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.
