Thursday, May 10, 2012

Tips to avoid frontal sinus trephination complications

Frontal sinus trephination is traditionally performed to treat acute frontal sinusitis that does not respond to an antibiotic therapy. In complicated acute frontal sinusitis, trephination is used to drain pus and irrigate the sinus, preventing intracranial problems. Acute frontal sinusitis accompanied by orbital or intracranial extensions can be treated with trephination. The trephination, the simplest method for the frontal sinus entry, is used to explore frontal sinus and conduct biopsy. This surgery-sinus may however cause some complications, such as intracranial entry, osteomyelitis, scarring, sinocutaneous fistula formation, supraorbital hypesthesia and trochlea damage.  

Since frontal sinus hypoplasia (incomplete or underdevelopment of an organ or a tissue) occurs in a number of patients, chances of intracranial entry during small frontal sinus trephination are high. While accessing a small frontal sinus, loss of direction can cause intracranial entry. Stimulation of the body organs or sensory nerves causes sensation. Reduction in this sensation is medically called hypesthesia. These complications can however be avoided. Read on to learn useful tips to minimize the surgery-sinuscomplications.
  • Accurate evaluation of the penumatization pattern of the patient’s sinus is necessary.

  • Coronal and axial computed tomography (CT) scans will help in measuring height and depth of the sinus accurately. With the coronal CT scan, it is possible to asses how much bone has to be removed for entering into the sinus.
  • Incise medially, which means near the median plane of the supraorbital notch to prevent supraorbital nerve trauma.

  • Rounded burr gives more control while accessing the sinus than the perforating burr. So, operation with rounded burr is safer.
  • Enter the sinus through its floor instead of the anterior wall’s diploic bone to reduce the chances of osteomyleitis.

  • To place trephine, the surgical instrument, precisely in the correct position, especially in small frontal sinuses, image guidance is required.
  • During this surgery-sinus, avoid anterior wall’s cancellous bone containing marrow space. Osteomyleitis may develop if the marrow space is contaminated.

  • If fibrosis obliterates the frontal recess, trephination facilitates visualization of the sinus from both below and above.
  • If the trephine is inserted via the anterior wall, damage to supra-orbital nerve occurs, causing paresthesia or numbness.

  • Excessively laterally placed bony trephine can damage the supratrochlear neurovascular bundle.
  • Now-a-days a mini-trephination system is available to enter the sinus. It minimizes the incision size. From the incision, cultures can be collected.

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