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Imaging for Endoscopic Sinus           Surgery Dr. Prahlada N.B   M.S (PGIMER, Chandigarh)Karnataka ENT Hospital & Researc...
Imaging v/s Endoscopy         V/S
Surgery done without imaging
Imaging modalities        CT Scan is choice of ImagingPlain X-Ray        CT Scan             MRI
Patient Preparation• Course of Antibiotics & Decongestants• Sympathomimetic Nasal Spray 15 min before  CT procedure• Patie...
Reading CT Films•   Coronal Images•   Mark R/L sides properly•   Read from Nasion to Sphenoid sinus•   Study following in ...
Normal Anatomy
Coronal Section : At Nasion
Coronal Section : At Agger Nasi
Frontal RecessSagittal Section    Coronal Section
Lacrimal Apparatus
Coronal Section : At OMC
Anterior Skull Base
Ethmoid InfundibulumAxial Section     Coronal Section
Middle turbinate attachements  I Part     II Part     III PartVertical    Oblique     Horizontal
Lateral RecessCoronal Section     Sagittal Section
Coronal Section : At Post. Ethmoid
Posterior Ethmoid Cells (Onodi)Axial Section      Coronal Section
Coronal Section : At Sphenoid
Axial Section : At Frontal
Axial Section : At Optic nerve
Axial Section : At Maxillary sinus
Anatomical Variations
Variations : Frontal SinusCoronal Section     Axial Section
Variations : Frontal SinusCoronal Section    Axial Section
Variations : Frontal SinusAxial Section     Coronal Section
Variations : Frontal CellsType I                                  Type IIType III                                Type IV
Variations : Agger Nasi Cells
Variations : Agger Nasi CellsAgger causing disease   Large Agger Nasi cell
Variations : Frontal Recess
Variations : Anterior Skull Base Type I      Type II     Type III1 - 3 mm    4 - 7 mm     8 - 16 mm
Variations : Uncinate processMedially bent      Pneumatized
Variations : Bulla Ethmoidalis                    Absent Bulla
Variations : Ethmoid Sinus
Variations : Haller’s Cells
Variations : Middle turbinateConcha    Paradoxic MT   Interlamellar
Rostrum of the Sphenoid
Sphenoid Pneumatization types           Conchal
Sphenoid Pneumatization types           Presellar
Sphenoid Pneumatization types            Sellar
Variations : Sphenoid Sinus  Extensive         Pterygoidpneumatization    penumatization
Variations : Sphenoid SinusDehiscent nerves   ACP penumatization
Variations : Sphenoid SinusDehiscent Optic Nerve   Dehiscent Int. Carotid.a
Variations : Sphenoid SinusAbsent Septa      Multiple Septae
Variations : Sphenoid SinusSepta ending on Optic   Septa ending on Carotid
CT in Pathology
Acute Sinusitis• Air Fluid level• Mucosal thickening• Complete opacification of the sinus
Chronic Sinusitis•   Ethmoid sinus is commonly involved•   Mucosal thickening•   Bone remodeling due to osteitis•   Polypo...
Fungal Sinusitis•   Allergic fungal sinusitis•   Sinus mycetoma•   Acute invasive fungal sinusitis•   Chronic invasive fun...
Allergic fungal sinusitis• Complete opacification of multiple sinuses• Sinus expansion & erosion of sinus wall• High atten...
Sinus Mycetoma• Focal area of increased attenuation that is  created within a deseased sinus
Acute invasive fungal sinusitis• Aggressive bone erosion• Extension of disease into adjacent soft  tissues• Intrasinus hig...
Bening polyp• Homogenous, well circumscribed  hypodense/isodense mass
AC Polyp
Mucocoele• Hypodense, non-enhancing mass that fills  and expands the sinus cavity
MucocoeleFrontal               Sphenoid
Complications of FESS
Complication : NLD injury
Complication : ACF injury
Complication : CSF Leak
Complication :Orbital Haemorrhage
Complication :Medical rectus injury
Complication :Pneumo-encephaloceole
Complication :Optic Nerve injury
Complication : Haemorrhage
Thank youwww.kenthospitals.com/education/iess.html
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Imaging for Endoscopic Sinus Surgery



Preface

If not coincidence, at least it was in the same decade when endoscopic sinus surgery and computed tomography were introduced to Otolaryngologists, which have changed the approach to sinonasal problems dramatically. Probably, there are no such coincidences in the history of medicine where two new modalities of approaches appeared at the same time, to deal with the same problem and complement each other while doing so. The asset of improved visualization and magnification, available through endoscopes, has revolutionized the understanding of the pathophysiology of sinusitis, and resulted in better appreciation of the anatomy of the paranasal sinuses. However, non-invasive diagnostic endoscopy has its limits, and the deeper structures cannot be evaluated by endoscopy alone . Computed tomography, which has an ability to optimally display bone, soft tissue and air simultaneously, can not only complement endoscopic examination, it can provide a surgical road map delineating the anatomy, defining the obstructing lesions, and noting anatomic variations that may predispose to operative complications.

Computed tomography has scored over plain radiographs and polytomographs as an imaging modality in this area. Even though surpassing CT's capacity to image soft tissue, MRI is less suitable as an imaging modality for evaluation of this area because of the similar signal intensities for bone and air.

CT scanning has become imaging modality of choice and the cooperation required between the Radiologist and the Surgeon is mandatory for both evaluation and treatment of paranasal disorders. It is of paramount importance on the part of the Otolaryngologists to understand interpretation of CT films, Radiological anatomy of the paranasal sinuses, Anatomical variations and the pathology to complement the endoscopy findings for initial screening, surgical planning, reduce postoperative complications and to provide better results. This Presentations is prepared to help Otolaryngology colleagues to learn the Imaging/radiological aspects required for endoscopic sinus surgery.

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Imaging for Endoscopic Sinus Surgery

  1. 1. Imaging for Endoscopic Sinus Surgery Dr. Prahlada N.B M.S (PGIMER, Chandigarh)Karnataka ENT Hospital & Research Center, Chitradurga, Karnataka.
  2. 2. Imaging v/s Endoscopy V/S
  3. 3. Surgery done without imaging
  4. 4. Imaging modalities CT Scan is choice of ImagingPlain X-Ray CT Scan MRI
  5. 5. Patient Preparation• Course of Antibiotics & Decongestants• Sympathomimetic Nasal Spray 15 min before CT procedure• Patient to blow the nose just before procedure
  6. 6. Reading CT Films• Coronal Images• Mark R/L sides properly• Read from Nasion to Sphenoid sinus• Study following in all Sections - Nasal Septum - Lamina Papyracea - Skull Base
  7. 7. Normal Anatomy
  8. 8. Coronal Section : At Nasion
  9. 9. Coronal Section : At Agger Nasi
  10. 10. Frontal RecessSagittal Section Coronal Section
  11. 11. Lacrimal Apparatus
  12. 12. Coronal Section : At OMC
  13. 13. Anterior Skull Base
  14. 14. Ethmoid InfundibulumAxial Section Coronal Section
  15. 15. Middle turbinate attachements I Part II Part III PartVertical Oblique Horizontal
  16. 16. Lateral RecessCoronal Section Sagittal Section
  17. 17. Coronal Section : At Post. Ethmoid
  18. 18. Posterior Ethmoid Cells (Onodi)Axial Section Coronal Section
  19. 19. Coronal Section : At Sphenoid
  20. 20. Axial Section : At Frontal
  21. 21. Axial Section : At Optic nerve
  22. 22. Axial Section : At Maxillary sinus
  23. 23. Anatomical Variations
  24. 24. Variations : Frontal SinusCoronal Section Axial Section
  25. 25. Variations : Frontal SinusCoronal Section Axial Section
  26. 26. Variations : Frontal SinusAxial Section Coronal Section
  27. 27. Variations : Frontal CellsType I Type IIType III Type IV
  28. 28. Variations : Agger Nasi Cells
  29. 29. Variations : Agger Nasi CellsAgger causing disease Large Agger Nasi cell
  30. 30. Variations : Frontal Recess
  31. 31. Variations : Anterior Skull Base Type I Type II Type III1 - 3 mm 4 - 7 mm 8 - 16 mm
  32. 32. Variations : Uncinate processMedially bent Pneumatized
  33. 33. Variations : Bulla Ethmoidalis Absent Bulla
  34. 34. Variations : Ethmoid Sinus
  35. 35. Variations : Haller’s Cells
  36. 36. Variations : Middle turbinateConcha Paradoxic MT Interlamellar
  37. 37. Rostrum of the Sphenoid
  38. 38. Sphenoid Pneumatization types Conchal
  39. 39. Sphenoid Pneumatization types Presellar
  40. 40. Sphenoid Pneumatization types Sellar
  41. 41. Variations : Sphenoid Sinus Extensive Pterygoidpneumatization penumatization
  42. 42. Variations : Sphenoid SinusDehiscent nerves ACP penumatization
  43. 43. Variations : Sphenoid SinusDehiscent Optic Nerve Dehiscent Int. Carotid.a
  44. 44. Variations : Sphenoid SinusAbsent Septa Multiple Septae
  45. 45. Variations : Sphenoid SinusSepta ending on Optic Septa ending on Carotid
  46. 46. CT in Pathology
  47. 47. Acute Sinusitis• Air Fluid level• Mucosal thickening• Complete opacification of the sinus
  48. 48. Chronic Sinusitis• Ethmoid sinus is commonly involved• Mucosal thickening• Bone remodeling due to osteitis• Polyposis
  49. 49. Fungal Sinusitis• Allergic fungal sinusitis• Sinus mycetoma• Acute invasive fungal sinusitis• Chronic invasive fungal sinusitis• Chronic granulomatous fungal sinusitis
  50. 50. Allergic fungal sinusitis• Complete opacification of multiple sinuses• Sinus expansion & erosion of sinus wall• High attenuation areas due to metals
  51. 51. Sinus Mycetoma• Focal area of increased attenuation that is created within a deseased sinus
  52. 52. Acute invasive fungal sinusitis• Aggressive bone erosion• Extension of disease into adjacent soft tissues• Intrasinus high attenuation may not be present
  53. 53. Bening polyp• Homogenous, well circumscribed hypodense/isodense mass
  54. 54. AC Polyp
  55. 55. Mucocoele• Hypodense, non-enhancing mass that fills and expands the sinus cavity
  56. 56. MucocoeleFrontal Sphenoid
  57. 57. Complications of FESS
  58. 58. Complication : NLD injury
  59. 59. Complication : ACF injury
  60. 60. Complication : CSF Leak
  61. 61. Complication :Orbital Haemorrhage
  62. 62. Complication :Medical rectus injury
  63. 63. Complication :Pneumo-encephaloceole
  64. 64. Complication :Optic Nerve injury
  65. 65. Complication : Haemorrhage
  66. 66. Thank youwww.kenthospitals.com/education/iess.html

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