performed under local Image showing Reverse Trendelenburg position
anesthesia.
The incus is removed first. The stapedius muscle
Position: tendon is cut and the supra structure of stapes is
removed carefully. Small curettes are used to en-
The patient is placed in supine position, with large the oval window in its anterior and inferior
reverse Trendelenburg tilt and the neck extended. aspects. The promontory between the oval and
The head is turned away from the surgeon, with round windows are drilled in order to connect
the ear to be operated facing up. both the oval and round windows.
Close to the posterior end of the round window

The head is turned away from the surgeon, with niche, the posterior ampullary nerve can be ex-
the ear to be operated facing up. The patient is posed and sectioned. The vestibule and basal turn
draped with a craniotomy type drape that has a of cochlea are exposed widely to create a common
large window to visualize the face. cavity. The utricle and saccule are scraped from
the walls of the vestibule by using a right-angled
Technique: pick. Probing is done to determine the locations
of ampullae of semicircular canal.
Trans canal approach is preferred unless the pa-
tient has a narrow meatus. After destruction of the end organ, the vestibule
must be filled with gelfoam (soaked in gentamy-
112
cin / streptomycin. Ear lobe fat can also be used
to fill the cavity in lieu of gelfoam. Transmastoid approach:
CSF leaks if any should be repaired with tissue In this approach a post aural incision is used to
seal. The tympanomeatal flap can be replaced expose the mastoid bone. Cortical mastoidectomy
against the posterior canal wall and the ear canal is performed with a largest possible cutting burr.
is packed with gelatin foam. The aditus is identified and widened. The short
process of incus comes into view.
The superior and posterior peri labyrinthine air

cell tracts and retro facial air cells are removed
carefully to skeletonize the bony labyrinth. The
facial nerve should be identified. The tegmen
mastoideum is thinned out using a diamond burr.
Usually medium cutting burrs are preferred on
the bony labyrinth because the bone is very hard.
Continuous suction irrigation is used to remove

bone dust as drilling is continued. Care should be
taken to provide continuous irrigation when the
area over facial nerve is drilled. Labyrinthectomy
is started by drilling over the superior aspect of
Image showing tympano meatal flap being the lateral canal anteriorly and
elevated. drilling is carried out towards the posterior canal.
The lateral canal appears as a blue line.
It is opened along its superior surface. The infe-

rior surface should be preserved as a landmark
for the facial nerve. The drilling is continued in
the posterior direction to open up the posterior
canal. The drilling is continued superiorly until
the common crus and superior canal is identified
and opened. The neuroepithelia of the superior
and lateral ampulla is identified anteriorly and the
dense labyrinthine bone is removed to open up
the vestibule.
Image showing Foot plate of stapes and Round

window

Post op follow up:
The posterior canal is followed inferiorly and
medial to the facial nerve to visualize the poste- Post op antibiotic is required. Anti-emetic should
rior canal ampulla. The portion of the posterior be given routinely until nausea and vomiting
canal extending under the genu of the facial ceases. Vestibular sedatives may also be needed in
nerve should ideally be drilled with a diamond some patients for a few weeks.
burr. The horizontal segment of the facial nerve is
skeletonized. Bandage can be removed / changed after 24
hours. Sutures can be removed on the 7th post-
While performing labyrinthectomy bone should operative day. Patients should be gradually
be preserved in the following regions: mobilized and physiotherapy exercises should be
started. Patients should be encouraged to walk
• Over the inferior wall of lateral canal, to protect and take an active role in mobilization.
the second genu of facial nerve
• Over the inferior wall of the posterior canal to Patients should not drive until they are free
protect a high jugular bulb from attacks of spontaneous vertigo for at least 3
• Over the medial wall of the superior canal am- months.
pullae, to protect the facial nerve anterior to the
superior vestibular nerve at the fundus of internal
auditory canal
The surgery is complete when the neurosensory
epithelium of the three ampulla, utricle, and sac-
cule are visualized.
After exposing all five portions of neurosensory

epithelium, they should be removed with a sickle
knife taking care not to rupture the underlying
bony cribrosa.
Penetration in the cribrosa area can cause CSF

leak. If there is a CSF leak it should be immedi-
ately repaired with a soft tissue seal on the table
itself. Image showing all the components of labyrinth
opened up.
Attempt should always be made to remove ev-
ery vestige of neuroepithelium because a viable Complications:
remnant may give rise to spontaneous neuronal
activity with continuing vertigo. Mastoid cavity is CSF leak can occur when the cribrosa is frac-
closed in layers. tured. This can be managed by sealing the vesti-
bule with tissue graft / subcutaneous tissue.
114
Failure to locate the utricle is a possible compli-
cation. While aspirating the peri lymphatic fluid
from the vestibule, the utricle usually retracts
superiorly to lie medial to the horizontal segment
of the facial nerve. This situation can be managed
by the use of utricular hook.
Removing bone from the inferior aspect of the

oval window and connecting it to the round win-
dow improves access to the vestibule.
The horizontal segment of facial nerve may be

injured during trans canal labyrinthectomy.

cartilage into the posterior meatus
Meatoplasty 2. Excess underlying bone of the posterior bony
meatus
Introduction: 3. Inadequate meatal skin circumference. This
could predispose to stenosis leading to wound
In advanced middle ear infections and cholestea- disruption and infection.
toma a canal wall down mastoidectomy needs to
be performed with an intention of eradicating the Types of approaches used for meatoplasty:
disease process completely. At the end of canal
wall down procedure meatoplasty need to be per- 1. Endaural approach
formed. Meatoplasty is performed to widen the 2. Retro-auricular approach
external auditory canal and to make it continuous
with the middle ear and mastoid cavity. Stacke Meatoplasty:
Advantages of a wide meatoplasty include: This uses the endaural approach. An inferiorly
based posterior canal skin flap is created. A radial
1. Provides adequate ventilation to the mastoid incision is given at 12 o clock position cutting the
cavity and middle ear there by preventing bacte- posterior canal wall skin. A medial circumfer-
rial ential incision is given 2-3mm lateral to the ear
growth. It also reduces conditions favorable for drum. Lateral circumferential incision is provided
growth of pathogenic bacteria. through conchal skin. A strip of conchal cartilage
2. Debris accumulation can be easily identified is cut. Temporalis fascia flap should cover the
during regular followup and cleaned. entire facial ridge and inferior part of the cavity.
3. It helps the surgeon in identification of resid-
ual / recurrent pathology in the middle ear and Surdille flap:
mastoid
cavity This flap uses endaural approach. Circumferential
4. It supports rapid epithelialization and exterior- incision is given laterally in the external canal
ization of the mastoid bowl. skin leaving a larger TM flap and a smaller lateral
flap known as the Surdille’s flap. The Surdille flap
One major draw back of a very large meatoplasty is pushed posteriorly into cavity and held in place
is that it could cause misshape the ear making it by a BIPP pack. Superiorly, anterosuperior flap
look rather unnatural. Therefore, a balance should covers the attic and tegmen and inferiorly tympa-
be struck to create a wide enough meatoplasty to nomeatal flap covers the aditus and antrum.
fulfill the ventilation requirements and it should
not cause any distortion to the shape of the pinna.
Problems that need to be addressed by meatoplas-

ty:
1. Projection of the anterior edge of the conchal
116
Image showing Surdille flap
Image showing Lempert incision
Farrior meatoplasty:
Korner Meatoplasty:
This meatoplasty is performed via endaural ap-
This meatoplasty can be performed either by proach. In this type of meatoplasty a conchal ear
endaural or post aural approach. If endaural canal skin flap is created.
approach is preferred then Lempert / Heerman II
incision is preferred. In Heerman’s incision two Fleury meatoplasty:
radial incisions are given in the external auditory
canal at 6&12 o clock positions. A circumferential This type of meatoplasty is performed endaurally.
incision is used to joint these two incisions close It is a superior based vascular flap with a lateral
to the ear drum. circumferential incision starting at the 2 o clock
position.
These incisions divide the flap into medial tym-
panomeatal flap and a lateral korner’s flap. The
Korner’s flap is pushed posteriorly into the sur-
gical cavity and is held in position with a BIPP
pack.
Superiorly, anterosuperior flap covers the attic

and tegmen, while inferiorly the tympanomeatal
flap covers the aditus and antrum.

Image showing Fleury incision
Image showing Farrior meatoplasty incisions: Fleury incision has two components. One
circumferential incision to elevate tympanome-
1. Anterior circumferential incision at 4 o clock atal flap medially and a vertical incision at 10 o
positions clock position as shown above.
2. Posterior circumferential incisions
3. Vertical incisions
4. Anterior vertical incisions Large lateral flap of Surdile is created. This flap is
5. Posterior vertical incisions made to cover the facial ridge & lower part of the
6. Lateral incision – This allows further eleva- mastoid cavity. The vertical incision (skin) is su-
tion of skin tured first. It pulls the upper part of pinna further
upwards.
Skin over the conchal cartilage is elevated and a

strip of conchal cartilage is exposed. The conchal
cartilage is resected leaving behind the perichon-
drium. The folded skin is sutured to cover the
remaining exposed conchal cartilage.
Portman’s small 3 flap meatoplasty:
This flap is created via post aural approach. Fea-

tures of this meatoplasty are:
118
1. Three flaps are created i.e. lateral, superior, and
inferior Portmann’s large 5 flap meatoplasty with removal
2. There is no removal of conchal cartilage of cartilage:
3. Very useful for small cavities
4. Lateral circumferential incision from 12 to 6 The ear canal skin is divided at 9 o clock position.
o clock position is made 10 mm lateral to upper
tympanic membrane Laterally at the conchal cartilage the following
5. Upper lateral incision from the upper part of incisions are given:
circumferential incision to the spine of Henle
6. Similar lower incision from inferior edge of 1. One incision that turns infero anteriorly
circumferential incision towards the concha 2. One incision that turns supero anteriorly
This results in lateral, superior and inferior flap.
Image showing Portmann’s incision
A finger is placed through the canal exposing the

lateral flap. The flap is thinned out. When flap
elevation is complete, the conchal cartilage would
be visible. The flap is turned around the cartilage
and fixed to posterior aspect of the cartilage. This Image showing Portmann Y flap incision
flap will form lateral covering of the cavity and
facial ridge.
Ear canal skin is divided at 9 o clock position

up to the ear drum. This creates a superior flap
which covers the superior part of the cavity and
inferior flap which covers the facial ridge. Both
these flaps need to be thinned out.

conchal skin, cartilage and post auricular soft tis-
sue. This divides the lateral skin flap into superior
and inferior. Through retro-auricular approach
the conchal cartilage is exposed and excised. The
superior and inferior flaps are inverted onto the
posterior aspect of remaining conchal cartilage.
Image showing 5 flaps elevated
Superior and inferior flaps are further divided lat-

er. Conchal skin of lateral flap is elevated from the
cartilage. A triangular piece of cartilage is re-
moved. Skin from other two conchomeatal flaps
are also elevated.
Image showing incisions used for Sheehy meato-
To facilitate mobility of these two flaps, a trian- plasty
gular skin is removed from their tips. A total of
5 flaps are created. The created flaps are thinned 1. A vertical intercartilaginous incision at 12 o
out and sutured to the posterior aspect of concha clock position extending through skin, subcutis
with a single suture. The cavity is packed with down to the bone.
BIPP. 2. Another incision at 5 o clock position into
the conchal cartilage (indicated by the arrow)
Sheehy Meatoplasty: 3. Horizontal antero posterior conchal incision
at about 9 o clock position creating two concho-
This again is performed via the post aural inci- meatal flaps.
sion.
A vertical intercartilagenous incision at 12 o clock Fisch meatoplasty:
position is given parallel to the crus of helix. This is also performed via post aural incision.
Another incision is made at 5 o clock position One antero posterior incision is given over the
into the conchal cartilage. A horizontal incision conchal cartilage. The skin flap is elevated from
passes backward at 9 o clock position through the concha before resecting a major portion of the
120
cartilage. and periosteum are elevated and constitute a large
palva flap.
The two liberated flaps are inverted posteriorly Another incision is made along the entrance of
around the edge of the concha and sutured to the canal from 6 to 12 o clock through subcutane-
posterior aspect of concha creating a meatoplasty. ous tissue and periosteum.
Meatoplasty is performed by turning the pinna

backwards, making an intercartilaginous incision
at 12 o clock position and an incision through
conchal cartilage at 5 o clock position. Auricle
is pulled forwards and a large strip of conchal
cartilage is excised. Korner’s flap is turned around
resected, conchal and palva flap is elevated.
A radial incision is made at 9 o clock position

through the canal elevating an inferior and
superior canal skin flap. After canal wall down
mastoidectomy the modified palva flap is placed
in the cavity attached anteromedially and infero
anteriorly. This flap mainly obliterates the posteri-
Image showing incision for Fisch meatoplasty. or part of the cavity and sinodural angle.
The green shaded area indicates the amount of
conchal cartilage that is usually removed.
Landolfi’s modified Fisch technique:
An antero posterior incision is given.

Skin flap is elevated from the conchal cartilage
The conchal cartilage is exposed using scissors
the conchal cartilage is resected including the
anterior edge of crus of helix.
The conchal skin is inverted to provide epithelial

covering for the lateral wall of the mastoid cavity.
Palva flap:
This is actually a subcutis muscle clap. This has

a dual role of creating a wide meatoplasty and
cavity obliteration. This procedure is done via
post aural incision. The skin, subcutaneous tissue

Indications:
Retrolabyrinthine approach to petrous
apex 1. Resection of CP angle tumors
2. Resection of petrous ridge tumors

This approach is considered to be the unsung
hero of skull base surgery. This technique is
3. Vestibular neurectomy
ideally suited for patients with pathologies in-
volving the posterior cranial fossa with retained
4. Partial resection of the sensory root of 5th
hearing. Directly accessing the Cerebellopontine
cranial nerve
angle through temporal bone and avoiding neural
structures preserves hearing. This approach al-
5. Fenestration of symptomatic arachnoid cysts
lows for mobilization of the sigmoid sinus pos-
teriorly and access to the posterior fossa through
6. Meningiomas
the presigmoid space. This approach provides
excellent exposure laterally from the 4th cranial
7. Metastatic lesions
nerve to the upper border of the jugular tubercle.
There is only limited access to the ventral brain
8. Biopsy of brain stem lesions
stem and clivus.
9. In conjunction with other approaches in exten-
Factors that limit this approach:
sive skull base surgeries
1. Poorly pneumatized mastoid
Procedure:
2. Forward lying sinus
This surgery is performed under general anesthe-
sia. Patient is placed supine. Surgeon should be
3. High jugular bulb
seated comfortably during surgery. The patient’s
head is rotated 70° away from the surgeon. Hair is
4. Low lying tegmen
removed about 4 cms superiorly and post auricu-
larly in order to site the incision.
This approach can be used by itself for small tu-
mors or in conjunction with other techniques to
Facial nerve monitoring electrodes should be
gain greater exposure. These combined approach-
placed and verified for its function. Abdomen is
es include:
also prepared to harvest abdominal fat. Preopera-
tive antibiotics are also administered on the table.
Translabyrinthine approach Infratemporal ap-
Before starting the surgery, Intravenous mannitol
proach Trans cochlear approach Combined trans
and frusemide are administered to bring down
temporal approaches Retro sigmoid craniotomies.
the intracranial tension.
122
Incision:
Linea temporalis
A C shaped incision is made with a 15-blade
scalpel 3-4 cm posterior to the post aural crease Mastoid emissary foramen
extending up to the mastoid tip.
Asterion
Henle’s spine
The following triangles should be identified be-

fore actual drilling starts:
Fukushima outer mastoid triangle:
Three points of this triangle include:
• Posterior root of zygoma
• Asterion
Image showing incision for retrolarybrinthine • Mastoid tip

approach.
Skin and subcutaneous tissue flap is elevated an- Fukushima Inner triangle (Trautmann’s triangle)
teriorly up to the external acoustic meatus. Next
an offset incision is created through the tempora-
lis muscle, fascia and periosteum. This helps later • Anterior – Superior (anterior) semicircular
during wound closure as the wound can be closed canal
in layers. This layered closure helps in prevention
of CSF leak. • Superior – Superior petrosal vein
A periosteal elevator is used to elevate the perios- • Lateral – Sigmoid sinus

teum away from the cranium exposing the mas-
toid cortex. The following bony landmarks need • Inferior – Jugular bulb
to be identified:
McEwen’s triangle:
Root of the zygoma
• Flat triangle behind the external auditory canal
External auditory meatus

Image showing the various triangles around
mastoid bone Image showing posterior fossa dura area that
needs to be drilled to expose endolymphatic sac
Bone over the Fukushima’s outer triangle is
drilled out using a cutting burr. Under magnifi- A 11 blade and micro scissors is used to open the
cation a complete mastoidectomy is performed. dura anterior to sigmoid sinus. It is opened with
Proper size diamond burr bit is used to remove an anteriorly based C shaped flap as shown below.
bone overlying middle cranial fossa dura, sigmoid
sinus and posterior fossa dura. Maximal exposure The endolymphatic sac would be visualized infe-
of dura could be obtained by skeletonizing the rior to the posterior canal as a thickened area of
sigmoid sinus and jugular bulb completely. The dura. The dural flap is secured with stay sutures
lateral semicircular canal and posterior semicir- for better exposure. A neurosurgical cottonoid
cular canal should be well defined. patty is placed over the brain stem. This produces
a small amount of tension between the cerebel-
The entire course of mastoid segment of facial lum and the petrous ridge. The arachnoid adhe-
nerve should also be deroofed. Sinodural angle sions in this location are transected and CSF is
dura should also be exposed by careful drilling released. This causes the cerebellum to fall away
in the area. Bone over the posterior fossa dura from the petrous ridge allowing better visual-
between the posterior semicircular canal and ization of the CP angle. Posterior face of petrous
the sigmoid sinus should be removed with blunt ridge, and cranial nerves 7 and 8 in the center
dissection. Care must be taken to protect the of the field. In addition, this exposure provides
underlying endolymphatic duct and sac. Using access to the Cranial nerve 5 anteromedially.
gelfoam aditus and mastoid antrum is packed. Cranial nerves 9, 10, and 11 lie inferolaterally. It
The mastoid cavity should be copiously irrigated should be noted that the rostral division of the
with bacitracin solution in order to remove any anteroinferior cerebellar artery is associated with
bone dust that may be present there. the 7th and 8th cranial nerves. After comple-
tion of the procedure, meticulous hemostasis is
secured. The dural flap is approximated with 4-0
braided suture. The aditus, antrum, facial recess
124
and retrofacial air cells are covered with tempora-
lis fascia. The entire mastoid cavity is obliterated
using abdominal fat graft to prevent CSF leak.
The wound is then closed in layers.
Image showing endolymphatic sac being exposed Image showing structures seen after reflecting
posterior fossa dura
Complications:
1. Bleeding from dural venous sinuses
2. Cerebellar edema
3. Injury to cochlear nerve
4. Injury to facial nerve
5. Injury to intracranial blood vessels
6. CSF leak
7. Post op head ache
8. Conductive hearing loss if bone dust is not

properly removed by irrigation, or if the abdomi-
nal fat graft herniates into the middle ear cavity.

enable the arcuate eminence to be identified. At
Middle Cranial Fossa approach to Pe- this point the superior semicircular canal dehis-
cence
trous Apex
may clearly be visualized. The canal is opened
using diamond drill and then it is plugged. The
Introduction: canal may additionally be capped / resurfaced
using bone pate, bone
This surgical approach provides access to the wax or hydroxyapatite cement. Some surgeons
lateral skull base which includes the cranial side prefer to use soft tissue for the purpose of resur-
of petrous bone, internal auditory canal, genicu- facing the superior canal.
late ganglion of facial nerve and the petrous apex.
This classic neurosurgical approach was described This approach provides direct access to the ar-
way back in 1891 by Frank Hartley. He used the cuate eminence without the need for removing
intracranial, extradural approach to access tri- labyrinthine bone and exposure of the surround-
geminal ganglion to block ing skull base area.
it as a treatment of trigeminal neuralgia. The
overall morality in his hands was around 10%. Resurfacing of the dehiscent canal also prevents
chronic stimulation from the pulsating temporal
Cushing modified this approach slightly by min- lobe of brain.
imizing traction on the brain and also reduced
hemorrhage from middle meningeal artery by 2. Internal auditory canal decompression for:
providing less traction. This effort lowered the Skull base dysplasias (hyperostosis cranialis in-
mortality rate. The first authentic description of terna with encroachment of the internal auditory
this procedure as an approach to CP canal due to hyperostosis causing function loss of
angle was from the work of RH Parry 1904. He facial or vestibulocochlear nerves.
used this approach to section the vestibular nerve
as a treatment for intractable giddiness. William Facial nerve schwannomas
House popularized this approach by routinely
performing it to decompress internal auditory 3. Supralabyrinthine cholesteatomas
canal for cochlear otosclerosis. It was House who 4. Meningoencephalocele
first used this approach to perform removal of 5. CSF leak repair either during primary surgery
acoustic neuroma in 1961. or in the case of failed Transmastoid
surgery either intradural or extradural.
Indications: 6. Cholesterol granulomas / congenital cholestea-
toma of petrous apex
This surgical approach can be used for a variety of 7. Removal of a wide number of neurosurgical
indications which include: lesions
1. Resurfacing technique for superior semicircu- 8. Small tumors (>15mm) primarily located in
lar canal dehiscence syndrome. Middle cranial the internal auditory canal with serviceable hear-
fossa approach for managing this condition was ing (class a or b).
first described by Minor et al. A 4x4 cm craniot-
omy is drilled. The temporal lobe is retracted to
126
Arterial line should be started to monitor real
Preoperative evaluation: time blood pressure.
Patient should be catheterized in order to accu-
1. Pure-tone audiogram and speech audiogram. rately maintain fluid balance.
This helps in ascertaining whether the patient has Perioperative antibiotics need to be administered
serviceable hearing or not. (cefazoline / amoxycillin/clavulanic acid) and
2. HR CT scan. This is performed for diagnostic they should be continued for 1 week postopera-
purposes as in the case of bone dysplasias and tively.
superior canal dehiscence syndrome. Hydrocortisone administration intravenously
3. MRI scan with gadolinium if neuronitis / ede- is advisable in the event of intraoperative nerve
ma which is specific for evaluation of facial nerve. manipulation.
When gadolinium contrast is used, then normal
facial nerve enhances faintly in the geniculate Procedure:
ganglion area, tympanic and mastoid segments.
The cisternal, intracanalicular, labyrinthine and The hair over the temporal region is shaven and
parotid segments of the nerve do not normal- the surgical field is sterilized.
ly enhance. Enhancement of the nerve in these The head is fixed in a skull clamp. Patient is
regions should cause suspicion of inflammatory / positioned with 3-point body straps in order to
neoplastic process involving the nerve. Asymmet- allow easy rolling of the bed of the patient during
ric enhancement / thickening of the tympanic / surgery to improve exposure.
mastoid segments relative to the contralateral side Electrodes are placed to monitor facial nerve and
should be considered as abnormal. In Bell’s palsy, auditory brain stem response is also recorded by
MRI with gadolinium contrast demonstrates placement of electrodes in real time. To monitor
enhancement of the intracanalicular and labyrin- facial nerve electrodes are placed over orbicularis
thine segments of the facial nerve. There is also oculi and orbicularis oris. The ground electrode is
greater degree of enhancement of the geniculate placed on the chest. ABR click generator is placed
ganglion, tympanic and mastoid segments. over the operative side ear canal. The ABR elec-
4. Diffusion weighted MRI scan in patients with trodes are placed one on each mastoid and one
supralabyrinthal / congenital apex cholesteato- over the vertex.
mas.
5. Sequential brainstem-evoked auditory poten- Two incisions can be used.
tials can be used to detect subclinical auditory
nerve damage 1. Anterior/inferiorly based skin flap. This inci-
6. Vestibular function testing sion starts anterior to tragus, extending posterior-
ly to about 3-4 cms posterior to pinna, superiorly
Anesthetic considerations: 5-6 cm, and anteriorly again to the temporal hair
General anesthesia is preferred with orotracheal line. This incision is good for extended middle
intubation. Short acting non depolarizing cranial fossa approaches. The temporalis muscle
muscle relaxant should be used to facilitate nerve is reflected inferiorly.
monitoring equipment usage. 2. Posteriorly based skin flap. This incision starts
just behind the temporal hair line and a rounded

box shape approximately 6 cm wide is carried
back to approximately 6-7 cms. The incision is be- Elevation of muscle flap:
gun as low onto the pinna as possible. Temporalis
muscle flap is reflected anteriorly. If the skin flap is posteriorly based then anteriorly
based temporalis flap is elevated. If the skin flap
is anterior based then temporalis flap should be
inferior based. The surgeon should
be able to see the root of zygoma easily after ele-
vation of muscle flap.
Craniotomy:
Before proceeding on to craniotomy the anesthe-

siologist needs to administer 0.4 g /kg of manni-
tol. The patient is hyperventilated till the end tidal
carbon dioxide of 30 is reached.
The craniotomy is centered on the root of zygo-
ma.
Image showing the incision commonly used
The temporoparietal facial layer is attached to the

scalp during skin flap elevation. A large piece of
temporalis fascia is harvested prior to elevation of
the muscle flap, leaving behind a cuff of fascia on
either side of the muscle flap. This tissue will be of
immense help during wound closure.
Image showing craniotomy site marked
Image showing flap being elevated exposing tem-

poralis fascia
128
dura is elevated along the floor
of middle cranial fossa from posterior to anterior
so that the greater superficial nerve is protected.
During this stage the arcuate eminence, greater
superficial petrosal nerve and petrous ridge are
identified.
Image showing bone flap being elevated
Bone flap of 4.5 X 4.5 cm is marked and 4 mm

cutting burr is used to remove majority of the
bone. A 4 mm diamond burr is used to remove
the final layer of bone over the dura.
Branches of middle meningeal artery will be Cottonoids are placed anteriorly and posteriorly
encountered, and the same needs to be controlled during dural elevation. Brisk bleeding from the
using cautery or bone wax. The bone flap is ele- middle meningeal artery at the level of foramen
vated off the dura with the use of Joker elevator. spinosum may be encountered. This can be con-
The bone flap should be kept moist by placing a trolled by the use of bone wax or oxycel packing.
wet gauze over it. Now is the time to check the
exposure. If the bone window is not flush with the House urban retractor is placed under the lip of
tegmen, then the excess bone is removed using a petrous ridge at the anticipated location of the
drill. internal acoustic meatus.
Elevation of Dura:
Dura is circumferentially elevated from the over-

lying cranium. Bipolar cautery is liberally used
during this procedure to stop bleeding from the
dura. Oxygel cigars are placed under the bone
flap anteriorly, posteriorly and superiorly. Ideally

Drilling is begun using a 4-0 diamond burr over
the arcuate eminence. The superior semicircular
canal will lie perpendicular to the petrous ridge.
The superior canal is blue lined. The internal
auditory canal would be located at 60° anterior
to the blue lined superior semicircular canal. The
meatal plane over the internal auditory canal is
lowered down to the level of posterior fossa dura.
The superior semicircular canal forms the poste-
rior limit of dissection.
Image showing arcuate eminence The bone over the internal acoustic meatus is
drilled till it becomes paper thin. The thinned
Identification of arcuate eminence is vital as it out bone can be removed using a 90° pick. The
indicates the approximate level of the superior skeletonization of internal auditory canal should
semicircular canal which invariably lies under- be continued up to the level of Bill’s bar. The lab-
neath. Greater superficial petrosal nerve should yrinthine segment of the facial nerve is identified
also be identified before proceeding any further. at the transverse crest. The cochlea lies deeper
The internal acoustic meatus is known to bisect than the plane of the labyrinthine segment of the
the angle formed by these two landmarks. facial nerve. If the surgeon does not drill deep to
the facial nerve anteriorly then cochlea will not be
violated. Auditory brain stem potentials should
be continuously monitored by an audiologist at
this stage.
Image showing the location of the internal audi-

tory meatus
Image showing dura over the internal auditory

canal excised
130
Dura over the internal auditory canal over the Closure of craniotomy:
superior vestibular nerve is excised exposing the
contents. A direct auditory nerve electrode is The House urban retractor is removed to allow
placed between the dura of the internal acoustic the temporal lobe to re expand. Bone flap is re-
meatus and the cochlear nerve for monitoring the placed and secured. Wound is closed in layers.
cochlear action potential in real time.
The separation between the facial nerve and

superior vestibular nerve is identified at the level
of transverse crest. The facial nerve is separated
from the superior and inferior vestibular nerves
at this location.
Tumor occupying the internal acoustic meatus

can be addressed. In case of larger tumors then
it is necessary to debulk the tumor before estab-
lishing a plane between the facial nerve and the
tumor. If real time monitoring of ABR reveals
increased latency or reduction in the amplitude of
the recorded waves, the act of tumor dissection is
paused for several minutes.
Closure:
Before closure hemostasis should be ensured at

the internal auditory canal and cerebello pontine Image showing a Diagrammatic representation
angle. Facial nerve should be documented by of structures visualized during middle cranial
stimulation. ABR should reveal that hearing is fossa approach
intact after the surgery.
Now is the time to repair temporal bone defect. Complications:
Bone wax is applied to all open air cells. A large
temporalis muscle plug or abdominal fat is used General:
to close the temporal bone defect.
1. Facial nerve palsy
The inner table of the bone flap is placed over 2. Vestibulocochlear nerve damage
the defect to prevent temporal lobe herniation 3. CSF leak
into the middle ear cavity. Tissue glue is used to 4. Intracranial extradural / intradural bleeding
further strengthen the seal. 5. Meningitis

Rhinology
History
Etymologically the term “sinus” represents the

geographic term indicating a gulf, a creek or
bay. As per the sources of Ancient Egypt dated
between 3700 and 1500 BC it was revealed that
the anatomy of nose and paranasal sinuses was a
common knowledge. In fact during mummifica-
tion rituals where the brain needs to be removed,
it was performed via the nostrils, presumably by
passing via the ethmoidal air cells.
In Hippocratic Corpus (460-377 BC) indications

for rhinosinusitis and polypi were found. Aulus
Cornelius Celsus (14 BC) extensively describes
paranasal sinuses anatomy. During the 16th
century, Sansovino defined the paranasal sinuses
as “cloaca cerebri” meaning the cavities responsi-
ble for the drainage of corrupted spirits from the
head. Leonardo da Vinci recognized the rela-
tionship between maxillary sinus and the teeth as Image showing Leonardo da Vinci’s sketch of
documented by his drawings. The first clear idea human skull
of this was given by the anatomist Berengario da
Carpi. A popular story those days is worth a mention
here. A patient who underwent extraction of
Andrea Vesalio composed De Humani Corporis upper canine tooth found that a continuous
Fabrica in 1543. It is the most important medical outflow of pus was coming out of the wound site.
document of those times. In this document he When he attempted to probe the cavity with a
accurately described the maxillary, frontal and feather, he realized that it penetrated for a long
sphenoid sinuses. He also claimed that these distance. He consulted Highmore who convinced
spaces were filled with air. Giulio Cesare Casseri the patient explaining the nature of the maxil-
gave his name to the maxillary sinus (antrum lary sinus. Gradual improvement of anatomical
Casserii). The name closely associated with the knowledge over the centuries was fundamental
maxillary sinus is that of Nathalien Highmore for the evolution of surgical techniques. In 1743,
(antrum of Highmore). Montpellier Louis Larmorier gained access to the
maxillary sinus through the oral cavity. This ap-
proach was documented and published in 1768.
Dentist Anselme L.B.B. jourdain treated a maxil-
lary suppurative sinusitis with irrigations via the
natural ostium. This procedure was commonly
performed between 1760 and 1765 and didn’t
132
meet with the expected success. mm wide close to the floor of the nasal cavity.
One year later Berlin Hermann Krause modified
The very first officially recognized reference text this technique by adding a drainage tube. Three
that described normal anatomy of nasal cavities years later, Ernst G.F. Kuster proposed the valid-
and paranasal sinuses was “Normal and Patholog- ity of the sublabial approach via the canine fossa
ic anatomy of nose and its accessory pneumatic creating an opening not bigger than a little finger
cavities” published by Emil Zuckerkandl in 1882. on which he placed a rubber plug, which can be
In this treatise the nose was considered insepara- removed if need to facilitate drainage of maxillary
ble from the surrounding structures. This book antrum.
was the source of inspiration for all rhinologists
of those times. Markus Hajek after a few years In 1893 George Walter Caldwell popularized
following publication of this book published a Lemorier’s technique suggesting the possibility
book titled “Pathology and therapy of inflam- of creating a “window” in the lateral wall of the
matory diseases of the nose and nasal passages”. inferior meatus via the canine fossa. This ap-
Another book authored by Grunwald explained proach was performed for the first time in Europe
how acute and chronic inflammations were the in 1896 in Breslau by Georg Boenninghaus. He
cause for sinusitis. This book was titled as “Book slightly modified this technique placing a mucous
on the nasal suppuration”. flap on the created fenestration. An identical
procedure was described by Robert H S Spicer
Origins of Paranasal sinus surgery and Henry Paul Luc in London and Paris. An-
other modification which was proposed is the
In the 1st century in Pompei, speculum shaped counter opening of the maxillary sinus through
nasal dilators were used for the visualization of the inferior meatus. Howard Lothrop published
the nasal cavities. For a long time the role of in 1897, the importance of a big fenestration in
interventional treatment remained limited com- the inferior meatus.
pared to the diagnostic options due to the pecu-
liar conformation of this anatomical area which Raymond Charles Claoue adopted intranasal
comprises of slits, recesses, reduced volumes antrostomy as a treatment for chronic maxillary
and narrow passes restricted by bony walls. The sinus infections. He also published his experi-
chance of surgical drainage of paranasal sinuses, ence in 1912. All these conservative treatments
in particular of the maxillary sinus was consid- were set aside after the introduction of innovative
ered only from the 17th-18th century. radical interventions in 1900. During this time
Gustav Killian described the resection of the un-
Towards the end of the 19th century, several cinate process with the enlargement of the nearby
authors started to perform puncture of the maxil- ostium. Halle was the first author to claim a large
lary sinus. Johann von Mikulicz-Radecki suggest- personal experience on intranasal ethmoidectomy
ed that antrum could be accessed via the middle and frontal and sphenoidal sinusotomies.
meatus. He was the first surgeon to introduce in
1886 the concept of antrostomy for the drainage In 1909, Dahmer performed an inferior antros-
of maxillary antrum. He recommended creation tomy cutting the anterior part of the inferior
of an opening measuring 20 mm long and 5-10 turbinate. This opening was so wide, that the

patient could self irrigate their maxillary antrum
following this procedure. It was common knowl- In early 1920’s Harris Peyton Mosher of Harvard
edge that antrostomy carried out via the inferior University studied in depth the paranasal sinus-
meatus could become stenosed and hence a large es anatomy by performing meticulous cadaver
opening needs to be created to overcome this dissection. His interest was inspired by the an-
problem. atomical atlas published in 1920 in Philadelphia
by Schaeffer titled: “The nose, paranasal sinuses,
The first frontal sinus surgical procedure was de- nasolacrimal passageways and olfactory organ in
scribed in 1750. Despite more than two centuries man”.
since the description of the first procedure on the
frontal sinus, the optimal procedure still remains The first approaches to frontal sinus was first
unclear. Even though frontal sinus surgery makes evolved by ophthalmic surgeons. Alexander Og-
up only a small portion of all paranasal sinus sur- sten managed to reach the frontal sinus through a
gery, the literature is filled with publications on horizontal incision performed under the eyebrow,
the subject. In 1954 Ellis surmised that chronic drilling the bone and creating a breach sufficient-
frontal sinusitis is difficult to treat and the treat- ly wide to allow the opening of both frontal si-
ment modality could often be unsatisfactory and nuses. Afterwards, he modified this procedure by
sometimes disastrous. executing the incision more medially, at the root
of the nose. This technique was later described
The ideal treatment for diseases involving frontal in 1894 by Luc, who used it for the insertion of a
sinus is one that will provide complete relief of drainage tube in to the frontal sinus. This process
symptoms, eradicate the underlying disease pro- caused skin to grow inside the hole, causing terri-
cess, preserve the function of the sinus, cause the ble malformations. In order to avoid these com-
least morbidity and cosmetic deformity. Over the plications, Killian in 1900 performed an incision
last two centuries a variety of surgical procedures through the eyebrow preserving the supraorbital
have been described for managing frontal sinus region, so he obtained a complete exposure of the
disease. frontal sinus and reached the ethmoidal cells after
prolonging downward the previous incision.
Gerber and Kubo preferred middle meatal an-
trostomy which was performed using a perforator Zuckerkandl focused his studies on the sphe-
designed by Onodi in 1902. noid sinus. He also stated that it was possible to
reach the sphenoid sinus via the nasal cavities.
Sluder practiced complete removal of entire me- He drained the sphenoid sinus via this passage.
dial wall, preserving only the inferior turbinate. These studies formed the basis for transnasal
On the contrary, in 1910 Rethi recommended the sphenoidal approach for removing pituitiary
amputation of only the anterior two thirds of the lesions.
inferior turbinate. Lavelle and Harrison found a
higher rate of healing and a lower frequency of Recent advances that has taken place in the
complications in case of chronic sinusitis treated field of imaging and endoscopic surgical tech-
with an antrostomy performed via the middle niques have lead to a resurgence of intra-nasal
meatus. procedures for the management of frontal sinus
134
disease, particularly chronic frontal sinusitis disease. The mucosa was stripped to the level of
which could be a highly morbid / sometimes life frontal recess, and a stent was placed for tem-
threatening condition due to its potential compli- porary drainage. In 1898 Riedel described the
cations. Despite these advancements, orbital and first procedure for obliteration of frontal sinus.
intracranial complications following frontal sinus He advocated complete removal of the anterior
infections continue to occur. table as well as the floor of the frontal sinus with
stripping off the mucosa. This procedure had the
History of frontal sinus surgery can be conve- advantage of removing osteomyelitic bone as well
niently divided into three eras for better under- as allowing for easy detection of recurrent dis-
standing: ease. This procedure caused unsightly cosmetic
forehead deformity. Killian in 1903 described a
Era of Trephination (1750) modification of the Riedel-Schenke procedure.
This modification involved preservation of one
Era of radical ablation procedures (1895) centimeter bar of the supraorbital rim. He also
recommended an ethmoidectomy y with rota-
Era of conservative procedures (1905) tion of mucosal flap into the frontal sinus with
stenting to prevent stenosis. Killian’s procedure
was abandoned because of the high incidence of
Era of Trephination: late morbidity with restenosis, supraorbital rim
necrosis, postoperative meningitis and mucocele
Frontal sinus surgery was first described in the formation as well as death.
18th century. It was documented that as early as
1750, Runge performed an obliteration procedure Era of conservative procedure:
of the frontal sinus. The first report to be pub-
lished was in 1870 by Wells describing an external Because of the risk of significant cosmetic defor-
and intracranial drainage procedure for a frontal mity as well as the high failure rate of those abla-
sinus mucocele. tive external procedures, an era of conservatism
followed as a natural corollary. This era was char-
In 1884 Alexander Ogston described a trephi- acterised by intranasal approaches to frontal sinus
nation procedure through the anterior table to as well as external frontoethmoid techniques.
evaluate the frontal sinus. He also dilated the In 1908, Knapp described an ethmoidectomy
naso-frontal duct, curetted the mucosa and estab- through the medial wall and entering the frontal
lished drainage with a tube that was inserted into sinus through its floor, by which he removed dis-
the duct. This tube kept the duct patent. eased mucosa and enlarged the naso frontal duct.
This operation did not receive widespread recog-
Era of Radical Ablation Procedure: nition. In 1911, Schaeffer proposed an intranasal
puncture technique to re-establish the drainage
At the turn of the century a number of physicians and ventilation of the frontal sinus. Numerous
were advocating a radial frontal sinus procedure. complications were encountered which included
Kuhnt in 1895 described removing the anterior intracranial penetration. Between 1901 and 1908,
wall of the frontal sinus in an attempt to clear the Ingals, Halle, Good, and Wells described several

intranasal procedures in which the frontal process inferior meatus was Spielberg in 1922. He called
of maxilla was chiseled out, and a burr was used this procedure antroscopy. In 1981, Buiter e
to remove the floor of the frontal sinus. Straatman developed a surgical endoscopy assist-
ed method for the fenestration of posterior fon-
In 1914, Lothrop described a procedure to en- tanelle and in the next year Draf used the micro-
large the frontal drainage pathway in a way that scope matched with an angled optics endoscope.
would prevent restenosis as well as closure. The Heerman described an intranasal operation con-
procedure described a combined intranasal eth- ducted with a binocular microscope, specifically
moidectomy and an external ethmoid approach designed for more precise cleaning of the middle
to create a common frontal nasal communication and posterior ethmoid cells and sphenoid sinus.
by resecting the frontal sinus floor, the frontal
sinus septum and the superior nasal septum. Lo- Evolution of endoscopy led to the development
throp admitted that lack of visualization during of increasingly advanced tools to facilitate en-
the intranasal approach made the procedure more doscope assisted intranasal surgical procedures.
dangerous. Resection of the medial orbital wall The rigid nasal endoscope of Hopkins allowed
allowed collapse of orbital soft tissue into the eth- the surgeon to explore the interior of the nose in
moid area, with subsequent stenosis of the frontal detail. Adoption of rigid angled optics provided
drainage pathway. benefits for the display of the sinuses. Another
technical progress was represented by the intro-
History of endoscopic sinus surgery duction of an endoscope equipped with irriga-
tor-aspirator and angled optics, rotatable and
Bozzini described a simple appliance and its use interchangeable. Modern conception of function-
for lighting the internal cavities and the spaces of al endoscopic sinus surgery is attributed to Walter
the living animal’s body. He used his knowledge Messerklinger. He first published his article on
of physics to create a Lichtleiter (light conduc- the subject in 1967, stating that the anterior eth-
tor), which allowed him to explore the external moidal cells were the keystone of sinusitis. Mes-
auditory canal, the nasal cavities and oropharynx. serklinger and Stammberger developed a step-by-
Since this discovery, several versions of endo- step intervention of the lateral wall of the nose.
scopes have followed with different equipment.
At first, the endoscopes were specifically used for
diagnostic procedures, including the sampling of
histological specimen.
In 1903, Hirschmann published a study of five

ethmoids in which the middle turbinate was more
or less extensively removed. He was the first to
use a real endoscope for the examination of nasal
cavities and paranasal sinuses. Hirschmann and
Reichert introduced the endoscope in clinical
practice. The first surgeon who performed an
endoscopic probing of the maxillary sinus via
136
Antral Puncture and Lavage
Anatomy of inferior meatus:
Introduction:
Inferior meatus is the largest of the three meatus-
Focus on maxillary sinus cavity pathology dates es of the nasal cavity. This is actually the space
back to the 17th century. Treatment for suppura- between the inferior turbinate and the lateral
tion of maxillary sinus was common during that nasal wall. It extends almost the entire length of
period. One of the earliest descriptions of intra- the lateral wall of the nose. It is broader in front
nasal antrostomy as an approach to maxillary than behind which makes it easy
sinus was dated back to 1770 by Gooch. Routine for accessing the lateral nasal wall from here. An-
puncture of maxillary sinus via the inferior me- teriorly the nasolacrimal duct opens here.
atus was performed during 1880’s following the
classic publication of Lichwitz who designed the Inferior turbinate is a separate bone unlike the
classic trocar and cannula that can be used for superior and middle turbinates which are compo-
performing the procedure. nents of ethmoid bone. Inferior concha / inferior
turbinate matures via endochondral ossification.
Krause in 1887, Mickulicz in 1887 standard-
ized the procedure. Mickulicz understood the Articulations of inferior turbinate:
anatomical and physiological pitfalls of inferior
meatal antrostomy which included its propensity Anterior – Frontal process of maxilla
for spontaneous closure making it a temporary Anteromedial – Articulates with the uncinate
procedure. This was hence gradually replaced by process of ethmoid bone and lacrimal bone
canine fossa antrostomy (Caldwell Luc proce- Posteromedial – Perpendicular plate of palatine
dure) by 1897. bone
Acute maxillary sinusitis was common problem Indications for antral lavage:
during the 17th and 18th centuries. Radiological
investigations were not commonly available hence 1. Acute bacterial maxillary sinusitis causing pres-
antral lavage was used as a sure symptoms in middle of face
diagnostic as well as a therapeutic procedure for 2. Feeling of numbness of teeth / symptoms that
diagnosing and treating acute maxillary sinusitis. does not resolve with medical management
Antral puncture and aspiration remained gold 3. Patients with maxillary sinusitis who are not
standard for diagnosing acute maxillary sinusitis fit for general anesthesia to perform functional
for a long time. endoscopic sinus surgery
With the advent of functional endoscopic sinus 4. Patients on assisted mechanical ventilation
surgery antral lavage has fallen out of fashion. But who commonly develop sinusitis (nearly 40% of
it should be stated that it remains still the most them develop). Lavage in these patients can be
cost-effective procedure in diagnosing and man- performed as a bedside procedure under local
aging maxillary sinus infections. anesthesia to clear the pent-up secretions from
the maxillary sinuses.
138
5. In patients with permanent disability of muco- sia. Topical anesthesia is produced by using 4%
ciliary clearance mechanism like kartagener’s syn- xylocaine soaked nasal pledgets. Topical anes-
drome and Young’s syndrome. In these patients thesia lasts about 45 minutes which is more than
FESS is almost useless and only inferior meatal sufficient for completion of the procedure. While
antrostomy could salvage them. using 4% xylocaine topical anesthesia it should be
ensured that the maximum volume of drug used
Contraindications: should not exceed 7ml. A reasonable dose of xy-
locaine that is safe for topical use is 4mg/kg body
1. In young children in whom maxillary sinus is weight. By mixing xylocaine with adrenaline,
not fully developed. Maxillary sinus completes its the effect of the drug can be prolonged plus the
development only after the age of 9. added benefit of vasoconstriction which reduces
2. Blow out fracture of orbit / history of blow out bleeding. Ideal is to mix I ampule of adrenaline to
fracture of orbit because irrigated fluid from the one 30 ml bottle of 4% xylocaine. This will ensure
sinus could infuse into the orbit via the fracture that adrenaline concentration is about 1 in 10000
line causing orbital problems units. Cottonoids if available are preferred to
3. Patients who have undergone previous surger- pledgets.
ies involving the lateral nasal wall as the needle
could enter through the posterior wall of maxil- Each nasal cavity should be packed with 3 packs
lary sinus into the pterygopalatine fossa soaked with 4% xylocaine with 1in 10000 units
4. In patients with atrophic rhinitis because the adrenaline. Before packing the pack should be
lateral nasal wall will be pretty thick in these squeezed to remove excess xylocaine. The first
patients making the procedure rather difficult. It pack is placed over the floor of the nasal cavity,
may require a chisel and gouge to create inferior the second one is placed in the inferior meatus.
meatal opening in these patients. Simple trocar The third pack is placed in the middle meatus
and cannula would not do. area. Surgeon should be aware that the posterior
pharyngeal wall mucosa would also be anesthe-
Procedure: tized by xylocaine trickling into that area. This
could cause the patient to aspirate because the
This procedure involves introduction of a cannu- sensation is lost. The surgeon should be conscious
la into the maxillary sinus cavity via an opening about this problem while performing the proce-
made in the inferior meatus. This procedure is dure. The patient should be instructed not to sniff
rather outdated these days because the maxillary while nasal packing is done as it would promote
sinus drainage in the presence of normal muco drug to trickle into the posterior pharyngeal wall.
ciliary clearance mechanism is not dependent on
gravity. The beating cilia always propels the se- A short description of innervation of nose and
cretions from the sinus cavity towards the natural nasal cavity would not be out of place. Nasal
ostium which is situated slightly above. There is innervation can be simplified by dividing it into
no point in expecting gravity to work against the internal (mucosal) innervation and external (in-
natural muco ciliary clearance mechanism. nervation involving the skin of the nose).
This surgery is performed under local anesthe-

Innervation of external nose: turbinate and this innervates the posterior nasal
cavity. It is this ganglion that is blocked by the
The external nose is innervated by the ophthal- pledget placed in the middle meatus of the nose.
mic division of 5th cranial nerve, and maxillary The anterior and posterior ethmoidal nerves and
division of 5th cranial nerve. The superior aspect the sphenopalatine ganglion through the naso-
of the nose including the tip is supplied by In- palatine nerve provides sensation to most of the
fratrochlear nerve. The supratrochlear nerve and nasal septum. The cribriform plate holds the spe-
external nasal branch of anterior cial sensory branches of the olfactory nerve thus
ethmoidal nerves also supply this area. The infra catering to the sensation of smell.
orbital nerve supplies the inferior and lateral
aspects of the nose extending up to the lower The nerves that are blocked during antral wash
eyelids. are:
1. Superior alveolar nerve near the inferior me-

atus
2. Anterior ethmoidal nerve near the roof of nasal
cavity
3. Posteriorly the sphenopalatine ganglion
Image showing innervation of external nose
Sensory innervation of nasal mucosa:
The interior of nasal cavity is subdivided into the Image showing the theory behind antral wash
nasal septum, lateral nasal walls and the cribri-
form plate. The superior inner aspect of lateral
nasal wall is supplied by the anterior and posteri-
or ethmoidal nerves. The sphenopalatine gangli-
on is located in the posterior end of the middle
140
The patient is comfortably seated in a chair with
adequate back support. Eye pad should be used
to blind the patient. This will reduce the anxiety
level of the patient.
The Tilley Lichwitz trocar and cannula is passed

under the attachment of inferior turbinate and is
directed towards the outer canthus of the ipsi-
lateral eye. With a firm turn the inferior meatus
is punctured. While introducing index finger of
the surgeon should be placed at the junction of
anterior 1/3 and posterior 2/3 of the trocar can-
nula assembly. This will help in ensuring the safe
penetration depth. The trocar is gently removed
leaving the cannula in position. A syringe is con-
nected to the cannula and aspiration is attempted. Image showing Lichwitz trocar and cannula
If it is inside the maxillary sinus secretions could
be aspirated. If the sinus is empty then air will
be aspirated. If gross blood is aspirated then it
should be construed that the cannula is not inside
the maxillary sinus cavity. A Higginson’s syringe
which contains a bulb and a one-way valve is
connected to the cannula and the other end of the
syringe is placed inside a vessel containing water
at body temperature. Flushing can be performed
by squeezing the bulb of Higginson syringe.
Dilute potassium permanganate wash can also
given. Three successive washes should be given.
A kidney tray should be held under the patient’s
mouth. The patient can be asked to hold the tray
so that their mind will be diverted from the actual
procedure. When the antrum is being flushed the
patient should be asked to keep the mouth open
so that fluid used for irrigation will drain through
the patient’s mouth. Image showing the course of trocar and cannula

Image showing the nasal opening of nasolacri-
mal duct in the inferior meatus. Injury to this
structure should be avoided at all costs during Image showing the fluid used for antral wash
the procedure. draining through the antrostomy
Complications:
1. Bleeding
2. Orbital damage. Perforation of orbital floor will
cause proptosis and pain
3. Cheek swelling: This is caused by breaching the
soft tissue of the cheek and the anterior wall of
the sinus.
4. Air embolism due to injury to veins
5. Infection of maxillary sinus
6. Vaso vagal shock
Image showing pus draining out of inferior me-

atal antrostomy opening
142
Maxillectomy
Indications for maxillectomy:
Introduction:
1. Malignant tumors involving maxilla / lateral
The concept of maxillectomy was first described nasal wall
by Lazars in 1826. After this description it took 2. Fungal infections causing extensive destruction
nearly three years for Syme to perform the first of sinuses
maxillectomy (1829). Earlier attempts at this sur- 3. Chronic granulomatous diseases involving nose
gery failed because of excessive bleeding. Bleed- and sinuses
ing and infection were two scrooges which 4. As a part of combined excision of skull base
caused unacceptable morbidity and mortality in neoplasm
patients following maxillectomy. In 1927 Port-
mann & Retrouvey suggested sublabial transoral Partial maxillectomy procedures are indicated in
approach to remove maxilla. This approach patients with:
obviated the use of disfiguring facial incisions.
Rapid advances which took place in the field of 1. Slow growing tumors involving nose and sinus-
anesthesia and surgical techniques in 1950 rekin- es (inverted papilloma)
dled the interest in total maxillectomy as a viable 2. Tumors localized to inferior wall of maxilla
treatment option for malignant lesions involving
maxilla. It was during this period that Weber Important considerations before deciding on
Ferguson came out with his epoch making lat- surgery:
eral rhinotomy incision which caused very little
cosmetic deformity. Later various modifications 1. Extent of the lesion
of these incisions were used to perform maxillec- 2. Histopathology of the lesion
tomy. 3. Involvement of adjacent areas
4. Precise location of the bulk of the mass
In 1954 Smith did what was considered impos-
sible. He combined total maxillectomy with Role of Nasal endoscopy and clinical examina-
orbital exenteration. It was only after Smith’s tion:
demonstration of extended total maxillectomy
curative surgery for maxillary carcinomas began This is really vital in deciding not only the extent
to take center stage. Fairbanks & Barbosa (1961) of the disease but also in determining the optimal
described infratemporal fossa approach to resect treatment modality. It also helps in discussing
advanced malignancies of maxilla. These tumors prognostic issues with the patient and their near
were considered to be inoperable till then. ones.
In 1977 Sessions & Larson first envisaged medial It helps in examination of the nasal cavity and
maxillectomy and were also responsible for coin- also provides the first look at the disease process
ing the term. With the advent of nasal endoscope from which biopsy can be done. Spread of lesion
resection of tumors involving lateral nasal wall outside the confines of maxilla by eroding the
under endoscopic vision is the order of the day. antero lateral wall can be ascertained by careful

palpation of the anterior wall and in assessing the
integrity of the function of the inferior orbital
nerve. Erosion of the posterior wall of maxilla
with extension of lesion to pterygopalatine fossa
can be ruled out clinically by absence of trismus.
Histopathological diagnosis is a must before

deciding on the optimal management modality. If
tumor histology is suggestive of lymphoreticular
tumors / rapidly proliferating embryonal tumor
like rhabdomyosarcoma then irradiation is the Image showing Coronal and Axial CT show-
preferred treatment modality. ing Growth involving right maxilla eroding its
medial, inferior and antero lateral walls. Axial
Role of imaging: CT shows the same mass eroding posterior wall
of maxilla extending on to pterygopalatine fossa.
1. Both axial and coronal CT will have to be Pterygoid process is not visible on right side ?
performed in order to ascertain the extent of the eroded.
lesion.
2. Imaging also helps in deciding the optimal
osteotomy location during surgery. The level of
frontoethmoidal suture line should be identified
well in advance. Superior osteotomy above this
level will cause intracranial injury and CSF leak.
3. MRI is indicated in patients who have skull
base erosion in order to identify intracranial
extension.
Role of prosthodontist:
Preoperatively prosthodontist should examine the

patient and design an optimal prosthesis which is
actually a temporary one. This can be fixed imme-
diately after surgery. Final prosthesis can be fitted
after the completion of treatment which includes
irradiation / chemotherapy. Image showing Coronal CT nose and sinuses
showing soft tissue shadow involving inferior
portion of maxilla with erosion of the floor of
maxilla
144
Role of ophthalmologist: Ryles tube insertion:
Ophthalmic examination helps in ruling out oc- This is ideally performed before anesthetizing the
ular involvement. If orbit is involved then max- patient. Ryles tube in position will help in feeding
illectomy will have to be combined with orbital the patient during the initial post-operative peri-
exenteration. od. Even though it is not a must if inserted serves
a good purpose.
Procedure:
Hypotensive anesthesia can be administered if
This surgery is ideally performed under general there is no contraindication as it would help in
anesthesia. Administration of pre-operative anti- minimizing blood loss during the procedure. If
biotics has been considered to reduce incidence endotracheal intubation is preferred to tracheos-
of post op infections. Ideally it should be a broad tomy then oral intubation is ideal. The endotra-
spectrum antibiotic which could cover the nor- cheal tube should be secured to the side opposite
mal flora of nasal and oral cavities. to that of the tumor. It is anchored to the lower lip
without distorting the upper lip.
The question whether tracheostomy should be
performed or not is determined by the extent of Position:
lesion and the amount of palate that needs to be
removed. If large amount of palatal tissue needs Patient is put in supine position with head turned
to be removed to give adequate tumor margins 180° from the anesthetist.
then it is safer to resort to preliminary tracheos-
tomy. Incision:
Advantages of preliminary tracheostomy include: Even though various incisions are available au-
thor prefers to use Weber Ferguson incision and
1. Anesthesia can be administered through it its various modifications. Modifications of Weber
2. Provides unhindered view of oral cavity which Ferguson incision is necessary if other areas like
is helpful during oral phases of surgery orbit needs to be attended. Lateral canthotomy
3. It helps to secure airway during post op period can be combined with Weber Ferguson incision
even in the presence of intra oral edema. to expose orbital boundaries and malar area. Lip
splitting incision a modification of Weber Fergu-
Tarsorraphy is performed on the side of lesion. son incision is preferred if infratemporal fossa is
This helps in protecting eye and cornea from involved.
injury. Lateral tarsorraphy alone could suffice if it
could provide adequate eye closure. Ideally silk is
used to perform this procedure. Before perform-
ing tarsorraphy it would be prudent on the part
of the surgeon to apply eye ointment in order to
prevent excessive drying of cornea.

the midline.
3. Infraorbital component of the incision passes
about a couple of millimeters from the lower eye
lid margin till the malar eminence is reached.
Whatever may be the type of incision used

the skin is slit right through till periosteum is
reached. This enables cheek flap to be elevated
from the antero lateral surface of maxilla in the
subperiosteal plane. If the anterior wall of maxilla
is eroded by the mass with skin involvement then
dissection is slightly altered so that the involved
skin overlying the anterolateral wall of maxilla is
also removed en-bloc along with the tumor.
Probable bleeding sites encountered during this

incision:
1. Angular vein close to the inner canthus of eye.
If not ligated properly may cause irksome ooze
during surgery.
2. When lip is being split right in the middle labi-
al vessels may lead (superior labial artery)
Image showing the Weber Ferguson Lip splitting 3. Infra orbital vessels when infraorbital limb of
incision used in maxillectomy. the incision is being made.
Infraorbital nerve is sacrificed after taking a biop-

Weber Ferguson incision: sy from it to rule out perineural invasion. This is
mandatory in all patients with adenocarcinoma
Before actually beginning the process of incision of maxilla. Adenocarcinoma has a propensity to
the area should be marked and infiltrated with 1% spread via nerve sheaths.
xylocaine with 1 in 100,000 units adrenaline. This
infiltration if done properly will help in minimiz- After elevating the cheek flap, the inferior and
ing intraoperative bleeding during surgery. medial periorbita are elevated exposing the fol-
lowing areas:
The modified Weber Ferguson incision used in
total maxillectomy has three components. 1. Floor of orbit
1. Curving incision from the medial canthus to 2. Lacrimal fossa
the ala of the nose at the nasolabial sulcus. 3. Lamina papyracea
2. This incision is rounded inferiorly along the
upper border of upper lip till the center of the lip
is reached. The upper lip is ideally split right in
146
Image showing the infraorbital limb of the inci-
sion Image showing incision is ideally deepened up
to the subperiosteal plane by using diathermy
cautery. Use of cautery minimizes bleeding to a
great extent.
Identification of lacrimal sac and duct: This is a critical step during the procedure as
it gives excellent opportunity to the surgeon
The lacrimal sac is identified, dissected and re- to identify orbital involvement. If periorbita is
tracted. This maneuver stretches and exposes the breached by the tumor then it calls for histolog-
lacrimal duct. The nasolacrimal duct is usually ical confirmation of orbital involvement. Frozen
transected at its junction with the sac. The sac is section will of used during this stage of the proce-
marsupialized. This is performed by dividing the dure.
sac and suturing the edges to the periorbita.

the frontoethmoidal suture line. Above this line
dura is present. In tumors involving roof of the
ethmoid (Fovea) require skull base resection in
order to provide adequate tumor margins. If
fovea is not involved by the disease then ethmoid
bone is removed along the frontoethmoidal su-
ture line to provide adequate exposure.
Tip:
While performing the su-

perior cuts please ensure
that it is done in a direc-
tion parallel to the nasal
floor in order to avoid
inadvertent entry into
skull base.
Image showing transection at the level of malar
buttress using Gigli saw
Transection of infraorbital rim: Intraoral phase of surgery:
This is transected laterally at the malar buttress. Palatal incision

Gigli’s saw may be useful during this phase of
surgery. Incision is made over the hard palate from just
posterior to the lateral incisor till the junction
Tip: While using gigli saw during osteotomy pro- with that of the soft palate is reached. Incision is
cedures, saline should be dripped on the surgical deepened up to the level of periosteum. At the
field continuously to prevent tissue damage due junction of soft palate the incision curves hori-
to overheating which could occur during this zontally and extend up the maxillary tuberosity
procedure. where it is rounded.
The medial orbital rim is transected just below
148
Tip:
Bleeding will be mini-

mized if this area is also
infiltrated with 1% xy-
locaine mixed with 1 in
100,000 units adrenaline.
Image showing osteotome being used for palatal

resection
Division of hard palate:
Osteotomies over lateral orbital wall and posteri-
This is usually done using an osteotome / recip- or floor of orbit are completed thereby allowing
rocating saw. Author prefers to use osteotome. down fracture of maxilla. The only attachment
Palatal division is started about 2-3 mm from the remaining at this state is the pterygoid plate.
ipsilateral nasal septum (if the tumor margin per- Attachment of maxilla to pterygoid palate can be
mits). This can be modified to suit tumor mar- removed using a curved osteotome.
gins. Lateral incisor if present and uninvolved Maxilla can now be freed by lateral rocking
can be preserved for prosthesis fitment purposes. movements. At this stage brisk bleeding may
The central incisor can be compromised. It is be encountered. This is usually due to internal
easy to use osteotome from the cavity of the cen- maxillary vessels and pterygoid plexus. Packing
tral incisor after removing it. the entire area using a hot pack will help in con-
trolling bleeding. Majority of this bleeding re-
After completing palatal osteotomy the soft tissue duces appreciably with hot packing. In the event
attachments between hard and soft palate are of hot packing failing to control bleeding then
freed using sharp dissection / unipolar diathermy individual vessels will have to be cauterized using
cautery. bipolar cautery.

After the entire maxilla is removed the area is
washed with saline and betadine solution. Tem-
porary prosthesis is inserted. Gutta percha is used
to fashion this prosthesis. It is always optimal to
have a prosthodontist to do this job.
Image showing disarticulation of maxilla by gen-

tle lateral rocking movements
Image showing Obturator in position
Image showing hot pack in position after remov-

ing the entire maxilla
150
Image showing maxillectomy specimen
Bone cuts a pictorial review:
It will not be out of place to review the bone cuts

performed in total maxillectomy from osteology
point of view. Pictures below will give a clear cut
view of various osteotomies performed before
maxilla could be disarticulated.
Image showing wound closure

Image showing various bone cuts
Complications:
1. Intraoperative hemorrhage
2. Troublesome Epiphora
3. Damage to orbital structures
4. Damage to cornea
5. Visual disturbances
6. Loss of vision due to over packing the maxil-
lectomy cavity compromising vascularity of optic
nerve
7. Velopharyngeal incompetence (Nasal leak of
ingested fluids)
8. Cosmetic defects / scars
9. Trismus due to scarring of muscles of mastica-
tion
152
SUBMUCOSAL RESECTION OF NA- United States. Using a special saw, the deviated
SAL SEPTUM & SEPTOPLASTY portion of the nasal septum was removed along
with its corresponding mucosa. The results of this
procedure were therefore suboptimal.
Introduction:
Ingals (1882) was the first to introduce en-bloc
Nasal obstruction is a common complaint that
resection of small sections of septal cartilage.
brings the patient to a doctor. If it is caused by
Because of this innovation he is considered to be
deviated
the father of modern septal surgeries. During this
nasal septum then correction of this deviation be-
period cocaine was being widely used as topical
comes mandatory. A successful septal correction
anesthetic for surgical procedures.
surgical procedure really improves the quality of
life of the patient. Submucosal resection of na-
Ash (1899) was the first person to suggest that al-
sal septum and septoplasty are two commonly
tering the tensile curve of septal cartilage straight-
performed surgeries with an aim to correct the
ened it without resorting to actual resection.
septal deviation and improve nasal airway. The
type of surgery depends on the type of deviation.
Freer and Killain (1902 & 1904) described the
If the deviation of nasal septum is anterior to the
submucosal resection of nasal septum. This
Cottle’s line (a vertical imaginary line dropped
procedure served as the foundation of modern
between the nasal processes of frontal and maxil-
septoplasty techniques. They advocated raising
lary bones) septoplasty is preferred. If the devia-
mucoperichondrial flaps and resecting the car-
tion is posterior to this line submucosal resection
tilaginous and bony septum (which included
of nasal septum is preferred.
the vomer and perpendicular plate of ethmoid),
leaving 1 cm dorsally and 1 cm caudally to main-
History:
tain support.
First description of nasal surgery could be found
Metzenbaum and Peer (1929) were the first to
in the Ebers Papyrus (3500 B.C) written in Egyp-
manipulate the caudal septum using a variety
tian. The procedures described in this papyrus
of techniques. The classic SMR is ineffective /
was reconstructive in nature because rhinectomy
less effective in correcting this area of deviation.
was a frequent form of punishment those days.
Metzenbaum also in addition advocated the use
of swinging door technique.
Quelmatz (1757) was one of the earliest physi-
cians to address septal deformities. His famous
In 1937 Peer recommended removal of caudal
recommendation was the application of digital
portion of nasal septum, straightening it and then
pressure on the septum on a daily basis. He be-
replacing it in the midline position.
lieved this procedure could correct the deviation
and make the septum to become straight.
Cottle in 1947 introduced the hemitransfixation
incision and the practice of conservative septal
Adams (1875) recommended fracturing and split-
resections.
ting of nasal septum. Bosworth operation: This
was rather popular in late 19th century in the
154
2. During an acute episode of rhinitis
Cottle’s types of septal deviations: 3. In the presence of bleeding diathesis
4. If the patient is having untreated DM & HT
Cottle has classified septal deviations into three
types: Anesthesia:
Simple deviations: Here there is mild deviation of
nasal septum, there is no nasal obstruction. This This surgery can be performed both under local
is the / General anesthesia. GA is used only in appre-
commonest condition encountered. It needs no hensive patients. The basic advantage of LA is that
treatment. there is minimal bleeding during the surgery and
Obstruction: There is more severe deviation of the entire surgery can be performed as a day care
the nasal septum, which may touch the lateral procedure.
wall of the nose, but on vasoconstriction the
turbinates shrink away from the septum. Hence Position:
surgery is not indicated even in these cases.
Impaction: There is marked angulation of the The patient is placed in a reclining position with
septum with a spur which lies in contact with head end of the table raised.
lateral nasal wall. The space is not increased even
on vasoconstriction. Surgery is indicated in these The nasal cavities are packed strips of roller gauze
patients. dipped in 4% xylocaine with 1 in 100,000 units
adrenaline. The gauze strips should be squeezed
Indications of SMR: to remove excess xylocaine before inserting into
the nasal cavities. This is done to minimize xy-
1. Deviated nasal septum causing symptoms of locaine absorption by the nasal cavity mucosa as
nasal obstruction and recurrent head aches this could cause systemic toxicity. On no account
2. Deviated nasal septum causing obstruction to the volume of 4% xylocaine used for topical an-
ventilation of paranasal sinuses and middle ear esthesia should exceed 7ml. One strip is placed in
causing recurrent sinusitis and ear infections the floor of the nose, the second one is placed to
3. Recurrent epistaxis from a septal spur occupy the middle portion of the nasal cavity. The
4. As a part of septorhinoplasty for cosmetic cor- third strip is placed superior to the second one.
rection of external nasal deformities Both nasal cavities should be packed. The author
5. As a preliminary step in trans-septal trans prefers to pack the nose even if the surgery is
sphenoidal hypophysectomy, vidian neurectomy performed under GA as it shrinks the turbinates
6. To obtain cartilage graft thereby creating more space for the surgeon.
7. For closure of septal perforations
Infiltration of nasal septum:
Contraindications:
It is done at the mucocutaenous junction on both
1. Patients below the age of 17 as it would impede sides with 2% xylocaine with 1 in 100,000 adren-
growth of middle third of face by interfering with aline.
growth centers. Successful infiltration not only produces anes-

thesia in the area but also elevates the mucoperi-
chondrium as evidenced by blanching reaction
seen in the septal mucosa.
Killian’s incision is used. 15 blade knife is used
to cut the mucoperichondrium obliquely about 5
mm above the caudal border of the septal carti-
lage. Flaps are elevated on both sides of the nasal
septum exposing the bony and cartilaginous
portions of the nasal septum. The entire septum
including cartilage and bone is removed using a
combination of Ballanger’s swivel knife and Lucs
forceps.
Image showing mucoperichondrial flap elevated

on one side of the septum
Image showing incisions used in SMR & Septo-

plasty
The mucoperichondrial flap is sutured using 3-0

chromic catgut. The nose is packed gently with
ointment impregnated roller gauze or using a
Merocel nasal pack. Both nasal cavities should be
packed. Image showing mucoperichondrial flap elevat-
ed on the opposite side after incising the septal
cartilage
156
Indications:
Complications of SMR:
1. Symptomatic deviated nasal septum
1. Bleeding 2. As part of rhinoplasty procedures
2. Septal hematoma - If the nasal cavity is prop- 3. To remove septal spur that cause epistaxis
erly packed then this will not be a problem. If he- Contraindications:
matoma is present then it should be evacuated by 1. Acute nasal or sinus infection
application of digital pressure and nasal cavities 2. Untreated DM and HT
should be repacked again. 3. Bleeding diathesis
3. Septal abscess - This usually follows septal
hematoma Anesthesia is as enumerated for SMR surgery.
4. Septal perforation - Occurs when the other side The septum is infiltrated with 2% xylocaine with
of the nasal septum is breached during elevation 1 in 100,000 adrenaline. Incision is usually giv-
of mucoperichondrial flap en on the concave side of nasal septum. Freer’s
5. Depression of Bridge of nose - This usually oc- hemitransfixation incision is preferred. This is
cur at the supratip area due to too much removal made at the lower border of the septal cartilage. A
of cartilage along the dorsal border. unilateral incision is sufficient. Three tunnels are
6. Columellar retraction - This is seen often when created as shown in the figure below.
the caudal strip of cartilage is not preserved
7. Persistence of deviation - Usually is the result Exposure:
of incomplete surgery
8. Flapping septum - This is due too much remov- The cartilaginous and bony septum are exposed
al of septal framework. The septum flaps to either by complete elevation of a mucosal flap on one
side during respiration side only. Since the flap is retained on the oppo-
9. Toxic shock syndrome - This is due to strep- site side the vascularity of the septum is retained
tococcal / staphylococcal infection. It should be and not compromised.
diagnosed early and managed by removal of nasal Mobilization and straightening:
pack, hydrating the patient and infusing parenter-
al antibiotics. The septal cartilage is freed from all its attach-
ments apart from the mucosal flap on the convex
Septoplasty: side.
Most of the deviations are maintained by extrin-
Septoplasty is a conservative approach to sep- sic factors such as caudal dislocation of cartilage
tal surgery. As much as the septal framework is from the vomerine groove. Mobilization alone
retained. will correct this problem. When deviations are
The mucoperichondrial / periosteal flap is ele- due to intrinsic causes like the presence of healed
vated only on one side. Anesthesia and patient fracture line then it must be excised along with a
position is the same as for SMR surgery. strip of cartilage. Bony deviations are treated ei-
ther by fracture and repositioning or by resection
of the fragment itself.

Image showing various tunnels that are created during septal surgery
Fixation:
The septum is maintained in its new position by

sutures and splints.
Advantages of Freer’s incision:
1. The incision is cited over thick skin making

elevation of flap easy.
2. There is minimal risk of tearing the flap
3. The whole of the nasal septum is exposed.
4. If need arises Rhinoplasty can be done by
extending the same incision to a full transfixation
one.
Image showing the use of Wright suture to pre-
vent overlap
158
Advantages of Septoplasty:
1. More conservative procedure

2. Performed even in children
3. Less risk of septal perforation
4. Less risk of septal hematoma

was the weakest portion of all its boundaries.
Caldwell – Luc surgery
In 1835 John Hunter popularized intranasal
Introduction: antrostomy via the inferior meatus. George W
Caldwell of New York combined both canine
Caldwell Luc surgery is approximately 120 years fossa approach and inferior meatal antrostomy
old. This surgery till recently was an important with success in managing patients with maxillary
tool in the armamentarium of an Otolaryngol- sinusitis. This work became a sensational publica-
ogist. Now the indications for this procedure is tion in 1893 (New York Medical Journal). A sim-
getting fewer and fewer with Endoscopic sinus ilar procedure was routinely performed in France
surgery becoming common. by Henry Luc in 1897. Only difference between
The fundamental concept of this surgical ap- their two procedures was that Luc performed in-
proach is to replace the diseased / scarred muco- tranasal antrostomy via the middle meatus while
sa from maxillary sinus with a new one. This is Caldwell performed inferior meatal antrostomy
easily said than done. It is fairly simple to remove via the inferior meatus. Better understanding of
diseased mucosa. New mucosa replacement is mucociliary clearance mechanism has popular-
dependent on the regenerative capacity of the ized conservative surgical procedures like:
patient. This approach can also be used to access
adjacent areas, which could be difficult to access Fess
otherwise. This procedure is not without its own Mini Fess
set of complications. It is imperative on the part Balloon sinuplasty
of the surgeon to weigh in the benefits vs compli- It should be stressed that Caldwell Luc procedure
cations before advising the patient. provides the maximum exposure of maxillary
sinuses, floor of orbit and pterygopalatine fossa.
Description of paranasal sinuses have been traced
up to the 16th century. Berenger Del Carpi an Indications:
anatomist first described the existence of parana-
sal sinuses and also infections involving this area. 1. Mycotic maxillary sinusitis
Detailed description of maxillary sinusitis was 2. Multiseptate maxillary sinus mucocele
first provided by Nathaniel Highmore. Maxil- 3. A/C polyp (Recurrent)
lary sinuses hence bear the name “Antrum of 4. Oroantral fistula
Highmore”. He first attempted to drain the infect- 5. Revision procedures
ed sinus cavity by inserting a silver needle (bod- 6. Access for transantral sphenoidectomy, orbital
kin) through an empty tooth socket. By doing decompression, orbital floor repair, exploration of
this he was able to enter into the maxillary sinus pterygoplatine fossa
cavity and was able to drain infected pus from it. 7. Excision of tumors involving the antrum (in-
Many surgeons used this approach to drain max- verted papilloma)
illary sinuses. It was Lamorier in 1743 and De- 8. Visualization of orbital floor during orbital
sault in 1798 who successfully demonstrated that floor decompression surgeries
maxillary sinus cavity could be approached via 9. Removal of foreign bodies from maxillary
the canine fossa route. According to them this antrum
160
In patients with severe mucociliary irreversible
damage (Kartagener’s syndrome, Young’s syn- The adult maxillary sinus is about:
drome) this could be the only approach to drain
infected material from maxillary sinuses. 25-35 mm wide
36-45 mm high
Procedure: 38-45 mm long
This surgery can be done under local / general Its average volume is about 15 ml /(one fluid
anesthesia. ounce).
Superior wall of maxillary sinus – orbital floor.
This sometimes can be dehiscent. The infraorbital
nerve is on the roof of the sinus. Medially and
posteriorly the roof is composed of the floor of
the ethmoid sinuses.
Anterior wall of maxillary sinus – This wall con-

tains the nerves and vessels that supply the upper
teeth. This wall is thinner anteriorly and it thick-
ens posterolaterally where it joins the zygomatic
process. Septae are present anteriorly in about a
third of the cases.
Medial wall – This wall separates maxillary sinus

from nasal cavity. The inferior turbinate is at-
tached along the nasal wall below the level of
maxillary sinus ostium. The nasolacrimal duct
traverses the thicker bone at the junction of medi-
al and anterior walls and it opens into
the nose below the inferior turbinate in the mid-
Image showing canine fossa area marked out in dle meatus. Maxillary sinus communicates with
a human skull the nasal cavity via the maxillary sinus ostium in
the hiatus semilunaris of the middle meatus.
The maxillary sinus is lined by ciliated columnar
epithelium. The cilia beats towards the natural Posterior wall – This is formed by the infratem-
ostium thereby moving the secretions towards the poral surface of the maxilla and it separates the
natural ostium. Hence inferior meatal antrosto- sinus from the pterygomaxillary fissure and the
my does not ensure drainage of the sinus in the pterygopalatine fossa. Pterygopalatine fossa con-
presence of normal ciliary beat. tains the internal maxillary artery and its branch-
es, pterygopalatine ganglion and
its branches.

The dimensions of maxillary sinus cavity changes ing the periosteum from the anterior wall of max-
with age and could affect the surgery as the anat- illary sinus to avoid injury to this nerve. Branches
omy gets changed with age. The sinus expands of anterior and posterior superior alveolar nerves
at the rate of 2-3 mm / year and this process traverse through the bone to supply upper teeth
continues till adulthood. At birth maxillary sinus and gums. There is risk of injury to these nerves
is rather small and its floor lies 4 mm above the when antrostomy is extended too low. Injury to
floor of the nasal cavity. At the age of 9 the floor these nerves could cause loss of sensation of up-
of the maxillary sinuses is at the same level as that per dentition and gums.
of the nasal cavity. Their dimensions being 2x2x3
cms. In adults the sinus floor is 0.5 – 1 cm below
that of the nasal cavity. The alveolus of maxilla
atrophies in edentulous patients and the floor in
these patients could be still lower.
Anatomy of the canine fossa:
The canine fossa is the thinnest portion of the

anterior wall of the maxillary sinus. Hence it is
easy to breach this area and enter into the sinus.
Boundaries of the canine fossa include:
1. Canine eminence formed by the canine tooth –

medial
2. Root of the zygoma – laterally
3. Alveolar process of maxilla - inferiorly
4. Infraorbital foramen with the infraorbital nerve
superiorly
Image showing infraorbital nerve and its branch-
Infraorbital foramen: es
This foramen transmits infraorbital nerve, artery It should be pointed out that no significant blood
and vein. The infraorbital neurovascular bun- vessels are encountered during this surgical
dle traverses a groove in the orbital floor which procedure with the exception of small infraorbital
happens to be the roof of maxillary sinus. This vessels that exit from the infraorbital foramen.
area can also be dehiscent in some individuals. Significant bleeding is possible only when one
The neurovascular bundle exits via the infraorbit- breaches the posterior wall of the maxilla and
al foramen which is located approximately 5 mm enters the pterygopalatine fossa where internal
below the mid-portion of the inferior orbital rim maxillary artery can be encountered.
to enter the soft tissues of the cheek. Branches of
this nerve supply the lower eyelid, nose, cheek,
and upper lip. Care should be taken while elevat-
162
xylocaine adrenaline mixture and is placed in the
sublabial area on the side of surgery. This is done
to anesthetize the mucosa over canine fossa.
Infiltration local anesthesia is preferred in this

scenario. About 1 ml of 2% xylocaine mixed with
1 in 200,000 adrenaline is infiltrated over the ca-
nine fossa area. Since the mucosa over the canine
fossa would have already been anesthetized by the
cotton pledget soaked in 4% xylocaine the process
of infiltration would invariably be painless. This
infiltration blocks them inferior orbital nerve
and its branch anterior superior alveolar nerve.
The patient is also mildly sedated to alleviate the
anxiety.
If general anesthesia is preferred then the patient

should be positioned only after the anesthetist has
intubated the patient.
Image showing canine fossa and its relevant
anatomy
Incision:
Patient preparation:
Incision is given in the Bucco gingival sulcus. The
Patient should be placed in recumbent position length of the incision could be about 3 - 4 cms.
with head slightly elevated. Nasal cavities are Ideally the incision is begun at the canine emi-
packed with cotton pledgets dipped in 4% xylo- nence and should run laterally.
caine with 1 in 100,000 adrenaline. These pledgets
should be squeezed dry before insertion. This is Langenbachs retractor is used to retract the mu-
because the critical toxic dose of xylocaine in this cosal and soft tissue to expose the anterior wall of
concentration is about 7 ml. On no account this the maxilla.
amount should be exceeded.
Under direct illumination pledgets are placed in

Inferior meatus, floor of the nasal cavity and in
the middle meatus area. At least 10 – 15 minutes
interval should be given for the drug to take its
effect.
If the surgery is planned under local anesthe-

sia then one more cotton pledget soaked in 4%

In the next step a periosteal elevator is used to
elevate the periosteum from the anterior wall of
maxillary sinus till the infraorbital foramen be-
comes visible. Care should be taken not to dam-
age infraorbital neurovascular bundle.
Image showing sublabial incision
The retractor should be applied in such a way that

it should not cause excessive traction to the soft
tissue in the area. Excessive traction if applied can
lead to excessive cheek oedema post operatively
which could take about a week to subside com-
pletely.
Image showing Periosteal elevator being used

to elevate periosteum from the anterior wall of
maxilla
Anterior wall of maxillary sinus antrum is opened

up using a gouge and hammer or by cutting it
using a cutting burr. The size of the antrostomy
should be 1.5 – 2 cm in diameter and more or less
circular.
Instruments can be introduced via the antros-

tomy and the diseased mucosa can be curetted
Image showing Langenbachs retractor being out under direct vision. The entire maxillary
applied sinus cavity is directly visible through the antros-
tomy opening. Of course, there could be some
blind spots which may not be fully visible i.e. the
anterior wall and the antero lateral portion of
the sinus cavity. A wide angled nasal endoscope
164
can be introduced via the antrostomy opening to maxillary antrum via inferior meatal antrostomy.
visualize even these hidden areas. One end of the ribbon gauze used to pack the
antrum is brought out via the inferior meatal an-
If the pterygopalatine fossa needs to be ap- trostomy making their later removal via the nasal
proached then the posterior wall of the maxillary cavity that much easier. Mucosal wound is closed
sinus antrum should be breached using gouge using 3-0 chromic catgut. The antral pack can be
and hammer or a cutting burr. removed via the nasal cavity after 48 hours as it is
accessible through the inferior meatal antrostomy.
Creation of naso antral window in the inferior
meatus:
This process helps in removal of antral pack after

surgical procedure. Visualization of antral cavity
is possible through this opening. Miles retrograde
gouge is used for this purpose. This gouge has a
unique curvature which will enable it to slide into
the inferior meatus.
The gouge is held in the dominant hand with Image showing antrostomy in the canine fossa
index finger serving as a guard to control the
perforation process. The gouge is slipping into the
inferior meatus. As soon as it hinges in the lateral
nasal wall the medial wall of antrum is perforat-
ed at the junction of anterior third and posterior
2/3 of inferior meatus. Its unique tip ensures that
it holds the bone fragment after perforation is
made on withdrawal. Medicated nasal pack can
be introduced via the inferior meatal antrostomy
using long-curved forceps and delivered into the

Image showing sublabial incision wound being
sutured with absorbable suture material
Post-operative care:
Image showing the antral mucosa via the antros- 1. Ice packs can be used over cheek to reduce
tomy oedema and discomfort
2. Nasal and antral packing can be removed be-
tween 24-48 hours
3. Nose blowing is avoided as it could cause em-
physema of cheek area
4. If patient uses denture then it should not be
worn for at least a week to facilitate mucosal
healing
Complications:
1. Oedema over cheek – This can happen if

retraction of soft tissue in the area was firm and
not gentle. Sometimes subcutaneous emphysema
Arrow indicating antrostomy opening in a CT can develop due to leakage of air from the antrum
image into the subcutaneous tissues of cheek. This com-
plication is self-limiting and will reduce within a
166
week.
2. Injury to infra orbital nerve causing anesthesia
of upper teeth and lateral wall of nose. It can even
cause pain and numbness over the face
3. Injury to nasolacrimal duct while performing
inferior meatal antrostomy
4. Devitalization of teeth due to injury to its root

procedure can be performed under both LA /
Endoscopic inferior meatal antrostomy GA.
Introduction:
Nasal decongestion:
Since the introduction of Functional endoscopic
surgery inferior meatal antrostomy as a procedure Nasal mucosa is decongested by using pledgets
has taken a back seat due to the apprehension soaked in 4% xylocaine mixed with 1 in 10,000
that it could tamper with the normal mucocil- adrenaline. The pledget should be squeezed dry
iary clearance mechanism. In fact studies per- before insertion. This is done to avoid xylocaine
formed in 1980’s reported that if inferior meatal over dosage. Pledgets should be placed in inferi-
antrostomy is created the mucous bridges across or meatus, floor of the nasal cavity, and middle
the antrostomy and travels towards the natural meatus. If general anesthesia is used throat pack
ostium of the maxillary sinus. This can utmost be should be given to prevent aspiration.
considered to be only partially true. Current stud-
ies have demonstrated that drainage of mucous Infiltration:
does occur via the opening created in the inferior
meatus. 2% xylocaine with `1 in 100,000 units adrenaline
is used to infiltrate the inferior turbinate and the
Current indications for inferior meatal antrosto- corresponding portion of nasal septum. 0 degree
my: nasal endoscope is
1. Patients with chronic sinusitis not responding used for purposes of visualization. A Freer’s
to FESS elevator is inserted into the inferior meatus and
2. Patients in whom mucociliary clearance is the inferior turbinate is up fractured so that it lies
already affected due to cystic fibrosis / Young’s perpendicular to the floor of the nasal cavity. This
syndrome. These patients usually benefit from procedure is a must for adequate visualization of
inferior meatal antrostomy the inferior meatal area. The location of Hasner’s
3. Mycetoma present in the maxillary sinus cavity valve (lower end of nasolacrimal duct) is identi-
4. To visualize the difficult to see areas inside fied at the junction of anterior third and middle
maxillary sinus cavity third of the lateral nasal wall.
5. When regular post op surveillance is needed
6. During Caldwell Luc procedure antral packing A 90 degree angled J curette is ideal to perform
is done via the inferior meatal antrostomy created antrostomy. The lateral nasal wall is perforated
towards the end of the surgery with J curette about 1 cm posterior to Hasner’s
valve. The opening is then enlarged with the help
Endoscopic inferior meatal antrostomy: of back biting forceps. Now insertion of a 30 de-
gree nasal endoscope will help in better visualiza-
Nasal endoscope is a very useful tool for otolar- tion of the interior of maxillary sinus cavity.
yngologist. By using this tool the whole procedure
can be performed under direct visualization. This
168
Image showing the inferior meatus after medial-
ising the inferior turbinate Image showing inferior meatal opening
Complications
1. Premature closure of the antrostomy opening
2. Failure of drainage process due to the ciliary

movements of the sinus mucosa
3. Injury to dental roots
4. Bleeding
5. Trauma to nasolacrimal duct
Image showing a J curette being used to perforate

the inferior meatus

ance pattern. It is hence advisable that ciliary
In inferior meatal antrostomy is useful in the mucosa in the vicinity of natural ostium is better
following ways: left undisturbed.
1. Helps / facilitates dependent drainage of max- Inferior meatal antrostomy with mucosal flap:
illary sinus in the presence of secondary ciliary
dysfunction which is a feature in persistent maxil- This procedure helps in keeping the inferior me-
lary sinus infections. atal antrostomy opening patent for a long period
of time. Keeping the antrostomy opening patent
2. It provides alternate drainage pathway to the for long durations is a necessity when the patient
maxillary sinus till the ciliary mechanism be- is suffering from primary mucociliary disorders
comes functional. preventing effective clearance of secretions from
the maxillary antrum. The sinus thus depends on
3. It helps in removal of polypoidal tissue from gravity and a patent inferior meatal antrostomy to
the maxillary sinus antrum. keep the drainage process going. Patent opening
also would be helpful if periodical viewing of the
4. Useful in breaking large retention cysts present antral cavity is needed.
in the maxillary sinus antrum.
Procedure
5. Facilitates removal of fungal debris from the
maxillary sinus cavity Under GA/LA the nasal cavity is decongest-
ed first using cotton pledgets dipped in 0.05%
6. Helps in the process of irrigation to remove oxymetazoline. Specifically the inferior meatal
thick and tenacious secretions that could be pres- area is decongested. A Freer elevator is sued to
ent within the sinus cavity. medialize the inferior turbinate.
7. Large permanent antrostomy is indicated in As a first step the lower end of naso lacrimal
patients with primary ciliary dysfunction duct (Hasner’s valve area) is identified under the
inferior turbinate. It lies roughly 15 mm above
The effectiveness of an antral window in treat- the floor of the nasal cavity and 4-6 mm poste-
ing maxillary sinusitis and the precise location rior to the anterior end of the inferior turbinate.
of such a window has always been controversial. A monopolar cautery probe or 15 blade knife is
Hilding suggested that creation of an inferior used to make an incision below and anterior to
meatal window could be detrimental to long-term the Hasner’s valve. Mucoperiosteal flap is ele-
mucociliary clearance. On the other hand Fried- vated with a Freer elevator. The inferior portion
man and Torimumi demonstrated with radio- of the medial wall of maxillary sinus is opened
nuclide studies that inferior meatal antrostomy using a Miles retrograde gouge at the level of the
does not hinder mucociliary clearance towards mucosal incision. The opening can be widened
maxillary sinus natural ostium. Studies have also using a cutting burr. After the process of widen-
revealed that widening of natural ostium leads to ing is completed then the mucosal flap is inserted
some disruption of the normal mucociliary clear- in such a way that it covers the lower border of
170
Image showing inferior meatal mucosal flap procedure. (a) The U-shaped mucosal flap was positioned
on the nasal floor after the elevation from the meatal bone; (b) The flap was positioned across the
inferior lip of the bony window into the maxillary sinus after removing bony wall. NLD, Nasolacrimal
Duct. IT, Inferior Turbinate. MT, Middle Turbinate.
the opening completely and gets inserted into the

maxillary sinus cavity.

Vidian Neurectomy Wolff also managed to record changes in the nasal
mucosa when he interviewed psychiatric patients
Introduction: with chronic rhinitis. Turbinate biopsies from
these patients revealed hyperplasia of mucosal
Vidius in 1509 identified the vidian nerve in the glands which was filled with secretions. Lymph
floor of the sphenoid sinus while performing dis- channels were found to be dilated with predomi-
section in that area. This nerve is thought to play nant eosinophilia.
a role in the pathophysiology of rhinitis, epiph-
ora, crocodile tears, Sluder syndrome, cranial / Sectioning of greater superficial petrosal nerve as
cluster headaches. a treatment for vasomotor rhinitis was first pro-
posed by Zeilgelmann in 1934. This suggestion
In 1943 Fowler reported a rather unusual uni- was followed by Murray Falconer in 1954.
lateral vasomotor rhinitis following ipsilateral
stellate ganglion destruction. He also went to the
extent of suggesting that experimental surgeries
involving the stellate ganglion could throw light
on the fundamental mechanism of vasomotor
rhinitis. This was promptly taken up by Phil-
ip Henry Golding – Wood who suggested that
chronic vasomotor rhinitis should be considered
as simple secretomotor hyperactivity of the nasal
cavity mucosa. He concluded that emotional
stress played a role in the initiation and perpetua-
tion of vasomotor rhinitis.
Wolff in 1950 classified emotional effects on tar-

get organs as:
Stomach reactors – Who manifested with gastro-

intestinal disturbances following emotional stress
Pulse reactors – These patients showed changes in Image showing Murray Falconer
pulse rate in response to emotional stress
Nose reactors – These patients manifested with Murray Falconer’s petrosal neurectomy:
nasal congestion and discharge following emo-
tional stress. He performed this surgery under Local anesthe-
sia. The whole procedure was performed while
the patient is seated up.
172
Incision: the medial pterygoid plate. The mobilization of
mucoperichondrium extends forwards over the
Vertical incision is made above the zygoma one perpendicular plate of palatine bone. The spheno-
inch in front of the external auditory meatus. The palatine foramen comes into view and is identi-
temporalis muscle was split and the squamous fied and the vidian nerve is blindly cauterized as
portion of the temporal bone was exposed. A burr it exits from the foramen.
hole was performed in the squamous portion of
the temporal bone and the opening is enlarged till Golding – Wood’s transantral approach:
the floor of the middle cranial fossa is exposed.
The middle cranial fossa dura is gently stripped Inspired by the work of Malcomson Golding
from the floor and retracted with the help of wood started to work on the various approaches
retractors. While stripping the dura from the to vidian nerve. He popularized the transantral
middle cranial fossa it could be found attached vidian neurectomy. He considered it to be a rather
firmly to the foramen spinosum. This area could safe procedure in comparison to intracranial ap-
bleed during the dissection. The middle meninge- proach to the nerve popularized by Malcomson.
al artery which traverses this foramen was co-
agulated and cut. The foramen is plugged. From
now on the dura strips easily and the mandibular
division of trigeminal nerve is identified entering
the foramen ovale which lies medial and slightly
anterior to foramen spinosum. On stripping the
dura from the anteromedial face of petrous bone
the greater superficial petrosal nerve can be clear-
ly seen. Without causing any traction the nerve is
divided.
Malcomson in 1957 suggested that the vidian

nerve had a predominantly parasympathetic
effect. He also suggested that vidian neurecto-
my could offer relief in patients with vasomotor
rhinitis.
Malcomson’s approach to vidian nerve:
This is a rather blind approach. As a first step a Image showing Golding Wood
submucosal resection of nasal septum was per-
formed. The rostrum of sphenoid is identified. In
this area the muco-periosteum is elevated off the
anterior and inferior faces of the body of sphe-
noid. The mobilization of the mucoperiosteum is
continued laterally over to the medial surface of

Histological changes induced due to stimulation
In this procedure the maxillary antrum is opened of vidian nerve include:
via Caldwell Luc approach. The posterior wall of
the maxilla is identified and removed. The inter- 1.Enhanced secretory activity of nasal mucosal
nal maxillary artery can be controlled using clips. glands
The maxillary nerve is identified and traced up 2.Intense vasodilatation of deep venous plexus
to the foramen rotundum. This foramen serves 3.Increase in the periglandular blood supply
as the most important land mark in this surgical 4.Intense degranulation of mast cells
procedure. On exiting from the foramen rotun-
dum the maxillary nerve gives off branches to Acetylcholine and VIP have been implicated as
the sphenopalatine ganglion. The vidian nerve is the chemical mediators for these responses.
identified and resected here. Studies have shown
that despite there being an opening in the poste- Anatomy of vidian nerve:
rior wall of the maxilla it was not an hindrance to
wound management like antral wash etc. Accord- The vidian nerve is formed by post synaptic para-
ing to Golding – Wood even unilateral resection sympathetic fibers and presynaptic sympathetic
of vidian nerve provided relief on both sides of fibers. This is also known as the “Nerve of ptery-
the nasal cavities. goid canal”.
Golding-Wood in his classic paper on the role of Nerves that gets involved in the formation of
vidian neurectomy in the treatment of crocodile vidian nerve:
tears in 1963 observed “The only animal capable
of weeping in sorrow is the human with a doubt- 1. Greater petrosal nerve (preganglionic parasym-
ful exception to elephant.” This was in fact the pathetic fibers)
classic observation of Charles Darwin. 2. Deep petrosal nerve (post ganglionic sympa-
thetic fibers)
Effects of vidian nerve stimulation on nasal mu- 3. Ascending sphenoidal branch from otic gan-
cosa: glion Vidian nerve is formed at the junction of
greater petrosal and deep petrosal nerves.
“The parasympathetic innervation of the nasal
mucosa play a prominent role in the pathogene- This area is located in the cartilaginous substance
sis of chronic hypertrophic non allergic rhinitis”. which fills the foramen lacerum. From this area
Golding-Wood 1961. it passes forward through the pterygoid canal ac-
The vidian nerve provides the main parasympa- companied by artery of pterygoid canal. It is here
thetic supply to the nasal mucosa and maxillary the ascending branch from the otic ganglion joins
sinus mucosa. Stimulation of this nerve causes this nerve.
secretory and vasodilatory effects in animals.
The vidian nerve exits its bony canal in the ptery-
gopalatine fossa where it joins the pterygopalatine
ganglion.
174
Vidian canal: The parasympathetic fibers to the nasal muco-
sa enters the nose through the sphenopalatine
It is through this canal the vidian nerve passes. foramen. At the level of sphenopalatine ganglion
This is a short bony tunnel seen close to the floor the parasympathetic fibers synapse. Post synaptic
of sphenoid sinus. This canal transmits the vidian parasympathetic fibers from the sphenopalatine
nerve and vidian vessels from the foramen lace- ganglion arise at the pterygopalatine fossa. These
rum to the pterygopalatine fossa. post synaptic fibers are three in number. They are:
According to CT scan findings the vidian canal is 1. Nasal nerve – innervating the nasal mucosa
classified into: 2. Lacrimal nerve – innervating the lacrimal
gland
Type I: The vidian canal lies completely within 3. Greater palatine nerve – innervating the palate.
the floor of sphenoid sinus
Type II: In this type the vidian canal partially

protrudes into the floor of sphenoid sinus
Type III: Here the vidian canal is completely em-

bedded in the body of sphenoid bone
Image showing types of vidian canal

Image showing anatomy of the vidian nerve
176
Anatomy of sphenopalatine foramen: Indication for vidian neurectomy:
Detailed understanding of the anatomy of sphe- 1. Vasomotor rhinitis

nopalatine foramen is a must before performing 2. Intrinsic rhinitis
vidian neurectomy. This foramen is formed by the 3. Crocodile tears
articulation of the body of sphenoid and perpen-
dicular plate of palatine bone. Types of vidian neurectomy:
Boundaries: Trans septal vidian neurectomy Malcomson’s pro-

Superior – Body of sphenoid cedure is still practiced in some centers.
Anterior – Orbital process of palatine bone
Posterior – Sphenoid process of palatine bone
Inferior – Upper border of perpendicular plate of
palatine bone
This foramen is semicircular in shape and about a

quarter of an inch in diameter.
This foramen has a small notch inferiorly which
transmits the sphenopalatine artery. The naso-
palatine and superior nasal nerves also pass out
through the sphenopalatine foramen and lie
above the sphenopalatine artery.
Image showing sphenopalatine ganglion

Transpalatal vidian neurectomy:
This procedure is performed under general anaes-

thesia, with mouth opened by Boyle Davis mouth
gag. A curved incision is made in the hard palate
2 cm anterior to the posterior end of hard palate
and the same is extended laterally and posteriorly
till the last molar. The incision is deepened up to
the underlying bone but not in the lateral aspect
in order to avoid injury to the greater palatine
vessels. The mucoperiosteum is elevated until the
palatal aponeurosis is visualised. The soft palate
is incised from the posterior part of hard palate
and nasopharynx is entered. L shaped incision is
given with the long limb above the tubal elevation
in a postero anterior direction. The short limb
of the incision is sited between the posterior and
lateral wall of nasopharynx. Elevation of mucosa
in this region exposes the medical pterygoid plate
till its attachment to the basiocciput. The medial Image showing incision for transpalatal vidian
pterygoid is drilled leaving a wedge of bone in its neurectomy
superior aspect taking care not to injure internal
carotid artery above foramen lacerum in this re- Dangers of this procedure:
gion. The pterygoid canal is visualised as a dense
ivory bone in the region of cancellous bone. It is 1. Foramen lacerum with its internal carotid ar-
usually 2 – 3mm deep. Vidian nerve is identi- tery lie close to the area of dissection
fied in this region and cauterized. Palatal wound 2. Palatal fistula is a real danger if excessive cau-
closed in layers. tery is used in that area
3. The surgery should always be performed under
Complications : continuous vision if possible microscope should
be used. 300 mm objective is preferred in order to
1. Palatal fistula can occur if excessive cautery is have an optimal working distance.
used in that area
2. Injury to internal carotid artery can occur over
foramen lacerum if medical pterygoid drilling is
done far more superiorly.
178
Transnasal preganglionic vidian neurectomy:
In this approach the pterygopalatine fossa should

be accessed.
Anatomy of pterygopalatine fossa:
This is a small pyramidal space present behind

the posterior wall of maxilla, under the orbital
apex. The posterior wall of pterygopalatine fossa
which is formed by the medial pterygoid plate has
two important openings i.e. Foramen rotundum
situated supero laterally and the funnel shaped
opening of pterygoid canal infero medial to it.
The opening of the pterygoid canal is situated
close to the medial wall of pterygopalatine fossa.
This medial wall of the pterygo palatine fossa is Image showing vidian canal as seen in trans-sep-
formed by the perpendicular plate of palatine tal approach
bone which separates this space from the nasal
cavity.
The opening of the pterygoid canal and the
The perpendicular plate of palatine bone has two sphenopalatine foramen are situated in the same
processes, the orbital process anteriorly and sphe- horizontal plane. The pterygoid canal lies in the
noidal process posteriorly with a V shaped notch posterior wall while the sphenopalatine foramen
between them. lies in the medial wall of the pterygopalatine
fossa. These two foramen are separated by small
Since these two processes articulate above with amount of bone which forms the corner between
the body of sphenoid bone this notch gets con- the two walls.
verted into sphenopalatine foramen. It is this
foramen which is important in transnasal vidian Another important land mark that is important
neurectomy. in trans nasal vidian neurectomy is the ethmoidal
crest. This lies at the posterior end of bony attach-
ment of middle turbinate.
Just behind this crest lies the sphenopalatine fora-

men. This relation ship between the crest and the
foramen is always constant.
Note: The fleshy portion of the middle turbinate

often extends a little beyond the posterior end of

the middle turbinate.
Image showing Transverse section through right

pterygopalatine fossa showing: Endoscopic view of Ethmoidal crest
Transnasal vidian neurectomy is performed using

1. Posterior wall of maxillary antrum, 2. Pter- an operating microscope. This has been now
ygomaxillary fissure, 3. Foramen rotundum, 4. replaced with nasal endoscope. While using the
Foramen ovale, 5. Pterygoid process, 6. Sphe- operating microscope the objective should be
noid process of palatine bone, 7. Orbital pro- changed to that of 300 mm. This is a necessary
cess of palatine bone, 8. Vidian canal, 9. Sphe- step in order to ensure that the working distance
nopalatine foramen is adequate. The patient is placed supine with
head slightly elevated. The nasal mucosa and
turbinates are decongested using cotton pledgets
soaked in 4% xylocaine mixed with 1 in 10,000
adrenaline. A killians self retaining retractor is in-
serted under the middle turbinate and is opened
fracturing the middle turbinate medially. This
step is important as it provides wider access to the
middle meatus. The speculum is advanced ante-
riorly till the posterior end of the fleshy middle
turbinate is visualised. About a quarter cc of 2%
xylocaine mixed with 1 in 100,000 units adrena-
line is injected submucosally in the lateral nasal
180
wall. Endoscopic intrasphenoidal vidian neurecto-
Blanching of the area indicates adequate infiltra- my:
tion.
The preparation of patient for this procedure is
similar to that of Endoscopic sinus surgery. The
nasal cavity is decongested using a mixture of 4%
xylocaine with 1 in
10,000 adrenaline soaked pledgets.
Infiltration using 2% xylocaine mixed with 1

in 100,000 units adrenaline is performed in the
following areas:
Anterior wall of sphenoid sinus

Superior turbinates
Posterior end of middle turbinate
Step I : Lateralization of middle turbinate

This is performed under direct vision of 0 degree
4 mm nasal endoscope. This is a very important
step in this procedure. A Freer’s elevator is used
Image showing incision for endoscopic vidian for this purpose.
neurectomy
Step II : Perforation of anterior wall of sphenoid
Mucoperiosteum is incised from the lateral nasal sinus. This step is usually performed using a Fre-
wall using Rosen’s knife. The incision is a curved er’s elevator. This opening is widened inferiorly
one extending from the superior surface of infe- and laterally using Kerrison’s punch forceps.
rior turbinate in the lateral nasal wall extending The opening over the anterior face of sphenoid
up to the posterior end of middle turbinate. The sinus is widened till the vidian canal is identified.
ethmoidal crest is identified and removed expos-
ing the sphenopalatine foramen. The insulated Step III : The paper thin wall of the vidian canal is
cautery is advanced into funnel shaped opening perforated and the nerve is severed under direct
of the pterygoid canal cauterizing the nerve of vision. Bleeders if any are cauterized.
pterygoid canal. One major complication of this
surgical procedure is the development of opthal- It is mandatory to study the position of the vidian
moplegia. This is due to the probe sinking deep canal within the sphenoid sinus by doing a CT
into the pterygoid canal damaging the near by scan. If this is not done then the variations in the
abducent nerve. position of vidian canal inside the sphenoidal
sinus will create problems during surgery.

Endoscopic posterior nasal neurectomy:
In this procedure which is performed under di-

rect endoscopic vision the posterior superior and
posterior inferior nasal nerves are resected when
they come out of the sphenopalatine foramen.
The preparation is the same as for other endo-

scopic sinus surgical procedures.
Incision: A curved incision about 1.5 cms long

is made in the middle meatus from the posterior
end of superior margin of inferior turbinate to
the horizontal portion of the ground lamella of
the middle turbinate. The dissected mucoperios-
teal lining is folded back until the sphenopalatine
foramen and the superior portion of the perpen-
dicular plate of palatine bone is exposed. The
sphenopalatine artery is identified and separated Image showing Posterior superior and posterior
out of the way. The posterior superior and postero inferior nasal nerves held under the probe
inferior nasal nerves are sectioned and bleeders if
any are cauterized.
Image showing sphenopalatine artery exiting out Image showing sphenopalatine nerve
of sphenopalatine foramen
182
Complications of vidian neurectomy: sphenopalatine foramen is widened towards the
anterior face of sphenoid. The thin anterior wall
1. Dry eye due to decreased lacrimation of sphenoid sinus is penetrated using the Freer’s
2. Neurotorphic keratopathy elevator. The floor of the sphenoid sinus should
3. Ocular movement disturbances be visualized to study the course of the vidian
4. Blindness nerve.
Endoscopic vidian neurectomy: The vidian canal lies at the junction between the
floor of the sphenoid sinus and the lateral nasal
This procedure is performed under endoscopic wall. The vidian canal should not be confused
vision. Patient preparation is the same as for other with that of palatovaginal canal. Palatovaginal
endoscopic sinus surgical procedures. A curved canal which contains pharyngeal branches of the
suction tip is used to maxillary artery and pterygopalatine ganglion lies
palpate the lateral nasal wall behind the uncinate inferomedial to the vidian canal. The vidian nerve
and above the insertion of the inferior turbinate is exposed, resected and bleeders if any is coagu-
in order to identify the soft membranous portion lated.
of the posterior
fontanelle of the maxilla. On moving the suction Treatment of crocodile tears with vidian neu-
tip posterior to the posterior fontanelle, the hard rectomy:
bony anterior edge of palatine bone can be identi-
fied. A C shaped incision is made using a 15 blade This term crocodile tears was coined by Bogorad
at the junction between the posterior fontanelle to describe the unusual phenomenon of profuse
and the palatine bone. The incision starts just lacrimation which occurs during eating only. He
below the horizontal portion of the basal lamella coined this term because it was believed croco-
and ends just above the insertion of inferior tur- diles shed tears before devouring their prey. This
binate in the lateral nasal wall. condition could be a sequel to facial palsy.
Caution: The incision should not extend into the Other causes of crocodile tears include:
maxillary sinus via the posterior fontanelle.
1. Head injury
A posterior based mucoperiosteal flap is raised 2. Operative trauma
using a Freer’s elevator, exposing the palatine 3. Syphilitic lesion of geniculate ganglion
bone. During 3-4 mm of dissection the flap is
raised over the entire length of the incision. After This condition occurs due to anomalous regen-
this level the flap is raised only along the lower eration causing the secretomotor fibers from the
third of the incision i.e. just above the insertion of corda tympani nerve reaches the lacrimal gland
the inferior turbinate. This dissection is continued via the greater superficial petrosal nerve.
posteriorly till the anterior face of sphenoid sinus
is reached. Now the dissection proceeds upwards
exposing the ethmoidal crest and the underlying
sphenopalatine artery. The posterior rim of the

Is vidian neurectomy really useful?
This question is yet to be categorically answered.

In my personal experience I have performed
about 10 vidian neurectomies. Out of this num-
ber about 6 patients had questionable relief of
symptoms.
Interesting questions to be answered.
Should you perform bilateral vidian neurectomy

for significant relief of symptoms?
If performed there is a significant risk of dryness
of eye due to diminished lacrimation.
The only advantage of this procedure is that this

makes the operating surgeon more competent in
performing endoscopic skull base surgical proce-
dures.
184
Approaches to frontal sinus tomical constraints.
History of frontal sinus surgery History of frontal sinus surgery can be divided
into following era:
The first frontal sinus procedure was described in
1750. Despite more than two centuries since the 1. Era of trephination (1750)
description of the first procedure on frontal sinus,
the optimal procedure to access frontal sinus still 2. Era of radical ablation procedures (1895)
remains unclear. The frontal sinus surgery makes
up only a small portion of all surgeries involving 3. Era of conservative procedures (1905)
paranasal sinuses. Ellis in 1954 stated that “surgi-
cal treatment of chronic frontal sinusitis is diffi- 4. External fronto-ethmoidectomy (1897-1921)
cult, often unsatisfactory and sometimes disas-
trous. The sheer number of surgical techniques 5. Osteoplastic anterior wall approach (1958)
available are expressions of our uncertainty and
perhaps also our failure.” 6. Endoscopic intranasal approach
Ideal treatment for diseases involving frontal

sinus is the one that will provide complete relief Trephination Era:
of symptoms, eradicate the underlying disease
process, preserve the function of the sinus and Frontal sinus surgery was first described in the
cause the least morbidity and the least cosmetic 18th century. As early as 1750 Runge performed
deformity. an obliteration procedure of the frontal sinus. In
1870 Wells described an external and intracranial
Over the last two centuries a variety of surgical drainage procedure for frontal sinus mucocele. In
procedures have been described for the treatment 1884, Alexander Ogston described a trephination
of frontal sinus disease. These procedures includ- procedure through the anterior table to evacuate
ed external and intranasal approaches. Despite the frontal sinus. He also dilated the nasal frontal
the fact that over the years the incidence of com- duct, curetted the mucosa and established drain-
plications have decreased, orbital and intracranial age with a tube that was placed in the duct. At
complications, including meningitis, subdural the same time Luc described a similar procedure,
abscess, intra-cerebral abscess and osteomyelitis and two years later the Ogston-Luc procedure
continue to occur. did not gain popularity because of the high failure
rate due to nasal frontal duct stenosis.
Osteoplastic flap has been the mainstay of surgi- Radical ablation procedures (1895)
cal access to the frontal sinus. With advances in
the field of imaging and endoscopy, a new fron- During this era a number of physicians were
tier (intranasal approach) has become popular. advocating a radical procedure to clear frontal
Assessing the frontal sinus is a greater surgical sinus disease. In 1895 Kuhnt described a proce-
challenge than other sinuses owing to the ana- dure where in he removed the anterior wall of the

frontal sinus in an attempt to clear the disease. and ventilation of the frontal sinus. Numerous
The mucosa was stripped to the level of frontal re- complications were encountered which includ-
cess and a stent was placed for temporary drained intracranial penetration. Between 1901 and
age. In 1898 Riedel described the first procedure 1908, Ingals, Halle, Good, and Wells described
for obliteration of frontal sinus which involved several intranasal procedures to the frontal sinus.
complete removal of anterior table of frontal sinus Halle described a procedure in which the frontal
with mucosal stripping. This procedure had the process of maxilla was chiseled out and a burr
advantage of removing osteomyelitic bone as well was used to remove the floor of the frontal sinus.
as allowing for easy detection of recurrent dis- This surgery was rarely used because of its associ-
ease. This procedure caused unsightly deformity ated high mortality rate. The increased incidence
of forehead. In 1903 Killian described a modifi- of mortality and complications was the result of
cation of the Riedel procedure. In an attempt to inadequate visualization of the frontal recess.
minimize the cosmetic deformity he recommend-
ed preserving a one centimeter bar of the supra- In 1914 Lothrop described a procedure to enlarge
orbital rim. He also recommended an ethmoid- the frontal sinus pathway in a way that could
ectomy with rotation of a mucosal flap into the prevent restenosis as well as closure. The proce-
frontal recess with stenting to prevent stenosis. dure described a combined intranasal ethmoid-
Killian’s technique became popular during this ectomy and an external ethmoid approach to
era because it of the reduced incidence of cosmet- create a common frontal nasal communication by
ic deformity. This technique became unpopular resecting the frontal sinus floor and frontal sinus
later because of the high incidence of late morbid- septum and the superior portion of nasal septum.
ity with restenosis, supraorbital rim necrosis, post Lothrop admitted that due to lack of visualization
operative meningitis, and mucocele formation as during intranasal approach made the procedure
well as death. rather dangerous. Follow up of these patients
demonstrated that resection of the medial orbital
Conservative procedures (1905) wall allowed the collapse of orbital soft tissue into
the ethmoid area with subsequent stenosis of the
Since there is significant cosmetic deformity as frontal drainage pathway.
well as high failure rate external ablative pro-
cedures became rather uncommon and were Frontal sinus trephining
abandoned in favor of intranasal conservative
approaches and external frontoethmoidal tech- Definition:
niques. In 1908 Knapp described an ethmoid-
ectomy through the medial wall and entering Trephination of frontal sinus is a surgical pro-
the frontal sinus through its floor. He managed cedure where in a small opening is made in the
to remove diseased mucosa and enlarged the floor of frontal sinus facilitating drainage of its
naso-frontal duct. This surgery however did not contents.
receive wide attention.
History: Trephination of frontal sinus is nothing
In 1911, Schaeffer proposed an intranasal punc- new. It dates back to prehistoric times. Two Peru-
ture technique to re-establish the drainage vian skulls at the Museum of Man in San Diego
186
show evidence of frontal trephination.
Indications of frontal sinus trephining:
1. Acute sinusitis not responding to medical man-

agement
2. Can be used to identify frontal sinus opening

inside the nasal cavity during endoscopic sinus
surgery
3. To prevent stenosis of the frontal sinus infun-

dibulum after endoscopic sinus surgery
Procedure:
Before the actual procedure the size of the frontal

sinus must be assessed by taking a occipito frontal
plain radiograph. This view will actually demon- Image showing a Trephining kit
strate the size of frontal sinus. This procedure is a
must as it will help in deciding where to place the
opening.
Anesthesia:
This procedure can be carried out under both lo-

cal or general anesthesia. Commonly local anes-
thesia is preferred as it provides a relatively blood
less field.
2% xylocaine admixed with 1 in 10,0000 units

adrenaline is used as infiltrating agent. This mix-
ture has the advantage of providing anesthesia
as well as local vasoconstriction of blood vessels.
About 1/2 ml of this solution is infiltrated over
the trochlear nerve area (skin over the antero in-
ferior part of forehead). 10 minutes is given after
the injection for the drug to take effect.
Image showing the site of trephination

The point of trephenation is located as shown . Slow irrigation of the cavity
in the figure above. A horizontal line is drawn
between the superior limit of each orbit. Another Most of the complications following frontal
vertical line is drawn to intersect this horizontal trephination results from unfavorable anatomical
line exactly in the midline. The point of perfora- conditions. To avoid serious complications treph-
tion is located about 1 cm lateral to this midline. ination should not be performed if the pneuma-
This depends on the size of the sinus and the tization of the frontal sinus does not reach the
location of the inter-sinus septum. superior limit of the orbit. In these condition
trephination is not of much help since the fron-
No incision is necessary. A small puncture is tal sinus itself is pretty rudimentary and can be
made at this site using a hand drill. After perfo- accessed intra nasally using an endoscope.
rating the skin, the drill bit comes into contact
with the bone. Bone in this area is drilled out. 1. Brain injury
Hand drill is preferred since the power drills
reduce the sensitivity of the surgeon who is drill- 2. Cellulitis
ing making him loose control. Once the bone is
penetrated a needle made of teflon is put in place. 3. Orbital complications due to needle shift (com-
A small catheter can be connected to this needle mon in home environment)
and wash can be given using a syringe. Before
starting the irrigation procedure it must be ascer- Endoscopic frontal sinus surgery
tained whether the teflon needle is really inside
the frontal sinus. This can be done by visualising This surgery is commonly performed to drain
air bubbles when the syringe filled with saline is the obstructed frontal sinus. This surgery is
connected to the catheter. Initially irrigation is performed under general anesthesia. Cotton
done slowly under endoscopic control. pledgets soaked in 4% xylocaine with 1 in 1 lakh
units adrenaline is placed under superior, middle
Complications: and inferior meatus and allowed to be in place for
about 10 minutes before intubation. The patient
Complications can be avoided by following the is positioned with 20-30 degree elevation and
guidelines given below: gentle extension of the head. Nasal endoscopy is
performed using 30 degrees, 45 degrees and 70
Guidelines for safe frontal irrigation: degrees nasal endoscope.
. Radiographic evaluation of the size of frontal Steps of the surgery include:

sinus cavity
Uncinectomy
. Meticulous location of the site of trephination
Anterior ethmoidectomy
. Control with aspiration of a good needle posi-
tion before irrigation Complete frontoethmoidectomy
188
It represents superior and lateral pneumatization
Resection of agger nasi and anterosuperior of the anterior ethmoidal cell. This accounts for
attachment of the middle turbinate is needed the significant variation in frontal sinus anato-
to create a widely patent frontal recess. Ostium my. These include variations such as agger nasi
probe / ball probe is used to locate the outflow cell penumatization, prominent ethmoidal bullae
tract. The nasofrontal beak which is shelf like and supraorbital cells. Ethmoidal air cells may
bony process anterior to the frontal outflow tract be contained wholly within the frontal recess /
can be removed using a Kerrison rongeur / drill / frontal sinus and are termed frontal cells.
curette.
Bent’s classification of accessory frontal cells:
Further drainage would require removal of the
superior aspect of the nasal septum, this is need- The classification proposed by Bent grouped
ed if a bilateral frontal sinus drill out is desired. these cells into four different types based on their
In order to allow re-epithelialization, the surgeon location.
must not remove the posterior table mucosa.
Mucosal preservation is of utmost importance in Type I: This type represents a single frontal cell
routine, uncomplicated frontal sinus surgery. just above the agger nasi cell
A frontal sinus stent can be used in more compli- Type II: This type consists of a tier of two or more
cated cases where mucosal preservation may be air cells superior to the agger nasi cell.
difficult and typically when the neo-ostium is less
than 5 mm in diameter. Type III: This type has a single frontal cell which
is massive and it pneumatizes superiorly into the
FESS can also be used with trephination in the frontal sinus
presence of thick secretions, high frontal cells
within the sinus, and lateralized frontal sinus Type IV: These cells are contained entirely within
disease. Extended drainage of the sinus can be the frontal sinus, thus giving it a cell inside a cell
achieved by means of resection of the frontal appearance.
sinus floor.
Among these types III and IV are considered to
be invasive types.
Draf procedures Supraorbital cells: These cell pneumatize the

orbital plate of the frontal bone posterior to
Frontal sinus anatomy is highly variable. This in- the frontal recess and lateral to the frontal si-
cludes variation of the pneumatization within the nus. These cells appear to extend over the orbit,
frontal sinus itself and of the surrounding ante- appearing as the lateral cell in a coronal CT scan.
rior ethmoid cells. These variations have been de- Endoscopically these cells appear as separate ostia
scribed as causes of frontal sinus obstruction and present along the anterolateral aspect of the roof
resultant frontal sinus disease. Embryologically of the ethmoid. These cells lie postero lateral to
frontal sinus is the last paranasal sinus to develop. the frontal sinus ostia and anterior to the anterior

ethmoidal artery.
Failure of medical therapy warrants CT imag-
Intersinus septal cell: is a midline cell that pneu- ing and evaluation for surgery. One important
matizes the frontal bone between the two frontal aspect when considering indications for frontal
sinuses. sinus surgery is selecting the appropriate proce-
dure. Majority of primary surgical procedures
for chronic rhinosinusitis can be addressed by
a limited endoscopic sinusotomy which include
Draf 1 or 2A procedure. More challenging would
be identification of indications for an extended
endoscopic approach. Neo-osteogenesis and lat-
eralized middle turbinate are also potential indi-
cations for extended approaches. This condition
is the most common indication for an extended
endoscopic approach. Presence of a mucocele
may also necessitate an extended endoscopic
approach.
Anomalous frontal sinus anatomy including type

III and IV frontal cells can also be an indication
for extended approaches.
Narrow anterior-posterior dimension at the naso-

frontal beak could be a relative contraindication
for these extended approaches.
Image showing type II frontal cell
Indications for surgery Draf 1 procedure
1. Chronic frontal sinusitis Endoscopic approaches to frontal sinus is consid-

ered to be the accepted one. These approaches
2. CSF leak have been found to be effective in a diversity of
pathology, including laterally based lesions. The
3. Benign and malignant tumors of frontal sinuses classification system used to classify different
frontal sinus surgical approaches was described
Surgery should typically follow maximal medical by Draf in 1991. Other procedures like frontal
therapy. sinus rescue procedure as well as frontal balloon
catheter dilatation have also been described re-
Maximal medical therapy should include intrana- cently.
sal steroids, saline irrigations, oral antibiotics and
oral steroids. In Draf 1 procedure the frontal recess and infun-
190
dibulum are cleared first. This procedure involves
removing the superior portion of the uncinate Draf 2 Procedure
process, the anterior ethmoid cells and cells with-
in the frontal recess. Agger nasi cell is preserved Draf 2A and 2B procedures differ from Draf 1
in Draf 1 procedure. In this procedure the nar- procedure in that all cells within the frontal sinus
rowest part of the frontal recess is not manipulat- are cleared with direct opening of the internal
ed, structures inferior to the internal frontal sinus frontal sinus ostium. In Draf 2A procedure all
ostium are cleared. cells within the frontal recess lateral to the middle
turbinate attachment are opened in addition to
the structures cleared in Draf 1 procedure. A large
number of primary cases and many revision cases
as well can be addressed by Draf 2 technique.
Image showing Draf type I drainage procedure.

Image showing Draf type 2 a drainage procedure
1. Nasal septum
Draf 2B procedure involves extension of Draf 2A
2. Middle turbinate procedure to include the entire ipsilateral floor of
the frontal sinus. This includes removal of middle
3. Medial orbital wall turbinate attachment to the frontal sinus floor ex-
tending the dissection in a medial direction, with
4. Intersinus septum the nasal septum and intersinus septum being
the medial extent of dissection. This procedure is
considered more aggressive and potentially risky
due to dissection adjacent to the cribriform plate
and the potential for destabilization of the middle
turbinate.

Image showing Draf type 2b drainage procedure
Draf 3 procedure creates a single common drain-

age pathway for bilateral frontal sinuses. Frontal
sinus drill out and Endoscopic modified Lothrop
procedures are synonyms for the same procedure.
This procedure involves clearing of all structures
as done for Draf 2B plus the removal of the in-
tersinus septum and superior nasal septum. This Image showing upper end of uncinate process
procedure mandates the use of an angulated drill being removed
to ensure adequate removal of bone at the ante-
rior aspect of the common frontal neo-ostium.
The decision to proceed to extended endoscopic
frontal sinus procedures, including the Draf 2 B
and 3 procedures, is typically the result of severe
disease within the nasofrontal duct. This includes
neo-osteogenesis, osteitis and mucosal stenosis.
Anatomical considerations, including the pres-
ence of a lateralized middle turbinate / a promi-
nent nasofrontal beak can also influence the de-
cision to proceed with Draf 2 B and 3 procedures.
Draf 3 procedure could be an useful alternative
to external approaches for those situations like
difficult and recalcitrant frontal sinus disease.
Image showing agger nasi being deroofed
192
Image showing agger nasi air cell after deroofing Image showing the deroofed agger nasi and the
frontal outflow tract that lies medial to it. The
lateral wall of agger nasi should be removed to
clear the area
Image showing ball probe introduced into frontal

recess area
Image showing discharge flowing out of frontal
sinus

Image showing thick tenacious secretion flowing
out of frontal sinus Image showing frontal sinus as seen via widened
frontal sinus ostium.
Image showing suction tip inside frontal sinus

opening
Image showing the end result of Draf 3 procedure
194
scans)
Frontal sinus rescue
5. 65 degrees mushroom punch is useful in fron-
This procedure was first described by Citardi in tal recess dissection
1997. This was considered to be an alternative to
Draf 3 procedure / external frontal sinus oblit- 6. Hosemann punch which is an angulated mush-
eration in certain situations. This procedure is room punch with greater cutting strength is use-
intended to correct iatrogenic scarring of the ful for clearing osteitic bone from frontal recess.
frontal ostium making the sinus safe by prevent-
ing mucocele formation. The technique of this 7. Bachert / cobra forceps can be used to clear
procedure involves transposing a laterally based agger nasi and frontal recess cells
mucosal flap from the middle turbinate rem-
nant on to the medial skull base. A longitudinal 8. Powered instrumentation with angled drills is
incision is made in the middle turbinate remnant typically used when performing extended endo-
and lateral mucosal flaps are raised. The medial scopic approaches like that of Draf 3 procedure.
flap is resected along with the continuous mu-
cosa on the anterior skull base. The bony middle
turbinate remnant is then resected. The lateral
flap is then turned into the area of the previously
resected mucosa along the anterior skull base.
This procedure has the advantage of changing
the circumferential scar of the frontal duct into a
geometrical pattern for prevention of recurrent
scar formation.
One common element in various endoscop-

ic frontal sinus surgeries is the preservation of
mucosa within the nasofrontal duct in order to
prevent postoperative stenosis.
Image showing 45 degree mushroom punch
Scientific advances that play an important role in
the development of modern frontal sinus surgery:
1. Advances in optics and rod lens system
2. Instrumentation enabling image guided sur-

gery
3. High quality angled endoscopes
4. Advances in CT imaging (enabling thin section

(0.5mg/2ml) can be added to saline irrigations.
Oral regimens of postoperative prednisolone
(0.1mg/kg) and antibiotics are sometimes recom-
mended for several days postoperatively.
Debridement is an essential part of complete

postoperative care. Patients are seen 1 week post-
operatively for the first debridement under topical
anesthesia. The frontal recess area is suctioned
free of mucous / clot / crusting / bone fragments.
Crusts can be removed with forceps. Care is
taken not to cause excessive mucosal bleeding. If
purulence is encountered during postoperative
debridement, cultures can be taken and culture
specific antibiotics can be prescribed. It takes
approximately 12 weeks for the frontal recess area
to be fully healed.
Image showing Cobra forceps in action
Complications
Stenting of frontal sinus could be useful in pre- 1. Injury to periorbit

serving the results of surgical dilatation of frontal
sinus. A completed operation without stenting 2. Dural injury
resulted in complete obstruction of the duct. Cur-
rently silicone sheeting can be cut to shape and 3. Smell disturbance post operatively
inserted endoscopically to promote mucosaliza-
tion and patency following extended frontal sinus Endoscope assisted external approach to clear
surgeries. These stents can easily be removed in lateral lesions of frontal sinus
the outpatient setting after several weeks post
operatively. Surgery involving the frontal recess area and
frontal sinus still remains a challenge due to their
Post operative care complex and variable anatomy. Hence selection
of an appropriate approach depending upon
This is vital in preserving surgical results. Typ- the nature and site of the pathology is of utmost
ically they include topical irrigations as well as importance. Most of the lesions in ethmoids and
possible oral medications. Saline irrigations are sphenoid can be repaired endoscopically, but
begun on post operative day 1 and performed 3 the same is not true for lesions involving frontal
times daily for the first week. It can be decreased sinuses.
to once a day for another 6-12 weeks. If aller-
gic fungal sinusitis / substantial nasal polyposis Before the advent of endoscopic surgical proce-
is present, topical steroid such as budesonide dures, external techniques like frontoethmoidec-
196
tomy, osteoplastic flap with obliteration of frontal
sinus could be used to treat lesions of frontal 4. Complicated acute frontal sinusitis
sinus.
5. Pott’s puffy tumor
Patients with pathology in frontal sinus whose le-
sions are inaccessible with endoscope by endona- 6. Lateral frontal sinus mucocele
sal approach alone should be considered for this
approach. Preoperative evaluation which include 7. Repair of frontal sinus CSF leak
CT and MRI should be performed to ascertain
the suitability of the procedure. 8. Removal of osteoma
Procedure 9. Frontal sinus obliteration
A mini brow incision is made lateral to the su- Classic frontoethmoidectomy involves removing
praorbital foramen. Periosteum is incised and the lamina papyracea, opening and stripping the
the underlying bone is exposed. In case of CSF mucosa from the ethmoid sinuses up to cribri-
leak from the posterior table of the frontal sinus form plate, nibbling away the lateral wall of the
a bony window is made with 4 mm cutting burr frontonasal duct and floor of frontal sinus and
in the anterior wall of frontal sinus which can be stripping the mucosa from the frontal sinus.
enlarged as per requirement. Maximum width
of the window should not exceed 10 mm. The The classic external frontoethmoidectomy howev-
endoscope is inserted through the brow incision er is contrary to modern principles of endoscopic
and the interior of frontal sinus is examined. This sinus surgery which include:
window can be used to secure access to the fron-
tal sinus cavity. 1. Limiting surgery to diseased sinuses
External frontoethmoidectomy 2. Mucosal sparing
External approaches to frontal and ethmoid 3. Avoiding surgery to the frontal recess and fron-
sinuses are rarely used these days. This procedure tonasal duct
is performed only in centers in the developing
world where endoscopic sinus surgery expertise 4. Preserving middle turbinate
and instrumentation are not available.
5. Limiting resection of lamina papyracea to avoid
Indications for open approaches: medial prolapse of orbital soft tissues
1. Drainage of orbital abscess
2. Ethmoid artery ligation for intractable epistaxis
3. Biopsy of tumors

comes effectively obliterated by prolapsing perior-
Sewall-Boyden flap usage in external frontal bita. Stenting can delay, but will not prevent this
sinusotomy settling from occurring. This delay of course can
promote mucosalization of the area which may be
adequate for patency. This of course is not reli-
able.
Traditional external frontoethmoidectomy ap-
proaches have fallen out of favor because of The area of nasofrontal duct should be widened
unpredictable rates of frontal recess stenosis. This to ensure success and it should be performed by
is caused by the lack of mucosal preservation in removal of thick bone of the nasal process of the
the critical area of frontal recess. Sewall-Boyden frontal bone, frontal process of the maxilla and
flap is a modified external technique that creates the lateral half of nasal bone. The mucoperiosteal
mucosal coverage of the frontal recess area via a flap can then redrape itself easily into the sinus
medially based mucoperiosteal flap which yields without causing obstruction to the duct. The flap
a high degree of long term frontal sinus patency. itself comes from the anterior mucoperiosteum
Sewall-Boyden flap is a modified external tech- underlying the nasal bone and ascending process
nique that creates mucosal coverage of the frontal of maxilla. Based on the upper anterior septum,
recess via a medially based mucoperiosteal flap its axis of rotation is anterior to the original na-
which yields a high degree of long term frontal sofrontal duct. The bone of the nasal process of
sinus patency. This procedure can easily be per- the frontal bone and ascending process of maxilla
formed unilaterally with minimal morbidity. are therefore in the way of this axis and must be
removed in an anterior direction to allow the flap
Surgical technique to rotate smoothly and lie flush against the medial
frontal sinus. This step if performed diligently,
The success of this procedure is based on two the new duct is wide enough and the flap is of
concepts: sufficient length to lie comfortably in position
without a stent.
1. Creation of a wide new nasofrontal duct by
adequate bone removal. Surgical steps:
2. Lining of nasofrontal duct with a broad, septal- Step 1:

ly based mucoperiosteal flap.
Anterior external ethmoidectomy is first per-
Both these concepts are of equal importance. The formed. The extent of ethmoidectomy is deter-
problem is that the space for a new nasofrontal mined by the degree of the disease present and
duct cannot be obtained in a lateral direction the surgeon’s belief. The periorbita should be
despite the removal of a large amount of bone in elevated superiorly up the level of the supraorbital
the ethmoid region and the floor of the frontal notch to provide adequate exposure to the floor of
sinus. This is because the periorbita settles back the frontal sinus. This step involves detachment
medially and superiorly to its original position. of trochlea with the periorbita. It subsequently
The extra space created by drilling laterally be- returns to its original preop position. There have
198
not been any problems with persistent diplopia
as a result of this. Soft tissues over the nose on
the medial edge of the incision are elevated to the
midline of the nasal dorsum and caudally to the
end of the ipsilateral nasal bone, thereby exposing
the entire ipsilateral nasal bone.
Step 2:
The ethmoid sinuses are entered through the lac-

rimal fossa and exenterated posteriorly from this
location. The bone of the frontal process of the
maxilla and anterior lacrimal crest are left undis-
turbed at this point. Every effort should be made
to remove all bony septa and the lamina papyra-
cea to the level of the roof of the ethmoid sinuses.
Working forward along the roof of the ethmoid
sinuses frontal sinus can be entered. Its floor is
removed as far laterally as the supraorbital notch
and as far anteriorly as the supraorbital rim.
Kerrison rongeurs are useful for this purpose. All
abnormal mucosa is removed and the location of
the intersinus septum is noted. A minimum of Image showing bone removal in Sewall-Boyden
the anterior half of the middle turbinate is re- procedure
moved and its attachment is trimmed completely.
After injecting a suitable hemostatic solution like Step 3
1 in 100,000 adrenaline a cottle elevator is used to
develop a plane between the nasal bone and the The elevated mucoperiosteum is carefully pro-
underlying mucoperiosteum, beginning at the tected while using Kerrison rongeurs to remove
junction of the nasal bone and the upper lateral the lateral half of the nasal bone and the frontal
cartilage. This plane extends laterally underneath process of the maxilla working from inferior
the frontal process of the maxilla to connect with to superior. With increased exposure provided
the ethmoidectomy defect. The upper lateral by this bone removal, the mucoperiosteum is
cartilage is detached by necessity from the lateral carefully elevated off the roof of the nose at its
half of the nasal bone but remains attached me- attachment with the upper septum. The mucosa
dially and to the septum, thus retaining its posi- is protected with an elevator, while the triangle of
tion and the relationships of the nasal valve. The thick bone of the nasal process of the frontal bone
removal of the lateral half of the nasal bone has is removed to make it flush with the nasal septum.
not caused any external deformity. This maneuver will completely reveal the origi-
nal nasofrontal recess, which is often filled with
polypoidal mucosa. This mucosa, as well as the

mucosa of the medial sinus where the flap will lie
is removed. A scalpel is used to incise the muco-
periosteum distally at its junction with the upper
lateral cartilage. The incision is continued lateral-
ly to connect with the ethmoidectomy defect.
Step 4
Working cephalad along the edge of the remain-

ing nasal bone, a flap is cut sufficiently medially
to allow it to rotate comfortably and lie on the
medial half of the reconstructed nasofrontal duct.
The pedicle must be kept broad enough to main- Image showing the effects of Sewall-Boyden sur-
tain its blood supply. The flap should be trimmed gery. The first picture is preop and the next one
if it is too long to fit in the frontal sinus along the is post op.
intersinus septum or it its distal portion contains
polypoid degenerative mucosal changes.
The need for nasal packing is determined by the

amount of bleeding present and the preference
of the surgeon. If packing is resorted to it must
be ensured that it should not extend up into the
frontal sinus to lay up against the flap as it could
dislodge the flap.
Post op care involves saline irrigation, usually

beginning on the second or third post op day.
Frequent crust removal in the out patient set-
ting is recommended to prevent development of
synechiae.
200
Endoscopic frontal sinus surgery (Agger nasi
approach)
The introduction of endoscopic sinus surgery

techniques allowed re-establishment of venti-
lation and drainage function of the paranasal
sinuses. Conventional endoscopic frontal sinus
surgery is able to deal with a majority of chronic
frontal sinusitis. Recurrent / persistent frontal
sinus disease caused by scarring / stenosis could
be really challenging for the surgeon.
Procedure
I Image
Endoscopic frontal sinus surgery is performed
under general anesthesia. Patient is positioned Image showing the incision over the agger nasi
supine in the operating table with the head slight- area
ly lowered. The operative procedure is usually
performed using image guidance using a wide
angled 0 degree nasal endoscope. Incision is
positioned over the agger mucosa. The mucosa is
separated to expose the bony surface of the fron-
tomaxillary process and attachment of the middle
turbinate. The bone of frontomaxillary process is
drilled directly upward between the orbital plate
of the ethmoid bone and attachment of the mid-
dle turbinate. The bone of frontomaxillary pro-
cess is directly drilled out upwards between the
orbital plate of ethmoid bone and attachment of
middle turbinate using angled diamond burrs and
then the anterior upper attachment of uncinate
process and agger cells should be fully visualized.
After removal of fragile partitions of uncinate
process, frontal recess, agger cells are removed
with curettes or fine forceps under direct visual- Image showing opening being created in the floor
ization the floor of frontal sinus is identified and of the frontal sinus under endoscopic vision.
resected using an angled diamond burr to create
a more than 6 mm frontal drainage pathway. En-
doscopic management of ethmoid, maxillary and
sphenoid sinus is performed as needed.

Diagnostic Nasal Endoscopy
Synonyms: DNE, Nasal endoscopy, Diagnostic

nasal endoscopy.
Introduction:
Examination of nose has been revolutionized by

the advent of nasal endoscopes. These endoscopes
are nothing but miniature telescope. It comes in
the following sizes 2.7mm, and 4mm. It comes in
various angulations namely 0 degrees, 30 degrees,
45 degrees, and 70 degrees. The 2.7 mm endo-
scope is used for diagnostic nasal endoscopy and
in children. For diagnostic nasal endoscopy it is
Image showing frontal sinus opening (blue ar- better to use a 2.7 mm 30 degree nasal endoscope
row) if available. A 4mm 30 degree nasal endoscope
can also be used for diagnostic nasal endoscopy
in adults.
Indications of diagnostic nasal endoscopy:
1. To evaluate why a patient is not responding to

medication.
2. To determine whether surgical management is
necessary.
3. To examine the results of sinus surgery
4. To determine the effects of conditions such as
severe allergies, immune deficiencies and mu-
cociliary disorders (disorders that affect mucous
membranes and cilia)
5. To determine whether a nasal obstruction (e.g.,
polyps, tumor) is present in the nasal cavity
6. To determine whether any foreign bodies (e.g.,
small object inserted by a child) are lodged in the
nasal cavity
7. To remove a nasal obstruction or foreign mate-
rial from the nasal cavity
202
8. To determine whether an infection has moved patient to swallow. The endoscope is now turned
beyond the sinuses 90 degrees in the opposite direction, the uvula
9. To diagnose chronic recurrent sinusitis in chil- and soft palate comes into view. The endoscope is
dren with asthma again rotated by 90 degrees in the same direction,
10. To diagnose reason for anosmia (loss of the opposite side pharyngeal end of eustachean
smell). tube is visualised. In this field both eustachean
11. To evaluate any discharges from the nasal tubes become visible.
cavities like CSF.
12. To diagnose reason for facial pain / headaches. Second pass:
Procedure: Topical anesthetic 4% xylocaine is
used to anesthetise the nasal cavity before the After the first pass is over, the scope is gently
procedure. About 7 ml of 4% xylocaine is mixed withdrawn out and slide medial to the middle
with 10 drops of xylometazoline. Cotton pledgets turbinate. The relation ship between the mid-
are dipped in the solution, squeezed dry and used dle turbinate and nasal septum is studied. This
to pack the nasal cavity. Pledgets are packed in relationship is classified as TS1, TS2, and TS3.
the inferior, middle and superior meati. Packs are It depends on whether, after application of de-
left in place for full 5 minutes. Diagnostic endos- congestant both the medial and lateral surfaces
copy is performed using a 30 degree nasal endo- of the middle turbinate is visible (TS1), part of
scope. If 2.7 mm scope is available it is preferred the middle turbinate is obscured by septal devi-
because it can reach the smallest crevices of the ation (TS2), or the septal deviation is completely
nose. 4mm endoscope is sufficient to examine obscures the middle turbinate (TS3). The scope is
adult nasal cavities. gently slipped medial to the middle turbinate. The
sphenoid ostium comes into view. Secretions if
The process of examination can be divided into any from the ostium is noted.
three passes:
Third pass:
1. First pass / inferior pass
2. Second pass Is the most important of all the three passes. This
3. Third pass. pass studies the crucial middle turbinate area.
The middle turbinate is evaluated for its shape
First pass: and size as well as its relationship to the lateral
nasal wall and septum. A bulge just above and
In this the endoscope is introduced along the anterior to the attachment of the middle turbinate
floor of the nasal cavity. Middle turbinate is the suggests an enlarged agger nasi cells. Sometimes
first structure to come into view. Its superior the anterior tip of the middle turbinate may be
attachment is studied. Inferior surface of the mid- triangular. This shape has no significance unless
dle turbinate is studied. As the endoscope is slid it causes obstruction to the middle meatus. A
posteriorly the adenoid tissue comes into view. middle turbinate that is concave medially rather
On the lateral surface of the nasopharynx the than laterally is considered paradoxical. But par-
pharyngeal end of eustachean tube can be iden- adoxical turbinate which is symptomatic needs
tified. Its function can be assessed by asking the to be treated. If the middle turbinate is enlarged

due to the presence of a large air cell inside the
middle turbinate it is known as concha bullosa.
The middle turbinate is gently medialised using
its plasticity. The middle meatus comes into view.
The attachment of the uncinate process is care-
fully noted. Discharge if any from this area is also
recorded. If accessory ostium is present it comes
into view now. Accessory ostium is present more
posteriorly. Normal ostium is actually not visible
during diagnostic nasal endoscopy. Accessory
ostium is spherical in shape and oriented antero-
posteriorly, while the natural ostium of maxillary
sinus is oval in shape and oriented transversely.
Image showing endoscopic view of uncinate

process
Image showing inferior surface of inferior turbi-

nate (endoscopic view)
Image showing endoscopic view of maxillary

sinus ostium
204
Image showing sphenoid ostium

transversely over the skull to the opposite side.
Bicoronal approach to frontal sinus This can be curved slightly forwards at the skull
following but posterior to the hairline. The inci-
Brief Surgical Anatomy sion is often extended preauricularly to provide
access to the zygomatic arches.
The layers of the scalp include from superficial to
deep: skin, subcutaneous tissue, galea or fronta- Initially, the incision is made deep to sub-apo-
lis muscle, subgaleal fascia, and the periosteum. neurotic areolar tissue and the flap is raised along
Over the temporalis muscle, the layers of soft this plane, leaving the periosteum intact. Rarely
tissue are more complicated. Above the temporal clips are applied to the edges of the flap to aid in
line of fusion, which is at the level of the superior hemostasis. The periosteum is incised about 3 cm
orbital rim the layers include: skin, subcutaneous above the supraorbital rim and then the dissec-
tissue, temporoparietal fascia (facial nerve, and tion is carried out subperiosteally. This can be
the superficial temporal artery run in this layer), carried out until the nasoethmoid, nasofrontal
deep temporal fascia, temporalis muscle, and and fronto-zygomatic region are exposed. The
periosteum. Below the temporal line of fusion the supraorbital neurovascular bundle is freed from
layers include: skin, subcutaneous tissue, tem- the foramen by cutting them at the lower edge of
poroparietal fascia, superficial layer of the deep the foramen.
temporal fascia, temporal fat pad (middle tempo-
ral artery runs in this pad), deep layer of the deep The lateral and temporal dissection follows the
temporal fascia, temporalis muscle, periosteum. outer surface of temporal fascia up-to approx-
For males, the emphasis appropriately focuses on imately 2 cm above the zygomatic arch. At the
the status of the hairline. In some cases of mild point where the temporal fascia splits into two
male pattern baldness, the incision may be placed layers, an incision running at 45˚ upwards and
posteriorly to hide it in the remaining hair. The forward is made through the superficial layer of
patient should be aware that the incision may temporal fascia. This incision is connected ante-
become visible if hairline recession continues. It riorly with the lateral or posterior limb of supra-
must be ensured that the planned incision will orbital periosteal incision. Because the frontal
afford adequate exposure for the planned proce- branch of facial nerve courses obliquely 1.5 cms
dure. lateral to the eyebrow and not more than 2 cms
above the brow, the connection between the
Bicoronal Incision: fascia and the periosteal incisions should be at
least 2 cms lateral and 3 cms above the eyebrow.
It is an ideal incision for approach to upper one- The posterior extension of the temporal incision
third of facial skeleton and the anterior cranium. of the fascia is extended to cartilaginous auditory
This extends from one temporal region to the canal.
other and involves a major part of the scalp. For
this incision, it is recommended to shave the hair Once a plane of dissection is established deep to
for only a strip of 3-4 cms where the incision the superficial layer of temporal fascia, the dissec-
is to be made. The incision begins at the upper tion is continued inferiorly until the periosteum
attachment of the helix on one side and extended of the zygomatic arch is reached. The periosteum
206
is incised and the zygoma, frontal bone, superior
and lateral orbital margins, nasal bone and part Disadvantages
of parietal and temporal bone are exposed. When
hemicoronal incision is planned, this incision will a) Loss of hair due to injury to hair follicle in the
be stopped just short of midline. incision line
b) Poor scar in case of male type baldness
c) Inadequate access to middle third of facial
skeleton
d)Excessive haemorrhage
e) Potential for damage of temporal branch of
facial nerve resulting in weakness of frontalis
muscle.
f) Post-operative hematoma due to wide dissec-
tion of scalp
g) Sensory disturbance, anaesthesia or paresthesia
affecting supraorbital and preauricular region.
h) Trismus, ptosis and epiphora are also reported.
Various methods for hemostasis of bicoronal

incisions are
a) Use of surgical clips

b) Cautery
c) Injection of lidocaine with epinephrine
Image showing Bicoronal incision
Advantages
Maximum exposure of upper one-third of facial

skeleton and fronto-parietal region of cranium is
exposed by this incision.
This helps in management of
a) Extensive craniofacial trauma

b) Correction of craniofacial deformities
c) Single incision allows management of facial
trauma and concomitant craniotomy if indicated
d) Good cosmetic result
e) Avoids injury to facial structures Image showing intraop picture of bicoronal flap
f) Allows harvest and placement of cranial bone
grafts

The Bicoronal flap is a well-recognized technique
for accessing mid facial region. Although the
procedure seems to be extensive, it has very less
morbidity compared to other procedures to gain
access to entire mid facial region. We have at-
tempted this article to review the indication, mer-
its and probable complications of this approach
with a brief description about anatomy and the
technique as such.
208
cells
FESS
Aim of FESS:
Introduction:
1. Disease clearance
FESS is the acronym for Functional Endoscopic
Sinus Surgery. This procedure has revolutionized 2. Improvement of drainage
the management of sinus infections to such an
extent the hitherto commonly performed antral Instruments:
lavage has been relegated to history.
1. Nasal endoscope
Middle meatus area: This is a crucial area for the
drainage of anterior group of sinuses. Any pa- 2. Camera (endo)
thology in this area could effectively compromise
this rather critical drainage process. The success 3. Monitor
of FESS depends on how effectively this area is
cleared. 4. Surgical instruments
Stamberger’s hypothesis: Procedure: Could be performed both under local

/ G.A.
Stamberger proved that drainage from the maxil-
lary sinuses always occurred through the natural 1. Uncinectomy
ostium. He also demonstrated that the cilia of the
epithelium covering the maxillary sinus cavity 2. Bullectomy
always beat towards the natural ostium propelling
the mucous and secretions through the ostium. 3. Identification of natural ostium
He also demonstrated that a more dependent
inferior meatal antral opening had no role in this 4. Widening the natural ostium
clearance because the cilia always pushed the se-
cretions towards the natural ostium. So he found
there is no logic in performing inferior meatal Uncinectomy:
antrostomy to clear the pent up secretions.
This is the first step in all endoscopic sinus sur-
Pathology affecting middle meatus: gery. Endoscopic sinus surgery is usually per-
formed under Hypotensive general anesthesia.
1. Gross deviated nasal septum Prior to administration of anesthesia the nasal
cavity is packed with cotton pledgets dipped in a
2. Concha bullosa of middle turbinate obstructing mixture of 4% xylocaine with 1 in 100,000 adren-
the middle meatus aline. The cotton pledget should be squeezed
dry before inserting into the nasal cavity. Three
3. Infections involving the anterior ethmoidal air cotton pledgets are used for this purpose.

cosa to non sterile / contaminated inspired air.
One pledget is placed inside the inferior meatus,
one in the middle meatus and one inside the roof
of the nasal cavity.
Uncinectomy is the first step in middle meatal

antrostomy. Removal of uncinate opens up the
middle meatus. Open approaches to maxillary
sinus were first described in early 1700’s. The
famous procedure Caldwell - Luc surgery was
first described in US by George Walter Cald-
well and Henri Luc of France in 1893 and 1897.
Subsequent studies added to the knowledge of
physiologic drainage pattern of the maxillary
sinus which was dependent on the mucociliary
clearance mechanism led to the introduction of
Endoscopic sinus surgery.
Functional endoscopic sinus surgery is based

on the surgical approach performed by Mes-
serklinger and Wigand via the osteomeatal Image showing uncinectomy being performed
complex. FESS has become the standard surgical using a back biting forceps
treatment for chronic maxillary sinusitis. The un-
cinate process is the most important component Anatomy of Uncinate process:
of osteomeatal complex. This structure prevents
direct contact of the inspired air with the maxil- The uncinate process is a wing shaped (boomer-
lary sinus mucosal lining. It acts like a shield and ang shaped) piece of bone. It forms the first layer
plays a role in the mucociliary activity. or the lamella of the middle meatus. Anteriorly
it attaches to the posterior edge of the lacrimal
This should not be considered as a vestigial struc- bone, and inferiorly to the superior edge of the
ture, on the other hand it plays a vital role in the inferior turbinate. Superior attachment of the
ventilatory mechanisms of the nasal cavity. This uncinate process is highly variable.
thin semicircular piece of bone is considered to
be a key component of the ventilation of the nasal It may be attached to the lamina papyracea, or
cavity. This small piece of bone also serves to pro- the roof of ethmoid sinus, or sometimes to the
tect the anterior sinuses from bacteria and aller- middle turbinate. It should be pointed out that
gens by preventing the nonsterile / contaminated the configuration of the ethmoidal infundibulum
inspired air from reaching the sinus surfaces. At and its relationship to the frontal recess depends
this juncture it must be stressed that inadvertent largely on the behavior of the uncinate process.
and injudicious removal of this piece of bone
would result in greater exposure of the sinus mu- The uncinate process can be anatomically clas-
210
sified into three types depending on its superior to the ethmoidal infundibulum.
attachment. The anterior incision of the uncinate
is not clearly identifiable as it is covered with mu-
cosa which is continuous with that of the lateral
nasal wall. Sometimes a small groove is visible
over the area where the uncinate process attaches
itself to the lateral nasal wall.
Image showing type II uncinate insertion
Type II uncinate insertion
Here the uncinate process extends superiorly to

the roof of the ethmoid. The frontal sinus opens
directly into the ethmoidal infundibulum. In
Image showing Type I uncinate insertion these cases a disease in the frontal recess may
spread to involve the ethmoidal infundibulum
Type I uncinate insertion: and the maxillary sinus secondarily. Sometimes
the superior end of the uncinate process may get
In type I uncinate the process bends laterally in divided into three branches one getting attached
its upper most portion and gets inserted into the to the roof of the ethmoid, one getting attached to
lamina papyracea. The ethmoidal infundibulum the lamina papyracea, and the last getting at-
in this scenario is closed superiorly by a blind tached to the middle turbinate.
pouch known as the recessus terminalis (terminal
recess). In this type the ethmoidal infundibulum Type III uncinate insertion
and the frontal recess are separated from each
other so that the frontal recess opens into the In this type the superior end of the uncinate
middle meatus medial to the ethmoidal infundib- process turns medially to get attached to the
ulum as shown in the figure above. The opening middle turbinate. Here also the frontal sinus
of the frontal recess lie between the uncinate drains directly into the ethmoidal infundibulum.
process and the middle turbinate. Drainage and Uncinate process should be removed in all endo-
ventilation routes of the frontal sinus run medial scopic sinus surgical procedures in order to open

up the middle meatus. In fact this is the first step
in endoscopic sinus surgery. Rarely the uncinate Surgical Procedure:
process itself may be heavily pneumatized causing
obstruction to the infundibulum. Uncinectomy which the preliminary step to mid-
dle meatal antrostomy is performed ideally under
Atelectatic uncinate process: general anesthesia. It can also be performed
under local anesthesia. The author prefers general
In this scenario the free end of the uncinate anesthesia because it causes less discomfort to the
process shows hypoplasia and gets attached to the patient and the risk of aspiration is minimal when
medial wall of orbit or to the inferior section of compared to the procedure performed under
lamina papyracea. general anesthesia. This is because 4% xylocaine
This condition is generally seen together with an which is used to anesthetize the nasal mucosa
opacified hypoplastic maxillary sinus. This sce- trickles down the throat and anesthetizes the
nario should be identified from CT images before posterior pharyngeal wall also. During surgery
surgery otherwise it would cause orbital compli- the patient will not be able to feel the secretion in
cations as the surgeon could inadvertantly enter the throat and hence swallowing reflex is blunted
into the orbit while performing uncinectomy in leading to aspiration. Some surgeons prefer to
this area. inject 0.5 ml of 2% xylocaine with adrenaline into
the lateral nasal wall over the uncinate area before
incising it. This procedure is expected to reduce
bleeding during the surgery. The author does not
infiltrate uncinate process because the threat of
bleeding is virtually non existent in hypotensive
anesthesia which is preferred for all endoscopic
sinus surgical procedures. On the other hand
inadverntant entry of xylocaine into the orbit may
cause transient medial / inferior rectus palsy.
Classic uncinectomy:
This is begun after decongesting the nasal mucosa

by packing it with 4% xylocaine with 1 in 1 lakh
units adrenaline. This decongests the nasal mu-
cosa thereby reducing the bleeding and creating
more intranasal space for the surgeon to work.
Image showing Type III uncinate insertion The incision is placed over the anterior end of the
uncinate process, which feels softer to palpation
with sickle knife when compared to the hardness
of the lacrimal bone that lies anterior. The inci-
sion can be given in either both inferior to superi-
or or from superior to inferior direction.
212
After the incision using a sickle knife the unci-
nate is medialized and removed using a Blakesley
forceps (straight one). Small tags especially the
inferior portion of the uncinate can be removed
using a 45 degree Blakesley forceps. The free edge
of the uncinate process should be grasped for
total removal. It can be removed by a medial turn
of the forceps towards the nasal septum. Removal
of uncinate process opens up the middle meatus
of the nasal cavity.
Image showing back biting forceps nibbling the

lower portion of the uncinate process
Image showing uncinate being removed using a

sickle knife
Image showing lower portion of uncinate re-

moved

Image showing the scenario after total uncinec- Image showing middle portion of uncinate pro-
tomy. Note Bulla is visible after removing the cess being mobilized (swing door technique)
uncinate
Swing door technique:
Reverse cutting / Back biting forceps is used in

this technique. As a first step the inferior free
margin of uncinate process overlying the max-
illary ostium is cut. An incision is made in the
superior margin to form a flap from the uncinate.
The hinged uncinate (on its anterior margin)
can be moved with an elevator or ball probe. An
angled true cut forceps is used to grasp the free
edge of the uncinate process in order to remove
it. This step is followed by submucosal removal
of the horizontal process of the uncinate process
and subsequent trimming of the mucosa to fully
visualize the maxillary ostium. Once the unci-
Image showing horizontal portion of uncinate nate process is removed the natural ostium of the
process exposed maxillary sinus can easily be identified.
214
Complications:
1. Bleeding
2. Injury to orbital contents
3. Injury to lacrimal duct (seen in swing door
technique when using back biting forceps).
In order to minimize complications during un-

cinectomy the possible variations pertaining to
uncinate process should be borne in mind and
studied by CT imaging before embarking on this
procedure.
Image showing Bulla exposed after removal of

uncinate
After complete removal of uncinate process mid-

dle ethmoid group of air cells comes into view.
Largest of the middle ethmoid cells happens to be
the Bulla ethmoidalis. Next step in surgery would
be to deroof the middle ethmoid cell. Only after
Image showing widened maxillary sinus ostium removing the middle ethmoid cell will the sur-
geon be able to access the posterior ethmoidal
group of air cells.

While clearing the frontal recess area it should be
ensured that the mucosa surrounding the frontal
sinus ostium should be left undisturbed because
any manipulation in this area could lead to osteal
narrowing and frontal sinus drainage obstruction.
Image showing bulla deroofed
Bulla deroofing is ideally performed in its inferior

surface. It should be remembered that the lateral
wall of bulla forms the medial wall of the orbit.
Hence it should be left undisturbed. This portion
of the bone is known as lamina papyracea. Fron-
tal recess area is cleared next. Angled endoscope
(45 degrees) is ideally used to visualize this area.
Oedematous mucosa from this area should be
cleared in order to visualize the frontal recess
area. Image showing frontal sinus cavity as visualized
using a 70 degree nasal endoscope
In order to access the posterior ethmoid group of

cells the basal lamella which becomes visible after
deroofing the bulla. The structure that becomes
visible as soon as bulla is deroofed is the basal
lamella. Posterior ethmoid cells lie behind the
basal lamella. In order to reach posterior eth-
moid cells the basal lamella should be breached.
Before actually perforating the basal lamella, the
roof of the maxillary sinus is identified. Medial
and inferior portion of basal lamella is perforat-
ed with a J curette at the height of the roof of the
maxillary sinus.
Image showing the frontal recess area
216
Image showing posterior ethmoidal cells exposed Image showing basal lamella perforated
after perforating the basal lamella which is the
horizontal portion of the middle turbinate. Posterior ethmoids are dissected until the anteri-
or face of the sphenoid sinus is reached. The skull
base is identified. Further dissection will lead on
to the sphenoid sinus.
Indications for endoscopic sinus surgery
Functional endoscopic sinus surgery is common-

ly performed for inflammatory and infectious
sinus disease. Common indications for FESS
include:
1. Chronic sinusitis not responding to medical

management
2. Recurrent sinusitis
3. Nasal polyposis
Image showing J curette being used to perforate
the basal lamella in the medial and inferior 4. Antrochoanal polyp
portion.
5. Sinus mucoceles

significantly to nasal obstruction which could
6. Excision of tumors of nose and sinuses limit endoscopic visualization during surgery.
Such patients should be informed prior the need
7. CSF leak closure of septoplasty in conjunction with endoscopic
sinus surgery.
8. Orbital decompression
Inferior turbinate extends along the inferior lat-
9. Optic nerve decompression eral nasal wall posteriorly up to the nasopharynx.
In patients with significant allergic component
10. DCR the inferior turbinate could be boggy and oedem-
atous. These patients would benefit from inferior
11. FB removal turbinate reduction at the time of endoscopic
sinus surgery. The inferior meatus is another
12. Control of epistaxis important landmark where the nasolacrimal duct
opens. The NLD opening is located approxi-
mately 1 cm beyond the most anterior edge of the
Contraindications to Endoscopic sinus surgery inferior turbinate.
1. Intraorbital complications of acute sinusitis i.e. As the endoscope is further advanced into the
orbital abscess, frontal osteomyelitis etc. An open nasal cavity the middle turbinate becomes visi-
approach, with or without the assistance of endo- ble. This is the key landmark in endoscopic sinus
scopic vision is preferable in these cases. surgery. It has two components i.e. the vertical
component lying in the sagittal plane, running
2. After two failures of endoscopic surgery to from posterior to anterior, and a horizontal com-
manage CSF leak. ponent lying in the coronal plane, running from
medial to lateral. This horizontal component
3. Failure to manage endoscopically frontal sinus separates the middle ethmoid air cells from the
disease is an indication for open procedure. posterior ethmoids. This portion is also known as
the basal lamella. A surgeon needs to breech the
Applied anatomy basal lamella to reach the posterior ethmoid air
cells. Superiorly the middle turbinate attaches to
Immediately on entering the nasal cavity the first the skull base at the cribriform plate, hence care
structures encountered are the nasal septum and should be taken while manipulating the middle
inferior turbinate. The nasal septum is made up turbinate as it could lead to microfractures in the
of quadrangular cartilage anteriorly, this extends cribriform plate area causing CSF rhinorrhoea.
up to the perpendicular plate of ethmoid bone
posterosuperiorly and the vomer bone posteroin-
feriorly.
Recognizing deviations of nasal septum preoper-

atively is important because they could contribute
218
Image showing deviated nasal septum as viewed Image showing uncinate process
through an endoscope
Natural ostium of maxillary sinus
Uncinate process Once the uncinate process is removed, the natural

ostium of the maxillary sinus can be visualized
This is the next key structure that needs to be just posterior to the uncinate process, about one
identified in endoscopic sinus surgery. Complete third of the distance along the middle turbinate
uncinectomy is a must for successful endoscop- from its anterior edge. It lies approximately at the
ic sinus surgery. This is a L shaped bone of the level of the inferior border of the middle turbi-
lateral nasal wall and it forms the anterior border nate, superior to the inferior turbinate.
of the hiatus semilunaris (or infundibulum). The
infundibulum is the location of the osteomeatal The natural ostium is the destination for the
complex where the natural ostium of the maxil- mucociliary flow within the maxillary sinus. To
lary sinus opens. For patients with sinus disease, ensure optimal results, the surgically enlarged
a patent osteomeatal complex is critical for im- maxillary sinus antrostomy should include the
provement of symptoms. Anteriorly the uncinate natural ostium. Failure to include the maxillary
process attaches to the ethmoidal process of the sinus ostium in endoscopic surgical antrostomy
inferior turbinate. could be one of the key reasons for failure of the
surgery.
Maxillary sinus is approximately 15 ml in volume.

It is bordered superiorly by the inferior orbital
wall, medially by the lateral nasal wall and inferi-

orly by the alveolar portion of the maxillary bone.
Image showing natural ostium of maxillary sinus Image showing suprabullar recess
indicated by curved black arrow. Bulla and mid-
dle turbinate (MT) are also marked. Ethmoid air cells
The ethmoid sinus consists of a variable number

Ethmoid bulla of air cells (7-15 in number). The most superior
border of these cells is the skull base. Supraor-
The next structure encountered is the ethmoid bital ethmoidal cells could be present. A careful
bulla which is one of the most constant of all review of CT images of the surgeon to all these
anterior ethmoid air cells. It lies just beyond the variations.
natural ostium of the maxillary sinus and forms
the posterior border of the hiatus semilunaris. Sphenoid sinus
The lateral extent of the bulla is the lamina papy- Exenteration of the posterior ethmoidal cells
racea. Superiorly, the ethmoid bulla may extend exposes the face of the sphenoid. The sphenoid
all the way up to the ethmoid roof. Sometimes sinus is the most posterior of all paranasal si-
a suprabullar recess could exist above the roof of nuses, sitting just superior to nasopharynx and
the bulla. A careful preoperative review of the just anterior and inferior to the sella turcica. The
patient’s CT scan clarifies this relationship. anterior face of the sphenoid sits approximately 7
cm from the nasal cavity opening on a 30 degree
axis from the horizontal.
220
to grasp the free uncinate edge and to remove it.
Many important structures are related to the Instead of a sickle knife a back biting forceps can
sphenoid sinus. The internal carotid artery is typ- be used to remove the uncinate process.
ically the most posterior and medial impression
seen within the sphenoid sinus. Bone lining over
this artery could be dehiscent in some cases. Maxillary antrostomy
The optic nerve and its bony encasement produc- Once the uncinate process is removed the natural
es an anterosuperior indentation within the roof ostium will come into view. Ipsilateral eye can be
of the sphenoid sinus. In 4% of cases, the bone palpated to ensure that there is no dehiscence of
surrounding the optic nerve could be dehiscent. lamina papyracea and also to confirm the loca-
It is necessary for controlled opening of the tion of the lamina. The natural ostium is typically
sphenoid sinus, typically at its natural ostium is situated at the level of the inferior edge of the
critical for a safe surgery. middle turbinate about one third of the way back.
Location of the natural ostium of the sphenoid True cutting instrument is used to circumfer-
sinus is variable. In approximately 60% of per- entially enlarge the natural ostium. Optimal
sons, the ostium is located medial to the superior diameter of the maxillary antrostomy is not clear.
turbinate and in 40% it could be located lateral to A diameter of 1 cm would allow for adequate
the superior turbinate. outflow and for post operative monitoring in
the office. Care should be taken not to penetrate
lamina papyracea.
Endoscopic uncinectomy
Anterior ethmoidectomy
Functional endoscopic sinus surgery usually
begins with uncinectomy. If the uncinate process The ethmoid bulla is identified and opened
can be visualized without manipulation of mid- next. a J curette could be used to open the bulla
dle turbinate, uncinectomy can be performed at its inferior and medial aspect. Once the cell
directly. Otherwise, middle turbinate is gently is entered, the bony portions may be carefully
medialized, carefully using the curved portion of removed using a microdebrider or true cutting
the Freer elevator to avoid mucosal injury to the forceps. Complete resection of lateral portion
turbinate. Forceful medialization and fracture of of bulla facilitates proper visualization and dis-
the turbinate should be avoided. section posteriorly. While working laterally care
should be taken to maintain an intact lamina
Uncinectomy can be performed via an incision papyracea.
with either the sharp end of the Freer elevator or
a sickle knife. Thee incision should be placed at The rest of the anterior ethmoid cells can be un-
the most anterior portion of the uncinate process, capped with a J curette and further opened with
which is softer on palpation in comparison with a microdebrider or a true cutting forceps. Initial
the firmer lacrimal bone where the nasolacrimal use of curette usually allows for tactile sensa-
duct is located. Then a Blakesley forceps is used tion and determination of the thickness of the

bone and also verifies proper orientation prior to skull base and the lamina. The surgeon should
further opening of cells with powered instrumen- be aware that the skull base slopes inferiorly at
tation. Care should be taken to avoid mucosal an angle of 30 degrees from anterior to posterior.
stripping, since mucosal preservation results in The skull base lies lower posteriorly than anteri-
superior postoperative outcomes. orly. This dissection is taken back to the face of
the sphenoid.
Anterior ethmoidal air cells should be cleared up
to the skull base, while exercising caution when
approaching the roof of the ethmoid. Use of
image guidance is advisable during this phase of
dissection in order to prevent penetration of skull
base.
While moving posteriorly to new air cells, the

surgeon should ideally enter inferiorly and me-
dially and then subsequently open laterally and
superiorly once the more distal anatomy can be
judged by visualization and palpation. Anterior
ethmoidectomy is complete when the basal lamel-
la of the middle turbinate is reached.
If the disease process is limited to the anterior

ethmoidal air cells and maxillary sinus, the proce-
dure could end with simple anterior ethmoidecto-
my and maxillary sinus antrostomy. If CT images Image showing horizontal lower portion of unci-
reveal significant disease in the posterior ethmoid nate overhanging the natural ostium
and sphenoid sinus then posterior dissection is
appropriate.
Posterior ethmoidectomy
This begins with perforating the basal lamella just

superior and lateral to the junction of the vertical
and horizontal segments of middle turbinate. The
L shaped strut of the middle turbinate should
be preserved in order to ensure stability of the
middle turbinate. The lateral and superior por-
tions of basal lamella may be removed using the
microdebrider. Posterior ethmoid cells can be Image showing location of sphenoid ostium
taken down keeping in mind the location of the
222
Image showing location of natural ostium after Image showing anterior ethmoidectomy com-
removal of horizontal portion of the lower unci- pleted demonstrating frontal recess, vertical and
nate process horizontal segments of middle turbinate
Uncinate completely removed showing bulla and

suprabullar recess
Image showing the location of puncture at the
junction of vertical and horizontal segments of
middle turbinate

Image showing posterior ethmoid cell opened
Image showing anterior and posterior ethmoidal
arteries
After surgery the nasal cavity is packed with

merocel pack which is left in situ for a week.
Risks associated with FESS include:
1. Bleeding
2. Synechiae formation
3. Orbital injury
4. Diplopia
5. Orbital hematoma
Image showing posterior ethmoid cells opened 6. Blindness

and sphenoid sinus ostium becomes visible
(green circle) 7. CSF leak
8. Nasolacrimal duct injury/epiphora
224
tions following ethmoidal sinusitis which include
External ethmoidectomy orbital cellulitis, orbital subperiosteal abscess,
orbital abscess, superior orbital fissure syndrome
Ethmoidal sinusitis is one of the most compli- and cavernous sinus thrombosis.
cated pathologies in ear / nose / throat practice.
Because of its critical location, ethmoidal sinusitis 3. Managing chronic ethmoidal sinusitis in areas
can become really dangerous and difficult con- where facilities for endoscopic sinus surgery is
dition to treat. Types of surgical interventions not available.
include:
Procedure
1. Intranasal ethmoidectomy using nasal endo-
scope This surgery is ideally performed under General
anesthesia because manipulating the globe can be
2. External ethmoidectomy uncomfortable for the patient. Incision, a curvi-
linear one about 3 cm long is made at the mid-
3. Transantral ethmoidectomy point between the medial canthus and the middle
of the anterior nasal bone. The skin is incised,
Ethmoid sinuses begin their development during and the dissection is carried down to the perios-
infancy and continue to expand during the early teum. The angular artery could come in the way
childhood. The ethmoid sinuses are paired struc- and should be transected and ligated. Dissection
tures, and are divided into anterior and posterior is carried subperiosteally to the posterior lacrimal
ethmoidal cells. The division is provided by the crest, avoiding damage to the lacrimal excretory
basal lamella of the middle turbinate. Ethmoid structures. The medial canthal tendon may need
sinuses in adults have an average length of 4.5 cm to be released, to allow an easier access to this
and a height of approximately 3 cm. area. If this is done care must be taken to reposi-
tion it correctly. The posterior crest may need to
Walls of ethmoid sinus are composed of max- be removed. Dissection can be extended supe-
illary, palatine, frontal, lacrimal and sphenoid riorly to the frontoethmoid suture as this is the
bones. Lateral to the sinus lies the lamina papyr- demarcation between the ethmoid and anterior
acea and superiorly is the fovea ethmoidalis. Ulti- cranial fossa.
mate drainage pathway for secretions from ante-
rior ethmoidal cells is the osteomeatal complex in Complications
the middle meatus. The posterior ethmoidal cells
drain into the superior meatus. 1. Cutaneous scar could lead to medial canthal
webbing, telecanthus, and medial canthal dys-
Indications for surgery topia, especially if the medial canthal tendon is
released and not properly positioned.
1. Patients who have not responded to medical
therapy for 3-6 weeks duration 2. Periorbital oedema, injury to extraocular mus-
cles with diplopia, parathesias in the distribution
2. Patients who have developed orbital complica- of the supraorbital, supratrochlear, and infrat-

rochlear nerve distributions and blepharoptosis
can also occur.
3. Globe injury
4. Blindness can occur fro hematoma / excessive

pressure on the globe, occluding the central reti-
nal artery during the surgery.
Image showing incision for external ethmoidec-

tomy (Lynch incision).
226
the advent of CT scan x-ray paranasal sinuses was
Endoscopic Management of Fronto ethmoidal the only diagnostic tool available. X-ray would
mucocele usually reveal the loss of normal haustrations
found in the frontal sinus. Infact it was even con-
A mucocele is an epithelium lined mucous considered pathognomonic.
taining sac. It usually develops when the sinus os-
tium gets obstructed by chronic sinusitis, polyps Using a 4mm 0° nasal endoscope the surgery is
or tumors. These mucoceles are known to erode performed. The complete surgery was performed
the bone and may involve the brain and orbit. It under general anesthesia. On deroofing the agger
may also present as a forehead mass with pro- nasi cell the contents of the mucocele started to
ptosis as in this patient. Classification of Frontal extrude. The frontal sinus ostium was widened.
mucocele: When the scope was introduced through the
widened frontal ostium the posterior table of the
Frontal mucoceles have been classified into 5 frontal sinus was found to be eroded. The frontal
types depending on its extent. lobe of the brain was clearly visible. The brain
can be identified by its characteristic pulsations
Type I: In this type the mucocele is limited to the coinciding with the patient’s respiration.
frontal sinus only with or without orbital exten-
sion. Type II: Here the mucocele is found involv- The major advantages of endoscopic approach are
ing the frontal and ethmoidal sinuses with or
without orbital extension. 1. The procedure has minimal risk
Type IIIa: In this type the mucocele erodes the 2. There is no scar
posterior wall of the frontal sinus with minimal
or no intracranial involvement. 3. Intranasal drainage path can be created
Type IIIb: In this type the mucocele erodes the 4. Minimal complications
posterior wall with major intra cranial extension.
Type IV: In this type the mucocele erodes the

anterior wall of the frontal sinus.
Type Va: In this type there is erosion of both an-

terior and posterior walls of frontal sinus without
or minimal intracranial extension.
Type Vb: In this type there is erosion of both

anterior and posterior walls of frontal sinus with
a major intracranial extension. Among mucoce-
les affecting the various paranasal sinuses frontal
mucoceles are the most common (65%). Before Image showing agger nasi cell

Contents of mucocele seen extruding after agger
nasi cell was opened
228
TESPAL (Trans nasal endoscopic sphenopala-
tine artery ligation)
History:
This procedure was first reported by Budrovich

and Saetti in 1992. This procedure can safely be
performed under GA. / L.A.
Indication:
1. Epistaxis not responding to conventional con-

servative management.
2. Posterior epistaxis
Procedure:
Image showing the position of sphenopalatine
The nose should first be adequately decongest- artery
ed topically using 4% xylocaine mixed with 1 in
50,000 units adrenaline.
A 4mm 0 degree nasal endoscope is introduced

into the nasal cavity. The posterior portion of the
middle turbinate is visualized. 2% xylocaine with
1 in 1lakh units adrenaline is injected in to this
area to further reduce bleeding.
Incision:
An incision ranging between 10 - 20 mm is made
vertically about 5 mm anterior to the attachment
of the middle turbinate. The mucosal flap is gently
retracted posteriorly till the crista ethmoidalis is
visualized. The crista ethmoidalis is a reliable land
mark for the sphenopalatine artery. The artery en-
ters the nose just posterior to the crista. The crista
can in fact be removed using a Kerrison’s punch Image showing wide antrostomy performed
for better visualization of the artery.

Image showing infiltration with 2% xylocaine
with adrenaline being performed Image showing flap being stripped exposing the
bone
Image showing flap being elevated

Image showing crista ethmoidalis
230
Following successful ligation / cauterization, the
area is explored posteriorly for 2 - 3 mm to ensure
that no more vessels remain uncauterized.
Image showing the sphenopalatine artery

Image showing the cauterized point
Nasal packing is not needed.
Complications of TESPAL:
1. Palatal numbness
2. Sinusitis
3. Decreased lacrimation
4. Septal perforation
5. Inferior turbinate necrosis
This procedure in combination with transnasal

anterior ethmoidal artery ligation ensures that
epistaxis is controlled reliably.
Image showing sphenopalatine artery being

cauterized
The sphenopalatine artery is clipped using liga

clip or cauterized as it enters the nasal cavity. This
is done as close to the lateral nasal wall as possi-
ble; this would ensure that the posterior branches
may also be reliable included.

Endoscopic Transnasal Optic nerve Decom- advocated for traumatic optic neuropathy. They
pression include observation, medical corticosteroid ther-
apy and optic nerve decompression. During early
Introduction: 1900’s transcanal deroofing of the optic canal
was widely practised for traumatic optic neurop-
The optic nerve is the second cranial nerve and athy treatment. It was in 1920 Sewell performed
is the nerve of vision. It is about 5 cm long and is a transethmoidal optic canal decompression by
divided into three segments. About 3 cm of the removing lamina papyracea and medial wall of
nerve is in the orbit and is protected by orbital fat optic canal. Recent advances in endoscopic
around it. 1 cm of the nerve is enclosed in a bony instrumentation and intranasal sinus surgical
canal on the lateral wall of the sphenoid sinus. techniques have refined the entire process of optic
Another 1 cm of the nerve lie intracranial or nerve decompression.
within the brain cavity.
Currently intranasal transethmoidal transphenoi-
Vision loss may occur from compression of the dal endoscopic approach is gaining popularity.
nerve from injury (due to hematoma), mucocele
of sphenoid sinus or the posterior ethmoids. Indications:
Endoscopic optic nerve decompression can be 1. Traumatic optic neuropathy

performed with very little or nil morbidity. This 2. Skull base tumors involving optic nerve
procedure is mainly done for traumatic optic neu- 3. Fibro-osseus lesions of skull base encroaching
ropathy. This procedure can be performed under on to the optic nerve canal
General anesthesia. There is virtually no scar and 4. Graves ophthalmology associated with optic
the duration of hospital stay is not more than a neuropathy
couple of days. 5. Idiopathic intracranial hypertension
History: Contraindications:
Hippocrates was the first to note the association 1. Complete disruption of optic nerve or chiasma
of trauma just above the eyebrow and gradual vi- 2. Complete atrophy of the nerve
sion loss. During the 18th century the association 3. Carotid cavernous fistula
between frontal trauma and loss of vision without
evidence of ocular injury was very well appreci- Surgical anatomy:
ated. It was Battle in 1890 who distinguished the
difference between penetrating direct injury from Optic canal:
non penetrating indirect optic nerve injuries. The optic nerve enters the optic canal at the su-
20th century saw significant progress in classifica- peromedial corner of the orbital apex. This canal
tion, pathophysiology and management of is about 10 mm long. It contains the optic nerve,
optic nerve injuries. ophthalmic artery and sympathetic plexus.
Historically three treatment modalities have been Lateral – Optic canal is separated from the supe-
232
rior orbital fissure by a bony ridge known as the
optic strut.
Image showing optic foramen
Ophthalmic artery:
This artery arises from the medial aspect of the

Image showing anatomy of orbit anterior loop of the internal carotid artery just
above the cavernous sinus.
The tendon to which the extraocular muscles are
attached (Annulus of Zinn) is attached to the up- Intracranial it is located medially and below the
per, medial and lower margins of the optic canal optic nerve. In the optic canal the artery pass-
from 12 – 6 O clock. The extraocular muscles that es within the optic nerve sheath and below the
insert into the Annulus of Zinn include superior, optic nerve. There are variations of the position
medial, inferior and lateral rectus muscles. of the ophthalmic artery within the canal. It can
be found anywhere between 3 and 6 O’ clock so
The optic canal courses in a posteromedial direc- caution must be exercised when incising the optic
tion. The walls of the optic canal is formed by the nerve sheath.
body of sphenoid, and the lesser wing of sphe-
noid. At the intracranial end it is shielded laterally Optic nerve:
by the anterior clinoid process. The lateral wall of
the optic canal is formed by the optic strut that The optic nerve exits the orbit via the optic canal
blends superolaterally into the anterior clinoid and courses posteromedially to the optic chiasma
process. The superior wall is formed by the ante- where there is a partial decussation of its fibers
rior root of the lesser wing of sphenoid bone; the from the temporal visual fields of both eyes. Optic
medial wall is formed by the sphenoid bone. nerve unlike peripheral nerves is ensheathed in
all three meningeal layers. The reason behind this
unique feature is that t he optic nerves are part of

central nervous system as they are outpouchings segments require transplanum and transsellar
of the diencephalon during embryonic develop- approaches.
ment. This nerve hence is not capable of regenera-
tion. Damage to optic nerve produces irreversible Clinical features of traumatic optic neuropathy:
blindness.
1. Vision loss after blunt / penetrating trauma
Traumatic optic neuropathy: 2. Slit lamp examination and fundus examination
are normal
This is a condition in which acute injury to the 3. Defects in color vision
optic nerve from direct / indirect trauma results 4. Defects in visual fields
in vision loss. The most common cause of trau-
matic optic neuropathy is indirect injury to the Pupillary reaction:
optic nerve. This is thought to be the result of
transmitted shock from the orbital impact to the An afferent pupillary defect is a necessary finding
intracanalicular portion of the optic nerve. Direct in these patients. Normally light shone in one eye
traumatic optic neuropathy results from penetrat- causes equal pupillary constriction on both sides.
ing injury or from bony fragments in the optic In patients with afferent pupillary defect, light in
canal piercing the optic nerve. Sometimes orbital the affected eye causes only mild construction
hemorrhage and optic nerve sheath hematoma of pupils, while light in the unaffected eye cause
can also cause optic neuropathy by direct com- normal constriction on both sides.
pression.
Symptoms include:
Classification of traumatic optic neuropathy:
1. Blurry vision
Traumatic optic neuropathy can be classified 2. Scotomas
according to the location of injury. 3. Visual field defects
4. Decreased color vision
1. Head of the optic nerve
2. Intraorbital segment Diagnosis of traumatic optic neuropathy is purely
3. Intracanalicular segment clinical. CT can be performed to visualize the
4. Intracranial segment optic nerve as well as the optic canal. Optic canal
should be clearly evaluated for evidence of frac-
The most common sites of indirect traumatic ture.
optic neuropathy are the intracanalicular segment
(since the nerve is adherent to the periosteum) Automatic visual field testing (Humphrey visual
and the intracranial segment. field testing) can be used to document visual field
defects.
The nerve can also be compressed at the level of Visual evoked potential can be used to document
intracranial segment and the optic chiasma. This the electrical activity of the optic nerve.
is usually caused by tumors like meningioma
and pituitary adenomas. Decompression of these
234
Pathophysiology of optic neuropathy: prognosis.
It is rather poorly understood. Some of the ac- Traumatic optic neuropathy is the most common
cepted facts include: indication for optic nerve decompression. De-
1. Optic nerve avulsion compression is ideally considered only in cases
2. Optic nerve sheath hematoma where there is a displaced fracture of the optic
3. Penetrating FB or bony fracture canal, with no evidence of anatomical disruption
of the nerve. In patients with preserved light
Traumatic optic neuropathy is an indirect event perception surgical decompression is considered
that occurs shortly after or during blunt trauma with / without administration of steroids.
to the superior orbital rim, lateral orbital rim,
frontal area or the cranium. This is postulated to Timing of intervention is also controversial,
occur due to transmitted forces via the orbital but ideally speaking decompression should be
bones to done as soon as possible after optic neuropathy
the orbital apex and optic canal. Elastic deforma- is diagnosed, and especially so if it is of sudden
tion forces of the sphenoid bone allows transfer onset. In patients with traumatic optic neurop-
of the force to the intracanalicular segment of the athy along with fractures of sphenoid wing and
optic nerve. anterior clinoid process with displacement, lateral
decompression via pterional approach should be
Contusion of intracanalicular portion of optic considered.
nerve produces localized optic nerve ischemia
and edema. The edematous ischemic axons result Procedure:
in further neural compression within the fixed
diameter optic canal predisposing to the develop- The instruments used in endoscopic sinus surgery
ment of intracanalicular compartment syndrome. are used in this surgery also. In addition through
The basis of optic nerve decompression is enlarg- cut dissecting instruments and powered instru-
ing this bottle neck area of optic foramen in order ments are also used. A 4 mm fine diamond burr is
to prevent ischemia caused due to nerve swelling. commonly used. When using powered
drill adequate irrigation should be ensured in
Endoscopic optic nerve decompression contro- order to avoid thermal damage to the nerve
versies: during drilling process. The entire procedure is
Nerve decompression should be performed performed ideally under general anesthesia with
only for indirect traumatic optic neuritis. Direct the patient supine and head elevated.
traumatic optic neuritis is an irreversible injury. The nasal cavity is packed with 4 % xylocaine
Studies reveal that there is a close association with 1 in 100,000 units adrenaline. This decon-
between initial visual acuity and final results after gests the nose and shrinks the turbinate thereby
the procedure. Patients who are blind and have increasing the working space for the surgeon.
extremely poor light perception when exam- It also reduces mucosal bleed during the entire
ined first are poor candidates for the procedure. process.
Fractures involving the optic canal as well as a
fragment impinging on the nerve carry worse

Technique:
Anterior and posterior ethmoidectomy is per-

formed first. In addition natural ostium of the
maxillary sinus is also widened. A complete eth-
moidectomy will ensure that the lamina papyra-
cea is exposed in its entirety.
A wide sphenoidectomy is performed. The anteri-

or wall of sphenoid is resected to the level of skull
base and up to the level of lamina papyracea. This
procedure helps in the identification of orbital
axis and the orbital apex.
Image showing removal of uncinate process
Identification of the orbital apex and the optic
canal:
The safest way to identify these structures is to

resect the lamina papyracea posteriorly, starting
about 10 – 15 mm anterior to the face of the sphe-
noid sinus. Since lamina papyracea can be sepa-
rated and removed with a Freer’s elevator. If it is
thick then it needs to be drilled using a 4 mm dia-
mond burr and reduce it to an egg shell thickness.
Care should be taken not to injure the periorbita
and the underlying extraocular muscles. If perior-
bita are injured then fat could be seen protruding
into the operating field.
After removal of posterior portion of lamina Image showing sphenoid ostium exposed
papyracea, the periorbita is followed posteriorly
where it could be seen converging at the orbit-
al apex. The thick bone between the posterior
ethmoid and the sphenoid is known as the optic
tubercle.
236
This thinned out bone is removed using a Freer
elevator. This exposes the optic nerve sheath. The
optic nerve sheath is incised along the optic nerve
and through the annulus of zinn. The incision
is placed at the superomedial quadrant, as the
ophthalmic artery is located in the inferomedial
quadrant of the optic canal.
Image showing optic tubercle
Image showing optic nerve inside sphenoid sinus
Image showing widened sphenoid ostium
The annulus of Zinn is attached to the superior,

inferior and medial margins of the orbital junc-
tion The bony protrusion of the optic canal into
the sphenoid sinus is identified. It is the continu-
ation of the optic tubercle. Diamond burr is used
to thin this area of bone to egg shell thickness.

Fracture Nasal bones and promptly treated leads to:
Introduction 1. Nasal deformities

2. Intranasal dysfunction like nasal block
Nose is the most prominent part of the face, Fracture nasal bone is known to cause higher
hence it is likely to be the most common struc- incidence of morbidity and complications when
ture to be injured in the face. Although fractures compared that of fractures involving other facial
involving the nasal bones are very common, it is bones.
often ignored by the patient. Patients with frac-
tures of nasal bone will have deformity, tender- In order to treat this condition properly it is nec-
ness, haemorrhage, edema, ecchymosis, instabili- essary to accurately diagnose this condition by:
ty, and crepitation. These features may be present 1. Looking for crepitus and tenderness over the
in varying combinations. This article discusses nasal bone area
the pathophysiology of these fractures, role of ra- 2. Radiographic evaluation of nasal bones. Ra-
diography and ultrasound in their diagnosis and diography helps in diagnosis and classification
their management. of nasal bone fractures, and also in checking the
adequacy of reduction.
Nasal bone fractures are common because:
Clinicians are more interested in knowing:
1. Nose happens to be the most prominent por-
tion of the face 1. Location of fracture site (like sidewall, dorsum,
2. Increasing number of road traffic accidents or the entire nasal bone)
3. Increasing incidence of domestic violence 2. To know whether the fracture involves the right
4. Increase in the number of individuals taking nasal bone / left nasal bone or both sides
part in contact sports 3. Whether there is any displacement of the
fractured fragments (medial / lateral), presence of
Anatomy: absence of comminution.
4. To identify the presence of concurrent fractures
Nasal bones are paired bones. Both these bones to other facial bones / nasal septum. When there
project like a tent on the frontal process of is the presence of fractures involving other facial
maxilla. In the midline they articulate with one bones / severe fractures of nasal septum it is pru-
another. Just under this midline articulation lies dent to perform open reduction.
the nasal septum. Superiorly the nasal bones are
thicker where it articulates with the nasal process Pathophysiology:
of frontal bone. This area is relatively stable and
firm. Nasal bone fractures commonly occur at the The following points should be borne in mind
transition zone between the proximal thicker and before attempting to understand the pathophysi-
distal thinner portions. This zone precisely corre- ology factors that lead to fractures involving nasal
sponds to the lower third of the nasal bone area. bones.
Fractures involving nasal bones if not properly 1. Nasal bones and underlying cartilage are sus-
238
ceptible for fracture because of their more promi- 6. Nasal bones undergo fracture in its lower por-
nent and central position in the face. tion and seldom the upper portion is involved in
2. These structures are also pretty brittle and the fracture line. This is because the upper por-
poorly withstands force of impact. tions of the nasal bone is supported by its articu-
3. The ease with which the nose is broken may lation with the frontal bone and frontal process of
help protect the integrity of the neck, eyes, and maxilla.
brain. Thus it acts as a protective mechanism. 7. Because of the close association between nasal
4. Nasal fractures occur in one of two main pat- bone and the cartilaginous portions of the nose,
terns- from a lateral impact or from a head-on and the nasal septum it is quite unusual for pure
impact. In lateral trauma, the nose is displaced nasal bone fractures to occur without affecting
away from the midline on the side of the injury, these structures. If closed reduction alone is
in head-on trauma, the nasal bones are pushed performed to reduce nasal bone fractures without
up and splayed so that the upper nose (bridge) correction of nasal septal fractures, this could
appears broad, but the height of the nose is col- cause progressive nasal obstruction due to uncor-
lapsed (saddle-nose deformity). In both cases, the rected deviation of nasal septum. This is because
septum is often fractured and displaced. of the tendency of the nasal septum to heal by
5. The nasal bone is composed of two parts: A fibrosis which causes bizarre deviations like “C”
thick superior portion and a thin inferior portion. “S” etc.
The intercanthal line demarcates these two por-
tions. Fractures commonly occur below this line. Since nose is the most prominent portion of the
face, its supporting bony structures have low
breaking strength the naso ethmoidal complex
fractures when exposed to forces of about 80
grams. This fact was demonstrated by Swearinger
in 1965.
Classification of nasal bone fractures:
Stranc Robertson classification :
Stranc and Robertson suggested that lateral forces

accounted for the majority of nasal bone frac-
tures. They also inferred that younger patients
tend to have fracture dislocation involving large
segments while older patients tended to have
comminuted fractures. In 1978 Stranc and Rob-
Image showing external deviation of the contour ertson came out with their classification of nasal
of nose bone fracture based on the direction of impact
and the associated damage. In this classification
they also took into consideration the degree of
damage to nasal bones and the nasal septum. This

classification was based on the clinical exam- and joins at a point where the nasal bone becomes
ination of the nose and face. It did not take into thicker. This point is about 2/3 of the way along
account radiological findings. its length. The fractured segment usually regains
its position because of its attachment along its
Type I injury: lower border to the upper lateral cartilage. The
nasal septum is not involved in this particular
Fractures due to this type of injury does not injury. Class I fractures do not cause gross lateral
extend behind the imaginary line drawn from displacement of nasal bones, though a persistent
the lower end of nasal bone to the anterior nasal depressed fragment may give it the appearance.
spine In this type of injury the brunt of the attack In children these fractures could be of green stick
is borne by lower cartilaginous portion of the variety and a significant nasal deformity may
nasal cavity and the tip of the nasal bones. This develop subsequently during puberty when nasal
type of injury may cause avulsion of upper lateral growth accelerates. Clinically this fracture will
cartilages, and occasionally posterior dislocation present as a depression over the nasal bone area.
of septal and alar cartilages. There may be tenderness and crepitus over the
affected nasal bone.
Type II injury:
This type of injury involves the external nose, Radiological evidence may or may not be present.
nasal septum and anterior nasal spine. In fact class I fracture of nasal bone is purely a
Patients with this type of injury manifest with clinical diagnosis.
gross deviations involving the dorsum of the nose
including splaying of nasal bones, flattening of Class II fractures: These fractures cause a sig-
dorsum of nose and loss of central support of the nificant amount of cosmetic deformity. In this
nose. group not only the nasal bones are fractured, the
underlying fronto nasal process of the maxilla is
Type III injury: also fractured. The fracture line also involves the
This injury involves orbit and intracranial struc- nasal septum. This condition must be recognized
tures. clinically because for a successful result both the
nasal bones as well as the septum will have to be
Harrison’s classification: reduced. Since both the nasal bones and the fron-
to nasal process of maxilla would have absorbed a
Fractures involving nasal bones are divided into considerable amount of force, the ethmoidal
three categories depending on the degree of dam- labyrinth and the adjacent orbit should be intact.
age, and its management.
The precise nature of the deformity depends on
Class I fractures: Very little force is sufficient to the direction of the blow sustained. A frontal
cause a fracture of nasal bone. It has been esti- impact may cause comminuted fracture of nasal
mated to be as little as 25-75 pounds / sq inch. bones causing gross flattening and widening of
Class I fractures are mostly depressed fractures the dorsum of the nose. A lateral blow of similar
of nasal bones. The fracture line runs parallel to magnitude is likely to produce a high deviation of
the dorsum of the nose and naso maxillary suture the nasal skeleton. The perpendicular plate of eth-
240
moid is invariably involved in these fractures, and
is characteristically C shaped (Jarjaway fracture of
nasal septum).
Class III fractures: Are the most severe nasal inju-

ries encountered. This is caused by high velocity
trauma. It is also known as naso orbital fracture /
naso ethmoidal fracture. Recent term to describe
this class (Naso orbito ethmoid fracture) indicates
the clinical importance of orbital component in
these injuries. These fractures are always asso-
ciated with Le Fort fracture of the upper face
involving the maxilla also. In these fractures the
nasal bone along with the buttressing fronto nasal
process of maxilla fractures, telescoping into the
ethmoidal labyrinth. Two types of naso ethmoidal
fractures have been recognized:
Type I: In this group the anterior skull base,

posterior wall of the frontal sinus and optic canal
remain intact. The perpendicular plate of ethmoid Image showing the types of fracture nasal bones
is rotated and the quadrilateral cartilage is rotated
backwards causing a pig snout deformity of the Murray’s classification:
nose. The nose appears foreshortened with anteri-
or facing nostrils. The space between the eyes in- Murray etal after examining nearly 70 patients
crease (Telecanthus), the medial canthal ligament with fracture nasal bones classified them into 7
may be disrupted from the lacrimal crest. types. This classification was based on damage
suffered by the nasal septum. This is actually a
Type II: Here the posterior wall of the frontal pathological classification.
sinus is disrupted with multiple fractures involv-
ing the roof of ethmoid and orbit. Sphenoid and Clinical pointers towards the diagnosis of frac-
parasellar regions may sometimes be involved. tures involving nasal bones:
Since the dura is adherent to the roof of ethmoid
fractures in this region causes tear in the dura 1. Injuries involving middle third of face
causing csf rhinorrhoea. Pneumocranium and 2. History of bleeding from nose following injury
cerebral herniation may complicate this type of 3. Oedema over dorsum of nose
injury. 4. Tenderness and crepitus over nasal bone area
5. Eyelid oedema
6. Subcutaneous emphysema involving eyelids
7. Periorbital ecchymosis

According to Sharp X-rays of nasal bone fails to
reveal fractures in nearly 50% of the patients.
Clinical examination:
This should include careful examination to rule

out deformities involving nose and middle third
of face. Clinical photograph of the patient should
be taken in order to document the deformity.
Patient should be quizzed regarding the presence
of deformities in the area prior
to injury. Acute injury photographs will help the
surgeon to convince the patient that fracture re-
duction has been done in an appropriate manner.
Studies reveal that nearly 30% of the patients 9 are
not satisfied with the post reduction outcome.
Radiology:
Image showing fracture nasal bone as seen in
X-ray of nasal bone has very minimal role in the x-ray nasal bones
diagnosis of fractures involving the nasal bones.
CT scan of nose and sinuses helps in identifying
fractures involving other facial bones and in Le-
fort II and Lefort III fractures. Ultrasound using
10 MHz probe gives a clear view of the nasal bone
area thereby facilitating easy identification of
fractures. It also has the advantage of nil radiation
hazard to the patient. Many images can be tak-
en without any problem. It is also cost effective.
According to Lee the accuracy of ultrasound in
identifying fracture nasal bone was close to 100%
while for conventional radiographs it was close to
70%.
Image Axial CT of nose and sinuses showing

buckling of nasal septum due to fracture
242
Management:
Indications for closed reduction according to
If fractures of nasal bones are left uncorrected it Bailey:
could lead to loss of structural integrity and the
soft tissue changes that follow may lead to both 1. Unilateral / Bilateral fracture of nasal bones
unfavourable appearance and function. The man- 2. Fracture of nasal septal complex with nasal de-
agement of nasal fractures is based solely on the viation of less than half of the width of the nasal
clinical assessment of function and appearance; bridge.
therefore, a thorough physical examination of a
decongested nose is paramount. Closed reduction can be performed under local /
general anaesthesia. This decision should be made
Patients with fractures involving nose will have by the surgeon taking the patient into confidence.
intense bleeding from nose making assessment a There is no difference in the results produced
little difficult. Bleeding must first be controlled by between surgeries performed under local anaes-
nasal packing. These patients also have consid- thesia and general anaesthesia.
erable amount of swelling involving the dorsum
of the nose, making assessment difficult. These . Patients seem to tolerate fracture reduction un-
patients must be conservatively managed for at der local anaesthesia
least 3 weeks for the oedema to subside to enable .
precise assessment of bony injury. According to Preoperative profile photograph of the patient is a
Cummins Fracture reduction should be accom- must. This will give a general idea about adequacy
plished when accurate evaluation and manipula- of reduction.
tion of the mobile nasal bones can be performed;
this is usually within 5-10 days in adults and 3-7 Local anaesthesia:
days in children. Reduction is ideally performed
immediately after injury before oedema sets in. This requires a thorough understanding of inner-
If oedema has already set in it is prudent to wait vation of nose.
for it to subside because it is difficult to ascertain
adequacy of reduction in the presence of oedema. Innervation of nose:
1. Closed reduction For effective administration of local anaesthesia

2. Open reduction a complete understanding of sensory innervation
3. Conservative management of nose and nasal cavity is a must. Innervation of
nose can be divided into:
Closed reduction:
1. Innervation of mucosa within the nasal cavity
This is the most preferred treatment modality in 2. Innervation of external nose and its skin cov-
all acute phases of fractured nasal bones. Even ering
if large deviations are seen closed reduction can
be attempted prior to rhinoplasty as this would Sensory innervation of external nose:
simplify the task of the plastic surgeon.

External nose and its skin lining is innervated by
ophthalmic and maxillary divisions of trigeminal
nerve.
Superior aspect of the nose is supplied by – Su-
pratrochlear and Infratrochlear nerves (branches
of trigeminal nerve) and external nasal branch of
anterior ethmoidal nerve.
Inferior and lateral parts of the nose – is supplied

by infraorbital nerve.
1. Superior inner aspect of the lateral nasal wall

is supplied by anterior and posterior ethmoid
nerves
2. Sphenopalatine ganglion present at the posteri-
or end of middle turbinate innervates the posteri-
or nasal cavity
3. Nasal septum is supplied by anterior and pos-
terior ethmoidal nerves. Sphenopalatine ganglion
also contributes to the sensory supply to the nasal
septum via its nasopalatine branch.
4. Cribriform plate superiorly holds the olfactory Image showing innervation of nose
special sensation fibers.
Infiltration:
Both topical and infiltrative anaesthesia is used 2% xylocaine is infiltrated in the following areas:
for reduction of nasal bones.n4% xylocaine topi- 1. Through the intercartilagenous area over the
cal is used to pack the nasal cavity. 4% xylocaine nasal bones
mixed with 1 in 100000 adrenaline is used to 2. Over the canine fossa
pack the nasal cavity. This not only anesthetizes
the nasal cavity mucosa but also causes shrinking Most of class I fractures can be reduced by closed
of the turbinates making instrumentation easier. reduction and immobilization using Plaster of
Both nasal cavities are packed. The amount of Paris cast. In majority of cases digital pressure
4% xylocaine used should not exceed 4 ml as the alone is sufficient for the job.
toxic dose is about 7 ml of 4% xylocaine. It must
be borne in mind that 2% xylocaine is also going
to be used as infiltration anaesthesia. One cotton
pledget soaked in 4% xylocaine is inserted just
under the upper lip and held in position for a
couple of minutes.
244
of the nasal bones and septum
2. Deviation of nasal pyramid of more than half
of the width of the nasal bridge.
3. Fracture dislocation of caudal septum
4. Open fractures involving the nasal septum
5. Persistent nasal deformity even after meticu-
lous closed reduction
Open reduction is preferred for all class III nasal

bone fractures. The problem here is even though
the nasal bones can be reduced the adjacent sup-
porting bones (components of the ethmoidal lab-
yrinth) do not support the nasal bones because of
their brittleness. It is always better to reconstruct
and stabilise the anterior table of the frontal bone
so that other parts of nasal skeleton can derive
support from it. Formerly transnasal wires were
Image showing fractured nasal bone being used to fix the nasal bones, but with the advent of
kneeded back into position plates and screws the whole scenario has under-
gone a dramatic change.
If the fractured fragments are impacted then a
Welsham’s forceps will have to be used to disim-
pact and reduce the fractured nasal bone. In the
event of using Welsham’s forceps to disimpact
the nasal bone, there will be extensive trauma
to the nasal mucosa causing epistaxis. The na-
sal cavity of these patients must be packed with
roller gauze, with application of an external splint
to stabilise the bone. In these patients it is also
imperative to elevate the collapsed nasal septum
using Ash forceps.
After successful reduction the nasal cavity should

be packed with antibiotic ointment impregnated
gauze.
Open reduction:
Indications: Image showing Ash forceps being used to disim-

pact the nasal septum
1. Extensive fractures associated with dislocation

Nasal injuries in children:
Ellis procedure of management of Class III frac-
tures: Children’s nose is mostly cartilaginous in nature
containing small bones that are soft and more
Aims of the procedure include: compliant more capable of absorbing forces
due to injury. It is also a common fact that birth
1. Provision of adequate surgical exposure to trauma could be the cause for septal deviations in
provide an unobstructed view of all components these patients. Septal hematoma is more common
of the fracture. in children.
2. The medial canthal ligament should be identi-
fied. This is rarely avulsed and is usually attached In children it is better to avoid open reduction
to a large fragment of bone. Once identified the procedures and stick to closed manipulation
ligament should be reattached and secured to techniques. Digital manipulation is the best
the lacrimal crest. This step will avoid the future technique. While attempting to perform digital
development of telecanthus. reduction manipulation the surgeon should be
3. Reduction and reconstruction of medial orbital aware that the feel of bone snapping back into
rim. place is not evident in children. Careful
This can be achieved by use of transnasal 26 visual assessment of the shape of the nose is a
gauge wires. If plates are used they should be very must to ascertain adequacy of reduction.
thin otherwise they will become conspicuous
once the wound has healed. Fracture zygoma Management
4. Reconstruction of medial orbital wall and floor
with bone grafts Zygoma is a very crucial component which main-
5. Realignment of nasal septum tains facial contour. Fractures involving zygoma is
6. Augmentation of dorsum of the nose by the use very common, in fact it is the second most com-
of bone grafts mon facial bone to the fractured following facial
7. Accurate soft tissue readaptation should be trauma (next only to nasal bones). Fractures
encouraged by placing splints. involving maxilla not only creates cosmetic de-
formities, it also causes disruption of ocular and
Complications of nasal bone fracture: mandibular functions too. This article attempts
to discuss in detail the etiopathogenesis and the
1. Cosmetic deformity (saddle nose, pig snout various management options available. It also
deformity). This is actually common in patients includes our 3 years’ experience in treating these
who have septal hematoma following injury to patients at Stanley Medical College Chennai.
nasal bones. During the period of 3 years between 2010 - 2012
2. Persistent septal deviation about 82 patients got treated in our institution for
3. CSF leak Faciomaxillary trauma.
4. Orbital oedema / complications
5. Nasal block / compromise of nasal functions Introduction:
Zygoma plays a vital role in maintaining facial
246
contour. This is because the facial contour is di- bones and their attachments to one another. The
rectly influenced by underlying bony architecture. central midface contains many fragile bones that
could easily crumble when subjected to strong
1. Fracture and dislocation of this bone not only forces. These fragile bones
causes cosmetic defects but also disrupts ocular are surrounded by thicker bones of the facial but-
and mandibular functions too. The zygomatic re- tress system lending it some strength and stability.
gion is a prominent portion of the face next only
to the dorsum of the nose. This predisposes this Components of Buttress system:
bone to various trauma.
For better understanding the components of the
2. The bony architecture of this bone is rather facial buttress system have been divided into:
unique, it enables it to withstand blows with
significant impact without being fractured. At the 1. Vertical buttresses
most it gets disarticulated along its suture lines. 2. Horizontal buttresses
Fractures can involve any of the four articulations
of zygoma which include zygomatico-maxillary Vertical buttress:
complex, zygomatic complex proper, orbitozy-
gomatic complex. Fractures involving zygoma These buttresses are very well developed.
should be repaired at the earliest because it can They include:
cause both functional and cosmetic defects. Im-
portant functional defects involving this bone is 1. Nasomaxillary
restriction of mouth opening due to impingement 2. Zygomaticomaxillay
on the coronoid process. 3. Pterygomaxillay
4. Vertical mandible
3. It is hence mandatory to diagnose and treat this Majority of the forces absorbed by midface are
condition properly. It is also important to reduce masticatory in nature. Hence the vertical buttress-
this fracture and fix it accurately, because skele- es are well developed in humans.
tal healing after inadequate reduction can cause
reduced projection of malar region of the face Horizontal buttresses:
leading on to cosmetic deformities. Accurate as-
sessment of position of the fractured bone should These buttresses interconnect and provide sup-
be performed in relation to skull base posteriorly port for the vertical buttresses.
and midface anteriorly. This assessment is very They include:
important before reduction is attempted to ensure 1. Frontal bar
accurate reduction of the fractured fragments. 2. Infraorbital rim & nasal bones
3. Hard palate & maxillary alveolus
Importance of facial buttresses in fracture of mid-
dle third of face:
The buttress system of midface is formed by

strong frontal, maxillary, zygomatic and sphenoid

This classification suggested by Knight etal in
1961 helped to determine prognosis and optimal
treatment modality for these individuals.
Group I fractures:
In these patients fracture lines in zygoma could

be seen only in imaging. There is absolutely no
displacement. These patients could ideally be
managed conservatively by observation and by
asking the patient to eat soft diet.
Group II fractures:
This group includes isolated fractures of the arch
of zygoma. These patients present with
trismus and cosmetic deformities.
Group III fractures:

This include unrotated fractures involving body
of zygoma.
Image illustrating the Buttress system of the Group IV fractures:

facial skeleton This involves medially rotated fractures of body
of zygoma.
Classification of zygoma fracture:
Group V fractures:
Leefort classification: This involves laterally rotated fractures of body of
zygoma. This type of fracture is very unstable and
1. Non displaced – Symptomatic treatment. No cannot be managed by closed reduction. Open
reduction necessary reduction will have to be resorted to.
2. Displaced – Closed reduction is necessary
3. Comminuted – Open reduction is necessary Group VI fractures:
4. Orbital wall fracture – If ocular symptoms pre- This is complex fracture. It has multiple fracture
dominate it should be attended first. After lines over the body of zygoma. This condition is
oedema subsides then open reduction can be difficult to manage by closed reduction. Open
attempted. reduction and microplate fixation is indicated in
5. Zygomatic arch fracture – Open reduction with these patients. This type of fracture should not be
stablization using micro plates / wiring. managed by closed reduction alone because the
presence of oedema / haematoma would mask the
Knight & North classification: cosmetic deformity giving an impression that re-
duction has occurred. After reduction of oedema
248
and followed by the action of masseter the frac- mouth. Repair of fractures involving this area
tured fragment may distract making the cosmetic should be carried out through multiple approach-
deformity well noticeable. es which include:
Mason’s classification of fracture zygoma: Bicoronal approach

Intraoral approach
Mason etal used CT imaging to classify various Eye lid approach
forms of fracture zygoma. CT imaging provides
the most accurate information about facial skele- Studies reveal that primary bone healing allows
ton. Fractures involving facial bones, their posi- quicker and stronger bone formation than callous
tions, whether it is displaced or not can be clearly healing. Rigid fixation of fractured fragments
seen in CT scan images. promote primary healing in preference to callous
formation. While performing open reduction it
Mason classified fractures involving zygoma into: should be borne in mind that Titanium plates are
preferred to biodegradable ones when the process
1. Low energy injury of reduction leaves small gaps between fractured
2. Medium energy injury fragments.
3. High energy injury
Clinical features:
Low energy injury:
1. Anaesthesia / Paraesthesia of that side of the
Low energy fractures involving zygoma involves face
minimal or no displacement of fractured frag- 2. Inability to open the mouth
ments. In this group of patients fractures are 3. Flattening of zygomatic area
commonly seen in the frontozygomatic suture 4. Diplopia
line. This area is very stable and hence fractures 5. Subconjunctival haemorrhage
involving this area can be treated conservatively. 6. Eye lid oedema
7. Periorbital haemorrhage
Middle energy injury: 8. Lateral canthal dystopia
9. Ipsilateral epistaxis
Fracture zygoma due to middle energy injury 10. Buccal sulcus haematomas
causes fractures of all its supporting buttresses. 11. Enopthalmos in orbital floor fractures
There may be mild to moderate displacement
and comminution. These patients invariably need Opthalmic examination is a must if any of the
eyelid / intraoral approach for adequate reduction opthalmic manifestations of fracture of zygoma
and fixation of fracture. is seen. In the presence of ruptured globe, retinal
detachment and traumatic optic nerve atrophy
High energy injury: management of ophthalmic manifestations take
precedence over fracture reduction procedure.
This injury frequently causes Lefort fractures.
These patients have difficulty in opening their

Axial CT image of nose and sinuses showing Image showing reduction being performed via
fracture of zygoma with medial displacement intraoral route
(stable)
Orbital exploration is indicated in the following
circumstances:
1. Severe comminution
2. Displacement of orbital rim
3. Displacement of greater than 50% of the orbital
floor with prolapse of orbital contents into the
maxillary sinus
4. Orbital floor fracture of greater than 2 cm2
5. Combination of inferior and medial orbital
wall fractures
6. Suspected involvement of orbital apex
Our patients commonly presented with cosmetic
defect of the malar area, followed by trismus.
Image showing depressed fracture of zygoma Isolated zygomatic arch fracture:

(medial displacement)
This fracture can be managed easily without the
necessity of internal fixation / splinting if reduc-
tion is performed within the span of 72 hours
250
following injury. Fractures involving zygomatic
arch can cause inability of movement of mandi-
ble. These fractures can be reduced using Gillie’s
temporal approach or Dingman’s supraorbital ap-
proach. Other approaches include Buccal sulcus
approach.
Ruler test:
This is a rather useful clinical test to identify

patients with fracture of zygoma. Two rulers are
used as shown in the figure below to perform this
test. These rulers are placed in front of the ears.
Ruler is found to deviate on the side of fracture.
Image showing incision for Gillies procedure
Image showing ruler test being performed
Gillie’s technique of reducing fracture zygoma:
Small incision is made over temporal area super-

ficial temporal artery is avoided.

Image showing Auricularis superior muscle is cut
along the line of its muscle fibers
Image showing Periosteal elevator is inserted

through the incision and the fractured fragment
is elevated. A gauze piece is used as a leverage
Image showing temporalis fascia cut with a knife
252
Image showing fracture arch of zygoma being
reduced
Image showing two point fixation
Zygomatic complex fractures:
These fractures are invariably managed by open

reduction with two point / three point fixation. Two point fixation is sufficient in a majority of
patients. Rarely when fracture is extensive and
Surgical procedure is performed usually after associated with lateral displacement of fractured
4- 6 weeks following injury. If fractures are more fragments three point fixation need to be resorted
than 3 months old then osteotomy will have to be to.
performed. Bone grafts need to be used to per-
form accurate repair. Usually two point fixation Bicoronal approach may be used to approach this
is sufficient in majority of patients. Two point area for open reduction purposes. Eye brow inci-
fixation involves microplate fixation at zygomati- sion / transconjunctival incisions can also be used
co-frontal and zygomatic arch areas. When using to access this area.
microplates for zygomatico-frontal area care
should be taken to position it slightly posteriorly
so that untoward subcutaneous projection of the
plate can be avoided.

tetrapod structure.
This type is subdivided into three subgroups:

Type A1 zygomatic arch alone is fractured.
Type A2 fracture of lateral orbital wall.
Type A3 fracture of inferior orbital rim
Type B fracture:
This type of fracture involves all 3 buttresses. Also
known as Tripod fracture. This fracture will have
to be treated by two point fixation / three point
fixation techniques.
Type C fracture:
These are comminuted fractures involving zygo-
ma.
Orbital floor is the weakest component of the zy-
Image showing three point fixation gomatic-maxillary complex. Type A3, B and C are
associated with fracture of the floor of orbit with
As shown in the figure three point fixation risk of injury to orbital contents.
includes fixing:
1. Frontozygomatic suture
2. Infraorbital rim
3. Zygomatico maxillary buttress
Classification of zygomatico-maxillary complex

fractures:
Zingg’s classification:
Zingg in 1992 had separated zygomatico-maxil-

lary complex into three types:
1. Type A
2. Type B
3. Type C
Type A :
This type is associated with one component of the
254
Blow out Fracture
Introduction:
Blow out fracture of orbit is defined as fracture

of one or more of its internal walls. This injury
is typically caused by blunt trauma to orbit. In
pure terms this definition does not involve the
orbital rim. If fracture of orbital rim is associated
with fractures of one or more of its internal walls
then the term complex blow out fracture is used.
Even though there is nothing complex about it,
this term is used to stress the importance of non
involvement of orbital rim in blow out fracture. Image showing bony anatomy of orbit
Blow out fracture is actually a protective mech-
anism which ensures that sudden build up of The medial canthal tendon attaches via a thick
intraocular pressure which could be detrimental limb to the anterior lacrimal crest and by a
to vision does not occur following frontal injury thinner limb to the posterior lacrimal crest. This
to orbit. thinner limb contains the Horner’s muscle. Simi-
larly the lateral canthal ligament also contains two
History: limbs.
Blow out fracture of orbit was first described by The thin anterior limb blends with the orbicularis
Lang in early 1900’s. The exact description of the oculi muscle and the periosteum of lateral orbital
fracture and the terminology (blow out fracture) rim. The thicker posterior limb gets attached to
was first coined by Converse and Smith. It was the Whitnall’s tubercle of the zygoma. The medial
infact Smith who first described inferior rectus canthal tendon is intimately related to the lacri-
entrapment in between the fractured fragments, mal system.
causing decreased ocular mobility.
The upper and the lower puncta begin 5 – 7 mm
Anatomy of orbit: lateral to the medial canthus and continue as
common cannaliculus into the lacrimal sac lo-
A brief discussion of anatomy of orbit will not be cated between the anterior and posterior limbs of
out of place here. Bony orbital cavity is formed by medial canthal tendon within the lacrimal fossa.
contributions from:
The lacrimal sac empties its contents into the in-
1. Lacrimal bone ferior meatus through the nasolacrimal duct. The
2. Orbital process of maxilla lacrimal gland is located in the lateral portion of
3. Orbital process of zygoma the upper lid. It is divided into a larger orbital and
4. Orbital process of frontal bone smaller palpebral portion by the lateral horn of
5. Ethmoid bones levator aponeurosis. Anteriorly the gland’s orbital

portion is in contact with the orbital septum. Buckling theory: This theory proposed that if a
force strikes at any part of the orbital rim, these
Extraocular muscles: Include 2 oblique and 4 forces gets transferred to the paper thin weak
rectus muscles. The superior oblique muscle due walls of the orbit (i.e. floor and medial wall)
to its oblique course is in direct contact with the via rippling effect causing them to distort and
periorbita of the roof, and medial wall of orbit at eventually to fracture. This mechanism was first
the level of trochlea. All the 4 recti muscles arise described by Lefort.
from the annulus of zinn and gets inserted into
the sclera.
Classification of blow out fracture:
1. Orbital floor blow out fracture - Commonest

2. Medial wall blow out fracture – This is rare
even though it is lined by the paper thin lamina
papyracea, because of the support it receives from
the bony Ethmoidal labyrinth.
3. Superior wall blow out fracture – rare
4. Lateral wall fracture – involves zygoma
Signs of blow out fracture:
1. Periorbital ecchymosis (very commonly seen in

blow out fractures)
2. Disturbances of ocular motility
3. Enophthalmos Image showing the direction of forces causing a
4. Infraorbital nerve hypoaesthesia / anesthesia blow out fracture
Puttermann in 1974 firmly believed that no
patient with blow out fracture of orbit should un- Hydraulic theory: This theory was proposed by
dergo surgical reduction before 4 -6 weeks after Pfeiffer in 1943. This theory believes that for blow
injury. He firmly out fracture to occur the blow should be received
believed that given time tissue oedema and hema- by the eye ball and the force should be transmit-
toma will regress improving patient’s condition. ted to the walls of the orbit via hydraulic effect.
Theories accounting for blow out fracture: The So according to this theory for blow out fracture
exact mechanism causing blow out fracture is yet to occur the eye ball should sustain direct blow
to be elucidated. Two theories have been going pushing it into the orbit. Water House in 1999 did
around for quite sometime. They are: a detailed study of these two mechanisms by ap-
1. Buckling theory plying force to the cadaveric orbit. He infact used
2. Hydraulic theory fresh unfixed cadavers for the investigation.
256
He described two types of fractures: A complete ophthalmic examination is a must in
all these patients.
Type I: A small fracture confined to the floor of
the orbit (actually mid medial floor) with her- Indications for surgical repair:
niation of orbital contents in to the maxillary 1. Persistent diplopia in the primary position of
sinus. This fracture was produced when force was gaze
applied directly to the globe (Hydraulic theory). 2. Symptomatic disturbance of ocular mobility –
if persisting for more than 2
Type II: A large fracture involving the floor and weeks is considered to be an absolute indication
medial wall with herniation of orbital contents. by many. This two week window is considered
This type of fracture was caused by force applied because it is the time taken by edema / hemato-
to the orbital rim ma of orbit to resolve. Two weeks after the injury
(Buckling theory). fibrosis and adhesions begin to
develop. Any surgery performed before develop-
Clinical features of blow out fracture: ment of adhesions / fibrosis has best results.
3. Radiological evidence of extraocular muscle
. Intraocular pain entrapment
. Numbness of certain regions of face 4. Enophthalmos of more than 2 mm
. Diplopia 5. Large fractures involving the floor of the orbit
. Inability to move the eye (more than 50% of the floor is involved)
. Blindness 6. Infraorbital nerve hypoaesthesia / anesthesia
. Epistaxis 7. Presence of oculo cardiac reflex (common in
trap door type of fracture).
Patient may also show signs of:
Surgical repair should be performed immediately
. Enophthalmos – This can be measured objec- in these patients.
tively by Hess charts and Binocular single vision.
. Oedema Surgical repair should be delayed:
. Haematoma 1. When there is presence of hyphema
. Globe displacement 2. Ocular rupture
. Restricted ocular mobility 3. Extensive oedema
. Infraorbital anesthesia
Causes of ocular motility disturbances:
Proptosis in these patients is sinister because it
indicates retrobulbar / peribubar hemorrhage. 1. Intraorbital tissue hemorrhage – usually re-
Pupillary dysfunction associated with visual solves during the first week of injury
disturbances indicates injury to optic nerve and 2. Intraorbital tissue oedema – resolves during the
it is an emergency. Patient must be taken up for second week of injury
immediate optic nerve 3. Entrapment of extraocular muscles
decompression to save vision. 4. Entrapment of orbital fat
5. Direct damage to extraocular muscles – causes

adhesions and scarring within two weeks of inju-
ry. This stage should be considered to be point of
no return as surgical results are poor.
6. Direct damage to nerve supply of extraocular
muscles
7. Direct damage to blood supply of extraocular
muscles
Blow out fracture involving orbital floor:
This is the commonest type of blow out fracture

encountered. The floor of the orbit is divided in
to medial and lateral segments by the Infraorbit-
al nerve. The segment of the floor medial to the
nerve is larger and more fragile, hence is com-
monly involved in blow out fractures.
Boundaries of medial segment of orbital floor:

1. Inferior orbital fissure – posteriorly
2. Bony canal of Infraorbital nerve – laterally
3. Orbital rim – anteriorly
4. Inferior aspect of lamina papyracea (Laminar Image showing clinical photograph of a patient
bar) –medially with blow out fracture right orbit
Lateral segment of the floor of orbit: Classification of orbital floor fractures:

This segment is smaller, thicker and stronger than
the medial segment of orbital floor. Fractures According to fracture patterns, fractures involv-
involving this segment are pretty rare. ing orbital floor may be classified into three types.
This classification helps in deciding the optimal
management modality.
1. Trap door type – This type of fracture occurs

when a large fragment of the medial floor of the
orbit is fractured and remains still attached to
the laminar bar medially. This fracture resembles
a trap door hinged at the laminar bar (lamina
papyracea).
2. Medial blow out – This type of fracture occurs
when there is bone disruption between the lami-
nar bar and the Infraorbital nerve.
3. Lateral blow out – This type of fracture causes a
258
comminution from the laminar bar to the lateral graphs, hence CT scan is diagnostic.
orbital wall.
Imaging:
X -ray paranasal sinuses:
May show the classical “tear drop sign” of pro-

lapsed orbital contents. The fractured fragment
may also be visible. The corresponding maxillary
sinus may appear hazy due to the presence of
hemosinus.
Image of Coronal CT paranasal sinuses showing

tear drop sign in the right orbit
Clinical features of fracture medial wall:
1. Periorbital oedema
2. Ecchymosis
3. Subcutaneous emphysema due to escape of air
from ethmoid sinus in the periorbital space
4. Epistaxis
5. Enophthalmos – According to Pearl enophthal-
mos is worse in medial blow out fractures than
fractures involving other walls of orbit.
Image showing classic tear drop sign in xray Classification of medial wall of orbit:
paranasal sinuses Type I – Pure medial wall of orbit fracture
Type II – Medial wall and floor of orbit fracture
CT scan is diagnostic. Type III – Fractures involving medial wall, floor
Blow out fracture involving the medial wall of of orbit and trimalar fracture
orbit: Type IV – Fractures involving medial wall, floor
Fractures involving medial wall of orbit may of orbit, maxillary, naso orbital, and frontal bones
occur alone or as part of more complex orbital
fractures. Pure medial wall fractures are really
rare. Fractures involving
medial orbital wall may be missed in plain radio-

Image showing type I fracture of medial orbital Image showing type III fracture of medial orbit-
wall al wall
Image showing type II fracture of medial orbital

wall
Image showing type IV fracture of medial orbital

wall
260
to decide the optimal management modality. A
These classification systems are based on CT scan brief review of anatomy of lateral orbital wall
findings. wont be out of place here. The lateral orbital wall
is formed by the zygomatic bone anteriorly. This
Type I medial orbital wall fractures are commonly bone is responsible for mid face prominence. The
caused by assault, while other types of fractures posterior wing of sphenoid forms the posteri-
are caused by road traffic accidents. or portion of the lateral orbital wall along with
the anterior corner of the middle cranial fossa.
Visual disturbances were commonly seen in type Fractures involving the greater wing of sphenoid
I, II, and III fractures involving the medial wall of is very rare.
orbit, and is very rare in type IV fractures.
Articulation between the zygomatic bone and
Eye ball injuries are common in type II fractures greater wing of sphenoid is very broad and is the
of medial wall. Diplopia and enophthalmos are commonest site in fractures involving lateral or-
commonly seen in type II fractures. bital wall. Fractures involving lateral wall of orbit
is also associated with disruption of zygomatic
Displacement of orbital walls and herniation of bone articulations with frontal, temporal and
soft tissues were quite high for type I, type II and maxillary bones.
type IV injuries. It is very uncommon in type III
injuries, suggesting that when there is associated Clinical features:
malar fracture then the fragments are more linear
without any displacement. 1. These patients have varying degrees of mid face
deformities
Type I fractures can be repaired using fronto 2. Displacement of lateral orbital wall has a dra-
ethmoidal lesion / Lynch Howarth and reduction matic effect on the position of the eye. The lateral
of prolapsed orbital contents and supporting the orbital rim is approximately at the equator of the
wall using Marlex mesh, whereas other types of globe.
fractures involving medial orbital wall can be re- Infro lateral displacement of the lateral orbital
paired by subciliary / transconjuctival approach- wall will have significant change in the position of
es. the orbit when compared to that of simple infra-
orbital floor blowout fracture.
Fractures involving lateral orbital wall: 3. Visual loss may occur due to injury to the optic
nerve. Whenever there is visual loss then retro-
Fractures of lateral orbital wall is always associat- bulbar hemorrhage, penetrating foreign body
ed with fractures of zygoma and malar complex- or bony fragment impinging on the optic nerve
es. This fracture is common in adults and is very should be considered.
rare in children. 4. Lateral canthal dystopia
This fracture should be suspected in all patients 5. Ecchymosis
who have severe facial injury. 6. Subconjunctival hemorrhage
Imaging is a must not only for diagnosis but also Axial and coronal CT scans should be taken in all

these individuals. ary incisions.
Management: Zygomaticomaxillary buttress can be accessed via

Repair of open globe injuries takes precedence buccogingival incision. To reduce comminuted
over fracture reduction. In patients fractures of zygoma a temporal / coronal incision
with globe injuries fracture reduction can always may be used. Use of resorbable plates and screws
be delayed. If intraocular pressure is found to be is advisable in young children who have actively
very high, bedside lateral canthotomy / cantholy- growing bones.
sis should be
performed immediately to reduce the tension. If For non comminuted fractures of zygoma a two
done immediately this procedure will save vision point fixation with titanium miniplate is advis-
in a majority of these patients. If the orbit appears able. The first point is ideally in the infra orbital
tense and tight surgical evacuation of orbital he- rim and the second point over the frontozygo-
matoma should be resorted to. matic suture line is desirable.
Specific management of these fractures are de- Orbital roof fractures:

pendent on the following factors:
Orbital roof fractures always occur together with
1. Degree of displacement of fractured fragments that of frontal roof fractures. It can cause diplo-
2. Comminution of fracture pia due to intraocular muscle entrapment. These
3. Intracranial extension of sphenoid fracture patients may also present with enophthalmos /
Non displaced / mildly displaced fractures can exopthalmos. The commonest cause of diplopia
be managed conservatively. If fracture causes in these patients is the entrapment of connective
displacement with visual loss / ocular motility tissue around superior rectus within the frac-
disturbance, enophthalmos, flattening of malar tured bony fragments. It is just sufficient if this
eminence fracture repair is indicated. Before entrapped tissue could be freed by endoscopically
actually embarking on surgical repair preexisting removing the fractured bony fragments.
corneal incision wounds need to be evaluated for
possible leak during surgery. Although there may Surgical approach to orbit:
not be significant elevation of intra ocular pres-
sure aqueous fluid may leak through preexistent Orbital cavity can be accessed by various surgical
corneal wounds causing collapse of the globe. It approaches. These approaches can be classified
always pays to repair corneal wounds if any be- according to the area of orbit that becomes acces-
fore the actual reduction procedure. sible.
Before surgery a forced duction test should al- 1. Approaches to lateral wall and orbital roof
ways be performed to rule out intraocular muscle 2. Approaches to medial wall of orbit
entrapment. 3. Approaches to the floor of the orbit
Lateral upper eyelid crease incision can be used to
expose zygomaticofrontal suture line. Infraorbital
rim can be exposed via transconjuctival / subcili-
262
Approaches to lateral wall and orbital roof in- Upper blepharoplasty:
clude:
a. Lateral brow incision First the supratarsal fold is marked. It is typically
b. Upper blepharoplasty incision 8-9 mm above the ciliary line. Xylocaine with
c. Coronal incision adrenaline is injected subcutaneously, down to
the lateral orbital rim at the zygomaticofrontal
Lateral brow incision: Is suited for exposing fron- suture. Skin is incised, and the underlying orbicu-
tal and zygomatico sphenoid sutures. The lateral laris oculi muscle should be divided parallel to its
portion of the superior orbital rim is also exposed fibers. This is ideally done using scissors. Dissec-
well by this incision. The brow incision is placed tion is then performed in a plane superficial to
just below the hair follicles of lateral 2-3 cm of the the orbital septum and lacrimal gland, until the
upper eyebrow. lateral orbital rim and zygomaticofrontal suture
as needed. The advantage of this approach is the
cosmetically acceptable scar.
Coronal approach:
This approach provides excellent access to medial,

superior and lateral walls of orbit, as well as the
zygomatic arch. It gives excellent access to both
orbits and dorsum of the nose.
The coronal incision begins at the upper attach-

ment of helix and extends transversely over the
Image showing lateral brow incision and blepha- skull vault to the opposite side. The incision
roplasty incision slightly curves forwards over the vertex of the
skull just behind the hair line. This incision can
Before placing the incision lateral brow approach also be extended to the preauricular area to
xylocaine is infiltrated inferior and parallel to the expose the zygoma and zygomatic arch. The line
lateral border of the upper eyebrow. Incision is of incision should be marked previously and
made just below the upper eyebrow with 15 blade. infiltrated with xylocaine mixed with 1 in 100,000
The incision is deepened and carried through units adrenaline. The flap is raised leaving the
skin and orbicularis oculi. The periosteum over periosteum intact.
lateral orbital rim is sharply
dissected and elevated using a Freer’s elevator. Raney clips (liga clips) are applied to the edges
of the flap to secure hemostasis. The perioste-
Major disadvantage of this approach is the scar- um is incised about 3 cm above the supraorbital
ring which takes place. That is the reason why ridges, and the dissection should be continued in
upper blepharoplasty approach became popular. the subperiosteal plane. Care should be taken to
release the supra orbital neuro vascular bundles
from the notch / foramen.

very simple one and easy to perform. The inci-
This subperiosteal dissection is continued inferi- sion area is marked and infiltrated with xylocaine
orly till naso ethmoidal and naso frontal sutures mixed with 1 in 100,000 units adrenaline. Ideally
are exposed. Laterally the dissection follows the the incision should hug the infra orbital rim. Or-
outer layer of temporalis fascia till about 2 cms bicularis oculi muscle should be slit along its long
above the zygomatic arch. At the level of the arch axis. Orbital contents are retracted to expose the
of zygoma the temporalis fascia splits to enclose floor of orbit. This approach gives rise to post op-
temporalis muscle. At this point an incision erative oedema. This incision also causes visible
which runs antero superiorly at 45 degrees is scar just below the lower eyelid.
made over the superficial layer of temporalis
fascia. This is done to spare the frontal branches
of facial nerve.
This incision is connected anteriorly with the lat-

eral or posterior limb of the supraorbital perioste-
al incision.
The plane of dissection deep to the superficial lay-

er of temporalis fascia is carried inferiorly till the
zygomatic arch is reached. The periosteum in this
area is incised and reflected over the zygomat-
ic arch, zygoma, and lateral wall of orbit. After
satisfactorily reducing the fracture the wound is
closed in layers.
Disadvantages of this approach: Image showing transcutaneous incision for orbit-

al floor exposure.
1. Extensive incision
2. Alopecia Subciliary / Subtarsal approaches to orbital floor:
3. Numbness of forehead area
4. Injury to temporal branch of facial nerve Converse originally described this incision as an
approach to orbit in 1944. He was also instru-
Surgical approaches to orbital floor have been mental in devising a variant of this incision i.e.
classified into: subtarsal approach. Both of these incisions are
1. Transorbital – Transcutaneous, Transconjuncti- types of transcutaneous incision. For this incision
val and subciliary approaches local anesthesia mixed with adrenaline is infiltrat-
2. Transantral – includes endoscopic approach ed subcutaneously into the lower eyelid along the
3. Combined approach infra orbital rim. A lateral temporary tarsorha-
phy is performed to protect the orbital contents
Transcutaneous orbital rim incision is usually during the procedure. A subciliary cutaneous
given just below the lower eyelid. This approach is incision is made 2mm below and parallel to the
264
eyelash line. This incision is usually performed
using a 15 blade. Medially this incision should
fall short of the punctum, while laterally it can be
extended even up to 15 mm beyond the lateral
canthus. The lateral extension of this incision is
preferred should be extended horizontally and
not inferiorly in order to promote formation of
aesthetically acceptable scar.
Dissection proceeds in the subcutaneous plane

superficial to orbicularis oculi muscle. At the level
of lower end of tarsal plate orbicularis oculi mus-
cle is divided parallel to the direction of muscle
fibers. Orbicularis oculi muscle over the tarsal
plate should be protected to maintain lower lid
structure and support. The dissection now follows
the preseptal plane down to the level of orbital
rim. The periosteum is incised over the anterior
portion of infraorbital rim. This elevation of
the periosteum proceeds up to the level of orbital Image showing subciliary and subtarsal ap-
floor. proaches
In subtarsal variation of this procedure the inci- Transconjunctival approach to orbit: This meth-
sion is sited in the subtarsal fold about 5-7 mm od was popularized by Tessier. Converse etal
below the eyelash line. After repair a Frost suture reported treating a series of patients with blow
is applied to support the lower eyelid. out fracture involving the floor of the orbit using
this incision. This is the most preferred approach
Advantages of this approach: for orbital surgeries because of low complication
rates and excellent cosmesis. In this method the
1. Easy to perform lower eye lid is pulled forward. To increase the
2. Gives broad access to the floor of orbit laxity a lateral canthotomy should be performed.
Disadvantages include: Lateral canthotomy: is performed by incising the

skin, subcutaneous tissue and orbicularis oculi
1. Lower lid malposition muscle horizontally. The incision should ideally
2. Scarring of lower eyelid be sited in the skin crease of the outer canthal re-
gion. The lateral canthal tendon is visualized and
its inferior limb alone is severed.

orbit and the defect can be closed using appropri-
ate prosthesis.
The major advantage of this procedure is there is

virtually very minimal scar formation. It is very
quick to perform and involves no skin, muscle
dissection.
Dissection in the plane of orbital septum is
avoided, hence there is very minimal chances of
vertical shortening of lower eyelid. The only dis-
advantage is the limitation of access to the medial
portion of the orbital floor.
Image showing canthotomy being performed In cases of blow out fractures involving the
medial portion of the floor of the orbit Cald-
Two methods can be performed via this incision. wel luc procedure can be performed to reduce
the fracture fragment. Nasal endoscope can be
1. Preseptal method and introduced through the caldwel luc fenestra to
improve visualisation.
2. Retroseptal method.
The prolapsed orbital contents are freed and
Preseptal method: In this method incision is reduced. Fractured fragments repositioned if
made at the edge of the tarsal plate to create a possible and stabilized using plate and screws. If
space in front of the orbital plate to reach the defect is large prosthesis can be utilized to stabi-
orbital rim. The floor of the lize the orbital floor.
orbit is reached by dissecting the Muller’s muscle
and the eyelid fascia. Dissection then proceeds
between orbital septum and orbicularis oculi
muscle. The periosteum lining the infraorbital
rim should be excised and dissected to expose
completely the floor and lateral wall of the orbit if
necessary.
Retroseptal method: In this method an incision

is sited 2mm below the tarsal plate to reach the
orbital rim. Image showing transconjunctival incision
Either of the above methods grants access to the

floor of the orbit. Mild retraction is applied to the
globe to visualize the floor of orbit fully. Pro-
lapsed orbital contents can be pushed back into
266
caused by scarring that occurs in this area due to
Complications of transconjunctival approach to excessive tissue damage. Unipolar cautery when
orbital floor: used to make conjunctival incision should be
used in the lowest possible setting. Laceration and
1. Eye lid avulsion conjunctival tears should be avoided.
2. Button holing of lower eyelid
3. Canthal dehiscence While performing lateral canthotomy lysis of the
4. Cicatricial ectropion superior crus of lateral canthus should be avoid-
5. Entropion ed. Only the inferior crus should be lysed. More-
6. Lower eyelid retraction over while performing lateral canthotomy exces-
7. Scleral show sive incisions of conjunctiva should be avoided.
8. Hematoma
9. Prolonged chemosis It has been shown proper canthotomy avoids
10. Lacrimal sac laceration excessive traction of lower eyelid during surgery,
thus prevents lid lacerations.
Factors that can cause problems with transcon-
junctival approach:
1. Approach to the medial wall of orbit

2. Proptosis / orbital swelling
3. Severe chemosis
4. Severe swelling of lower eyelids
5. Laceration / trauma to conjunctiva
Protection of cornea is another vital aspect in

avoiding complications in transconjunctival ap-
proaches. This can be achieved by:
1. Placing plastic corneal shield Image showing lateral canthus exposed before
2. Use of Jaeger retractor which protects the cor- canthotomy
nea while retracting the orbit Placement of inci-
sion – This is also vital in avoiding complications.
The incision should ideally be placed between

the lower border of tarsus and the fornix. This
incision avoids injury to the tarsal plate and also
prevents scarring of
the orbital septum. Efforts should be taken to pre-
vent undue tissue damage in this area as scarring
in this area will lead to a lot of problems later. Image showing canthotomy performed
Majority of the complications of this procedure is

Image showing exposure of inferior conjunctiva
after placing traction sutures
Image showing subconjunctival dissection
Conjunctival incision marked with bipolar for-

ceps
Image showing periosteal incision
Image showing monopolar cautery used to incise

the conjunctiva Image showing subperiosteal dissection
268
Technical aspects of conjunctival closure:
Granulations have been found to occur when

there is improper healing of conjunctival suture
line. This eventually leads to scarring of fornix. To
avoid this complication limited closure of con-
junctiva has been resorted to. Only two sutures
are given using 6 – 0 catgut on either side of li
bus. Any extra sutures given always leads to prob-
lems of granulation in the area.
Resuspension of inferior canthal tendon:
Image showing orbital floor being exposed This is another important step in transconjuctival
procedures where lateral canthotomy has been
resorted to. If not performed properly canthal
migration has been known to occur in the inferi-
or direction. It is always better to use permanent
suture materials like Teflon impregnated braided
polyester suture material to suspend the inferi-
or canthal tendon. In case extensive dissection
was performed to expose the lateral wall of orbit
by stripping orbital periosteum in that area, the
inferior canthal tendon should be secured to
the lateral bony wall of orbit by using 30 gauge
wire. This will prevent canthal migration in these
patients. If both superior and inferior crura of
lateral canthal tendon were excised during sur-
gery then reconstruction gets a bit complicated.
Image showing fracture floor of orbit exposed In these patients the inferior crus must be reat-
tached to the lateral orbital wall just posterior and
superior to Whitnall’s tubercle. This is usually
done by using 30 gauge wires. Then only should
the superior crura should be reattached.
Image showing polyethylene implant

Reconstruction of lateral canthal angle:
This is another aspect of repair that should be

taken note of. After securing the inferior crura of
lateral canthal ligament reconstruction of lateral
canthal angle must be resorted to. This is usually
performed using absorbable sutures taking care to
line up the anatomic eyelid markers.
Resuspension of orbicularis muscle:
This is the next step that should be carefully

performed. The orbicularis muscle which was
elevated off the lateral orbital periosteum should
be resuspended carefully using 4-0 absorbable
sutures. Usually it is resuspended in an over cor-
rected position. This is done to allow for change
in position due to fibrosis. Image showing subciliary and subtarsal incisions
Frost stitch:
Endoscopic reduction / repair of blow out frac-
This stitch is usually used to splint the lower ture:
eyelid during the period of repair. This is usual-
ly a must in patients with excessive chemosis / Indications:
proptosis. This stitch is usually placed through
the lower eyelid and suspended from the fore- They are more or less identical to that of tradi-
head with the help of a tape at least for a period tional repair procedures. Indications include:
of three days following surgery. This provides 1. Isolated fractures involving the floor of the
excellent splinting to the lower eye lid during this orbit with extraocular muscle entrapment.
crucial phase of healing. 2. Preoperative Enophthalmos
3. More than 50% disruption of orbital floor
4. Trap door and medial blow out fractures of
floor of orbit respond the best to Endoscopic
repair.
In lateral blow out fractures of orbital floor En-
doscopic repair will jeopardize the Infraorbital
nerve as extensive dissection is necessary in that
area.
270
Procedure: injure dental roots, Infraorbital nerve and the
nasal aperture. As an alternative a bone saw can
Primary surgeon if he is right handed should be used to remove a 1 x 2 cms plate of bone from
stand to the right of the patient. The table is usu- the canine fossa area and can always be plated
ally turned 180 degrees from anesthesia equip- back in position after surgery is over. This proce-
ment. The assistant surgeon and the nurse should dure is considered more anatomical as the area of
be on the left side of the patient. Monitor should surgery is reconstructed.
be placed at the head end of the patient. Both the
surgeon and his assistant should have an unob- A retractor is used to retract the upper lip. Ideally
structed view of the monitor. a Greenberg retractor is best suited for the pro-
cedure because of its self retaining nature. If not
Incision: available a Langhan’s retractor can also be used.
Caution should be exercised while retracting the
The upper buccal sulcus on the side of injury is upper lip in not causing excessive traction to the
infiltrated with 2% xylocaine mixed with 1 in Infraorbital nerve.
100,000 units adrenaline. This infiltration helps
in elevation of soft tissue and periosteum from A 30 degree endoscope is introduced through the
the anterior portion of the maxilla. It also has antrostomy with the angulation facing upwards.
the added advantage of minimizing bleeding. A The entire floor of the orbit can be studied. If nec-
4 cm sub labial Caldwell incision is given in that essary the maxillary sinus can be irrigated with
area exposing the anterior wall of the maxilla. saline via the irrigation sheath of the endoscope
Dissection is performed in a subperiosteal plane and sucked out clearing blood clots and other de-
up to the level of Infraorbital foramen. Excessive bris from the maxillary sinus cavity. This step will
traction should not be exerted in the Infraorbital help in better visualization of the area of interest.
nerve area. The natural ostium of maxillary sinus can be
located in the postero superior portion of
A 4 mm antrostomy is performed over the ca- the medial wall of the sinus. The infra orbital
nine fossa are. This is the thinnest portion of the nerve could be seen as a while line running from
anterior wall of the maxilla. Boundaries of canine the orbital apex to the Infraorbital foramen. It is
fossa include: imperative on the part of the surgeon to identify
the maxillary sinus ostium and infra orbital nerve
1. Canine eminence medially before proceeding further, in order to avoid inju-
2. Maxillary tuberosity laterally ry to these structures.
3. Infraorbital foramen superiorly
4. Superior alveolar margin inferiorly Pulse test: This test is usually performed after
completely visualizing the floor of orbit as well
The antrostomy is widened using kerrison’s as the above mentioned vital intra sinus struc-
rounger. Final dimensions of antrostomy should tures. This test is performed while the floor of the
at least be 1 x 2cms and should lie about 2mm orbit is fully under Endoscopic view. Pressure is
below the Infraorbital foramen. When enlarging applied to eye ball causing mild displacement of
the antrostomy care must be taken not to the fractured floor of orbit. This can be visual-

ized endoscopically to assess the dimensions of fractured fragment. The lateral edge of the bone
fracture as well as the extent of prolapse of orbital flap is retracted inferiorly; the orbital fat will im-
contents. mediately prolapse into the maxillary sinus. This
fat tissue would have been entrapped within the
fractured fragments of bone. A periosteal eleva-
tor is used to gently reduce the prolapsed orbital
contents into the orbital cavity. The bone flap is
hinged back into position. Care should be taken
to ensure that this flap doesn’t entrap orbital fat /
Infraorbital nerve. Inter-fragmentary resistance
maintains the reduction in place. If there is frag-
mentation of the lateral edge of the bony flap then
Inter-fragmentary resistance may not be sufficient
to maintain the bone flap in position. Then this
procedure cannot be used and other methods of
stabilization of fracture should be resorted to.
Keys to Endoscopic repair of trap door fracture

include:
1. Meticulous dissection of lateral fracture mar-

gins
2. Minimal dissection over laminar bar, thus
Image showing plane of dissection in retroseptal maintaining stability of the hinge region
transconjunctival incision 3. Complete reduction of orbital contents
Endoscopic repair of trap door fracture: Endoscopic repair of medial blow out fracture:
In trap door fracture of orbital floor there is These fractures pose real challenges during En-
mild – moderate degree of orbital fat herniation. doscopic reduction. These fractures are usually
Strangulation of herniated orbital contents are comminuted and unstable, hence requires more
common in these patients. This area appears dissection and an implant for reconstruction of
endoscopically as enlarged and tense area. These orbital floor. About 5 – 7mm of maxillary sinus
fractures can be managed by reduction and re- mucosa should be dissected around the fracture
positioning of the fractured and displaced frag- taking care to protect the maxillary sinus osti-
ments. No prosthesis is necessary. As a first step um and the Infraorbital nerve. The entire cir-
in reduction of these fractures an angled elevator cumference of the fracture should be visualized.
is used to expose 5 – 7 mm of maxillary sinus Bleeding if any should be controlled using either
bone close to the lateral edge of the defect. Care oxymetazoline pledgets or adrenaline pledgets.
is taken not to disrupt the mucosa over the hinge
area as it would cause complete disruption of the All fractured fragments should be separated from
272
the periorbita and removed. After defining the
margins of fracture 3 – 5 mm dissection of the Postoperatively all patients should undergo CT
orbital surface of the defect is performed. This scan to ensure that no orbital fat / contents are
step releases the periorbita around the defect entrapped, and no bony fragments have been
to accommodate the implant. After this step a pushed into the orbit during placement of im-
greater degree of prolapse of orbital contents into plant.
the maxillary sinus cavity could be seen. This may
seem to be worse than the pre op condition, but is Patients with zygomatico - maxillary complex
to be expected. Silastic sheet of approximate size fractures also have orbital component injury. It
is introduced. The implant is resized and shaped should be borne in mind that there is a possibility
according to the size of the defect by trial and of orbital floor fracture worsening after reduction
error. It should be roughly 1.5 – 2 mm larger than procedures involving the zygoma component. All
the size of the defect. these patients must undergo Endoscopic exam-
ination of the orbital floor bearing in mind
Orbital contents are gently reduced using a peri- of this possibility. If there is also associated frac-
osteal elevator and the implant is inserted. The ture of orbital floor then it should be managed
implant is usually held in position by the orbital endoscopically.
rim and the posterior bony shelf. The implant
should ideally be positioned between the medial Combined Transconjunctival – Endonasal –
and lateral shelves. A pulse test should be per- Transantral approach:
formed to ensure that the implant is firmly in
place. A forced duction test should also be per- This approach is finding prominence in ophthal-
formed to rule out orbital content entrapment. mology literature. Important drawback of this
procedure is extensive removal of lateral nasal
Key points that must be borne in mind while wall to facilitate Endoscopic visualization. With
managing Medial blow out fracture endoscopical- the introduction of 70 degree endoscopes remov-
ly: al of lateral wall can be minimized.
1. The entire circumference of the defect should Procedure:

be visualized
2. All the fractured bone fragments should be Patient is placed supine with head in a slightly
removed because while inserting elevated position. The nasal cavity is packed with
a prosthesis some of them may be pushed into the 4% xylocaine and 1 in 10000 adrenaline. This
orbital cavity helps in decongesting the nasal mucosa as well as
3. Complete dissection and visualization of poste- reducing bleeding during surgery. Under Endo-
rior shelf is critical scopic guidance the lateral nasal wall is infiltrated
4. Medial fracture margin is difficult to define with 2% xylocaine with 1 in 100,000 units adrena-
because it is oriented vertically, hence aggressive line. The following structures should be removed:
dissection in this area should be avoided. 1. Uncinate process
5. The implant can be maintained in position by 2. Ethmoidal bulla
the anterior, posterior and lateral shelves. 3. Basal lamella

The tissues can be held in position by inflated
After removing these structures a partial poste- bulb of Foley’s catheter placed inside the max-
rior ethmoidectomy should be performed. The illary antrum and nasal packing. Merocel is the
condition of medial orbital wall is examined. A preferred nasal pack as it can be left in situ for
gentle push to the eye ball can be seen as bulging more than 2 weeks without any fear of complica-
of medial orbital wall through the nasal cavity. tions.
Similarly a gentle tug to the medial rectus muscle Caution: This approach is not suitable for small
will help in identification of entrapment of medial children with tooth buds in the anterior wall of
rectus muscle within the fracture fragments (this the maxillary antrum.
is called forced duction test). If the orbital con-
tents are found to be prolapsed through the defect
in the medial wall of orbit, then it must be gently
reduced. If forced duction test is positive then
the entrapped extraocular muscle (medial rectus
in this case) should be freed under Endoscopic
vision.
The Natural ostium of maxillary sinus is enlarged

both in the anterior and posterior directions. This
is done in order to visualize the floor of the orbit
through the maxillary antrum. A 70 degree 4mm
nasal endoscope is used to visualize the interior
of the maxillary sinus cavity. In case there is pro-
lapsed orbital tissue / Infraorbital nerve then an
incision is made in the palpebral conjunctiva just Image showing Diagrammatic representation of
below the tarsal plate. Dissection can be pursued Endoscopic view of fractured orbital floor via the
in the preseptal plane to reach the inferior border maxillary antrum
of the orbit. At the level of Infraorbital rim the
periosteum should be incised to gain access to the Materials used for reconstruction of orbit:
floor of the orbit. On reaching the orbital floor
the prolapsed tissue is reduced back into the orbit 1. Teflon sheets
by dual approach (above and below via the maxil- 2. Titanium meshes
lary antrum). Reduction via the maxillary antrum 3. Iliac bone crests
is performed under Endoscopic guidance. Orbital 4. Septal cartilage
floor should be reconstructed if the defect is more 5. Biomaterials made from polylactide polymers
than 2 cm. If there is Enophthalmos then medial
wall of the orbit should also be reconstructed. Preference of graft material depends on the sur-
Thin autologous iliac bone grafts are best suited geon’s choice and his experience with using such
for this purpose. prosthesis.
However ideal reconstruction material should
274
have the following features: 2. It can migrate posteriorly towards the orbital
apex causing further complications.
1. Material should be thin, strong and light on
weight
2. It should be easily cut and shaped
3. Once molded it should retain its shape
4. It should be radio opaque facilitating further
radiological studies
Implant related complications include:
1. Infection and extrusion of implants

2. Displacement / migration of implants causing
ectropion and diplopia
3. Lacrimal obstruction and epiphora
4. Capsular contracture over implants leading to
pain
5. Presence of implant may lead to chronic smol-
dering inflammation delaying the process of
normal healing
Advantages of titanium meshes as an implant
material: Image showing endoscopic view of blow out frac-
1. It is easy to trim and mould according to the ture orbit
dimensions of orbit. This feature is very pertinent
when dealing with combined blow out fractures
involving the floor and medial wall of orbit.
2. Its mesh like structure enables tissue to grow
around it as well as through the pores. This
affords a stabilizing effect to the graft material
preventing its migration
3. It has excellent tensile strength even when cut
to thin sizes. Hence can be safely used to bridge
large defects of orbital floor
4. It can be sterilized by conventional means
5. It produces less artifacts in CT images
Draw backs of titanium mesh:
1. It is very difficult to remove in cases of infec- Image showing the interior of maxillary sinus as
tion as the tissue would have grown around and viewed from canine fossa approach
through the pores of the mesh.

Image showing orbital content reduced and car-
Image showing prolapsed orbital content into tilage graft inserted to hold the contents inside
maxillary sinus cavity in bow out fracture the orbit
Image showing orbital contents being reduced

and fracture fragment replaced
276
Use of Foley’s catheter in anterior wall fractures vated over the anterior wall of maxilla. Fractured
of maxillary sinus fragments seen dislodged from the anterior wall
of maxilla can be repositioned with a plate and
Introduction: screw / metal wire.
Maxilla acts as a bridge between the skull base Inferior antrostomy is performed. 16 size Foley’s
superiorly and the dental occlusal plane inferior- catheter introduced through it and is inflated with
ly. It is associated intimately with the oral cavity, air until fracture segments are aligned. Foley’s
nasal cavity and orbits. This relationship makes catheter is removed after two weeks.
the maxilla an important structure both function-
ally and cosmetically. Fracture involving these
bones could lead not only to cosmetic disfigure-
ment but can also be life-threatening. Timely
and systematic repair of these fractures provides
the best chance to correct deformity and prevent
unfavourable sequel.
Image showing sublabial incision
Image showing anterior wall of maxilla as shown

in CT scan
Procedure:
Patient is placed in supine position. Head is

turned towards the opposite side. Infiltration of
gingivolabial sulcus is made using 2% xylocaine Image showing Foley’s catheter in place
with 1 in 100,000 adrenaline. Periosteum is ele-

injuries, falls and work related accidents. The
severity of facial fractures are directly related to
the degree of force applied and the velocity of
injury. Over 50% of severe Faciomaxillary injury
are accompanied by other associated injuries.
CLASSIFICATION OF MIDDLE THIRD FRAC-

TURES
Middle third fractures can be broadly classified as

A) Le fort I ,II ,III
B) Erich’s in 1942 , as per the direction of fracture
line- Horizontal , Pyramidal ,Transverse.
C) Depending on the relation of fracture to zygo-
matic bone –
Subzygomatic ,
Image showing patient on the day of discharge Suprazygomatic.
with Foley’s catheter in place D) Depending on the level of fracture – Low level
, Mid level ,High level.
Note:
Le fort classification of Maxillary Fractures:
Use air to inflate the bulb of Foley’s catheter.
René Le Fort described a classification of maxil-
Faciomaxillary trauma and upper airway injuries lary fractures in 1901 which is still used today,
are very common and pose problems in airway although fractures are usually of mixed types.
management. There may be associated injuries to Three predominant types were described.
the cranial fossae and brain, cervical spine, skele-
ton and chest. Hence a multidisciplinary manage- Le Fort I fractures (horizontal) also known as
ment involving otolaryngologists, oral surgeons Guerin’s fracture /floating fractures may result
and dentists, plastic surgeons, ophthalmologists, from a force of injury directed low on the max-
neurosurgeons, anaesthetists and trauma sur- illary alveolar rim in a downward direction. It
geons is what is to be coordinated and followed separates the palate from the remainder of the
rather than fragmented care. facial skeleton.
Faciomaxillary and upper airway injuries are due The fracture extends from the nasal septum to the
to sharp or blunt injuries to the head or neck. lateral pyriform rims, travels horizontally above
Sharp injuries usually result in lacerations and the teeth apices, crosses below the zygomatico-
penetrating injuries, whereas blunt injuries result maxillary junction, and traverses the pterygomax-
in fractures to the facial skeleton. Over 50% of illary junction to interrupt the pterygoid plates.
facial trauma are the result of motor vehicle ac-
cidents. Rest are due to physical violence, sports
278
Image showing Lefort I, II and III types of fractures
Le Fort II fractures (pyramidal/Subzygomatic

fractures) may result from a blow to the lower
or mid maxilla. Such a fracture has a pyramidal
shape and extends from the nasal bridge at or
below the nasofrontal suture through the frontal
processes of the maxilla, inferolaterally through
the lacrimal bones and inferior orbital floor and
rim through or near the inferior orbital foramen,
and inferiorly through the anterior wall of the
maxillary sinus; it then travels under the zygoma,
across the pterygomaxillary fissure, and through
the pterygoid plates.
Image showing Lefort I fracture

the pterygoid plates to the base of the sphenoid.
As it involves the ethmoid bone, it may affect the
cribriform plate at the base of the skull.
Image showing Lefort 3 fracture

Image showing Lefort 2 fracture
Despite the LeFort classification, maxillary
Le Fort III fractures (transverse/Suprazygomatic fractures may often be a mixed variety. Similarly,
fracture), also termed Craniofacial Dysjunc- facial fractures may be comminuted and may not
tions/”Dish-Face”deformity, and may follow im- be symmetrically distributed.
pact to the nasal bridge or upper maxilla; usually
as a consequence of superiorly-directed blows to Nevertheless, comminuted fractures usually
the nasal bones. follow the LeFort fracture lines. LeFort II and
III fractures involve the orbit and are frequently
These fractures start at the nasofrontal and fron- associated with orbital blowout fractures through
tomaxillary sutures and extend posteriorly which ocular muscles may herniate.
along the medial wall of the orbit through the
nasolacrimal groove and ethmoid bones. The
thicker sphenoid bone posteriorly usually pre- Acute Management:
vents continuation of the fracture into the optic
canal. Instead, the fracture continues along the The major concern during acute management of
floor of the orbit along the inferior orbital fissure Faciomaxillary and neck injuries is airway
and continues superolaterally through the lat- patency. Once that has been managed, other
eral orbital wall, through the zygomaticofrontal life-threatening injuries and trauma-related major
junction and the zygomatic arch. Intranasally, system failure may be addressed. Thus, treat-
a branch of the fracture extends through the ment priorities are to clear and secure the airway,
base of the perpendicular plate of the ethmoid, control haemorrhage, treat hypovolaemia, and
through the vomer, and through the interface of evaluate for associated life threatening injuries.
280
When these are satisfied, management is directed 6) Occlusal radiograph for split palate.
towards the facial, neck and other injuries.
CT scan is preferable
GENERAL MANAGEMENT
DEFINITIVE MANAGEMENT
In patients without airway obstruction, a 30°
head-up position is preferred so as to encourage Goals of treatment –
drainage of blood, saliva and CSF away from the 1) Precise anatomical reduction to cranial base
airway. This also helps in preventing obstruction above and to the mandible below.
by the disrupted tissue. Following airway man- 2) Stable fixation of reduced fragments
agement, maxillary and mandibular fragments 3) Preservation of blood supply to fractured site.
can be repositioned and a head wrap applied to 4) Restoration of function.
maintain stabilization.
REDUCTION OF MAXILLA
The definitive approach towards Faciomaxillary
fractures can be planned after a “grace period” of 1. Manual reduction.
up to 10 days taking into account patient comfort. 2. Reduction with wires.
But in orbital injuries when ocular function is at 3. Reduction using disimpaction forceps.
risk, an early surgery is mandatory. When gross 4. Reduction by means of traction(elastics)
facial swelling occurs, definitive surgery should Closed reduction can be done in
be delayed and measures like wound debride- 1) Non displaced fracture
ment, removal of foreign bodies, closure of facial 2) Grossly comminuted fractures
lacerations, ice packs, and head-up nursing to re- 3) Fractures exposed by significant loss of overly-
duce venous pressure and encourage fluid resorp- ing soft tissues.
tion should be instituted. Prophylactic antibiotics 4) Edentulous maxillary fractures
should be used in those with CSF rhinorrhoea, 5) In children with developing dentition.
compound wounds and when operative fixation Open reduction to be done in
of fractures is performed. 1) Displaced fractures
2) Multiple fractures of facial bones
RADIOLOGICAL EVALUATION 3) Fractures of edentulous maxilla with severe
displacement.
Once the patient is fully stabilized, radiologic 4) Edentulous maxillary fracture opposing an
evaluation should commence. edentulous mandibular fracture.
When using Plain films, the following radio- 5) Delay of treatment and interposition of soft
graphs should be taken – tissues between non-contacting displaced
1) Lateral skull view fracture segments.
2) Water’s view 6) Specific systemic conditions contraindicating
3) PA & AP views of skull IMF.
4) OPG
5) Towne’s view- zygomatic arches, vertical rami
of mandible.

Surgical Approaches: the introduction of a curved urethral sound into
the maxillary sinus. The sound is advanced until
Multiple approaches are often required to achieve the blunt tip of it is against the hollow of the
the necessary exposure in cases where open interior surface of the zygoma. By applying man-
reduction is required. Common routes for Fa- ual pressure over the zygoma while maintaining
ciomaxillary fractures viz. Labio buccal, Gillies, pressure on the inner surface of the zygoma with
and lateral brow incisions, Coronal & Hemicoro- the sound, the zygoma can be fairly easily manip-
nal, Midfacial Degloving, Transconjunctival/Sub- ulated bimanually.
ciliary will not be discussed here.
Palpation of the fracture lines and or the malar
Transantral approach: eminence is used to evaluate the reduction. Inter-
nal fixation can then be carried out if needed.
This is basically the Caldwell-Luc approach and
is easily utilized in cases where there is a defect in
the anterior maxillary wall, giving direct access
to the orbital floor, lateral nasal wall, and inner
aspects of the zygoma and zygomaticomaxillary
buttress. This access can be used prior to repair of
the anterior maxillary wall, or the defect can be
left unrepaired if it is small.
Alternatively, a defect can be created surgically.

Through this opening, elevators or other instru-
ments such as urethral sounds (see below) can be
used to assist in reduction of fractures. Maxillary
sinus packing to support an isolated lateral nasal
wall or orbital floor fracture can also be intro-
duced through the opening, with the end of the
packing material brought out through the defect
or through a nasoantral window.
Nasoantral window:
This method of access to the inner surface of the

zygoma has been useful in cases where reduction
of the zygoma is difficult and there is a desire to
avoid additional surgical approaches. It can be
utilized in combination with other approaches or
alone in cases where closed reduction is planned.
The technique requires the creation of a nasoan-
tral window under the inferior turbinate to allow
282
Clinical features:
Endoscopic orbital decompression
Before attempting to manage a patient with Thy-
Introduction: roid associated orbitopathy accurate assessment
should be made regarding the disease activity,
Orbital decompression surgery has been indicat- temporal progression and its severity. Basic aim
ed in patients with compressive optic neuropathy, is to differentiate active stage of the disease from
severe corneal exposure, cosmetic deformity due the burnt-out stage. Treatment of these two
to proptosis. Traditional orbital decompression conditions are rather different. Active moderate
approaches were fraught with complications. to severe congestive orbitopathy may need active
With the advent of nasal endoscopes decom- intervention whereas mild congestive orbitopathy
pression is being carried out transnasally under needs observation. Vision threatening dysthyroid
endoscopic guidance. The entire medial wall of optic neuropathy occurs in less than 5% of pa-
orbit can be taken down transnasally using nasal tients with Graves’ disease.
endoscope, and the inferior wall of orbit can be
removed using the same approach. Currently Clinical features of optic neuropathy / impending
endoscopic orbital decompression is being per- optic neuropathy include:
formed commonly with very minimal compli-
cations. The aim of this paper is to review the 1. loss of visual acuity
current literature on the subject. 2. Disturbances in color vision
3. Visual field defects
Thyroid associated orbitopathy can cause severe 4. Afferent pupillary defect
facial disfigurement. In severe cases it could 5. Swelling involving optic disc
lead even to blindness. Surgical decompression
of orbit could very well alter facial appearance. Diagnosis can be confirmed by measuring Visual
Patients with thyroid associated orbitopathy Evoked Potentials. If it shows increase in latency
should be warned that only a marginal improve- or reduction in amplitude the diagnosis is con-
ment to facial appearance is possible. Frequent firmed. If these patients are not picked up early
surgical procedures may be needed to produce and aggressively treated 30% of them may suffer
optimal results. This procedure should never be irreversible vision loss. Risk factors for optic neu-
considered as a beautification exercise. Majority ropathy include older age, smoking and male sex.
of Thyroid associated orbitopathy patients don’t
require surgical treatment. The need for surgery Pathophysiological mechanism implicated in
increases significantly with age. Need for surgery optic nerve involvement:
triples after the age of 50. During active phase of
this disease Medical management with immuno- Compression of optic nerve / its blood supply by
suppressive measures should be the first line of the orbital contents especially by the hypertro-
management. phied intraocular muscles have been implicated.
Studies have correlated intraocular muscle size
and restriction of ocular mobility with incidence
of optic neuropathy. Proptosis does not correlate

well with the risk of optic neuropathy. Because of entially posteriorly and by the orbital septum an-
the potential risk of blindness due to dysthyroid teriorly. Orbital septum is a rather stiff and tight
optic neuropathy, this condition should be man- structure allowing limited forward displacement
aged under war footing. Immediate decompres- of the eye in response to increased orbital volume.
sion surgeries in these patients do not result in Intact orbital septum can withstand pressures
better results when compared to high dose intra- up to 50 mm Hg, rarely even up to 120 mm Hg
venous methyl prednisolone therapy. Therefore, in some patients. The term “Compartment syn-
high dose of intravenous methyl prednisolone has drome” was first used in orthopedics to indicate
been advocated as the first line of treatment. If increased tissue pressure within enclosed space.
intravenous steroid does not improve the situa- The term “Orbital Compartment syndrome”
tion in a couple of days then orbital decompres- was first used by Kratky et al in 1990. Significant
sion surgery must be resorted to in order to save increase in intraorbital pressure may compromise
vision. Patients who do not respond adequately vascularity of optic nerve causing irreversible
to intravenous steroid therapy should be suspect- blindness. Inadequate blood flow in the posteri-
ed to have orbital apex compression syndrome. or ciliary arteries, central retinal artery or vein
This can be addressed only by decompression of or vasonervorum of optic nerve causes ischemic
orbital apex area via medial orbitotomy. In some optic neuropathy or slow optic nerve degenera-
patients dysthyroid orbital neuropathy can occur tion. Thyroid associated orbitopathy should be
without any compression in the orbital apex area. differentiated from Dysthyroid optic neuropathy
Increased orbital pressure may cause this con- by performing ultrasound imaging of orbit. If B
dition. MRI scan helps in differentiating these scan shows enlarged muscle bellies with normal
two conditions. Orbital decompression surgeries tendons then the diagnosis of Thyroid associated
to manage exophthalmos reduction should be orbitopathy is confirmed.
performed only after ophthalmological symp-
toms have stabilized at least for a period of 3- 6 It helps in differentiating between active and in-
months. One should not be in a hurry to per- active (burnt out diseases). In thyroid associated
form orbital decompression procedures, because orbitopathy the extraocular muscles are iso-
studies have revealed that early surgeries is not of intense to normal muscle on T1-weighted images
help, on the contrary if performed early during and hyperintense in T2-weighted images depend-
the course of the disease it could lead to orbital ing on tissue edema. Presence of tissue edema is
motility problems. If orbital decompression is an indication of active disease. The correlation
indicated it should be performed before extra- between water content and inflammatory activity
ocular muscle / eye lid surgery, because it could can be detected with MRI short term inversion
affect both extraocular muscle balance and eyelid recovery sequencing (STIR Sequencing). Only
position. drawback of MRI is its inability to accurately
image bony orbital structures. If decompression is
Pathophysiology of orbital compartment syn- being planned then CT imaging of orbit is a must.
drome:
Anatomically orbit is an enclosed cone shaped

compartment. It is bounded by bone circumfer-
284
2001 popularized this procedure.
Orbital decompression techniques:
Bony orbital decompression:
History:
Orbital decompression can be performed by
Earliest report of orbital decompression was removal of one or more walls of the orbit. Graded
published by Dollinger in 1911. In 1931 Naffziger orbital decompression is always preferred de-
popularized transfrontal orbital roof decompres- pending on the degree of proptosis. This concept
sion. The advantage of this approach was that was first suggested by Kikkawa et al. Three wall
it allowed access to orbital apices of both sides decompression provides the best proptosis re-
and hence was very useful in managing bilateral duction with acceptable esthetic appeal. During
disorders. The flip side was that proptosis reduc- 1980’s two wall decompression involving medial
tion was not impressive. This procedure was also and inferomedial walls of orbit was practiced.
time-consuming needing assistance from neu- This procedure had a high incidence of post-op-
rosurgeon on the table. Communication of orbit erative diplopia due to inferior displacement of
with cranial contents lead to the development of globe. This can easily be avoided by preserving
pulsating proptosis. Sewall (1936) used medial the inferomedial strut between ethmoid and max-
approach to decompress orbit. In this approach illary sinuses. Goldberg 16 et al.
the entire medial wall of orbit was taken down
after performing a complete ethmoidectomy. If Demonstrated that deep lateral wall decompres-
needed it can be extended up to the sphenoid si- sion alone caused 4.5 mm reduction in proptosis.
nus also allowing orbital contents to prolapse me- He used the term extended lateral orbital decom-
dially into the nasal cavity. Hirsch in 1950 used pression to include three key areas: Lacrimal
the technique described by Lewkowitz to perform keyhole – area around lacrimal gland fossa Basin
inferior orbitotomy by removing the floor of the of the infraorbital fissure – the portion of zygo-
orbit through Caldwell – Luc approach. Walsh matic bone and lateral maxilla around infraorbital
and Ogura in 1957 13 used Caldwell – Luc trans fissure.
antral approach to decompress both inferior and
medial orbital walls. Sphenoid door jam – Thick trigone of greater
wing of sphenoid which borders infratemporal
Orbital contents were allowed to prolapse into fossa laterally and middle cranial fossa posteri-
maxillary antrum and nasal cavity. This approach orly. This area makes the largest volume of bone
had the advantage of doing away with skin inci- contribution to orbit. Removal of bone from this
sions in the face. This approach too had its own area reduces proptosis by 6 mm.
flip side i.e. postoperative diplopia and infraor-
bital nerve hypesthesia. With the popular use of
nasal endoscope, the entire nasal cavity could be
accessed easily under endoscopic vision. Kennedy
et al. 15 In 1990 performed endoscopic decom-
pression of orbit by removing the medial wall of
the orbit under endoscopic vision. Michel et al. In

Image showing the types of orbital decompression surgeries
Lateral orbitotomy – Dollinger (1911)
Superior orbitotomy – Naffziger (1931)
Medial orbitotomy – Sewall (1936)
Inferior orbitotomy – Hirsch (1950)
Endoscopic Medial wall decompression: wide middle meatal antrostomy is performed. The
floor of the orbit and the posterior wall of maxilla
This procedure is still under evaluation. Since the should be clearly visible through the antrostomy.
approach is trans nasal, facial incision is avoided. A wide antrostomy won’t get blocked even after
The medial wall of orbit is rather thin in this area. the prolapsing orbital content fills the nasal cavity
After exenteration of ethmoidal air cells this wall and maxillary sinus.
can easily be taken down allowing the orbital Infraorbital nerve should be visualized using a
contents to prolapse into the nasal cavity. This 45° endoscope because this represents the lateral
procedure can be performed either under LA or limit of bone resection. Frontal recess area should
GA. The nasal cavity is decongested. Complete be cleared adequately. Trans ethmoidal sphenoi-
uncinectomy and ethmoidectomy is performed. A dotomy should also be performed. Anterior limit
286
of resection corresponds to nasolacrimal duct, inferior wall is taken down it could cause hypo-
while superior limit corresponds to the floor of globus (inferior displacement of orbit).
anterior cranial fossa marked by the presence of
ethmoidal arteries. Fat removal orbital decompression:
Inferiorly resection should stop at the level of in- This procedure was first reported by Olivari in
sertion of inferior turbinate. Author invariably re- 1988. This procedure was considered to be rela-
moves middle turbinate to create more space for tively safe when compared to bony decompres-
the prolapsing orbital contents. Lamina papyracea sion according to him. Removal of 6ml of fat on
should be completely skeletonized and removed an average contributed to satisfactory results. It
using periosteal elevator. Lamina is removed care- has been estimated that normal average orbital fat
fully without traumatizing periorbita. It should volume is about 8ml. This could increase to 10 ml
completely be removed till the posterior ethmoid, in patients with thyroid associated orbitopathy.
close to the optic nerve where the bone is thicker. This procedure is suited for patients who have a
Only after fully exposing the periorbita should it volumetric increase in orbital fat deposition caus-
be incised to allow fat to prolapse into the nasal ing proptosis. Patient selection should be careful-
cavity and maxillary sinus cavity. Endoscopic ly made after performing MRI imaging of orbit.
decompression could achieve proptosis reduc- Infero medial removal of orbital fat could be a
tion between 3 – 5 mm. Greater reduction can be worthwhile option of treating proptosis as this
achieved if combined with lateral orbitotomy. It area is devoid of crucial anatomical structures.
is very important to retain lamina papyracea in
the region of frontal recess to prevent obstruction Lateral orbitotomy (lateral wall decompression):
due to prolapsing orbital fat.
This approach is credited with the maximum
Complications of this procedure include: reduction of exopthalmos. Indications for this
procedure include:
1. Diplopia
2. Sinusitis 1. Esthetic rehabilitation for exphthalmos
3. Frontal & maxillary sinus mucocele 2. Retrobulbar pressure
4. CSF leak 3. Exposure keratopathy / Lagopthalmos
4. Dysthyroid optic neuropathy
Walsh – Ogura decompression: Traditionally this
procedure has been performed to manage Graves Procedure:
ophthalmopathy. This surgery is performed via This surgery is ideally performed under general
trans antral Caldwell Luc approach. Two walls of anesthesia. Skin incision begins at the lateral third
orbit are removed i.e. medial and inferior walls. of upper eyelid crease. It follows a sigmoid course
Medial wall removal is difficult in this procedure over the zygomatic bone. Orbital rim is exposed
as it is difficult to visualize lamina papyracea tran- by blunt
santrally, hence it is virtually impossible to com- dissection. Temporalis muscle in this area should
pletely decompress medial wall of orbit 18. This also be removed till the periosteum becomes
procedure is entirely not risk free. If too much visible.

This exposed periosteum is cut along the orbit-
al rim and stripped away from the bone. Globe
and orbital contents are transferred nasally using
malleable retractors. Two osteotomies need to be
performed to remove the lateral orbital wall. The
first osteotomy is just above the frontozygomatic
suture line and the next one is at the beginning of
frontal process of zygoma. After complete remov-
al of lateral orbital wall, the average increase in
orbital volume works out to 1.6 ml. Periorbita is
opened now. Prolapsing fat can be removed. A
small suction drain is placed behind the globe
and the wound is closed in layers.
Compression bandage is a must during first 24

hours. Amount of blood in the drain and pupil- Image showing piecemeal removal of lamina
lary reflex should be constantly checked during papyracea (medial wall of orbit)
the first 24 hours after surgery. It should be borne
in mind that intraocular bleeding can cause pre-
cipitous increase in ocular pressure compromis-
ing vision.
Complications of this procedure include:
1. Diplopia
2. Loss of vision due to bleeding and increase in
intraocular tension
3. Temporary numbness over zygomatico tempo-
ral supply area of trigeminal nerve
4. Mild oscillopsia during chewing
Image showing lower portion of lamina papyra-

cea (medial wall of orbit) being removed.
288
Image showing prolapse of orbital fat inside the
nasal cavity after lamina papyracea is removed

Endoscopic DCR Further contraction of orbicularis oculi muscle
and the lacrimal muscle with minimal contribu-
Introduction: tion from gravity compresses the fluid collected
Lacrimal system starts with the lacrimal gland in the sac to the nasolacrimal duct situated in the
which is situated in a pad of fat in the dorsolateral antero lateral wall of the nose, passing anterior to
part of the orbital cavity and drains into con- middle turbinate mostly and opening in the ante-
junctival sac via many excretory ducts. The tear rior portion of the inferior meatus of the nose.
film serves as a blanket of moisture over corneal
surface thereby preventing dryness of eye. Tears Tarsal plates and tarsal fibers keep the puncta
are spread all over the conjunctival lining by opening directed towards conjunctival lining in
the blinking action of upper and lower eyelids. the lacrimal lake area. Epiphora can also occur
Tears collect in the medial canthal segment of eye whenever the eyelid is in abnormal position.
where lacrimal lake is situated. Blockage of nasolacrimal duct whether due to
intra luminal, extra luminal causes decreased
Orbicularis oculi muscle acting on the medial outflow of lacrimal fluid and resultant stasis of
canthal ligament including the lacrimal muscle, secretions causes inflammation of naso lacrimal
pump the lacrimal fluid into upper puncta (nearly duct as well as lower sac area. Recurrent blockage
30%) and lower puncta (70%) during contraction of nasolacrimal duct ultimately leads to complete
stage of the muscle. Relaxation of orbicularis oc- adhesions and permanent blockage resulting in
uli and lacrimal muscle directs fluid from puncta dacryocystitis.
and canaliculus to the lacrimal sac as a negative
pressure is created in the sac lumen. History
Surgical treatment of dacryocystitis dates back

nearly 2000 years. Celsus, in the first century de-
scribed a way of creating an artificial passageway
into the nose by using hot cautery to puncture
through the lacrimal bone. A procedure more or
less similar to this was performed by Galen in the
second century.
Better understanding of lacrimal anatomy and

physiology led to the development of more mod-
ern techniques starting from the 18th century.
Some of the procedures like dacryocystectomy
is no longer advocated. It is of course still being
Image showing lacrimal lake used in patients who are really sick and debilitat-
ed, in patients who are on anticoagulants which
cannot be stopped.
290
Several avenues were tried during the early 20th approach. The advent of nasal endoscopes has re-
century to manage patients with dacryocystitis. vived interest again in the intranasal approach. In
One such procedure was an attempt to drain addition to avoiding scar formation endoscopes
the lacrimal sac into the maxillary sinus. Many provide excellent visualization.
intranasal approaches were described during this
period, some of them advocating opening up or How we have reached a stage where all DCR’s are
resection of the lower aspect of the nasolacri- being performed with nasal endoscope by the
mal canal as well as use of glass tubes or wire to ENT surgeon. It should be stressed that 90% of
keep the new passageway patent. It was West and lacrimal pathways belong to the nasal cavity and
Polyak who popularized these procedures with it is more appropriate for an ENT surgeon to be
reasonable success. involved in the management of dacryocystitis.
Earliest operation resembling the modern ex- Embryology:

ternal DCR was attempted by Woolhouse in
England during the 18th century. He advocated A clear understanding of embryology of lacrimal
extirpation the sac, by perforating the lacrimal system is necessary to understand congenital ab-
bone and placing a drain made of gold, lead / normalities of the nasolacrimal drainage system.
silver. During early 20th century other surgeons The walls of orbit are embryologically derived
attempted to open the sac without removing most from neural crest cells. Ossification of orbital
of it. Various stenting materials were used to walls is completed by birth except for its apex.
maintain the patency of the ostium. The lesser wing of sphenoid is initially cartilag-
inous, unlike the greater wing and other orbital
The first dacryocystorhinostomy was performed bones that develop via intramembranous ossifica-
by Toti in 1940. This surgery was basically intend- tion. The membranous bonesmsurrounding the
ed for relief of lacrimal obstruction. Toti initially lacrimal excretory system are well developed at 4
performed this through an external incision. months of intrauterine life and ossify at birth.
He accessed the sac via an external incision and
elevating the periosteum over the sac area. The The lacrimal gland begins development at the 25
lacrimal bone is nibbled out exposing the sac. The mm embryologic stage from solid epithelial
medial wall of the sac was excised using a cana- buds arising from the ectoderm of the supero-
licular probe as a guide. A corresponding piece of lateral conjunctival fornix. Mesenchymal con-
nasal mucosa is also removed. densation around these buds forms the secretory
lacrimal gland. The early epithelial buds form
He advocated suturing of the edges of the incised the orbital lobe in the first two months, whereas
mucosa everting them creating a permanent the secondary buds which appear rather late at
drainage of tears into the nasal cavity. The only 40 - 60 mm stage, develop into the palpebral lobe.
difficulty encountered in this procedure was Canalization of the epithelial buds to form ducts
significant bleeding from angular vessels. Mosher occur at 60 mm stage.
was the first person to embark on intranasal
approach to the sac in 1921, but he too avoided
it in favor of combined external and intranasal

The developing tendon of the levator palpebrae nasolacrimal system, supernumerary puncta, and
superioris muscle divides the gland into two lobes lacrimal fistula.
around the 10th week of development. The lac-
rimal gland continues to develop until 3-4 years Anatomy:
after birth.
Osteology:
The excretory system begins its development at an
earlier stage. In the 7 mm embryo, a depression Thick bone from the frontal process of maxilla
termed the naso-optic fissure develops, bordered forms the anterior lacrimal crest which marks the
superiorly by the lateral nasal process and infe- front end of the fossa. In contrast, thin lacrimal
riorly by the maxillary process. The naso optic bone forms the posterior lacrimal crest, which
fissure or groove gradually shallows as the struc- marks the rear boundary of the fossa. These two
tures bordering it grow and coalesce. Before it is bones fuse at a suture line that traverses the lacri-
completely obliterated however, a solid strand of mal fossa in a vertical direction. The inferior end
surface epithelium becomes buried to form a rod of the lacrimal sac tapers as it enters the naso-
connected to the surface epithelium at only the lacrimal canal formed by the maxillary, lacrimal,
orbital and nasal ends. The separation from the and inferior turbinate bones. The nasolacrimal
surface typically occurs at 43 days of embryonic duct runs within the osseous canal for a distance
life. The superior end of the rod enlarges to form of approximately 12 mm. It continues beneath the
the lacrimal sac, and gives off two columns of inferior turbinate as a membranous duct for an
cells that grow into the eyelid margins to become additional 5 mm before opening into the inferior
the canaliculi. meatus. The duct orifice is found at the junction
of middle and anterior thirds of the meatus, ap-
Canalization of the nasolacrimal ectodermal rod proximately 8 mm behind the anterior tip of the
begins at about the 4th month proceeding first inferior turbinate. It is covered by a flap of muco-
in the lacrimal sac, the canaliculi, and lastly the sa known as the Hasner’s valve, which is thought
nasolacrimal duct. The central cells of the rod de- to prevent reflux of nasal secretions.
generate by necrobiosis, forming a lumen closed
at the superior end by conjunctival and canalicu- When viewed from within the nasal cavity, the
lar epithelium and closed at its inferior end by the lacrimal sac is located beneath the bone of the lat-
nasal and nasolacrimal epithelium. eral nasal wall just in front of the anterior attach-
ment of the middle turbinate. In some patients,
The superior membrane at the puncta is usually the agger nasi cells of the anterior ethmoidal cells
completely canalized when the eyelids separate at overlie the sac, producing an obvious bulge in the
7 months of gestation, and therefore is normally lateral nasal wall in this location. The superior
present by birth. In contrast the inferior mem- border of the sac may extend above the level of
brane frequently persists in newborns, resulting turbinate attachment. The posterior end of the
in congenial nasolacrimal obstruction. Abnor- sac often extends beneath the middle turbinate,
malities of development in this region, occurring behind a landmark known as maxillary line.
typically after the 4th month of gestation can
result in congenital absence of any segment of the
292
Image showing osteology of orbit and face
The maxillary line is an important landmark for The maxillary line is an important landmark for
endoscopic DCR. It is easily identified as a cur- endoscopic DCR. It is easily identified as a cur-
vilinear eminence along the lateral nasal wall, vilinear eminence along the lateral nasal wall,
which runs from the anterior attachment of the which runs from the anterior attachment of the
middle turbinate to the root of the inferior turbi- middle turbinate to the root of the inferior turbi-
nate. Its location corresponds to the suture nate. Its location corresponds to the suture
line between maxillary and lacrimal bones. Ex- line between maxillary and lacrimal bones. Ex-
posure of the posterior half of the sac typically posure of the posterior half of the sac typically
requires removal of thin uncinate process and requires removal of thin uncinate process and
underlying lacrimal bone located posterior to the underlying lacrimal bone located posterior to the
maxillary line. Exposure of anterior sac neces- maxillary line. Exposure of anterior sac neces-
sitates removal of thicker bone in front of the sitates removal of thicker bone in front of the
maxillary line. maxillary line.

Image showing anatomy of lacrimal sac
Whitnall described orbital rim as a spiral with nasolacrimal canal. On the frontal process of the
its two ends overlapping medially on either side maxilla just anterior to the lacrimal fossa, a fine
of the lacrimal sac fossa. The medial orbital rim groove sutura longitudinalis imperfecta of weber
is formed anteriorly by the frontal process of the (sutura notha). This suture runs parallel to the
maxilla rising to meet the maxillary process of the anterior lacrimal crest.
frontal bone. The lacrimal sac fossa is a depres-
sion in the inferomedial orbital rim, formed by It is a vascular groove through which small twigs
the maxillary and lacrimal bones. It is bounded of the infraorbital artery pass through to supply
anteriorly by the anterior lacrimal crest of maxil- the bone and nasal mucosa, and should always
lary bone and the posterior lacrimal crest of the be anticipated during lacrimal surgery to avoid
lacrimal bone posteriorly. bleeding.
The lacrimal fossa is approximately 16 mm high, The medial orbital wall is formed anterior to
4-9 mm wide, and 2 mm deep. This fossa is slight- posterior, by the frontal process of maxilla, the
ly narrower in women. The fossa is widest at its lacrimal bone, the ethmoid bone, and the lesser
base, where it is confluent with the opening of the wing of the sphenoid bone. The thinnest portion
294
Image showing anatomy of lacrimal sac
of the medial wall of orbit is the lamina papyra-

cea, which covers the ethmoid sinuses laterally.
The many bullae of ethmoid pneumatization
appear as a honey comb pattern medial to the
ethmoid bone. The medial wall of orbit becomes
thicker posteriorly at the body of the sphenoid
and again anteriorly at the posterior lacrimal crest
of the lacrimal bone.
The fronto ethmoidal suture is very important

landmark in orbital anatomy as it indicates the
level of roof of ethmoid sinus. Bony dissection su-
perior to this suture line would expose the dura.
The anterior and posterior ethmoidal foramina
conveying branches of ophthalmic artery
and the nasociliary nerve are located in the fron-
toethmoidal suture, 24 mm and 36 mm posterior Image showing anterior lacrimal crest
to the anterior lacrimal crest respectively.

Image showing anatomy of nasolacrimal duct
The anterior lacrimal crest is an important land-

mark during external dacryocystorhinostomy, as The lacrimal bone at the lacrimal fossa has a
the anterior limb of the medial canthal tendon mean thickness of 106 microns, which allows it
attaches to the anterior lacrimal crest superiorly. to be easily penetrated to enter the nasal cavity
This attachment of the medial canthal tendon is during surgery. In a patient with maxillary bone
often detached from the underlying bone along dominant lacrimal fossa, the thicker bone makes
with the periosteum in order to gain better expo- it more difficult to create the osteotomy in exter-
sure during surgery. nal DCR.
A vertical suture runs centrally between the At the junction of the medial and inferior orbital
anterior and posterior lacrimal crests, represent- rims, at the base of the anterior lacrimal crest, a
ing the anastomosis of the maxillary bone to the small lacrimal tubercle may be palpated external-
lacrimal bone. A suture located more posteriorly ly to guide the surgeon to the lacrimal sac located
within the lacrimal fossa would indicate predom- posterior and superior to it. In nearly a third of
inance of maxillary bone, whereas a more anteri- orbits this tubercle may project posteriorly as an
orly placed suture would indicate predominance anterior lacrimal spur.
of the lacrimal bone. The nasolacrimal canal originates at the base of
296
Note the ostium of the maxillary sinus lie approximately in a vertical line to the Ante-
rior ethmoidal foramen.
the lacrimal sac and is formed by the maxillary tion due to irritation of cornea / conjunctiva (FB,
bone laterally and the lacrimal and inferior tur- trigeminal nerve stimulation).
binate bones medially. The width of the superior
portion of the canal measures on an average 4-6 Epiphora:
mm. The duct courses posteriorly and laterally in
the bone shared by the medial wall of the maxil- Usually occurs due to poor lacrimal drainage
lary sinus and the lateral nasal wall for 12 mm which could be due to:
to drain into the inferior meatus of the nasal 1. Mechanical obstruction of lacrimal drainage
cavity. system related to trauma, dacryocystolithiasis,
sinusitis and congenital nasolacrimal duct ob-
Epiphora: struction in children.
This term is used to indicate excessive tear secre- 2. Lacrimal pump failure (functional epiphora)
tion. Causes for epiphora include: may be caused by eyelid laxity (facial palsy), eye-
lid malposition and punctum eversion.
1. Hypersecretion
2. Epiphora
3. Combinations of the above
Hypersecretion:
Excessive tearing is caused by reflex hypersecre-

Assessment:
Patients with obstruction of the lacrimal system

commonly present with epiphora. When da-
cryocystitis is present, purulent discharge in the
medial canthal region can occur.
History of nasal airway obstruction, drainage, or

epistaxis must be sought to rule out nasal causes
of epistaxis.
Clinical History & Examination:
Detailed history should be taken to rule out /

differentiate:
1. Differentiate between hypersecretion, lacrima-

tion and epiphora Image showing tear efflux on applying pressure
2. Define the pathological process over medial canthus of the eye
3. Distinguish whether tearing is due to a func-
tional or anatomical disorder Preoperative ophthalmologic examination begins
4. Identify the site of blockage with inspection of the ocular surface and eyelid
5. If required a surgical approach may be defined structures. Gentle pressure over the lacrimal sac
may produce reflux of mucopurulent material
Physical examination: suggestive of lower sac obstruction. The puncta
are evaluated for scarring or strictures. The can-
Should include: aliculi are gently probed using Bowman lacrimal
probe after anaesthetizing the eye using propara-
Eyelids: lower lid laxity, ectropion, entropion, caine. Any resistance encountered when passing
punctum eversion, trichiasis, and blepharitis. the probe is noted.
Medial canthus: Lacrimal sac enlargement below
the medial canthal tendon. Presaccal stenosis is excluded because this condi-
tion is not suitable for endoscopic DCR. Results
Palpation of lacrimal sac: Reflex of mucopurulent of visual acuity, extraocular motility, and visual
material from the punctum; pressure over the sac field defects are also noted.
in acute dacryocystitis would cause pain.
Special investigations:
Diagnostic tests can be used to identify the cause

of obstruction and to choose the appropriate
298
treatment modality. These tests can be classified lated next using a punctum dilator if the punctum
as: is small.
1. Anatomical tests used to locate the site of ob-

struction:
a. Diagnostic probing
b. Syringing
c. Dacryocystography
d. Nasal examination
e. Imaging
2. Physiological / Functional tests
a. Fluorescein dye appearance
b. Scintigraphy
c. Saccharine test
3. Secretion tests
a. Schirmer’s test
b. Bengal rose test
c. Tear film breakup test
d. Tear lysozyme test
Diagnostic probing & lacrimal syringing: Image showing lower punctum being dilated
Diagnostic probing and irrigation of lacrimal

system are very important anatomical tests. They
provide valuable information about the site of
obstruction, but usually don’t give information
about functional efficiency. These are really useful
skills an otolaryngologist needs to learn from the
ophthalmologist.
Syringing: Image showing punctum dilator
This procedure can easily and safely be performed A 24-gauge intravenous cannula is inserted into
in the OPD under local anesthesia. the inferior canaliculus, it should be aimed verti-
cally
Steps: first and then turned horizontally. The lower can-
aliculus is straightened by pulling the lower eyelid
Topical anesthesia is secured by application of downwards and laterally.
1 – 2 drops of oxybuprocaine / Benoxinate HCL
0.4% or The tip of the cannula is advanced to 3-4 mm into
4% xylocaine onto the puncta. The puncta is di- the canaliculus. A 2 ml syringe filled with distilled

water is attached to the cannula and is irrigated lacrimal duct obstruction. Despite the passage of
by pushing the plunger of the syringe. Initially fluid under the positive pressure of the irrigation
a small (00) probe should be used, followed by cannula, partial nasolacrimal duct obstruction
progressively larger probes if possible. If a hard can create enough resistance to inhibit tear drain-
stop is felt during probing the canaliculi it means age under physiologic pressures.
that the probe has come into contact with the lac-
rimal bone suggesting that the lacrimal drainage Probing and irrigation will help in the assess-
is patent up to the lacrimal sac. Rarely a soft stop ment of anatomical and functional status of the
may be felt indicating that the probe’s progress is lacrimal drainage system. If performed correctly
impeded by soft tissue suggesting the presence of it is a safe procedure providing extremely useful
stenosis or obstruction of the canalicular sys- diagnostic information, as well as assistance in
tem. Soft stop can also be cause by kinking of the the surgical planning when pathology is encoun-
canaliculus created by bunching of the soft tissues tered. In cases of trauma, this procedure can help
in front of the probe tip. Such kinking can be to assess the integrity of the system and look for
eliminated by withdrawing the probe, increasing the presence of canalicular injury. It is very useful
lateral traction on the lid and probing again. in cases of epiphora, which could be caused due
to over production of tears or due to inadequacy
Once the probe reaches the lacrimal sac as in- of the drainage system. This procedure an be used
dicated by the hard stop, it is rotated superiorly as a treatment for congenital nasolacrimal duct
with the body of the probe against the brow. Once obstruction.
the probe is rotated to the level of supraorbital
notch at the superior orbital rim, it is guided Lacrimal drainage system begins at the puncta,
down the nasolacrimal duct, directed slightly pos- which are located medially on the margins of the
teriorly and laterally as it is advanced. Resistance upper and lower eyelids. Each punctum leads to
at this level should not be overcome by force, in- its own canaliculus. These canaliculi (upper and
stead the probe should be withdrawn and reintro- lower) pass approximately 2 mm vertically, then
duced. Once the probe is believed to have passed turn 900 and run 8-10 mm medially to join the
to the level of the inferior meatus, its position can lacrimal sac. In majority of patients these canalic-
be confirmed by using a nasal endoscope into the uli join to form a common canaliculus that enters
inferior meatus. the lacrimal sac. Some patients at this point may
have a fold of tissue that is considered to create a
If irrigation is successful and no reflux exists, but functional one-way valve preventing reflux into
the lacrimal sac becomes distended with no saline the canaliculi. This value is known as the valve of
passage into the nose, then it demonstrates naso- Rosenmuller.
lacrimal duct obstruction with a competent valve
of Rosenmuller that prevents reflux back into the The lacrimal sac lies in a bony fossa in the anteri-
canalicular system. In some patients, some degree or medial orbit and extends inferiorly to form the
of reflux through the opposite canalicular system nasolacrimal duct. This duct measures 12 mm in
could be observed, but the patient would still feel length and has a distal valve of Hasner, before it
the taste of saline trickling down the throat. This opens into the nose thorough an ostium at the
indicates that the patient may have partial naso- inferior meatus. This ostium is patent in approx-
300
Diagram illustrating lacrimal drainage system
imately 50% of infants at birth. If it is not patent helps to identify the cause of epiphora and also
at birth, it usually becomes patent during the first assist in surgical planning
few months of life. 3. In case of trauma to eyelid or medial face,
probing and irrigation will help to determine if
Delayed or incomplete patency is the cause of there is injury to the lacrimal drainage system.
congenital nasolacrimal duct obstruction. In In patients with acute trauma, a visible lacrimal
infants the distance from the punctum to the level probe inserted into the canaliculus or leakage
of inferior meatus is approximately 20 mm. of irrigation fluid through traumatized eyelid is
an indication for canalicular injury and must be
Indications for probing & irrigation: addressed during planned repair of trauma.
4. In patients with congenital nasolacrimal duct
1. Should be performed whenever analysis of the obstruction that does not resolve by the age of 12
lacrimal drainage system is indicated months, probing and irrigation is performed un-
2. In the case of nasolacrimal obstruction related der anesthesia to achieve patency of the system.
epiphora, this procedure provides insight into the
location and severity of obstruction if present. It

Contraindications for probing & irrigation: a functional measure of tear drainage that in-
volves the placement of a drop of fluorescein dye
1. Obstruction due to acute dacryocystitis. In in to the eye. A cotton tipped applicator is placed
these patient’s palpation of a distended lacrimal into the inferior meatus adjacent to the nasolac-
sac produces reflux of mucopurulent material rimal ostium at 2 and 5 minutes. If dye is recov-
from the canalicular system. Presence of this ered, patent anatomy and physiologic functions
reflux confirms complete nasolacrimal duct can be confirmed. This test is prone for high false
obstruction and no further diagnostic testing is negative rate which can range up to 42%. Rigid
indicated. endoscope can be used to directly visualize the
2. Presence of acute canaliculitis. Active infection dye in the inferior meatus. When Jones I test is
can make passage of probe difficult. Another con- abnormal, then Jones II test may be used to evalu-
cern being the presence of stones within the can- ate anatomic patency in the presence of increased
aliculus. Probing can force these stones to migrate hydrostatic pressure of tear flow. A canaliculus
deeper into the canaliculus making its subsequent is irrigated with clear saline using a syringe with
removal difficult. blunt tipped needle. If saline passes into the nose
or mouth a partial nasolacrimal duct obstruction
Complications: is likely since this obstruction could be overcome
by the pressure of irrigation but not passive flow.
1. Injury to canaliculi
2. Injury to nasolacrimal duct If fluorescein stained saline does not flow freely
3. Creation of false passage into the nose, but regurgitates from the other
4. Stenosis punctum, a high-grade anatomic obstruction is
likely at the level of the lower sac or duct. Such an
obstruction may be amenable to surgical correc-
tion by DCR.
If the Jones II test results in regurgitation of clear

saline from a punctum, canalicular or common
canalicular obstruction is suggested. Conjunc-
tivodacryocystorhinostomy (CDSR) with Jones
tube placement may be useful in such patients to
bye pass the proximal blockage.
Radiological investigations are done if doubt

exists about the surgery that is required. Both
Dacryocystography and scintigraphy provide
some idea of the level of obstruction and whether
Jones Dye Tests: a tight common canaliculus is contributing to the
epiphora.
Jones dye tests can help in assessing the patency
of the lacrimal drainage system. The Jones I test is
302
Dacryocystography:
This is indicated when there is obstruction in the

lacrimal system with syringing. It can assist
with understanding the internal anatomy of lacri-
mal system.
Indications include:
1. Complete obstruction - size of the sac, deter-

mining the exact site of obstruction (common
canaliculus or sac)
2. Incomplete obstruction and intermittent tear-
ing - site of stenosis, diverticula, stones, and
absence of anatomical pathology
3. Failed lacrimal surgery - size of the sac
4. Suspicion of sac tumors
Nuclear lacrimal scintigraphy:
This is a functional test, and is useful to assess the

site of delayed tear transit. It is especially
helpful in difficult cases with an incompletely
obstructed system (questionable eyelid laxity and
questionable epiphora).
CT:
Is used with tumors, rhinosinusitis, facial trauma,

and following facial surgery. In the presence of
concomitant sinus disease, CT assists a surgeon to
address the sinuses at the same time as the DCR.
MRI is rarely used to investigate patients with

epiphora.

Hadad-Bassagasteguy flap 9. No external incision needed
Introduction: The following are the important preop consider-

ations:
Hadad-Bassagasteguy flap is a vascular pedicled
flap of nasal septal mucoperiosteum and mu- 1. Size of the anticipated post surgical defect
coperichondrium based on the posterior septal 2. History of prior nasal septal flap harvest, nasal
artery, which is in turn a branch of sphenopala- or endoscopic sinus surgery or septoplasty
tine artery. It is considered to be a workhorse for 3. History of nasal trauma and septal fracture
reconstruction in extended endonasal skull base 4. History of septal perforation
surgery. 5. This is not a viable option for reconstruction of
very anterior fossa defects or when cancer in-
It should be noted that the success rate of endo- volves septal tissue or if the sphenoid rostrum is
scopic endonasal repair of traumatic CSF leaks involved by malignancy
with this 6. This may not be a viable option in children
type of nasoseptal flap is about 95%. less than 10 years of age as the size may not be
adequate to cover the skull base defect in this age
Indication: group.
1. Skull base reconstruction after endonasal sur- Technique of harvesting Hadad flap:
gery Nasal hairs should be trimmed. Nasal passag-
2. Reconstruction following transnasal hypophy- es should be examined and mucous if present
sectomy should be removed using suction.
3. Management of traumatic CSF leaks Nasal mucosa and turbinates are decongested
by packing with Cotton pledgets soaked in 4%
Advantages: xylocaine mixed with 1 in 100,000 adrenaline.
Care should be taken not to exceed the toxic dose
1. Well vascularized with pedicled blood supply of xylocaine which is 7 ml. The pledgets should be
(nasoseptal artery) squeezed dry before packing the nasal cavity.
2. Superior arc of rotation Using a 2 ml syringe filled with 1% xylocaine with
3. Customizable surface area which can be mod- 1:100,000 adrenaline infiltration is given in the
ified following areas:
4. Provides adequate surface area to cover the
entire anterior skull base 1. Sublabial area
5. Can be stored in the nasopharynx during the 2. Posterior portion of nasal septum
entire procedure 3. Posterior portion of middle turbinate
6. Promotes fast healing and decreases the risk of 4. Anterior face of sphenoid
CSF leak 5. Over the sphenopalatine artery
7. It is sturdy and pliable 6. Anterior portion of the septum on the side of
8. Can be taken down and reused in revision surgery
cases Using a 15 blade knife or angled Colorado tipped
304
Bovie cautery (setting at 10) posterior incisions
are given first. Post op instructions:
Superior incision - Is made just beneath the sphe- 1. No nose blowing

noid ostium which should be identified in the 2. Humidification of inspired air to prevent for-
first place. This incision is carried forward onto mation of nasal crusts
the nasal septum at a level approximately 1-2 cm 3. Increase in intracranial pressure is avoided by
below and parallel to the most superior aspect of using stool softners and open mouth sneezing.
the septum (avoiding the olfactory epithelium). 4. Foley’s catheter can be removed on the 5 th day
The incision is carried forward along the septum following the surgery
until it is across the anterior edge of the inferior 5. Use of saline nasal spray reduces the incidence
turbinate. At this point this incision is carried of crusting in the nose.
downwards vertically in order to connect it with
the planned inferior incision. Reverse Hadad flap:
Inferior incision - Is made above the level of the This flap helps in prevention of crusting of the ex-
choana. It is carried down to the nasal septum posed nasal septal cartilage. This flap is harvested
and just above the maxillary crest, all the way from the other side after creating a septal window
forward to meet the vertical limb of the superior by excising the septal cartilage. It is used to cover
incision. If a larger flap is needed then this in- the exposed cartilage.
cision can be carried even along the floor of the
nasal cavity.
The flap is elevated from anterior to posterior

using a Cottle elevator, once started one can use a
suction.
Freer to elevate the flap. The nasoseptal flap is

elevated in a subperichondrial and subperiosteal
plane back to the anterior face of the sphenoid
sinus between the posterior superior and inferior
incisions in order to preserve the vascular pedicle.
Once fully elevated this flap can be tucked into
the nasopharynx.
After completion of surgical procedure, the flap is

rotated and placed over the defect in such a way
that the entire skull base defect is covered by the Image showing superior incision of Hadad flap
flap. Fibrin glue can be used to secure the flap in
its position. Inflatable foleys catheter can be used
to secure the graft in its place.

Image showing superior incision of Hadad flap
Image showing vertical incision of Hadad flap
306
Endoscopic hypophysectomy
History:
1980’s heralded the nasal endoscope. It soon be-

came an important tool in the armamentorium of
the otolaryngologist. It really took them to areas
which were previously beyond their realms of
imagination. Access to these areas soon became
reality. The illumination and visualization pro-
vided by the nasal endoscope was simple unpar-
alleled. Simultaneously CT scan study of para Image showing the distance between anterior
nasal sinuses also gained in popularity, enabling nares and skull base
the surgeon to have an exact understanding of the
anatomy of this crucial area. Soon the “neglect- Presellar type:
ed sinus” (adage for sphenoid sinus) became the
most studied sinus. In fact it threw up an import- In this type the air cavity does not penetrate
ant gateway to access pituitary gland. beyond the coronal plane defined by the anterior
sellar wall.
It was Jankowski etal in 1992 who performed suc-
cessful endonasal endoscopy assisted resection of Presellar type penumatization
pituitary adenoma. In fact they reported success- Sellar type:
ful removal in three patients. It soon became a In this type the air cavity extends into the body of
sensation, and surgeons all over started following the sphenoid below the sella and may extend as
it. far posteriorly as the clivus. This type is common-
ly seen in 85% of individuals.
Surgical anatomy:
Post sellar pneumatization
A study of surgical anatomy of sphenoid sinus is
a must for successful completion of this surgical The sphenoid ostium is located in the sphenoeth-
procedure. Depending on the extent of pneuma- moidal recess. It can be commonly seen medial
tization sphenoid sinus has been classified into to the superior turbinate about 1.5 cms superior
three types i.e. conchal, presellar and sellar. to the posterior choana. In fact it lies just a few
millimeters below the cribriform plate.
Conchal type:
The right and left sphenoidal sinus is separated by
In this type the area below the sella is a solid a intersinus septum. The position and attachment
block of bone without an air cavity. This type is of this septum is highly variable.
common in children under the age of 12 because
pneumatization begins only after the age of 12.

cranial nerves. It also contains some amount of
fatty tissue.
The prominence of internal carotid artery is the

postero lateral aspect of the lateral wall of sphe-
noid sinus. This prominence can be well identi-
fied in pneumatized sphenoid bones. On the ante-
ro superior aspect of the lateral wall of sphenoid
sinus is seen the bulge formed by the underlying
optic nerve. These two prominences are separated
by a small dimple known as the opticocarotid re-
cess. The optic nerve and internal carotid artery is
separated from the sphenoid sinus by a very thin
piece of bone. Bone dehiscence is also common in
this area.
In well pneumatized sphenoid sinus, the ptery-

goid canal and a segment of maxillary division of
trigeminal nerve could be identified in the lateral
recess of the sphenoid sinus.
Image showing presellar type of sphenoid pneu-
matization
Possible variations of intersinus septum are as

follows:
1. A single midline intersinus septum extending

on to the anterior wall of sella.
2. Multiple incomplete septae may be seen
3. Accessory septa may be present. These could be

seen terminating on to the carotid canal or optic
nerve.
Lateral wall of sphenoid sinus: is related to the

cavernous sinus. This sinus is formed by splitting
of the dura. It extends from the orbital apex to Image showing post sellar type of pneumatiza-
the posterior clinoid process. Cavernous sinus tion
contains very delicate venous channels, cavernous
part of internal carotid artery, 3rd, 4th and 6th
308
The roof of the sphenoid (planum sphenoidale) hormones are indications for early surgery to
anteriorly is continuous with the roof of ethmoid- achieve endocrinological cure.
al sinus. At the junction of the roof and posterior
wall of sphenoid the bone is thickened to form Patients with suspected aneurysm should under-
the tuberculum sella. Inferior to the tuberculum go angiography.
sella on the posterior wall is the sella turcica. It
forms a bulge in the midline. The bone over the
sella could be 0.5 - 1 mm thick. This may get thin-
ner inferiorly. It is hence easy to breech the sella
in this tinnest part. This area can be easily identi-
fied by a bluish tinge of the dura which is visible
through the thin bony covering.
The main portion of the pituitary gland lies in the

sella turcica and is connected to the brain by a
stalk known as the infundibulum. In front of the
infundibulum, the upper aspect of the gland is
related directly to pia archnoid. The subarachnoid
space hence extends below the diaphragm. This
anatomy should be borne in mind before open-
ing up the pituitary through the sphenoid sinus.
The pituitary gland is related superiorly to the
optic chiasma and below to intercavernous sinus.
Inadvertant trauma to this sinus could cause trou-
blesome bleeding, hence care should be taken to
avoid this structure.
Indications for endoscopic hypophysectomy:

Image showing interior of sphenoid sinus
Secretory / Nonsecretory pituitary tumors. Non
secretory tumors reach a large size before be-
coming symptomatic. These patients present
with ocular symptoms due to pressure over optic
chiasma, oculomotor nerve dysfunction due to
involvement of cavernous sinus.
Most prolactin secreting pituitary adenomas

respond well to bromocriptine, hence surgery can
be withheld in these patients.
Tumors secreting growth / adrenocorticotrophic

ized using bipolar cautery. The sphenoidotomy
is extended to the opposite side by removing the
rostrum of sphenoid. About 1 cm of the posterior
part of vomer is removed with reverse cutting
forceps.
After this step both ENT and Neurosurgeon work

as a team. The neurosurgeon applies suction
through left nostril to ensure that the operating
field is clear. The bulges formed by the internal
carotid artery and optic nerve are identified. Care
must be taken while the intersinus septum is re-
moved because it could be directly attached to the
internal carotid artery, hence true cut instruments
should be used.
A ball probe is used to access the thickness of the

Image showing anatomy of pituitary anterior wall of the sella, fracturing it at the thin-
nest portion. A kerrison punch is used to widen
Surgical technique: the opening. Dural bleeding is controlled using
bipolar cautery. A cruciate incision is made. The
Nasal cavities are decongested by use of nasal vertical limb of the incision should not extend
packs mixed with 4% xylocaine with 1 in 10,000 too superiorly to avoid subarachnoid space. The
units adrenaline. intercavernous sinus should be avoided inferiorly.
Since most of these tumors are gelatinous and
This surgery is performed under general anesthe- semisolid in nature, they can be easily sucked out
sia. by using a suction. Blunt ring curettes are used to
remove the tumor completely.
The patient is positioned supine with head elevat-
ed to 30 degrees. Patient’s bladder is catheterised The tumor removal is done in a systematic man-
to monitor urinary output in the post op period. ner. It is usually started from the floor, then
laterally and finally the supra sella component if
Nasal endoscopic examination is performed using any is attended to. The nasal cavity is packed with
0 degree and 30 degrees nasal endoscope. The Merocel.
sphenoid ostium is identified in the sphenoeth-
moidal recess on both sides. Surgery is usually Post operative care:
started on the side where the sphenoid ostium is The patient is kept in surgical ICU for 24 hours.
better visualized. The sphenoid ostium is wid- Urinary output is monitored. Adequate doses of
ened inferiroly and medially till the floor of the antibiotics are used parentally.
sphenoid sinus is reached. The septal branch of
sphenopalatine foramen if encountered is cauter-
310
Complications: stripping of sphenoid mucosa, trauma to cavern-
ous sinus, trauma to internal carotid artery. Per-
1. CSF leak sistent post op bleeding could be caused due to
trauma to sphenopalatine artery and its branches.
2. Diabetes insipidus
Intrasellar hematoma: Transient / permanent loss
3. Intrasellar hematoma of vision may be caused due to intrasellar hema-
toma / or due to direct damage to optic chiasma.
4. Death due to trauma to internal carotid artery In cases of intrasellar hematoma, CT scan should
be done to clinch the diagnosis. Immediate evac-
5. Blindness due to damage to optic nerve uation of heamatoma should be done.
CSF leak: Contraindications:
This is one of the commonest intraoperative 1. Poor general condition of patient

complication. The usual cause is trauma to the
diaphragma with instruments like curette, forceps 2. Conchal type of sphenoid pneumatization
etc. This area is very thin and highly susceptible
to trauma. When csf leak is identified intraopera- 3. Prolactinomas
tively, the defect should be identified and repaired
with intrasellar placement of abdominal fat and
fibrin glue. Lumbar drainage is performed for 5
days. Minor weeping defects of dura can be ex-
pected to heal on its own.
Meningitis: This is an uncommon complication

following surgery. Organisms involved include
staph aureus, strep. pneumonia etc. Broad spec-
trum antibiotics should be used to manage these
patients.
Diabetes insipidus: This complication may be

transient / permanent. Commonly this condi-
tion is transient in nature. These patients should
be managed with intranasal administration of
desmopressin. Permanent diabetes insipidus may
be caused by damage to pituitary stalk. during
surgery.
Bleeding: Intraoperative bleeding may be caused

due to inadequate nasal decongestion, excessive

Management of CSF rhinorrhoea
Introduction
CSF is formed primarily in the choroid plexus

found in the lateral, third and fourth ventricles.
Extra choroidal formation of CSF is from the
paranchymal capillaries and from intra cellular
water metabolism CSF flows from its production
sites in the two lateral ventricles through the
foramina of Monro into the third ventricle and to
the fourth ventricle through the aqueduct of syl-
vius. Flow continues through the fourth ventricle,
located in the brain stem and communicates with
the cisterna magna through the midline foramina
of Luschka from the cisterna magna. CSF flows
into the subarachnoid space. CSF is absorbed into
the cerebral venous system through the arachniod
villi. CSF is formed at the rate of 0.35ml/min ,
or 350500ml / day and it varies with circadian Image showing CSF formation and circulation
rhythm. The total volume of CSF is turned over
about three times a day. The normal CSF pressure Etiology and classification
is 5156 mm Hg or 515 cm water in prone position
and increases to 40 cm of water with movement CSF Rhinorrhoea is classified according to the
into sitting position. CSF pressure varies with the etiology developed by omaya. He divided CSF
time of the day, age of the patient, activity level, rhinorrohea into traumatic and atraumatic. The
respiratory and cardiac cycles. Neurologic sys- latter is subdivided into atraumatic with normal
tems may develop when the pressure higher than pressure and atraumatic with high pressure.
20cm of water is sustained.
Classification of CSF Rhinorrhoea:
Functions of CSF:
Traumatic causes
Physical support and buoyancy for the brain. Accidental
Maintain safe intracranial pressure. Surgical
Removal of byproducts of metabolism.Regulate Non traumatic causes
the chemical environment of the brain. High pressure leaks
Tumours
Hydrocephalus
312
fractured bone edges and the point where the an-
terior ethmoidal artery enter the lateral lamella in
the place of least resistance in the entire skull base
that a CSF fistula can occur.
In some patients avulsion of olfactory fibres from

the cribiform plate by the shearing forces of a
blunt trauma can rarely cause rhinorrhoea in the
absence of fracture . Transverse fractures through
the petrous bone cause CSF leak in to the middle
ear and drain through the Eustachian tube to the
nasopharynx (Otorhinorrhoea). Rarely a cranio
orbital fracture together with the laceration of
conjuctival sac may cause CSF to leak from the
eye (Occulo Rhinorrhoea )
Hyposmia or anosmia:
Image showing routes of CSF leak
Hyposmia or anosmia is due to olfactory nerve
Normal pressure leaks: damage from fracture of the cribriform plate.
Congenital anomaly RECURRENT ATTACKS OF MENINGITIS:

Spontaneous
Osteitis Infection alone may be the first sign of fistula
Osteomyelitis without history of CSF Rhinorrhoea, most of the
Traumatic CSF Rhinorrhoea patients are belong to the delayed post traumat-
ic group. Possible explanations for this are, Age
related shrinkage of brain previously plugging a
Accidental Trauma: defect.
Accidental trauma in the most common etiolo- Cerebral – dural scar that sealed the scar did not
gy (80%)12 of CSF leaks. Leaks occur in 23% of provide reliable barrier to infection.
patients with closed head injury and it 30% of pa- Growing fractures of the ethmoid leading to
tients with skull base fractures. CSF rhinorrhoea the formation of a herniated encephalocele that
may occur directly through the anterior cranial stretched and ruptured as a result of intracranial
fossa or indirectly from the middle or posterior pulsations.
fossa through the eustachean tube. Most frequent
sites of CSF rhinorrhoea are Fovea ethmoidalis,
Cribriform plate posterior wall of frontal sinus
and Sphenoid sinus. Because the anterior cranial
fossa dura adherent to the bone is easily torn by

for diagnosis.
BEDSIDE TESTS:
False positive results are possible in patients with
Halo sign / Target sign: chronic liver disease, inborn errors of glycopro-
A clear watery fluid leakage from the nose is tein metabolism, genetic variants of transferrin,
likely to be CSF. If the fluid is mixed with blood neuro psychiatric disease and rectal carcinoma .
or nasal discharge the presence of CSF is indicat- when these pathologic conditions are suspected
ed by halo sign. The discharge is placed on filter sampling of venous blood should be sampled for
paper CSF will migrate farther and form ring comparison.
like pattern around the blood and mucus in the
center. BETA TRACE PROTEIN:
HAND KERCHIEF TEST Beta trace protein is a another brain specific pro-
A wet hand kerchief that dries without stiffening tein produced mainly in the leptomeninges and
suggestive of CSF leak. choroid. It is the second most abundant protein in
CSF after albumin. It can also found in serum and
GLUCOSE OXIDASE TEST STRIPS perilymph . Beta trace protein is a reliable marker
for detection of CSF in nasal secretions and it is
The test strips are positive at a relatively low level used most commonly in Europe.
of glucose. Reducing substances in the lacrimal
gland secretions and nasal mucus may cause a GLUCOSE CONCENTRATION:
positive reaction. Hence a negative test excludes
the present of CSF but a positive result cannot be Glucose more than 30mg /dl or two thirds of
interpreted except in the presence of CSF infec- blood glucose in clear nasal fluid indicates the
tion. presence of CSF in the nasal discharge.
Laboratory tests CHLORIDE CONCENTRATION

Chloride concentration more than 110 mg/l sug-
BETA – 2 TRANSFERRIN gests that the fluid is most likely CSF.
Beta2 transferrin is highly sensitive and specific
in identifying fluid as CSF. Role of Imaging:
Beta 2 transferrin is a polypeptide involved in
ferrous iron transport. PLAIN RADIOGRAPHY
Plain radiography are of limited value but they
It is produced by desialisation of the normal Beta may show skull base fractures, fluid in the para-
1 transferrin in CSF through cerebral neuramin- nasal sinuses and intracranial air.
idase. It is found only in CSF, perilymph and
vitreous humor. PLAIN CT SCAN
Plain CT brain is recommended in cases of spon-
Nasal secretions can be tested for the presence of taneous CSF leak to exclude causes such as intra
this protein and less than 1 ml of fluid is required cranial mass or hydrocephalus.
314
the use of contrast (or) spinal puncture. On the
HIGH RESOLUTION CT ( HRCT ) T2 weighted fast spin echo the CSF has a char-
acteristic bright signal that can generally dis-
HRCT provides thin sections (0.61mm) in both tinguished from inflammatory paranasal sinus
the axial and coronal planes. The axial images secretions. MRC is consider positive if herniation
shows the posterior wall of frontal sinus and of brain tissue or arachnoids through a bony
sphenoid sinuses. Coronal images shows the defect and CSF signal in the paranasal sinuses
ethmoid complex, roof of sphenoid sinus and the continues with CSF in the sub – arachnoid space.
tegmen of the middle ear. HRCT is able to identi- MRC is superior to CTC in cases of Multiple
fy even the smallest bone defect along with skull dural defects.
base with high sensibility. HRCT is independent
on leak activity at the time of imaging. RADIONUCLIDE CISTERNOGRAM (RNC):
CISTERNOGRAPHY (CTC): RNC is similar to CTC in that the radio active

material most commonly TE99 is injected intra-
In CTC an intrathecal injection of non ionic con- thecally followed by gamma camera imaging in
trast medium in the lumbar region. In the pres- different positions. RNC is particularly useful in
ence of active leak CTC demonstrates movement low volume or intermittent leaks. In such cases
of the contrast through the defect. The rate of RNC is combined with endoscopic placement of
detection is lower if no leak is present at the time nasal pledgets that are placed in sphenoethmoid
of investigation. The site of leakage is indicated by recess ,middle meatus and olfactory cleft before
bony dehiscence, contrast agent in the adjacent starting the study. After imaging the blood sam-
para nasal sinuses,distortion of subarachnoid ples are taken and the pledgets are removed at the
space and brain herniation. CTC is of particular same time,the normal ratio (radionuclide count
use when the frontal and sphenoid sinuses act as in pledgets / radionuclide count in blood sam-
reservoirs. ple) should be &lt; 0.37, the pledget with highest
count is assumed to have been nearest to the leak.
CTC is contra indicated in patients with active
meningitis and increased intracranial pressure. INTRATHECAL FLUORESCEIN:
Weakness of this technique includes its inability
to detect an active leak at the time of study,ad- This technique is highly successful and accurate
verse reactions, and increase exposure to radia- in diagnosing and localizing an active CSF leak
tion. Contrast agents such as iohexol and most commonly used as an adjacent to intraop-
iopamidol have a lower incidence of side effects. erative localization of a skull base defect .10ml of
CSF is
MAGNETIC RESONANCE CISTERNOGRA- withdrawn by lumbar puncture is mixed with 0.2
PHY (MRC): to 0.5ml of 0.5% fluorescein and slowly injected
through a lumbar drain. Fluorescein stained CSF
MRC is a non invasive technique that can detect can be seen as bright yellow or green. Use of a
CSF fistula in multiple planes which does not blue light filter makes the test sensitive upto 1 in
involve 10 million. Side effects of this technique includes

lower extremity weakness, numbness , gener- such as azetazolamide or with ventriculo peri-
alized seizures, opisthotonus and cranial nerve toneal shunting. Leaks that do not resolve with
deficits. normalization of intracranial pressure need surgi-
cal management. Normal pressure non traumatic
PET Scan: leaks rarely close with conservative therapy and
almost always require surgical exploration.
PET scan has been used to demonstrate a leak in
some difficult cases where the side and site of the Antibiotic prophylaxis remains controversial .
fistula is not obvious. This is particularly useful Untreated CSF rhinorrhoea has been associated
in cases of CSF otorrhoea where it is not clear with a 25% risk of meningitis. Risk of meningitis
whether the leak is from posterior fossa or middle is greater with delayed CSF leakage.
cranial fossa.
Longer duration of CSF leakage:
Management:
Concurrent infection:
Most CSF leaks resulting from accidental and The arguments against antibiotic prophylaxis are
surgical trauma heal with conservative measures The antibiotics commonly used penetrate CSF
over poorly. If the antibiotics are used a combination
a period of 710 days . Conservative management of cotrimazole which is bactericidal in CSF and
consists of Bed rest with head end elevation, amoxicillin or penicillin which are bactericidal in
Avoidance of straining activities such as nose nasal mucosa is recommended.
blowing, sneezing and coughing.
Antibiotics may promote resistant strains of
Use of laxatives and stool softeners to reduce organisms within the nasopharynx and conse-
straining. quently lead to infection with resistant or unusual
organisms.
If the leak does not resolve within 3 days inter-
mittent or continuous drainage of CSF may be Surgical Management:
tried for the next 4 days with removal of 150ml/
day. Continuous CSF drainage is hazardous and The surgical management of CSF Rhinorrhoea
should be used in caution . Over drainage can can be divided into intracranial and extra cranial
lead to intracranial aeroceles, severe brain dis- approaches. Dandy described the first surgical
placement and coma. Intermittent drainage of 20 repair through a bifrontal craniotomy in 1929 .
30ml over and 8 hour period into a closed system
is safer. Dohlman was the first to document the first
A nontraumatic high pressure leaks caused by intracranial repair of CSF leak in 1948 .In 1981
increased intracranial pressure will probably Wigand described closure of CSF leak using an
resolve if the intracranial pressure is normalized. endoscopic approach . Majority of traumatic
Intra cranial pressure can be normalized by use of CSF fistulas heal without surgical intervention.
diuretics Patients who develop CSF rhinorrhoea, shortly
316
after trauma do not need surgery to close the CSF las may be repaired through a Trans labyrinthine
fistula. approach. If the hearing is intact, they should be
approached via the posterior fossa.Leaks from the
Indications for early surgery are: sphenoid sinus area are difficult to approach via
the intracranial route.
Penetrating injury including gunshot wounds.
Intra cranial surgery is indicated when operating
Anterior cranial fossa surgery indicated for other for associated craniofacial injuries.
reasons such as intracranial hematoma or to
repair compound facial fractures with accessible Large bone defects that may be difficult to repair
dural tears being treated at the same time. endoscopically.
Meningitis once treated. The fistula site cannot be identified by endoscopic

examination.
A large intracerebral aerocele.
Tumours with intracranial extension that are not
Herniation of brain tissue through the nose. amenable to endoscopic resection.
Radiological appearances that indicate a low Advantages of intracranial repair are:

probability of natural dural repair.
Improved exposure
Delayed surgery is indicated for failed conserva- Ability to identify multiple defects
tive management – CSF leak persisting beyond 10 Repair can also be done even under condition of
days. increased intra cranial tension
Disadvantages of intra cranial repair are
Recurrent or delayed CSF leak after 10 days. Increased morbidity
Recurrent aerocele after 10 days. Permanent anosmia
Meningitis or abscess at any time after surgery. Trauma related to brain retraction
When CSF rhinorrhoea results from surgery the Increased hospital stay
dural injury should be repaired when it occurs.
Post operative leaks will usually close with con- Extra cranial repair of CSF leak:
servative management.
Extra cranial approach includes anterior osteo-
Intra cranial repair of CSF leak. plastic approach via bicoronal or eyebrow inci-
Repair of anterior fossa fistulas can be ap- sion, external ethmoidectomy, transethmoidal
proached by frontal anterior fossa craniotomy. sphenoidectomy and transseptal sphenoidectomy
Middle cranial fossa leaks from a petrous fracture have lower morbidity rates, higher success rates
is rare they are best approached through a sub- and no anosmia .They provide that best exposure
temporal craniotomy. Posterior fossa leaks from of the sphenoid, parasellar and posterior eth-
the posterior petrous surface are often associated moids, cribriform plate, fovea ethmoidalis and
with hearing loss. If the hearing is lost these fistu- fistulas in the posterior wall of frontal sinuses .

Cerebral damage and the lateral extensions of the reach endoscopically and inferior posterior ex-
frontal and sphenoid sinuses cannot be assessed. tension may be difficult to reach from an external
approach .Once the tear is localized, the nasal or
Disadvantages: sinus mucosa around the site of the tear is re-
moved for about 5mm to expose the bone around
Facial scar the defect this allows attachment of the free graft
Facial numbness to the bone . Sinus mucosa continues to secrete
Orbital complications mucus and may separate the graft from the recip-
ient bed if the mucosa is not removed . when the
Endoscopic repair of CSF leak: appropriate mucosa is removed a diamond burr
or curette can be used to abrade the recipient bed
Endoscopic approach to CSF fistula depends bone lightly and stimulate osteogenesis . If the
on the suspected site of the lesion. presence of dural defect in smaller than the bony defect the
intracranial lesions,comminuted fractures of the dural defect is enlarged to the size of bony defect
cranial base , fracture of posterior wall of frontal for the adequate support of graft material with the
sinus are contraindications for endoscopic re- underlying bone.
pair. Patients who have an active CSF tear during
surgery will not requires placement of fluorescein Graft materials:
intrathecally . Fluorescein can help identify the
site of small leak that is intermittent or that has Historically, non vascularized graft such as peric-
recently stopped leaking ,if bluelight filter is used ranium, temporalis fascia, facia lata , muscle ,fat,
on the light source even the smallest quantities of allograft or synthetic dura or surgical cellulose
fluorescein can be visualised. mesh were used . These graft carried high risk of
necrosis , post operative CSF leaks and infection.
CSF leaks at the ethmoid sinus or the lateral Today dural closure in accomplished by auto graft
lamella of cribriform plate will require complete such as temporalis fascia , fascia lata, abdominal
endoscopic anterior and posterior ethmoidec- fat , septal mucoperichondrium and turbinate
tomy to gain wide exposure to skull base . CSF bone .
leaks at the cribriform plate approached directly
through olfactory groove. Sphenoid sinus CSF Lypolised cadaver dura and bovine pericardium
tears can be approached in many ways includ- are also be used. These grafts are further support-
ing a trans – septo sphenoid approach, ap- ed by local or free vascularized tissue .The fibrin
proach through the spheno – ethmoid recess or sealant provides a temporary water tight closure
a transethmoid approach. Defects located in the and creates a additional barrier to CSF leak.
lateral recess of sphenoid sinus are difficult to ac-
cess by the transeptal or transethmoid approaches Applying the graft:
and may requires an endoscopic transpterygoid
approach . Defects directly involve the frontal The graft is applied using various techniques
recess may require a combined approach using
endoscopic and open techniques because the
superior extent of the defect may be difficult to
318
Image showing on lay grafting process Image showing underlay grafting technique
The onlay technique is generally employed for Bath plug technique of closing CSF leak:
defects located in the lamina cribrosa where the
presence of olfactory nerve filaments make it dif- Once the defect has been prepared the skull
ficult to dissect dura from the adjacent skull base. base defect is measured. If the size of the defect
is measured if the size of the defect is less then
Cartilage or bony graft is placed on the extra cra- 12mm a fat plug is harvested from the ear lobe.
nial surface of the skull duraplasty is then com- If the defect is larger than 12mm, fat is obtained
pleted with a second layer of free muco perichon- either from the region of the greater trocanter
drium. This technique can also be used in lateral of the thigh or from the abdomen. The fat of the
wall of extensively pneumatized sphenoid sinus. ear lobe is preferred because the fat globules are
tightly bound and easy to work with. The fat plug
Underlay technique: should be the same diameter as the defect and
1.5 to 2cm long. A free mucosal graft is harvested
This is ideal for defects located in the fovea eth- from the lateral nasal wall (usually on the oppo-
moidalis. Graft material is positioned between the site side of CSF leak)
dura and the bone. A 4 – 0 vicryl is knotted through the one end of
the fat and the suture passed down the length of
fat plug. The fat plug is placed below the defect
and a malleable frontal sinus probe in used to
introduce the fat plug through the defect , once
the fat plug has been safely introduced the plug is
stabilized with the probe and the suture is gently

pulled. The free mucosal graft is slide up the vic-
ryl suture to cover the slightly protruding fat plug
and skull base defect.
Image showing Bath plug technique
Cuff – link repair:
This technique uses a double layer of lyophilised

dura or fascia to sandwich the dural defect, taking
advantage of the hydrostatic CSF pressure to seal
the defect and stop the leak. This is a variation
of bath plug technique to repair sellar and clival
defects successfully.
320
a vertical limb which splits the upper lip. The
Lateral Rhinotomy vertical limb is given just lateral to the philtrum
of the upper lip to facilitate better healing without
This approach is one of the most commonly used excessive scar formation.
technique for exploration of difficult to remove
sinonasal masses. Despite the fact that endoscop- Lip splitting incision can be used to access the
ic approaches and tools has progressed rapidly bony architecture of the middle third of the face.
during the past decade, the excellent exposure Incision begins just below the medial canthus of
provided by lateral rhinotomy makes it a very the eye along the lateral edge of the nasal bone
suitable approach for resection of sinonasal mass- and frontonasal process of maxilla. Incision
es with extensive spread. should stay as close to the lateral nasal sulcus as
possible. Angular vessels could be encountered,
This is an established approach to the midfacial and the same should be ligated / cauterized to
skeleton. The standard incision is placed over the control the bleed. On deepening this incision
nasofacial groove. the lateral wall of the nose can be everted and the
interior of the nasal cavity is exposed. If lip split-
Indications: ting incision is used the skin flap can be elevated
in such a manner in order to expose the anterior
Generally few these days because of the populari- wall of the maxilla, pyriform aperture and the
ty of endoscopic sinus surgery. interior of the nasal cavity.
1. Benign masses involving nose and sinuses
2. Malignant lesions involving nose and sinuses
3. Diseases of nose and sinuses with orbital in-

volvement
This surgery is usually performed under general

anesthesia.
Incision:
Incision used is the classic Moore’s lateral rhi-

notomy incision. The incision is given close to
the lateral nasal groove up to the ala of the nasal
cartilage. If better exposure is needed then this Image showing classic lateral rhinotomy incision
incision is combined with the lip split where in indicated by blue line and the lip splitting ver-
this incision is combined with that of a horizon- sion indicated by dashed lines.
tal limb along the upper border of upper lip and

Image showing the incision area being infiltrated
with 2% xylocaine with 1 in 100,000 adrenaline.
Image showing lateral rhinotomy incision being

given
322
Surgical approaches to Nasopharynx access nasopharynx.
Nasopharynx is a difficult area to access surgically Lateral rhinotomy

due to Transnasal transmaxillary approach
Midfacial degloving
1. Its central location Lefort I osteotomy
Maxillary swing approach
2. Its surrounding facial skeleton, skull base
Lateral rhinotomy: This approach exposes the na-
3. Presence of great vessels and lower cranial sal cavity and choana well. It can be used alone or
nerves in combination with other approaches to enhance
exposure of nasopharynx. This approach is useful
Ideal surgical approach to nasopharynx should: in resection of anteriorly placed tumors.
1. Provide adequate exposure to nasopharynx for

tumor resection
2. Great vessels must be safely controlled
3. Lower cranial nerves should be spared - a diffi-

cult task indeed.
Surgical approach chosen is dependent on
1. Extent of tumor
2. Surgical expertise
3. Facilities available
Classification of surgical approaches:
!. Anterior approach Image showing Lateral rhinotomy incision
2. Inferior approach
3. Lateral approach
Anterior approaches:
The following anterior approaches can be used to

maxillae to be down fractured. Access to central
Transnasal transmaxillary approach: In this ap- skull base and nasopharynx is ensured without
proach lateral rhinotomy is combined with medi- any visible facial scars.
al / subtotal maxillectomy. This approach exposes
the nasopharynx, ipsilateral spheno-ethmoidal
complex, pterygopalatine fossa and medial end of
infratemporal fossa.
Midfacial degloving approach:
This is a bilateral transnasal, transmaxillary

approach. The advantage of this procedure is
that it is performed via sublabial incision thereby
avoiding facial scar. In this approach infraorbital
nerves on both sides are safeguarded, midface is
degloved subperiosteally up to the level of root of
the nose. Bilateral medial maxillectomy is per-
formed to improve exposure. The pterygopalatine
fossa and the medial end of infratemporal fossa is
ideally exposed.
Image showing Lefort I osteotomy
Maxillary swing approach:
This is one of the common approaches to naso-

pharynx. It exposes the nasopharynx and sur-
rounding areas from the anterolateral aspect.
through Weber Ferguson incision maxilla is sep-
arated from its bony attachments and swung lat-
erally intact with the masseter muscle and cheek
flap. Access to opposite side can be established by
removing the posterior portion of nasal septum.
Image showing midfacial degloving approach After tumor resection, the maxilla is swung back
and fixed to facial skeleton.
Lefort I osteotomy: In this approach through a
sublabial incision a transverse maxillary osteoto- Inferior approaches:
my is performed through both maxillary sinuses
allowing the whole hard palate and both inferior Transpalatal approach: Nasopharynx can be
324
accessed by raising palatal mucoperiosteal flap off
the hard palate, separating the soft palate from
its bony portion. The posterior edge of bony hard
palate is removed as much as it is necessary to
access the nasopharynx. Greater palatine neuro-
vascular bundle must be mobilized bilaterally to
prevent flap necrosis.
Image showing transpalatine approach
Mandibular swing approach:
This is actually a combination of transcervical,

transmandibular, transpalatal approach via Fra-
zier incision. Soft tissues including parotid gland
are elevated from the mandible. Mid portion of
the ascending ramus of the mandible includ-
ing the coronoid process is cut and removed to
facilitate exposure and to prevent post operative
trismus. The lateral and medial pterygoid muscles
are divided to enter the nasopharynx. Tracheos-
tomy is a must to secure the airway. Dead space
after tumor removal needs to be repaired.
Lateral approach: This approach is via infratem-

poral fossa. This approach is limited by facial
nerve and carotid sheath. It is used when the
tumor extends laterally to involve the parapha-
ryngeal space.

Midfacial degloving approach: Nasal vestibule on both sides
Introduction:
Bilateral intercartilagenous infiltration extending
This approach which was popularised by Cas- around the dorsum of the nose, and the anterior
son et al and Conley is best suited for inferiorly wall of maxilla on both sides, up to the glabella of
located tumors with minimal ethmoidal involve- frontal bone.
ment. This is more suited for bilateral lesions.
This procedure is not suited for extensive tumors
which extent higher into the anterior labyrinth Transcutaneous injection into the orbit along its
with involvement of frontal sinus area. medial wall
Procedure:
Sublabial infiltration from the third molar across
This surgery is ideally performed under general the midline to the opposite third molar
anesthesia. Bilateral temporary tarsorraphy is per-
formed. The area of surgery is liberally infiltrated
with 1% xylocaine mixed with 1 in 200,000 units Trans oral greater palatine injection is also given
adrenaline. Infiltration minimizes troublesome
bleeding during surgery. The areas to be infiltrat-
ed include: The procedure is started with complete transfix-
ion incision, which is connected to bilateral in-
tercartilagenous incisions. Elevation of soft tissue
Subperichondrial plane of nasal septum from the nasal dorsum is performed through the
intercartilagenous space. The soft tissue elevation
over dorsum of nose is continued over the anteri-
Membranous portion of nasal septum or wall of maxilla on both sides. Elevation of soft
tissue should also continue over the glabella and
frontal bone. Supero laterally the elevation should
Inferior and middle turbinates on both sides extend up to the medial canthal region. The
intercartilagenous incision is extended laterally
and caudally across the floor of the vestibule to
Nasal tip be connected with the transfixation incision. This
results in a full circum vestibular incision on both
sides.
Nasal spine
After the transnasal incisions are completed the
sublabial incision is performed. It extends from
Floor of the nose on both sides the first molar on one side across the midline
up to the first molar on the opposite side. This
326
incision can be extended up to the third molar if
more exposure is needed. The incision is carried
down the submucosa, and muscles over anterior
wall of maxilla. At the pyriform aperture region
this incision is connected to intranasal incisions.
Periosteal elevators are used to elevate the soft
tissue over the anterior walls of both maxilla
up to the level of the orbital rim taking care to
protect the infraorbital vessels and nerve. The
entire midfacial skin is stripped from the dorsum
of the nose and anterior wall of maxilla. This flap
includes the lower lateral cartilages, columella
with its medial crura. The elevation is continued
till the level of glabella superiorly and medial
canthus laterally. The bony nasal pyramid and
the attached upper lateral cartilages are exposed
completely. Two rubber drains (Penrose type) are
passed through the nose and upper lip and are
used to retract the midfacial flap along with the
upper lip. Once in every 15 minutes one of the Image showing mucosal incision for midfacial
drain should be released to allow blood supply to degloving approach
the middle portion of the upper lip.
The anterior wall of the maxilla is drilled out.
Infraorbital neurovascular bundle should be
identified and preserved. Bone removal continues
superomedially towards the ethmoidal complex.
Nasolacrimal sac and duct need to be managed
before bony cuts of maxillectomy are performed.
Nasolacrimal duct can be transected at the orbital
floor level.
The whole anterior wall of maxillary sinus is

drilled out including the lateral portion of nasal
bone including the edge of the pyriform aperture.
Image showing midfacial degloving approach

being performed

Oblique cut of the orbital floor from the orbital
rim medial to the infraorbital foramen extending
postero medially to join the fronto ethmoid cut in
the posterior ethmoid region. All these bone cuts
should include the attached soft tissues.
The posterior attachment to the ascending pro-

cess of palatine bone is severed using a heavy
scissors.
Complications of midfacial degloving:
Anesthesia over infraorbital nerve area
Epiphora
Nasal valve stenosis
Image showing the exposure in midfacial deglov-

ing approach
Bone cuts for medial maxillectomy:
Cut along the nasal bone from the pyriform aper-

ture to the glabella a few millimeters anterior to
the nasomaxillary groove.
A horizontal cut is made just below the glabella

directed posteriorly towards the frontoethmoid
suture line.
Antero posterior cut along the fronto ethmoidal

suture line.
328
Transpalatal approach to Nasopharynx: the palate via greater palatine foramen bilaterally
at the posterior edge of the hard palate.
Introduction:
Procedure:
Wilson in 1951 described this approach. This ap-
proach gives exposure to nasopharynx as well as Before embarking on the surgical procedure, 1%
extensions into the sphenoid sinus and choana. It xylocaine with 1 in 100,000 adrenaline is infil-
gives no visible scar and post op healing is good. trated along upper dental alveolar ridge of hard
This approach is useful in dealing with masses in palate. Throat should be packed with roller gauze
the nasopharynx with minimal extension into the to prevent aspiration.
choana and sphenoid sinus.
Patient is put in tonsillectomy position. A for-
ward curved incision is made just in front of the
Indications: junction of hard and soft palate. Mucoperios-
teum is separated either way. Posterior spine of
JNA stage I the hard palate is removed. Incision is extended
laterally and downwards on either side along the
Small nasopharyngeal tumors pterygomandibular raphe. The mucosa of the
lateral pharyngeal wall is not divided and care is
Contraindications: taken not to damage the greater palatine vessels.
A good view of nasopharynx is achieved in this
Tumors extending to nasopharyngeal side walls. procedure. The mucous membrane on the side
of the growth is incised with a blunt knife. Thus
Preparation: with blunt dissection the periosteum is elevated,
growth is separated and finally avulsed in one
1. Preoperative emboliization for JNA / vascular piece.
lesions
2. Preformed acrylic place / splint custom de-

signed to aid in closure of palatal defect.
Anesthesia:
General anesthesia.
Position: Supine with extended neck.
Anatomy:
Neurovascular supply to the mucosa of palate is

from greater palatine vessel pedicles which reach

Surgical approaches to anterior skull base dale and lesser wings of sphenoid.
Introduction: Cribriform plate is perforated by multiple olfac-

tory nerves that extend from the olfactory mu-
Tumors involving anterior skull base and para- cosa to the olfactory bulbs. A bony fissure exists
nasal sinuses are challenging to treat because of between the lesser and greater wing of sphenoid,
their rarity, wide diversity of tumor types and the superior orbital fissure which gives passage to
variability of extent of involvement. The route cranial nerves III, IV, and VI cranial nerves and
of spread of these tumors is determined by the superior ophthalmic vein. Laterally and superior-
complex anatomy of craniomaxillofacial compart- ly lies the optic canal bordered by the body of the
ments. Hypothetically these tumors can invade sphenoid and by the superior and inferior roots of
laterally into the orbit and middle cranial fossa, the lesser wing of sphenoid which gives passage
inferiorly into the maxillary antrium and palate, to the optic nerve, ophthalmic artery, and sym-
posteriorly into the nasopharynx and pterygo- pathetic nerves. Both the superior orbital fissure
palatine fossa and superiorly into the cavernous and optic canal open in to the middle cranial
sinus and brain. fossa and are common affected by central skull
base lesions.
Surgery happens to be the most important treat-
ment modality of anterior skull base tumors. The thin cribriform plate is easily breached by
Combined craniofacial techniques for resection tumors, but the orbital plates of frontal bone are
of anterior skull base tumors was described first made of thick compact bone which could act as
by Ketcham etal in 1963. Since this description, an effective barrier to tumor growth into the an-
anterior skull base surgery has evolved to a great terior cranial fossa. Majority of tumors affecting
extent due to better understanding of local anato- the anterior skull base arise from the sinonasal
my of the area, advances in imaging and surgical region.
techniques.
Preop evaluation:
Anatomy:
All patients should be evaluated by a head and
Anterior skull base is a complex compartment an- neck surgeon, a neurosurgeon, anesthesiologist,
atomically. This area can be defined as the portion and plastic surgeon. Cross sectional imaging play
of the skull base adjacent to the anterior cranial a vital role as road map for the surgeon which
fossa. Boundaries of anterior skull base include: involves CT and MR imaging. Currently PET/CT
in combination is useful in determining the stage
Medial border - Cribriform plate of the disease and in differentiating recurrent
from residual disease. Surgeon needs to perform
Lateral border - Orbital plates of frontal bone that angiography only when confronted with vascu-
goes on to form the roof of orbits and ethmoid air lar lesions like JNA. Along with angiography
cells emboliization of the blood vessel supplying the
tumor can be resorted to in order to minimize
Posterior border - Is formed by planum sphenoi- bleeding during the procedure.
330
Weber Fergusson incision:
Open surgical approaches to anterior skull base:
In patients with malignant tumors infiltrating the
Adequate exposure of anterior skull base usually lateral maxillary wall a total maxillectomy should
requires a combined intracranial and extra-cra- be performed via a Weber-Fergusson incision.
nial approach. Commonly a team of neurosur- This approach involves an extension of the lat-
geons and otolaryngologists usually perform this eral rhinotomy incision by including splitting of
procedure. The choice of extra-cranial approach upper lip. This incision permits complete expo-
depends on the site and extent of the tumor and sure of maxilla from the upper alveolar ridge to
aesthetic considerations. Most importantly it also the orbit. This allows exposure of the superior
depends on the experience of the surgeon with and inferior aspects of maxilla and its complete
the chosen approach. en bloc resection. The soft tissue of the cheek is
raised from the anterior walls of maxilla, tran-
Extent of exposure of these approaches include secting the infra-orbital nerves and vessels if the
frontal sinus anteriorly, the clivus posteriorly, the superior and inferior aspects of the maxilla need
frontal lobe superiorly, and the paranasal sinuses to be approached. Upper cheek flap is developed
, the pterygo-maxillary fossa and infratemporal laterally and superiorly up to the level of the
fossa inferiorly. The lateral boundaries of this inferior orbital rim and the maxillary tuberosity.
approach include both superior orbital walls. Inferiorly it can reach the pterygomaxillary fossa.
Trans facial approaches: Lynch incision:
Lateral rhinotomy - This approach is used in This incision is very rarely used now a days as
tumors involving nasal cavity and maxillary sinus a sole approach. It can be used as an extension
without palatal invasion. Benign tumors with of the Weber-Fergusson incision. This incision
anterior maxillary wall involvement can also be extends along the lower border of the eyebrow /
similarly approached. This approach allows for in a skin crest along the upper eyelid, allowing it
wide exposure of maxillary antrum, nasal cavity, to be concealed at the hair skin junction. If the
ethmoidal sinuses, and sphenoid sinus. The facial incision is made inside the eyebrow it could leave
incision extends along the lateral border of the a thick and noticeable scar, giving poor cosmetic
nose, about 1 cm lateral to the midline. Superi- results. This incision can be extended laterally
orly it starts from just below medial canthus of up to the level of the lateral canthus, or inferiorly
they and extends down through the skin crest can be extended to include the lateral rhinotomy
bordering the nasal ala. It is continued towards incision.
the philtrum. The flaps can be developed to the
level of maxillary tuberosity laterally, the upper
gingival sulcus inferiorly, the frontal sinus and
infraorbital rim superiorly and to the nasion and
nasal septum medially.

In elderly and irradiated patients, the redundant
skin and subcutaneous tissue of the lower eyelid
tend to swell as the incision may include the lym-
phatic drainage of this area.
Midfacial degloving approach - This incision

combines the sublabial incision used in external
approaches to sinus surgery with the intranasal
incision used in cosmetic rhinological surgery.
The main advantage of this approach over con-
ventional lateral rhinotomy is the avoidance of
facial incision. This approach was originally
designed for benign tumors. The midfacial de-
gloving approach involves a complete transfixa-
tion incision, with a complete intercartilaginous
incision. This effectively separates the upper lat-
eral cartilage from the lower lateral cartilage, the
latter of which is later included with a superiorly
retracted flap. In the next step degloving of the
Image showing Lynch Howarth incision facial soft tissue from the nasal skeleton and max-
illa is performed. This can be achieved through a
Dieffenbach incision - This incision along with sublabial incision that extends from first molar to
its modified forms are used to approach tumors first molar on the opposite side.
involving the infra-orbital rim and root of zy-
goma. It can be extended up to the level of the Craniofacial resection:
medial canthus, or inferiorly to be included in a
lateral rhinotomy incision. The classical Dieffen- This technique is an established one for the sur-
bach incision extends along the lower border of gical excision of tumors involving the anterior
the eyelid along a skin crest. The incision extends skull base and paranasal sinuses. This technique
from the medial canthus to the lateral canthus. A incorporates a combination of transfacial and
later modification of this incision is the subciliary transcranial procedures in order to allow broad
incision, which is performed just below the cilia exposure of anterior cranial fossa and subcrani-
of the eyelid, or the midciliary incision performed al compartment. Initially a lateral rhinotomy is
halfway between the Dieffenbach and subciliary made, followed by a medial maxillectomy, ante-
incisions. rior and posterior ethmoidectomy and sphenoid-
ectomy. Sphenoidectomy is usually performed
The superior border of the flap includes the in- under a microscope. The cribriform plate and
fra-orbital rim and orbit; its inferior border is the frontal recess are exposed along with the lamina
anterior maxillary wall; laterally it is extended to papyracea bilaterally.
expose the maxillary tuberosity and root of the
zygoma; medially it extends up to the nasal bone. Elevation of the coronal flap and frontal crani-
332
otomy is performed. Craniotomy includes the
frontal bone ffrom the level of the glabella below
to roughly 4-5 cm above the skull base superiorly.
Lateral borders of the craniotomy are the midpu-
pillary line bilaterally. The dura is incised next
and if needed the frontal lobes can be retracted
superiorly thereby exposing the anterior skull
base from above. The final stage of the surgery
include resection of the tumor, which extends
through the cribriform plate.
Advantages of this technique: Image showing the anterior division of nasal

septum
1. Provides excellent exposure and access to the
orbital, spheno-ethmoidal and paranasal cavities.
2. Resection of intradural and extradural tumors

can be performed in a single procedure that al-
lows precise reconstruction of thee dura.
Major limitation of this procedure is the need

for frontal lobe retraction which could lead to
encephalomalacia, brain oedema and subdural
bleeding. These complications are more common
in the elderly.
Image showing inferior portion of nasal septum

divided and opposite nasal cavity is entered
Image showing lateral rhinotomy

Image showing opposite nasal cavity entered Image showing pericranial flap based on tempo-
ral vessels elevated
Image showing Bicoronal flap being elevated Image showing pericranial flap (Horse shoe
shaped) being raised
334
Image showing frontal lobe of brain exposed
Image showing Burr holes created in the frontal after dural excision
bone. Three holes in a triangular form is created
and bone cuts made connecting these holes ele-
vating a triangular shaped frontal bone flap.
Image showing retraction of frontal lobe
Image showing frontal lobe dura incised using a

coronal incision. Superior sagittal sinus should
be located and secured with the help of neurosur-
geon during this stage

Subcranial approach:
This is a single stage procedure that can be used

for tumors involving the anterior skull base. The
extent of exposure with the subcranial approach
includes the frontal sinus anteriorly, the clivus
posteriorly, the frontal lobe superiorly and para-
nasal sinuses inferiorly. Laterally, the boundaries
of this approach are both superior orbital walls.
Subcranial approach has some major advantages:
1. It affords direct exposure of the anterior skull

base from anterior to posterior instead of from
above and below which is the feature in craniofa-
cial approach.
2. It allows simultaneous intradural and extradu-

ral tumor removal from anterior to posterior.
3. Does not require facial incision.
4. Minimal frontal lobe manipulation is needed.
Subcranial approach involves a coronal incision

and osteotomy of naso-fronto-orbital bone seg-
ment allowing access to the intra and extra-crani-
al compartments of the anterior skull base.
Major disadvantage of this procedure is the risk of

osteoradionecrosis in post radiotherapy patients.
336
Laryngology
medical management and associated with halito-

Tonsillectomy: sis, persistent sore throat and cervical adenitis.
Definition: 4. Streptococcal carrier state unresponsive to

medical treatment.
Surgical removal of palatine tonsils is known as
tonsillectomy. 5. Quinsy
History: Cornelio Celsus Roman physician was 6. Tonsillitis associated with abscessed nodes.
the first person to describe tonsillectomy in
1st century BC. Surgical removal of tonsils has 7. Infectious mononucleosis with severely ob-
been practised as long as three thousand years structing tonsils that is unresponsive to medical
as per Hindu literature. Versalius (1543) was the management.
first one to describe the tonsil in detail includ-
ing its blood supply. Pare in 1564 designed an
equipment that allowed placing an oval shaped
instrument around the uvula to cut it off by Obstruction:
strangulation. This instrument underwent further
modification by Hildanus in 1646. Physick (USA) 1. Sleep apnoea
in 1828 created the first tonsillotome. From 1909
tonsillectomy surgery became a common and safe 2. Adenotonsillar enlargement associated with cor
surgical procedure. It was Cohan who adopted pulmonale, and failure to thrive
ligature of bleeding vessels to control periopera-
tive hemorrhage. Another instrument that gained 3. Dysphagia
popularity was the Sluder’s guillotine.
4. Speech abnormalities (Rhinolalia clausa)
Indications for tonsillectomy: 5. Cranio facial growth abnormalities
Infections: 6. Occlusal abnormalities
1. Recurrent acute tonsillitis - more than 6 epi-

sodes / year or 3 episodes / year for more than 2
years. Other causes
2. Recurrent acute tonsillitis associated with other 1. Embedded foreign body

conditions like : Cardiovascular disease associat-
ed with recurrent streptococcal tonsillitis. Recur- 2. Tonsillar cysts
rent febrile seizures.
3. As a surgical approach to other structures like
3. Chronic tonsillitis that are unresponsive to Styloid process Glossopharyngeal nerve Parapha-

ryngeal space. the lower lip. In this scenario the surgeon will
have to use a slotted tongue blade (Doughty)
Only absolute indication for this surgery is Ob- which will not compress the endotracheal tube. If
structive sleep apnoea syndrome ordinary blade is to be used then the tube should
be anchored to one side preferably to the left at
Pre op preparations: the cheek.
Position of the patient:
1. One week course of antibiotics (Surgery should Rose position. This position was first described by
not be performed during acute infections involv- a Theatre Nurse “Rose” hence the name. In this
ing tonsils as this would increase complications). position the head and neck are extended by keep-
ing a small sandbag under the shoulder blades of
2. Parent counseling regarding post operative care the patient.
of the child It can actually be performed as a day
care procedure. Advantages of Rose position:
1. There is virtually no aspiration of blood or

secretions into the airway.
Pre op investigations:
2. Both hands of the surgeon are free. This po-
1. X-ray chest PA view sition helps in proper application of the Boyles
Davis mouth gag.
2. Complete hemogram
3. The surgeon can be comfortably seated at the
3. Bleeding time and clotting time head end of the patient
4. INR Procedure:
5. Blood grouping and Rh typing The mouth of the patient is opened using Boyle
Davis mouth gag. This mouth gag is held in
position using a “M” stand / Draffin Bipod. This
ensures that the patient’s mouth is kept open by
Anesthesia: the instrument and both the hands of the surgeon
are free.
General anesthesia - Orotracheal / Nasotracheal
intubation Nasotracheal intubation is not possi- The oral cavity of the patient is cleared off secre-
ble in the presence of enlarged adenoids because tions using a Yanker’s suction tip. The tonsil is
it could cause trauma to adenoid with resultant medialized using a tonsil holding forceps (vulsel-
bleeding. If orotracheal intubation is preferred lum). Tonsil holding forceps is held in the left
then the tube can be anchored in the middle to hand to medialize right tonsil and right hand to
338
medialize the left tonsil. A little bit of ambidex-
terity will help the surgeon a lot. CryoTonsillectomy:
After medialization of tonsil mucosal incision is Tonsillectomy can also be performed using a cryo
made medial to the anterior pillar using a toothed probe. CryoSurgery is a process in which very
forceps (Waugh’s tenaculum forceps). The inci- cold instrument or substance is applied to ton-
sion is deepened and rounded along the superior sil and it is removed by the process of repeated
pole of tonsil freeing it. A cotton ball is inserted freezing and thawing. The temperature reached
inside the superior pole and is pushed gently during cryo is dependent on the medium used
peeling the tonsil off its capsule. After the tonsil : - 82 degrees centigrade by carbondioxide - 196
is peeled till the tonsillo lingual sulcus it is snared degrees centigrade by liquid nitrogen Any of the
and removed using Eve’s tonsillar snare. Using above can be used in tonsil surgery. The major
Eve’s tonsillar snare reduces bleeding because it advantage of this procedure is minimal bleeding.
crushes and cuts the tonsillar tissue. Crushing The major disadvantage of this procedure is the
the tissue ensures that tissue thromboplastin is operating time involved. This procedure is used
released facilitating coagulation. only in patients with known bleeding diathesis.
After the tonsil is removed on both sides bleeders

if any are tied / cauterized. A mollison’s retractor
can be used to retract the anterior pillar to visual- Laser tonsillectomy:
ize tonsillar fossa better.
Tonsillectomy can be performed using laser. A
carbon-dioxide laser of a KTP laser can be used.
Major advantage of laser surgery is reduced
Types of Tonsillectomy: bleeding. Laser seals all bleeders effeciently. The
flip side being increased operating time and the
The above said method is known as the dissection cost of laser equipment.
and snare method.
Intra-capsular tonsillectomy:
In this method tonsil is removed from its capsule.

Guillotine method: Special instruments are needed for this purpose.
Micro debrider with a 45 degree hand piece is
The tonsils were removed during olden days used for this surgery. The major advantage of
using this method. This method has been aban- this procedure is that it causes less trauma to the
doned because of the risks of bleeding. In this pillars and mucosa of the oro pharynx uvula and
method a guillotine is used to simply chop off the soft palate.
tonsil. This term guillotine is derived from the
French which literally means chop off the head. Harmonic scalpel tonsillectomy:
In medieval France prisoner’s life was taken off by
this method. Harmonic scalpel is an ultra sound coagulator

and dissector that uses ultra sonic vibrations to sub capsular plane) during dissection, ligation
cut and coagulate tissues. The cutting operation of bleeders, using bipolar cautery to coagulate
is made possible by a sharp knife with a vibratory the bleeding vessels. Trauma to the anterior and
frequency of 55.5 KHz over a distance of 89 micro posterior pillars. Trauma to posterior pillar causes
meters. Coagulation occurs due to transfer of nasal regurgitation whenever the patient attempts
vibratory energy to tissues. This breaks hydrogen to drink fluids after surgery. It may also cause
bonds of proteins in tissues and generates heat undesirable changes in the voice i.e. Rhinolalia
from tissue friction. The temperature generated aperta. Teeth must be taken care when mouth gag
by harmonic scalpel is less than that of electro is bing applied. Any loose tooth, dentures must
cautery hence it is safer (50 - 100 degrees centi- be removed before intubation because the loose
grade as compared to that of 150 - 400 degrees teeth can easily be dislodged and be aspirated.
centigrade). The major disadvantage is the ex- Trauma to the lips and gums: can be avoided by
pense of the equipment and the increased dura- using the right sized tongue blade. The size of the
tion of surgery. blade can be measured by placing it between the
mentum and the angle of the mandible.
Coblation tonsillectomy:
Intermediate complications:
It is also other wise known as cold ablation. This
technique utilizes a field of plasma, or ionised so- Are mostly haemorrhage. Haemorrhage during
dium molecules, to ablate tissues. The heat gener- immediate post op period is also known as reac-
ated varies from 40 - 80 degrees centigrade, much tionary haemorrhage. This is caused due to
lower than that of electro cautery. The major
advantage of this procedure is reduced bleeding 1. Wearing off of the hypotensive effect of the
and reduced post operative pain. anaesthesia during the immediate post op period.
Complications of tonsillectomy: 2. Slipping of ligature These patients must be

taken to the operation theatre, reanaesthetised
Complications can be classified in to immediate, and the bleeders must be ligated or cauterised.
intermediate and delayed. If bleeding is diffuse and uncontrollable pil-
lar suturing can be resorted to. This is done by
Immediate complications: suturing both the anterior and posterior pillars
after placing a gauze or gelfoam in the tonsillar
Mostly encountered on the table during surgery. fossa. If gauze is used to pack the tonsillar fossa,
The most common of them being the complica- silk is used to suture the pillars and these sutures
tions of general anaesthesia. Next is troublesome must be removed after 48 hours and the gauze is
intra operative bleeding. This is common in removed. On the other hand if absorbable mate-
poorly prepared tonsillectomies (i.e. patients who rial like gel foam is used the pillars can be sutured
have been taken up for surgery without a pre op with chromic cat gut and the sutures need not be
course of antibiotics), hot tonsillectomy (i.e. quin- removed.
sy tonsillectomy). Bleeding can be controlled by
proper dissection, staying in the correct plane (i.e.
340
Delayed complications: Are mostly due to infec-
tions. These commonly occur a week after the
surgery. Bleeding during this period is known
as secondary haemorrhage. Antibiotics are used
to control infections. Conventional Cold steel
tonsillectomy.
Image showing incision given medial to the ante-

rior pillar of the tonsil
Image showing mouth open with a mouth gag
Image showing cotton ball being inserted under

the superior pole
Image showing the patient in Rose position

Image showing tonsil dissected from the tonsillar
fossa. Tonsil is seen attached just to the lower Image showing coblation wand being used to
pole create the incision medial to the anterior tonsil-
lar pillar
Image showing coblation surgery of tonsil
Image showing coblation wand used to dissect

tonsil out of the tonsillar fossa
342
Image showing patient in Rose position with
mouth open and nasotracheal tube in position
Image showing empty tonsillar fossa following
surgery
Image showing snare wire being used to snare

tonsil out of its fossa

the prevaccination era
Adenoidectomy
Removal of Nasopharyngeal tonsil surgically is

known as adenoidectomy. Indications:
Usually in children adenoidectomy is performed

in conjunction with tonsillectomy because failure
to remove adenoid tissue along with tonsil will Infections:
cause compensatory hypertophy of adenoid tissue
to occur leading on to problems later. 1. Purulent adenoiditis
History: 2. Adenoid hypertrophy associated with CSOM

with effusion
Adenoidectomy was first perfromed in the late
1800’s when Willhelm Meyer of Copenhagen, Chronic recurrent otitis media
Denmark, proposed that adenoid vegetations
were responsible for nasal symptoms and im- CSOM with perforation
paired hearing. Adenotonsillectomy was routinely
performed begining in the early part of the 1900’s Obstruction:
when tonsils and adenoids were considered as
reservoirs of infection that caused many different 1. Excessive snoring
types of diseases.
2. Sleep apnoea
3. Adenoid hypertrophy associated with Cor-

Other indications that were considered those pulmonale Failure to thrive Dysphagia Speech
days were: As a treatment of anorexia Mental abnormalities
retardation Nocturnal enuresis To promote good
health In 1930’s and 1940’s widespread use of ade- Others:
notonsillectomy became controversial because:
Adenoid hypertrophy associated with chronic
sinusitis
1. Antimicrobial agents became effective in treat-

ing adenotonsillitis
Adenoidectomy is most frequently combined
2. The fact that the incidence of respiratory infec- with tonsillectomy / Grommet insertion.
tions in older children declined became appreci-
ated 3. There was an increased risk of bulbar po-
liomyelitis following adenotonsillectomy during
344
Investigations: can be diagnosed clinically by the presence of
bifid uvula. Hence the presence of bifid uvula is a
X-ray chest PA relative contra indication for adenoidectomy. The
largest size St Clair Thompson adenoid curette
Complete Hemogram should be introduced under the soft palate to
engage the adenoid tissue. The head of the patient
Bleeding time / Clotting time is stabilized using the non dominant hand. The
adenoid is curetted out with a single firm scraping
INR motion from superiorly to inferiorly. The adenoid
bed is examined for any remnant tissue using a
The author advocates one course of pre op antibi- dental mirror. Nasopharynx is packed with gauze.
otic therapy preferably with Amoxycillin. After a few minutes the gauze can be removed
safely and bleeding would have stopped.
Anesthesia:
General Anesthesia with Naso tracheal / oro

tracheal intubation. Naso tracheal intubation Complications following adenoidectomy:
is avoided if the adenoid is too large in size as
it would lead to bleeding. In patients with large Early:
adenoid tissue orotracheal intubation is pre-
ferred. The endotracheal tube is anchored in the 1. Bleeding (This is more common when adenoid
midline and taped to the lower lip. The patient is is curetted out)
positioned in Rose position (supine with a shoul-
der roll to achieve extension of the neck). The 2. Aspiration of retained blood clot causing acute
surgeon should ideally use Doughty’s modified airway obstruction (Coroner’s clot) Late: 1. Nasal
tongue blade which has a slot in the middle which discharge
would accommodate the endotracheal tube with-
out compression. The mouth gag is opened to fa- 3. Grisel syndrome (atlanto axial instability)
cilitate better exposure of oral cavity. To improve
visualization of nasopharynx a nasal cather is 4. Nasopharyngeal stenosis
inserted through one / both nostrils and brought
out through the oral cavity. Both ends of the 5. Velopharyngeal insufficiency
catheter are secured with an artery forceps. This
procedure would retract the soft palate anterior- 6. Regrowth of adenoid tissue
ly. The size of the adenoids is assessed by digital
palpation or by using a dental mirror. Presence of 7. Torticollis: Because the adenoids are removed
aberrant / dehiscent internal carotid artery should from the posterior wall of the nasopharynx over
also be looked for. The palate should be palpated the spine and superior constrictor muscle, chil-
to exclude occult cleft palate as proceeding with dren can have a stiff neck or spasm of the neck,
adenoidectomy in patients with occult cleft palate occasionally with torticollis. Torticollis is a rare
would lead to rhinolalia aperta. Occult cleft palate occurrence. Warm compresses, a neck brace, and

anti-inflammatory medications may be helpful
for relieving the spasm and pain.
Adenoidectomy can also be performed using

other tools like Microdebrider or coblator. The
advantage using these tools is that the adenoid
tissue can be completely removed under direct
observation.
Suction diathermy adenoidectomy:
The tip of the suction diathermy is bent to 90

degrees with the introducer still in place so as
to prevent kinking and occlusion of lumen. The
introducer is removed and the suction tip is con-
nected to continuous suction apparatus. Monop-
olar diathermy is set at 38 watts. With the mirror
held in the non dominant hand, the suction
diathermy is passed behind the soft palate. Using Image showing adenoid curette being intro-
a combination of sweeping motions and localized duced behind the soft palate to scoop out the
spot welding to kill the bleeders adenoid tissue is adenoid tissue
coagulated and removed.
Image showing hypertrophied adenoid tissue
Image showing adenoid tissue being scooped

out
346
Image showing coblation adenoidectomy

Quinsy Drainage 5. Hot potato voice (muffled voice). Rhinolalia
clausa.
Introduction:
6. Trismus
It is also known as peritonsillar abscess. It still
remains a common entity in the emergency wing 7. Halitosis
of the Hospital and otolaryngological practice.
Incidence: Estimated to be 30 cases per 100,000 Examination:
people per year. Mean age affected: Commonly
involves persons between 20-30 years. It shows no Pharyngitis would be evident. In almost all
sexual predisposition. Both male and female sexes patients there is a certain degree of soft palate oe-
are affected equally. It is very rare in children dema with bulging of tonsil. The uvula would be
under the age of 5. seen deviated away from the infected tonsil. On
gentle pressure over the swelling using a tongue
Site of involvement: depressor will cause blanching.
Quinsy usually occurs near the superior pole This condition should be differentiated from:
of the palatine tonsil, just outside the tonsillar
capsule between the superior constrictor and the Intratonsillar abscess
palatopharyngeus muscles. It should be noted
that quinsy could be closely related to tonsillar Peritonsillar cellulitis
artery, internal carotid artery and facial arteries.
Hence during incision and drainage adequate Infectious mononucleosis
care should be taken not to give a deep incision
to drain the abscess. The role of emergency care Odontogenic infections Aneurysm of internal
physician is to identify this condition, render ap- carotid artery
propriate treatment and provide adequate follow
up till the patient recovers fully. Intraoral ultrasound:
Symptoms: This can be performed under emergency sitting.

It shows high degree of sensitivity and specificity.
1. Fever This test will help in differentiation between cel-
lulitis and abscess in this area. It will also exclude
2. Sore throat another dangerous condition i.e. aneurysm of
internal carotid artery.
3. Intense pain while swallowing. Pain radiates to
ipsilateral ear (referred otalgia). Microbiology:
4. Drooling of saliva because it is very painful for A mixture of aerobic and anaerobic bacteria can
the patient to even swallow saliva be isolated from the pus drained from quinsy. The
common aerobic organism isolated being Strep-
348
tococcus group A, beta-hemolytic streptococci This is more used as a proof for the present of pus
group C and G and staphylococcus aureus. The before proceeding to perform incision and drain-
common anaerobic bacteria isolated from pus age. The pus can be sent for culture and sensitivity
aspirated from peritonsillar infections include in order to decide on antibiotic cover that should
Fusobacterium Necrophorum. This organism is be provided post operatively.
gram negative obligate anaerobic pleomorphic
rod. 2. Incision and drainage: This is performed with
patient in sitting position to prevent aspiration
Pathophysiology: of pus into the larynx. First the oral cavity and
throat of the patient is sprayed with 4 % topi-
Infection usually starts in the crypta magna from cal xylocaine spray to anaesthetize the mucosa.
where it spreads beyond the confines of the cap- A Saint Claire Thompson quinsy forceps, or a
sule causing peri tonsillitis initially, and periton- guarded 11 blade can be used. The 11 blade is
sillar abscess later. Another proposed mechanism guarded to prevent the blade from penetrating
is necrosis and pus formation in the capsular area, the tonsillar substance deeply and damaging
which then obstructs the weber glands, which underlying vital structures like internal carotid
then swell, and the abscess forms. artery. Guarding can be done by applying tape
over the entire length of the blade save the 3 mm
Weber’s glands: tip portion which is left exposed. If a blade is used
to drain quinsy then after penetrating the abscess
These are mucous (minor) salivary glands pres- a sinus forceps or a small curved artery forceps
ent in the space superior to the tonsil, in the soft should be introduced via the incision and dilated
palate. There are 20 - 25 such glands in this area. in order to ensure that pus drains freely. Site of
These glands are connected to the surface of the incision: Is commonly over the point of maxi-
tonsil by ducts. The glands clear the tonsillar area mum bulge. It can also be made at the junction
of debris and assist with the digestion of food between a horizontal imaginary line drawn from
particles trapped in the tonsillar crypts. If Weber’s the base of the uvula to the anterior pillar and a
glands become inflamed, local cellulitis can devel- vertical imaginary line drawn along the anterior
op. Inflammation causes these glands to swell up pillar. After incision is made a sinus forceps is
causing tissue necrosis and pus formation i.e. the introduced to complete the drainage procedure.
classic features of quinsy. These abscesses gener- Six weeks after I&D tonsillectomy is performed
ally form in the area of the soft palate, just above in this patient to prevent further recurrence. This
the superior pole of the tonsil, in the location of is known as interval tonsillectomy. Quinsy tonsil-
Weber’s glands. The occurrence of peritonsillar lectomy.
abscesses in patients who have undergone tonsil-
lectomy further supports the theory that Weber’s 3. Quinsy tonsillectomy / Hot tonsillectomy: Even
glands have a role in the pathogenesis. though some authors advocate this procedure, it
is highly risky. Bleeding will be profuse during
Management: the procedure. There is always an impending
danger of septicemia due to systemic spread of
1. Needle aspiration if the swelling is minimal. infection because the natural anatomical barriers

are breached during the procedure.
Image showing St Claire Quinsy forceps being

introduced
Image showing pus streaming out once the inci-

sion is made
350
Class II / Grade II tongue tie:
Tongue Tie Release
This is also considered as an anterior tongue tie.
Tongue tie is diagnosed during physical examina- In this class the frenulum is attached just behind
tion. This is a rare (incidence 3-4%) and definite the tip of the tongue. The tongue is not heart
congenital abnormality. This can be identified by shaped but the tongue tie is clearly visible.
the fact that the tongue is anchored to the floor of
the moth by a tight band of tissue. Class III / Grade III tongue tie:
Tongue is a highly mobile organ made up of This is considered to be posteriorly attached fren-
longitudinal, horizontal, vertical and transverse ulum. A thin membrane is seen in the frenulum,
intrinsic muscle bundles. The extrinsic muscles and this is the difference between class III and
are the fan shaped genioglossus which is inserted class IV.
into the medial part of the tongue and the sty-
loglossus and hyoglossus which insert in to the Class IV / Grade IV tongue tie:
lateral portion of the tongue. Ths sublingual fren-
ulum is a fold of mucosa connecting the midline This is also a posterior tongue tie without the
of the inferior surface of the tongue to the floor of presence of thin membrane in the frenulum.
the mouth. In tongue tie the frenulum is actually These patients are able to elevate the front and
thick, tight and short. sides of the tongue but the mid tongue cannot
be elevated. This type of tongue tie is commonly
Tongue tie can be diagnosed in an infant who has missed.
difficulty in protruding the tongue over the lower
lip and gum ridge. This commonly cause pain and Problems due to tongue tie:
soreness of nipple while the baby is breast fed.
Classification of Tongue tie: 1. Infants with tongue tie have difficulty in breast
feeding as the mother will develop sore nipples
Tongue tie is classified into 4 grades. Grades 1 because the child finds it difficult to attach its
and 2 are anteriorly attached frenulum while in mouth to the nipple. This would result in the
grade 3 and 4 the frenulum is posteriorly at- mother terminating breast feeding prematurely
tached. causing various problems to the child.
Class I / Grade I tongue tie: 2. Speech defects can also occur due to tongue tie.
This can cause dysarthria
This is the real tongue tie and the tongue is clas-
sically heart shaped. The frenulum attaches to the Treatment:
tip of the tongue hindering tongue movement to
a great extent. This is indicated if the child has feeding problems
The child has speech problems (dysarticulation)
Surgery: This procedure involves frenotomy or

frenuloplasty. chromic catgut.
Frenotomy:
This is a simple surgical procedure which can be

performed with / without anesthesia. The doctor
examines the lingual frenulum and uses a sterile
scissors to snip the frenulum free. This procedure
is quick and cause only minimal discomfort to
the patient. There are only few nerve endings and
blood vessels in this area and hence there is rela-
tively no pain or bleeding during the procedure.
Even if bleeding occurs it is going to be only a few
drops. The baby can be breast fed immediately
after the procedure.
Complications: Image showing stabilizing suture applied to sta-

bilize the tongue
1. Infection
2. Bleeding
3. Damage to sublingual salivary gland ducts
4. Scarring can reattach the tongue back to the

floor of the mouth
Frenuloplasty:
This is a more extensive procedure needing an-

esthesia. General anesthesia is usually preferred
in children. This procedure is indicated when the Image showing tongue being lifted by lifting the
frenulum is too thick for frenotomy. The fren- stay suture and the frenulum is incised using a
ulum is cut using 11 blade or fine scissors. It is 11 blade knife.
absolutely essential for the surgeon to get through
the posterior component of the tongue tie for the
procedure to be effective. The tongue tie that has
been fully released has a diamond shaped wound.
If there is no diamond shaped wound then the re-
lease is considered to be incomplete. The wound
is closed with absorbable suture material like 3 -0
352
Image showing sutures being applied

under controlled conditions using the theatre
Tracheostomy facilities available. Performing this surgery under
sub optimal conditions / on bed side is fraught
Attempts to save a life from suffocation has been with dangers. It is always better to shift the pa-
made since ancient days. Portrait of tracheostomy tient to the theater and perform the surgery there.
has been found on Egyptian tablet. It was Homer
around 1000 BC who The staff of ICU should be adequately trained to
described that Alexander the Great saved the life handle these patients. Tube care is most import-
of his soldier from suffocation by opening up the ant in these patients. Majority of the post-oper-
trachea with the tip of his sword. ative complications of this procedure arise from
the fact that tube care is not proper in these pa-
Early tracheostomies were performed for respira- tients. The tracheostomy tube should be removed,
tory obstruction, but the spectrum of indication cleaned and replaced at least once a day.
expanded to include respiratory failure, respira-
tory paralysis and removal of retained secretion Applied Anatomy of Trachea
from respiratory tract and reduction of anatomi-
cal dead space. A complete knowledge of surgical anatomy of the
larynx and trachea is a must for all otolaryngolo-
Majority of tracheostomies are performed under gists. Their ability to perform life saving surgical
emergency settings and they are all open pro- procedures like the tracheostomy and coming out
cedures. Currently percutaneous tracheostomy successful depends on this aspect. All possible
is gaining importance. This surgery is known to anatomical variations and knowledge of adjacent
have complications also. The operating surgeon crucial anatomical structures is a must.
should weigh the risk benefit ratio before advising
the patient to undergo this procedure. Trachea serves as a conduit between the lungs
and atmospheric air. The patency of this structure
This basic life saving procedure should be taught is rather paramount for life to survive. Oxygen
to all practitioners of modern medicine. It only from the atmosphere travels to the lungs and
this procedure was in vogue during the first world carbon dioxide from the lungs flows back to the
war many a life could have been saved. atmosphere via the trachea.
The timing of tracheostomy is usually controver- Cartilage is a tubular structure which is partially
sial. That is the reason behind Moser’s indication made up of cartilage and partly membranous. It
for tracheostomy which states that “one should connects the larynx superiorly (cricoid cartilage
perform tracheostomy the moment he thinks of larynx to be precise) and the two main bronchi
about it”. Many surgeons swear by this Mosher’s inferiorly. Cricoid cartilage is the only complete
dictum. Advances in surgical techniques and cartilage of the entire human airway. Even the
intubation procedures have managed to decrease tracheal cartilages are incomplete posteriorly and
the risks involved in performing tracheostomy. is closed by tracheal membrane.
Ideally all tracheostomies should be performed It is the lower edge of cricoid cartilage that de-
354
fines the beginning of the trachea. This is the
most critical area of the entire airway. Cricoid
cartilage is signet ring shaped cartilage. The
mucous membrane lining the interior of cricoid
cartilage is highly sensitive to injury and irrita-
tion. Significantly irritation / injury in this area
causes fibrosis leading on to stenosis of the airway
at the subglottic level.
The lower end of the trachea is known as the cari-

na. At this level the right main bronchus takes off
at a steep angle and the left main bronchus takes
off at a more horizontal direction. Right main
bronchus could be considered crudely as a con-
tinuation of trachea. Foreign bodies in the trachea
usually migrates to the right main bronchus since
it is in direct continuity to the trachea.
Image showing upper portion of trachea at-
The beginning of trachea (cricoid level) is at the tached to cricoid cartilage
level of 6th cervical vertebra and the Carina is at
the level of T4 vertebral body. The length of tra- Tracheal tube support / Scaffolding:
chea on an average is about 11 cm. Normal range
being 10-13 cms in males. It is a little shorter in Tracheal lumen is supported by 18 – 22 D shaped
females. “rings”. The anterior and lateral walls of these
rings are made of C shaped cartilage and the
In human adults the trachea lies anteriorly in the posterior wall of the trachea is membranous con-
neck. It then dives posteriorly in to the medias- necting the two arms of the C. Trachealis muscle
tinum as it traverses towards the Carina which run longitudinally on the posterior aspect of the
happens to be its lower end. The angle of descent membranous posterior portion of trachea. This
is more acute in children. It tends to become muscle also
more horizontal with age due to the presence of abuts the anterior wall of oesophagus.
kyphosis of spine and the tethering effect of the
left main bronchus under the aortic arch. This An intercartilagenous membrane connects the
change needs to be considered while positioning inferior edge of the upper cartilage to the superior
the patient for tracheostomy. In elderly patients edge of the cartilage below.
the length of the trachea tends to be constant and
does not increase with neck extension. In young There are approximately two rings of cartilage per
persons the cervical portion of the trachea tends centimeter of trachea. Each tracheal ring on an
to lengthen when the neck is extended. average is about 4 mm in height. The tracheal wall
is about 3 mm thick. The average external diam-
eter of trachea is about 2.3 cm in coronal dimen-

Image showing the lower end of trachea
sion and1.8 cm in sagittal dimension. of trachea to pull the cartilaginous C arms togeth-
er.
At birth the cross-sectional lumen of trachea is
more or less circular. As the child grows into an As the individual ages or in the presence of ob-
adult the lumen takes an ovoid form. If the lumen structive air way disorder, the lateral diameter of
is circular even in an adult it should be consid- the lumen tends to narrow, while the anteroposte-
ered as an adult variant. The luminal diameter of rior diameter increases.
trachea varies with alterations in the intraluminal This causes the classic “saber sheath” trachea. The
pressure. These alterations are known to occur walls of this tracheal formation may show trache-
during: al wall calcification.
1. Normal respiration In chronic obstructive pulmonary disease there is

2. Ventilation ring softening causing anteroposterior narrowing
3. Valsalva maneuvers of the lumen. In addition, if the posterior tra-
4. Coughing narrows the lumen of trachea by cheal wall is thickened then luminal obstruction
causing the trachealis muscle of the posterior wall could result during coughing or while the patient
356
breaths out. corresponding tracheal arteries from the contra-
lateral side. This segmental arrangement of blood
Histology of luminal mucosa: supply limits circumferential tracheal dissection
to no more than 1-2 cm on either side of a tra-
The lumen of trachea is lined by ciliated pseu- cheal anastomosis due to devascularization and
dostratified columnar epithelium. This epitheli- ischemia.
um contains mucous secreting Goblet cells. This
mucosa also has ducts that
connect mucous glands in the submucosa to the
surface of tracheal lumen. The surface mucous
and cilia act in unison to trap and expel particles
/ microbes that could enter the airway. Some-
times air borne irritants can cause temporary /
permanent damage to this muco ciliary clearance
mechanism.
In long term cigarette smokers there is increased

mucous production and defective ciliary func-
tion. These individuals are more dependent on
effective cough mechanism to clear their airways
(the classic smokers cough).
Tracheal blood supply:
Successful tracheal dissection requires a complete

and thorough understanding of its blood supply.
Any inadvertent disruption to its blood supply
would cause tracheal ischemia and necrosis. This
is airway surgeon’s nightmare. One important as-
pect that a surgeon has to bear in mind is that ar-
teries feeding the trachea approaches the tracheal
wall laterally and vascularizes it in a segmental
fashion along its longitudinal axis. As the seg-
mental arteries supplying the trachea reaches the
lateral wall of trachea they branch superiorly and
inferiorly in a longitudinal fashion forming anas- Image showing segmental blood supply to the
tomoses with segmental arteries above and below. tracheal rings
It is within the intercartilagenous ligaments the
tracheal arteries branch into anterior and poste-
rior branches that travel circumferentially within
the tracheal wall where they anastomose with the

The arterial supply divides trachea into the Up- from the left sided aortic branches and right main
per (cervical) and lower (thoracic) trachea. The stem bronchus is supplied by one right sided
tracheo-oesophageal branches of inferior thyroid aortic branch.
arteries supply blood to the cervical trachea from
the right and left thyrocervical trunks that branch Anatomical relationships of trachea:
off the subclavian arteries. The first tracheo-oe-
sophageal branch supplies the lower cervical The thyroid gland is rather intimately related to
trachea, the second branch supplies the middle the trachea. The two lobes of thyroid gland sit
cervical trachea and the third branch supplies the anterolateral to the proximal cervical trachea.
upper cervical trachea. The superior thyroid Isthmus a thin strip of midline thyroid tissue con-
artery does not directly supply the trachea but nects the two lobes of thyroid across the anterior
forms an anastomosis with the inferior thyroid wall of trachea.
artery where fine branches supply the thyroid
isthmus and the adjacent anterior tracheal wall. Isthmus usually covers the anterior tracheal wall
between the second and third tracheal rings. The
The thoracic trachea and the Carina receive blood inferior thyroid artery in addition to supplying
supply from the bronchial arteries that arise the proximal trachea also supplies the inferior
directly from the aorta. The superior, middle and thyroid gland. The isthmus of thyroid gland will
inferior bronchial arteries supply blood to rest of be encountered during tracheostomy and it needs
the trachea and Carina. The superior bronchial to be either pushed away / resected and tied be-
artery arises from the anteromedial aspect of the fore exposing the trachea. Improper dealing with
descending thoracic aorta lateral to the Carina this thyroid tissue will cause torrential bleeding
and posterior to the left main bronchus. This to occur on the table endangering the life of the
vessel supplies blood to the anterior portion of patient.
the Carina. The principal and posterior branches
of the superior bronchial artery pass behind the The oesophagus is in close relationship with the
posterior wall of the oesophagus to supply the trachea throughout its entire course. It begins
proximal right main bronchus. at the level of cricoid cartilage (c6 vertebra lev-
el) and runs downwards towards the stomach.
The middle bronchial artery arises from the aorta It joins the stomach at the gastro oesophageal
distal to the superior bronchial artery. It travels junction which lies along the left posterior border
posterior to the medial aspect of the left main of the trachea. Fibroelastic membranes and rare
bronchus to supply the Carina as it anastomoses muscle fibres lie between the longitudinal muscle
with anterior branch of the superior bronchial of outer oesophagus and the trachealis muscle.
artery. The right posterior border of trachea runs along
the anterior aspect of the vertebral bodies.
The inferior bronchial artery arises off the right
posteromedial ascending thoracic aorta to supply Rarely the oesophagus may be found more later-
the left main bronchus. The patterns of branching ally on the left side making it more vulnerable to
of bronchial artery are highly variable. In major- injury during mediastinoscopy. The right and left
ity of cases the left bronchial tree receives blood vagus nerves travel distally through the neck in a
358
position posterolateral to the corresponding com-
mon carotid arteries. The right and left recurrent
laryngeal nerves are branches of vagus nerves and
they go on to innervate the true vocal cords. They
enter the larynx between the thyroid and cricoid
cartilages under the inferior horn or cornua of
thyroid cartilage.
The origin of left recurrent laryngeal nerve differs

from that of the right one. The left recurrent
laryngeal nerve originates distal to the aortic arch
where it dives and courses posterolaterally just
lateral to ligamentum arteriosum. At this point it
recurves and ascends toward the cricoid cartilage
within the left tracheo oesophageal groove. The
right nerve branches off the right vagus nerve
just distal to the right subclavian artery where it
recurves and ascends towards the cricoid carti-
lage in the right tracheo oesophageal groove. A
non-recurrent laryngeal nerve is a rare variant
runs from the right vagus directly towards the
larynx. Surgeon should be aware of the course of Image showing recurrent laryngeal nerve as seen
this nerve as injury to it would cause paralysis of laterally
vocal folds.
A number of large blood vessels lie in close prox- The azygos vein courses superiorly along the right
imity to the trachea and should always be respect- anterior aspect of trachea. This vein courses supe-
ed during tracheal surgeries. The brachiocephalic riorly along the right side of the thoracic vertebral
artery / innominate artery is the first branch of Column before bending anteriorly to join the
the aortic arch. The innominate artery runs from superior vena cava lateral and just superior to the
left to right along the anterior surface of trachea. right tracheobronchial angle. During mediasti-
This occurs at the right anterolateral portion of noscopy this landmark should not be confused
the distal and middle third of trachea. with that of an enlarged node because inadver-
tent attempt at biopsy in this area would lead to
The left common carotid artery is the next branch torrential bleeding.
of the aorta. It starts to the left of the trachea’s
midline and runs superiorly from right to left
over the left anterolateral trachea. The superior
vena cava courses towards the right atrium along
the right anterior aspect of the trachea.

Image showing the course taken by both recurrent laryngeal nerves
The main pulmonary artery lies anterior and to

the left of the carina. It branches namely right and Indications of Tracheostomy:
left pulmonary artery run laterally and anterior to
the corresponding main stem bronchi before they Even though tracheostomy is a life saving pro-
branch into the lobar arteries of the right and left cedure it has its own indications. Surgeons are
lungs. This positioning of the pulmonary arteries tempted by the Mosher’s adage which states the
to the main stem bronchi should be remembered best moment to do tracheostomy is “when you
when attempts are made to mobilize the subcari- think about it”.
nal and tracheobronchial lymph nodes is attempt-
ed during mediastinoscopy. Excessive traction on Indications for tracheostomy can be classified
the right sided lower paratracheal nodes causes under these headings:
massive blood loss as these nodes are in close
proximity to the first branch of the right pulmo- 1. In upper airway obstruction (obstruction
nary artery. above the level of larynx). Tracheostomy is indi-
360
Image showing the relationship between large blood vessels and trachea
cated in all cases of upper airway obstruction ir- 3. For bronchial toileting: Chronically ill patients
respective of the cause as an emergency life saving who do not have sufficient energy to couch out
procedure. It is also indicated in impending upper bronchial secretions may have to undergo trache-
airway obstruction as in the case of angioneurotic ostomy with the primary air of sucking out the
oedema of larynx. bronchial secretions through the tracheostome.
2. For assisted ventilation: In comatose patients 4. In patients on prolonged intubation: Trache-

who do not have the required respiratory drive. ostomy will have to be done on these patients to
Air way in these patients can be secured by per- prevent subglottic stenosis from developing.
forming a tracheostomy and the patient can be
connected to a ventilator for assisted ventilation.
In these patient’s metal tube cannot be used. Only
cuffed portex tube can be used.

when compared to that of emergency tracheos-
In addition to these broad indications specific tomy. When the anesthetist is not confident of
indications are as below: securing the airway via orotracheal / nasotracheal
route then it becomes an indication for
1. Congenital anomalies involving upper airway tracheostomy.
(laryngeal hypoplasia / vascular web etc.).
2. Upper airway foreign body that cannot be dis- When performed in critically ill patients who re-
lodged with Heimlich and other basic cardiac life quire prolonged mechanical ventilatory support,
support maneuvers tracheostomy reduces dead space and airway re-
3. Trauma to neck causing injury to thyroid / cri- sistance, and improves clearance of Broncho pul-
coid cartilages / hyoid bone / great vessels monary secretions. This makes the patient more
4. Subcutaneous emphysema when air way is comfortable and co-operative as less sedation is
threatened needed. Since the glottic reflexes are intact, there
5. Facial fractures that could cause upper airway is less likelihood of aspiration occurring. There is
obstruction (comminuted fractures of midface a general improvement in the clinical status of the
and mandible) patient following tracheostomy.
6. Oedema of upper airway due to trauma, burns,
infection or anaphylaxis It is also easy to wean the patient from the ven-
7. As a prelude to major head and neck surgical tilator if the patient is under tracheostomy when
procedures where air way needs to be secured for compared to endotracheal intubation because of
better post-operative management. lesser airway resistance. This enables the patient
8. Severe sleep apnoea not amenable to CPAP to breath freely through the tracheostomy tube.
devices / other less invasive surgeries. This should
be considered as a last-ditch effort when every- Airway resistance is determined by two factors:
thing else fails.
9. When permanent tracheostomy is needed after Resistive components of lung dynamics – The
total laryngectomy best indicator for this factor is peak airway pres-
10. After partial laryngectomy procedures sure and dynamic compliance.
11. Failed extubation – If extubation following
surgery fails for some reason then tracheostomy Elastic components of lung dynamics – The
may be performed to secure the airway. indicator being plateau pressure and static com-
12. Anticipated intubation difficulties in patients pliance.
with anteriorly placed larynx and with a very
short neck In patients on tracheostomy the peak airway pres-
13. In patients with bilateral abductor paralysis sure and static compliance improves because of
when airway needs to be secured on an urgent the shorter length of the tracheostomy tube com-
basis. pared to that of endotracheal tube. This manifests
as lower resistance to breathing.
Difficult intubation scenario should be identified
fairly early to facilitate elective tracheostomy on
the table. Elective tracheostomy has fewer risks
362
Bjork’s flap can safely be created only in elective
Types of Tracheostomy tracheostomies and not under emergency setting.
This flap can be created with minimal complica-
1. Temporary tracheostomy: This life saving tions but needs some amount of patience on the
procedure is usually performed as a temporary part of the operating surgeon to perform.
measure to secure the airway while perform-
ing complex head and neck surgical procedures Contraindications for performing Bjork’s flap:
which involve airway sharing with the anesthetist.
Securing the airway electively also helps in pre- 1. In pediatric tracheostomies. The amount of
venting post-operative airway obstructions. cartilage present in the trachea of children is so
less that adjacent vital structures could well be
Indications: damaged when this flap is attempted.
2. This procedure is best avoided when tracheos-
a. Prior to any complex head and neck surgeries tomy is performed to secure air way in patients
where airway is under threat with laryngeal malignancies because it is usually
b. To tide over problems caused by impending performed as an emergency procedure.
airway obstruction due to oedema involving 3. Ideally not performed in an irradiated neck
mucosal lining of supraglottis / glottis / subglottis because the skin would be thickened and the
areas. tracheal cartilage would have undergone fibrotic
c. When airway is threatened due to the presence changes. Any attempt to create cartilage flap in
of Foreign bodies these patients would invariably result in a failure.
d. In ICU setting where the patient needs to be 4. In obese patients the neck is short and it would
kept on ventilator for more than 7 days. be difficult to create a Bjork flap of sufficient size
e. In patient’s with altered sensorium / coma to 5. If a surgeon is alone performing tracheostomy
keep the lower airway free of secretions. then Bjork’s flap is ideally avoided
In this procedure decannulation is ideally per- Surgical technique:

formed within a span of 2 weeks. A small modifi-
cation in the surgical procedure where in instead This procedure can be performed either under
of removing a small local anesthesia or general anesthesia.
portion of anterior tracheal wall cartilage an Ideally any neck surgery should be performed un-
inferior based cartilage flap (Bjork flap) is creat- der good lighting conditions. The same goes with
ed. This flap can be anchored to the skin of the tracheostomy also. Different sized tracheostomy
stoma to keep the stoma open. When it is time to tubes should also be available.
decannulate all that needs to be done is to remove
the stay suture anchoring the cartilage flap to the Position:
skin of the stoma. The flap will fall back on to the
anterior wall of the trachea closing off the stoma. Supine with neck extended by placing a small
In 1952 Bjork created this inferior based cartilage sandbag under the shoulder blades of the patient.
flap through the 2nd 3 rd and 4th tracheal The shoulders should be symmetrically placed
rings and anchored it to the stomal skin using silk to ensure that the trachea stays in the midline

always. The area where surgery is going to be per- should be peeled away from the anterior
formed should be painted with povidone iodine wall of trachea.
liberally and the patient draped.
Key landmarks should be marked over the skin.

They include Hyoid bone, thyroid cartilage and
cricoid cartilage. Transverse skin incision is usu-
ally placed at half way between the lower border
of cricoid cartilage and the supra sternal notch.
This area is infiltrated with 2% xylocaine mixed
with 1 in 100000 adrenaline. About 5 ml of the
local anesthetic can be used. Some amount of
infiltration should also be given along the medial
border of lower third of sternomastoid muscles
on both sides. Image showing Langenbeck retractor
Before start of surgery the patient should be At this stage it would be useful to identify the
premedicated with sedatives and anxiolytics. This cricoid cartilage to assess where exactly trachea
will ensure better co-operation on the part of the should be opened. Tracheostomy is usually
patient. performed between the 3rd and the 4th tracheal
rings. A small amount of 2% xylocaine with 1 in
The incision is usually transverse in elective 100000 adrenaline is infiltrated into the trachea
tracheostomy and vertical in emergency setting. to suppress the cough reflex if the surgery is being
The incision is given at the half way mark be- performed under local anesthesia.
tween the lower border of cricoid cartilage and
the suprasternal notch. The incision is usually 3 In order to perform Bjork’s flap, the tracheal
cm long and may even be extended if needed. The incision should be inverted U shaped one. The
skin and subcutaneous fat are dissected out and transverse portion of the U incision is made in
are held away from the field by using retractors. the intercartilagenous zone between the second
Langenbeck retractors are used for this purpose. and third tracheal cartilages. This step is usually
If the surgeon is performing the surgery alone performed using a 15 blade. The downward ver-
then self-retaining retractor is ideal. tical incisions are then performed ideally using
scissors. The vertical limbs of the incision go
Blunt dissection is performed along the midline through the 3rd and 4th tracheal rings. The first
of neck pushing away the strap muscles from tracheal ring should be avoided because of the
midline. The isthmus of thyroid gland comes into fear of subglottic stenosis.
the field when the soft tissues and muscles are
retracted from the midline. The isthmus is divid- The cartilage flap is stitched to the subcutaneous
ed and tied using diathermy and silk. The anterior tissue. Suction is applied through the tracheos-
wall of trachea becomes visible. Trachea can easi- tome to clear the secretions. Appropriate sized
ly be identified by its rings. The pretracheal fascia portex cuffed tracheostomy tube is introduced.
364
The tube is anchored by tying the tape. Cuff is
inflated.
Image showing Bjork flap being created

Prophylactic indications:
After abdominal / thoracic surgical procedures

the cough reflex is blunted predisposing to devel-
opment of pneumonia. A mini tracheostomy in
these patients will help in preventing pneumonia.
Therapeutic indications:
To clear sputum in patients with COPD, or in

other conditions where there is sputum retention.
Contraindications:
1. Must be performed only by trained personal

2. If landmarks in the neck are not clear then this
procedure should not be performed.
3. Should not be performed under extreme air-
way emergencies
Image showing Bjork flap anchored to the skin 2. Permanent or end tracheostomy - This is done
around the stoma in patients who have underwent total laryngecto-
my. This is also known as the end tracheostomy.
The main advantage of Bjork’s flap tracheostomy Here after the removal of larynx, the proximal
is during post-operative management of these end of trachea is anchored to the skin. Patient
patients. The tracheostomy tube can easily be needs to live the entire duration of the life by
removed cleaned and replaced without fear of breathing through the tracheostome.
airway occlusion. There is virtually no chance of
false track creation while reinserting the trache- Major draw back in these patients is the loss of
ostomy tube after cleaning it. speech. Voice rehabilitation procedures need to
be performed in them in order at least to restore
partial speech function.
During decannulation the fistula may close rather 3. Mini tracheostomy – This procedure is one
slowly which is in fact beneficial in some patients type of cricothyroidotomy. This is commonly
in weaning them out of the tracheostomy. performed as an emergency procedure to secure
the airway as well as to prevent aspiration. Crico-
Indications include prophylactic and therapeutic thyroid membrane is incised through a vertical
indications. incision and the tracheostomy tube is introduced
through it to secure the airway.
366
Image showing Cricothyroidotomy
In mini tracheostomy a small cannula is passed The kit contains:

through the incision made in the cricothyroid
membrane. A separate kit known as mini trache- 1. A special scalpel
ostomy kit is available for this very purpose. This 2. Cannula
procedure was popularized by neurosurgeons. It 3. Obturator
involves use of a specialized kit. 4. Suction tube
5. A tape to anchor the tube

serted through the cricothyroid membrane and a
No sedation may be needed for this procedure as small amount of the anesthetic can be infiltrated.
this would invariably be performed in dire emer- Patient should start coughing if the needle is in
gency settings. More over patients would already the correct position. A vertical incision is made
be hypoxic and hence sedation is contraindicated over the skin long enough to ensure that there is
for fear of respiratory depression. To perform this no resistance at the level of skin. This will ensure
procedure an assistant is always needed. This is better palpation of the trachea. A guarded knife
not a procedure to be performed by a single sur- can be used to cut through the skin subcutaneous
geon. An assistant is necessary to hold the head tissues and the cricothyroid membrane. A dilator
steady as these patients are invariably restless due can be introduced to dilate the opening and the
to hypoxia. This is a bed side procedure and can tracheostomy tube can be introduced and actually
be performed while the patient is supine in the be guided by the dilator.
bed. The head of the patient is usually inclined
up. It is ideal to place a pillow under the shoulder In Seldinger’s technique a special needle known
blades of the patient while the head is stretched as the Tuohy needle is used to perforate
over the back of the pillow. the cricothyroid membrane instead of the knife.
This needle is introduced through the skin inci-
This position keeps the trachea stretched in the sion at right angles to that of the trachea. A pop
midline preventing its lateral movement. The could be felt as the needle passes through the
oxygen mask is fixed to the patient’s face upside anterior wall of the trachea. The needle is kept
down in order to avoid the tubing coming in the still and a syringe filled with water is connected to
way during surgery. it and aspirated to ensure that the needle is inside
the trachea. If unsure it is best to incise the crico-
The thyroid cartilage is identified next. It is usual- thyroid membrane with a knife and dilate it using
ly easy to identify it in males than in females. The a mosquito forceps.
cricoid cartilage would be just below the thyroid
cartilage. If there is any doubt it is better to go low The syringe is removed while the needle is still
into the trachea than high above the level of vocal inside the trachea. A guide wire (using its flexible
cords. end) is passed through the needle into the tra-
chea. Ideally before this procedure it is better to
Risk of injury to isthmus is a strong possibility. If point the needle towards the carina. A dilator is
a guide wire and dilator is used then this would passed over the guide wire repeatedly to dilate the
be a minimal problem only. If knife is used then opening. Then tracheostomy tube is introduced
there is a distinct possibility of bleeding from using the guide wire to guide it into position.
injury to isthmus of the thyroid gland.
4. Percutaneous tracheostomy - Since the advent
The thyroid cartilage is fixed between two fin- of open tracheostomy efforts were made to devise
gers. It ensures that the trachea is kept in position a procedure which will enable access into the
till the cannula is inserted. Local anesthetic (2% trachea without a surgical incision or a minimal
xylocaine with 1 in 100000 adrenaline) is injected surgical incision. Percutaneous tracheostomy was
over the site of incision. The needle can be in- devised with just this purpose in mind.
368
2. Routine use of fibreoptic bronchoscopy has
Advantages of percutaneous tracheostomy: been advocated.
3. The use of single beveled dilator has been sub-
1. It is a simple procedure stituted by the use of multiple dilators.
2. Very easy to perform under emergency situa-
tions Ciaglia’s procedure:
3. Can be performed easily on the bed side
4. Can be performed by paramedics The vital signs of the patient are continuously
monitored during the procedure. The patient is
Evolution of percutaneous tracheostomy: ventilated with 100% oxygen during the whole
procedure. The patient is
The first tracheostomy technique that did not sedated using a narcotic analgesic, and often a
require neck dissection was first described by non depolarising neuromuscular blocker is used.
Sheldon in 1957. He used a specially designed The neck of the patient is extended to bring up
slotted needle to blindly enter the tracheal lumen. the trachea closer to the skin.
This needle served as a guide for the introduction
of a stillete and a metal tracheostomy tube. The vertex of the patient is properly supported.
A 2 cm skin incision is located at the level of 1st
In 1969 Toyee refined this technique making it and the 2nd tracheal rings. The wound is then
incisional rather than dilational. In this technique dissected bluntly using artery forceps. The exist-
after the trachea was cannulated using a needle, ing endotracheal tube is then slowly withdrawn to
the tracheostomy tube was loaded on to a stiff a level just above the first tracheal ring, the needle
wire boogie that contained a small recessed blade. is then inserted through the incision to penetrate
This boogie along with the tracheostomy tube was the trachea between the second and the third
advanced through the needle tract thereby plac- tracheal rings.
ing the tracheostomy tube inside the trachea. This
procedure was fraught with risks and para trache- The J tipped guide wire is inserted through the
al insertions occurred commonly and hence did needle till it hits the level of carina. The needle
not become popular. is then withdrawn. Beveled plastic dilators are
introduced over this guide wire and the opening
In 1985 Ciaglia perfected the technique of percu- is dilated to create a tracheostome. When the dil-
taneous tracheostomy which is currently gaining atation is adequate a special tracheostomy tube is
popularity. He named this procedure dilational inserted over the guide wire. The dilators can be
subcricoid percutaneous tracheostomy. (PDT). used as obturators. In properly performed percu-
taneous tracheostomy the tracheostomy tube
This technique has undergone three significant will pass through the isthmus of the thyroid, there
modifications: will not be any significant bleeding because the
1. The tracheal interspace for cannulation has procedure is purely dilatational.
been moved down by two rings caudal to
the cricoid cartilage. This was done to prevent the
development of subglottic stenosis.

Paul’s modification of Ciaglia technique: these methods the basic steps are the same but for
This modification was introduced in 1989. Paul modifications in the dilatation technique.
advocated the use of fibreoptic bronchoscope
through the endotracheal tube to facilitate percu- 6. Translaryngeal tracheostomy: This was first
taneous tracheostomy. described by Fanconi etal. The major aim of this
procedure is to prevent damage to the posterior
The advantages of this modification are: membranous wall of the trachea. The dilatation
1. Use of bronchoscope allows for correct place- in Ciaglia technique is directed in a downward
ment of tracheostome. direction causing significant anteroposterior
2. It ensures that the guide wire is introduced in a compression of the tracheal wall.
midline position.
3. It prevents damage to posterior tracheal wall Sometimes this compression is sufficient to cause
during introduction of needle. rupture of the membranous posterior tracheal
4. It helps in video recording the whole procedure wall. In this technique this excess anteroposte-
for instructional purposes. rior pressure is avoided since the tracheostomy
tube is pulled upwards through the larynx in an
The major disadvantages of this modification are: inside out manner. The procedure is similar to
Ciaglia technique till the introduction of a guide
1. It involves more time. wire through the first and the second tracheal
2. More trained personal and special equipment interspaces. The similarity ends here. The guide
are needed. wire is passed through the needle into the lar-
3. The procedure is more expensive. ynx in a retrograde fashion, in fact it traverses
To reduce the operating time a single curved coaxially alongside the endotracheal tube till it
dilator (Blue rhino dilator) is utilized instead of reaches the oral cavity from where it is pulled out
multiple dilators. Since this dilator is soft and has using a Magill’s forceps. The aim of the next step
a more physiologic curvature it does not cause exis to create a room for the tracheostomy tube to
tensive damage to the soft tissues and the tracheal traverse the larynx since an endotracheal tube is
walls. already in position. To achieve this the existing
endotracheal tube in position is replaced with a
Rapitrach technique: This was first introduced in smaller endotracheal tube using the same guide
1989 by Sachachner with an intention in facili- wire as a guide. The J tip (oral cavity end) of the
tating a rapid tracheostomy. A special Rapitrach guide wire is then attached to a special trocar and
dilator was used. A rapitrach has two sharp tracheostomy tube assembly. The guide wire is
blades designed in such a way that it slides over pulled through its neck end. This pulls the trocar
the guide wire and an opening is made when it along with the tracheostomy tube through the
is dilated. This procedure had a high incidence larynx into the trachea. Here excessive tension to
of damage to the membranous posterior tracheal the posterior tracheal wall is avoided. When the
wall. To avoid this complication in 1990 Griggs trocar causes tenting of skin in the neck a small
used custom-made forceps known as the How- incision is made over this tenting and the trocar
ard Kelly forceps. The tip of the forceps can be is delivered out along with the tracheostomy tube.
opened to create a tracheostome. In fact, in all The endotracheal tube is removed, and the tra-
370
cheostomy tube is anchored in place.
Contraindications:
Since these procedures involve an already intu-
bated patient it calls for excellent coordination 1. A patient already in intense stridor.
between the surgeon and the anesthetist. 2. Laryngeal malignancies
3. Short neck individuals
Routine pre-operative ultrasound examination of 4. When proper trained personal is not available
the neck is a must because it will identify the site 5. Large thyroid gland
of an unusually large inferior thyroid veins which 6. When ultrasound reveals an abnormally large
could cause troublesome bleeding during the inferior thyroid vein.
procedure.
7. Cricothyroidotomy:
This is an emergency procedure performed to

secure the airway in the even of failure of oth-
er conventional methods of securing the same.
Another important aspect that should be borne in
mind that in these patients performing conven-
tional tracheostomy should be considered to be
too dangerous.
Indications:
Trauma causing oral / pharyngeal / nasopharyn-

geal bleeding.
Facial muscle spasm / Laryngospasm
Image showing Blue Rhino dilator Uncontrollable emesis
Upper airway stenosis / congenital deformities
Clenched teeth
Oropharyngeal oedema
Maxillo facial injuries
Cervical spine immobilization secondary to inju-
ry spine
This procedure is contraindicated in children.
The procedure is the same as described under
mini tracheostomy.
Incision is made in the Cricotracheal membrane

Image showing Rapitrach dilator and a appropriate sized tracheostomy tube is
introduced thereby securing the airway.

of the non-dominant hand (thumb, middle and
Types of Cricothyroidotomy: index fingers). The index and middle fingers are
placed lateral to the thyroid cartilage while the
There are three main approaches to cricothyroid middle finger is used to palpate the structures.
membrane penetration.
Needle Cricothyroidotomy: This is ideally per-

formed under real emergency scenario. Patient
is positioned in supine. The neck is extended by
placing a small sand bag / towel roll under the
shoulder blades of the patient. Patient’s neck
should be in the centre and the head should be
held in a straight vertical position.
This ensures that the trachea always stay in the

midline. Vital structures in the neck are usually
present lateral to the midline. It is very easy for
the surgeon to get lost in the neck if the head is
not held straight. Trachea should be palpated
during every stage of the procedure.
The surgical field is sterilized by using povidone Image showing various midline landmarks on
iodine paint. Sterile towels are used to drape the the neck
neck of the patient. Local anesthesia is commonly
used to anesthetize the area of surgery. 2% xylo- With the dominant hand a large bore needle /
caine with 1 in 100000 units adrenaline is used to angiographic catheter is introduced. The needle is
infiltrate the area. The use of adrenaline ensures attached to a syringe filled with 1 ml of 2% xylo-
that the operating field is relatively blood free. caine. The needle is directed caudally at 45-degree
angle. While the needle is being advanced neg-
Identification of anatomical landmarks: This is ative pressure is applied to the syringe. If it is in
the next step in the procedure. The thyroid car- the air space air bubbles could be seen inside the
tilage should be first identified. This is the most syringe. A few drops of xylocaine is infiltrated on
prominent landmark in the neck. In males it is verifying the position of the needle by the pres-
represented by the prominent Adam’s apple. ence of air bubbles. This is done to prevent the
cough reflex.
It may be a little difficult in females, yet can be
palpated accurately. The cricoid cartilage is next If angiographic catheter is used the needle is
identified. The cricothyroid membrane lies be- withdrawn allowing the catheter to be in situ. In
tween these two cartilages. The area is stabilized the event that this catheter is not available then a
by holding the thyroid cartilage with three fingers 3 ml syringe can be used to perforate the crico-
372
thyroid membrane. After the needle is ensured
to be in position the piston of the syringe can
be withdrawn and the syringe with its needle Percutaneous Cricothyroidotomy:
attached and in place within the airway can be
connected to oxygen supply using appropriate
adapters.
Image showing piston pulled out of the 3 ml sy-

ringe and airway adapter is introduced into the
syringe barrel as shown.
Image showing Syringe being used to perforate

the cricothyroid membrane.
Note: Green line – Hyoid bone
Brown line – Thyroid cartilage
Orange line – Cricothyroid membrane
Image showing oxygen source connected to the

airway adapter

Jet ventilation device is the ideal way to deliver
oxygen via cricothyroidotomy. A tracheal hook should be inserted at the superi-
or end of the incision retracting the skin and the
Percutaneous cricothyroidotomy: (Seldinger cricothyroid membrane upwards. This process
Technique): is ideally performed by the assistant. The scalpel
should be in place till the hook is inserted. If the
This procedure is more or less similar to that incision is lost then it can easily be identified by
of needle cricothyroidotomy with some minor means of bubbles coming out the created open-
differences. Angiographic catheter is used in this ing. The incision is dilated using Trousseau ’s
procedure. Once the needle is verified to be at tracheal dilator.
the correct spot a guide wire is passed through
the needle. The needle is removed as soon as the Using the dominant hand, the tracheostomy tube
guide wire reaches its destination. A 15-blade is introduced into the airway between the two
scalpel is used to make an incision in the skin blades of the tracheal dilator. Once the tube gets
close to the guide wire. The incision is more or through the membrane it should be rotated 90
less a stab incision. degrees in a caudal direction. The obturator is
removed and the tracheostomy tube is anchored
A dilator and catheter are inserted together to the neck.
through the stab incision close to the guide wire.
In fact, they need to be inserted through the wire. Rapid 4 step technique:
The guide wire
and the dilator are removed once the airway cath- This can be performed under dire life-threatening
eter is inside the airway and is secured properly. situations. The steps include:
Surgical Cricothyroidotomy: Palpation

Stab incision
The position of the patient is similar as for any Inferior traction
other type of tracheostomy. This surgery is ide- Tube insertion
ally performed under local anesthesia. With
the non-dominant hand stabilizing the thyroid This process is really rapid when compared to
cartilage, a 15-blade knife is held in the dominant other techniques. It is also dangerous because of
hand and a vertical incision (usually skin deep) is the higher complication rates.
given between the thyroid and cricoid cartilage.
There may be a small amount of venous bleeding. Complications of Cricothyroidotomy:
The cricothyroid membrane is palpated through
the incision using the index finger of the Early complications:
non-dominant hand. A horizontal stab incision
is made through the membrane using a 11-blade Bleeding
scalpel. A distinct pop could be felt as the scalpel Incorrect placement of tracheostomy tube leading
breaches the cricothyroid membrane and enters on to formation of false
the trachea. passage
374
Subcutaneous emphysema invariably to secure the airway during the threat
Obstruction of airway of impending airway obstruction.
Oesophageal / mediastinal perforation
Aspiration Surgical procedure:
Vocal fold injury
Pneumothorax Anesthesia: Under emergency situations it is per-
Laryngeal injury formed under local infiltration anesthesia. Under
Perforation of posterior tracheal wall which is elective conditions it is performed under general
membranous in nature anesthesia.
Thyroid injury
Hypercarbia (common in needle cricothyroidot- Position: Supine with neck hyperextended.
omy)
Incision: Emergency tracheostomy is performed
Late complications: with a vertical incision extending from the lower
border of cricoid cartilage up to 2cm above supra
Dysphonia sternal notch.
Infections This area is also known as the Burn’s space and is
Hematoma devoid of deep cervical fascia.
Persistent stoma
Scarring Elective tracheostomy is performed through
Glottic / Subglottic stenosis a horizontal incision at 2cm above the sternal
Laryngeal stenosis notch.
Tracheo oesophageal fistula If performed under emergency settings local
Tracheomalacia anesthesia is preferred. The drug used is 2 % xy-
locaine with 1 in 100000 adrenaline. 2 ml of this
8. High tracheostomy – Is usually performed only solution is infiltrated in to the Burns space.
during dire emergencies. It is performed between
the 1st and 2nd tracheal rings. This procedure is Through a vertical incision extending from the
not being performed these days because of the lower border of cricoid cartilage up to 2cm above
high incidence of subglottic stenosis in these the sternal notch the skin, platysma, and cervical
patients. This is ideal in patients with carcinoma fascia are incised.
larynx because the larynx can be resected along Branches of anterior jugular vein if any are ligated
with the tracheostoma there by facilitating cre- and divided. Sternohyoid and Sternothyroid mus-
ation of neo stoma in virgin tissue. cles are retracted using langenbachs retractors.
The anterior
7. Low tracheostomy – is usually performed in wall of trachea is exposed after splitting the
patients with tracheal stenosis. It is performed pretracheal fascia. The tracheal rings are clearly
between the 4th and the 5th tracheal rings. identified. Few drops of 2% xylocaine is instilled
into the trachea through a syringe. This process
8. Elective tracheostomy – This is the common- serves to desensitize the tracheal mucosa while it
ly performed tracheostomy. This is performed is being incised. Incision over the trachea is sited

between the second and the third tracheal rings.
If the tracheostome is planned for a long duration
then it is better to excise a portion of the tracheal
ring completely. If tracheostomy is planned for
a short duration of less than a month then the
cartilage is not completely removed but partially
excised creating a flap based either superiorly or
inferiorly. This is known as the Bjork flap. This
flap can be sutured to the skin to keep the trache-
ostome open. Tracheostomy tube is inserted into
the opening and the wound is closed with silk.
During dissection when one approaches the

trachea in the midline it is found to lie under the
following structures:
1. Platysma muscle
2. Superficial cervical fascia
3. Branches of anterior jugular vein Image showing tracheal cartilage being incised
4. Sternohyoid, and Sternothyroid muscles. between the second and third tracheal rings
5. Thyroid isthmus at the level of second tracheal
ring
6. Pretracheal pad of fat through which inferior
thyroid veins may wander, and sometimes thy-
roidea ima artery may be found in this plane.
A wet gauze is placed over the tracheostome in

order to moisturize the inspired air.
If the patient is to be connected to a ventilator,

then a portex tube is used. If the tracheostomy
is performed to relieve acute airway obstruction
then a metal tracheostomy tube like the Fuller or
Jackson is preferred.
Image showing stoma created over the anterior

wall of the trachea
376
Advantages of metal tracheostomy tube:
1. It is cheap
2. Easy to maintain
3. Patient will be able to speak by occluding the
tube. This is possible in Fuller’s tube because of
the presence of speaking valve.
4. It is not irritating to the tracheal mucosa
5. Makes decannulation procedure easy.
Decannulation procedure:
The process of weaning the patient from the tra-

cheostomy tube is known as decannulation. This
process varies in adults and pediatric age groups.
Decannulation in adults:
Image showing Fuller’s Biflanged tracheostomy If the patient is on portex tube then it should be
tube being inserted changed into a metal one. The opening of the
tracheostomy tube is occluded using a spigot. Ini-
tially this spigetting is done during day time for
2 days. If the patient tolerates spigetting during
day time for this duration then it is kept spigetted
for full period of 24 hours. If the patient tolerates
spigetting of this duration then the tube can be
removed and the wound can be approximated
and plastered. There is also the option of surgical
closure of the tracheostome wound.
Decannulation in children:
Children easily get accustomed to tracheostome.

They also become dependent on tracheostome,
this is due to the fact that a small child has a very
poor respiratory reserve. So proper care must
Image showing the Fuller’s tube anchored around be taken while decannulating them. In children
the neck the tracheostomy tube is replaced by smaller and
smaller sized tubes in 48-hour duration till the
smallest size is reached after which complete de-

cannulation is possible. The whole process could
take at least a week to complete. Complications following tracheostomy can be
divided into:
Precautions to be taken while performing pediat-
ric tracheostomy: Early complications
Intermediate complications
1. The procedure is carried out as much as possi- Delayed complications
ble with the endotracheal tube or bronchoscope
in place. This will ensure that trachea is easily These complications are known to arise during
identified on the procedure itself or immediately after in the
palpation thereby avoiding inadvertent paratra- post-operative period.
cheal dissection which could lead to disastrous
complications because of the large blood vessels 1. Bleeding: As with any surgical procedure
present close by. bleeding is one of the immediate complications.
2. Surgeon should stay close to the midline and Neck is a highly vascular area. Large vessels are
should never deviate from it. Inferior dissection known to occupy positions just lateral to the
should be limited because of fear of damaging trachea. Isthmus of thyroid gland lies directly
apical pleura. anterior to 2nd and 3rd tracheal rings. While
Since the neck of the child is so short that there operating surgeon should ensure the operating
is space constraint for the surgeon during the field is reasonably bleeding free to ensure preci-
procedure. sion does not take a back seat. All these patients
3. Tracheal stay sutures should be used to anchor due to hypoxia will have more than normal
the trachea to the neck. vascularity in the neck area due to dilatation of
4. A pediatric tracheostomy tube is available in blood vessels. In emergency setting securing the
two lengths for a given diameter. The longer one airway takes precedence over hemostasis. In this
should be used in children and the shorter one in scenario a surgeon should focus on securing the
infants. The choice of tracheostomy tube is very airway instead of securing hemostasis. As soon as
important in children. the tracheostomy tube is inserted bleeding mi-
raculously stops in most of these cases. Typically,
Complications of tracheostomy: the bleeding is from the anterior jugular venous
system. If these veins are encountered during sur-
Like any other surgical procedure tracheostomy gery then it should be divided and ligated. Small
also has its own set of risks and complications. In bleeders can be controlled by using cautery. If
the field of surgery there is nothing like simple, the surgeon deviates away from the midline then
easy and complication free surgical procedure. injury to great vessels is also possible. In children
The only thing surgeon will have to ensure before the size of the trachea and carotids are more or
embarking on less similar and hence should not be mistaken
a surgical procedure is to ensure that all pre- one from the other.
cautions have been taken to get over the known 2. Subcutaneous emphysema: This is a minor
complications that could arise as a result of the complication. This is known to occur if pretrache-
procedure. al fascia is not completely stripped away from the
378
trachea. If too small a tube is used then it could erative period will be a little difficult because the
cause subcutaneous emphysema. track between the tracheal stoma and skin would
3. Pneumothorax – This involves air leakage into not have formed. Hurried attempts to reinsert the
the mediastinum. This is a serious complication tube would cause it to go through a false passage.
which is caused due to inadvertent damage to api- The ideal way to reinsert the tube in these pa-
cal pleura of the lung. Right lung lies at a higher tients is to put them in neck extended position
level than the left. When the patient is hyperven- bringing the trachea forwards. The trachea can
tilating the apex of right lung will occupy lower then be visualized after retracting the soft tissues
portion of the neck. It could be damaged if the with tracheal retractor. The stoma should clearly
patient is restless on the table. This complication be visualized before attempting to reinsert the
is more common in children. Inter-coastal drain- tube.
age should be resorted to in order to tide over the 2. Infection in the trachea around the tracheos-
acute crisis. tome. (Tracheitis).
4. Damage to oesophagus. This is always associ- 3. Development of granulation tissue close to the
ated with trauma to the posterior wall of trachea. stoma. This will cause bleeding from around the
This will cause the patient to aspirate whenever tube. The granulation tissue should be removed
food / liquid is swallowed. surgically
5. Sudden apnoea immediately on opening the before decannulation could be attempted.
trachea because of carbon dioxide wash out 4. Tracheal mucosa could be damaged due to
which could reduce the respiratory drive. In this pressure from the tracheostomy tube, friction
scenario using carbogen inhalation could help. from the tube, infections.
This problem can be avoided by gradually open-
ing up the trachea by dilating the opening slowly. Delayed complications:
This will prevent sudden carbon dioxide washout.
6. Tracheostomy tube block due to inspissated These complications are due to long term pres-
secretions / blood clot. ence of tracheostomy tube inside the trachea. This
is more common when the tube is present inside
Intermediate complications: the trachea for more than
16 weeks.
1. Dislodgement of tracheostomy tube. This 1. Thinning of trachea due to the tracheostomy
accidental decannulation is common in obese tube rubbing against the tracheal mucosa. This
patients with a short neck. This happens because condition is known as tracheomalacia.
the pretracheal tissue thickness is increased in 2. Development of tracheo oesophageal fistula
these patients due to accumulation of fat. While 3. Supra stomal collapse. This condition requires
insertion the neck would have been in a hyperex- additional surgical procedure to repair it.
tended position bringing the 4. Persistent tracheo cutaneous fistula after decan-
trachea closer to the neck. After surgery when the nulation.
patient assumes normal position there is every 5. Pneumonia due to infection
chance of tube slipping out of the stoma because 6. Dislodged tube entering the airway. This is
the trachea will slip back to its normal position. common if the same tube is used for prolonged
Reinsertion of the tube in the immediate post-op- duration of time. This is an emergency. This con-

dition could cause acute symptoms like air hun-
ger, bouts of explosive cough (if the flange comes
into contact with carina). X ray chest is usually
diagnostic as all these tubes are radiopaque.
Immediate bronchoscopy is indicated in these
patients
X-ray chest showing broken flange of tracheosto-

my tube in the airway
Ideal way to prevent late complications occurring

include:
1. Clean tracheostomy site
2. Good tracheostomy tube care
3. Regular airway examination
High risk groups who are more prone to develop

complications:
1. Children / new borns / infants
2. Smokers
3. Obese individuals
4. Diabetics
5. Immunocompromised patients
6. Persons with chronic respiratory diseases
7. Persons on steroids
380
out of favor. The strategies for organ preservation
Total Laryngectomy surgery include horizontal partial and vertical
partial Laryngectomy. Currently supracricoid
Historical perspectives: partial Laryngectomy and near total
Laryngectomy are slowly gaining ground.
History credits Patrick Watson for having per-
formed total 1. Total Laryngectomy is still indicated in ad-
Laryngectomy. This happened way back in 1866. vanced laryngeal malignancies with extensive
Careful study of Patrick Watson’s description of cartilage destruction and extralaryngeal spread of
the case has revealed that he performed a trache- the lesion.
ostomy on a live patient and performed an autop- 2. Involvement of posterior commissure / bilateral
sy Laryngectomy on the same patient. Ironically arytenoid involvement
the patient died of syphilitic laryngitis. It was Bill- 3. Circumferential submucosal disease associated
roth from Vienna who performed the first total with / without bilateral vocal fold paralysis
Laryngectomy on a patient with growth larynx. 4. Subglottic extension of the tumor mass to in-
This happened on December 31 1873. Bottini of volve cricoid cartilage
Turin documented a long surviving patient fol- 5. Completion procedure after failed conservative
lowing total Laryngectomy (10 years). Laryngectomy / irradiation
6. Hypopharyngeal tumors originating / spread-
Gluck critically evaluated total Laryngectomy pa- ing to post cricoid area
tients and found that there were significantly high 7. Radiation necrosis of larynx unresponsive to
mortality rates (about 50%) during early post antibiotics and hyperbaric oxygen therapy
operative phases. This prompted him to perform 8. Severe aspiration following partial / near total
total Laryngectomy in two stages. In the first Laryngectomy
stage he performed tracheal separation, followed 9. Massive nodal metastasis – In these patients
by total Laryngectomy surgery two weeks later. total Laryngectomy should be accompanied by
This staging of procedure allowed for healing of block neck dissection.
tracheocutaneous fistula before the actual Laryn-
gectomy procedure. Patient selection:
In 1890’s Sorenson one of the students of Gluck Enumerated below are the patient requirements
developed a single staged Laryngectomy pro- for a successful total Laryngectomy.
cedure. He also envisaged the current popular a. Patient should be medically fit for general anes-
incision Gluck Sorenson’s incision for total Lar- thesia.
yngectomy. b. Patient should be adequately motivated for post
Laryngectomy life
c. Patient should have adequate dexterity of hands
Indications: / fingers to manage the Laryngectomy tubes
d. Positive biopsy proof is a must
With the current focus on organ preservation e. Screening for metastasis – This should include
procedures, total Laryngectomy is slowly falling CT imaging of neck

f. Evidence of second primary should be sought both sides. The horizontal limb of the incision is
in all these patients before surgery. used to encircle the tracheostome.
g. Airway assessment by anesthetist is a must. In
patients with obstructed airway tracheostomy
should be performed before intubation. This pre-
liminary tracheostomy can be performed under
local anesthesia. Care should be taken to site the
skin incision at the intended site of tracheostomy
stoma. This helps to avoid the Bipedicled Bridge
of skin between the skin flap and tracheostomy
site.
Procedure:
Total Laryngectomy is performed under general

anesthesia. Patient is usually positioned with a
mild extension of the neck. This can be achieved
by placing a small sand bag under the shoulder of
the patient. If available the patient can be placed
over a table with head holder. This allows for the
head of the patient to be cantilevered with ade-
quate head support. Ryle’s tube should be intro- Image showing Gluck Sorenson’s Incision
duced before the commencement of surgery.
Incision:
The following points should be borne in mind

before deciding the type of incision to be used.
1. Whether patient has been irradiated or not
2. Whether block neck dissection is planned / not
Common incision used to perform total Laryn-

gectomy is the Gluck Sorenson’s incision. This
is actually a “U” shaped incision with incorpo-
ration of stoma into the incision line. The major
advantage of this incision is that there is minimal
intersection with the pharyngeal closure
line. The vertical limbs of the incision is sited just Image showing lateral view of Gluck Sorenson’s
medial to the sternomastoid muscle. The upper incision
limit of the incision is the mastoid process on
382
Mobilization of larynx: sheath
Medially – Pharynx and larynx contained in the
The skin flap “U” shaped is elevated in the sub- visceral compartment of neck
platysmal plane. Dissection of the flap along with
the platysma in this plane will ensure that the
vascularity of the flap is not compromised. The
skin of the neck receives its blood supply from
the perforators of platysma muscle. The elevated
flap is stitched out of the way. The anterior jugular
vein and the prelaryngeal node of Delphian are
left undisturbed and should be ideally included
with the specimen.
The medial border of sternomastoid muscle is

identified on each side. The general investing
layer of cervical fascia is incised longitudinally
from the hyoid bone above to the clavicle below.
The omohyoid muscle is divided at this stage. The
division of omohyoid muscle enables entry into
the loose areolar compartment of the neck.
Image showing the neck flap sutured out of the
way revealing the underlying structures i.e.
sub-mandibular salivary gland and digastric
sling
Division of strap muscles:
The strap muscles are divided at this stage. These

muscles are divided close to their sternal mar-
gins. Division of these strap muscles exposes the
thyroid gland. Now is the time to decide whether
to perform total /hemithyroidectomy. In case
of massive bilateral / midline tumors of larynx
total thyroidectomy is preferred. In patients with
Image showing flap being elevated in the subpla- unilateral laryngeal involvement with malignant
tysmal plane tumors a hemithyroidectomy is preferred. The
risk to thyroid gland is imminent in patients with
Boundaries of loose areolar compartment of neck: transglottic growth.
This compartment is bounded by:
Patients with transglottic growth should un-
Laterally – Sternomastoid muscle and carotid dergo total thyroidectomy. If thyroid needs to

be removed then ligation / division of superior
and inferior pedicles of thyroid gland should be
performed at this stage. The middle thyroid vein
should be carefully sought and divided. Ligation /
division of middle thyroid vein should be per-
formed with care because this vein drains directly
into the internal jugular vein causing irksome
post operative bleed if not performed with care.
In patients whom hemithyroidectomy is to be
performed the inferior thyroid pedicle on the side
of preservation should be retained / protected.
In these patients the inferior parathyroid glands
should also be protected. The thyroid lobe to be
preserved is dissected off the laryngotracheal
skeleton from medial to lateral.
Image showing strap muscles being divided
Image showing strap muscles being elevated

Image showing mobilization of thyroid gland
384
Image showing middle thyroid vein exposed
before ligation
Image showing the recurrent laryngeal nerve
Image showing clamping of middle thyroid vein

Image showing inferior parathyroid gland

Suprahyoid dissection:
The anterior jugular vein is ligated after ligating

it superiorly and inferiorly. The hyoid bone is
skeletonized by detaching the mylohoid, genio-
hyoid, digastric sling and hyoglossus muscle from
medial to lateral. These muscles are divided in the
subperiosteal plane of hyoid bone.
Dissection is continued till the pharyngeal cavity

is entered. Epiglottis will come into view at this
stage. The sternohyoid and thyrohyoid muscle
attachments to the lower border of hyoid bone are
left undisturbed.
Laryngeal cartilage skeletonization is performed Image showing suprahyoid dissection

now. This is done by rotating the posterior bor-
der of thyroid cartilage anteriorly and by upward Delivery of epiglottis:
traction. The constrictor muscles should be As soon as the pharynx is entered the epiglottis
released from the inferior and superior cornu by can be visualized. Care is taken not to enter into
sharp dissection. At the level of superior cornu the pre-epiglottic space. This can be avoided by
the laryngeal branch of superior thyroid artery high pharyngeal entry. The same can be grasped
should be identified and ligated before it pene- with a forceps and be delivered out.
trates the thyro-hyoid membrane.
Image showing epiglottis being delivered and

Image showing skeletonizing of hyoid bone held between forceps
386
Removal of larynx:
The larynx is ideally removed from above down-

wards. This approach is better since the inside
of larynx can be seen and there is absolutely
no danger of cutting into the tumor mass. The
surgeon shifts to the head end of the patient. The
epiglottis is held with a pair of allis forceps and
pulled forwards. The pharyngeal mucosa is cut
with scissors laterally on each side of epiglottis,
always aiming towards the superior cornu of thy-
roid cartilage. The constrictor muscles are divided
along the posterior edge of thyroid cartilage if not
divided already. The pharyngeal mucosal cuts are
joined inferiorly by a horizontal mucosal cut just
below the level of cricoarytenoid joints. At this
place there is good cleavage plane along the pos-
terior cricoarytenoid muscle. The larynx is totally
separated by incising it from the tracheal rings Image showing head end dissection. Position of
(between the second and third rings). Formerly the ryles tube is to be noted.
the tracheal rings were used to be cut in a beveled
fashion to enable fashioning of a good tracheal
stoma, now the tracheal ring is sliced cleanly This suture picks up the edges of mucosa but
between two rings as this will cause least damage does not pierce it thus facilitates sticking together
/ trauma to tracheal cartilage with resultant good of submucosal edges. The suture knots should
healing. always be on the inside. The pharyngeal closure
can be reinforced by suturing a second facial layer
Pharyngeal repair: and a third reinforcing layer of pharyngeal con-
strictors.
After removal of larynx the gloves and instru-
ments are changed. Pharyngeal closure may be After pharyngeal mucosal repair, the skin is repo-
performed in a straight line fashion of in a T sitioned and sutured back. The trachea is exteri-
shaped fashion. In the case of T shaped repair orized and sutured to the edges of the skin flap.
there is always a threat of a three point junction A suction drain is placed in the neck to prevent
forming. The three point junction is a notorious hematoma from lifting up the flap during the post
place for formation of pharyngeal fistula. 3- 0 op period.
vicryl is used for performing pharyngeal closure.
During pharyngeal closure the extramucosal
Connell stitch is performed.

Image showing Connell’s suture being performed
Image showing horizontal incision joining the

pharyngeal mucosal incisions just below the level
of cricoarytenoid joints.
Image showing the “T” shaped pharyngeal mu-

cosal defect with Ryles tube in between
Image showing pharyngeal defect being sutured
in a “T” shape
388
Image showing skin flap being repositioned
Complications:
1. Drain failure: Failure of drain to maintain

vacuum will cause the skin flap to life up due to
formation of hematoma
2. Hematoma – If formed should be identified
and evacuated early
3. Infection of skin flap – This can be seen during
the first week following total Laryngectomy. This
can be identified by redness of the skin flap
4. Pharyngocutaneous fistula – Commonly de-
velops during the second week – sixth week. If
present compression dressing should be done till
it heals. This is common in irradiated patients.
5. Wound dehiscence
6. Tracheal stenosis
7. Pharyngo oesophageal stenosis causing Dys-
phagia
8. Hypothyroidism / Hypoparathyroidism

Alonso extended this procedure to resect the
Conservative laryngectomy upper portion of thyroid cartilage along with the
supraglottis thus modifying supraglottic partial
Introduction: laryngectomy.
Organ preservation is becoming common these
days. This applies to larynx also. Laryngeal Supracricoid laryngectomy was first described by
malignancies if identified early can be effectively Australian surgeons Major and Reider in 1959.
managed by conservative resection procedures of
larynx.
Principles of organ preservation surgeries involv-
Advantages of organ preservation: ing larynx:
1. The patient need not live with the stigma of
permanent 1. Adequate local control of the malignant lesion
tracheostomy should be ensured
2. Speech is preserved to the maximum extent 2. Accurate assessment of three dimensional ex-
3. There is effective separation of air and food tent of the tumor
channels 3. The cricoarytenoid unit should be considered
4. Post operative recovery is very fast as the
5. Option of salvage total laryngectomy is still an functional unit of the larynx
option if the conservative procedure fails 4. Adequate cuff of normal tissue should be
excised along with the malignant tumor to mini-
History: mize the chances of local
recurrence.
The first Laryngectomy procedure was performed 5. The physiological functions of larynx (respi-
by Billroth in 1874. The origin of conservative ration, speech and swallowing) should be main-
laryngeal surgery for malignancy is nearly a cen- tained without
tury old. Initially only vertical hemilaryngectomy compromising the loco-regional control of can-
and supraglottic laryngectomy were commonly cer.
performed only to be abandoned due to vari- Current definition of organ preservation laryn-
ous problems like tumor recurrence, inadequate gectomy:
tumor margins and other complications due to It is defined as a combination of surgical pro-
inadequate tissue repair techniques. With the ad- cedures that removes a portion of the larynx,
vent of excellent antibiotics and modern surgical while maintaining its physiological functions i.e.
equipments like laser has created a renewed inter- (respiration, phonation and swallowing) without
est in conservative laryngectomy procedures. compromising the local control of malignancy, its
cure rates and obviates the need for a permanent
Vertical partial laryngectomy was refined in the tracheostomy.
US by Som. A French surgeon Huet described a
procedure in which a portion of the supraglottis Patient evaluation:
was excised without the upper portion of thyroid
cartilage in 1938. Later the Uruguayan surgeon This is the most important part in the whole sur-
390
gical planning. factors are not included in the currently available
staging protocol.
Evaluation should include:
Types of Conservative laryngectomies:
a. Detailed history
b. Dynamic assessment of larynx – This includes There are two major classes of conservative laryn-
indirect laryngoscopic examination, video laryngectomy procedures. They include:
goscopic examination, stroboscopy. Vocal cord
fixation should be distinguished from arytenoid 1. Vertical partial laryngectomy
fixation which implies involvement of cricoary- 2. Horizontal partial laryngectomy – Two types
tenoid joint (a contraindication for conservative i.e. Supraglottic partial laryngectomy and supra-
procedures). cricoid partial laryngectomy
c. Static assessment of larynx – Staging laryngos-
copy Vertical partial laryngectomy:
d. Imaging – CT, MRI and PET scans
e. Head & Neck examination In this procedure the larynx is entered via a
f. Exclusion of synchronous lesion in the aerodi- midline vertical thyrotomy incision. One half
gestive tract of the larynx can be removed. There are various
g. General medical evaluation including lung modifications of this procedure in order to ensure
function tests, cardiac evaluation, nutritional complete tumor clearance.
status, motivation, rehabilitation advice.
Gorden Buck performed a laryngofissure surgery
Even though accurate staging of the tumor is a followed by complete excision of the tumor mass
must for successful conservative laryngectomy for laryngeal cancer in 1851. Solis Cohen in 1869
the currently available staging system is fraught introduced transcervical vertical partial laryn-
with a number of pitfalls. They include: gectomy and was able to achieve long term cure
for laryngeal malignancy. The goal of this surgery
1. The difference in the behavior pattern of severe is resection of a portion of thyroid cartilage with
dysplasia and carcinoma in situ is unclear and the cancer at the glottic level while preserving
is not reflected in the currently available staging the posterior paraglottic space. It is hence very
system. suitable in managing early glottic cancers (T1 &
2. Even though anterior commissure involvement T2 lesions) without the involvement of anterior
is vital in deciding the outcome of any partial commissure.
surgeries it is not reflected in the existing TNM
staging system available Variants of vertical partial laryngectomy:
3. Motion impairment of vocal folds is purely
subjective with a high degree of observer varia- A classification system has been proposed for
tion. This could lead to an erroneous staging vertical partial laryngectomy based on the extent
4. The size of the lesion and its molecular charac- of resection.
terization (over expression of p53 oncogene) are
important determinants of tumor behavior. These Type I Standard vertical

Type II Fronto lateral Tracheostomy:
Type III Antero frontal
Type IV Extended (any procedure in which one As a preliminary step a tracheostomy should be
arytenoid is removed) performed under local anesthesia via a transverse
skin crease incision. Through the tracheostome a
Indications for vertical partial laryngectomy: Laryngectomy endotracheal tube (Laryngoflex) is
introduced. It is shaped like a Shepard’s crook.
1. Large T1 glottic cancer – best results are possi-
ble if the lesion is confined to the middle third of
the vocal cord
2. Small T2 glottic cancer with minimal supra-
glottic / subglottic extension
3. Early glottic cancer that is difficult to visualize
endoscopically
4. As a salvage procedure in patients with radio-
therapy failure of early / intermediate cancer.
Contraindications for vertical partial laryngecto-

my:
1. Involvement of cricoarytenoid joint

2. Involvement of thyroid cartilage
3. Involvement of more than a third of opposite
cord Image showing laryngoflex endotracheal tube
It should be stressed that failure rates are higher Advantages of laryngoflex endotracheal tube:
in patients with:
1. Its shape helps in anchoring the tube to the
1. Involvement of anterior commissure as these anterior chest wall without fear of tube migration.
tumors have a propensity to involve the subglottic 2. After insertion this tube is away from the field
area. of surgery
2. Impaired vocal cord mobility due to involve- 3. The presence of curvature prevents develop-
ment of paraglottic space i.e. Thyroarytenoid ment of excessive pressure over the stoma while
muscle involvement makes things pretty difficult. the patient is being ventilated
Procedure: Incision:
This surgery is performed under general anesthe- Gluck Sorenson incision is preferred. This inci-
sia. sion ensures adequate exposure of the surgical
field. It is a curved incision extending along the
anterior border of sternomastoid muscle from the
392
mastoid tip on both sides. In the midline incision
of both sides are joined at the level of tracheal sto-
ma. Before incising the skin it is always better to
mark the incision over the skin using skin pencil.
Image showing cervical flap being raised

Image showing Gluck Sorenson incision marked
on the neck of the patient After elevating the cervical flap the strap muscles
of the neck are identified. The Sternohyoid mus-
Elevation of flap: cle on the side of surgery should be identified,
separated and held aside using a tape. This muscle
Neck flap is raised in the subplatysmal plane. This is vital during reconstruction of the defect which
plane is ideal because blood supply to the flap is arises after vertical partial Laryngectomy.
derived from the platysma muscle.
The sternothyroid and thyrohyoid muscles are di-
After elevating the cervical flap the strap muscles vided at the level of the thyroid cartilage and held
of the neck are identified. The Sternohyoid mus- apart using tied silk threads.
cle on the side of surgery should be identified,
separated and held aside using a tape. This muscle The perichondrium over the lamina of the thyroid
is vital during reconstruction of the defect which cartilage on the side of the surgery is elevated and
arises after vertical partial Laryngectomy. dissected out. Its lateral attachment to the lateral
/ posterior border of thyroid cartilage should be
preserved. This perichondrium can be reliably
used to reconstruct the surgical defect after sur-
gery.

Image showing thyroid perichondrium incision
marked
Image showing Sternohyoid muscle being sep-

arated
Image showing sternohyoid muscle held apart by

tapes
Image showing perichondrium being incised
394
As shown in the figure a fissure burr is used to
make a vertical cut in the middle of thyroid carti-
lage beginning at the thyroid notch. Care must be
taken not to enter the larynx at this juncture. The
inner perichondrium of the thyroid cartilage is
left intact till the interior of larynx is completely
examined from below.
Examination of interior of larynx from below:
This is possible by incising the cricothyroid liga-

ment and visualizing the vocal folds from below.
If there is no subglottic extension the surgery can
proceed without any modifications.
Image showing perichondrium being stripped

away
Before incising the perichondrium it is always

better to infiltrate saline under the perichon-
drium in order to facilitate easy elevation of the
same.
Image showing ligation of superior laryngeal

pedicle
Image showing cartilage cuts being made on the

thyroid cartilage using a burr

the inner perichondrium of the thyroid cartilage
Ligation of superior laryngeal pedicle: in the midline. The thyroid cartilage opens like
a book revealing the contents of the larynx. The
This is a must before the interior of larynx is growth in the vocal cords can be clearly viewed
entered. If done before entering larynx the field now. The lamina of the thyroid cartilage is held
inside the larynx would be dry without any trou- using Allis forceps / Babcocks forceps. The whole
blesome bleeding. The superior laryngeal artery of one side of the larynx is removed by cutting the
and vein should be identified close to the superior attachments along with the true and false vocal
pole of larynx on its lateral aspect and are ligated. folds. The cut should not be made across the
arytenoid cartilage as it would cause troublesome
swelling in patients who have undergone preop-
erative irradiation. The arytenoid cartilage and its
muscular process are usually retained as it is very
rare for malignant lesion to involve cartilage.
Image showing larynx being entered in the mid-

line
Two more cuts are made in the horizontal di- Image showing one half of thyroid cartilage be-
rection over the thyroid cartilage. These cuts are ing held with Babcocks forceps
made using fissure burr. The superior transverse
cut is made just below the superior border of the
thyroid cartilage and the inferior transverse cut is
made in the lower border of the thyroid cartilage
just above the level of cricoid cartilage.
Entry in to larynx:
The larynx is entered in the midline after incising
396
ed larynx. The redundant cervical fascia can be
sewn over this muscle in order to strengthen it.
Image showing the inside of larynx with normal

opposite side after removal of one half of the
larynx Image showing the redundant pyriform fossa
mucosa being used to line the larynx on the
Repair: involved side
This is the most critical element of the whole sur-

gical procedure. If not done properly it could lead
to breathing and feeding difficulties. The pyriform
fossa mucosa which is redundant on the side of
laryngeal resection is dissected out and used to
line the interior of larynx on the involved side.
The strap muscles sternothyroid and thyrohyoid

are used to reconstruct the vocal folds. This is
made possible by suturing their everted edges to-
gether using a non-absorbable suture like prolene.
The other strap muscle Sternohyoid which was

retracted and held away using tapes can be mobi- Image showing the cervical fascia being sutured
lized to line the lateral surface of the reconstruct- over the Sternohyoid muscle

The wound is closed in layers after keeping a Ro-
movac drain in place. Frontolateral vertical partial laryngectomy:
In this surgical procedure a portion of the op-

posite cord is also removed sparing the opposite
arytenoid.
Image showing skin closure being performed

after placing a drain
Complications: Image showing the area of resection
1. Emphysema – Is common due to air leak in the

immediate post-operative period. It can be man-
aged by compression dressing.
2. Oedema of remaining arytenoid
3. Polypoidal changes in the laryngeal mucosa –
Needs to be excised if present
4. Laryngeal stenosis
5. Laryngocele
Image showing the extent of resection in the fron-

tolateral partial laryngectomy
398
Indications:
1. Vocal cord tumors involving the full length of

the cord up to the anterior commissure
2. The tumor should not involve more than ante-
rior 1/3 of the opposite cord
3. The false vocal cords and the lateral ventricular
wall should be free of the tumor
This procedure permits removal of one vocal

cord completely along with anterior commissure,
the anterior part of opposite cord and the corre-
sponding portions of upper subglottis.
Procedure:
Since this surgery requires a clear view of in-

tra-laryngeal soft tissues intubation via a prelim- Image showing cartilage incision
inary tracheostomy is always better. An apron
flap incision is always better as it can be easily
extended to perform neck node dissection also.
Procedure is almost the same as described for
vertical partial laryngectomy. The difference lies
in the cartilage incision. Two vertical incisions
are made on the thyroid cartilage after resection
of the perichondrium on either side of midline.
Superior and inferior tunnels are created under
the thyroid cartilage
Image showing wedge of thyroid cartilage being

removed along with soft tissue

tissues should be done with extreme care using
The ala of the thyroid cartilage is carefully sep- thin fine instruments
arated using retractors leaving the freed central 4. When a self retaining retractor is used to hold
portion attached to the soft tissues. Slight tension the thyroid laminae apart it should be used gently
is transmitted to these soft tissues by gentle as it could cause fracture of thyroid cartilage
traction in a lateral direction of the ala of thyroid 5. While making the posterior cut to remove the
cartilage. The interior of the larynx is entered on mass the
the side opposite to that of the tumor through the articulation between the arytenoid cartilage and
cricothyroid ligament at the inferior border of the cricoid cartilage should not be disturbed as it
thyroid cartilage. A scissors is introduced through is essential for normal speech production
the inferior cleavage created and the intralaryn- 6. Exposed portions of arytenoid cartilage should
geal soft tissues are cut and the mass along with be covered with mucosa because a bare cartilage
lamina of the thyroid cartilage is removed in toto. carries with it the risk of perichondritis and adhe-
While removing the mass in to it should be freed sion formation
posteriorly. The exact placement of the posterior 7. The region of prelaryngeal lymph nodes should
incision depends on the degree of tumor exten- be carefully examined to rule out metastasis in
sion toward the arytenoid cartilage. patients with tumor involving the anterior com-
missure
– If the tumor has not reached the vocal process 8. If resection of an entire arytenoid needs to be
then the incision should run anterior to the vocal done then a total laryngectomy should be resort-
process ed to as a partial one with removal of arytenoid
– If the tumor has reached up to the tip of the cartilage is really meaningless.
vocal process then the resection should include
the vocal process also freeing it from the body of Repair:
the arytenoid cartilage
– If vocal process is extensively involved then the The inner lining is provided by the redundant
resection should pass through to include the body pyriform mucosa on the side of the lesion. The
of the arytenoid as well. strap muscles of the neck can be used to add bulk
to the laryngeal reconstruction.
Tips:
Anterior frontal partial laryngectomy & its mod-
1. While incising the cricothyroid ligament to ifications:
enter the larynx the incision should not be placed
in the midline. It should be placed lateral to the The original principle of this surgery is that it is
midline on the side of the healthy cord. This more frontal than lateral. In all other aspects it
provides greater freedom of movement over the is technically similar to other types of vertical
anterior commissure area partial laryngectomies. This procedure is appro-
2. Meticulous anterior fixation of the true and priate for small tumors confined to the anterior
false cords is a must and should be done without commissure with very minimal supraglottic /
causing excessive tissue tension subglottic extension. Studies have revealed that
3. Subperichondrial elevation of laryngeal soft a majority of centrally located malignant lesions
400
spread superiorly along the petiole of the epiglot-
tis. In order to provided reliable clearance during
surgery it is prudent to include the angle of the
thyroid cartilage and either part or whole of the
epiglottis to ensure reliable tumor clearance (ex-
tended frontal partial laryngectomy).
Indications for classic anterior partial laryngecto-

my:
1. Tumors confined to the circumscribed area of

anterior commissure
2. Showing minimal subglottic / supraglottic
extension
3. Tumors that have not reached the inferior bor-
der of thyroid cartilage or the stem of the epiglot-
tis superiorly
4. Tumors involving no more than anterior 1/4 of
the vocal cords
5. These tumors should not have caused bilateral
vocal cord fixation Image showing the lines of resection of anterior
partial laryngectomy
Indications for extended anterior partial laryn-
gectomy include:
The surgical procedure of extended anterior par-
1. All the conditions listed above plus tial laryngectomy adds to the classic operation the
2. Midline tumor extension above the anterior following:
commissure
reaching the stem and perhaps part / whole of the 1. Removal of epiglottis
epiglottis and the pre-epiglottic space 2. Removal of hyoid bone
3. Removal of pre-epiglottic space
Principle of anterior partial laryngectomy:
Surgical differences between vertical partial and
The classic anterior partial laryngectomy involves anterior partial laryngectomy:
removal of anterior portions of both true vocal
cords along with the anterior commissure and In anterior partial laryngectomy the subperichon-
adjacent anterior portion of thyroid alae. drial soft tissue dissection extends slightly farther
from the midline on either side. The cartilage
incision is virtually shaped like an equilateral
triangle with its apex at the level of thyroid notch.
The incision over cricothyroid ligament is placed

further laterally in order to facilitate complete
visualisation and removal of the mass. 1. The supraglottic region’s embryological origin
is different from that of glottic and subglottic or-
Since anterior commissure is removed in this pro- igin. It arises from the embryonic buccopharyn-
cedure a meticulous reconstruction of this area is geal analge while the glottis and subglottis arise
a must otherwise it would lead to post operative from the embryonic tracheobronchial anlage.
laryngeal stenosis. In order to prevent this com- 2. Due to this embyrological different origin early
plication from occurring retention sutures should tumors of supraglottis stops short of the level of
be placed through the newly fashioned anterior vocal folds. It extends only up to the level of false
commissure and tied outside the larynx in order cords only.
to secure the opposing epithelial surfaces of the 3. Supraglottic tumors have a tendency to spread
laryngeal interior. superiorly and anteriorly and are hence charac-
terised as ascending tumors
4. Supraglottic tumors have a propensity to pene-
Tips: trate the epiglottis and involving the pre-epiglot-
tic space
1. Laryngeal advancement sutures should be
placed on both sides to provide secure fixation of
both true and false cords Indications:
2. In extended anterior partial laryngectomy it is
important to identify and preserve the superior 1. The tumor should be confined to the supraglot-
laryngeal nerve on either side. Bilateral disrup- tic region of endolarynx and should not extend
tion of this nerve is known to cause severe dys- inferiorly past the false cords
phagia which could be troublesome. 2. Both arytenoids should be uninvolved and
freely mobile
Horizontal partial laryngectomy: (Supraglottic 3. The tumor should not have reached the oro-
partial laryngectomy) pharynx (should not involve the lingual surface of
epiglottis)
Alonzo introduced this technique in 1947. He 4. Aryepiglottic fold and post cricoid area should
performed this surgery as a two staged procedure. be free
Som in 1959 converted this surgery into a single
stage procedure and popularized it. This proce- Principle of surgery:
dure is name thus because the initial cut to enter
the larynx is through a transverse / horizontal The entire upper portion of the larynx is removed
cut. Since the incision is distant from the cancer it up to the level of true vocal cords thereby pre-
allows safe entry into the larynx for serving all the vital laryngeal functions. Since
tumor inspection without the risk of tumor the whole of the supraglottic area is considered
breach. to be a single oncological unit it is mandatory to
This procedure is intended to treat pure supra- remove the entire supraglottic area even in pa-
glottic tumors. The rationale of this procedure is tients with unilateral involvement. If the lesion is
based on the following oncologic principles: extensive then hyoid bone and posterior third of
402
the tongue can also be sacrificed.
A flap of outer perichondrium is dissected care-
Surgical technique: fully from the thyroid cartilage and reflected
downwards. This procedure exposes roughly up-
This surgery is performed under general anesthe- per 2/3 of the anterior surface of thyroid cartilage.
sia which is administered via tracheostomy. The
classic Gluck Sorenson laryngectomy incision is
preferred as it provides excellent exposure of the
neck.
The larynx is skeletonized more on the side of the

greater involvement.
The sternohyoid muscle is divided just below the

hyoid bone and is reflected below. The thyrohyoid
muscle is removed. The larynx is rotated towards
the opposite side with the help of a single pronged
hook. The pharyngeal constrictors are released
from the posterior border of the thyroid cartilage
with the help of scissors. The hyoid bone is not
divided / removed but is conserved. Image showing the upper 2/3 of thyroid cartilage
being exposed after reflection of external peri-
On the same side of the lesion an incision is made chondrial flap.
through the external perichondrium of the thy-
roid cartilage in a horizontal direction. This perichondrial flap could be used in the re-
construction process after completion of surgery.
The superior cornu of the thyroid cartilage is ex-
posed and divided. Ipsilateral superior laryngeal
artery, vein and nerve are ligated. The laryngeal
soft tissues are bluntly separated from the thyroid
cartilage in the subperichondrial plane up to the
level of vocal folds on both sides. The upper por-
tion of the thyroid cartilage is resected on the side
of greater involvement using fissure burr.
The pharynx is entered at the level of the resected

superior cornu of the thyroid cartilage. The inside
of the larynx can now be clearly seen and the ex-
tent of the growth can be assessed accurately.
Image showing outer perichondrial incision The free border of the epiglottis is grasped with

Babcock’s forceps and delivered via the pha- an surgeons Majer & Reider in 1959. They per-
ryngotomy incision. The mucosa on the lingual formed cricohyoidopexy in order to avoid perma-
surface of epiglottis is carefully dissected off the nent tracheostomy. Since the results were highly
cartilage. If epiglottis is involved by the tumor variable it fell in to disrepute. In 1970 French
then this step should be skipped. surgeons Labayle and Piquet modified this proce-
dure and rechristened it as subtotal laryngectomy.
The line of resection for dividing supraglottis They standardized the reconstruction procedure
from the rest of the larynx starts from the tense as cricohyoidopexy (CHP) / cricohyoidoepiglot-
aryepiglottic fold on the side of greater involve- topexy (CHAP).
ment anterior to the prominence caused by ary-
tenoid cartilage using scissors. This cut extends This surgical procedure bridges the gap between
through the supraglottic soft tissues towards the partial open procedures and total laryngectomy.
ipsilateral cord passing anterior to the arytenoid Traditionally glottis was considered to be the
towards the ventricle. This incision continues functional unit of larynx which maintains the
towards the lateral ventricular wall above the level physiological functions like production of speech
of vocal cords. This incision is then extended to and sphincteric function while swallowing.
include the opposite supraglottic area also. The
specimen is completely freed by cutting through Since 1980 the concept of functional unit of
the floor of the vallecula on the lingual side. The larynx has undergone tremendous changes. It is
cut surfaces of soft tissues are covered by mucosa these changes that helped us to refine the tech-
stripped from the pyriform fossa. nique of supraglottic partial laryngectomy. Stud-
ies have demonstrated that the real functional
The first layer of closure is performed to cover unit of larynx happens to be the cricoarytenoid
the laryngo pharyngeal defect. This is done by unit. The driving force of phonatory function
suturing the perichondrial flap from the thyroid depends on a mobile and sensate cricoarytenoid
cartilage to the mucosa resected from the lingual unit. The vocal cords and the thyroarytenoid
surface of epiglottis. muscle provides refinement and range to the
The second layer of closure is established by reap- sound generated.
proximation of strap muscles.
Components of cricoarytenoid unit:
Contraindications:
1. Cartilages – Cricoid (signet ring), arytenoids,
1. Involvement of cricoid / thyroid cartilage corniculate and cuneiform cartilages
2. Impaired mobility / fixity of vocal cords 2. Muscles – Posterior cricoarytenoid, lateral cri-
3. Impaired tongue mobility coarytenoid and interarytenoids
4. Mucosal invasion of both arytenoids 3. Nerves – Recurrent laryngeal nerve and superi-
5. Extension into the glottic area or laryngeal nerve.
Supracricoid partial horizontal laryngectomy: According to this cricoarytenoid functional unit

concept speech & swallowing is possible by pre-
This procedure was first described by two Austri- serving one / both cricoarytenoid unit with spe-
404
cial attention to the attachment of posterior and
lateral cricoarytenoid muscles. This also allows Indications:
the neoglottis to abduct / adduct postoperatively.
To ensure a good surgical outcome all the compo- 1. In T1, T2, T3, Glottic / Transglottic / supraglot-
nents of cricoarytenoid unit should be preserved. tic tumors
2. Selected T4 lesions with limited invasion of
Vocal cord fixation occurs due to the involvement thyroid cartilage without involving the outer
of paraglottic space by the tumor / invasion of perichondrium
thyroarytenoid muscle. This surgical procedure 3. Salvage surgery after failure of radiotherapy
facilitates safe excision of paraglottic space /
thyroarytenoid muscle. It also allows for complete Contraindications:
excision of lateral and posterior cricoarytenoid
muscle if the arytenoid on the tumor bearing side 1. Involvement of interarytenoid area
needs to disarticulated. 2. Fixed arytenoids
3. Involvement of mucosa over arytenoids
Procedure: 4. Subglottic extension
5. Extralaryngeal spread of the tumor
In this surgical procedure true vocal cords, false 6. Invasion of hyoid bone
cords, paraglottic space along with entire thyroid
cartilage can be excised. If need be the pre-epi- Surgical procedure:
glottic space and the epiglottis can also be in-
cluded in the resection. If during reconstruction This procedure is performed under general anes-
a CHEP is planned lower 1/3 of the epiglottis is thesia. Intubation via a preliminary tracheostomy
retained. If need be the arytenoid on the tumor will solve a lot of perioperative problems. The
bearing side can also be excised in order to secure procedure begins with the standard apron inci-
a good tumor free margin. However it is essential sion and elevation of subplatysmal flaps superi-
to conserve one intact and sensate cricoarytenoid orly up to 1cm above the level of hyoid bone and
unit and the entire cricoid cartilage. inferiorly up to the level of clavicles. The ster-
nohyoid and thyrohyoid muscles are transected
Post operative laryngeal reconstruction: along the superior border of thyroid cartilage. The
medial laryngeal vessels are ligated at this stage.
Is usually accomplished by using elements of The sternothyroid muscles are transected at the
the intact cricoarytenoid unit and a cricohyoid level of inferior border of thyroid cartilage. The
impaction. For adequate wound closure a pexy is inferior constrictor muscle and the external thy-
done between the cricoid and hyoid bone, or by roid cartilage perichondrium are transected along
using the preserved portion of the epiglottis. Non its posterior border. The pharyngeal constrictors
absorbable sutures should be used for cricohyoid should be excised close to the posterior border of
impaction. thyroid cartilage in order to protect the internal
laryngeal nerve branches.
The pyriform fossae are released. Disarticula-

tion of cricoarytenoid joint is performed on the tissue on the posterior third of tongue. Strap mus-
involved side staying close to the joint in order to cles are used as a second layer support.
preserve the recurrent laryngeal nerve.
The isthmus of the thyroid gland is transected

right in the middle. Blunt dissection is performed
along the anterior tracheal wall in order to free
the trachea. This mobilizes the trachea thereby
facilitating tensionless reconstruction.
The periosteum of the hyoid bone is incised and a

freer’s dissector is used to dissect out the pre-epi-
glottic space from the posterior surface of hyoid
bone. The larynx is entered through the vallecula
superiorly and through the cricothyroid mem-
brane inferiorly. The larynx is grasped with Allis
forceps and endolaryngeal cuts are made. The
endolaryngeal cuts are begun from the unin-
volved side. A vertical incision is made anterior
to the arytenoid from the aryepiglottic fold to the
cricoid using scissors. The entire paraglottic space
lies anterior to this cut while the pyriform fossa
lies posterior to it. The whole of the paraglottic
space is included in the specimen while the pyri-
form fossa on the uninvolved side is spared. This
incision is connected to that of the cricothyroid
membrane incision above the superior border of
cricoid cartilage.
The thyroid cartilage is grasped and fractured

in the midline to open it like a book. Excision of
the tumor bearing side is thus completed under
direct vision. The arytenoid/arytenoids remaining
after the surgery should be pulled forwards to the
posterolateral aspect of cricoid cartilage with the
help of 2-0 vicryl. This avoids posterior sliding of
the arytenoids.
Cricohyoidpexy is performed. The hyoid bone
and the cricoid cartilage are secured with the help
of three submucosal sutures using 0 prolene. Mid-
line one is placed first taking care to grab a bit of
406
13. Adrenal gland
Lingual thyroid and its management
Embryology:
Introduction:
A brief discussion of embryology of thyroid gland
Lingual thyroid is caused by a rare developmental will not be out of place as this would ensure better
disorder caused due to aberrant embryogenesis understanding of the pathophysiology involved in
during the descent of thyroid gland to the neck. the formation of ectopic thyroid gland.
Lingual thyroid is the most frequent ectopic loca-
tion of thyroid gland. Prevalence rates of lingual Initially thyroid gland appears as proliferation
thyroid vary from 1 in 100,000 to 1 in 300,000. of endodermal tissue in the floor of the pharynx
Review of literature reveals that only about 400 between tuberculum impar and hypobranchial
symptomatic cases have been reported so far. This eminence (this area is the later foramen caecum).
could well be an understatement and statistical Cells of thyroid gland descend into the mesoderm
anomaly. above aortic sac into the hypopharyngeal emi-
nence (later pharynx) as cords of cells. During
History: this descent thyroid tissue retains its communica-
tion with foramen cecum. This communication is
Hickmann recorded the first case of lingual thy- known as thyroglossal duct. This duct disappears
roid in 1869. Montgomery stressed that for a con- as soon as the descent is complete.
dition to be branded as lingual thyroid, thyroid
follicles should be demonstrated histopathologi- Thyroid gland descends in front of the hyoid bone
cally in tissues sampled from the lesion. and laryngeal cartilages. By 7th week it reaches its
final destination in front of trachea. At this time
Common locations of ectopic thyroid gland a small median isthmus develops connecting the
include: lobes of thyroid gland. The gland begins to func-
tion by the 3rd month when thyroid follicles start
1. Between geniohyoid and mylohyoid muscles to develop. Parafollicular or c cells that secrete
(sublingual thyroid) calcitonin are developed from ultimobranchial
2. Above the hyoid bone (suprahyoid prelarynge- bodies.
al)
3. Mediastimum Persistence of thyroglossal duct even after birth
4. Pericardial sac leads to the formation of thyroglossal cyst. These
5. Heart cysts usually arise from the remnants of thyro-
6. Breast glossal duct and can be found anywhere along
7. Pharynx the migration site of thyroid gland. They are
8. Oesophagus commonly found behind the arch of hyoid bone.
9. Trachea Important diagnostic feature is their midline
10. Lung location. Normal development and migration of
11. Duodenum thyroid gland needs an intact Tbx1-Fgf8 pathway.
12. Mesentery of small intestine This pathway has been identified as the key reg-

ulator of development of human thyroid gland.
Tbx1 regulates the expression of Fgf8 in the me- Symptoms:
soderm, it is postulated that Fgf8 mediates critical
Tbx1-dependent interactions between mesoder- Majority of these patients are asymptomatic. They
mal cells and endodermal thyrocyte progenitors. will have no problems other than swelling in the
posterior portion of their tongue.
Tbx1 is not expressed by thyroid primordium, but
is strongly expressed by the surrounding meso- Symptoms caused by lingual thyroid include:
derm. It is also expressed by pharyngeal endo-
derm lateral to thyroid primordium. Thyroid 1. Dysphagia
organogenesis associated with the expression of 2. Dysphonia
a set of transcription factor encoding genes. They 3. Bleeding from the mass
include Nkx2-1, Foxe1, Pax8 and Hhex1 genes. 4. Sleep apnoea
Expression of these genes in thyroid primordium 5. Hypothyroidism
is also dependent on Tbx1 gene expression. 6. Dyspnoea (rarely)
In rare cases lingual thyroid could undergo ma-
lignant transformation.
Features seen on examination:
Image showing development of thyroid ventral to

foramen cecum
It commonly occurs in females. Female:Male ratio

is 4:1. Even though lingual thyroid may mani-
fest at any age it is commonly seen in patients in Image showing lingual thyroid mass
whom there is extra demand of thyroxine by the
body which causes it to undergo physiological
enlargement. It is commonly seen during early
childhood and teens.
408
Image showing migration of thyroid gland
Lingual thyroid could be seen as pinkish mucosa to palpate the neck in the region of thyroid to
covered mass over the posterior third of tongue. ascertain whether normal thyroid tissue is present
On palpation this mass could be felt as solid firm in the neck.
and fixed mass. It would be seen attached to the
tongue at the junction of anterior 2/3 and poste- Investigation:
rior 1/3.
Ultrasound neck:
This is where approximately foramen cecum is
supposed to be present. Attempt should be made In all patients with lingual thyroid the presence of

normal thyroid in the neck should be ascertained.
This can easily be done by performing ultrasound
examination of neck. It will reveal the presence or
absence of normal thyroid gland in the neck.
Image of X-ray soft tissue neck lateral view show-

ing a globular soft tissue mass in the region of
Image showing ultrasound neck with absence of tongue above the level of hyoid bone
thyroid gland in the neck
X-ray soft tissue neck lateral view:
This will just reveal the presence of soft tissue

shadow in the region of the tongue. It will also
demonstrate the lower extent of the mass.
CT scan:
This will help in accurately assessing the extent of

lesion. If contrast is used it would give valuable
input regarding its vascularity. CT scan of neck
will also categorically reveal the presence or ab-
sence of normal thyroid tissue in the neck.
Image showing CT scan axial cut taken at the

level of lower border of mandible clearly shows
soft tissue mass occupying the posterior portion
of tongue.
410
Image showing Technitium 99 scan. It clear-
Image of CT scan neck axial view with contrast ly shows increased uptake in the region of the
shows absence of thyroid gland in the neck. The tongue (due to lingual thyroid tissue) and ab-
internal jugular vein and carotid artery could sence of uptake in the neck region due to absence
be seen as enhancing masses. Jugular vein of one of normal thyroid tissue in this area.
side appears to be predominantly enlarged.
Role of radio active iodine uptake studies:
Technetium 99 scan is virtually diagnostic. It will This helps in ascertaining the functional status of
clearly reveal the radioactive isotope uptake by the thyroid gland. It also helps in ascertaining the
the thyroid tissue present on the tongue. It will viability of the transplanted ectopic thyroid gland
also clearly demonstrate the presence or absence 100 days after the surgical procedure.
of thyroid tissue in the neck region.
Both I 131 and I 123 can be used for this purpose.
These images are obtained in either dynamic or I 123 has a favorable dosimetry for imaging. Since
static mode 20 minutes after intravenous injec- it is produced in a cyclotron it is rather expensive.
tion of 74-111MBq of Technitium 99 pertechne- Whereas I 131 is reactor produced and is reason-
tate. Its molecular weight is comparable to that of able cheap. It is also freely available. It has poor
iodine and is transported actively into the thyroid imaging characteristics and emits beta radiation.
tissue via the sodium iodide symporter system. Its half life is about 8 – 10 days as compared to 12
hours of I 123. Hence I 123 is preferred for func-
tioning radioactive imaging purposes.
Radioactive iodine is usually administered in

small doses orally and uptake is measured at dif- gual thyroid masses. It is ideally suited for lesions
ferent intervals i.e. 2 hrs, 4 hrs, 24hrs and 48 hrs. which are above the level of hyoid bone. Clinical-
ly if the posterior border of the swelling is seen
Estimation of serum T3 T4 and TSH levels: on depressing the tongue with a tongue depressor
then one can safely go ahead and remove the
This will help in assessing the functional status of mass transorally.
the ectopic gland. Invariably majority of these pa-
tients are euthyroid. If TSH levels are raised then Transoral removal is assisted by:
suppression can be attempted using regular doses
of oral thyroxine. 1. Cautery
2. Coblation
Management: 3. Debrider
4. Laser
Conservative: If the lingual thyroid is the only
functioning thyroid suppression therapy using Surgery is usually performed under general
regular oral doses of thyroxine can be attempted. anesthesia induced via nasotracheal intubation.
This is more so in patients whose normal phys- This is the preferred intubation modality in these
iological requirement of thyroxine is raised as patients as it would avoid troublesome bleeding
during periods of active growth, menarche, preg- following intubation trauma.
nancy etc. This suppression therapy will
help in preventing abnormal physiological en- Patient is placed in Rose position. Boyles Da-
largement of the ectopic thyroid tissue. vis mouth gag is used to hold the mouth open.
Throat is packed tightly using ribbon gauze to
Surgical management: avoid spillage into larynx. The mass is held with
a tenaculum forceps and is pulled anteriorly. The
Indications for surgery: anterior border is incised using diathermy cautery
1. If the mass produces obstructive symptoms / coblator /laser. The tumor is gently dissected
2. If the mass produces bleeding and stripped away from the lingual tissue. Perfect
3. If the mass demonstrates sudden increase in hemostasis is secured by coagulating the bleeding
size points seen in the base of the tumor.
4. If malignancy is suspected
Debrider blade can be used to shave off the tumor
FNAC is not advised as it would cause unneces- from the tongue base. Bleeding points seen in the
sary bleeding. Similarly instead of biopsying the base can be cauterized using bipolar cautery.
lesion total excision is preferred.
Advantages of transoral approach:
Methods of excision:
1. Easy to perform
Transoral method of excision: 2. Neck incision is avoided
3. Patient’s recovery is rapid
This method of excision is preferred for small lin- 4. Complications are minimal
412
is proceeded in the subplatysmal plane.
Transmandibular translingual approach:
This approach is very useful in removing very

large lingual thyroid masses.
Procedure:
Preliminary tracheostomy is performed under

local anesthesia. General anesthesia is introduced
via tracheostome. This protects and takes control
of the airway in an efficient manner.
An incision over the mucoperiosteum of the buc-

cogingival sulcus is performed over the interior
region of mandible and the bone over the mental
area is exposed. A midline vertical osteotomy of
the mandible is performed. The tongue is sec-
tioned sagittally in the midline up to the floor of
the mouth till the tongue base is reached.
The lingual thyroid mass is excised in toto. The
wound is closed in layers. The mandible is immo-
bilized by wiring and dental arch bar.
Advantages:
1. Excellent visualization
2. No need for ligating lingual vessels
3. Important structures are spared i.e lingual Image showing the transmandibular approach
nerve, hypoglossal nerve, and submandibular
salivary gland
The following structures are identified:
Lateral pharyngotomy approach:
1. Carotid bifurcation
This approach is preferred if transpositioning of 2. Lingual artery
lingual thyroid is planned. Anaesthesia is induced 3. Superior thyroid artery
via nasotracheal intubation. Patient is positioned 4. Hypoglossal nerve
in such a way that the neck is slightly extended.
An oblique curved incision is made about 8 cms
long in the left lateral portion of upper neck just
anterior to sternomastoid muscle. The dissection

Using the finger guide passing through the oral lingual thyroid mass.
cavity to the left lateral pharynx at the level of
base of tongue a lateral transverse pharyngotomy Infiltration:
of 3-4 cms is made inferior to the hypoglossal
nerve and above the hyoid bone. Through this The surgical area in the neck is liberally infiltrated
pharyngotomy opening the posterior 1/3 of using Tumescent fluid.
tongue, epiglottis and lingual thyroid mass could
be identified. The gland is dissected out of the Tumescent fluid is prepared using:
tongue.
1. One litre of ringer lactate solution
The right side of the mass is totally freed of the 2. 40 ml of 2% xylocaine
tongue. The mass is mobilized by an encircling 3. 1ml of 1 in 1000 adrenaline
incision over the tongue. A small attachment 4. 20 ml of 8.4% soda bicarb
to the left side of tongue base is retained. This
will ensure adequate vascularity to the mass Advantages of using Tumescent fluid infiltration:
after transposition. The mass is delivered via the
pharyngotomy opening and is implanted in the 1. Breaks open tissue planes facilitating easy dis-
left side of the neck with its attachment to the section i.e Hydrodissection
left tongue base remaining intact. The wound is 2. Reduces bleeding due to vasoconstrictive effect
closed in layers. of adrenaline
3. Facilitates uniform heat dissipation when dia-
Advantage: thermy is used during surgical procedure
4. Prevents development of local tissue level aci-
The most important advantage of this approach dosis
is that it ensures tension free transposition of lin-
gual thyroid to the left side of neck. After trans-
position the gland can easily be examined on the
left lateral neck of the patient.
Suprahyoid midline approach:
This approach is preferred in removing large

lingual thyroid mass even if it extends to a level
below that of hyoid bone.
Procedure:
This surgery is performed under general anesthe-

sia administered via nasotracheal intubation. This Image showing infiltration given
intubation modality prevents intubation injury to
414
Ryles tube should be left in place at least for 3
Incision: days.
Transverse skin crease incision is made at the

level of hyoid bone. Skin, subcutaneous tissue and
cervical fascia are elevated in the subplatysmal
plane.
Sticking on to the subplatysmal plane helps in

preserving the cervical branches of facial nerve.
Dissection in this plane is continued and the flap
is raised above the level of hyoid bone.
Image showing Hyoid bone exposed
Image showing suprahyoid incision
Supra hyoid dissection:
In this stage the muscles attached to the hyoid

bone are cut and dissected subperiosteally.
The supra hyoid muscles are split and the oral Image showing skeletonizing of hyoid bone
cavity is entered. Using a finger guide inside the
oral cavity the mass is pushed downwards and
delivered via the suprahyoid neck incision. The
mass is removed in full. The wound should be
meticulously closed in layers. Ryles tube should
be inserted to facilitate early feeding. Ideally the

Image showing suprahyoid subperichondrial Image showing Lingual thyroid attached to the
dissection base of tongue
Image showing lingual thyroid being delivered

into the neck. It is being held with a Babcock’s
forceps Image showing wound closure in layers
416
After surgery all these patients should be started
on oral supplemental doses of thyroxine.
If you are wondering about the status of parathy-

roids, you need not worry as they will be in their
normal position i.e. neck because embryologically
their developmental process is different.

Elongated styloid process (Eagle’s syndrome) of the stylohyoid apparatus.
Introduction: The styloid process shows lot of Anatomy: Embryologically the styloid process
variations in its length. In majority of patients it is derived from the second branchial arch ( a
is about 20 – 30 mm long. Technically speaking component of Reichiert’s cartilage). It is a slender
when the length of styloid process exceeds 30 mm bony structure extending antero inferiorly from
then it is considered to be elongated. The clinical the petrosal aspect of temporal bone. In front of
signs and symptoms associated with elongat- the styloid process the following structures are
ed styloid process was first described by Eagle seen:
in 1937. Later this condition became known as
Eagle’s syndrome / Elongated styloid process. The 1. Internal maxillary artery
signs and symptoms of elongated styloid process 2. Lingual nerve
are pretty vague and often at best misleading. 3. Auriculotemporal nerves
These patients usually go medical shopping vis- Posterior to the styloid process the following
iting neurologists, dental surgeons, psychiatrists structures are seen:
and surgeons. The diagnosis of this condition 1. Internal jugular vein
requires awareness and vigilance. This condition 2. Internal carotid artery
can be confirmed by palpating the tonsillar fossa, 3. Cervical sympathetic chain
infiltration of local anesthetic agents and imaging 4. Last 4 cranial nerves (9,10,11, and 12)
studies.
History:
Historically the ossification of stylohyoid ap-

paratus can be divided into three periods. This
division is purely for better understanding. Era of
anatomists: Anatomists belonging to 17th centu-
ry described ossification of stylohyoid apparatus
they encountered during dissection as normal
variants as they were not privy to the clinical
details and patient history. Era of diagnostic
radiologists: This period includes the early 20th
century. Due to advances in radiological anatomy,
radiologists were able to identify ossification of
stylohyoid apparatus and correlate this condition
with that of the symptoms expressed by the pa- Image showing the styloid process
tient. Eagle under whom this syndrome is named
belonged to this era. Era of panoramic radiology: Structures attaching to the styloid process:
This period includes the mid 20th century. Rou- These include:
tine study of panoramic radiographs by dental
surgeons threw up more such cases of ossification 1. Stylopharyngeus muscle – medially
418
2. Stylohyoid muscle – laterally
3. Styloglossus muscle – anteriorly
4. Two ligaments stylohyoid and stylomandibular
also gets attached to this process
Gossman’s classification of types of elongated

styloid processes: Gossman studies about 4000
patients with elongated styloid process and classi-
fied it into three types.
1. Elongated
2. Crooked
3. Segmented
4. Very elongated
Correll’s classification of elongated styloid pro-

cess:
Type I: Elongated styloid process

Type II: Pseudoarticulated styloid process
Type III: Segmental styloid process
Image showing the types of styloid process as described by Correll

styloid process.
Langlais classification:
Type III (segmental variety): This type is com-
This classification suggested by Robert Langlais posed of non continuous portions of styloid
included the three types as described by Correll, process due to interruptions in the mineralized
to facilitate radiological classification of elongated segments. Radiologically it appears like segmental
styloid process included the term calcification. He mineralized stylohyoid complex.
describes 4 types of calcifications in addition to
the three types of styloid process as described by Patterns of calcification seen in elongated styloid
Correll. process:
1. Calcified outline: Is seen in a majority of elon-
gated styloid process. Radiologically it appears
with a thin radio opaque border with central
lucency (resembling radiographs of long bones).
2. Partially calcified stylohyoid process: Radio-
Correll’s classification Calcification pattern of logically this type of styloid process has a thicker
styloid process radio opaque outline with almost complete opaci-
fication in some areas.
Type I - Elongated Calcified outline 3. Nodular complex: This type of styloid process
Type II – Pseudo artic- Partially calcified has a knobby / scalloped outline, with partial or
ulated complete calcification
Type III - Segmental Nodular 4. Compete calcification: This type of styloid pro-
Completely calcified cess appears radiologically as completely calcified
with no radiolucent inner core.
Type I elongated styloid process: Radiologically
this type of styloid process appears as an unin-
terrupted image, its length ranging from 25 – 30
mm. Radio graphically a styloid process which is
25 mm long is considered to be elongated sty-
loid process. If orthopantomograms are studied
a styloid process of about 28 cm is considered to
be normal because of the inherent magnification
involved in this imaging modality.
Type II (Pseudoarticualted variety): In this type

the styloid process is joined to the mineralized
stylomandibular / stylohyoid ligament through
a single pseudo articulation. This articulation
commonly appears superior to the level of the in- Image of CT scan showing elongated styloid
ferior border of the mandible. Radiologically this process
type of styloid process appears like an articulated
420
Symptoms: Common symptoms associated with tion of post tonsillectomy scar tissue towards the
elongated styloid process include: elongated styloid process resulting in the im-
pingement of one or more of the following cranial
1. Vague pain in the neck nerves i.e. 5,7,9 and 10.
2. Foreign body sensation in the throat
3. Pain in the throat Carotid artery syndrome: In this type the carot-
4. Painful swallowing id arteries are intermittently compressed during
5. Pain while changing head position head turning movements of neck. Head rotation
6. Pain in the ear in these patients classically causes compression
7. Pain over temporomandibular joint of internal carotid artery and sympathetic chain
8. Pain radiating to upper limb resulting in syncope, ipsilateral headache and or-
bital pain. Compression of external carotid artery
Probable causes of stylalgia: causes pain in the distribution of temporal and
maxillary branches.
1. Fracture of ossified stylohyoid ligament –
caused by trauma, sudden laughter or epileptic Clinical tests to confirm elongated styloid pro-
seizures cess:
2. Nerve compression by elongated / malposi-
tioned styloid process. Glossopharyngeal nerve is 1. Palpation of tonsillar fossa: This elicits similar
commonly involved pain / aggravation of pre existing pain.
3. Degenerative and inflammatory changes asso- 2. Xylocaine infiltration test: Patients suspect-
ciated with elongated styloid process ed of having elongated styloid process on being
4. Irritation of pharyngeal mucosa infiltrated about 2 ml of 2% lignocaine into the
5. Impingement of carotid vessels by the elongat- tonsillar fossa have significant reduction in pain.
ed styloid process (carotidynia). A positive xylocaine infiltration test usually indi-
cates Eagle’s syndrome.
Classic features of stylalgia: include
1. Dull and nagging pain Theories of ossification of stylohyoid apparatus:
2. Pain becomes worse on deglutition
3. Pain radiates to the ear and mastoid region. In humans the cervicohyal element of second
branchial arch degenerates with time. It should be
Note: Eagle’s syndrome should be considered in noted that its fibrous sheath, which has a poten-
all patients with vague craniofacial pain. tial to ossify persists as stylohyoid ligament. The
stylohyoid process ossifies between 5-8 years
Eagle classically described two types of Symptom after birth, and any variation in this ossification
complexes. process leads to the creation of elongated styloid
process. Hence the term ossification should be
Classic Eagle’s syndrome: Commonly develops in ideally used instead of calcification.
patients following tonsillectomy. These patients
have persistent throat pain and globus pallidus.
These symptoms could be caused due to contrac-

Steinmann’s theory of ossification of styloid appa- These symptoms may be explained by the theo-
ratus: ry of aging and developmental anomaly. Aging
Steinmann proposed three theories to account for has been found to decrease the elasticity of soft
ossification of styloid apparatus. tissues causing tendinosis to develop between the
stylohyoid ligament and the lesser horn of hyoid
Theory of reactive hyperplasia: bone. This tendinosis causes symptoms mimick-
ing Eagle’s syndrome. These patients can hence
This theory suggests that if the styloid process is be labelled as suffering from pseudo stylohyoid
appropriately stimulated its terminal end un- syndrome.
dergoes ossification at the expense of stylohyoid
ligament. The stimulus could even be pharyngeal Medical management:
trauma.
Includes local infiltration with hydrocortisone
Theory of reactive metaplasia: This theory sug- and bupivacaine into the tonsillar fossa transoral-
gests that traumatic stimulus would induce ly. Injection of triamcinolone acetonide (40mg /
certain ligamentous sections of stylohyoid liga- ml) at the site of maximum tenderness may help
ment to undergo metaplastic changes provoking in certain patients. Triamcinolone is used for its
intermittent ossification of the same. Metaplasia anti-inflammatory and fibrinolytic effect.
is possible due to the presence of osseous centres
within the stylohyoid ligament. When stimulated Surgical management: This involves completely
these osseous centres becomes ossified forming breaking and removing a large portion of the
osseous links causing ossification of stylohyoid elongated stylohyoid component. Two approaches
ligament. can be used:
1. Intraoral
Theory of anatomic variance: This theory suggests 2. External
that the stylohyoid process and stylohyoid liga-
ment gets ossified very early in life. This phenom- Intraoral approach: can be performed after tonsil-
enon could be considered as normal anatomical lectomy via the tonsillar bed.
variant. This theory accounts for the presence of
elongated styloid process in childhood. Glogoff procedure:
According to Steinmann true Eagle’s syndrome This is a transpharyngeal procedure to approach

may either be caused by reactive hyperplasia or styloid process. It is performed under general an-
reactive metaplasia of stylohyoid apparatus. This esthesia after putting the patient in Rose position
does not include the symptom complex caused (hyperextended and open-mouthed position).
by long standing ossified stylohyoid complex as If the styloid process could be palpated through
is the case in the theory of anatomical variance. the tonsillar fossa, it can be used as a landmark
These patients should ideally managed conser- for incising the pharyngeal mucosa. The inci-
vatively. Occasionally elderly patients may pression site should be infiltrated with 2% xylocaine
ent with symptoms of Eagle’s syndrome without mixed with 1 in 100,000 adrenaline in order to
radiological evidence of elongated styloid process. reduce mucosal bleeding. A 1 cm long incision
422
is sufficient to expose and remove the styloid
process. After slitting the pharyngeal mucosa, the
tissue over styloid process is fixed with the help
of fingers. Using a Negus knot adjuster, the tissue
over the styloid process can be slit open and the
periosteum over the styloid process stripped.
Once the styloid process has been visualized it
can be removed with the help of a rongeur. After
securing perfect hemostasis the wound is closed
with absorbable sutures.
Another easy intraoral approach is currently be-

ing practiced by dental surgeons. In this method
the incision is given along the ascending border
of the ramus of mandible after infiltrating the area
with 2% xylocaine and 1 in 80000 adrenaline. The
incision should be deepened by cutting through Image showing styloid process exposed
mucosal and submucosa. By blunt dissection
with a curved artery forceps medial to the medial External approach:
pterygoid muscle and lateral to the superior con-
strictor muscle the styloid process is exposed. The This gives excellent exposure and access to the
periosteum is incised without disturbing the at- whole of the styloid process. Approach is via a
tachments to the styloid process and is degloved. Risden incision (submandibular approach). A
The styloid process can easily be removed by in skin crease incision is made approximately 2 cm
fracturing it with an artery forceps. below the angle of the mandible.
Posterior extension of platysma muscle is iden-

tified. Using a combination of blunt and sharp
dissection the posterior border of the mandible
is exposed. The submandibular gland is dissect-
ed and retracted anteriorly. The posterior belly
of digastric was dissected and identified, then
the same was retracted laterally. The external
carotid arterial system is identified and retracted
forwards. Digital palpation of the surgical field
will reveal the location of the elongated styloid
process. The styloid process and stylohyoid
ligament were identified after careful dissection.
The stylohyoid ligament is transected at the tip of
the styloid process if it is not calcified. If calcified
Image showing intraoral incision then a bone nibbler needs to be used. The same

bone nibbler is used to cut a 2.5 cm segment of
the elongated styloid process.
Wound is closed in layers. Immediately below

the investing fascia under the external carotid
or internal maxillary artery the styloid process
is identified and exposed. The periosteal lining
along with muscle attachments is stripped away
from the styloid process. The styloid process is
excised and the wound is closed in layers.
Image showing retraction of submandibular

gland
Image showing Risden incision
Image showing elongated styloid process exposed
424
Tonsillar bed approach:
In this approach tonsillectomy is performed first.

The muscles of tonsillar bed are dissected and
retracted using Negus curved artery forceps. As
soon as the styloid process become visible an inci-
sion is made at the tip of the styloid process and is
stripped using Negus knot adjuster. The elongated
styloid process is broken using a bone nibbler and
is removed. The wound is closed by interrupted
absorbable sutures.

the inferior border of the clavicle and from the
Classification of Neck dissection lateral border of the strap muscles to the anterior
border of trapezius muscle. Included in this speci-
Introduction: men are the spinal accessory nerve, the internal
jugular vein and the sternomastoid muscle. It was
Currently several types of cervical lymph node Crile in 1906 who first described the procedure
dissections are in vogue in the surgical manage- of systematic removal of lymphatics of the neck.
ment of head and neck malignancy. It is highly He also firmly believed that removing the internal
essential to adopt a common nomenclature for jugular vein was essential because of its intimate
the nodal groups in the neck and the surgical relationship to the lymph nodes of the neck. He
procedures followed in their removal. The clas- preserved the spinal accessory and ansa hypo-
sification of neck dissections recommended by glossal nerves were preserved. Martin in 1950
the American Academy of Otolaryngologists said that the concept of cervical lymphadenecto-
primarily takes into account the nodal groups of my for cancer was inadequate unless the entire
the neck that are removed and secondarily the node bearing tissues of one side of the neck was
anatomic structures that are preserved. Common- removed. He also believed that this was not possi-
ly preserved anatomical structures include the ble unless the spinal accessory nerve, internal jug-
spinal accessory nerve and the internal jugular ular vein and sternomastoid muscle are included
vein. When the various types of neck dissections in the specimen. He also said that normal lym-
are analyzed using the above point of view, three phatic flow is interrupted by metastasis in a node,
types of neck dissections can be described. causing further tumor dissemination to occur in
any direction and a less radical operation would
They are radical and modified radical, selective disseminate and stimulate the growth of tumor
and extended types. The newer classification mass. Removal of sternomastoid muscle facilitates
evolved has managed to remove certain types of access to internal jugular vein and the removal of
selective neck dissection thereby reducing the jugular chain of nodes.
confusions involved. It was also pointed out by
the American Academy of Otolaryngologists in Indication:
2001, regardless of what name a neck dissection is
given, the operative record should reflect accu- 1. Radical neck dissection is indicated in patients
rately what was done during surgery in terms with clinically obvious lymph node metastasis.
of the nodal groups that were removed and the
important neural and vascular structures that 2. Large cervical nodal metastasis
were removed or preserved. The surgeon also
must orient the surgical specimen for the pathol- 3. Cervical metastasis involving multiple nodal
ogist and identify the different nodes groups it areas of neck
contains. This will help the pathologist in gener-
ating a meaningful report. Classification of neck 4. Should be performed only in patients with
dissections: Radical neck dissection: This surgical malignant tumors of head and neck Radical neck
procedure is defined as en bloc removal of lymph dissection is not indicated in patients with no
node bearing tissues of one side of the neck from palpable lymph nodes.
426
2. Causes less cosmetic deformity even when per-
Modified radical neck dissection: formed bilaterally
This category of neck dissection procedures 3. It has been shown that spinal accessory nerve
includes the various modifications that have in majority of cases is not in proximity to the
been incorporated into the procedure of radi- grossly involved nodes and hence its preservation
cal neck dissection with the intention to reduce does not compromise the oncologic soundness of
the morbidity by preserving one or more of the the surgery.
following structures: the spinal accessory nerve,
internal jugular vein and sternomastoid muscle. Indications:
Three neck dissections have been included in this
category. They differ from each other only in the 1. Used in surgical treatment of neck in patients
number of neural, vascular and muscular struc- with clinically obvious nodal metastasis
tures that are preserved.
2. In patients with multiple nodal involvement in
1. Modified radical neck dissection with preserva- various nodal levels
tion of spinal accessory nerve
3. Spinal accessory nerve should not lie close to
2. Modified radical neck dissection with preserva- the involved node
tion of spinal accessory nerve and internal jugular
vein
3. Modified radial neck dissection with preser- Modified radical neck dissection with preserva-
vation of spinal accessory nerve, internal jugular tion of spinal accessory nerve and internal jugular
vein and sternomastoid muscle. This procedure vein:
also goes by the name functional neck dissection
Modified radical neck dissection with preser- This surgery involves the dissection of node bear-
vation of spinal accessory nerve: This surgery ing tissues of one side of the neck en bloc preserv-
involves en bloc removal off lymph node bearing ing the spinal accessory nerve and the internal
tissues of one side of the neck from the inferior jugular vein. Usually this procedure is decided on
border of the mandible to the clavicle and from the table when during the course off neck dissec-
the lateral border of strap muscles to the anterior tion the Metastatic tumor in thee neck is found
border of trapezius. The spinal accessory nerve is to be adherent to the sternomastoid muscle but
preserved. The internal jugular vein and sterno- away from the accessory nerve and the internal
mastoid muscle is included in the specimen. jugular vein. This scenario occurs occasionally in
patients with hypopharyngeal / laryngeal tumors
Advantages: with metastasis under the middle third of sterno-
mastoid muscle.
1. Preservation of spinal accessory nerve prevents
frozen shoulder development Modified radical neck dissection with preserva-
tion of spinal accessory nerve, internal jugular

vein and sternomastoid muscle: Selective neck dissection:
This surgery involves en bloc removal of lymph This involves removal of only the nodal groups
node bearing tissues of one side of neck, includ- that carry the highest risk of containing metas-
ing lymph node levels I – V preserving the spinal tasis according to the location of the primary, pre-
accessory nerve, internal jugular vein and ster- serving the spinal accessory, internal jugular vein
nomastoid muscle. It should be borne in mind and sternomastoid muscle. This procedure was
that the muscular and vascular aponeurosis of the popularized in 1960’s by surgeons at The Univer-
neck delimits compartments filled with fibroad- sity of Texas Anderson Cancer Centre.
ipose tissue. The lymphatic system of the neck
contained within these compartments can be ex- Justification for this procedure:
cised in an anatomic block by stripping the fascia
off muscles and vessels. Except the vagus nerve 1. This procedure preserves the functional and
which runs within the carotid sheath, the nerves cosmetically relevant structures.
of the neck don’t follow the aponeurotic compart-
ment distribution. The phrenic nerve and bra- 2. This procedure is also anatomically justified.
chial plexus are partially within a compartment. Studies have demonstrated that cervical metasta-
The hypoglossal and spinal accessory nerves run sis occur in predictable patterns in patients with
across compartments. Unless these nerves are squamous cell carcinomas of head and neck.
directly involved by tumor, they can be dissected
free and preserved. 3. Nodal groups frequently involved in patients
with carcinomas of oral cavity are the jugulodi-
Indications: gastric and midjugular group of nodes.
1. This surgery is the treatment of choice even in 4. Nodes of submandibular triangle are frequently
N0 neck patients with squamous cell carcinoma involved in patients with carcinoma of the floor of
of the upper aero digestive tract, especially when mouth, anterior tongue and buccal mucosa. These
the primary is in the larynx or Hypopharynx. The tumors can metastasize to both sides of the neck.
nodes of submandibular triangle are at low risk in
these patients and hence need not be removed. 5. Tumors of oral cavity metastasized most fre-
quently to the neck nodes in levels I, II, and III,
2. This surgery is indicated in the treatment of N1 whereas carcinomas of oropharynx, Hypophar-
neck when the Metastatic nodes are mobile and ynx and larynx involved mainly thee nodes in the
are no greater than 2.5 – 3 cms. levels II, III and IV.
3. This surgery is indicated in patients with well 6. Selective neck dissection provides the surgeon
differentiated carcinoma of thyroid who have with some staging information.
palpable nodal metastasis in the posterior triangle
of neck. 7. This procedure can be used for the elective
treatment of regional lymphatics with excellent
survival rates.
428
posterior border of sternomastoid muscle.
There are four selective neck dissections de-
scribed: Indications:
Selective neck dissection of level I – III: 1. This procedure in indicated in the treatment of
neck in patients with squamous cell carcinoma of
This is also known as Supraomohyoid neck the larynx, oropharynx and Hypopharynx.
dissection. If the selective dissection covers even
level IV nodes then it is known as “Extended 2. For tumors of the supraglottis and posterior
Supraomohyoid neck dissection”. The nodes re- pharyngeal wall the dissection is often bilateral.
moved are those contained in the submental and
submandibular triangles (level I), Upper jugular
region (level II), the midjugular level (level III).
The posterior limit of dissection is marked by the Selective neck dissection level VI:
cutaneous branches of cervical plexus and the
posterior border of sternomastoid muscle. The This procedure is also known as anterior neck
inferior limit is the omohyoid muscle as it crosses dissection or central compartment dissection.
the internal jugular vein. This procedure involves removal of prelaryngeal,
pretracheal as well as paratracheal nodes on both
Indications: sides.
1. This procedure is commonly used in the man- Indication:

agement of neck in patients with oropharyngeal
malignancies. 1. This procedure is used to treat patients with
cancer of midline structures of the anterior inferi-
2. In patients with midline oropharyngeal tumors or aspect of the neck and thoracic inlet.
then bilateral neck dissection should be carried
out as nodes of both sides are at risk in these 2. Cancers involving thyroid gland
patients.
3. Cancers involving glottic / subglottic regions
Selective neck dissection levels II – IV: of larynx Selective neck dissection for cutaneous
malignancies of the head and neck: The extent of
This dissection is also known as “lateral neck regional node dissection in patients with cuta-
dissection”. It involves removal of the upper (level neous malignancies depends on the location of
II), middle (level III) and lower (level IV) jugular the primary lesion and the nodal groups that are
groups of nodes. The superior limit of dissection likely to harbor metastasis. This is described sep-
is the digastric muscle and the mastoid tip. The arately because of the extensive lymphatic drain-
inferior limit is the clavicle. The antero medial age that is possible. In these patients the parotid,
limit is the lateral border of sternohyoid muscle. facial, and external jugular groups will have to
The posterior limit of dissection is marked by the be addressed along with the classical neck node
cutaneous branches of cervical plexus and the dissection.

7. Facial / cerebral oedema – due to ligation of
Extended neck dissections: internal jugular vein. This is more pronounced
when internal jugular veins on both sides are
This surgical procedure includes removal of ligated.
any lymph node groups / structures that are not
routinely removed in neck dissection. This could 8. Blindness – very rare. Occurs after bilateral
be skin of neck, carotid artery, levator scapulae radical neck dissection. Possible causes include
muscle, vagus, hypoglossal nerves. Nodal struc- intraoperative hypotension associated with severe
tures could be retropharyngeal, paratracheal and venous distention. Bilateral occipital lobe infarcts
upper mediastinal. have also been implicated as possible factors
Problems with neck dissection: 9. Apnea – Some patients become apnoeic due
to loss / diminished ventilatory responses due
1. In radical neck dissection procedures the spinal to carotid body denervation after bilateral neck
accessory nerve is removed. This causes denerva- dissection.
tion of the trapezius muscle. This muscle is one
of the most important shoulder abductors. This 10. Jugular vein thrombosis
destabilizes the scapula causing it to flare. The pa-
tient will not be able to abduct the shoulder above 11. Jugular vein blow out – Common in patients
90 degrees. The classic feature is the shoulder following post operative radiotherapy
syndrome characterized by pain, weakness and
deformity of shoulder girdle. The shoulder dys- Levels of neck nodes
function is not only due to dysfunction of spinal
accessory nerve, but also can occur secondary to Lymphatics of neck:
glenohumeral stiffness caused by weakness of the
scapulo humeral girdle muscles and post opera- Six levels are currently used to describe the
tive immobility. complete nodal anatomy of neck. The concept of
sublevels has been introduced into the classifica-
2. Cosmetic neck deformity tion because certain zones have been identified
within the six levels, which may have clinical
3. Infection significance.
4. Air leaks – This can cause flap necrosis. When Level I lymphatics: This has been further subdi-
these leaks are associated with tracheal wound vided into two sublevels.
it is sinister. Suction drain should be inserted to
prevent this complication Sublevel IA (submental) includes nodes within
the submental triangle. This triangle is bounded
5. Bleeding by the anterior bellies of digastric muscles and the
Hyoid bone.
6. Chylous fistula
Sublevel IB (Submandibular): This level includes
430
Image showing classification of Neck dissection
lymph nodes within the boundaries of anterior ary is the stylohyoid muscle, and the posterior
belly of digastric muscle, the stylohyoid muscle, boundary is the posterior border of sternomas-
and inferior border of the body of the mandible. toid muscle. Two sublevels have been identified
in this level.
Level II lymphatics: (Upper jugular) This includes
nodes located around the upper third of the inter- Sublevel IIA: Includes nodes located anterior to
nal jugular vein and spinal accessory nerve. This the vertical plane defined by the spinal accessory
extends from the skull base above to the inferior nerve.
border of hyoid bone below. The anterior bound-

Sublevel IIB: Includes nodes located posterior to suprasternal notch. The lateral boundaries are the
the vertical plane defined by the spinal accessory common carotid arteries.
nerve.
Nodes not included in these levels should be
Level III: Midjugular nodes - includes nodes referred to by the name of their specific nodal
located around the middle third of the internal group; these include superior mediastinal group,
jugular vein extending from the inferior border retropharyngeal group, periparotid group, bucci-
of the Hyoid bone above to the inferior border nator group, post auricular group and suboccipi-
of cricoid cartilage below. The anterior (medial) tal group of nodes.
boundary is the lateral border of the sternohy-
oid muscle, and the posterior (lateral) boundary
is the posterior border of sternocleidomastoid
muscle.
Level IV: Lower jugular nodes - Includes nodes

located around the lower third of internal jugular
vein extending from the inferior border of the cri-
coid cartilage above to the clavicle below.
Level V: Posterior triangle: includes nodes located

along the lower half of the spinal accessory nerve
and the transverse cervical artery. The supracla-
vicular nodes are also included in the posterior
triangle group. The superior boundary of this
level is the apex formed by convergence of ster-
nomastoid and trapezius muscles. A horizontal
plane marking the inferior border of the anterior
cricoid arch separates level V into two sublev-
els. Sublevel VA lie above this plane. This plane
includes spinal accessory nodes. Sublevel VB lie
below this plane. This level includes the nodes
that follow the transverse cervical vessels and the
supraclavicular nodes with the exception of Vir-
chow node which is located in level IV.
Level VI: Anterior compartment: Nodes in this

compartment include thee pre and paratrache-
al nodes, precricoid (Delphian node), and the
perithyroidal nodes including the nodes along the
recurrent laryngeal nerves. The superior bound- Image showing Levels of Neck Nodes
ary is the hyoid bone, the inferior boundary is the
432
Image showing the vertebral artery
Image showing spinal accessory nerve
Image showing vagus nerve

Image showing the Brachial plexus

Image showing carotid sheath opened
434
Mandibular swing approach swing approach was the one popularized by Spiro.
This procedure is ideally performed under gen-
Introduction: eral anesthesia. Preliminary tracheostomy should
be performed because extensive intra oral oede-
The mandibular swing approach provides excel- ma following surgery will compromise airway
lent exposure for the surgical treatment of benign during early post op phases. Endotracheal tube
/ malignant lesions involving the oral cavity, intubation is performed via the tracheostome and
oropharynx and the parapharyngeal space. The the tube is anchored to the chest. A nasogastric
advantages of this procedure include: tube should be introduced before surgery.
1. It provides minimal cosmetic and functional

disability
2. The reconstruction is rather simple and does
not involve complex procedures.
3. The oncological principle of this procedure is
also rather sound. Studies performed by Mar-
chetta et al have clearly shown that periosteum
of mandible is not involved when there is normal
tissue existing between the tumor and the man-
dible. This can be clearly assessed preoperatively
by performing accurate biopsy of the lesion and
marking the margins.
History of the procedure:
Roux in 1836 described this surgical technique.

Sedillot used the same procedure in 1844 to
remove an intraoral mass. In 1862 Billroth first
performed segmental resection of mandible in
order to gain access into the oral cavity. After Image showing incision for Mandibular swing
Billroth this procedure was largely forgotten till approach
1959 when head and neck oncology group of
Sloan-Kettering cancer hospital again popularized The lower lip is divided up to its full thickness.
this procedure. The inferior labial artery could start bleeding
It was only after Spiro’s publication of his success- during this stage and should be secured.
ful report following this procedure others started
to follow suit. The neck incision should always be carried out in
the subplatysmal plane in order to avoid injuring
Surgical technique: the marginal mandibular branch of facial nerve.
The deep cervical fascia enveloping the subman-
The technique used in present day mandibular dibular gland should also be incised.

The mandibular periosteum is incised over the Mandibular osteotomy:
mandibular symphysis area. It is elevated for
about 2 cms on both sides. This is performed in the midline. This is usually
performed using a fissure burr / Gigli saw in a
stepwise pattern. This small step at the site of
osteotomy helps is locking up the fragments of
the mandible when wiring / plating is done after
surgery is over. Paramedian osteotomy can be
performed as a small variation between the lateral
incision and canine teeth. This paramedian
osteotomy provides reasonable access into the
oral cavity without causing damage to digastric
and genioglossus muscles thus preventing po-
tential muscle necrosis and potential dead space
formation.
Image showing incision deepened
Image showing step osteotomy being marked on

the mandible
Image showing mandibular periosteum being

stripped
436
Image showing stepped midline osteotomy per-
formed on the mandible
Image showing intraoral incision Red arrow

Intraoral procedure: shows the liberal amount of tissue left medial to
the mandible which could make reconstruction
This is the next step. It is performed by making easy.
a paralingual intraoral incision. This incision
continues in the paralingual gutter extending up Mandibular fixation:
to the anterior tonsillar pillar. It can be extend-
ed upwards to reflect the soft palate also if need This step should be carried out after intraoral
arises for a better exposure. Adequate cuff should incision has been closed adequately using chro-
be left in the paralingual area to make reconstruc- mic catgut or other monofilament sutures. As a
tion easy. first step a mandibular reduction forceps is used
to hold the mandible fragments together. Stabili-
It is always better to identify, dissect the wharton’s zation can be achieved either by using plate and
duct and reflect it along with the swung mandi- screws or wiring. If plate and screws are planned
ble. This when done early during the intra oral to be used during fixation it is imperative to fash-
procedure will help in preventing the late compli- ion the plate in such a way that it would hug the
cation arising due to blocked wharton’s duct. contour of the mandible before proceeding with
mandibulotomy. It is also better to make holes
If exposure is not adequate then lingual nerve can even before mandibulotomy as this would ensure
be transected. A sincere attempt should be made accurate reduction and fixation later.
to reanastomose the nerve during closure.

Image showing the status immediately after mid- Image showing intact lingual vessels and Hyo-
line splitting of mandible. Note the geniohyoid glossus muscle
muscle is still intact.
Image showing the begining of intraoral dissec- Image showing tumor mass visible after mandib-
tion. Note the Wharton’s duct has been separated ular swing
and held apart using proline. This helps in its
identification during repair.
438
Complications:
1. Injury to the marginal mandibular nerve if the

dissection is not performed under subplatysmal
plane
2. Injury to Wharton’s duct leading to post opera-
tive sialadenitis of submandibular gland
3. Injury to lingual artery
4. Injury to lingual nerve
5. Non union / Mal union of mandible
6. Wound infection
7. Osteomyelitis
8. Plate exposure / plate fracture
Image showing mandible fragments wired in

position
Wound is ideally closed in layers.
Image showing wound closure completed

Instrumentation:
Diagnostic and therapeutic sialendoscopy
The diameter of the salivary duct sets the limit
Introduction: for the size of the instruments that can be used
within them. The mini endoscopes that are used
Common disorders of salivary glands involve ob- for cannulating the salivary gland duct can be
struction involving their ductal system. Salivary divided into:
gland calculi comprises the most common cause
of enlargement of salivary glands. Obstructions 1. Flexible – The unique advantage of this endo-
could be caused by the presence of calculi, stric- scope is its flexibility making it easy to negotiate
tures of the duct etc. Sialoendoscopy is the most the kinks and bends present in the salivary gland
preferred mode of treating obstructions involving duct. These flexible scopes cause lesser trauma to
major salivary glands. Major advantage of this the duct. A major disadvantage is that it cannot
procedure is that it can be performed under local be pushed through a stenotic segment of a duct.
anesthesia as an office procedure. Its pushability is rather limited. Handling is also
difficult. They are also very fragile and have a
History: short life span when compared to the rigid and
semirigid counterparts.
It was Konigsberger and his colleagues first used
sialoendoscopy and lithotripsy to treat salivary 2. Rigid – These scopes have larger diameter and
gland calculi in 1990. During the year 1991 hence more stable. Its pushability is rather good.
Gundlach and colleagues published their experi- The image produced has excellent resolution. A
ence of doing sialoendoscopic procedures. Katz camera can be attached to the scope making re-
in 1991 used a 0.8 mm flexible endoscope to cording process rather simple. One major advan-
diagnose sialolithiasis and to remove them from tage of these scopes is that they can be autoclaved.
major salivary glands. It was Kongisberger and
colleagues who successfully used a flexible mini 3. Semirigid - This has been recently introduced.
endoscope and intracorporeal lithotriptor to frag- It has a small diameter, offers a clear view and be-
ment major salivary gland calculi, thus opening cause of its semirigid nature has good atraumatic
up new vistas. pushability making it easy to introduce it into the
ducts of major salivary glands.
In 1994 Arzoz and his colleagues first introduced
a 2.1 mm rigid endoscope which had a 1mm Semirigid scopes are of two types: Semirigid com-
working channel as sialendoscope. This was in- pact and Semirigid modular scopes.
deed a mini urethroscope.
They also used a Pneumoballistic lithotriptor Semirigid compact sialendoscope:
along with this endoscope to hit the calculus and
break it. This work was followed by Nahlieli who This system can be used for therapeutic purposes.
published his three years experience with rigid The components of this system are:
sialendoscope in the year 2000.
1. Compact semi rigid endoscope
440
2. Fibreoptic light transmission system tion channel making it difficult to clean. Plasma
3. Working channel sterilization invariably is inadequate to sterilize
4. Irrigation channel these scopes.
5. Fibreoptic image transmission system
6. The outer tube covers, stabilizes and protects The recent modular endoscopes are made of Niti-
all these components without adding on to the nol steel which is more flexible than conventional
diameter of the whole system. steel. It is highly advantageous while maneu-
vering a tortuous salivary gland duct. It should
Semirigid modular endoscopes: always be borne in mind that a more rigid system
is easier to steer.
In this type of endoscope the fibers used for
transmitting light and images are combined Role of outer diameter of the endoscope:
to form a single probe like instrument. This
probe can be used in combination with different This is the most important factor that determines
sheaths. Using a small single sheath would create whether the scope can negotiate the narrow
a diagnostic endoscope. The gap existing between channels of salivary gland ductal system. These
the outer sheath and the optical system can be scopes are usually 1.5 mm in circumference. It is
used as irrigation channel. If a single large lumen this size that makes it easy for the scope to ne-
sheath / double lumen sheath is used then the gotiate salivary gland ductal system. Some of the
whole system transforms into a potent surgical semi rigid scopes made by Karl Storz have a slight
tool. bend near its tip, this feature helps the scope in
negotiating the branches of the ducts easier. This
The space inside the lumen can be used for intro- bend of course has its drawbacks. It reduces the
duction of various instruments. Major drawback effective diameter of the sheath there by making
of these modular systems is that sometimes air it difficult for insertion of straight surgical in-
may get entrapped struments via the portal. The intraductal position
into the channel blurring the field of vision. of these scopes can easily be ascertained by the
transillumination effect created over the skin. The
Advantages of modular endoscopes: shaft of the endoscope is provided with markings
which indicates the distance the scope has been
1. Economy – The optical system is the most introduced into the ductal system.
expensive part of any endoscopic system. In this
model the same system can be used for a variety Diameter of working channel:
of procedures.
The same optical system can be combined with This aspect is important inorder to perform
different sheaths there by creating a versatile tool. certain specialized therapeutic tasks using sialen-
2. Hygenic – Since the space between the sheath doscope. The working diameter has a direct effect
and the optical system is adequate on the stability of the instrument used in sialen-
for cleaning the system the scope can be cleaned doscopic therapeutics. Working channel diameter
easily there by ensuring hygiene. In comparison of 0.8 mm is a must for using instruments such as
the compact endoscopes have very thin irriga- forceps, balloons, or baskets. These instruments

occupy about 0.4 mm of this working channel
space. Studies have shown that the incidence Sterilization procedures for sialendoscopes:
of metal fatigue is directly correlated with this
diameter. Sialendoscopes are highly fragile instruments.
Since these instruments when used for diagnostic
The smaller this diameter more the chance of purposes come into contact with intact mucosa
metal fatigue. semicritical sterilization procedures like wiping
the scope with savlon / spirit gauze would be
sufficient.
Scopes used for therapeutic purposes should be

autoclaved. Since these instruments are highly
fragile only limited number of autoclave cycles
can be performed.
Image showing sialendoscope
Image showing semi rigid sialendoscope
Image resolution produced by sialendoscopy

system:
Image resolution of sialendoscopy system is very

good because of dense packing of optical fibers.
Most modern sialendoscopes have a resolution of
6000 pixels.
Instruments used in therapeutic sialendoscopy:

Image showing curved tip of sialendoscope Forceps:
Two types of forceps are available:
442
1. Grasping forceps with serrated edges. These
forceps are useful in dilating the ducts and grasp-
ing and removing small stone fragments after
crushing the calculus.
2. Cup forceps with sharp edges. This forceps is
useful in crushing calculus and taking biopsy of
suspicious tissue.
These two forceps can easily be attached to an
universal handle. Ideally the handle which allows
rotation of the tip of the forceps is considered to
be advantageous.
Image showing toothed forceps used in sialendo-
scopic procedures
Image showing universal handle
Diagrammatic representation of the tip of thera-

peutic semirigid sialendoscope
Image showing cutting forceps

Baskets:
Baskets are very useful in removing salivary gland

calculi. These baskets are classified according to:
1. Number and form of their wires
2. Type of tips
3. Presence or absence of outer sheath
These baskets can be attached to the universal

handle provided. These handles need not provide
rotatory movement of the tip of the basket com-
pared to the ones used along with forceps.
Baskets with higher number of wires (more than

4) are very useful in removing small stones. Bas- Image showing grasper
kets made of strong wires (made of nitinol steel)
are very useful in dilating the salivary gland duct
and in negotiating the stenotic segment. Dilators:
These dilators are conical in shape and are used

in the identification of the papillae and duct of
major salivary glands. Two types of dilators are
available:
1. Conical sharp dilator is useful in the initial

identification and dilatation of the salivary duct
papillae
2. Conical blunt dilator which can be introduced
into the duct after the identification and dilata-
tion of the papilla. Conical sharp dilators when
Image showing a typical basket forceps used inside the ducts can cause trauma to the
ductal mucosa and hence are best avoided in this
Graspers: scenario.
This is a mixture of forceps and basket. But its Solex soft lumen expanders:
use is highly limited. This instrument is slowly
finding its way out because of the propensity to The advantage of this instrument is that it is avail-
traumatize the ductal mucosa. This invariably able in different sizes. It contains an outer sheath
leads to ductal stenosis after the procedure which and an inner dilator. The advantage of this system
is a highly unwelcome complication. is that after dilatation the inner probe can be re-
444
moved leaving the outer sheath in the duct. ly used. They need a special syringe system for
inflation. Major advantage of this high pressure
Sialendoscope can easily be passed through this balloon is that they can easily be introduced
sheath, and calculi if any can be removed. Major via the sialendoscope port. Some of these high
advantage of leaving the outer sheath is that it pressure balloons have sharp cutting margins and
prevents damage to the ductal mucosa while the hence are very useful in fragmenting large sali-
calculus is being removed. vary ductal calculi.
Image showing microburr tip used to fragment

salivary duct calculi
Cytology Brushes:
Image showing solex soft lumen expander
These brushes were originally designed to take
Drills and micromotor system: biopsy from ducts of mammary glands. These
brushes can be used to harvest cells from inac-
Microdrills play a vital role in fragmenting the cessible areas of salivary glands there by facili-
salivary gland calculi there by facilitating easy tating tissue diagnosis. These brushes have been
atraumatic removal. These microburrs have a designed in such a way that they can easily pass
diameter of 0.38 – 0.4 mm. through the portal of a sialendoscope. These
brushes need to be handled with great care as
Balloons: they are very flimsy and can easily be damaged.
These are of two types:

1. Low pressure type – This balloon expands
rapidly with minimal insufflation. These balloons
are of limited use because of their propensity to
rupture easily.
They are useful in dilating thin membranous
areas.
2. High pressure balloon – These are common-

2. Glandular swelling associated with pain
Ultrasonic examination is a must before diagnos-
tic sialendoscopy. Before ultrasonic examination
if a sialagogue is administered it would go a long
way in assessing the cause and region of salivary
gland obstructive pathology. Even though ultra-
sound
examination would clinch the diagnosis in ma-
jority of cases it could create difficulties in the
following scenario:
1. Ultrasonic examination fails to distinguish be-
tween non echogenic stone and stricture. In this
Image showing cytology brush scenario diagnostic sialendscopy helps in arriving
at a diagnosis.
Indications: 2. Ultrasonic examination fails in the quantitative
assessment of salivary gland obstruction, because
1. Diagnostic ultrasound does not precisely assess the three
2. Therapeutic dimensional
size of the salivary gland calculus. It also fails
Diagnostic indications include any suspected to assess the extent of stenotic segment or their
obstructive salivary gland disease. number in cases of multiple stenosis.
3. If intraductal removal of calculi is planned then
Therapeutic indications: ultrasound exam is not suited because it cannot
precisely assess the diameter of the duct.
1. Treatment of salivary gland calculi which in-
volves localization fragmentation and removal. It Sialogram:
may also be used as a guide for external approach
calculi This investigation helps in the accurate assess-
removal. ment of the complete ductal system of the salivary
2. Localization and dilatation of strictures. gland. This is much better than sialendoscopy
3. In managing chronic sialadenitis by irrigation because it images the complete ductal system.
4. In the management of recurrent juvenile si- Major disadvantages of sialography is that it can
aladenitis expose the patient to unnecessary radiation. It
can also show false positives in the presence of air
Diagnostic sialendoscopy: bubbles which may be mistaken for salivary gland
Before embarking on this procedure a detailed calculus.
patient history should be taken.
Pointers in the history that could suggest obstruc- The advantage of sialendoscopy in these patients
tive salivary gland disease include: is that it can effortlessly be switched to the thera-
1. History of glandular swelling associated with peutic mode in the same session.
food intake.
446
projects it on a digital monitor. It should be borne
Diagnostic sialendoscopy: in mind that a sphincter system is present near
the papilla of Wharton’s duct. Any damage to this
The advantage of this procedure is that it can be system may lead to unnecessary salivary drooling.
performed under local anesthesia. The mucosa of Papillotomy should be avoided in wharton’s duct.
oral cavity can be anesthetized by topical use of The same sphincter system of Stenson’s duct is
4% xylocaine. located posteriorly hence papillotomy of stenson’s
duct will not cause sphincter problems. Before
Additional infiltration anesthesia of the ductal introduction of the endoscope the zero position
area can be achieved by infiltration with 2% xylo- of the scope should be ascertained by focussing
caine with 1 in 10,00000 units adrenaline. on a letter. It is also prudent to orient onself to the
direction of the instrument channel of the sialen-
Step I: doscope before the actual introduction. When
performing sialendoscopy of submandibular
Dilatation of the papilla of salivary gland duct. salivary gland the sublingual salivary gland duct
This can be achieved by insertion of a sharp could be seen opening in to the anterior part of
conical dilator. Further dilatation is possible by wharton’s duct.
the introduction of a blunt conical dilator. If the
papilla is stenosed / narrowed due to persistent This opening usually lies 5 mm posterior to the
inflammation then papillotomy may have to be papilla. This is one of the reasons for avoiding
resorted to. papillotomy in wharton’s duct. While performing
sialendoscopy the lining mucosa of the ductal
Step II: system should be carefully examined. In a healthy
gland the ductal mucosa appears shiny and the
Creation of artificial cavity. As performed in underlying blood vessels can be clearly seen. In
abdominal laproscopic procedures an artifi- salivary glands affected by chronic sialadenitis the
cial cavity will have to be created to enable easy mucosal lining of the duct shows matted appear-
passage of sialendoscope. This cavity creation is ance with submucosal ecchymosis.
achieved by irrigation of isotonic saline via the
duct. The saline irrigated should be mixed with The presence of intraductal calculi if any should
4% xylocaine. The saline lubricates the duct of the be documented. In wharton’s duct the calculi are
gland facilitating easy passage of sialendoscope. usually seen at its bifurcation. This bifurcation is
The local anesthetic mixed with saline takes away present because of the presence of two portions
the pain and discomfort of insertion. (superficial and deep lobes of the submandibular
gland). In parotid duct calculi usually lie posteri-
Step III: or to its curvature.
The outer sheath of sialendoscope is inserted via

the major salivary gland duct. The endoscope
follows later. The endoscope is attached to an en-
docamera which faithfully captures the image and

tea leaves can also be identified and if possible
Ductal polypi: can also be removed.
Ductal polypi when present will be seen as filling Therapeutic sialendoscopy:

defects in a sialogram. They can be clearly seen in
sialendoscopy and if necessary biopsy can also be Even though sialendoscopy has been used for
performed. therapeutic purposes it should at best be consid-
ered to be an adjunct visual control of therapeutic
Intraparenchymal sialoliths: procedures.
Presence of sialoliths in the parenchyma of sali- Sialendoscopy can be effectively used in dilatation
vary glands can also be observed if present close / of salivary duct strictures.
adjacent to the ductal system.
Dilators rigid / balloon types can be used for the
Occult radiolucent calculi: same.
Role of sialendoscopy in the management of sali-
It should be borne in mind that nearly 70% of pa- vary gland calculi:
rotid gland calculi are radiolucent and quarter of
submandibular calculi are radiolucent. Diagnosis The aim in the management of sialolithiasis is to
of radiolucent calculi can be made only by ob- remove the calculus completely.
serving filling defects in a sialogram or by direct Sialendoscopy should be considered as one of the
visualization through sialendoscope. many management modalities available. Calculi
of submandibular gland measuring less than 4
Kink’s and strictures: mm can be removed
under sialendoscopic vision using basket. Simi-
Kink’s and strictures present in the salivary gland larly calculi measuring 3 mm and below can be
ductal system can be observed best in a sialo- removed using the same technique from parotid
gram. The same may be confirmed by performing duct. Any calculi measuring more than the above
sialendoscopy. mentioned size needs to be broken down into
small manageable bits using either crushing for-
Presence of pelvis like ductal formation of whar- ceps or extracorporeal / laser lithotripsy.
ton’s duct:
When the calculi has been shattered to smaller
This is one of the rare congenital anomalies that manageable bits they can be removed translu-
can be picked up while performing sialendoscopy. minally under endoscopic visualization. Normal
Instead of the routinely seen bifurcation / trifur- submandibular and parotid ducts measure 1.5
cation the main duct assumes a pelvis like forma- mm with the narrowest portion being 0.5 mm
tion thus leading to obstruction in the drainage of at the level of papilla. Hence the stone’s diameter
saliva. which can be handled by sialendoscopy should
not be larger than 150% of the diameter of the
Presence of intraductal foreign bodies like hair, anterior ducts.
448
Before attempting to remove salivary gland cal-
culi conservatively patients should been encour-
aged to take sialogogues like bubble gum and the
enlarged gland can be massaged in an attempt to
flush out the calculi from the duct. Only when
this conservative approach fails other invasive
modalities of treatment should be considered.
Management of chronic sialadenitis:
Sialendoscopes can be used to clear mucous plugs

which are a common feature of chronic sialade-
nitis. The duct also can be dilated by irrigation of
normal saline through the ductal system.
Difficult scenario:
Therapeutic endoscopes may be large and would

have difficulty in negotiating the major salivary
gland ductal system. In these cases a modified
Seldinger technique can be attempted. The papilla
of the duct is dilated and then the outer sheath of
the scope is passed through it.
The instrument used for calculi removal (guide

wire, basket) etc is passed through it while the
endoscope follows the same.
Side effects of therapeutic endoscopy:
1. Temporary swelling due to irrigation of the

duct
2. Perforation of ductal wall
3. Wire basket blocks
4. Lingual nerve paraesthesia
5. Ranula
6. Ductal strictures
7. Post op infections

Voice rehabilitation following total laryngecto- 1. Active respiratory support
my 2. Adequate glottic closure
3. Normal mucosal covering of the vocal cord
Introduction: 4. Adequate control of vocal fold length and ten-
sion.
The current 5 year survival rate of patients follow-
ing laryngectomy ranges between 75-80%. Larynx The vibrations of the vocal folds are complex in
is the second commonest site for cancer in the nature and are known as the glottic cycle. This
whole of aero digestive tract. Commonest malig- cycle involves glottic opening and closing at set
nancy affecting larynx is squamous cell carcino- frequencies determined by the subglottic air pres-
ma. Surgery carries a good prognosis. Conserva- sure. Normal vocal folds produce three typical
tive laryngeal surgeries are getting common by vibratory patterns:
the day. After total laryngectomy there is a pro-
found alteration in the life style of a patient. The 1. Falsetto
patient is unable to swallow normally, associated 2. Modal voice
with profound changes in the pattern of respira- 3. Glottal fry
tion. Olfaction is also affected. The importance of
speech is not appreciated unless it is lost. In falsetto or (light voice) the glottic closure is not
complete, and only the upper edge of the vocal
Physiology of phonation: fold vibrates. In Modal voice complete glottic
closure occurs. This occurs in a majority of mid
Voice is produced by the respiratory system with frequency range voice. During this modal voice
active lungs forming the bellows pumping air into production the vocal fold mucosa vibrates inde-
the laryngeal cavity. Vibrating air in the larynx pendently from the underlying vocalis muscle.
generates voice. Clear and understandable speech This is the basic frequency at which a person
is created by articulators (lips, tongue, teeth etc.). phonates. The modal frequency in adult males is
120 Hz while in adult females it is 200 Hz.
The larynx acts as a transducer during phonation
converting the aerodynamic forces generated Glottal fry is also known as low frequency phona-
by the lungs, diaphragm, chest and abdominal tion is characterized by closed phase. This closed
muscles into acoustic energy. This energy trans- phase is long when compared to the open phase.
duction precisely at the space between the two The vocal cord mucosa and vocalis muscle vibrate
vocal folds. in unison.
However subglottic and supra glottic pressures During phonation two vibratory phases occur i.e.
also play a role in this transformation of aerody- open and closed phases. The open phase denotes
namic energy into sound energy. the phase during which the glottis is at least
partially open, while the closed phase denotes the
The requirements of normal phonation are as phase when the vocal folds completely occlude
follows: the glottic chink.
450
Oesophageal speech:
The open phase can be further divided into
opening and closing phases. The opening phase Patients after total laryngectomy acquire a certain
is defined as the phase during which the vocal degree of oesophageal speech. In fact all the other
folds move away from one another, while during alaryngeal speech modalities are compared with
the closing phase the vocal folds move together in that of oesophageal speech. It is the gold stan-
unison. dard for post laryngectomy speech rehabilitation
methods during 1970’s.
One important physiologic parameter which
must be noted during phonation is the mucosal In this method air is swallowed into the cervical
wave. The mucosal wave is an undulation which esophagus. This swallowed air is immediately
occur over the vocal fold mucosa. This wave expelled out causing vibrations of pharyngeal
travels in an infero superior direction. The speed mucosa. These mucosal
of mucosal wave ranges from 0.5 - 1 m/sec. The vibrations along with tongue in the oral cavity
symmetry of these mucosal waves must also be cause articulations. The exact vibrating portion
taken into consideration while studying the phys- in these patients is the pharyngo esophageal
iology of voice production. Any mild asymmetry segment. This segment is made up of muscula-
between the two vocal folds must be considered ture and mucosa of lower cervical area (C5 – C7
as pathological. segments).
The function of vocal folds is to produce sound This method is very difficult to learn and only 20
varying in intensity and pitch. This sound is then % of patients succeed in this endeavor. Patients
modified by various resonating chambers present with oesophageal speech speak in short bursts, as
above and below the larynx and are converted the bellow
into words by the articulating action of the phar- effect of the lungs are not utilized in speech gen-
ynx, tongue, palate, teeth and lips. eration. The vibrations of muscles and mucosa of
cervical esophagus and hypopharynx are respon-
The consonants of speech can be associated with sible for speech production. Oral cavity plays
particular anatomical sites responsible for their an important role in generation of oesophageal
generation i.e. ‘p’ and ‘b’ are labials, ’t’ and ’d’ are speech.
dentals and ‘m’ and ‘n’ are nasals.
Air from the oral cavity is swallowed into the cer-
Methods of alaryngeal speech: vical oesophagus before speech isgenerated. There
are two methods by which air can be pumped
There are 3 methods of alaryngeal speech. They into the cervical oesophagus. They are:
include:
Injection method: In this method the person
1. Oesophageal speech builds up enough positive pressure in the oral
2. Electrolarynx cavity forcing air into the cervical oesophagus.
3. Tracheo oesophageal puncture This is achieved by elevating the tongue against
the palate. Air can also be injected into the cer-

vical oesophagus by voluntary swallowing. Lip can also be attempted. 30 Units of Botulinum tox-
closure along with elevation of tongue against the in is injected via anterior portion of the neck (via
palate generates enough positive pressure within the tracheostome over the posterior pharyngeal
the oral cavity to force air into the cervical oe- wall bulge.
sophagus. This method is also known as tongue
pumping, glossopharyngeal press and glossopha- Common cause of failure to develop oesophageal
ryngeal closure. This method is effective before voice:
speaking Obstruent phonemes like plosives,
fricatives and affricatives. 1. Presence of cricopharyngeal spasm
2. Disorders involving pharyngo oesophageal
Inhalational method: segment
3. Poor motivation on the part of the patient
This method uses the negative pressure used in
normal breathing to allow air to enter the cervi- Cricopharyngeal spasm can be managed by per-
cal oesophagus. The air pressure in the cervical forming cricopharyngeal myotomy on a routine
oesophagus below the cricopharyngeal sphincter basis in all patients undergoing total laryngecto-
has the same negative pressure as air in the tho- my. If this fails Botulinum
racic cavity. Hence during inspiration, this pres- toxin injection can be resorted to.
sure falls below atmospheric pressure. Laryngec-
tomees often learn to relax the cricopharyngeal Advantages of oesophageal speech:
sphincter during inspiration thereby allowing air
to get into the cervical oesophagus as it enters 1. Hands free speech
the lung. This trapped cervical column of air is 2. No additional equipment is necessary
responsible for speech generation. Patients are 3. No additional surgery is necessary
encouraged to consume carbonated drinks during
the initial phases of rehabilitation. Gases released Disadvantages of oesophageal speech:
can be expelled into the cervical oesophagus
causing speech generation. 1. Significant training is necessary
2. Controlling pitch and loudness can be really
The major advantage of oesophageal speech is difficult in these patients
that the patient’s hands are free. The patient does 3. The fundamental frequency of oesophageal
not have to incur cost of a surgical procedure or a speech is about 65 Hz which is about half of the
speaking device. normal adult male speaker. Its intensity is also
pretty low making it difficult for the speaker to he
Nearly 40% of patients fail to acquire oesopha- understood in noisy environments.
geal speech even after prolonged training. This
could be due to cricopharyngeal spasm / reflux Electrolarynx:
oesophagitis. Reflux must be aggressively treated.
Cricopharyngeal myotomy must be performed in These are vibrating devices. A vibrating electri-
patients with cricopharyngeal spasm. Botulinum cal larynx is held in the submandibular region.
toxin injection into the cricopharyngeus muscle Muscular contraction and facial tension can be
452
Image of Flow chart showing various voice restoration options following laryngectomy
modified to generate rudiments of speech. The They are:

initial training phase to use this machine must
begin even before the surgical removal of larynx. 1. Pneumatic - Dutch speech aid, Tokyo artificial
This helps the patient in easy acclimatization after speech aid etc.
surgery. There are three types of electro larynges 2. Neck
available. 3. Intra oral type
Among these three types neck type is common-

ly used. It should be optimally placed over the

neck for speech generation. Hypoesthesia of neck over the stoma during phonation. These equip-
during early phases of post op period may cause ment are expensive and need to be maintained.
some difficulties in proper placement of this type
of artificial larynx. If this device cannot be used Voice restoration surgeries in patients who have
intra oral devices can be made use of. undergone Laryngectomy:
1. Neoglottic reconstruction
2. Shunt techniques
Neoglottic reconstruction:
Numerous surgeons all over the world attempted

to develop a reliable tracheohyoidpexy procedure
which could restore voice function in patients
who has undergone Total Laryngectomy. Most of
these techniques were abandoned due to compli-
cations.
Shunt technique:
Image showing electrolarynx This technique involves creation of shunt between

trachea and oesophagus. This technique was first
developed by Guttmann in 1930. Lots of modifi-
While using intra oral type cup must form a tight cations have occurred, but the basic concept re-
seal over the stoma so that air does not escape mains the same. Basic aim of this procedure is to
during exhalation . The oral tip of the tube is divert air from the trachea into oesophagus. The
positioned in the oral cavity. The pneumatic place where sound is generated depends on where
artificial larynx uses the patient’s exhaled air to the fistula enters pharynx / oesophagus.
create the fundamental sound. A rubber, plastic,
or steel cup is placed over the stoma, creating a Creation of shunt between trachea and oesopha-
seal. A tube is then directed from the cup into the gus usually failed because:
mouth. The exhaled air vibrates a reed or rub-
ber diaphragm within the cup, creating a sound. 1. Aspiration through the fistula
Speech quality can be varied through a number 2. Closure of fistula
of mechanisms. Changes in breath pressure can
affect pitch and loudness. This lead to the development of one way voice
prosthesis designed by Blom and Singer which
The major disadvantage of these electro laryngees was introduced via the puncture wound.
is their mechanical quality of speech. There is also
a certain degree of stomal noise. With practice a
patient can reduce stomal noise by placing fingers
454
Image showing he advantages of electrolarynx
Tracheo esophageal puncture (TEP): airway.
This procedure for restoration of speech in pa- Voice prosthesis is actually a one way valve made
tients who have undergone total laryngectomy of medical grade silicon. This is a barrel shaped
was first introduced by Blom and Singer in 1979. device with two flanges. One flange enters the oe-
In addition to the procedure of tracheo oesopha- sophagus while the other one rests in the trachea.
geal puncture Blom – Singer developed a silicone It actually fits snuggly into the tracheo-oesopha-
one way slit valve which can be inserted into the geal puncture wound. This prosthesis is provided
puncture wound. This valve formed a one way with a unidirectional valve at its oesophageal
conduit for air into the oesophagus and also pre- end. Indwelling prosthesis usually have more
vented leakage of oesophageal contents into the larger and rigid flanges when compared to that of

Image showing the disadvantages of electrolarynx
Image showing the type of shunts
456
non-indwelling ones. Non-indwelling prosthesis
has a safety medallion attached to the main struc-
ture to prevent accidental aspiration.
TEP can be performed either immediately after

laryngectomy or 6 weeks following successful
laryngectomy. TEP performed along with laryn-
gectomy is known as Primary TEP and if per-
formed 6 weeks after laryngectomy it is known as
Secondary TEP. It should be stressed that radio-
therapy poses no threat to TEP. This procedure
initially was reserved for patients who have failed
to acquire oesophageal speech even after pro-
longed effort, and are displeased with the voice
produced by artificial larynx. Currently Primary
TEP is getting popular.
Anatomical structures involved in TEP:
TEP should ideally be performed in the midline,

thereby decreasing the risk of bleeding from mid-
line vessels. Structures that need to be penetrated
during TEP procedure include:
Image showing types of voice prosthesis
1. Membranous posterior wall of trachea
2. Oesophagus (Consists of 3 muscles layers coat- Advantages:
ed with oesophageal mucosa)
3. Interconnecting tissue in the tracheo-oesopha- 1. The risk of separation of tracheo-oesophageal
geal space wall is minimized
2. The tracheo-oesophageal wall is stabilized by
the prosthesis to some extent
Primary TEP: 3. The flanges of the prosthesis protects trachea
from aspiration
Hamaker etal were the first to perform prima- 4. Stomal irritation is less
ry TEP in 1985. They concluded primary TEP 5. Important advantage is that patient becomes
should always be attempted whenever possible. familiar with the prosthesis immediately follow-
In this type the tracheo-oesophageal prosthesis is ing surgery.
inserted immediately during total laryngectomy 6. Post op irradiation is not a contraindication
surgery. Sufficient length of prosthesis should be
used.

Image showing advantages of TEP
Because of the excellent exposure provided during 3. Gronningen buttons

total laryngectomy this surgery is rather easy to 4. Provox prosthesis
perform. This procedure is ideally performed
before pharyngeal closure. The puncture is per- The Blom-singer and Panje devices should be
formed through the pharyngotomy defect. It is taken out by the patients themselves for cleaning
ideal to insert the Ryle’s tube through this opening and reinsertion whereas Gronningen and Provox
to facilitate early post-op naso gastric feeding. This are indwelling prosthesis and need not be removed
tube is ideally left in place for at least 3 weeks. and cleaned.
Panje voice button:

Prosthesis used in TEP:
This is a biflanged tube with a one way valve 10.
1. Blom-Singer prosthesis This enables speech in laryngectomy patients by
2. Panje buttons allowing air from trachea to pass into the oesoph-
458
Image showing disadvantages of TEP
agus. It can easily be inserted into the tracheo-oe-

sophageal fistula already surgically created for Major advantage of Panje voice button is that it
this purpose. can be easily removed, cleaned and reinserted by
the patient themselves.
Usually an introducer is provided along with
the prosthesis which makes introduction rather
simple. This is a non-indwelling prosthesis and
should be removed and cleaned once in 3 days.

Image showing patient selection criteria for performing TEP
460
Image showing contraindications for TEP
Image showing Panje speaking valve

Gronningen Button:
This TEP speaking prosthesis was introduced

by Gronningen of Netherlands in 1980. Even
though it was very useful initially, its high airflow
resistance delayed speech development in some
patients. With the introduction of low airflow
resistance Gronningen button now it is getting
popular among surgeons.
Image showing Panje introducer
Image showing Gronningen button
Blom – Singer prosthesis:

Image showing Panje voice button being inserted
This device was first designed by Eric Blom, a
speech therapist and Mark Singer a surgeon in
1978. They inserted this prosthesis into surgically
created tracheo – oesophageal fistula. This pros-
462
thesis acted as a one way valve allowing air to pass
from trachea into the oesophagus, and prevent- Blom-singer dual valve prosthesis:
ed aspiration into the trachea. This prosthesis is
shaped like a duck bill. The duck bill end of the This prosthesis has two valves which ensures
prosthesis should reach the oesophagus, while there is absolutely no risk of aspiration, while
the opposite end shaped like a holed button rests air is allowed to flow from the trachea into the
snugly against the tracheostome. This is actually oesophagus. This prosthesis is suitable in whom
an indwelling prosthesis which can be safely left primary voice prosthesis has failed due to leak
in place for at least 3-4 months without the need from oesophagus into the trachea.
for cleaning.
Image showing dual valve Blom-singer prosthesis
Image showing Blom-Singer prosthesis Provox prosthesis:
This prosthesis is available in varying lengths This is an indwelling low air flow resistance pros-
(6mm – 28mm). thesis.
The advantage of this prosthesis is the extended
Classical Blom-Singer prosthesis is indwelling life time. It can last anywhere between 1-2 years
one. Since it needs higher pressure to open up it if properly used. Insertion and maintenance of
can cause problems in some patients. Currently this prosthesis is also pretty simple and straight
low pressure Blom-singer prosthesis has been forward.
introduced. This is also made of medical grade
silicone with a one way flapper valve replacing the
duck bill. Only difference being the low pressure
Blom-singer prosthesis is non-indwelling type
and can be easily maintained by the patient.

Pt should pass oe- Patients should pass
sophageal insufflation oesophageal
test insufflation test be-
fore insertion
Secondary TEP:
This procedure is usually performed 6 weeks fol-

lowing laryngectomy. Secondary TEP allows time
for the patient to develop oesophageal speech.
Image showing Provox prosthesis Traditionally secondary TEP is usually performed
with the help of rigid oesophagoscopy for direct
The advantage of this prosthesis is the extended visualization of the proposed TEP site. This pro-
life time. It can last anywhere between 1-2 years cedure is performed under GA / LA. If planned
if properly used. Insertion and maintenance of under LA then flexible oesophagoscope is used to
this prosthesis is also pretty simple and straight identify the TEP insertion area.
forward.
Current modified procedure followed by the
Major problem with all these silicone prosthesis author:
is candida growth. They are constantly exposed to This procedure is performed under local infiltra-
candida from the oesophagus. They grow on the tion anaesthesia. Patient is placed on the opera-
inner surface of the prosthesis preventing the one tion table in a recumbent position. A small roll of
way valve from functioning. drape is placed under the shoulders of the patient
to provide mild extension at the level of neck. The
Types of tracheo-oesophageal prosthesis and their end tracheostomy tube is removed. 12 0 clock
features: position of the tracheostome is clearly visualized.
In dwelling Non Indwelling Yanker’s suction is introduced into the oral cavity
Can be left in situ for Must be removed can of the patient. It is pushed inside till it hitches
6 months cleaned every 3 /4 against the posterior wall of the tracheostome at
days 12 o clock position.
Requires specialist to Patient can do it
do the job themselves 2% xylocaine with 1 in 100,000 adrenaline is
Less maintenance Periodical mainte- injected via the tracheostome in the exact area
nance needed where the tip of Yanker’s suction hitches against.
Incision is made exactly in the area where the tip
Tracheostoma 2 cms Tracheostoma more
of Yanker’s suction hitches at the 12 0 clock posi-
than 2 cms needed
tion of tracheostome.
464
Image showing end tracheostome after removal of tracheostomy tube
This incision is widened and deepened till the

anterior wall of oesophagus is punctured. Care 4. Hypertonicity problems
should be taken not to injure posterior wall of
oesophagus. The tip of the suction in fact protects 5. Delayed speech
the posterior wall of oesophagus from injury. The
puncture site is widened using a curved artery
forceps. Minimal stomal diameter should be at
least 2 cms. Caution:
After ensuring that the TEP is fairly widened, the It is always better to perform transnasal oesoph-
Blom-singer Prosthesis is introduced and an- ageal insufflation test before TEP insertion. This
chored with silk around the neck. test will assess the response of pharyngeal con-
strictor muscle to
Problems caused due to TEP insertion: oesophageal distension in these patients.
1. Leakage through prosthesis
2. Leakage around prosthesis
3. Immediate aphonia / dysphonia

Image showing Yanker’s suction tip being inserted into the oral cavity of the
patient
Image showing incision being made using a 11 blade knife
466
Image showing the incision being widened using a curved artery forceps
Image showing TEP in situ anchored around the neck

Trans nasal oesophageal insufflation test: aged to communicate using artificial larynx.
Intraoral type of artificial larynx is preferred.
The transnasal oesophageal insufflation test is a
subjective test that is used to assess the pharyn- Intermediate phase:
geal constrictor muscle response to oesophageal
distention in the laryngectomy patient. The test During this phase the patient is discharged from
is performed using a disposable kit consisting the hospital and is requested to attend Speech
of a 50-cm long catheter and tracheostoma tape therapy sessions at least thrice a week. During
housing with a removable adapter. The catheter is this phase the patient should be informed of the
placed through the nostril until the 25-cm mark type and size of the prosthesis. Breathing exer-
is reached, which should place the catheter in the cises are taught during this phase. Patient should
cervical oesophagus adjacent to the proposed learn how to push in air from the trachea into the
TEP. The catheter and the adapter are taped into oesophagus via the TEP.
place. The patient is then asked to count from 1
to 15 and to sustain an ‘‘ah’’ for at least 8 seconds Final phase / Phase of normalcy:
without interruption.
During this phase patient is able to communicate
Multiple trials are performed to allow the patient with near normal voice. Patient learns how to
to produce a reliable sample. The responses ob- remove, clean and reinsert the prosthesis.
tained are the following:
Common problems of TEP speakers are caused
1. Fluent sustained voice production with mini- by:
mal effort
2. A breathy hypotonic voice indicating a lack of 1. Improper location of Tracheo-oesophageal
cricopharyngeal muscle tone puncture site
3. Hypertonic voice 2. In appropriate size of the puncture
4. Spastic voice due to spasm of cricopharyngeus 3. Presence of cricopharyngeal spasm
muscle 4. Leakage through and around the prosthesis
Rehabilitation following TEP: Location of TEP:
Speech language pathologist should be actively The puncture site is ideally located at 12 0 clock
involved in rehabilitation of patients following position in relation to the tracheostome. It is
insertion of TEP prosthesis. The rehabilitation placed about 1 – 1.5 cms from the tracheocutane-
process starts while the patient is still hospitalized ous junction 14. If located superior to the stomal
and is usually continued during the first week of rim patient will find it difficult to occlude the
surgery. During this period the speech and lan- stoma in order to produce speech. Similarly if the
guage pathologist should assess the tracheostome stoma is located deep inside the trachea then in-
and site of TEP. Focus should be directed to iden- sertion of the prosthesis becomes rather difficult.
tify leaks from inside or around the prosthesis.
During this initial stage patient can be encour- Size of the puncture:
468
quality voice. If leak is persistent then the shaft
This aspect is important for fluent speech. The of the prosthesis can be plugged using q tip while
size of the stoma should at least be 2 cms for pro- swallowing food.
duction of fluent speech. If the size of the stoma
is smaller than 2 cms it is prudent to enlarge it
appropriately to benefit the patient. Management of leaks through prosthesis:
Size of the prosthesis: Cause Solution

Valve in contact with Replace prosthesis of
Appropriate size prosthesis should be chosen to posterior wall of oe- different length and
avoid leak. Presence of leak from the prosthesis sophagus size
/ around the prosthesis creates lots of problems.
Prosthesis length too Remeasure TEP and
If leak occurs around the prosthesis then larger
short for the puncture refit with a prosthesis
sized prosthesis should be chosen to avoid this
“Pinching valve” of appropriate size
problem.
Valve deterioration Valve should be re-
Presence of cricopharyngeal spasm: placed
Fungal colonization Treat with Nystatin
This again impedes production of fluent speech in of the prosthesis paint / replace with
these patients. This can be identified by perform- fungal resistant pros-
ing Transnasal oesophageal insufflation test. If thesis
this test is positive then cricopharyngeal myoto- Back pressure High resistant pros-
my can be performed. thesis
Mucous / food lodg- Clean the prosthesis
Alternatively Botulinum toxin injection has ment
reduced spasm of this crucial area. On an average
30 units of Botulinum toxin 15 when injected in
to this area serves the purpose.
Leakage from / through the prosthesis:
Seen when inappropriate size of prosthesis is used

(too small than the size of the stoma). Delayed
leakage is caused due to colonization of the pros-
thesis by candida.
Management of leak:
Prosthesis can be removed and cleaned with

brush and flushed with saline. Consumption of
carbonated beverages helps in generating good

Management of leaks around the prosthesis:
Cause Solution
TEP location Remove TEP allow
it to close and then
re-puncture
Unnecessary dilata- Defer dilatation and
tion during routine perform it only if it is
placement absolutely needed
Thin tracheo-oesoph- Select customized
ageal wall 6mm / less prosthesis
Prosthesis of incor- Choose the correct
rect length and size sized prosthesis
Poor tissue integrity Choose custom pros-

due to irradiation thesis
chemotherapy
470
Submandibular salivary gland excision the posterior belly and the XII nerve runs imme-
diately deep to the digastric tendon.
Indication:
Mylohyoid muscle:
1. Sialolithiasis
2. Chronic sialadenitis This is a flat muscle attached to the mylohyoid
3. Benign tumors involving submandibular sali- line on the inner aspect of the mandible, the body
vary gland of the hyoid bone, and by a midline raphe to the
4. Malignant tumors involving submandibular opposite muscle. It is a key structure when excis-
salivary gland ing the submandibular gland, as it forms the floor
of the mouth, and separates the cervical form of
Surgical anatomy: the oral part of the submandibular gland. One
important aspect for the surgeon to remember is
The submandibular gland has two components: that there are no important neurovascular struc-
1. Oral - Above the mylohyoid muscle tures superficial to the mylohyoid muscle. The
2. Cervical - Below the mylohyoid muscle. Con- lingual nerve and the XII nerve are deep to the
nected to the oral component by a tail that passes muscle.
around the posterior border of mylohyoid muscle.
The mylohyoid muscle which forms the dia- Marginal mandibular nerve:
phragm of the mouth separates the oral compo-
nent from the cervical component. This branch of the facial nerve which supplies the
depressor anguli oris runs within the investing
Major portion of the submandibular gland is situ- layers of deep cervical fascia overlying the gland
ated mainly in the submandibular triangle (Level and may loop up to 3 cms below the ramus of the
1b) of the neck. The oral component extends mandible.
some distance along the submandibular duct im-
mediately deep to the mucosa of the floor of the It is composed of 4 parallel running branches.
mouth. The duct opens close to the midline in the It crosses over the facial artery and vein before
anterior floor of the mouth. ascending to innervate the depressor anguli oris
(the muscle of lower lip). In order to protect this
The cervical portion of the gland is immediately nerve, one should incise skin and platysma at
deep to the platysma, and is encapsulated by the least 3 cms below the mandible and incise the
investing layer of deep cervical fascia. facial covering of the submandibular gland just
above the hyoid bone and do a subcapsular resec-
Digastric muscle: tion of the gland.
This muscle forms the anteroinferior and pos- Lingual nerve:

teroinferior boundaries of the submandibular
triangle. It is an important landmark as there are This is a large flat nerve and it runs in the later-
no important structures lateral to the muscle. The al floor of the mouth above the submandibular
facial artery emerges from immediately medial to gland. Its ends secretomotor fibers to the sub-

mandibular ganglion which innervate the gland. surgeon elects to preserve the artery.
It comes into view during submandibular gland
excision when the gland is retracted inferiorly Mylohyoid artery and vein are encountered by the
and the mylohyoid is retracted anteriorly. surgeon when the submandibular gland is elevat-
ed from the lateral surface of the mylohyoid.
Hypoglossal nerve:
Investigations:
This nerve enters the submandibular triangle
posteroinferiorly and medial to the hyoid bone, Ultrasound salivary gland is an important diag-
crosses the submandibular triangle in an an- nostic tool in submandibular lesions. It is very
terosuperior direction and exits into the mouth useful especially in submandibular gland superfi-
behind the mylohyoid muscle. It traverses the cial lesions.
medial wall of the submandibular triangle, where
it is applied to the hyoglossus muscle. This nerve CT & MRI should be used to investigation tumor
is covered by the thin layer of fascia, which is spread, local invasion, and perineural invasion
distinct from the submandibular capsule and is in cases of malignancy of submandibular gland.
accompanied by thin walled ranine veins that are Other pre op investigations include those man-
easily torn at surgery dated for anesthesia fitness.
Nerve to mylohyoid:
Anesthesia:
This is a branch of the third division of the tri-
geminal nerve and it innervates the mylohyoid General anesthesia with orotracheal intubation
and anterior belly of diagastric. It is generally with tube secured to contralateral corner of
not looked for or preserved at surgery. But when mouth.
diathermy is used to mobilize the gland off the
mylohyoid muscle, contractions of the mylohyoid Position:
and anterior belly of digastric is usually noted due
to stimulation of this nerve. Patient is supine with head end of the table ele-
vated to reduce bleeding with face turned to the
Facial artery: opposite side.
This is identified during excision of submandib- Incision:

ular salivary gland. It enters the submandibular
triangle posteroinferiorly from behind the poste- The skin incision is made at the hyoid level or 3
rior belly of digastric and hyoid. It courses across cm below the inferior border of mandible. Flap is
the posteromedial surface of the submandibular elevated in the subplatysmal plane up to the level
gland, and reappears at the superior aspect of the of inferior border of mandible.
gland where it joins the facial vein to cross the
mandible. A few anterior branches enter the sub-
mandibular gland and have to be divided if the
472
Image showing anatomy of submandibular salivary gland
Protection of marginal mandibular nerve: Maneuver).
If dissection is proceeded in the subplatysmal Identification of lingual nerve and hypoglossal

plane then there is less chance of this nerve being nerve:
damaged. Identification of facial vein is the key
to identify this nerve. The facial vein is identified The submandibular gland is freed from the
at the notch of the mandible and at the superior anterior belly of digastric and the lateral surface
border of the submandibular gland. The marginal of mylohyoid muscle. The mylohyiod vessels are
mandibular nerve can then be exposed above the divided.
facial vein through dissection of the superficial
cervico-fascial layers. If needed the facial vein The free edge of the mylohyoid muscle is iden-
can be divided and slung superiorly to protect tified and retracted superiorly and laterally to
the marginal mandibular nerve (Hayes Martin expose the lingual nerve, hypoglossal nerve and

Image showing facial vein in the neck exposed
Image showing incision for submandibular sali-

vary gland excision
Image showing lower pole of submandibular

gland exposed
Image showing flap being raised
474
wharton’s duct.
After ligation of the facial artery and vein superi-
orly, the submandibular gland is retracted inferi-
orly to identify the submandibular ganglion that
is then divided to free the lingual nerve, it should
be ensured that the nerve should not be included
in the tie.
Identification and division of the facial artery:
The Wharton’s duct is divided after identification

of hypoglossal nerve. If the surgery is performed
for sialolithiasis, the surgeon should follow and
divide the duct anteriorly close t the floor of the
mouth in order not to leave behind the calculus.
Image showing lingual nerve (pointed with the
The submandibular gland is then reflected inferi- tip of curved artery forceps)
orly and the facial artery is identified, ligated and
divided as it exits from behind the posterior belly
of digastric muscle.
The submandibular gland is then removed by se-

curing its pedicle with a set of clamps. The pedicle
can be tied with silk. Suction drain is placed in
the submandibular gland bed and the wound is
closed in layers.
Image showing Wharton’s duct
Image showing facial vein exposed

Complications:
1. Injury to marginal mandibular nerve

2. Injury to lingual nerve
3. Bleeding
476
bilities in one device.
Kashima surgery for bilateral abductor paraly-
sis of vocal cords using coblation Incision is made 1 mm in front of the vocal
process of arytenoid and a 3.5-4 mm C-shaped
Introduction: portion of the posterior 1/3 of the vocal cord is
ablated from the free border of the membranous
Bilateral Vocal Fold Paralysis is a surgical emer- cord, extending 4 mm laterally over the ventric-
gency which has to be promptly addressed and ular band. This created about 6-7 mm transverse
airway secured, voice preservation taking a back- opening at the posterior glottis. Vocal process
seat. is ideally not exposed. Anterior 2/3 of the vocal
fold is left undisturbed and hence phonation and
In this context two terms need to be explained sphincteric function of larynx is maintained.
-BVFI & BVFP. Bilateral Vocal Fold Immobil-
ity (BVFI) is a broad term which encompasses
all forms of reduced or absent movement of the
vocal folds; whereas Bilateral Vocal Fold Paralysis
refers to the Neurological causes of BVFI and spe-
cifically refers to the reduced or absent function
of the Vagus nerve or its distal branch, the Recur-
rent Laryngeal Nerve.
These patients will always have tracheostomy per-

formed because they manifest with stridor. Basic
aim of this procedure is to secure adequate airway
space enabling the surgeon to decannulate the
patient at the earliest. This procedure also goes
by another name “Posterior cordotomy”.
Surgical Procedure:
This surgery is performed under general anes-

thesia. It is administered via tracheostomy. A Image showing bilateral abductor paralysis
Kleinsasser suspension laryngoscope is inserted
and the larynx is inspected under endoscopic
visualization. Larynx is inspected, mobility of
the cricoarytenoid joint is checked with a probe.
Original procedure was performed by kashima
and Dennis using carbondioxide laser. Author
uses coblator for this procedure. The wand used
is PROcisee MLW plasma wand which provides
ablation, coagulation, irrigation and suction capa-

Image showing bilateral abductor paralysis of
vocal folds Image showing the end result of Kashima’s pro-
cedure
Bilateral abductor paralysis:
Bilateral abductor paralysis is a surgical emergen-

cy. The most common cause of BVFP is iatro-
genic, and of the surgeries Thyroid surgery is the
most common culprit. It is often diagnosed a few
days postoperatively. When detected on table,
extubation should be deferred and airway secured
by a Tracheostomy.
Causes of Bilateral vocal fold paralysis:
Causes of bilateral vocal fold paralysis can be

divided into:
Image showing laryngeal wand used to perform Mechanical Neurologic

posterior cordotomy Inflammatory Radiation injury
Malignancy Metabolic
478
Surgery Toxins
Gout
Mechanical causes:
Ankylosing spondylitis
Acute complications of intubation include aryte-
noid dislocation, anterior dislocation of thyroid Reiter syndrome
cartilage relative to cricoid causing recurrent
laryngeal nerve injury. SLE
Hyperextension of neck causing stretching of Chrons disease

vagus nerve.
Neurological causes:
Excessive cuff pressure causing recurrent larynge-
al nerve injury. Arnold chiari malformation
Chronic complications of intubation: DM
Posterior glottic stenosis caused by prolonged Meningomyelocele

traumatic intubation.
ALS
Stent placement in proximal esophagus
Myasthenia gravis
Surgical causes:
Hydrocephalus
Thyroid surgery
Radiation causes:
Parathyroid surgery
Radiation therapy
Esophageal surgery
Post radiation fibrosis
Tracheal surgery
Chondronecrosis
Brain stem surgery
Anterior approach to cervical disk

Clinical features:
Inflammatory causes:
The chief complaints of a patient with BVFP are
Mumps related to airway, voice and swallowing. Onset of
symptoms may be Acute, Sub acute or Chronic
Rheumatoid arthritis depending on etiology.

A patient usually presents with airway difficulty post op.
in the form of stridor. Initially when the vocal
cords are far apart voice will be breathy in nature.
Over time, vocal cords may get medialised, and
then the patient will have a near normal voice and
cough, despite stridor. Aspiration and dysphagia
may or may not be a part of the symptom com-
plex.
Evaluation:
A thorough history and Head & Neck and laryn-

geal examination should be done. An X-ray Chest
and CT Neck (Skull base to Thoracic inlet on the Image showing incision for Kashima’s procedure
right, and up to Aortic arch,on the left) are to be
taken.
Video laryngoscopic Examination will show vocal

cords in the paramedian position. An EMG
should be taken 30-40 days (baseline) after injury
and then 1 month later.
Normal action potential – normal nerve

Absent potentials – non functioning nerve
Defibrillating potentials – worsening nerve
Polyphasic potentials –regenerating nerve.
Now, which cord to operate? We should choose

the more medially placed cord for the procedure.
If both cords are in identical positions, go for the
cord that shows at least a trace of mobility. If both Image showing tip of laryngeal wand
cords have equal mobility and are in identical
positions, the surgeon should choose the side to Complications of posterior cordectomy:
which he has a better access.
Postoperative edema
Post operatively, apart from antibiotics, patients Granuloma formation
should be given anti-reflux treatment for up to Scar formation
8 weeks. They can be decanulated around 6-8 Posterior glottic web
weeks. But in our center, thanks to Coblation we
were able to spigot the patients on the first post-
operative day and decannulate them 72 hours
480
Vocal fold surgery
Vocal fold surgery is indicated in the following

scenario:
1. Vocal nodule
2. Vocal cord cyst
3. Vocal cord polyp
4. To biopsy a suspicious lesion from vocal fold
Anesthesia:
In this surgery the anesthetist and the surgeon

will have to share the airway. This surgery is
performed under general anesthesia. Micro laryn-
geal endotracheal tube is used for the purpose of
intubation. This tube has a cuff that will inflate in
to a round shape when inflated.
This ensures that the surgeon has an unimpeded
vision of both the vocal cords. If this endotracheal
tube is not available, then a small sized tube is
used.
Image showing suspension laryngoscope
Position:
The patient is placed in supine position. Neck is

extended by placing a small sandbag behind the
shoulder blade of the patient. The head is slight-
ly flexed by the surgeon before insertion of the
suspension laryngoscope. The suspension laryn-
goscope is inserted through the oral cavity.
It should be placed in the middle of the oral cav-

ity to get a symmetrical view of vocal folds. The
tip of the laryngoscope is placed just below the
epiglottis so that the anterior commissure of the
vocal folds is visible clearly to the surgeon. The
laryngoscope is fixed to the chest of the patient
using a chest piece.
Image showing vocal cord cyst

The surgeon is seated at the head end of the pa-
tient. If the surgeon prefers to use microscope to
visualize vocal folds then the objective lens of 400
is chosen. Currently laryngoscopes are available
which has rigid endoscope ports through which
12-degree rigid endoscope can be inserted. A
camera can be attached to the endoscope to make
the images visible in the monitor. The surgeon
can perform the surgery by seeing the monitor.
Image showing microlaryngeal scissors being

used to excise a vocal cord granuloma
Image showing bucket forceps being used to

grasp vocal fold polyp
A micro laryngeal bucket forceps can be used to

hold the cyst / polyp arising from the vocal cord.
A micro laryngeal scissors can be used to remove
the polyp / cyst.
Image of vocal cord after removing the polyp
482
Micro flap technique:
This is ideally used to remove cysts involving the

vocal folds. In this procedure, an incision is made
along the superior surface of the lesion near the
interface of the normal and abnormal tissues.
Dissection is performed in separate planes to
isolate the lesion. The diseased tissue is removed,
the spared epithelium is trimmed and laid back
over the defect to optimally oppose the epithelial
layers. This limits scar tissue formation.

cancer resection of involved portion of larynx)
Laryngeal framework surgeries may benefit from laryngeal framework surgery.
Isshiki’s classification of thyroplasty:

The first description of surgery involving the la-
ryngeal framework dates back to 1915 when Payr Isshiki described four different types of thyroplas-
described it. It was Isshiki who popularized the ty which included:
procedure in 1970.
Type I thyroplasty - Medialization of vocal folds
Surgical modification of the cartilage framework commonly performed in patients with unilateral
of larynx so that vocal folds can approximate bet- vocal cord paralysis.
ter / have more tension / allowing better vibration
of vocal folds for voice production. Type II thyroplasty - Lateralization of the vocal
folds
Structures included in the laryngeal framework:
Type III thyroplasty - Shortening of vocal folds
Thyroid cartilage done in order to lower the pitch of the vocal fold
vibration.
Right & left arytenoids
Type IV thyroplasty - Lengthening of vocal folds.
Cricothyroid cartilage This surgery is performed to raise the pitch of
vocal fold vibration.
Classification of laryngeal framework procedures:
Type I thyroplasty (Medialization thyroplasty):
1. Medialization thyroplasty / laryngoplasty
This is the most commonly used procedure to
2. Arytenoid repositioning (arytenoid adduction correct unilateral vocal fold paralysis. In this
or adduction arytenoidpoexy) type of thyroplasty a rectangular portion of the
thyroid cartilage is mobilized and pushed towards
3. Cricothyroid repositioning (approximation / the medial side using a piece of silastic block of
subluxation) proper shape. This entire procedure is performed
under local anesthesia. Formerly when this pro-
Main advantage: cedure was performed the piece of thyroid carti-
lage was kept along with the implant and sutured.
Laryngeal framework surgery is typical done with Currently the piece of thyroid cartilage is cut and
the patient awake and sedated. This enables the removed to avoid complications.
surgeon to make intraoperative adjustments to
achieve optimal vocal fold function and voice.
Patients suffering from voice disorders due to vo-

cal cord paralysis, tissue loss (as it happens after
484
Advantages of Gor-Tex:
Gor-Tex is expanded polytetrafluroethylene has

obvious advantages as an implant material in
Medialization thyroplasty procedures.
1. It is malleable
2. Its position can easily be adjusted within the

thyroid cartilage window
3. Only a small fenestration is necessary in the

lamina of thyroid cartilage to introduce this mate-
Image showing type I thyroplasty rial
Instead of silastic block other material can be 4. This procedure is reversible and has very few
used to medialize the vocal cord. These material complications
include:
5. Creates less oedema when compared to that of
1. Fat silastic and hence over correction is not possible
2. Silicon block 6. Resultant quality of voice is really good
3. Gortex History: Hoffman and McCullouch reported the

first case of medialization thyroplasty using Gor-
Medialization thyroplasty using Gortex: Tex in May 1996
Introduction: Indications of Gor-Tex Medialization thyroplasty:
Vocal cord paralysis is a rather common prob-

lem causing speech problems to the patient. If 1. Unilateral vocal fold immobility due to pa-
the other cord doesn’t compensate adequately ralysis, paresis, atrophy 2. Unilateral vocal fold
these patients may have troublesome aspiration scarring / soft tissue loss 3. In select cases of Par-
also. Aspiration happens to be the most dreaded kinson’s disease with vocal fold atrophy
complication of vocal fold paralysis. Management
of these patients is possible only by performing
Medialization thyroplasty (Ishiki type I thyro- Contraindications of Gor-Tex thyroplasty:
plasty). Various graft materials have been used in
this procedure. Presently lot of interest has been 1. Previous history of irradiation
generated in Gor-Tex medialization thyroplasty.

2. Malignant lesions involving larynx thyroid cartilage. A septal elevator is introduced
through the inferior margin of thyroid lamina
3. Poor abduction of contralateral vocal fold as and the paraglottic space is compressed medially
this would cause impairment of airway while the voice of the patient is assessed. If the
result is acceptable then 1 cm wide Gor-Tex strips
Procedure: This procedure is ideally performed dipped in bacitracin solution is introduced via the
under local infiltration anesthesia using 2% xylo- inferior margin of thyroid lamina and delivered
caine mixed with 1 in 100,000 units’ adrenaline. via the window. The amount of Gor-Tex insertion
is dependent on the improvement of quality of
Incision: Horizontal skin crease incision begin- voice.
ning at the mid portion of the thyroid cartilage
extending to the paralyzed side. The strap muscles If necessary use prolene sutures passing via the
are separated away from midline and held apart inferior strut of thyroid lamina to stabilize Gor-
from the operating field using umbilical tape. Tex. Wound is closed in layers after keeping a
penrose drain.
A tracheal hook is used at the level of laryngeal
prominence and pulled medially. This helps in
mobilizing the cartilage better. The thyroid carti- It is very important to perform pre operative and
lage perichondrium is incised in the midline and post operative video laryngeal examination.
extended laterally towards the paralyzed side. The
thyroid lamina on the paralyzed side is skeleton-
ized up to the level of cricothyroid membrane.
Strips of cricothyroid muscle that come in the
way are excised.
Dimensions of cartilage cuts:
Appropriate size of cartilage window is about

5mm x 10mm. The lower border of the window
should be about 3mm above cricothyroid mem-
brane. This ensures that the lower strut of thyroid
lamina doesn’t fracture when window is being
created. Anterior border of the window is about
8mm posterior to midline. If thyroid cartilage is
calcified then fissure burr can be used to create Image showing strap muscle over thyroid ala
the window. The inner perichondrium is ele- exposed
vated from the under surface of thyroid lamina
using scissors. The inner perichondrium incised
posteriorly and inferiorly. It is not incised anteri-
orly. Now the cricothyroid membrane is incised
in order to separate it from the lower border of
486
Image showing ala of thyroid cartilage exposed
after retracting the overlying strap muscles Image showing Gortex being introduced through
the cartilage window
Image showing cartilage window created Image showing cartilage window closed using
interrupted absorbable sutures

Injectable medialization thyroplasty: ryngeal paralysis has found to improve the static
location of the vocal fold.
Introduction:
6. Possible induction of fibrosis could cause last-
There are many injectables used in the manage- ing fullness of the vocal fold that would persist
ment of glottic incompetence following vocal fold even after resorption of the injected material.
paralysis. At the moment no single material is Treatment with temporary agents could provide
considered ideal for this purpose and hence com- effect that could last for long durations because of
promises become a necessity by matching the best this effect.
material to suit the patient’s needs.
Short term injectables include:
Materials used in injectable laryngoplasty are
classified as long term and short term injectables Carboxymethylcellulose and gelfoam. This ma-
depending on the duration of the effect. terial is found to be useful in patients who would
like to test drive the procedure before proceeding
Duration of benefit depends on: with a material with long term effects. This mate-
rial is also very useful to manage sulcus vocalis if
1. The type of material used. injected in to Reinke’s space.
2. Location of the material injected. Placement in Intermediate term injectables:

the Reinke’s space provides longer effect than in
the better vascularized and more mobile TA/LCA These include hyaluronic acid derivatives and col-
muscles. Material injected into these muscles lagen derivatives. These materials are considered
would be repositioned rapidly. to be more forgiving and requires less accuracy
in delivery to specific sites of larynx than long
3. Altered nature of the recipient bed as in the term injectables. This material is suited when the
case of reduced blood supply to vocal folds procedure is carried out in a clinic setting rather
following irradiation or reduced inflammatory than an operation theatre.
response if the patient is on immunosuppresants
would experience longer duration of effect. Hyaluronic acid derivatives include:
4. Degree of reinnervation of larynx. Some Hylaform

degree of reinnervation is common and could
provide an improved bulk and tone to the existing Juvederm
cord.
Restylane
5. The location of the vocal fold during recovery
(re-innervation with synkinesis rather than full Long term injectables:
movement) has the potential to favorably affect
the location of vocal process. Early injection Include calcium hydroxyapatite
shortly after identification of symptomatic la-
488
Autologous fat
Carboxymethylcellulose and glycerin water based
Autologous fascia gel:
Permanent injectables: Duration of effect 1-2 months following which

rapid re absorption occurs. This material is
Teflon injected lateral to the vocal ligament using 25-27
gauge needle. This material provides superior
Silicone vibratory mucosal outcomes compared to that of
gelfoam. This material has no reported allergic
Increased stiffness to a medialized paralyzed complications.
vocal cord is considered by many to be desirable.
A greater pitch range is anticipated to result from Prolaryn plus:
a normal vocal fold striking the properly posi-
tioned and stiffened paralyzed vocal cord. Simi- This injectable contains microspheres of calci-
larly a narrow pitch range is anticipated to result um hydroxyapetitie in Prolaryn gel. Duration of
from the limited frequencies entraining a normal action is expected to last a couple of years. This
cord with a well medialized and floppy paralyzed material is injected lateral to vocal ligament using
vocal fold. 25-27 gauge needle. About 10% extra material is
injected to compensate for gel absorption. This
Normal vocal fold mucosa has a very low viscos- material provides superior vibratory mucosal
ity at phonatory frequencies of vibration. Sub- waves compared to gelfoam, but could be worse
stances similar to normal mucosa are less likely to when compared with that of hyaluronate based
impair mucosal wave and hence are more likely injectables. It has a very low allergic potential.
to be used for superficial injection. The higher
the viscosity of the injected substance the more Cymetra:
likely it is to impair the mucosal wave. The more
viscous a substance, the more lateral it should This contains micronized alloderm. This is a
be injected. Low viscosity superficial injectables micronized allograft of cadaveric human dermis
include: carboxymethylcellulose, hyaluronic acid which is aseptically processed to remove cells but
hydrogels and autologous fat. preserve the dermal extracellular matrix. It could
contain traces of antibiotics. Reported duration
Intermediate viscosity injectables usually injected of action being 2- 12 months. This material is
into deep layer of lamina propria include collagen injected in the deep layer of lamina propria using
derivatives, autologous fascia and calcium hy- 18-22 gauge needle.
droxyapatite.
Bovine derived collagen:
High viscosity injectables which are injected into
the thyroarytenoid muscle include teflon, silicone This comprises of bovine dermal collagen sus-
etc. pension. It is more viscous and has a slower rate
of absorption. Reported duration of action being

4-8 months. It is usually injected into deep layer Poor cough
of lamina propria using 22-26 gauge needle.
Contraindications:
Cosmoplast:
1. Inability to perform direct laryngoscopy
This is prepared form human fibroblasts in a syn-
thetic extracellular matrix. Its reported duration Unstable cervical spine
of action is about 4-6 months. It is injected to
deep layer of lamina propria using 22-26 gauge Unable to obtain exposure of larynx (retrognath-
needle. ia)
General contraindications for injection laryngo- 2. Other approaches that could be considered:
plasty:
Percutaneous injection through cricothyroid
1. Acute laryngeal inflammation membrane.
2. Inadequately controlled malignancy Transoral injection using videolaryngoscopic

exposure.
3. Rapidly progressing disease of upper aerodiges-
tive tract Transcutaneous injection laryngoplasty:
4. Bilateral laryngeal paralysis This is an office based procedure that allows

immediate reduction of symptoms. This proce-
dure can be performed under local anesthesia.
Indications for injection laryngoplasty: Two persons are needed to perform this proce-
dure. An assistant passes the nasopharyngoscope
Symptomatic glottic insufficiency: through the patient’s nasal passage and suspends
it above the larynx so that the surgeon can have a
1. Laryngeal paralysis / paresis in patients whose full view of the larynx. The surgeon then passes a
recovery of mobility is uncertain. needle connected to a syringe (Brunning’s sy-
ringe) filled with augmentation material trans-cu-
2. Glottic insufficiency with mobile vocal folds taneously into the vocal fold.
(presbylaringis).
Positioning:
Symptoms: Patient is seated upright in a chair during this

procedure and is instructed to lean forwards
Dysphonia slightly with the chin up.
Dysphagia
490
Technique:
After the skin becomes numb the nasopharyn-
Transcutaneous injection laryngoplasty aims to goscope is passed transnasally. Nasal mucosa
medialize a patient’s vocal cord. The needle of should be anesthetized using 4% xylocaine
attached to the syringe is placed through the thy- soaked cotton pledgets inserted into the nasal
rohyoid membrane, thyroid cartilage or through cavity prior to insertion of nasopharyngoscope.
the cricothyroid membrane. The surgeon passes the needle with the attached
syringe through the skin via any of the three ap-
Before actually begining the injection process the proaches which include:
following structures should be outlined in the
neck: Transthyroyoid membrane approach - The thy-
rohyoid membrane lies between the hyoid bone
Hyoid bone superiorly and the thyroid cartilage inferiorly. In
this approach, the injectable needle is passed in
Thyroid cartilage an inferior direction through the midline thyro-
hyoid membrane and directed laterally into the
Cricoid cartilage vocal fold.
All these structures are marked over the skin us- The skin superior to and overlying the thyroid
ing skin marker. Skin area has to be anesthetized notch is anesthetized with 1% xylocaine. A
as per the approach using xylocaine 2% with 1 in syringe filled with augmentation material with
100,000 units adrenaline. a 25 gauge needle is passed superior to the thy-
roid notch through the skin, subcutaneous tissue
and pre-epiglottic space, superior to the vocal
folds into the airway. Once the needle enters the
airway, it can be visualized with the nasopharyn-
goscope and directed laterally into the vocal fold.
The augmentation material is placed within the
paraglottic space under direct visualization.
Transthyroid cartilage approach - This approach

is best used in younger patients before the thyroid
cartilage has ossified. In this approach, the vocal
fold is approached laterally and the needle is
passed through the skin and thyroid cartilage and
then into the vocal fold.
The thyroid prominence and lower thyroid car-

tilage border are marked in the midline with a
Image showing surface marking in the neck skin marking pen. The level of the vocal fold is
midway between these two points and travels in a

plane perpendicular to this line. The skin over-
lying this area is anesthetized with 2% xylocaine
injection. A 25 gauge needle attached to a sy-
ringe filled with augmentation material is passed
through the lateral thyroid cartilage into the vocal
fold. The position of the needle is visualized on
the monitor via the nasopharyngoscope. Aug-
mentation material is placed within the paraglot-
tic space under direct visualization.
Transcricothyroid membrane approach - This

approach allows for entry into the airway in the
subglottic region in which the needle is passed
into the vocal fold from below. The cricothyroid
membrane is located inferior to the vocal folds
between the thyroid and cricoid cartilages. The
position of the thyroid and cricoid cartilages are
marked on the skin with a skin marking pen. The
skin overlying the midline cricothyroid mem-
brane is injected with 2% xylocaine. A fibreoptic
laryngoscope is passed through the nose and Image showing injection laryngoplasty
positioned just above the epiglottis by the assis-
tant. A syringe with a 27 gauge needle is passed Hints:
in the midline neck through the cricothyroid
membrane. The needle is visualized passing into 1. Always visualize the needle in the correct posi-
the airway. The needle is passed underneath the tion before injecting. Blind injection should not
true vocal fold and inserted into the paraglottic be performed.
space. Augmentation material is placed within
the paraglottic space under direct vision. 2. Patient should not eat or drink for at least 1
hour after the procedure to allow the effect of
The injectable needle is directed towards the pos- anesthesia to subside.
terior vocal fold. For a patient with an immobile
or hypomobile vocal fold the injection is directed 3. Some augmentation products like Cymetra
lateral to the vocal process. The goal of the in- require reconstitution with saline prior to injec-
jection is to rotate the arytenoid medially and to tion. The process of reconstitution should be
medialize the true vocal fold. If needed a second performed before the patient is anesthetized.
injection is placed more anterior to the mid-por-
tion of the vocal fold. 4. As the vocal fold is injected, it should be seen
to bulk up rather immediately. If this does not
occur then the needle needs to be repositioned
as extrusion through the cricothyroid space has
492
been noted in cadaver experiments that too in on the screen of the monitor.
female larynges.
A special injection needle (Merz Aesthetics) is
5. Approximately 0.6-0.8 ml of the material is used. The needle is a long curved one and is at-
needed to medialize a male vocal cord and 0.4 ml tached to the syringe. The length of the needle is
is needed for a female vocal cord. Slight over cor- such that it can be introduced via the oral cavity
rection should be performed to account for some to reach the superior surface of the vocal folds.
resorption of material.
6. Distance from the anterior neck skin to the

vocal fold is 15.8 mm in males and 13.9 mm in
females in the transcricoid membrane approach.
7. A slight bend in the needle 2 cm away from

the tip when created could assist in directing the
needle to the vocal fold more easily in the tran-
scricothyroid membrane approach.
Complications:
1. Some patients have allergic reactions to inject-

ed compounds.
Image showing the special needle used to inject
2. Patients can develop stridor following the vocal folds transorally
injection. The surgeon should be careful not to
over-inject the vocal fold too much. The needle attached to the syringe is passed via
the oral cavity and the augmentation material is
3. Augmentation material can be misplaced in injected under direct vision in the lateral border
the vocal folds and extrude after injection to the of the vocal fold making it swell.
incorrect compartments. This can be managed by
observation or removal under vision.
4. FB reactions can occur
Transoral injection thyroplasty:
In this procedure which is performed under local

anesthesia the nose and throat are anesthetized
using 4% xylocaine spray. Nasopharyngoscope is
inserted via the nasal cavity and stabilized by the Image showing transoral injection being per-
assistant in such a way the entire larynx is visible formed

voice can be produced easily without any strangu-
Montgomery thyroplasty implant system: lation sensation experienced by the patient. Too
wide a separation would make the voice sound
This system has evolved after years of research breathy and weak.
and the main advantage of this system is that it
eliminates the process of customizing the implant Type III thyroplasty:
at the time of surgery. The system consists of
different sizes and shapes of shims made of silas- This procedure involves shortening of the vocal
tic. It has the most proven success rate and the folds thereby lowering the pitch of the voice gen-
duration of the procedure is also ideal. Another erated.
advantage is that it does not require suturing.
This surgery is used to treat female-to-male gen-
der identity disorder after completing hormone
therapy. Hormone therapy results in the voice
Type II thyroplasty of patients becoming low pitched. This surgical
technique is used to reduce the anteroposterior
This is also known as lateralization thyroplasty. diameter of the thyroid cartilage causing the vocal
This surgery is used in conditions like adductor folds to shorten and relax. With the decrease in
spasmodic dysphonia. Generally, lateralization tension of the vocal fold the voice becomes lower
thyroplasty is intended to prevent tight closure of pitched. This procedure is effective for diseases
glottis. like vocal fold atrophy, sulcus vocalis, mutation
voice disorder etc.
This surgery can be performed under local anes-
thesia. An incision is made at the midline of the Procedure:
thyroid cartilage. A silicon wedge is used to fix
the incised thyroid cartilage in the newly abduct- This surgery is performed under local anesthesia
ed position. to allow the voice to be monitored. A horizontal
skin incision is made in the neck. A vertical inci-
Optimal thyroid cartilage separation: sion is made to separate and retract strap muscles
laterally and expose the thyroid ala on one side.
This is a crucial decision a surgeon needs to take. An incision of about 7 mm long is then made
The width of separation of the incised cartilage with a 11 blade on the lateral side of the thyroid
edges is based on the patient’s ease of phonation cartilage. After splitting the thyroid cartilage on
and voice quality checked intraoperatively. On one side, the cartilage edges are overlapped mak-
the operating table the edges of the incised car- ing the voice low pitched. Fixation is important.
tilage edges are gradually separated with the use
of curved tip hemostatic forceps taking care not
to injure the perichondrium with the tip of the
instrument. The patient is asked to produce vocal
sounds such as vowels or phrases, the separation
width is adjusted to the optimal point where the
494
Image showing strip usually about 3 mm wide
removed and the edges sutured after overlap.
Nonabsorbent sutures need to be used.
Type 4 thyroplasty:
This procedure involves lengthening of vocal

folds thereby raising the pitch of the voice.
Indications:
This procedure is done in people with bow

shaped vocal folds.
Androphonia
Gender dysphonia

Relaxation thyroplasty (Management of Puber- viously patient was put on nil per oral for 6 hours.
phonia) Just have a look at the atlas of our procedure and
then we will the see the procedure in detail in
The persistence of adolescent voice even after pu- discussion part.
berty in the absence of organic cause is known as
puberphonia. The condition is commonly seen in
males. Normally adolescent males undergo voice
changes due to sudden increase in length of vocal
cords due to enlargement of thyroid prominence
(Adam’s apple). This is uncommon in females
because their vocal cords do not show sudden
increase in length. This sudden increase in length
of vocal cords is due to sudden increase in testos-
terone levels found in pubescent males. Children
reach puberty around 12 years of age when their
hormone levels begin to become elevated. In
males, this is also the age when their larynx has
a rapid increase in size. The vocal cords become
longer and begin to vibrate at a lower pitch (or
frequency). This explains why most males go Image a horizontal incision was made at the
through the period of voice breaks. The vocal lower border of the thyroid cartilage
cords are trying to adjust to their new dimen-
sions. No such laryngeal changes take place in
females who continue using a high pitched voice.
According to Banerjee the incidence of puber-

phonia in India is about 1 in 9,00,000 population.
Even though the incidence is low, for a individual
it causes social and psychological embarrassment.
In infants laryngotracheal complex lies at a higher
level. It gradually descends. During puberty in
males the descent is rapid, the larynx becoming
larger and unstable and on top of it the brain is
more accustomed to infant voice. The boy may
hence continue using high pitched voice even af- Image showing strap muscles retracted and thy-
ter puberty or it may break into higher and lower roid cartilage exposed
pitches.
Procedure:
Procedure was done under local anaesthesia. Pre-
496
Image showing thyroid cartilage skeletonized
Image showing thyroid perichondrium being

elevated
Image showing thyroid perichondrium being

incised Image showing 2 – 3 mm strips of cartilage
incised either side of the midline of the thyroid
cartilage with fissure burr and knife.

Image showing the ends of thyroid cartilage
Image showing vertical incisions in either side of approximated with sutures after pushing the
midline in the thyroid cartilage middle segment
Image showing mid portion of thyroid cartilage

pushed inside
498
Equipment used in otolaryngology surgery
Diathermy ducing pain, spasm or burn. In 1891 d’Arsonval

published rather similar findings but also noted
Introduction: that the current directly influenced body tem-
perature, oxygen absorption and carbondioxide
The word diathermy means “heating through” elimination, increasing each as the current passes
refers to the production of heat by passing a high through the body.
frequency current through tissue. This term
was coined in 1908 by the German physician Bovie basing his electrosurgical unit on the work
Karl Franz Nagelschemidt. In the medieval ages and discoveries of his predecessors constructed
hemostasis was sometimes achieved by red hot a diathermy unit that produced high-frequency
stones or irons applied to the bleeding surface ( current delivered by a cutting loop which can
a heroic and rather risky procedure). Within the be used for cutting, coagulation and dessication.
surgeon’s armamentarium electrosurgical devic- This instrument was first used by Cushing to
es stand out as one of the most used equipment. remove vascular tumors.
Credit for the design of this equipment should
go to Bovie who is considered to be the father of Electro-surgery requires the presence of a circuit
electrosurgical devices. for current to flow. In the absence of a complete
circuit the current will seek ground. Electro-
Glodwyn described three eras in the development surgical generators prior to 1970 were “ground
of modern electrosurgical devices: referenced” (the flow of energy was in relation
to earth ground). In this situation anytime the
Era I - This era began with the discovery and use patient came in contact with a potential path
of static electricity. The time frame of this era is to ground, the current would choose a path of
rather unclear. least resistance. This could result in current flow
through an electrocardiogram pad or through
Era II - This era is aptly termed as “era of galva- an intravenous pole in contact with the patient.
nization” in memory of Luigi Galvani’s accidental If the current density were high enough at the
discovery in 1786. He described muscle spasms point of contact, there is always the possibility for
in frog’s legs hanging from copper hooks as they a patient to suffer from burn. This hazard was
brushed the iron balustrade in his home. This eliminated with the introduction of generators
discovery along with subsequent experiments led that were isolated from the ground, confining the
to the birth of electrophysiology. current flow to the circuit between the electrode
and the patient return electrode, which offers a
Era III - This era dates back to 1831. This era was low resistance pathway for current to return to
triggered by discoveries of Faraday and Henry the generator from the patient. Passage of elec-
who simultaneously showed that moving magnet tricity through the body can cause an increase in
could induce an electrical current in wire. body temperature. The heating effects produced
are central to the desired function of the electro-
It was in 1881 Morton demonstrated that oscil- surgical instrument; the rate at which tissues are
lating electric current at a frequency of 100 kHz heated plays a crucial role in determining clinical
could pass through human body without in- effect. When an oscillating current is applied to

tissue, the rapid movement of electrons through
the cytoplasm of cells causes the intracellular 100 degrees centigrade - tissue vaporizes (cutting)
temperature to rise. The amount of thermal ener-
gy delivered and the time of delivery will dictate Due to the very small surface area at the point of
the observed effects on the tissue. In general the electrode, the current density at this point is
temperature below 45 degrees centigrade will really high, producing a focal effect allowing the
cause reversible thermal damage to the tissues. tissues to heat up rapidly. In monopolar diather-
As tissue temperatures starts to exceed 45 degrees my, since the current passes through the body, its
centigrade, the proteins in the tissue become density decreases rapidly as the surface area the
denatured losing their structural integrity. Above current acts across increases. This allows focused
90 degrees centigrade, the liquid in the tissue heating of tissues at the point of use, without
evaporates, resulting in desiccation if the tissue is heating up the body.
heated slowly or vaporization if the heat is deliv-
ered rapidly. Once the temperatures reach 200 Electrosurgical generators can apply energy in
degrees centigrade the remaining solid compo- either a monopolar or bipolar fashion. Monop-
nents of the tissue are reduced to carbon. olar delivery of energy to tissue requires that the
current from the generator pass from the active
The principle behind the use of diathermy in electrode through the patient and out of the body
surgical practice is that it uses very high frequen- through a dispersive electrode pad connected to
cies (0.5 - 3 MHz) of alternate polarity radio wave the generator to form a complete circuit. Bipolar
electrical current to cut or to coagulate tissue delivery of energy does not require a dispersive
during surgery. This allows diathermy to avoid return electrode pad because both the active elec-
the frequencies used by body systems to generate trode and the return electrode are integrated into
electrical current, such as skeletal muscle and the energy delivery forceps with the target tissue
cardiac tissue thereby allowing body physiology being grasped between to complete the circuit.
to be broadly unaffected during its use.
Types of diathermy:
It also allows for precise incisions to be made
with limited blood loss and is used in nearly all Configuration of the diathermy device can either
surgical disciplines. Radio frequencies generat- be monopolar or bipolar. Both actions require
ed by the diathermy heat the tissue to allow for the electrical circuit to be completed, but vary
cutting and coagulation, by creating intracellular how this is actually achieved.
oscillation of molecules within the cells. Depend-
ing on the temperature generated different results Monopolar - In this mode of action, the electrical
could be achieved: current oscillates between the surgeon’s elec-
trode, through the patient’s body, until it meets
60 degree centigrade - cell death occurs (fulgura- the grounding plate (positioned underneath the
tion) patient’s leg) to complete the circuit.
60-99 degrees centigrade - dehydration occurs Bipolar - In this mode, the two electrodes are
(tissue coagulation) found on the instrument itself. The bipolar ar-
500
rangement negates the need for dispersive elec- does the corresponding tissue effect. Electrosur-
trodes, instead a pair of similar sized electrodes gical generators provide delivery in two types of
are used in tandem. The current is then passed modes: Continuous and interrupted. The contin-
between the electrodes. uous mode of current output is often referred to
as cut mode and delivers electrosurgical energy as
Bipolar is commonly used in surgery involv- continuous sinusoidal waveform. The interrupt-
ing digits, in patients with pacemakers to avoid ed mode of current delivery is referred to as the
electrical interference with the pacemaker and in coagulation mode.
microsurgery to catch bleeders.
Modern appliances offer a wide variety of electri-
cal waveforms. In addition to the pure cut mode,
Cutting / coagulation: there are often blended modes that modify the
degree of current interruption to achieve varying
There are two main settings of diathermy (cutting degrees of cutting with hemostasis.
and coagulation).
The size and geometry of the electrodes delivering
Cutting uses a continuous wave form with a low the energy play an important role in achieving the
voltage. In the cutting mode, the electrode reach- desired effect. The smaller the contact area of the
es a high enough power to vaporise the water electrode, the higher the potential current con-
content. Thus in this mode, it is able to perform centration that can be applied to the tissue. The
a clean cut but it is less efficient at coagulating. In most important factor in achieving the desired
the cutting mode the focus of heat is more at the surgical effect with electrosurgical unit lies in the
surgical site, using sparks being the more focused surgeon’s manipulation of the electrode.
way to distribute heat. In the cutting mode, the
tip of the electrode is held slightly away from the
tissue.
There is a mixed mode (blend) acting in between

as both cutting and coagulating modes.
In endoscopic sinus surgery, insulated equipment

should be used and must be checked regularly to
ensure that insulation is intact. Non insulated
metallic equipment could potentially create an
alternative electrical pathway so it should be kept
at a safe distance from the active electrode.
Modern electrosurgical generators offer a wide Image showing the cautery arrangement inside
variety of electrical waveforms. They are capable the operation theatre
of modulating signals depending on the mode
setting. As the output wave forms change, so

Another recent application of bipolar cautery
is the sealing of vessels is gaining importance.
Electrosurgically sealed vessels demonstrated
equal effect when compared with that of vascular
staples, titanium clips sutures etc.
Complications:
1. Users of monopolar electrosurgery in patients

with implanted pacemakers should consult the
manufacturer of the devices before operating it.
2. When using electrocautery (monopolar) on pa-

tients with prosthetic conductive joints, every ef-
fort should be done to place the conductive joint
out of the direct path of the circuit. If the patient
has a left hip prosthesis then the return electrode
pad should be placed on the patient’s right side.
3. Off-site burns Image showing bipolar probe
Image showing electrocautery with attached

unipolar probe.
502
instrument with several important features which
Operating Microscope include:
1. High precision optics

Before the advent of surgical microscope sur-
geons had been using various magnifying systems 2. High power coaxial illumination
mounted on spectacles or headbands. These sys-
tems for the sake of convenience can be grouped 3. Adjustable magnification features
in to three categories:
4. Proper working distance
1. Single lens magnifiers
5. Unobstructed view of the entire surgical field
2. Prismatic binocular magnifiers
6. Its mechanical system should offer good stabili-
3. Telescopic systems ty maneuverability and heads up display.
Single lens magnifiers - Used convex lenses for 7. Stereopsis should provide the third dimension
magnifying with a fixed magnification and a very of the field of view. This really increases the safety
short working distance. Major disadvantage of of the surgical process
this system happens to be the fixed magnification
level and a very short working distance. 8. Multiple optical ports like viewer port, camera
port should be available
Telescopic system - This system has the advantage
of had better working distance. Keeler Galilean Technical aspects:
system was the first telescopic system to be intro-
duced in 1952 and was provided with a two times Operating microscope can be divided into a
magnification at 25 cm distance. In addition microscope body, light source and a supporting
to this feature, a set of five different telescopes, structure. Each of these components are vital for
which could separately be fixed on a spectacle the performance of the microscope. In addition
frame using screws provided the surgeon with the to these three basic conventional parts, modern
choice of magnification from 1.75 - 9 times with a microscopes have adopted advanced technologies
working distance ranging from 34 to 16.5 cm. to facilitate visualization and surgical navigation.
Prismatic binocular magnifiers - This is a binocu- Body of the microscope:

lar loupe which uses prism and lenses to achieve
stereopsis. Carl Zeiss company came out with This has all the high precision optics that could
a binocular loupe with a working distance of 25 provide a clear magnified image with the min-
cms which really opened the door for microsur- imum distortion. The binoculars mounted on
gery. the microscope head offers stereopsis. Multiple
optical ports are open for adaptation of imaging
Surgical operating microscope is a precision devices like video cameras or for assistants for

viewing the surgery real time.
Optical system:
Light source:
This is the main determinant of the imaging qual-
This is usually installed away from the micro- ity that a system can achieve. It is basically a bin-
scope to avoid heating the optics or the surgical ocular setup with eyepieces on top with a close up
site. Commonly used light sources include xenon lens at the end. The close up lens is also known
light bulbs, halogen light bulbs or LED bulbs. as the objective lens whose magnification can be
Illumination from these bulbs are transmitted to changed along with the working distance simply
the microscope through a fiber guide which then by replacing the objective lens. In addition to
passes through the objective lens and illuminates these lenses there is a zoom changer which is a
the surgical site at a distance that is subject to the series of lenses moving in and out of the viewing
focal length of the objective lens. Good illumi- axis or a system that changes the relative posi-
nation especially the coaxial ones has the ability tions of lens elements. Commonly used objective
to overcome the shadow and dimness of the field lenses in otolaryngology include:
of vision. In coaxial illumination the front light
hits the object surface perpendicular to the object 100 -200 mm lenses - Used in otological / middle
plane. ear surgeries.
Based on the configuration there are four types of 300 mm lenses - Used in nasal surgeries
surgical microscopes:
400 mm lenses - Used in laryngeal surgeries
Microscope on casters
The same microscope can be utilized for ear nose
Wall mounted microscopes and throat surgeries by simply changing the ob-
jective lenses.
Table top microscopes
Magnification:
Ceiling mounted microscopes
Surgeons from many fields have recognized the
The on caster stand mounted microscopes are usefulness of magnification. The total magnifica-
very popular because of its mobility. It should be tion of the surgical microscope is determined by
stressed that ceiling mount / wall mount micro- all the four optical components in the microscope
scopes help in efficient space management. which include:
The support structure of a modern operating Focal length of the objective lens
microscope has precision motorized mechanics
so that the microscope can be balanced easily and Zoom value
adjusted flexibly to the exact position. The funda-
mental task of the support structure is to keep the Focal length of the binocular tube
microscope stable.
504
Magnifying power of eyepieces
Xenon lamp emits light with a broad spectrum
Magnification power of modern microscopes from ultraviolet to infrared. The spectrum is
usually varies form 4X to 40X, and is usually relatively smooth in the visible range, but it has
selected through a manual or motorized magni- some spikes in the near-infrared range. Xenon
fication changer. Human eyes have an inherent light has a color temperature of 4000-6000 K,
resolution of 0.2 mm but with 20X magnification which is similar to sunlight. Therefore, the bright
it can be increased to 0.1 mm. This adds to the white light is able to offer a naturally colored view
confidence of the surgeon while working in criti- of the anatomy. Halogen lamp also covers a wide
cal areas. and continuous spectrum including visible and
Near infrared light. It has a slightly lower color
Light source: temperature (3200-5000 K) which means that the
light does not look as “white” as xenon light.
Old generation microscopes were provided with
traditional incandescent bulbs which had their Disadvantage of halogen and xenon lamps is that
own disadvantages which included limitations they emit heat, to avoid optics from being heated
in the brightness levels and color reproduction. up the light source (halogen/xenon) are placed
Currently there are three main types of light away from the optics.
sources:
Illumination arrangement:
Xenon lamp
The tissue surface that is viewed under a surgical
Halogen lamp microscope is usually wet and highly reflective.
The light that comes from an angle can easily be
LED lamp reflected away and cause a dark view. Coaxial
illumination is the solution to this situation. This
Among these three LED provides illumination illumination matches the optical axes of illumi-
in the visible wavelength with good brightness, nation and visualization (lens). Coaxial illumi-
stability, longer life and with less power consump- nation reduces the diameter of the illuminated
tion, less heat. This lamp is hence ideal for oto- area and it can be directed into narrow and deep
laryngologists and ophthalmologists. LED lamps cavities. This feature is helpful for otolaryngolog-
has the following disadvantages too: ical surgery.
The higher color temperature and narrower The light path for coaxial illumination for oto-
wavelength range makes the light not as close to laryngological surgeries usually forms a small
sunlight. angle with the observation axis in the range of 6
degrees. This is called as the small angle of illu-
Its spectrum is insufficient for fluorescence guid- mination where in illumination is concentrated
ed applications. and evenly distributed. With the small angle of
illumination the shadow appears at the edge of
It is difficult to replace. the viewing field and does not disturb the vision

of the surgeon. hold the microscope in position. In modern mi-
croscopes all six axes can be fully balanced with
Balancing & positioning: two pushes of a button. Intraoperative re-balance
can be quickly and accurately accomplished with
Surgical microscopes should be quick and effort- a single push of button on hand-grip.
less to move and should remain stationary once
the position is established. Balancing or the forc- In recent years a robotic auto-positioning feature
es and movements from all directions should be has been added to the state of the art surgical
achieved. Brakes / bracing devices are needed to microscopes.
Image showing the types of illumination
506
Draping the microscope:
Visualization system:
Microscope should be draped during the process
of surgery. These drapes helps in minimizing Clear and bright visualization of the surgical site
wound infections and maintains the sterile area. is the ultimate goal of using an operating mi-
These drapes are very thin, transparent and is croscope. In addition to the good image quality
made out of heat resistant plastic film. It should provided by high precision optics and sufficient
cover the entire microscope and should be avail- illumination, the steroscopic view offers depth
able in sterile packaging which can be opened information is another non negligible feature a
prior to surgery. Features of the microscope microscope should possess.
drapes include:
Microscope users can observe the surgical site
1. Should have adequate number of ocular pock- in various ways. All microscopes have one main
ets observation port and one rear / lateral port for
co-viewers and one for attachment of camera /
2. It should not reduce the working distance imaging systems. All these optical ports offer an
almost identical field of vision.
3. It should not obstruct the surgeon’s view
Stereopsis:
4. Drapes should be glare free. As light passes
through the objective lens and illuminates the This is very important key feature of binocular
surgical field, some of the light would be reflected surgical microscopes. In monocular micro-
by the lens cover on the drape. This can cause scopes depth cues lie in perspective projection,
chromatic and spherical aberrations. Removing occlusion size, shading and motion parallax, the
the cover would cause contamination of surgical stereoscopic depth is based on minor disparities
instruments. A dome shaped lens cover can re- between two images presented to two eyes. The
duce the reflection without compromising magni- light coming out of the objective lens is divided
fication. into two parts and forms two slightly different
images into two channels. In surgery, especially
Control: when working with magnification, perspective,
and size cues may be lost, therefore the stereopsis
Surgical microscopes can be controlled in differ- brought by binocular is essential to provide a 3 D
ent ways. Ideally foot control is preferred because impression of the surgical field. An optical design
the surgeon would like to have both hands free that enhances stereo visualization for operating
during the entire process of surgery. Foot switch microscopes is the FusionOptics technology. This
and mouth switches are provided in different sets two separate beam paths in the optical head,
microscopes for this purpose. Currently eye con- providing the depth of field and high resolution
trolled microscopes are the trend. It uses IR-LED respectively. The two paths are then merged in
to illuminate the surgeon’s eye and a large CCD the observers brain into a single, optical spatial
sensor is used to detect the reflected infrared light image. Because of this combination of depth and
from the surgeon’s eye movement tracking. resolution, the interruptions for refocusing can be

avoided.
Image showing ENT operating microscope
Image showing the binocular head of the operat-

ing microscope
508
Lasers mirror as the laser beam.
Introduction: The first lasing medium to be used was ruby.

Currently a number of lasing materials are avail-
Laser (Light Amplification by Stimulated Emis- able which include:
sion of Radiation) has been used in otolaryngol-
ogy for nearly 50 years and currently has been Gas:
accepted part of the armamentarium of the oto-
laryngologist. A tremendous amount of work has Carbondioxide
been done ot refine the existing understanding
and techniques. Argon
Basic principle: Liquid:
This involves the lasing medium, an energy Dye lasers

source and an optical cavity. The energy gener-
ated by the energy source is used to elevate the Solid:
atomic particles of the medium to higher energy
states. This situation is known as population in- Neodymium:Yettrium
version and acts as a continual source of photons.
The excited particles then return to their normal Aluminum Garnet
state with the emission of energy in the form of
photon, the wavelength of which is determined Semiconductor diodes
by the characteristics of the lasing medium. As
the photon encounters another exited elements, Free electron laser
it stimulates the release of another photon of
the same wavelength, and it travels in the same Various excitation methods are employed and the
direction and in phase. In this way the light is laser may be used in continuous wave or various
amplified. pulsed mode.
The optical cavity containing the lasing medium Tissue interactions with lasers:
has a 100% reflective mirror at one end and a
semi reflective mirror at the other end. The pho- Laser light falling on tissues may be reflected,
tons travelling along the axis of the mirrors are scattered, transmitted or absorbed. Out of all
reflected and thus continue travelling within the these interactions only absorbed light causes a
optical cavity and simulating the release of more tissue reaction.
photons. Photons not travelling along the axis of
the mirrors are not repeatedly reflected and thus Reflection:
are not amplified. This process of reflection pro-
duces a temporally and spatially coherent beam Part or whole of laser light is reflected back
of light which escapes via the semi-reflective

Image showing physics of laser
Scatter: Absorption:
Laser energy scatters in the tissues and its pen- Laser energy is absorbed by the tissue. It is exactly
etration deep into the tissues becomes limited. this absorbed energy that produces the effect on
Shorter the wavelength of laser more of the ener- the tissue. The main substance that absorbs the
gy is scattered. laser is called the primary chromophore. Ab-
sorption produces mainly kinetic excitation of
Transmission: the absorbing molecules. This kinetic excitation
produces thermal effects ranging from reversible
The light is transmitted through the tissue with- hyperthermia through enzyme deactivation, pro-
out causing any effect on tissues through which tein denaturation, and coagulation to dehydra-
it passed. Argon laser has been used to coagulate tion, vaporization and carbonization.
retinal vessels without any damage to cornea, lens
or the vitreous. The effect of laser on tissue depends on the
absorbed energy. At a temperature of 60 degrees
centigrade, there is protein denaturation, but
tissues can recover from here. At 80 degrees cen-
510
tigrade there is degradation of collagen tissue and Photochemical:
at 100 degrees centigrade, cells and their pericel-
lular water convert into heat that causes tissue ab- Ultraviolet lasers with wavelength of 248 and 312
lation. Lasers can hence be used to cut, coagulate nm can ionize DNA and RNA respectively. They
blood vessels or vaporize the tissue. When a burn could even be carcinogenic. This effect of specific
is caused by a laser beam there is some degree of lasers (argon) has been used in photodynamic
collateral damage. therapy to selectively destroy cancerous tissue.
Zones of tissue damage can be divided into: Photodissociation:
Zone of vaporization: This effect of laser breaks C-C bonds, divides

collagen without heating it. This feature is made
A crater is created due to tissue ablation and use of in excimer laser in LASIK procedures to
vaporization leaving behind only a few flakes of reshape the cornea for refractive errors.
carbon.
Classification of laser as per electromagnetic
Zone of thermal necrosis: spectrum:
This zone is just adjacent to the zone of vapor- Visible lasers:

ization. There is associated tissue necrosis. Small
blood vessels, nerves and lymphatics are sealed. Visible light has a wavelength of 400-700 nm.
Lasers that fall within this range are known as vis-
Zone of thermal conductivity and repair: ible lasers. They have different colors from violet
to red (VIBGYOR). Since these laser beams are
This zone recovers with time. visible they don’t require a separate aiming beam
to focus them. Argon laser has blue color (488-
Properties & effects of lasers: 514 nm). KTP laser (512nm) is also in the visible
range and has blue green color.
Depending on the wavelength of laser energy, it
produces the following effects: Invisible lasers:
Photothermal: Lasers in the ultraviolet zone (1-380nm) and

infrared zone (>760 nm) are not visible. Infra red
This produces heat energy that is used to cut, lasers are further subdivided into near infrared
coagulate or vaporize tissues. lasers (760-2500 nm), mid infrared lasers (2500-
50,000 nm). There are no lasers in the far infrared
Photoacoustic: zone.
It can be used to break stones and is used in lith- Lasers that can be transmitted through optical
otripsy. fibers include:

Argon KTP Nd:YAG Er:YAG Ho:YAG Diode Laser delivery mode:
laser
Continuous mode:
Lasers used in ear surgeries include:
It provides constant stable energy as the active
Argon - 514 nm KTP -532 nm Carbondioxide - medium is continuously kept in a stimulated
10,600 nm Er:YAG - 2960 nm mode.
In ear surgeries lasers are used to vaporize small Pulsed mode:

glomus tumors, acoustic neuromas, small A-V
malformation, granulation tissue or adhesions in This gives interrupted beam as the active medium
the middle ear cavity. Lasers have also been used is intermittently activated for a short time.
to perform myringotomy, perforation of foot plate
during stapes surgery, and coagulation of mem- Q - switched mode:
branous posterior canal in BPPV.
This mode provides very short pulses in a con-
Operational parameters: trolled manner. Pulses range between 10 ns and
10 milliseconds.
1. Wave length of laser beam : The exact proper-
ties of laser depends on its wavelength Advantages:
2. Power: Is actually the output from the machine Precision

and is measured in watts. Higher the power, more
is the energy delivered to the tissues Rapid ablation of tissues
3. Exposure tine: It is measured in seconds Excellent hemostasis
4. Spot size: This is actually the area exposed to Minimal post op pain
the laser beam. Spot size is the minimum at focal
length. Focused beam is used for cutting and de- Minimal tissue oedema
focussed beam is used for coagulation / ablation
of tissues. Disadvantages:
5. Power density: It is the power delivered per Expensive

unit area of spot size and is measured in watts/
square cm. This indicate intensity of the beam. Expensive to maintain
6. Exposure to laser: This value is the power den- Safety precautions need to be taken
sity multiplied by duration of exposure in seconds
and is measured in joules/ cubic cm. Types of lasers used in otolaryngology:
512
Argon laser:
KTP lasers can be used on soft tissue ablation
This lies in the visible spectrum. Does not eed (tonsillectomy). This will depend on their capac-
pointing ray. It is absorbed by hemoglobin. Hence ity for small spot size delivery. KTP lasers can
it is used to treat portwine stain, hemaingioma be delivered by quartz fibers. The unpredictable
and telengiectasis. When focused to a small point effects of argon laser on soft tissue limit its appli-
it can vaporize the target tissue. This laser is used cation in the airway.
to create a hole in the foot plate of stapes. It needs
a drop of blood to be placed over the foot plate Nd:YAG laser:
for this effect to occur.
This laser has a wavelength of 1064 nm and lies in
Because of the excellent absorption of the argon the infrared zone. It is in the invisible range and
laser by hemoglobin, the major clinical applica- requires a separate aiming beam of visible light to
tion has been ophthalmology and dermatology. focus. It can pass through clear fluids and is also
This laser has been useful for coagulation of reti- absorbed by pigmented tissue as the case may in
nal blood vessels in instances of diabetic retinop- eye and urinary bladder. In otolaryngology it has
athy and for the treatment of port-wine stain. been used to debulk tracheobronchial and esoph-
ageal lesions for palliation.
KTP laser:
It is poorly absorbed by water, and hence pene-
This laser also lies in the visible spectrum. It has a trates tissue deeply. The energy is not dissipated
wavelength of 532 nm. These waves are absorbed at the surface, as is the case with carbondioxide /
by hemoglobin and can be delivered via optical KTP 532 and argon lasers. It scatters within the
fibers. This laser is also used ins tapes surgery, en- tissue depending on the degree of tissue pigmen-
doscopic sinus surgery to remove polypi, inverted tation for absorption.
papilloma and vascular lesions.
The Nd:YAG laser can be transmitted through
KTP and argon lasers have similar characteristics. commonly available flexible quartz fibers making
Both these lasers operate in the visible spectrum it possible to be used in the tracheobronchial tree.
at the wavelength of 532 and 518 respectively. Because the laser beam diverges approximately 10
These lasers can be delivered through flexible degrees as it leaves the fiber, the closer the fiber to
fibers. Both these lasers are well absorbed by the tissue the smaller is the spot size. Care should
pigmented tissue and hemoglobin and are poorly be taken to apply the laser energy in brief expo-
absorbed by pale tissue thus making them good sures of 1 second or less at a power setting below
coagulators and fairly good ablators of pigmented 50 Watts. Continuous application of the laser at
tissue. Compared with the Nd:YAG laser, howev- high power settings could result in “popcorn” ef-
er, this effect on tissue is superficial. Spot sizes of fect which is an explosion of the tissue caused by
0.15 mm can be achieved depending on the optics high energy below the tissue surface that creates
used that create high power densities capable an expanding cavity.
of cutting and ablating tissue independent of its
wavelength absorption. The Nd:YAG laser wavelength has little visible ef-

fect on colorless tissue, and the laser beam readily through optical fibers. It needs special articulated
traverses it, causing thermal damage to the more arms and mirrors that reflect the laser beam to
pigmented underlying structures. This will be the spot of the lesion. This laser beam is absorbed
useful when treating a lesion in the tracheobron- by tissues high in water content and is not color
chial tree. The white color of the tracheal carti- dependent. Reflection and scatter through tissues
lage will not absorb laser energy, and the energy is minimum. Its tissue effect is in depth and in
will be transmitted through the cartilage and pos- adjacent tissues laterally. Clinically it is used in
sible damage to the underlying vascular and lung laryngeal surgeries to excise papillomas.
tissues. The thermal effect of laser goes beyond
its immediate area of visible impact. The surgeon The carbondioxide laser is sometimes misused
should take care to protect the underlying soft for excision of benign laryngeal lesions. A sur-
tissues. Mucosal charring and blood deposition geon who does not understand the effects and
on the tracheal wall can enhance the absorption soft tissue interaction of carbondioxide laser may
of Nd:YAG laser beam. Rapid progression of choose a large spot size (> 0.5 mm), continuous
thermal energy can ensue causing tracheal perfo- exposure or high power (> 10 W) when perform-
ration. ing phonatory surgery. Such choices could result
in poor voice quality because of excessive muco-
The Nd:YAG laser has two delivery modes: sal scarring and fibrosis.
Contact - In this mode it is good for cutting soft Advancements in laser technology and microma-
tissue and even thin bone. It is however not nipulator optics have enable the diameter of the
adequate for hemostasis. When used in contact carbondioxide laser spot to be reduced when used
mode, the Nd:YAG laser energy concentrates at with a 400 mm focal length. The focal length of
the tip of the fiber and causes limited vaporiza- this laser was reduced from 2 mm in the early
tion of tissue and little damage to the surrounding 1970s to 0.8 mm in the early 80s and to 0.3 mm in
tissue. This mode is good for coagulating blood 1987. Necessary laser wattage has been reduced
vessels less than 1 mm in diameter; its effect on from 10 to 2 watts because of the higher beam
soft tissue is similar to that of carbondioxide laser. concentration or power density.
Non contact mode - In this mode it is useful in Diode laser:

the treatment of vascular tumors and pigmented
lesions because of its excellent penetration into This has a wave length of 600-1000 nm. It can be
tissue. Since absorption is efficient in this type of delivered via optical fibers and is moderately ab-
tissue, laser power can be reduced to half that is sorbed by melanin and hemoglobin. Diode lasers
usually necessary for vaporization. Photocoagu- are used for turbinate reduction, laser assisted
lation is the desired effect. stapedectomy and tonsillar ablation.
Carbondioxide laser:
Safety precautions:
It has a wavelength of 10,400 nm in the invisible
range. It requires an aiming beam of visible light Eye protection to surgeon and assistant by wear-
to focus the laser beam. This laser does not pass ing goggles. Wavelength specific glasses should
514
be worn to prevent retinal damage. Patient’s eye is then excised using either microscissors or laser.
should be protected by double layer of saline Development of microspot, micromanipulator
soaked cotton eye pads. All exposed areas of face facilitated tissue excision with precise cutting and
are covered by saline soaked pads. minimal damage to the surrounding mucosa and
underlying vocalis muscle. In addition since the
Endotracheal tubes: carbondioxide laser is used in a no touch mode it
permits unobstructed observation of the surgical
Wave specific tubes are available. Rubber tubes field so as to note the effect of laser on the tissue
are better than PVC as they are more resistant to layer by layer. Carbondioxide laser has been used
laser hits. PVC tubes when hit by laser can gener- to remove benign laryngeal lesions and is espe-
ate toxic fumes. These endotracheal tubes should cially effective for vascular polyps, large sessile
be covered by reflective aluminium foils. The nodules and cysts and for the evacuation of pol-
cuff of the endotracheal tube should be inflated ypoid myxomatous changes.
with blue dye mixed saline and covered with wet
cottonoids. In case of accidental hit by laser blue The key to successful laryngoscopic excision is
color effusion will warn the surgeon. good exposure. Anterior commissure laryn-
goscope is preferred to expose the vocal cords.
Anesthetic gases: Kleinsasser laryngoscope which is suspension
based and can be anchored to the chest of the
Non inflammable gases are used. Halothane / patient can be used. Main advantage of suspen-
enflurane are preferred to nitrous oxide. Concen- sion laryngoscope is that when it is used both the
tration of oxygen should not exceed 40%. hands of the surgeon are free.
As a first step the carbondioxide laser is usually

Smoke evacuation: used with a microspot delivery system with a 0.3
mm spot diameter to outline the area around the
Constant suction should be used to suck out lesion. A power setting of 1-3 watts is sufficient
fumes released out of laserization of tissue. with intermittent pulses of 1/10 second. The
usual magnification setting on the microscope
Laryngology is one area in which lasers are often is 16 times, but for smaller lesions a magnifica-
used. The laser of choice happens to be the tion setting of 25 times would be optimal. When
carbondioxide laser, because of the precise cut- the process of outlining the lesion is completed
ting and superficial well delineated effect of the through the mucosal surface, the mucosa can
carbondioxide laser. It is used in laryngology for be easily separated from the surrounding tis-
all delicate phonosurgical procedures, precise sue using a microlaryngeal forceps. If a vessel is
excision of carcinoma in situ or early T1 tumors encountered at that moment then coagulation is
and vaporization of bulky obstructing carcinoma achieved by defocussing the laser beam.
of upper airway.
Carbondioxide laser can be used for welding
The carbondioxide laser can also be used for de- tissue. The effect of welding is caused by coag-
lineating or circumscribing the lesion. The lesion ulation of protein at the mucosal edges. Hence

carbondioxide laser can be used for approximat- missure laryngoscope.
ing mucosal edges after removal of vocal nodule
/ vocal polyp. The process of welding is achieved
by approximating the mucosal edges using mi-
crolaryngeal forceps, defocusing the beam and
aiming at the junction of the mucosa and firing
the laser at power ranges between 100-500 mW.
The decision to use carbondioxide laser mi-

crospot excision or the microscissors mainly
depends on the size of the lesion, its character
(sessile / pedunculated) with a narrow stalk,
the preferred technique is by microforceps and
microscissors. This is rather quicker and more
efficient and it has the advantage of avoiding
thermal damage. When laser is used for benign
lesions, it is very important to provide constant
tissue tension throughout the procedure to avoid
heat coagulation of the specimen and to pre-
vent damage to surrounding tissue. To keep the
laser excision in an even plane of dissection, it is
important to outline the lesion at the begining of Image showing vocal polyp
the procedure. This step would loosen the speci-
men from the surrounding mucosa and define the
appropriate depth of excision.
The carbondioxide laser with a 0.3 mm impact

spot is used at 1-3 W of power in a pulse mode
of 0.1 second. All these patients should receive
decadron 10 mg immediately before the proce-
dure to prevent post op laryngeal oedema.
Another common application of carbondioxide

laser is arytenoidectomy for the management of
bilateral vocal fold paralysis. Endoscopic tech-
niques of arytenoidectomy avoids open laryngo-
fissure procedure.
It is important to expose the posterior commis-

sure during endoscopic arytenoidectomy. This Image showing Co2 laser excision of vocal polyp
exposure is accomplished using a posterior com-
516
The arytenoid to be resected should be well
exposed, as should the posterior commissure
and at least half of the other arytenoid cartilage.
The carbondioxide laser is coupled to an oper-
ating microscope with a 400 nm objective lens.
The laser is et at pulse duration of 0.1 second in
repeat intermittent mode at a power of 10W and
a focused spot size of 0.8 mm. The laser pow-
er can be lowered accordingly when a smaller
spot impact is used. The mucosa overlying the
arytenoid cartilage is vaporized, exposing the
underlying cartilage. The corniculate cartilage
and apex of the arytenoid are vaporized using the
laser in continuous mode. The upper body of the
arytenoid cartilage is vaporized after ablating the
perichondrium that overlies it, using the laser in
the continuous mode at a power setting of 15 W.
The lower body of arytenoid cartilage is vapor-
ized working laterally to medially with the laser
Image showing KTP contact laser probe in action set at 0.1 second in intermittent pulses at a power
setting of 10 W. The vocal and muscular process-
es are vaporized using the same laser settings.
The mucosa is cut 2-3 mm in front of the vocal
process so as to create a triangular posterior air-
way. A small area lateral to the vocalis muscle is
vaporized to induce scarring and promote further
lateralization during the healing process.
The carbondioxide laser is coupled with an oper-

ating microscope with a 400 mm objective lens.
This enables precise hands off, relatively bloodless
endoscopic laryngeal surgery.
In the field of rhinology lasers are used often for

vaporization of hypertrophied turbinates and oc-
casionally for coagulation of small blood vessels
in the milder forms of hereditary hemorrhagic
telangiectasia.
Image showing papilloma vocal fold being ex-
cised using KTP contact laser When used in non-contact mode, the Nd:YAG

laser is a good coagulator. It has been used suc-
cessfully for coagulation of vascular lesions of the
nose such as low flow venous malformations and
hereditary hemorrhagic telengiectasis. Injury to
nasal septum and turbinates can occur because of
scatter or reflection of the laser beam, but injury
can be avoided by using low power (20-25 watts)
and short exposures (0.5-0.7) seconds.
Image showing medial portion of arytenoid

being vaporized
Image showing laser beam (red spot) being fo-

cused during arytenoidectomy
Image showing the partial removal of medial

portion of arytenoid.
518
Use of carbondioxide lasers in management of
choanal atresia has many advantages. The trans-
nasal approach using laser ablation has proved
useful. This coupled with the use of operating
microscope with 300 mm objective lens really
provides the surgeon with an excellent view of the
surgical field. Because of the hemostatic effects
of laser, the post operative oedema is minimal or
absent.
Image showing laser being used to dissolve the

atretic plate
Image showing the atretic plate in choanal atre-

sia
Image showing atretic plate fully removed

KTP laser was successfully used by Levine in the of the neuroepithelium present in the vestibule
field of rhinology. The laser was focused at 9-12 because the transmitted heat will dissipate on the
W for cutting the tissue and 4-5 W for coagu- footplate surface or in the perilymph.
lating / vaporizing. Before cutting any tissue
that could probably bleed the laser is used as a Lasers used in ear surgery are helpful in revision
coagulator in a defocused low power mode. For procedures. They are helpful in cutting adhesions
managing vascular lesions, the laser is used in a bloodlessly without exerting force or manipulat-
circular fashion, peripherally to centrally, starting ing middle ear structures.
at the edges of the lesion and finally approaching
the central vessels. Oral cavity:
Role of lasers in otology is rather controversial In the oral cavity laser is mainly sued as a he-
but currently stapedectomies are performed using mostatic cutting knife and carbondioxide laser
laser. KTP laser is used for this purpose. In order is ideal in these situations. It can be used with a
to vaporize the stapes foot plate, the laser with a handpiece or with a micromanipulator to delin-
spot size of 50-100 micro meter is used, pulse du- eate and resect small tumors of the tongue, floor
ration of 10 msec, and a power of 0.7 W is ideal. of the mouth, and mucosa of the cheek. The
Laser stapedotomy has some unique advantages advantages of carbondioxide laser include good
where in the fracturing or mobilizing the foot hemostasis, precise cutting and when coupled
plate is less when the posterior crus is vaporized with operating microscope surgery becomes
before removing suprastructures thus decreasing very safe. The advantages of microscope is that it
the risk of a floating foot plate. Stapedotomy can permits magnification with better appreciation of
also be performed easily with minimal trauma the laser effects on the tissue. Microscopic vision
and without vibration. is preferred for stationary targets like the floor of
the mouth, palate, immobile tongue and retromo-
The argon, carbondioxide and KTP lasers have lar area. Handpiece is preferred for mobile areas.
been found to be useful in ossicular surgery. The The surgical defect is not sutured or grafted but is
carbondioxide laser is easy to use because of its left to heal by second intention.
articulating arm delivery system that can be con-
nected to the operating microscope and because The application of laser technology to the endo-
of its small spot size (0.2-0.3 mm at a focal length scopic treatment of patients with tracheobron-
of 250 mm). The surgeon can operate using a chial mass lesions began with the use of carbon-
no-touch technique with good visualization and dioxide laser to ablate tumors such as respiratory
precise ablation of the ossicles. papillomas. With the introduction of Nd:YAG
lasers which has special hemostatic qualities
The argon and KTP laser beams are usually de- enhanced the safety of laser procedures in the
livered through a flexible fibre that is held in the tracheobranchial tree. Laser therapy can be used
hand like middle ear instrument. repeatedly for the palliation of malignant tra-
cheobranchial obstruction. The hypervascularity
The excellent absorption by water of the carbon- of many malignant endobronchial neoplasms
dioxide laser energy is a good protective measure are best treated with Nd:YAG laser because of its
520
coagulation properties.
Image showing carinal mass removed using laser
Image showing mass lesion obstructing the cari-

na
Image showing circumferential incision marked

with a laser on the tongue in order to excise it
Image showing Nd:YAG laser probe being used to fully
debulk the mass

The anesthetic management of patients who
require laser bronchoscopy can be challenging
to the anesthesiologist. In high risk / elderly
patients the procedure is carried out with topi-
cal lidocaine, intravenous sedation and assisted
ventilation. With this topical technique, control
of cough is rather difficult. If general anesthesia
is preferred then Jet ventilation anesthesia can be
resorted to.
Image showing the incision deepened and the

edges of the lesion lifted up to facilitate excision.
The red dot is the laser beam.
Image showing tongue tissue excised with laser
522
Coblation technology in Otolaryngology
Initially coblation technology was used in ar-
Introduction: throscopic surgeries immensely benefiting in-
jured athletes. Coblation is non-thermal volumet-
The technology of using plasma to ablate biolog- ric tissue removal through molecular
ical tissue was first described by Woloszko and dissociation. This action is more or less similar
Gilbride. By their pioneering work in this field to that of Excimer lasers. This technology uses
they proved that radio frequency current could be the principle that when electric current is passed
passed through local regions of the body without through a conducting fluid, a charged layer of
discharge taking place. particles known as the plasma is released. These
charged particles has a tendency to accelerate
Radio frequency technology for medical use (for through plasma, and gains energy to break the
cutting, coagulation and tissue dessication) was molecular bonds within the cells. This ultimately
popularized by Cushing and Bovie. Cushing an causes disintegration of cells molecule by mole-
eminent neurosurgeon found this technology ex- cule causing volumetric reduction of tissue.
cellent for his neurosurgical procedures. First use
of this technology inside the operating room took Medical effects of plasma has spurred a evolu-
place on October 1st 1926 at Peter Bent Brigham tion of new science “Plasma Medicine”. It is now
Hospital in Boston, Massachusetts. It was Dr evidently clear that Plasma not only has physical
Cushing who removed a troublesome intracranial effects (cutting and coagulation) on the tissues
tumor using this equipment. but also other beneficial therapeutic effects too.
Plasma not only coagulates blood vessels but also
The term coblation is derived from “Controlled decontaminates surgical wound thereby facilitat-
ablation”. This procedure involves non-heat driving better wound healing. Therapeutic application
en process of soft tissue dissolution using bipolar of plasma assumes that plasma discharges are
radio-frequency energy under a conductive medi- ignited at atmospheric pressure.
um like normal saline. When current from radio
frequency probe pass through saline medium it Plasma Medicine:
breaks saline into sodium and chloride ions.
This field of medicine can be subdivided into:
These highly energized ions form a plasma field 1. Plasma assisted modification of biorelevant
which is sufficiently strong to break organic surfaces
molecular bonds within soft tissue causing its 2. Plasma based decontamination and steriliza-
dissolution. Coblation (Controlled ablation) was tion
first discovered by Hira V. Thapliyal and Philip E. 3. Direct therapeutic application
Eggers. This was actually a fortuitous discovery in
their quest for unblocking coronary arteries using Plasma assisted modification of biorelevant sur-
electrosurgical energy. In order to market this faces:
emerging technology these two started an upstart This technique is used to optimize the biofunc-
company ArthroCare. Coblation wands were ex- tionality of implants, or to qualify polymer sur-
hibited in arthroscopy trade show during 1996. faces for cell culturing and tissue engineering.

For this purpose gases that do not fragment into Management of chronic wound: Eventhough
polymerisable intermediaries upon excitation plasma does not play direct role in wound heal-
should be used. Gases that do not fragment in- ing, its bactericidal and fungicidal effects helps in
clude air, nitrogen, argon, oxygen, nitrous oxide wound healing.
and helium. Exposure to such plasma leads to
new chemical functionalities. Surgeries: Currently plasma technology is being
used to perform blood less surgeries like tonsil-
Plasma based decontamination and sterilization: lectomy etc.
Not all surgical instruments can be effectively Types of cold atmospheric Plasma (CAP):
sterilized using currently available technologies. CAP’s basically are of 3 types:
This is due to the fact that plastics cannot be
effectively be sterilized by conventional means as 1. Direct Plasma - It has a single needle electrode
it could get degraded on exposure to steam and which generates plasma source. It is useful in
heat. Plasma discharges have been found to be re- managing skin lesions.
ally useful in this scenario because of its low tem- 2. Indirect Plasma is generated between two
perature action. The nature of plasma actions on electrodes and is transported to the area of appli-
bacteria extends from sublethal to lethal effects. cation in an entrained gas flow. This is the com-
Sublethal effects cause bacteriostatic changes, monly used technology in plasma wands current-
while lethal effects cause bacteriocidal changes. ly used in
coblation surgical procedures.
Growth of drug resistant bacteria MRSA in 3. Hybrid plasma - combines the technique of
hospital environment poses a great challenge in both direct plasma and indirect plasma. Ground-
sterilization efforts. Ideal sterilization mechanism ed wire mesh electrode is used for this purpose.
should be fast and efficient. Studies reveal that
plasma devices perform this action rather effort- A broad spectrum of plasma sources dedicated
lessly. for biomedical applications have been developed.
Direct therapeutic applications: These include:
Antifungal therapy: Plasmas can be employed to 1. Plasma needle

treat fungal infections. Common fungal ailments 2. Atmospheric pressure plasma plume
like T pedis can be managed using plasma tech- 3. Floating electrode dielectric barrier discharge
nology. 4. Atmospheric pressure glow discharge torch
5. Helium plasma jets
Dental care: Periodontal infections are common 6. Dielectric barrier discharge
in older age group patients and pregnant mothers. 7. Nano second plasma gun
Plasmas have an ability to penetrate microscopic
openings between teeth and gum destroying the
offending organism.
524
1. Strong electrical field
2. Shock mechanical wave
3. Free radical production
4. Strong UV radiation
5. Production of ozone if oxygen is present in the
system
K.R. Stalder and J. Woloszko did pioneering work

in formation of microplasma produced by electri-
cal discharges in saline environment. This mi-
croplasma caused surgical ablation of tissues and
improved surgical outcomes.
Wand is the electrode (disposable) used in cobla-
tion as a knife to cause ablation.
Image showing the plasma needle. The glow is

cold enough to be touched
Dielectric barrier discharge:
This is the technology used in therapeutic cob-

lators. This is characterised by the presence of at
least one isolating layer in the discharge gap.
Plasma:
Image showing coblator wand with three elec-
The effectiveness of coblation technology is due trodes separated by ceramic
to the formation of plasma. Chemically speaking
plasma is a form of ionized gas. The term ionized For effective use of this technology for surgical
indicate the presence of at least one unbound procedures the plasma generated by the wand /
electron. The presence of electrons and ions electrode should be uniform. The uniformity of
makes plasma an electrically conductive media plasma can be ensured by:
better than copper or gold.
1. Increasing pre ionization of the gas thus ensur-
Plasmas are generated by electrical discharges in ing generation of more avalanches
direct contact with liquids. Electric underwater 2. Shortening of voltage rise time
discharges create the following phenomena:

Image showing state of the matter
Therapeutic applications of plasma: 3. UPPP

4. Tongue base reduction
Plasma treatment is known to cause coagulation 5. Turbinate reduction
of large bleeding areas without inducing addi- 6. Kashima procedure for bilateral abductor pa-
tional collateral tissue necrosis. Other methods ralysis
causing coagulation act thermally producing 7. Papilloma vocal cords
a necrotic zone around the treated spot. Non
thermal coagulation is caused due to release of Na Technology overview:
and OH ions which causes release of thrombin. Coblation technology is based on non heat driven
process of soft tissue dissolution which makes use
Coblation technology is widely used in the field of bipolar radio frequency energy. This energy is
of otolaryngology for performing: made to flow through a conductive medium like
normal saline. When current from radio-frequen-
1. Tonsillectomy cy probe passes through saline medium it breaks
2. Adenoidectomy saline into sodium and chloride ions.
526
These highly energized ions form a plasma field
strong enough to break organic molecular bonds
within soft tissue causing its dissolution. Since
1950’s high frequency electrosurgical apparatus
have been in use. In conventional high frequen-
cy apparatus heat is made use of to cause tissue
ablation and coagulation. The heat generated
happens to be a double edged weapon causing
collateral damage to normal tissues. Coblation is Image of RF generator
actually a beneficial offshoot of high frequency
radio frequency energy. The excellent conduc-
tivity of saline is made use of in this technology. Effect of plasma on tissue:
This conductivity is responsible for high energy
plasma generation. The effect of plasma on tissue is purely chemical
and not thermal. Plasma generates H and OH
Stages of plasma generation: ions. It is these ions that make plasma destructive.
OH radical causes protein degradation. When
First stage – (Vapor gas piston formation): coblation is being used to perform surgery the
This is characterised by transition from bubble interface between plasma and dissected tissue acts
to film boiling. This decreases heat emission and as a gate for charged particles.
causes increase in surface temperature. In nutshell coblation causes low temperature
molecular disintegration. This causes volumetric
Second stage – Stage of vapor film pulsation: Tis- removal of tissue with minimal damage to adja-
sue ablation occurs during this stage. cent tissue 10. (Collateral damage is low).
Third stage – Reduction of amplitude of current
across the electrodes.
Differences between coblation and conventional
Fourth stage : Dissipation of electron energy electrosurgical devices:
at the metal electrode surface Fifth stage (stage
of thermal dissipation of energy): This stage is Coblation Electrosurgi-
essentially due to recombination of plasma ions, devices cal devices
active atoms and molecules. Temperature 40-70 degrees 400-600 de-
Centigrade grees centi-
These stages explain why coblation is effective grade
if applied intermittently. This ensures constant
Thermal pen- Minimal Deep
presence of stage of vapor film pulsation which is
etration
important for tissue ablation.
Effects on Gentle re- Rapid heat-
target tissue moval/ disso- ing/charring/
lution burning/cut-
ting

Effects on Minimal dis- Inadvertant Components of Coblation system:
surrounding solution charring /
tissue burning 1. RF generator
2. Foot pedal control
Electrocautery: 3. Irrigation system
4. Wand
This involves direct current. Electrons flow only
in one direction and they dont enter the patient’s
body. High tissue temperatures are reached caus-
ing lots of collateral damage.
Monopolar diathermy:
Active electrode is located in the surgical equip-

ment. Return electrode is the diathermy earth
pad placed on the patient. The generator directs
current from the active electrode, through the
patient’s body, to the
grounding electrode and then back to the genera-
tor. Good for heavy bleeders.
Bipolar diathermy:
Conventional bipolar cautery - current is deliv- Image showing irrigation system

ered through a forceps like device. One prong
serves as active electrode, while the other serves
as return electrode. Current flows from one prong
through the tissue
to the other prong.
Coblator:
Active and return electrodes are housed in the
same shaft.
Operates at low temperature and frequency. Cur-

rent has to travel only through a shorter path and
does not travel through the patient.
Image showing pedal
RF generator:
528
7. Kashima’s procedure for bilateral abductor
This generator generates RF signals. It is con- paralysis
trolled by microprocessor. This generator is 8. Turbinate reduction
capable of adjusting the settings as per the type of 9. Nasal polypectomy
wand inserted. It automatically senses the type of 5. Cordectomy
the wand and adjusts settings accordingly. Man- 6. Removal of benign lesions of larynx including
ual override of the preset settings is also possible. papilloma
Two settings are set i.e. coblation and cauteriza- 7. Kashima’s procedure for bilateral abductor
tion. For a tonsil wand the recommended settings paralysis
would be : 8. Turbinate reduction
9. Nasal polypectomy
Coblation – 7 (plasma setting)
Cauterization – 3 (Non plasma setting) There are different types of wands 11 available to
perform coblation procedure optimally. Tonsil
Similarly the foot pedal has two color coded ped- and adenoid wand is the commonly used wand
als. Yellow one is for coblation and the blue one for all oropharyngeal surgeries. This wand will
is for RF cautery. This device also emits different have to be bent slightly to reach the
sounds when these pedals are pressed indicating adenoid. Laryngeal wand is of two types. Normal
to the surgeon which mode is getting activated. laryngeal wand which is used for ablating laryn-
geal mass lesions. Mini laryngeal wand is used to
Even though coblation is a type of electro sur- remove small polyps from vocal folds. The main
gical procedure, it does not require current flow advantage of mini laryngeal wand is its ability to
through the tissue to act. Only a small amount of reach up to the subglottic area.
current passes through the tissue during cobla-
tion. Nasal wand and nasal tunneling wands are
commonly used for turbinate reduction. Separate
Tissue ablation is made possible by the chemical tunneling wands are available for tongue base
etching effect of plasma generated by wand. The reduction.
thickness of plasma is only 100-200 μm thick
around the active electrode. Equipment specification:
Otolaryngological surgeries where coblation tech- 1. Modes of operation – Dissection, ablation, and
nology has been found to be useful include: coagulation
2. Operating frequency – 100 khz
1. Adenotonsillectomy 3. Power consumption – 110/240 v, 50/60 Khz
2. Tongue base reduction
3. Tongue channeling
4. Uvulo palato pharyngoplasty
5. Cordectomy
6. Removal of benign lesions of larynx including
papilloma

Image showing interior of coblation wand
Coblation wand has two electrodes i.e. Base elec- between the electrodes. Hence a smoking wand
trode and active electrode. These electrodes are should be flushed using a syringe to remove soft
separated by ceramic. Saline flows between these tissue ablated particles between the electrodes.
two electrodes. Current generated flows between
these two electrodes via the saline medium. Sa- The generated frequency from coblator should at-
line gets broken down into ions thereby forming least be 200 kHz since frequencies lower than 100
active plasma which ablates tissue. kHz can cause neuromuscular excitation when
Efficiency of ablation can be improved by: the wand accidentally comes into contact with
neuromuscular tissue.
1. Intermittent application of ablation mode
2. Copious irrigation of normal saline Coblator has been designed to operate in two
3. By using cold saline plasma generated becomes different modes:
more efficient in ablating tissue. Cold saline can
be prepared by placing the saline pack in a refrig- Ablation mode: As the RF controller setting is
erator over night. increased from 1 to 9 in the coblation mode, the
performance of the wand transitions from ther-
Coblation is a smokeless procedure. If smoke is mal effect to ablative effect due to creation and
seen to be generated during the procedure it in- increase in the intensity of plasma. When the
dicates the presence of ablated tissue in the wand controller setting in the coblation mode increases
530
the plasma field increases in size and the thermal
effect decreases accordingly. Controller Unit:
Coagulation mode: All coblation wands have This is nothing but a Radio frequency generator.
been designed to operate in coagulation mode This unite generates RF signals. It is controlled
for hemostasis during surgery. Since the wand by a microprocessor chip. This unit is capable of
is bipolar in nature, it sends energy through the adjusting settings according to the type of wand
desired tissue area, through resistive heating inserted. It has also features of manual over ride
process. of automatic settings.
For example automatic settings for a tonsil wand

Coblator setup would be:
The following are the parts of Coblator: Coblation - 7 (Plasma setting)

Cauterization - 3 (non plasma setting)
1. Controller unit
2. Flow control Unit
3. Foot control unit
Image showing the back side of coblator:
1. Alarm volume adjuster knob

2. Coolant fan vent
3. Slot for power cable

Controller input power requirements: Setting up coblator system steps:
1. Power cable is plugged into the rear port of the

Voltage 90-120 volts AC console
Frequency 50-60 Hz 2. Power switch in front of the console is switched
on
RMS Current 8 Amps Max
3. Connect the foot pedal and the wand cable to
Fuse rating T8 amps 250 V AC the corresponding receptacle on the front of the
for 120 VA controller. As soon as the wand is connected to
the receptacle, the type of wand would be sensed
by the microprocessor inside and console and
Controller power output: the default settings of the particular type of wand
would be displayed. If for some reason the default
Fundamental fre- 100 kHz settings need to be adjusted then it can be done
quency using the up / down arrows present on either side
Voltage range 0-300 VMS @ 100 kHz of the settings displayed.
Maximum power 400 watts @ 250
output Ohms
Operating tempera- 10 0 c to 40 0 C
ture
Image showing the front side of controller unit:
1. Coblation setting
2. Coagulation setting
3. Wand port
4. Foot pedal port
5. Flow control unit port
6. Hazard lamp
532
4. For using wands along with saline irrigation, Saline should only drip when the surgeon steps
the flow control valve unit is clamped to the IV on the pedal. Non stop flow of saline through the
stand. 500ml / 1000 ml normal saline is hung at wand indicates that the saline tube has not prop-
a height of 3 feet above the patient for ensuring erly passed through the pinch cock valve of the
optimal saline flow. flow control unit.
5. Plug one end of the flow control cable into the
rear of flow control valve unit, and the other end 8. Connect the OR suction tubing to the suc-
into the receptacle on the front of the controller. tion tubing of the wand. Recommended suction
6. Connect the IV tubing from the saline bottle pressure should ideally be between 250-300 mm
to the wand after passing through the pinch valve of Hg.
of the flow control unit. Valve switch is pressed
upwards so that green light is illuminated to open During surgery the tip of the wand emits a glow
the pinch valve. which is known as the plasma. Plasma generation
7. Open the irrigation tubing roller clamp to is necessary for tissue ablation. The color of the
manually start the saline flow. The saline can glow is dependent on the type of medium used.
be seen coming out of the tip of the wand. The Use of sodium chloride (Normal saline) solution
drip rate is adjusted by using the roller clamp of as the medium causes yellow colored
IV tube to the desired level. The valve switch is glow (plasma) while potassium chloride medium
pressed down to auto position. causes pinkish blue plasma glow.
During coblation surgery the tissue could be
Image showing the power switch in front of the console

Image showing flow control unit clamped to the saline stand. Note the
IV cable passing through a pinch cock valve
seen turning brown. This does not indicate heat that emitted when the coagulate pedal is pressed.
induced charring but tissue oxidation. Surgeon who regularly use this equipment for
surgery could just by listening to the sound emit-
ted by the alarm on pressing either of these pedals
During surgery copious irrigation with normal will know which is being pressed just by hearing
saline increases the quality of plasma generat- the sound.
ed. Sometimes if the quantity of saline irritation
needs to be increased for better ablation of tissue.
In this scenario the flow can be increased by ap-
plying direct pressure to the saline bag.
Typical tonsil wand (Evac 70) has ports for irri-

gation, suction and a connecting cable which is
connected to the front side of the console.
During surgery it could be noticed that the alarm

sound emitted when ablate pedal is different from
534
Wands
There are different wands available for different

surgical procedures.
These wands include:
1. Tonsil wand
2. Laryngeal wand
3. Microlaryngeal wand
4. Nasal wand
5. Needle wands for tongue base reduction and
turbinate reduction
Tonsil wands:
This wand is also known as Evac 70 wand. It has

Image showing the two types of plasma glow a triple wire molybdenum electrode. This triple
depending on the medium wire electrode is very useful for tissue ablation.
Its bipolar configuration suits efficient hemosta-
sis. The shaft is malleable and hence can be bent
to suit various anatomical configurations of oral
cavity. It can also be bent so much that adenoids
can be reached via the oral cavity route under the
soft palate. It has integrated suction and irrigation
facility. Normal saline is used for irrigation pur-
poses. Normal saline acts as a medium through
which Radio frequency current passes causing
release of plasma. This integrated irrigation and
suction facility obviates the necessity of separate
suction during surgical procedures.
Image showing tonsil wand
Tonsil wand happens to be the work horse of the
entire system. It is also the most commonly used
wand. The basic advantages of tonsil wand are:
1. Plasma generated by the electrodes are opti-

mized for adequate tissue ablation
2. The depth of injury is very less and hence there

is no collateral tissue damage
3. The temperature generated between the elec-
trodes is 40-70° C. This temperature does not
cause airway fire and it is hence safe to use.
4. The presence of multiple electrodes ensures
quick and stable establishment of plasma layer,
maintains the stability of the plasma layer and
also maximizes the plasma layer.
EVac T&A:
This is the most aggressive of the coblator wands.

It behaves like tonsil suction wand because of
its ability to simultaneously dissect, ablate and
remove tissue. It has a stronger suction with a
larger electrode. It is longer and more malleable
than the classic EVac 70 wand hence can be used
to remove adenoid tissue.
Image showing Tonsil wand (E-Vac 70) in action
Major advantage of Evac 70 group of wands is

that the wand shaft is malleable and thus can be
bent to accommodate variable patient anatomy.
This feature also helps in accessing the choanal
area during adenoidectomy.
EVAC 70 XTRA:
This wand is a variation of the classic EVAC 70

tonsil wand in that it is efficient in ablating tissue.
Key features of this wand include:
* It has a triple wire electrode configuration

which efficiently removes both adenoid and ton-
sillar tissue.
* It has integrated suction and irrigation ports
making it a convenient all in one tool during
surgery
Image showing Evac 70 triple electrode wand * Its shaft is about 6 inches longer than that of
classic Evac 70 wand making it suitable for ac-
cessing choanal area during adenoidectomy.
536
* The shaft is also malleable hence it can be bent variations of the patient’s oropharynx.
confirming to the varying oropharyngeal anato-
my of the patient.
Image showing the tip of Procise Max wand

along with its flat screen electrode.
Image showing the ports and electrodes of EVAC Excise Pdw Plasma wand:
70 XTRA wand
This is considered by many surgeons to be a fine
Procise Max wand: dissecting instrument which delivers the effect of
coblation with the tactile feel of monopolar
This wand is suited for rapid ablation of tissue cautery. By design it has a single wire-loop elec-
with good hemostasis. This wand is particularly trode, with thinner and smaller shaft length
useful during adenoidectomies where rapid abla- which facilitates better surgical field visualisation.
tion of tissue with adequate hemostasis is a must.
It has a flat screen electrode configuration with Advantages of Excise Pdw Plasma wand:
high power suction port. Its ablation is about 20%
more than that of EVAC 70 Ultra. Its improved 1. It is a fine dissector, hence excellent surgical
suction capability prevents clogging of the wand plane can be created and maintained.
by ablated tissue. This wand is slightly thinner 2. Depth of thermal injury is less
than that of EVAC 70 wand thereby provides im- 3. Coagulation mode is useful to coagulate bleed-
proved visibility during surgeries. Since it is also ers
malleable it can be bent to confirm to anatomical 4. Its integrated suction and irrigation features

completes the system It is provided with visual markers to ascertain
5. Very useful in performing tonsillectomy and the depth of insertion before actually ablating the
Uvulo palato pharyngoplasty tissue. These depth markers are colored orange
for better visibility.
Tip diameter - 1.3 mm

Length of the electrode area - 10.5 mm
Distance from tip to bend - 42.6 mm
Number of visual markers - 2
Color of visual markers - Orange
Image showing EVAC 70 HP Xtra Plasma wand

Image showing Excise Pdw Plasma wand show-
ing its single wire loop electrode
EVAC 70 HP Xtra Plasma wand:
This wand is slightly longer and more malleable

than the conventional EVAC 70 wand. It has a
triple electrode configuration. Because of its extra
length and malleability it is very useful during
adenoidectomy, especially while removing tissue
close to the choanal area.
Reflex Ultra PTR wand:
These wands are used for turbinate reduction sur- Image showing Reflex Ultra PTR wand
geries. These wands are designed to suit varying
anatomy of nasal turbinates. It is thin and sleek.
538
Technical specifications:
Tip diameter - 1.7 mm

Length of electrode area - 10 mm
Distance from the tip to bend - 56.1 mm
Number of depth markers - 3
Color of depth markers - Black
Image showing tip of Reflex Ultra PTR wand
Turbinate reduction wands have the following

default setting:
Coblate - 4
Coagulate - 2 Image showing Reflex ultra 45 wand
Coblation channeling technique is used to reduce ReFlex Ultra SP:

the size of the turbinates. This same technique This is a soft palate wand. This is designed for
is also used for tongue base reduction surgical rapid dissection and
procedures. Major advantage of these tunneling channeling of soft tissue during Uvulo palato
technique is that only submucosal tissue is ablat- pharyngoplasty and other snoring treatment
ed sparing the mucosal surface. Multiple channels procedures. It has an adjustable saline delivery
can be created for optimal tissue ablation. sheath which makes it suitable for cutting and
submucosal tissue shrinkage if desired. It has a
Reflex ultra 45 wand: distal ablative electrode and a proximal thermal
electrode. This feature helps the wand to cut and
These wands have slightly longer shaft length shrink tissue simultaneously.
to cater to large turbinates. Both anterior and Default setting of this wand is:
posterior portions of the turbinate can be ablat-
ed using this wand. Since it is longer than Reflex Coblate - 4
Ultra PTR wand it has three depth markers. These Coagulate - 2
markers are colored black.

tion, irrigation, suction and bipolar coagulation.
Its unique curvature and the tip adds to the preci-
sion and visibility during the surgical procedure.
Image showing the tip of Reflex Ultra SP wand
Reflex Ultra 55 wand:
This is also a soft palate wand. This wand also has Image of PROcize EZ View wand
a distal ablative electrode and proximal thermal
electrode. This wand can also be used for chan- Default settings:
neling procedures of soft palate.
Coblate - 7
It is bent at 55 degrees which follows the curva- Coag - 3
ture of soft palate.
Coblation assisted nasal polypectomy is associat-
Default setting of this wand is: ed with a significant reduction in blood loss when
compared to that of debridement. Coblation
Coblate - 4 Assisted FESS (CAFESS) is a new technique of
Coagulate - 2 treatment for chronic sinusitis and nasal polypi.
It is currently holding out lots of promise. Lim-
PROcise EZ View wand: itations of coblator in nasal surgeries is largely
caused by the size of the wand and the saline
This wand is used for nasal surgeries. This wand delivery system. Increasing the amount of irriga-
offers all the benefits of coblation technology in a tion delivered will improve the efficiency of the
small diameter device. This wand integrates abla- system. The shaft width of PROcise EZ view wand
540
is 50% less than that of Evac 70 wand. To improve
irrigation 1 litre saline bag should be used.
PROcise LW:
Coblation technology can be used in laryngeal

surgeries like removal of laryngeal polyp, cysts.
This technology can also be used to perform
Posterior cordotomy (Kashima’s procedure) in
patients with bilateral abductor paralysis. Major
advantage of this technology in laryngeal sur-
gery is the absence of airway fire risk. The shaft is
malleable.
It has a screen electrode which is capable of swift-
ly debulking the target tissue. Its malleable shaft
adapts to the patient anatomy.
Image showing PROcise LW wand in action
Image showing PROcise LW wand
Image showing posterior cordotomy performed

PROcise MLW Plasma Wand:
This wand has been designed for precise con-

trolled removal of laryngeal and subglottic le-
sions. This wand is ultra slim and is suited for
working inside small anatomy. It provides abla-
tion, coagulation, irrigation and suction capabili-
ties in one single versatile device.
Image showing PROcise MLW plasma wand in

action
Image showing PROcise MLW Plasma wand
It has a single wire active electrode configuration.

It provides pinpoint precision for ablation pro-
cess. There is no risk of airway fire. Its extended
length increases the field of vision. It also allows
anterior commissure to be reached.
Working length of shaft is: 19 cms

Shaft outer diameter is 2.8 mm
Default settings:
Coblate - 7
Coagulate - 3
542
my is caused due to spasm involving pharyngeal
Coblation Tonsillectomy: musculature. This is avoided if dissection stays
away from the capsule.
Introduction:
Coblation tonsillectomy is performed under
Currently coblation is being attempted to re- general anesthesia. Patient is put in Rose position
move tonsillar tissue. This process was invented (the same position that is used for conventional
by Philip E Eggers and Hira V Thapliyal in 1999. tonsillectomy). Operating microscope is used for
Coblation tonsillectomy received FDA approval visualisation. Lowest magnification is chosen.
in 2001.
Advantages of performing coblation tonsillecto-
Advantages of coblation tonsillectomy: my under magnification:
1. Less bleeding 1. Capsule is easy to identify under magnifica-

2. Preservation of capsule is possible if done un- tion and hence can be preserved by performing
der magnification. If capsule is preserved there is extra-capsular tonsillectomy
less post operative pain 2. Microscopic images can be connected to a
3. Tonsillar reduction surgeries can be performed monitor. Surgeon hence has the option of operat-
in young children without compromising the im- ing seeing the monitor as they do in endoscopic
munological function of the lymphoid tissue sinus surgery
3. The entire surgical procedure can be recorded
The Procedure: and documented, hence it is useful for teaching
and training students of otolaryngology.
Coblation technology uses bipolar radio-frequen-
cy waves transmitted via isotonic saline solution.
This process generates plasma which ablates
tissue. Temperature required for ablation is about
60 degree centigrade. Since there is no abnormal
heating of tissue during coblation
there is very minimal collateral damage to ad-
joining tissue. Author prefers to use cold nor-
mal saline while performing coblation surgeries
because the quality of plasma is better with cold
saline. Normal saline is refrigerated overnight to
make it cold. Evac 70 wand is used to perform
tonsillectomy.
Coblation tonsillectomy is ideally performed

under microscopy inorder to identify the tonsillar Image showing microscope being adjusted before
capsule. If the dissection stays extra-capsular post coblation tonsillectomy
operative pain is less. Pain following tonsillecto-

While adjusting the microscope it should be en-
sured that both tonsils appear in the same field as
seen during regular tonsillectomy procedure. At
this point it should be borne in mind that there
is a learning curve involved in this technology.
The following tips would ensure that this curve is
surmounted seamlessly.
1. Always start with a clean slate. This facilitates

easy learning process.
2. The wand should be held in such a way that it
forms an angle of 30 -40 degrees with the tissue
that needs to be ablated because for adequate
plasma generation saline should come into con-
tact with the electrodes.
3. While performing tonsillectomy the want
should not be in physical contact with the tissue,
but should be perilously close to it. This would
ensure proper formation of plasma.
4. When confronted with a bleeder, the wand
should hover over the bleeder (Tim’s Hover Image showing the proper way of holding the
technique). Invariably this stops the bleeding. In wand while performing tonsillectomy on the left
the event of persistent bleeding then wand should side
be placed in contact with the bleeder and cautery
pedal needs to be pressed. Since this procedure If excess smoke is generated during coblation
is performed under magnification, even a small surgery then it indicates tissue is caught between
bleeder will appear magnified. the electrodes. The wand should immediately
5. Ablate pedal should be pressed intermittently be declogged using saline irrigation. “Beware of
for effective and efficient generation of plasma. smoky wand”.
Studies have shown that the quality of plasma
generated is rather poor when ablate mode is For a beginner right sided coblation tonsillec-
continuously used by continuous pressure on the tomy is easier if the dominant hand is right. For
pedal. performing left coblation tonsillectomy the wand
6. Use of copious irrigation during the procedure should ideally be held in the left hand. This may
is a must. This ensures continuous generation of take some doing if the dominant hand is right.
plasma. Tonsil is held with tonsil holding forceps and
gently pulled medially. wand should be held at an
angle of 30 - 40 degrees with the tissue being ab-
lated. This will ensure that saline gets into contact
with the bipolar electrode available at the tip of
the wand.
544
Incision is made just medial to the anterior pillar.
Ablation can start either from lower pole to upper
pole or from upper pole to lower pole according
to the preference of the surgeon. The process of
ablation should be uniform and the wand should
stay close to the tonsillar tissue and away from the
capsule to prevent damage to it. If ablation is not
uniform then the surgeon will end up digging a
pit in the tonsillar tissue and also will encounter
more bleeding than envisaged.
Image showing the right way of doing coblation

tonsillectomy. Incision is seen being given from
inferior pole to superior pole of tonsil.
Image showing the wrong way of ablating tonsil-

lar tissue. Note formation of pit in the tonsillar
tissue associated with bleeding.
Image showing coblation tonsillectomy about to

be completed

Debulking of hypertrophied tonsils:
Performing tonsillectomy in young children is

not a commonly accepted procedures. Debate is
still raging on the influence of tonsillectomy on
immunity of the child. Debulking is a good trade
off, where in the hypertrophied tonsil can be
debulked leaving behind a sleeve of residual lym-
phoid tissue to take care of the child’s immunity.
This procedure was first performed using mi-

crodebrider. Bleeder’s are cauterized using bipolar
cautery. Use of coblation has made this surgery
easy to perform.
Image showing tonsillar fossa with intact capsule

after removal of tonsil.
A little medial traction of tonsil while ablation is

being performed will make separation of tonsil
from the fossa that much easier. Traction also
helps the surgeon to visualize the capsule. While
working close to the superior pole of tonsil injury
to uvula and soft palate should be avoided. Injury
to these structures during surgery will increase
post operative pain thereby negating the advan-
tage of coblation tonsillectomy.
Post operative secondary bleeding is common in Image showing Tonsillotomy (Tonsillar debulk-
coblation tonsillectomy when compared with that ing surgery) being performed
of conventional cold steel method. Bleeding is not
torrential but blood tinged saliva could be seen in While performing tonsillotomy the wand should
some patients during the second week following be in contact with the tissue, hence there is always
surgery. This is due to the formation of granula- the risk of wand getting clogged with debris and
tion tissue, which is part of the healing process. hence need to be declogged by flushing with a
syringe. Clogging can be reduced if the flow of
saline is increased. Author prefers to over ride the
546
auto mode of the irrigation system to manual and dered breathing in children. Majority of these
seeking the help of assistant to compress / squeeze disorders have been attributed to adenoid hyper-
the saline bag while performing the surgery. trophy. Large number of these patients undergo
Suction used during tonsillotomy procedure adenoidectomy alone or a combination of ade-
should be reasonably powerful so that there is no noidectomy and tonsillectomy.
unnecessary accumulation of fluid and debris in
the surgical field. Various methods of performing adenoidectomy
include:
Advantages of Tonsillotomy:
1. Conventional cold steel technique using ade-
1. Post operative pain is less noid curette
2. Child’s immunity is not compromised at least 2. Bipolar coagulation under endoscopic vision
theoretically 3. Adenoidectomy using microdebrider
4. Coblation adenoidectomy
Disadvantages of coblation:
Adenoid hypertrophy has a tendency to recur af-
1. Cost of wand is high. ter surgery. The recurrence rate has been found to
2. It can be used only once because secondary in- be highly variable between studies. Lundgren’s se-
fections / secondary bleeding following coblation ries put the recurrence rate between 4-8%, while
surgery using already used wand is high. Hill’s series showed a variation between 23.7-50%.
3. Reuse of wands should be discouraged because
plasma generation is not optimal when wands are Tolczynski (1955) attributed the variations in
reused. recurrence rates between different studies to the
following factors:
Coblation Adenoidectomy
1. Anatomical difficulties
Introduction: 2. Adenoid area is difficult to visualize
3. Adenoidectomy is often performed in a hurry,
Adenoidectomy is one of the most commonly sometimes under inadequate anesthesia. This
performed surgeries in children. Complications causes inadequate relaxation of palato-pharyn-
following adenoidectomy is fortunately rare. geus muscles interfering with surgical manipula-
Various surgical techniques have been devised to tion of adenoid pad
improve the outcome of tissue.
following adenoidectomy, and to reduce bleeding
during the procedure. Operating surgeon should Adequate removal of hypertrophied adenoid
lay emphasis on the safety, accuracy and outcome tissue is difficult using conventional currettage in
of the procedure before deciding on the surgical the following scenario:
technique. 1. When there is intranasal extension of adenoid
tissue.
During the past decade there has been an increase 2. Bipolar coagulation under endoscopic vision
i n awareness of high prevalence of sleep disor- 3. Adenoidectomy using microdebrider

4. Coblation adenoidectomy cidence of revision adenoidectomy at a later date.
Adenoid hypertrophy has a tendency to recur af- Coblation adenoidectomy is currently becoming
ter surgery. The recurrence rate has been found to popular because:
be highly variable between studies. Lundgren’s se- 1. It facilitates complete removal of adenoid tissue
ries put the recurrence rate between 4-8%, while under direct vision
Hill’s series showed a variation between 23.7-50%. 2. Bleeding is very minimal
3. Every area of the nasopharynx is accessible to
Tolczynski (1955) attributed the variations in the wand tip
recurrence rates between different studies to the 4. Lower incidence of left over residual adenoid
following factors: tissue
5. Lower risk of complications
1. Anatomical difficulties Coblation adenoidectomy can be performed un-
2. Adenoid area is difficult to visualize der direct vision by using an endoscope through
3. Adenoidectomy is often performed in a hurry, the nasal cavity / endoscope (angled) via throat
sometimes under inadequate anesthesia. This after retracting the soft palate.
causes inadequate relaxation of palato-pharyn-
geus muscles interfering with surgical manipula- The Procedure:
tion of adenoid pad
of tissue. Coblation adenoidectomy is performed under
general anesthesia. Author prefers to perform
Adequate removal of hypertrophied adenoid tis- tonsillectomy before adenoidectomy if coblation
sue is difficult using conventional curettage in the technique is used because the same wand used for
following scenario: tonsillectomy can be bent to perform adenoidec-
1. When there is intranasal extension of adenoid tomy thereby cutting down on wand cost. Evac 70
tissue. is preferred by the author for adenoidectomy. If
2. Bulky mass of adenoid tissue superiorly in the difficulties are encountered in reaching the roof
nasopharynx of nasopharynx the wand can be bent appropri-
3. Adenoid tissue in the peritubal region ately. Wand can be bent at the junction of anterior
In the light of above stated facts, to ensure com- and middle thirds.
plete or near complete removal of adenoid tissue,
direct / indirect visual assistance is mandatory. After completion of tonsillectomy under Rose
position, the tonsillar jack is removed. Sand bag
Recent study by Ezaat 2010 demonstrated that under the shoulder is also removed. Patient’s head
when routine endoscopic examination of na- is elevated to 30 degrees. (Head up position as
sopharynx was performed after conventional in nasal surgeries). If the nasal cavity is roomy
adenoidectomy about 14.5% of patients demon- enough the wand can be inserted along with the
strated residual adenoid tissue which was needed nasal endoscope through the nasal cavity and the
to be removed. He thus went on to conclude that surgery is performed. In the event of a narrow
routine endoscopic examination of nasopharynx nasal cavity the wand can be inserted through the
following adenoidectomy clearly reduced the in- mouth after retracting the soft palate using soft
548
rubber catheter passing through the nasal cavi- conventional adenoidectomy. Copious irrigation
ty. Nasopharynx can be visualised using a nasal of saline ensures adequate plasma generation for
endoscope passed through the nasal cavity or by tissue ablation. Currently Procise Max wand has
passing an angled endoscope through the oral been promoted as a better tool for coblation ade-
cavity under the soft palate. noidectomy by the manufacturer.
Wand can be used to ablate adenoid tissue. Ade- Advantages of Procise Max wand according to
noid tissue is ablated till muscles of the posterior manufacturer are:
wall of nasopharynx is exposed. The movement of
the wand while performing adenoid tissue abla- 1. Tissue ablation is rapid because of the unique
tion resembles that of removing cobweb in the flat screen electrode
roof of a room. Irrigation should be copious while 2. Suction port in this wand is also very effective.
ablating adenoid tissue as there is a risk of wand According to the manufacturer ablation rate of
getting clogged with ablated tissue. The risk of procise wand is about50% faster than that of con-
wand clogging is higher during adenoid ablation ventional Evac 70 wands.
because the wand is in direct contact with the
tissue.
One major draw back of this position is the risk

of aspiration. Conscious effort should be made on
the part of the surgeon to keep applying suction
periodically to prevent aspiration.
Currently coblation adenoidectomy is being per-

formed in the Rose position itself. After comple-
tion of tonsillectomy, the soft palate is retracted
by passing thin nasal suction catheters through
both the nasal cavities and delivering it through
the mouth. Soft palate can be retracted by tying
these catheter ends.
Image showing the tip of Procise Max electrode
After retraction of soft palate an angled telescope with its flat screen electrode
(30 degree 4 mm) can be used through the oral
cavity to visualize the nasopharynx. Evac 70 wand
can then be passed through the oral cavity to
reach up to the nasopharynx for ablating adenoid
tissue. Advantage of this procedure
is that there is absolutely no risk of aspiration.
Added advantage being that the patient’s posi-
tion need not be changed midway through the
procedure. The surgeon’s position too resembles

Image showing adenoid tissue being visualised
using an endoscope through the oral cavity
Image showing adenoidectomy begun
The procedure should be started with a straight
wand. To access difficult to reach areas the wand
can be bent for better access.
Image showing how to bend the wand
Image showing fumes arising from a clogged

wand
550
During surgery saline irrigation should be pro-
fuse. Recommended suction pressure should be Process of ablation should stop as soon as prever-
between 250-350 mm Hg. tebral fascia is reached. It can be identified by its
white color. Care must be taken not to damage
Coblation adenoidectomy is getting popular underlying prevertebral muscles. If bleeding is
because hither to blind procedure is now be- encountered it should be immediately cauterized
ing performed under direct vision. In coblation by using coagulation mode.
adenoidectomy tubal tonsil and adenoid tissue
around torus tubaris can be ablated with reason- Disadvantages of coblation adenoidectomy:
able confidence without fear of injury to
eustachean tube because it is being done under 1. Cost involved is high
direct vision. 2. Operating time is more when compared to
conventional adenoidectomy
For purposes of classification and management 3. Author encountered significant secondary
adenoid hypertrophy has been graded according bleeding following coblation adenoidectomy in
to the size of the tissue and its relationship with one patient. Post nasal pack and hospitalization
vomer, soft palate and torus tubaris. was needed before the patient recovered.
Coblation Kashima Procedure (posterior cordot-

omy)
Introduction:
Bilateral vocal fold paralysis is a surgical emer-

gency, which should be addressed immediatly.
Securing the airway takes precedence over quality
of voice.
Two terms need to be explained at this stage:
BVFI (Bilateral vocal fold immobility) and BVFP

(Bilateral vocal fold paralysis).
Bilateral vocal fold immobility: This is actually a

broad term encompassing all forms of reduced or
Image showing prevertebral fascia being exposed absent vocal fold mobility. Immobility could be
after ablation of adenoid tissue. Note copious due to mechanical fixation or neurological in-
saline irrigation volvement.
Bilateral vocal fold paralysis: This condition refers

to neurological causes of vocal fold immobility / Existing surgical options:
reduced mobility. This specifically refers to absent
function of vagus nerve or its distal branch the These include:
Recurrent 1. Tracheostomy
laryngeal nerve. 2. Total arytenoidectomy
3. Subtotal arytenoidectomy
Bilateral vocal fold immobility is a potentially 4. Transverse cordectomy
fatal disorder which needs to be diagnosed early 5. Vocal fold lateralization
and treated appropriately. 6. Reinnervation techniques
7. Kashima procedure
Causes of bilateral vocal fold immobility include:
Among these procedures tracheostomy should
1. Bilateral recurrent laryngeal nerve palsy be the initial life saving one. In case a patient is
2. Bilateral fixation of cricoarytenoid joint presenting with stridor then air way should be se-
3. Laryngeal synechiae cured at the earliest by performing tracheostomy.
4. Posterior glottic stenosis
5. Post intubation trauma Clinical features:
6. Inflammatory disorders
Management of bilateral abductor paralysis de-
It is important to differentiate these conditions. pends on the clinical presentation. This include:
Kashima surgery is indicated only in patients
with bilateral vocal fold paralysis. 1. Stridor due to airway compromise
2. Near normal voice
These conditions can be differentiated by:
Degree of stridor may vary depending on:
Taking detailed clinical history
Video laryngoscopic examination 1. Amount of glottic chink
Laryngeal electromyography 2. Arytenoid body mass
Palpating arytenoids under anesthesia (microla- 3. Presence / absence of co-morbidity
ryngeal examination) 4. Physical activity 10% of these patients need no
In the author’s series thyroidectomy constituted intervention. Some of these patients could be-
the most important cause for bilateral vocal fold come decompensated and develop stridor after
paralysis. physical activity or a bout of respiratory infection.
Aim of treatment: Causes of Bilateral abductor paralysis presented at

our institution:
1. To secure the airway
2. To preserve glottic sphincter mechanism 1. Surgical - commonly following total thyroidec-
3. To maintain voice quality. These patients in- tomy - 59%
variably have good voice. 2. Post intubation sequele 25%
3. Trauma - 2%
552
4. Neurological disorders - 15% airway is not adequate then the same procedure
5. Extralaryngeal malignancies 5-17% may also be repeated on the opposite side also.
For centuries tracheostomy was the treatment of Reker and Rudert modified Kashima’s procedure
choice for these patients. Even now all the exist- by a complementary resection in the body of
ing procedures are compared with that of tra- lateral thyroarytenoid muscle anteriorly from the
cheostomy. Tracheostomy hence still remains the initial triangular incision. This procedure enabled
gold standard against which all other treatment creation of better airway without compromising
modalities for bilateral abductor voice quality.
paralysis is compared. In 1922 Chevalier Jackson
introduced the procedure ventriculocordectomy
as a treatment procedure for bilateral abductor
paralysis. Major advantage of this procedure is
that it created
an excellent airway, but the voice became a bit
breathy because of excessive air leak while speak-
ing. In 1939 King proposed extralaryngeal aryte-
noidectomy.
In 1976 D.L. Zealer and HH Dedo attempted

to restore natural function of the vocal fold by
electrical stimulation of cricothyroid muscle with
varying degrees of success.
In 1979 Fernando R. Kirchner described a series

of patients who underwent lateralization of vocal
fold as a treatment modality for bilateral abductor
paralysis.
Image showing the site of resection in kashima’s
Kashima’s Posterior cordotomy: procedure
Surgical procedure introduced by Dennis Kashi-

ma in 1989 revolutionized the management of
patients with bilateral abductor paralysis. This
technique involves resection of soft tissues and
transection of conus elasticus. A C shaped wedge
of posterior vocal fold is excised begining
from the free border and extending to about
4 mm laterally. Rationale in this procedure is
release of tension of the glottic sphincter rather
than actual removal of glottic tissue. If the created

wand is ideal because its curvature suits manipu-
lation of the wand close to the vocal cords.
Malleability of this wand ensures that it can be

bent to facilitate better access. Major advantage
of coblation technology over laser / diathermy is
that there is absolutely no risk of airway fire.
When laryngeal wand is connected to the con-

troller the default settings get highlighted. Ab-
late - 7 Coag - 3. Suction should ideally be set to
approximately 250 mm of Hg. Saline flow should
be set to a minimal intermittent drip just enough
to produce plasma. Too much of saline
irrigation can cause aspiration.
Image showing Recker’s modification of Kashi-

ma’s procedure
Surgical Procedure:
This surgery is ideally done under general anes-

thesia. Klein sassaur suspension laryngoscope is
used to keep the mouth open during surgery. A
modification of Klein sassaur laryngoscope which
has a port for insertion of 12 degree telescope is
used. Camera can be attached to the telescope
and the surgery can be proceeded with by visual-
izing the vocal cord in the monitor.
Advantages of this modified Klein Sassaur sus-

pension laryngoscope are:
Image showing laryngeal wand tip
1. Image quality is excellent
2. Can be recorded
3. Can be used to teaching purposes
4. Both hands are free
Laryngeal wand is used for this procedure. This
554
Images showing steps of Kashima procedure
Ventricular band should be spared during the tages of this procedure.
surgery. Damage of ventricular bands could cause Author has performed 30 cases of coblation
unacceptable voice changes in a patient who un- Kashima procedure. All of them were successfully
dergoes this treatment. decannulated and weaned off the tracheosto-
my tube. Three year follow up of these patients
This enlarged posterior glottic space helps in im- showed no evidence of airway compromise.
proving the airway without compromising voice
quality. Since the anterior 2/3 of the vocal fold is Which cord to operate?
preserved, voice quality is usually good in these
patients. Bilateral abductor paralysis is a bilateral condi-
tion. Either of the two cords may be subjected to
Early decannulation: posterior cordotomy. Author believes the follow-
ing criteria could be used to decide which cord to
All these patients should be decannulated at the operate on.
earliest. It is preferable to spiggot the tracheosto-
my tube on the first post operative day itself.
This would facilitate natural airflow through the
glottis causing wound to heal better and faster.
This is infact one of the most important advan-

3. Scar formation
4. Posterior glottic web formation
Conclusion:
Posterior cordotomy (Dennis Kashima proce-

dure) using coblation technology is really prom-
ising therapy for patients with bilateral abductor
paralysis. This procedure restores sufficient glottic
space without causing damage to phonatory and
sphincteric functions of larynx.
Advantages of this procedure include:
1. Bloodless ablation
2. Precise ablation of tissue
3. No collateral damage to adjacent tissue
4. No oedema to tissues around larynx
5. Early decannulation is possible
Image showing Recker’s modification of Dennis

Kashima procedure
1. More medially placed cord is chosen for sur-

gery
2. If both cords are in identical positions then
the cord which shows at least a trace of mobil-
ity (during video stroboscopic examination) is
preferred.
3. If both cords show identical positions and
mobility then the surgeon should choose the cord
that provides the best access.
Post operatively all these patients should receive

antireflux treatment for a minimum period of 6-8
weeks.
Complications of Posterior cordotomy:
1. Post operative oedema

2. Granuloma formation
556
Endoscopic cordectomy 3. Bilateral abductor paralysis
Introduction: Cordectomy is contraindicated in patients with:
Cordectomy involves removal of entire mem- 1. Impairment of vocal fold immobility

branous portion of vocal fold along with vocalis 2. Involvement of thyroid cartilage by the tumor
muscle. If needed arytenoid cartilage also can be 3. When tumor involves either supraglottis /
removed. Inner perichondrium of thyroid car- subglottis
tilage also can be removed if involved by tumor.
Cordectomy via laryngofissure approach European laryngological society in the year 2000
was the commonly performed surgical procedure came out with a comprehensive classification of
for glottic carcinoma in olden days. Even now endoscopic cordectomy. 8 types of cordectomies
cordectomy remains the standard by which all were described by them.
other surgical treatments of glottic cancers are
measured. Type I cordectomy (Subepithelial cordectomy):
This procedure involves resection of vocal fold
Cordectomy can be performed by: epithelium, passing through the superficial layer
of lamina papyracea. This procedure spares deep-
1. Via laryngofissure er layers and thus the vocal ligament. This type of
2. Endoscopic cordectomy cordectomy is performed in patients with vocal
fold premalignant lesions or carcinoma in situ.
History of cordectomy: Since the entire epithelial covering of vocal fold is
removed, the specimen can be studied in detail by
In 1908, Citelli first performed cordectomy histopathologist to rule out malignant transfor-
externa through thyrofissure. In 1922 Chevalier mation. In addition to its inherent curative
Jackson described total cordectomy for a patient value, this procedure also serves as a good diag-
with bilateral abductor paralysis. Major drawback nostic source of tissue.
of the procedure described by Chevalier Jackson
was the poor quality of voice. Type II cordectomy (subligamental cordectomy):
Hoover modified the procedure described by This procedure involves resection of vocal fold
Chevalier Jackson by approaching the vocal cords epithelium, Reinke’s space and vocal ligament.
via laryngofissure. Dissection was submucosal. This procedure is performed by cutting between
Major advantage of this procedure is the availabil- vocal ligament and vocalis muscle. Vocalis muscle
ity of adequate mucosa for primary closure of the is preserved as much as possible. Extent of resec-
surgical wound. tion extends from vocal process to the anterior
commissure.
Indications of vocal fold cordectomy:
Indications for type II cordectomy:
1. Vocal fold dysplasia
2. T1 malignant lesions of vocal fold 1. In patients with severe vocal fold leukoplakia

Image showing Type I (subepithelial cordectomy)
2. When a vocal fold lesion clinically shows sign

of neoplastic transformation Type III cordectomy (Transmuscular cordecto-
3. Vibratory silence as seen during stroboscopic my):
examination
4. Lesion feels thick on palpation. Inability of This procedure is performed by cutting through
mucosa to move freely over underlying vocal fold the vocalis muscle. Resection involves epithelium,
structures lamina propria and portions of vocalis muscle.
Resection may actually extend from the vocal
process to anterior commissure.
In some patients for adequate exposure of the

entire vocal folds, partial resection of vestibular
folds may be needed. Resection of vestibular fold
is known as vestibulectomy. This procedure was
popularized by Swarc and Kashima.
Vestibulectomy is actually defined as subtotal

resection of vestibular fold Indications of vesti-
bulectomy include:
1. Removal of lesions confined to vestibular folds

2. To improve visualization and access to vocal
Image showing Type II cordectomy cords. The entire cord completely becomes visible
after vestibulotomy.
558
Image showing Type II cordectomy (Subligamental cordectomy)
Only risk in this procedure is bleeding from the

superior laryngeal artery. This brisk bleeding usu-
ally stops with 5 mins of tamponading with cot-
ton / gauze. Use of coblator has reduced the risk
of bleeding in these patients. Adequate amount of
vestibular fold can be removed thereby exposing
the entire superior surface of the vocal cord.
Transmuscular cordectomy is indicated for all

cases of small superficial cancers with mobile
vocal cords.
Image showing right vestibular fold hypertrophy

Image showing type III cordectomy
Image showing vestibulectomy being performed using laryngeal wand
560
Va).
Image showing type 4 cordectomy. Ventricular

band is removed to expose the vocal cord
Image showing vestibulotomy and the maxi-

mum extent to which the vestibular band can be In this type of cordectomy complete resection of
removed is marked by dotted line. involved vocal cord along with a segment / entire
portion of the opposite cord is also performed.
Total (Complete cordectomy) Type IV: Anterior commissure tendon is included in the
resection. The petiole of epiglottis needs to be
Resection in complete cordectomy extends from resected for complete visualization of the cords.
vocal process of arytenoid cartilage to anterior Resection of the contralateral ventricular band
commissure tendon. The depth of resection can can also be resorted to for better visualization.
reach up to the inner perichondrium of thyroid T1b tumor of vocal folds involving anterior com-
ala. If needed the perichondrium can also be missure can be managed by this procedure. Basic
included in the resection. Anteriorly advantage of using coblator in this setting is that
the incision is made in the anterior commissure. the resection can be performed without risk of
bleeding. Since there is very little collateral dam-
Attachment of vocal ligament to the thyroid age to adjacent tissues there is no post op laryn-
cartilage is cut completely. Total cordectomy can geal oedema. Another very important advantage
be extended to include the ipsilateral ventricular being there is absolutely zero risk of airway fire
fold. during surgery.
Extended cordectomy encompassing the contra-

lateral vocal fold is known as (Cordectomy Type

Image showing type Vb cordectomy encompass-
Image showing Type Va cordectomy ing the arytenoid cartilage
Extended cordectomy encompassing arytenoid specimen hence encompasses ventricular fold

cartilage (Type Vb cordectomy): along with sinus of Morgagni. Inferior margin of
resection in this type of cordectomy happens to
This procedure is indicated in patients with be the lower border of vocal fold.
vocal fold carcinoma involving vocal process of
arytenoid posteriorly. It spares rest of the aryte- Extended cordectomy encompassing subglottis
noid cartilage. The arytenoid is mobile in these Type Vd cordectomy:
patients. Arytenoid cartilage is totally / partially
resected along with vocal process. Posterior ary- If needed the cord resection can be continued
tenoid mucosa is preserved. Even if the vocal fold to include subglottis also. About 1 cm under the
is fixed, this procedure can be attempted if the glottis can be included in resection. This is usu-
arytenoid cartilage is mobile. ally done in order to expose the cricoid cartilage.
T2 carcinoma of vocal folds can be managed by
Extended cordectomy encompassing ventricular this type of cordectomy. According to certain
fold Type Vc cordectomy: surgeons this procedure does not create adequate
tumor margins.
Total cordectomy can be extended to include
ventricular fold. This is actually Type Vc cordec-
tomy. This procedure is indicated in patients with
ventricular cancers or for transglottic cancers that
spread from the vocal folds to the ventricle. The
562
2. Less expensive
3. Preserves voice and other protective functions
of larynx
Procedure:
This procedure is performed under general anes-

thesia. Orotracheal intubation using microlaryn-
geal endotracheal tube is preferred. Advantage of
microlaryngeal endotracheal tube is that it snugly
fits into the posterior glottis making the anteri-
or glottis better visible. The cuff when inflated
expands in a horizontal manner gently spreading
the posterior glottic space.
Author prefers to use Kleinsasser suspension

laryngoscope with a portal for 12 degree endo-
scope. Laryngoscope is passed through the oral
cavity of the patient. The patient’s head should be
Image showing type Vd cordectomy extended before introducing the laryngoscope.
Using endotracheal tube as a guide laryngoscope
Classification of cordectomy in to different types is advanced towards the glottis. It is ideal to insert
helps in: the laryngoscope with the 12 degree endoscope
inside the port illuminating the passage. Halogen
1. Deciding the efficacy of various types of cord- / xenon cold light source is preferred source
ectomy in managing vocal fold malignancies of light. The laryngoscope is introduced till the
2. To compare the results of various types of cor- petiole of epiglottis is reached. Both vocal folds
dectomies are clearly visible when the scope rests at the level
3. Helps in training surgeons to reproduce results. of petiole of epiglottis.
Success always lie in reproducing the original suc-
cess story If the scope is passed deep into the larynx, both
vocal and vestibular folds are displaced laterally
Aims of Endoscopic cordectomy: impairing visibility of free margins of vocal folds.
1. Eradication of malignant process If the scope does not reach the level of petiole of
2. Functional preservation epiglottis the ventricular band obscures the visi-
3. To stage the lesion bility of vocal folds. Once the laryngoscope is in
the correct position chest piece is used to stabilize
Advantages of coblation endoscopic cordectomy it in position. Ideally positioned laryngoscope
include: should reveal both vocal cords completely from
anterior commissure to the vocal process.
1. Easy and simple to perform

Image showing the correct positioning of the sus- Image showing the effects of not properly ad-
pension laryngoscope and its effect on the visibil- justing the anterior tilt screw of the chest piece.
ity of the vocal folds. (Anterior commissure area is obscured)
Laryngeal wand is used for ablation of tissue. It

should be remembered that coblator does not
ablate cartilage, hence it cannot be used to ablate
arytenoid cartilage. Irrigation should be set at the
lowest level because
of risk of aspiration. Frequent suctioning should
be resorted to to remove saline and tissue debris.
Microlaryngeal wand can be used for more pre-

cise ablation.
One advantage that could be observed while us-
ing coblation for laryngeal surgeries is that there
is no post operative oedema. This could be due to
minimal collateral damage to adjacent structures.
Image showing the effect if laryngoscope does not
reach up to the level of petiole of epiglottis. Note Ideally a plane should be developed between the
the prolapsing ventricular band obscuring the mass and the underlying portions of the vocal
right vocal cord. fold for successful and complete removal of the
564
tumor mass. Dissection should follow this plane
till the entire mass is removed. Inorder to develop
a plane the mass should be medialised using a
cup forceps.
While performing endoscopic coblation cord-

ectomy branches of external laryngeal vessels
may cause troublesome bleeding. They can easily
be controlled by coagulation / tamponade. The
author has encountered one case of bleeding from
external laryngeal vessels which took sometime
to control in his series of 15 cases. Further evalu-
ation is needed to ascertain the usefulness of this
technology in managing vocal fold malignancies.
Here are some screenshots from the author’s

surgical clippings on the role of coblation in the
management of vocal fold growth. This patient Image showing vocal fold mass being ablated
had growth right vocal cord. He refused to under- using coblation
go any surgery that involved external approach.
He consented to try out coblation ablation of
the mass. He was informed of the risks involved
in the procedure including the need to undergo
salvage laryngectomy at a later date. He was con-
vinced to undergo post op irradiation to which
he consented. he has been under follow up for the
last 1 year. He showed no evidence of recurrent /
residual mass in the vocal cord till date.
Image showing a plane being created under the

vocal fold mass in order to facilitate dissection

Image showing the vocal fold mass dissected out
Image showing the result of the surgery
566
Juvenile Papilloma of larynx:
Role of coblation in benign laryngeal lesions
This condition occurs in infants and children.
Classic features of juvenile papilloma larynx
Coblation is of immense value in the manage- include:
ment of benign lesions involving the larynx. 1. Multiple in nature
Obvious advantages of this technology being that 2. Aggressive in its behavior
it ablates tissue without abnormally increasing the 3. Known to recur after successful surgical re-
surface temperature. moval
4. Commonly caused by Human papilloma virus
There is hence absolutely nil risk of airway fire type 6 / type 1.
during the procedure. This technology has been 5. Infants get infected from infected mother’s
effectively used to treat the following laryngeal genitals during delivery
lesions:
This type of papilloma is frequently localised in
1. Papilloma of larynx the larynx. This condition can also undergo spon-
2. Laryngeal web taneous remissions.
4. Cysts involving epiglottis
5. Benign vocal fold lesions like cysts / hemangio- Clinical features:
mas / nodules.
1. Hoarseness of voice
Papilloma of larynx 2. Child may have difficulty while crying
3. When the masses enlarge in size airway com-
Introduction: promise has been known to occur causing stridor.
Laryngeal papillomatosis is a chronic condition On examination these lesions appear as whitish

caused by human papilloma virus infections. multiple friable masses. Commonly it involves
About 100 different papilloma viruses has been true vocal cords / false cords and rarely epiglottis.
identified. HPV virus 6 and 11 commonly affect These lesions have a predilection to involve squa-
the airway. These viruses are associated with low- mo columnar junctions.
est malignancy potential, whereas types 16 and 18
have the greatest malignancy potential. Human papilloma virus:
Papilloma larynx usually involves vocal cords, This is a small DNA containing non enveloped,
false cords and epiglottis. These masses are friable icosohedral (20 sided) capsid virus. The DNA
and bleed on touch. It usually occurs in two inside the iron is double stranded and circular.
forms:
1. Juvenile papilloma
2. Adult papilloma

Nearly 100 different types of human papilloma vi-
ruses have been identified. Children affected with
human papilloma virus 11 have more obstructive
airway early in the disease.
Classically human papilloma virus infects the

basal layer of the mucosa. The viral DNA enters
these cells and gets transcribed into RNA. This
RNA translates viral protein. After infection viral
DNA can actively be expressed or exist as latent
infection in the mucosa. During this latency peri-
od the mucosa remains clinically and histological
normal. During this latency period very little
viral RNA is seen within the mucosa. Reactiva-
tion can occur at any time causing the disease to
manifest itself. Human papilloma virus is part of
the normal commensal in the laryngeal mucosa.
HPV gets activated only in the presence of immu-
Image showing multiple respiratory papilloma- nocompetence. Most of the individuals have HPV
tosis affecting true and false cords specific killer T cells.
Genomic architecture of Human papilloma virus:
Viral genome of Human papilloma virus has 3

regions:
1. The upstream regulatory region

2. E region / Early region. These are potential on-
cogenes which are responsible for active replica-
tion of the viral genome
3. L region / Late region. These genes are respon-
sible for encoding viral structural proteins.
Human papilloma virus has the capacity to utilize

the host replication genes to facilitate its own
Image showing Human papilloma virus DNA replication. This virus induces epithelial
proliferation by increasing the level of expression
of epidermal growth factor or its ligands. It is also
known to facilitate cellular proliferation by inhib-
iting p53 (tumor suppressor gene).
568
subglottic area.
This virus is also capable of inactivating retino-
blastoma tumor suppressor protein (pRB). It is Since there is very little damage to adjacent tissue,
also known to cause degradation of TIP60 which tissue oedema is also reduced. There is no threat
is involved in the activation of apoptosis, enabling of airway compromise due to tissue oedema as is
the infected cell to survive longer and to replicate. the case with laser. Infact laser vaporization caus-
These viruses are also known to cause degra- es delayed oedema after a week / 10 days com-
dation of p130 which activates cell division by promising the airway, hence patients need to be
pushing cells in phase G0 to G1. hospitalized and kept under observation during
this period.
Ki67 expression is an important marker for mi-
totic activity which detects all stages of mitosis If possible it is better to avoid tracheostomy in
except G0 phase. Studies reveal that there is sig- these patients because papillomas have a tenden-
nificant correlation between the level of expres- cy to recur around tracheostomy stoma. If airway
sion of Ki67 and recurrence / malignant transfor- is not compromised, then care should be taken to
mation of respiratory papillomatosis. carefully intubate the patient under direct visual-
ization using CMac video laryngoscope. Intuba-
Role of coblation in surgical management of tion under vision causes less trauma and hence
laryngeal papillomatosis: less bleeding during intubation in these patients.
Microlaryngeal excision of these lesions is the

standard treatment protocol. Various modalities
of excision are being used including:
1. Cold steel excision

2. Microdebrider excision
3. Laser excision
4. Excision using coblation
Obvious advantages of coblation in this scenario

are:
Image showing stages of intubation using CMac
1. Tissue ablation without much collateral tissue
damage
2. Since ablation is performed by generation of
plasma which occurs at low temperatures there is
absolutely zero risk of airway fire.
3. Laryngeal and microlaryngeal wands used in
surgery can be used for precise ablation. These
wands are longer and hence can reach up to the

Image showing multiple papilloma larynx being removed using laryngeal wand.
Coblation in Micolaryngeal surgical procedures:
For performing microlaryngeal surgeries Micro-

laryngeal wand (MLW) is ideal. This wand has a
narrow shaft, longer than that of laryngeal wand
which facilitates removal of lesions even at the
level of anterior commissure. It can reach up to
the subglottic area. This wand is designed for
precise ablation and coagulation of the lesion.
Default console settings for this wand is Coblate 7
Coagulate 3.
As soon as the MLW is connected to the console

Image showing ET tube in situ this default settings is set. In exceptional cases
this setting can be manually overridden.
During the entire course of surgery it is better to
keep the saline irrigation to coblator to a min- Tip:
imum inorder to minimize risk of aspiration
during surgery. While performing microlaryngeal surgeries using
coblation technology the patient should be placed
in head down position (Trendelenberg). This po-
sition would prevent irrigated saline to flow into
the oropharynx thereby protecting the airway.
570
Standard cuffed microlaryngeal endotracheal Procedure:
tubes would suffice. For additional protection wet
cottonoids can be placed gently around the cuff. If To facilitate ablation the tip of microlaryngeal
needed jet ventilation can also be used along with wand should be held as close to the target tissue
this device. as possible. Care should be taken while ablating
to spare the adjacent normal tissue. The ablate
Procedure: pedal (yellow) should be pressed briefly for about
1-2 seconds for ablation to occur.
Patient is intubated using a microlaryngeal endo- The process of ablation is continued briefly by
tracheal tube. pressing the yellow pedal for allowing tissue di-
gestion at the tip of the electrode.
Features of Microlaryngeal endotracheal tube:
1. This tube has a small internal and external

diameter
2. Its internal diameter ranges from 4-6mm
3. It is 30 cms long with standard cuff
4. The cuff when inflated lies between arytenoid
cartilages, leaving anterior 2/3 of glottis unob-
scured for surgery
Image showing microlaryngeal endotracheal

tube
Image showing an ideally placed microlaryngeal

intubation tube with inflated cuff between ary-
tenoids. Note the entire anterior 2/3 of larynx is
visible and accessible.

Image showing angioma vocal fold Image showing ablation proceeding in all direc-
tions of the angiomatous mass
Image showing laryngeal wand being used to Image showing the vocal fold after removal of
ablate angioma vocal fold angioma
572
but rather common in adults. It is highly prev-
Advantages of coblation in microlaryngeal sur- alent in atopic individuals. Clinically lingual
geries: tonsillar enlargement is not commonly appreciat-
ed during routine clinical examination. It needs a
1. Damage to adjacent normal tissue is minimal discerning eye for
or negligible routine identification. Many of these patients are
2. Mucosal surface of vocal folds heal rather asymptomatic.
quickly as evidenced by the return of normal
mucosal wave pattern within 6 weeks following Rarely enlarged lingual tonsils can cause:
surgery
3. There is absolutely zero risk of airway fire 1. Globus sensation
4. There is absolutely negligible bleeding during 2. Change in voice
surgery 3. Chronic cough
5. Healing is rapid because formation of exudate 4. Choking attacks
is rather minimal 5. Dyspnoea (rare)
6. Even bilateral vocal fold lesions can be ad- 6. Sore throat (acute phase)
dressed in the same sitting because the risk of web 7. Leukocytosis (acute phase)
formation is rather minimal because of reduced 8. Abscess formation
exudate formation 9. Obstructive sleep apnoea
7. Anterior commissure lesions can be addressed 10 Recurrent acute epiglottitis
without fear of blunting Blood supply of lingual tonsil 2
:
Arterial:
Role of coblation in Lingual tonsillectomy Ascending pharyngeal
Dorsal branch of lingual artery
Introduction: Venous drainage: Is via the plexus of veins present
in the tongue base
Lingual tonsils are normal components of Wal-
dayer’s ring. This is a collection of lymphoid Lymphatic drainage:
tissue located at the base of tongue. They are two
in number situated posterior to the circumvallate Lymphatics from lingual tonsil drain into sup-
papillae of the tongue. They lie just anterior to the rahyoid, sub maxillary and upper deep cervical
vallecula. Lingual tonsils are divided in the mid- group of nodes.
line by the presence of median glosso epiglottic
ligament. Lingual tonsil tissue rests on the base- Innervation:
ment membrane of fibrous tissue which could
be considered analogous to tonsillar capsule of Glossopharyngeal nerve
palatine tonsil. Superior laryngeal branch of vagus nerve
Hypertrophy of this lymphoid tissue are rare in Causes of lingual tonsil hypertrophy:
children 1. Compensatory hypertrophy following adenoid-

ectomy with invisibility of epiglottis.
2. GERD (common in children)
3. Chronic infections Indications for surgical management of lingual
4. Impacted foreign body like fish bone tonsil:
1. Obstructive sleep apnoea caused due to en-
larged lingual tonsil. This should be considered as
an absolute indication.
2. Symptomatic enlarged lingual tonsil not re-

sponding to medical management including a
course of antireflux therapy
3. Recurrent attacks of epiglottitis (possible foci

from lingual tonsil)
Surgical management of hypertrophied lingual

tonsil involving the following technologies:
1. Conventional excision
2. Cryosurgery
3. Debrider
4. Coblation
Advantages of coblation technology in removal of

lingual tonsil are:
Image showing hypertrophic lingual tonsils
1. Bloodless field
Clinical gradation of lingual tonsil hypertropy: 2. Complete ablation is possible
3. Less post op oedema
Lingual tonsils can be graded endoscopically on a 4. Post op pain lesser than that of other proce-
scale ranging between 0 - 4. This grading is based dures
on their distribution and visibility of vallecula
and posterior third of the tongue. Procedure:
Grade 0 : No lingual tonsil enlargement Patient is put in tonsillectomy position. Mouth is

Grade 1: Lingual tonsil + in the tongue base. Vas- opened using Boyles Davis mouth gag. Operat-
cularity seen ing microscope is used to visualize the enlarged
Grade 2 : Lingual tonsil seen in the tongue base. lingual tonsil. Evac 70 tonsillar wand is used for
Vascularity no visible surgical procedure. Lymphoid tissue is really easy
Grade 3: Diffuse lingual tonsillar enlargement to ablate. It really melts on contact with plasma
with vallecula not visible generated by the wand. Fibrous tissue over which
Grade 4: Diffuse lingual tonsillar enlargement lingual tonsil tissue lies is rather resistant to abla-
574
tion. Lingual musculature is hence left intact even
after complete removal of lingual tonsillar tissue.
Since lingual musculature is left undisturbed, post
operative pain is less than that of other proce-
dures.
Evac 70 tonsil wand is used for ablating lingual

tonsil tissue. Care should be taken to use copious
irrigation as the wand is likely to get clogged with
ablated tissue.
Image showing the end result of lingual tonsil

ablation. Note the lingual musculature after
removal of lymphoid tissue
It should also be noted that it is imperative to

perform tonsillectomy if tonsil is already present
to reduce chances of recurrence.
Tip:
While holding the wand it should be held in such

a way that dripping saline gets into contact with
Evac 70 tonsil wand is seen ablating lingual the active electrode for adequate plasma genera-
tonsil tion. Ideally it should be held in such a way that
the active electrode is horizontal to the tissue
being ablated.

Role of coblation in Tongue base reduc-
tion Tongue base reduction using Evac 70 Tonsil-
lectomy wand: This procedure is also known as
Introduction: (SMILE) submucosal minimally invasive lingual
Potential sites of obstruction in obstructive sleep excision.
apnoea include:
1. Nose This procedure is preformed under general anes-
2. Palate thesia. Patient is positioned in tonsillectomy posi-
3. Tongue base tion. The tongue base area that is to be ablated is
4. Lateral pharyngeal wall collapse marked using GV paint.
Among these factors tongue base happens to be
a critical area of obstruction at the level of hypo-
pharynx. Lateral cephalometric radiography helps
in identifying tongue base obstruction. Mandible
and tongue are major determinants of airway
dimension. Genioglossus advancement used to
address this issue causes a stretching effect on lin-
gual musculature limiting its posterior displace-
ment during sleep. This procedure needs external
incision and a prolonged surgical procedure.
With the advent of coblation technology tongue
base can be selectively reduced without threat
of bleeding and tongue oedema. This procedure
can also be combined with the traditional Uvulo
palato pharyngo plasty procedure also.
Tongue base reduction using radio-frequency

was first introduced by Powel in 1999. Powel etal
estimated a median reduction of tongue base vol-
ume of 17% with a maximum reduction of 29%. Image showing posterior third tongue tissue
These values have not be corraborated by others. which needs to be ablated marked with GV
STUCK etal could not verify actual reduction paint. Note: The marking is triangular in shape
of tongue base volume / increase in retrolingual with apex pointing towards foramen caecum.
space. Moist cotton ball is placed behind the marking to
protect the adjacent areas from collateral dam-
They attributed symptomatic relief following the age.
procedure due to tissue stabilization caused by
scarring due to the procedure. Basic advantage of
coblation in tongue base reduction procedures is
that there is absolutely no risk of tongue oedema
following the procedure.
576
Image showing edges of the resected tongue base
sutured
Image showing Evac 70 tonsillar wand being
used Coblation assisted Lewis and MacKay operation:
This surgical technique involves midline glossec-

tomy combined with lateral coblation channeling.
Another modification of this procedure involves
channeling of posterior third of tongue instead of
midline glossectomy.
Reflex ultra 55 wand is used for tongue channel-

ing procedures.
These wands are needle wands with depth limiter

which helps in monitoring the depth of submuco-
sal penetration.
Image showing sectioning of the marked area in Tongue channelling can be combined with tongue
the posterior third of the tongue base resection.

out resection of tongue base. The same wand can
be used to ablate posterior third of tongue also.
Three points are chosen in the posterior third of
tongue.
The first point is just behind the foramen cecum,

while the other two are cited along the lateral
border of posterior third of tongue. In other
words the three points of the triangle marked in
the posterior third of the tongue is ablated using
reflex ultra 55 coblation wand.
Image showing Reflex Ultra 55 channeling wand
Reflex ultra 55 wand is used to reduce lateral bulk

of tongue. After completion of tongue base sec-
tioning, reflex ultra 55 channelling wand’s depth
limiter is adjusted to be about 2 mm. It is used to
penetrate the lateral border of tongue and cobla-
tion is applied at a setting of 6. Three points are
choosen along the lateral border of tongue and
the channelling wand is used to ablate. Ablation is
performed on both sides.
Ablation causes fibrosis of lingual musculature Image showing Tongue channelling done in the
thereby cause reduction in the tongue bulk. Cur- anterior portion of lateral border of tongue
rently available reflex ultra wands are provided
with saline irrigation facility. If older version of
these wands are used
then saline should be infiltrated into the area
before ablation is commenced.
Tongue channelling can alone be performed with-
578
This procedure can be performed under local
anesthesia. Reflex Ultra 55 wand is used for this
procedure. Seven channels should be created in
the tongue for channelling purpose. These chan-
nels include:
1. Three midline channels
Image showing tongue channelling being per-

formed in the posterior portion of lateral margin
of tongue
Usual time taken for optimal benefit following

tongue channelling could range between 4-6
weeks. One of our patients took nearly 2 months
for optimal benefit to occur following tongue
channelling.
Advantages of tongue channelling:

Image showing three midline channels in the
1. Can be performed as a day care procedure tongue marked in red
2. Can be performed under local anesthesia
3. Tissue destruction is not extensive 2. Two lateral channels on each side
4. Bleeding is minimal
5. No risk of upper airway obstruction due to
tongue oedema
One major drawback of this procedure is the
amount of tissue destruction cannot be accurately
predicted. This procedure needs to be repeated if
effect is not optimal even after 6 weeks.
Seven port coblation tongue channelling Proce-
dure:

mind of a surgeon which one to follow. It is
always prudent is to start off with the modality
which is least invasive and causes the least mor-
bidity and then proceed to other more adventur-
ous and more invasive procedures.
In the impression of the author it is best to start

the treatment with the seven channel lingual cob-
lation, and after assessing the benefits then other
more invasive procedures like tongue base resec-
tion, and genial tubercle advancement procedures
can be attempted.
Image showing lateral channels marked by red

dots
The three midline channels starts from 1 cm in

front of apex of the circumvallate papillae, mov-
ing forwards by 1-2 cms. Anterior most midline
channel should be sited at least 2.5 cms from the
tip of the tongue.
The lateral channels are created in the axial plane

with entry points created at the junction of dorsal
and lateral tongue mucosa. The reflex ultra probe
should ideally be directed towards the posterior
portion of the tongue.
This seven channel coblation procedure treats

both the middle and posterior thirds of tongue
rather than focussing on the posterior third alone.
The availability of multiple procedures for tongue

size reduction creates a healthy dilemma in the
580
Coblation in Uvulopalatopharyngoplasty
Introduction:
Currently UPPP (Uvulopalatopharyngoplasty) is

the commonly performed surgical procedure for
Obstructive sleep apnoea syndrome(OSA). This
procedure was first performed by Fugita in 1981.
Classically UPPP involves tonsillectomy, trim-
ming and reorientation of anterior and posterior
tonsillar pillars, combined with excision of uvula
and posterior portion of palate.
Various modifications of the above procedure has

been attempted to improve results. These include:
1. Complete removal of uvula and distal palate Figure showing Tonsillectomy being performed
2. Removal of part of palatopharyngeus muscle with preservation of pillar mucosa
and use of uvulopalatal flap
3. Use of coblation to perform UPPP
4. Laser assisted uvulopalatoplasty
Coblation Uvulopalatopharyngoplasty - The

Procedure:
This modification is also Robinson’s Modification.

The steps include -
1. General anesthesia - Nasal / Oral intubation
2. Tonsillectomy with preservation of pillar mu-
cosa
3. Caudal traction of uvula by elevating triangular
shaped flap of mucosa on either side
Bilateral resection of supratonsillar pad of fat.

Anterior and posterior pillars are sutured togeth-
er. Redundant uvular mucosa is sutured together Image showing triangular mucosal flap on either
thereby everting the soft palate. This opens up the side of uvula
nasopharyngeal airway.

Image showing completion of triangular flap
elevation on either side of uvula
Image showing Uvular stump eversion stitch

being applied. This stitch opens up the nasophar-
ynx
Uvular eversion stitch is applied from the tip of

the uvular stump to the anterior pillar of tonsil.
This suture everts the uvular stump thereby open-
ing up the nasopharynx.
Image showing Para Uvular wedge created is su-

tured with that of anterior pillar of tonsil evert-
ing the soft palate.
Image showing the result of uvular eversion
582
Pillar suturing: Robinson modified uvulopalatopharyngoplasty:
Suturing both anterior and posterior pillars Major advantage of this procedure is that it opens
together is the next step. This should be done on the lateral velopharyngeal ports. In this procedure
both sides. only the tonsils and submucosal fat are resected.
This should indeed be considered as reconstruc-
tive surgery and not ablation.
According to Friedmann 25% of patients with

obstructive sleep apnoea had problems related
to tonsils / palate. The remaining 75% of OSA
patients had problems pertaining to tongue and
tongue base.
He devised a simple observational classification

of tongue position in relation to soft palate which
could be used as a predictor for OSA.
Tongue position is classified into 4 types:
Type I tongue position is normal and does not

cause symptoms, while type IV tongue position
Image showing pillar suturing being performed causes severe problems at the level of tongue base
causing OSA.
Coblation as a tool can easily address tonsil,

palate, and tongue. Hence it is an excellent tool
in the surgical management of obstructive sleep
apnoea. No single treatment modality is success-
ful in the management of OSA.
It should be managed according to the area of
obstruction and could involve multiple surgical
procedures since obstruction can exist at multiple
levels.
Image showing end result of surgery

Image all 4 tongue positions described by Friedman
584
Malignant tumor of oropharynx Ablation using
Coblator
Introduction:
Soft palate is considered to be a portion of oro-

pharynx. Malignant tumors involving soft palate
accounts for roughly 2% of all head and neck ma-
lignancies. Squamous cell carcinoma happens to
be the predominant histological type. Soft tissue
tumors are usually bilateral.
Since soft palate plays an important role in

swallowing and phonation, resection of this area
is difficult to reconstruct functionally. Velopha-
ryngeal insufficiency is rather common in these
patients. Tumors involving this area usually pres-
ent with early lymph node involvement (usually
bilateral). Conventionally radiotherapy has been
the treatment of choice for soft palate malignan-
cies and surgery was used for rescue purposes
in radiation failed cases. Irradiation alone is not Image showing malignant growth soft palate
sufficient in managing these patients.
Procedure:
Synchronous or metachronous tumors along with
soft palate growth is also common. Ablation was performed using coblator under
general anesthesia. Evac 70 tonsillar wand was
Surgical ablation of soft palate malignancy: used for this purpose. Patient was positioned in
tonsillectomy position. The limits of the tumor
This is not popular because of the difficulties in- was assessed by careful palpation. The entire sur-
volved in surgical reconstruction of this area with gery was performed under microscopy.
reasonable functionality. Author attempted to re- Advantage of using microscope in this procedure
sect malignant tumor involving soft palate using is that tumor margins could be assessed with rea-
coblation technology. Surgery was attempted after sonable degree of accuracy.
getting consent from the patient. The plan was to
resect the tumor completely and subject the
patient to irradiation of the primary site and
neck. This patient did not manifest with nodal
involvement as revealed by CT scan of neck.
.

In authors opinion coblation technology can be
used to ablate oropharyngeal malignant tumors
up to T3 staging.
TNM staging for Oropharyngeal malignant tu-

mors:
Tx - Primary tumor cannot be accessed

T0 - No evidence of primary tumor
Tis - Carcinoma in situ
T1 - Tumor greater than 2 cm in its greatest di-
mension
T2 - Tumor more than 2 cms but less than 4 cms
in its greatest dimension
T3 - Tumor more than 4 cms in its greatest
Image showing proliferative mass involving the dimension or extension into lingual surface of
soft palate epiglottis. This stage is moderately advanced local
disease.
Evac 70 tonsillectomy wand is used for ablation T4a - Tumor invading larynx, deep extrinsic
purpose. Bleeders if any should be secured by muscles of tongue, medial pterygoid, hard palate
pressing the blue pedal of coblator while keeping or mandible
the wand in contact with the bleeder. Tumor was T4b - Tumour invades lateral pterygoid muscle,
ablated starting from its medial border. Care is pterygoid plates, lateral nasopharynx, skull base,
taken to ensure adequate surgical margin is left. or enclosing internal carotid artery.
Regional Nodes:
Nx - Regional node involvment cannot be as-

sessed
N0 - No regional node involvement
N1 - Metastasis in single ipsilateral node about 3
cms in its greatest dimension.
N2a - Metastasis into single ipsilateral node of
more than 3 cms but less than 6 cms in size
N2b - Metastasis into multiple ipsilateral nodes
none of which are more than 6 cms in size
N2c - Metastasis into bilateral or contralateral
nodes, none of which are more than 6 cms in size.
Image showing mass being held with a button N3 - Metastasis into a neck node the size of which
forceps is more than 6 cms
586
Metastasis:
M0 - No distant metastasis
M1 - Distant metastasis is present
Image showing mass about to be removed
Image showing the begining of the dissection

process
Image showing completion of resection
Image showing mass being mobilized and dis-

sected

Conclusion:
Advantages of coblation technology in managing

oropharyngeal malignant tumors include:
1. Relatively bloodless field

2. Mucosal healing is better because of less collat-
eral damage to adjacent normal tissue
3. Since this surgery is being performed under
microscopy tumor margins can be adequate
4. Even though it is a blunt instrument, author
did not face any difficulty with the plasma wand
as far as precision is concerned.
5. The wand can also be bent to suit oropharyn-
geal anatomy
588
genesis of Rhinophyma.
Rhinophyma Excision Role of Coblation
Stage II:
Introduction: Increased vascularity leads to this stage char-
acterised by thickened skin, telengiectasis with
The term Rhinophyma originates from the Greek persistent facial oedema (erythrosis). A small
term “rhis” meaning nose and “phyma” mean- number of these patients may progress to the next
ing growth. 1 This condition is characterised by stage.
thickening of skin over the nose due to soft tissue
hypertrophy. This condition is 5 times more com- Stage III:
mon in males than in females. This is very rarely This stage is the stage of acne rosacea. Features of
seen in children. This condition is considered as this stage include:
end stage
of sebaceous overgrowth and scarring from poor- 1. Erythematous papules
ly controlled acne rosacea. This condition is also 2. Pustules over forehead, glabella, malar region,
referred by the term “W.C. Fields nose”. This con- nose and chin Pustules can sometimes be seen in
dition is characterised typically by hypertrophic other areas like chest, scalp (bald areas).
nodular growths in the distal half of the nose.
The nose hence becomes ultimately fibrous and According to Wilkins these stages can also be
inflammed. The color of the skin usually changes called as prerosacea, vascular rosacea and inflam-
to deep red / purple due to the presence of diffuse matory rosacea.
telengiactesis.
Stage IV:
Virchow has been credited for having correctly This is the classic rhinophyma. Patients who go
associating rhinophyma with acne rosacea in on to reach this stage is rather small. Nose is the
1846. Even though acne rosacea is common in most common site affected.
women, progression to facial skin thickening
and Rhinophyma is common in men. This could Other sites involved include:
probably be attributed to androgen influence.
Zygophyma - zygomatic area
Clinical features: Mentophyma - Mental area
Otophyma - involving the pinna
Rebora’s description of various stages of Rhino-
phyma: Gross appearance:
Nasal skin appears erythematous with telengiec-
Stage I: tasis. The skin may
sometimes appear purple in color. In severe cases
This stage is characterized by frequent episodes the skin over the nose can have pits, fissures and
of facial flushing. According to Wilkin Rosacea areas of scarring. Inspissated sebum and bacterial
is essentially a cutaneous vascular disorder hence infection in these areas could cause foul odor to
flushing happens to be the first stage in the patho- emit in these patients. Nasal tip area is preferen-

tially enlarged. Nasal dorsum and side walls can d. Skin thickening with dermal and sebaceous
also be enlarged but to a lesser degree. gland hyperplasia
e. Dilated sebaceous gland duct become plugged
Hypertrophy of nasal skin cause damage to the with sebum
esthetic units of the face. Some of these patients f. Cystic changes in the dilated sebaceous gland
may suffer from secondary nasal airway obstruc- ducts
tion.
Clinical study of rhinophyma reveals the exis-
tence of two different clinical forms of the dis-
order. The first group demonstrated the features
commonly observed in classic rhinophyma. The
second group demonstrated a more severe form
of the disease with a different histology. In the
severe form inflammatory changes are less prom-
inent with thickening of dermis, and thinning
of epidermis. There is actual loss of observable
sebaceous units.
Dermal telengiectasis is more clearly seen in these

patient.
Freeman’s classification of rhinophyma depend-
ing on the severity of deformity:
Freeman reviewing 55 patients with clinically

confirmed rhinophyma devised a 5 stage classifi-
cation depending on the severity of deformity.
Image showing a patient with Rhinophyma 1. Early vascular type

2. Diffuse enlargement - Moderate
Tumorous growth can develop in late nodular 3. Localised tumor - Early
forms of disease causing severe cosmetic defor- 4. Diffuse enlargement - Extensive
mity. Bony and cartilagenous framework are not 5. Diffuse enlargement - Extensive with localised
involved in majority of these patients. tumor
Mark’s hypothesis 8 regarding genesis of rhino- Wiemer suggested that facial flushing which is
phyma: a feature of Rhinophyma could be due to con-
sumption of vasoactive foods and drinks (which
a. Vascular instability in the skin include alcohol) could be a coincidence and not
b. Loss of fluid into the dermal insterstitium and an etiological factor.
matrix
c. Inflammation and fibrosis Bacterial colonization along with plugged seba-
590
ceous glands have been consistently demonstrat- who provide history of worsening rosacea with
ed in patients with acne rosacea. This prompted their hormonal cycle
Anderson to postulate a link between Demodex 9. Dapsone can also be used to treat severe and
Folliculorum and acne rosacea in 1932. Focus on refractory forms of rosacea
infective etiology as a causative factor for rhin- 10 Tacrolimus ointment: It reduces itching and
opyma still continues, Helicobacter Pylori has inflammation by suppressing the release of cyto-
been implicated because many of these patients kines from T cells.
complained of gastrointestinal disturbances. The 11. Tetracycline and Doxicycline can be used as
current consensus is that this hypothesis has no antibiotics in these patients
scientific merit. Cutaneous malignancies can go
unnoticed in these patients. Role of surgery:
Squamous cell carcinoma, sebaceous carcinoma Surgery is indicated in severe cases of rhinophy-
and angiosarcoma have been reported in these ma not responding
patients. to conventional medical therapy. The lesion is ex-
cised taking care to preserve perichondrium. Raw
Management: area can be reconstructed using full thickness
skin graft. Preservation of perichondrium goes a
Aggressive management of acne rosacea may go long way in preventing scar formation. Excision
a long way in reducing the incidence of rhino- of the lesion can be performed using carbondiox-
phyma in these patients. Currently oral / topical ide laser / scalpel excision / dermabrasion / Weck
antibiotics and retenoids are the main stay in razor excision. Currently coblation technology
managing these patients. is being attempted with good results. This proce-
dure in addition to providing excellent bleeding
1. Regular facial massage: This helps in the reduc- control causes very little collateral damage there-
tion of facial oedema. by reducing scar tissue formation.
2. Avoidance of consumption of too hot / too cold
drinks
3. Avoidance of alcohol
4. Topical use of metronidazole (first line of man-
agement)
5. Topical azelaic acid (known to reduce bacterial
colonization and decreased production of kera-
tin)
6. Topical apha 2 agonist Brimonidine can be
used to manage erythema associated with acne
rosacea
7. Topical ivermectin has been approved by FDA
for treatment of inflammatory lesions associated
with rosacea. Image showing the patient intubated and draped
8. Oral contraceptives can be used in patients

After ablation of the lesion, split thickness skin
graft can be used to cover the lesion
Image showing lesion being held before the pro-

cess of ablation
Image showing the status three months post

surgery
Image showing the immediate result of ablation
592
the development at the capillary network stage.
Role of coblation in the management of oro- Arrest of development during the second stage of
pharyngeal hemangioma development of vascular system (retiform stage)
may produce venous, arterial or capillary malfor-
Introduction: mations.
Hemangiomas are the most common tumors of Classification of hemangiomas:

head and neck seen in children. Tongue and floor
of the mouth are the most common sites. Hemangiomas are classified into capillary, cav-
They are present at birth, gradually increase in ernous and combined
size and resolves either partially or completely varieties.
when the child reaches the age of 7. Although
these lesions are adhered to the parenchyma, Capillary hemangiomas (strawberry lesion)
there is no direct involvement of parenchyma. In
fact they do not contain tissue of the organ to Usually appears as red papular lesion, commonly
which they are attached. Cavernous hemangio- with a lobulated surface. Its rate of proliferation
mas are the most common type encountered. is alarming at birth, but involution tends to begin
during the 7th month of life.
Pathophysiology of Hemangiomas:
Cavernous hemangiomas:
Developmentally three stages have been observed These may remain in the subcutaneous / sub-
in vascular system differentiation. mucous plane. These lesions are smooth, poorly
defined and compressible. On palpation they
First stage:(Capillary network stage) resemble a bag of worms.
This stage consists of interconnected blood lakes
with no identifiable arterial or venous channels. They have a tendency to increase in size when
the child cries. Notoriously these hemangiomas
Second stage:(Retiform stage) do not involute fully and leave behind significant
This stage is characterised by development of morbidity.
separate venous and arterial stems on either side
of the capillary network Most of these hemangiomas are developmental in
origin and commonly contain both hemangioma-
Final stage: (Mature stage) tous and lymphangiomatous components.
They are more common in women.
This stage occurs within the first few months
of life and involves gradual replacement of the Cavernous hemangiomas of head and neck region
immature plexiform networks by mature vascular are currently being renamed as vascular mal-
channels. formations. In contrast to hemangiomas these
vascular malformations do not regress with age
Capillary hemangioma is more common and it and may infact increase in size.
represents an arrest in

Management:
Systemic corticosteroids happens to be the first

line of therapy even for most complicated heman-
giomas. Standard regimen include 2-4 mg / kg
prednisolone per day for 2 weeks and the drug
should be tapered before discontinuing the same.
Mechanism of action has been poorly under-
stood.
Interferon / Vincristine can be tried in patients

who are not responding to prednisolone therapy.
Mechanism of action of propranalol is that as a

Beta adrenergic agonist it results in vasoconstric-
tion causing color change and softening of the
mass even during the first day of therapy.
If medical management fails then surgical ex-

cision is the treatment of choice for cavernous
Image showing hemangioma of tongue hemangioma. Surgical options include:
Vascular malformations are congenital lesions, 1. Laser surgery

sometimes may become apparent only later in 2. Sterotactic radiosurgery
life due to progressive increase in size due to 3. Injection of sclerosing agents
increased intraluminal blood flow. These vascular 4. Cryotherapy
malformations usually do not involute, and their 5. Coblation
growth rate may be influenced by factors like
trauma, infection and hormonal changes. Coblation technology has its own inherent advan-
tages. It not only ablates hemangiomatous tissue
Classification of vascular malformations: but also causes very minimal collateral damage.
There is also no risk of air way fire as is the case
This is based on the predominant vessel type 2: with laser.
1. Capillary
2. Venocapillary
3. Venous
4. Lymphatic
5. Arterial
6. Mixed
594
Image showing hemangioma of posterior third of Image showing tonsil wand being used to ablate
tongue extending up to the pyriform fossa hemangioma
While performing excision / ablation of heman-

gioma involving posterior third of tongue and
pyriform fossa, the patient is put in tonsillectomy
position under general anesthesia. Bulk of the
ablation is proceeded with the use of Evac 70
tonsil wand, while difficult to reach areas like the
pyriform fossa is accessed using laryngeal wand.
Hemangiomas can be associated with various

syndromes. These include:
Rendo-Osler-Weber syndrome:
Autosomal dominantly inherited. Clinical fea-

tures include:
Multiple telengiectasis, GI tract involvement and Image showing the gross specimen after excision
occasional CNS involvement. This syndrome
commonly affects blood vessels causing dysplastic
changes with a tendency to bleed.

Sturge-Weber-Dimitri syndrome:
Also known as encephalotrigeminal angiomato-

sis. This condition is non familial and non inher-
ited condition featured by portwine stain, and
leptomeningeal angiomas.
Von Hippel-Lindau syndrome:
Genetic transmission with variable inheritance.

This syndrome is characterised by hemangiomas
of cerebellum / retina with presence of cystic
lesions in viscera. All patients with hemangiomas
should undergo complete evaluation to rule out
associated syndromes before taking up for surgi-
cal management.
596
Due to the very small surface area at the point of
Diathermy the electrode, the current density at this point is
really high, producing a focal effect allowing the
Introduction: tissues to heat up rapidly. In monopolar diather-
my, since the current passes through the body, its
The word diathermy means “heating through” density decreases rapidly as the surface area the
refers to the production of heat by passing a high current acts across increases. This allows focused
frequency current through tissue. This term heating of tissues at the point of use, without
was coined in 1908 by the German physician heating up the body.
Karl Franz Nagelschemidt. In the medieval ages
haemostasis was sometimes achieved by red hot Types of diathermy:
stones or irons applied to the bleeding surface ( a
heroic and rather risky procedure). Configuration of the diathermy device can either
be monopolar or bipolar. Both actions require
The principle behind the use of diathermy in the electrical circuit to be completed, but vary
surgical practice is that it uses very high frequen- how this is actually achieved.
cies (0.5 - 3 MHz) of alternate polarity radio wave
electrical current to cut or to coagulate tissue Monopolar - In this mode of action, the electrical
during surgery. This allows diathermy to avoid current oscillates between the surgeon’s elec-
the frequencies used by body systems to generate trode, through the patient’s body, until it meets
electrical current, such as skeletal muscle and the grounding plate (positioned underneath the
cardiac tissue thereby allowing body physiology patient’s leg) to complete the circuit.
to be broadly unaffected during its use.
Bipolar - In this mode, the two electrodes are
It also allows for precise incisions to be made found on the instrument itself. The bipolar ar-
with limited blood loss and is used in nearly all rangement negates the need for dispersive elec-
surgical disciplines. Radio frequencies generat- trodes, instead a pair of similar sized electrodes
ed by the diathermy heat the tissue to allow for are used in tandem. The current is then passed
cutting and coagulation, by creating intracellular between the electrodes.
oscillation of molecules within the cells. Depend-
ing on the temperature generated different results Bipolar is commonly used in surgery involv-
could be achieved: ing digits, in patients with pacemakers to avoid
electrical interference with the pacemaker and in
60 degree centigrade - cell death occurs (fulgura- microsurgery to catch bleeders.
tion)
60-99 degrees centigrade - dehydration occurs Cutting / coagulation:

(tissue coagulation)
There are two main settings of diathermy (cutting
100 degrees centigrade - tissue vaporizes (cutting) and coagulation).

Cutting uses a continuous wave form with a low
voltage. In the cutting mode, the electrode reach-
es a high enough power to vaporise the water
content. Thus in this mode, it is able to perform
a clean cut but it is less efficient at coagulating. In
the cutting mode the focus of heat is more at the
surgical site, using sparks being the more focused
way to distribute heat. In the cutting mode, the
tip of the electrode is held slightly away from the
tissue.
There is a mixed mode (blend) acting in between

as both cutting and coagulating modes.
In endoscopic sinus surgery, insulated equipment

should be used and must be checked regularly to
ensure that insulation is intact. Non insulated
metallic equipment could potentially create an Image showing unipolar diathermy handpiece.
alternative electrical pathway so it should be kept Yellow button is for cutting and the blue button
at a safe distance from the active electrode. is for coagulation. This handpiece needs to be
plugged into the diathermy console. It has three
pins (one positive, one negative and one earthing
pin).
Image showing diathermy console

Image showing bipolar probe. The forceps can be
used to coagulate the bleeders. This probe needs
to be connected to the diathermy console by us-
ing two pins (one + and one -).
598
three patterns of current flow:
RF cautery:
1. Fully rectified, filtered and is used mainly for
Also known as radio frequency / high frequency incision (micro smooth cutting) 90% cutting and
cautery. This electrical system is used for tissue 10% coagulation.
reduction purposes like turbinate reduction.
2. Fully rectified, used mainly for excision of
The technique of RF cautery involves the passage epidermal growths (50% cutting and 50% coagu-
of high frequency radio waves (2mHz) through lation).
soft tissue to cut/coagulate/remove soft tissue.
The resistance offered by soft tissue to radio waves 3. Partially rectified, used mainly for hemostasis
causes the cellular water to heat leading on to or coagulating vascular lesions (90% coagulation
release of steam which results in dissolution of and 10% cutting).
individual cells. The surgeon uses a hand piece
with an active electrode (different types for differ- There is minimal collateral damage (about 75
ent surgical applications) to transmit radio waves. micrometer) caused by RF cautery. The possible
The radio waves are focused on the tissue by an reasons for minimal collateral damage are:
antenna plate (also known as the patient plate)
that is placed behind the tissue in contact with 1. The electrodes don’t get heated during the
the patient’s skin. procedure
A radio frequency unit converts the standard 2. Only the tip of the electrode comes into to con-
household current (60 cycles) to high frequency tact with the tissue and that too for a very short
range (3-4 MHz). This device has both cut and time.
coagulation modes making it an effective tool for
various surgical procedures. 3. The diameter of the electrode is pretty small
and hence the electrode tissue interface is also
Mechanism of action: small.
The radio waves created by this device travel from 4. It uses high frequency power but at very low
the electrode tip to the patient and are returned intensity.
to the device via an indifferent plate antenna
placed under the patient’s body in the vicinity of
the surgical site. The antenna may or may not
require direct contact with the skin depending on Advantages of radiosurgery:
the manufacturer’s instruction and design. As the
current passes through the tissues, impedance to 1. Less bleeding
the passage of current through the tissue gener-
ates heat, which boils the tissue water creating 2. Quicker operating time
steam resulting in either cutting or coagulating
the tissue. This device is capable of producing 3. Rapid healing

4. Less collateral tissue damage
5. Less postoperative discomfort
Uses of RF cautery in otolaryngology:
1. Turbinate debulking
2. Tonsillectomy
Image showing Radio frequency tonsillectomy

about to be completed
Image showing Radio-frequency tonsillectomy
Image showing RF generator / console which is

used to convert 60 cycle ac current to high fre-
quency radio waves.
600
Suture Materials The type of suture material chose could vary de-
pending on the clinical scenario.
Surgical suture materials are used to close various Absorbable sutures:

wounds. It is imperative on the part of a surgeon
to know the various materials available and when This type of suture materials are broken down by
to use them abd where to use them. An ideal the body via enzymatic reactions or hydrolysis.
suture material should allow the healing tissue to The taken for this process to be completed varies
recover sufficiently to keep the wound edges close between the material used, location of the suture,
together once they are removed / absorbed. and patient factors. These sutures are commonly
used for deep tissues and tissues that heal rapidly,
The time taken for the healing process to occur and it can be used in small bowel anastomosis,
varies between the type of tissue: tying of small vessels near the skin and in closure
of deep cervical facia.
Days - Muscle, subcutaneous tissue and skin
Absorption times of commonly used absorbable
Weeks to months - Fascia / tendon sutures:
Months to n ever - vascular prosthesis Vicryl rapide - 42 days - This is the fastest absorb-
ing synthetic suture and is ideal for soft tissue ap-
At this point it should be stressed that regardless proximation, approximation of skin and mucosal
of the composition of the suture, the body will re- wounds where only short term wound support is
act to it as a foreign body and goes on to produce all that is needed. It is available in 5 sizes.
a fb type of reaction which could vary in severity.
Vicryl - 60 days - This is made of polyglactin 910.
Classification of suture material: It is absorbable, synthetic and braided suture.
This suture material holds its tensile strength for
In broad terms wound sutures can be classified 2-3 weeks in tissue and is completely hydrolyzed
into absorbable and non-absorbable materials. within 70 days. A monofilament version of this
These material can further be sub classified into suture is used in ophthalmology.
synthetic / natural sutures, and monofilament or
multifilament sutures. Monocryl - 100 days - This is a synthetic absorb-
able suture which is made from poliglecaprone
Ideal suture material should be the smallest possi- 25. It comes in dyed (violet) as well as undyed
ble to produce uniform tensile strength, securely forms. This is a monofilament suture material.
hold the wound for the required time for healing It is generally used for soft tissue approximation
and then be absorbed. The response to the suture and ligation. It is used frequently for subcuticular
material should be predictable and easy to handle. dermis closures of the facial wound. This suture
It should evoke minimal tissue reaction and has material has a low tissue reactivity, it maintains
the ability to be knotted securely. high tensile strength. It has a high degree of

“memory” or coil. Since it is slippery it is easy to being that they have a poor knot security and ease
pass through the wound. of handling.
PDS - 200 days - This is a sterile, synthetic ab- Multifilament - This is made up of several fila-
sorbable monofilament suture material made ments that are twisted together (braided silk / vic-
from polyester. This material is ideal for general ryl). They are easy to handle and hold their shape
soft tissue approximation. This suture material for good knot security but can harbor infections.
is very useful where a combination of absorbable
sutures and extended wound support is desirable.
Type Ab- Non Mono- Mul-
Non absorbable sutures: sorb- absorb- fila- tifila-
able able ment ment
These are used to provide long term tissue sup- Vicryl
port, remaining walled-off by the body’s inflam-
matory processes until removed manually if PDS
required. Uses for this material include suturing
tissues that heal rather slowly (fascia, tendons and Mono
closure of abdominal wall) or also in performing cryl
vascular anastomosis. Nylon
Suture materials can also be classified by their raw Prolene

origin as natural and synthetic.
Silk
Natural - Suture materials belonging to this
category are made of natural fibers (silk / catgut). Suture size:
They are less frequently used as they tend to pro-
voke a greater tissue reaction. Suturing silk is still The diameter of the suture will affect its handling
used regularly in securing surgical drains. properties and tensile strength. The larger the
size ascribed to the suture, the smaller the diam-
Synthetic - Suture materials of this category are eter is. For example a 7-0 suture is smaller than
made of man made materials (PDS / nylon). a 4-0 suture. When selecting a suture size, the
They tend to be more predictable than normal su- smallest size possible should be chosen, taking
tures, particularly in their loss of tensile strength into account the natural strength of the tissue.
and absorption.
Surgical needles:
Suture materials can also be sub classified de-
pending on their structure. This allows the placement of suture within the
tissue, carrying the material through with min-
Monofilament - This is a single stranded filament imal residual trauma. An ideal needle used for
suture(nylon, PDS, or prolene). These materials suturing should be rigid enough to resist distor-
have a lower infection risk. The only problem tion, yet flexible enough to bend before breaking.
602
Image showing different types of suture materials and their classification
It should also be as slim as possible to minimize A swaged end that connects the needle to the
trauma and sharp enough to penetrate tissue suture material.
without resistance / minimal resistance. It should
also be stable enough to be held with a needle A needle body or shaft which is the region
holder. grasped by the needle holder. The body of the
needle can be round, cutting or reverse cutting.
Common surgical needles are made of stainless
steel. They consist of: Round bodied needles are used in friable tissue.

Cutting needles are triangular in shape, and have
3 cutting edges to penetrate tough tissue such as
the skin, sternum and have a cutting surface on
the concave edge.
Reverse cutting needles have a cutting surface

on the convex edge and are ideal for tough tissue
such as tendon, or subcuticular sutures. They
have a reduced risk of cutting through tissue.
Needle point acts to pierce the tissue, begining

at the maximal point of the body and running to
the end of the needle, and can either be sharp or
blunt.
Blunt needles are used for abdominal wall clo-

sure, and in friable tissue, and can potentially re-
duce the risk of blood borne virus infection from
needle silk injuries.
Image showing a needle
Sharp needles pierce and spread tissues with min-
imal cutting and are used in areas where leakage
must be prevented.
604

Surgery

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What are some common surgical techniques discussed in the document?

What are some common surgical techniques discussed in the document?

What are different types of sutures and their properties?

What are different types of sutures and their properties?

Contents

About the author - 9

Historical aspects of otolaryngological surgery - 15

History of mastoid surgery - 20

Role of microdebriders in otolaryngology - 23

Approaches & mastoidectomies - 47

Modified radical mastoidectomy - 56

Ear lobe repair - 98

Surgical techniques in Otolaryngology

Retrolabyrinthine approach to petrous apex - 122

Middle cranial fossa approach to petrous apex - 126

Antral puncture & Lavage - 138

SMR & Septoplasty - 154

Caldwell-Luc Surgery - 160

Endoscopic inferior meatal antrostomy - 168

Vidian neurectomy - 172

Transpalatal vidian neurectomy - 178

Endoscopic posterior nasal neurectomy - 182

Approaches to frontal sinus - 185

Endoscopic frontal sinus surgery - 188

Draf Procedure - 189

Frontal sinus rescue - 196

Sewall-Boyden flap usage in external frontal sinusotomy - 198

Diagnostic nasal endoscopy - 202

Bicoronal approach to frontal sinus - 206

Anatomy of uncinate process - 210

Maxillary antrostomy - 222

Anterior ethmoidectomy - 222

Posterior ethmoidectomy - 222

External ethmoidectomy - 226

Endoscopic management of fronto ethmoidal mucocele - 228

Endoscopic Transnasal optic nerve decompression - 232

Fracture nasal bones reduction - 238

Classification of fracture zygoma - 248

Zygomatic complex fractures - 253

Blow out fracture of orbit - 255

Surgical approaches to orbit - 262

Leefort classification of maxillary fractures - 278

Endoscopic orbital decompression - 284

Endoscopic medial wall decompression - 286

Lateral orbitotomy - 288

Endoscopic DCR - 290

Hadad-Bassagasteguy flap - 304

Endoscopic Hypophysectomy - 306

Management of CSF Rhinorrhoea - 312

Intracranial repair of CSF leak - 317

Extracranial repair of CSF leak - 317

Lateral rhinotomy - 322

Surgical approaches to nasopharynx - 324

Maxillary swing approach - 324

Mandibular swing approach - 325

Midfacial degloving approach - 326

Transpalatal approach to nasopharynx - 329

Surgical approaches to anterior skull base - 330

Coblation tonsillectomy - 340

Quinsy drainage - 348