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To Sheila, Alex, Brendan, Briana, Christian, and all the residents and fellows at the Department of Otolaryngology-Head and Neck Surgery, University of Miami School of Medicine.

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This endoscopic sinus surgery (ESS) dissection manual illustrates a unique, anatomically based, and stepwise approach for learning to perform endoscopic sinus surgery. This approach has been used for years in teaching endoscopic surgical anatomy and technique to otolaryngology residents and fellows at the University of Miami School of Medicine. It combines all the best attributes of prior methodologies.

In this manual I illustrate how the bony ridge of the antrostomy and adjacent medial orbital floor can be very consistent and useful landmarks when performing ESS. By using the antrostomy ridge and medial orbital floor, in combination with columnellar measurements, even the most inexperienced surgeon can determine his or her approximate location within the ethmoid labyrinth and operate within a zone of confidence. Use of this approach also facilitates the determination of the correct anteroposterior trajectory into the posterior ethmoid and sphenoid sinuses. The methodical use of these landmarks keeps the surgeon oriented, especially when faced with significant anatomical distortion due to disease or prior surgery. That is, neither anatomical reference point appears to be significantly affected by inflammatory conditions or prior sinus surgery, and both are easy to find. Utilizing these consistent reference points minimizes the chance of inadvertent intracranial or intraorbital complications in the face of significant anatomical distortion.

The manual is divided into 20 dissections. Each of the dissections builds on the anatomical exposure and identification of key anatomical landmarks developed in the preceding dissection. In addition, an increasing degree of surgical skill and knowledge of the endoscopic paranasal sinus anatomy is required as the student progresses through all 20 dissections.

Therefore, one should complete each dissection before progressing to the next one in the manual. All the structures illustrated in each section should be completely identified. Remember that repetition is the key to developing an expertise in any surgical procedure. Finally, the endoscopic surgical skills acquired from this manual should be supplemented with additional reading from the references at the end of the manual to expand one's fund of knowledge in all the procedures discussed.

Roy R. Casiano


Preface v

1. Consistent and Reliable Anatomical Landmarks in Endoscopic Sinus Surgery:

A Historical Perspective 1

2. Surgical Instrumentation, Setup, and Patient Positioning 9

A. Surgical Instrumentation 9

B. OR Setup and Patient Positioning 12

3. Basic Dissection 19

A. Intranasal Examination 19

B. Inferior Turbinoplasty 22

C. Septoplasty 23

D. Middle Turbinoplasty 25

E. Uncinectomy and Identification of the Maxillary Natural Ostium 28

F. Middle Meatal Antrostomy 32

G. Anterior Ethmoid Air Cells 39

H. Posterior Ethmoid Air Cells 44

I. Sphenoid Sinusotomy 48 J. Frontal Sinusotomy 58

4. Advanced Dissections 63

A. Sphenopalatine and Vidian Foramen and Pterygomaxillary Fossa 63

B. Anterior and Posterior Ethmoid Arteries 70

C. The Nasolacrimal System and Dacryocystorhinostomy 72

D. Orbital Decompression 79

E. Optic Nerve Decompression and the Carotid Artery 83

F. Orbital Dissection 86

G. Extended Frontal Sinusotomy and the Lothrop Procedure 89

H. Extended Maxillary Antrostomy and Medial Maxillectomy 95

I. Extended Sphenoid Sinusotomy and Approach to the Sella Turcica 97 J. Anterior Skull-Base Resection 99

References 103


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