By Werner Hosemann, J Fanghänel
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Additional info for A Dissection Course On Endoscopic Endonasal Sinus Surgery
Demonstrate the nasolacrimal duct. • Resect the nasolacrimal duct and maximize the window. • Endoscopic inspection: note the broad exposure including the prelacrimal recess of the maxillary sinus. The lamina papyracea is very thin in places (50 u) and may be absent at some points. • Remove the lamina papyracea: an anterior area of the lamina papyracea can be carefully perforated by pressure from the sharp end of the doubleended elevator and then undermined. Proceeding in steps, push or fracture the bone medially and inferiorly like an egg shell and remove the pieces.
The anterior ethmoid and the agger nasi show varying degrees of anterior extension in relation to the lacrimal Fig. 33 Anatomy of the lacrimal drainage system. passages. In almost half of cases, the surgeon cannot avoid opening anterior ethmoid cells when thoroughly exposing the lacrimal sac (Talks and Hopkisson 1996). The lacrimal bone is usually only about 100 u thick in the area of the lacrimal sac, making it highly vulnerable (Hartikainen et al. 1996), especially during anteriorto-posterior dissection in the middle meatus.
Outline a rectangular, vertically oriented mucosal flap over the lacrimal duct (landmark: the agger nasi) and remove the mucosa. The frontal process of the maxilla is exposed anteriorly and portions of the lacrimal bone posteriorly. • Remove the bone with the punch (a chisel or bur would be used in vivo). • Try to probe the lacrimal passages from an external approach, and place tension on the lacrimal sac. • Remove the medial portions of the lacrimal sac. 11 Sphenopalatine Artery Fig. 35 Stenting of the lacrimal passages after previous fenestration of the right lacrimal sac from an endonasal approach (West technique).
A Dissection Course On Endoscopic Endonasal Sinus Surgery by Werner Hosemann, J Fanghänel