The mystery of orbital fat should not be so intimidating. The surgical mantra for chronic rhinosinusitis is to not expose orbital fat, however in specific instances it is imperative to take down the lamina papyracea to expose the orbital fat. Instances where this would be necessary would be for infections, tumors, orbital decompression as well as others. Specifically in this case, we surgically opened the maxillary antrum and took down the anterior ethmoid air cells. From here, we dissected laterally to the lamina papyracea and opened up the lamina where the orbital fat is exposed. This video shows that when you compress on the orbit the orbital fat moves and is displaced towards the path of least resistance in this case the opened up lamina and hence the fat moves towards the ethmoid air cells (ie medial). DOI: http://dx.doi.org/10.17797/wmjp1t36k5
Contributors: Gresham Richter Here we present endoscopic excision of a concha bullosa (a pneumatized middle turbinate) that was causing obstruction in the left nasal cavity. This particular patient failed medical management of his chronic sinusitis including antibiotic and steroid therapy. The concha bullosa was causing obstruction of the maxillary sinus ostium and deviation of the nasal septum. Resection of the concha bullosa was necessary in order to complete a functional endoscopic sinus surgery afterward and septoplasty (not shown). DOI # 10.17797/pyzfxehca8 Author Recruited by: Gresham Ritcher
Contributors: Michael Golinko, Kumar Patel and Bridget O'Leary LeFort I osteotomy and advancement in 18y/o female patient with maxillary hypoplasia DOI: https://doi.org/10.17797/1cu3tz50yf
Congenital nasal pyriform aperture stenosis (CNPAS) is defined as inadequate formation of the pyriform apertures forming the bony nasal openings resulting in respiratory distress and cyanosis soon after birth. Some clues such as worsening distress during feeding and improvement during crying may indicate a nasal cause of respiratory distress rather than distal airway etiology. Inability or difficulty passing a small tube through the nasal cavities may suggest CNPAS. The presenting clinical features of CNPAS can be similar to other obstructive nasal airway anomalies such as choanal atresia. Diagnosis is confirmed via CT scan with a total nasal aperture less than 11mm. CNPAS may occur in isolation or it may be a sign of other developmental abnormalities such as holoprosencephaly, anterior pituitary abnormalities, or encephalocele. Some physical features of holoprosencephaly include closely spaced eyes, facial clefts, a single maxillary mega incisor, microcephaly, nasal malformations, and brain abnormalities (i.e. incomplete separation of the cerebral hemispheres, absent corpus callosum, and pituitary hormone deficiencies). It is important to rule out other associated abnormalities to ensure optimal treatment and intervention. Conservative treatment of CNPAS includes humidification, nasal steroids, nasal decongestants and reflux control. Failure of conservative treatment defined by respiratory or feeding difficulty necessitates more aggressive intervention. The most definitive treatment for CNPAS is surgical intervention to enlarge the pyriform apertures. Contributors: Adam Johnson MD, PhD Abby Nolder MD
Our patient is a 20 year old boy with severe maxillary hypoplasia with a history of bilateral cleft lip and palate. We performed a maxillary advancement with distraction osteogenesis. Nikhil Kamath, BS Aaron Smith, MD Michael S. Golinko, MD Kumar Patel, PA-C
A 70-year-old male presented with persistent left-sided epistaxis, occurring 4 - 12 times a day for 3 weeks. Episodes lasted 10 - 15 minutes, but once required nasal packing at the ED. Introduction: Ligation of the sphenopalatine artery is often indicated for patients with persistent posterior epistaxis that cannot be attributed to other causes. This video demonstrates a step-wise endoscopic sphenopalatine artery ligation using hemoclips. Methods: In order to access the maxillary sinus cavity, a ball-tip probe was used to fracture the uncinate and a backbiter was used to remove the uncinate in its entirety. Once in the maxillary sinus, a backbiter was used to remove the tissue anterior to the normal ostium. A straight Tru-Cut was used to remove tissue posterior the natural ostium, taking down the posterior fontanelle. After this was done, a down-biter and a microdebrider blade were used to remove tissue inferior to the natural ostium towards the inferior turbinate. A caudal instrument was used to raise a subperiosteal flap just posterior to the left maxillary sinus posterior wall. Next, dissection from the inferior turbinate up to the top of the maxillary sinus was done from an inferior to superior direction, roughly 1 cm posterior to the posterior wall of the maxillary sinus. The sphenopalatine artery was seen coming out of the sphenopalatine foramen and soft tissue was dissected off this artery. Two hemoclips were placed over the entire artery. Results: The patient was sent to recovery in good condition and no adverse reactions were reported by the surgeon or patient. Surgeons: Alissa Kanaan, MD. Zachary V. Anderson, MD. Institution: Department of Otolaryngology - Head and Neck Surgery at the University of Arkansas for Medical Sciences.
A 49-year-old female presented with a one-year history of right frontal headaches, not controlled despite OTC medication. Work up with head CT revealed an osteoma of the right frontal sinus. The patient experienced no improvement in headache severity and elected to have surgical intervention. Methods: ENT Fusion Navigation system was used during the entire case. A ball-tip probe was used to fracture out the uncinate bone and a backbiter was used to remove the uncinate in its entirety. The natural ostium of the right maxillary sinus was then visualized. Again, the backbiter was used to remove tissue anterior to the natural ostium. A straight Tru-Cut was used to remove the ostium towards the posterior fontanelle. The right middle turbinate was resected in order to gain sufficient access for the resection of the osteoma. In order to remove the right middle turbinate, a turbinate scissors were used to make 3 cuts along the attachment of the middle turbinate and this was pulled down. A down biter was used to open up the maxillary sinus inferiorly. There was no tissue seen in the maxillary sinus. After this was done, an ethmoidectomy was performed by placing a J-curette behind the ethmoid bulla point anteriorly. This ethmoid bulla was removed along with several other anterior ethmoid cells. After this was done, a frontal sinus seeker was used to identify the right frontal osteoma. The patient did not have a right frontal sinus. Instead, an osteoma was in the area of what would have been the right frontal sinus or nasal frontal outflow tract. Image guidance was meticulously used to identify the osteoma. A 70-degree frontal drill was used and this osteoma was slowly drilled to remove as much as possible. Drilling was done from the posterior edge of the osteoma up to the skull base superiorly, to the lamina papyracea laterally and all bone that could be safely removed was removed. A right frontal propel stent was placed in the bony cavity created by the drill out and after this, the sinus was irrigated and suctioned. Results: The patient was sent to recovery in good condition and no adverse reactions were reported by the surgeon or patient. Surgeons: Alissa Kanaan, MD. Zachary V. Anderson, MD. Institution: Department of Otolaryngology - Head and Neck Surgery at the University of Arkansas for Medical Sciences.
This procedure was performed on a 6 year old male with chronic rhinosinusitis who had failed medical management and was subsequently found to have maxillary hypoplasia with computed tomography. Surgeon: Gresham T. Richter, M.D.
Prior to surgical incision, antibiotic prophylaxis is administered with appropriate intravenous antibiotics. The skin is incised and the posterior incision dissection is done perpendicular, straight down, through the subcutaneous fat. After the skin is incised, the dissection is beveled outward anteriorly. This creates a subcutaneous flap anteriorly. At all locations, the dissection is done down to, but not violating, the clavipectoral fascia. Anteriorly, any axillary creases or folds are obliterated by scoring of the subcutaneous tissue. The axillary breast tissue is then excised, marked for appropriate laterality, and submitted for permanent pathology. The resulting void is copiously irrigated and hemostasis is ensured. Long acting anesthetic is used to infiltrate the regional sites for postoperative analgesia. A 15-French Blake drain is placed posteriorly through a separate stab incision. The skin edges are meticulously aligned at the anterior and posterior edges with redundancy kept in the middle (Figure 6). The incisions are closed in two layers. An absorbable suture is used in interrupted buried fashion followed by an absorbable subcuticular stitch. 2-octyl cyanoacrylate liquid adhesive and self-adhering mesh (Dermabond Prineo) is placed superficially. Video 1 summarizes the technique.
This webinar will address the definition of zygomaticomaxillary complex (ZMC) fractures, will review pertinent literature, mechanisms of injury, classification, surgical approaches and complications. The presenter will make use of clinical photos and will allow an opportunity to answer questions.
Jose M Marchena DMD, MD, FACS
Associate Professor of Oral and Maxillofacial Surgery / Chief of Oral and Maxillofacial Surgery
University of Texas Health Science Center / Ben Taub Hospital
Dr. Jose Marchena obtained his dental degree magna cum laude from Harvard School of Dental Medicine and his medical degree from Harvard Medical School. He completed internships in oral and maxillofacial surgery and general surgery at Massachusetts General Hospital in Boston and his residency training at Louisiana State University Medical Center in New Orleans. Dr. Marchena is an associate professor of oral and maxillofacial surgery at the University of Texas Health Science Center in Houston. He also serves as chief of oral and maxillofacial surgery at Ben Taub Hospital in Houston and as vice president of Smile Bangladesh, a nonprofit organization dedicated to providing cleft lip and palate repair operations in rural Bangladesh.
Alfredo R. Arribas DDS, MS, FACS
Assistant Professor in Department of Oral and Maxillofacial Surgery
University of Texas Health Sciences Center at Houston
Received his Bachelor of Science (BS) and Doctor in Dental Surgery (DDS) Degrees from Universidad Peruana Cayetano Heredia in Lima, Peru, in 1996, certificates in Advanced Education in General Dentistry (AEGD) at University of Maryland School of Dentistry, in 1998, two - year General Practice Residency (GPR) Program at LSU Health Sciences Center in 2000 and Oral, Maxillofacial Surgery internship at LSU Health Sciences Center in 2001, and Oral and Maxillofacial Surgery Residency at LSU Health Sciences Center, New Orleans in 2012, where he was trained in full scope Oral & Maxillofacial Surgery. Obtained a Master of Science (MS) degree in Health Care Management from University of New Orleans in 2004. Fields of interests includes: maxillofacial trauma, facial reconstructive surgery, dental implants, dentoalveolar surgery and orthognathic surgery.
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