Intranasal Microsurgery of All Paranasal Sinuses, the Septum, and the Lacrimal Sac with Hypotensive Anesthesia

Abstract

Since 1958 all intranasal surgery at Krupp Hospital (including 2,986 operations in 1984) have been performed with the Zeiss operating microscope. Anesthesia with hypotension is important to improve the results. To facilitate focusing, a balanced movable position of the microscope directed by head motions of the surgeon and a semi-Fowler's position for the patient have proven best. Large fenestrations above and below the lower turbinates permit maxillary sinus surgery under direct binocular vision with the aid of mirrors or endoscopes. For the last 12 years the Caldwell-Luc approach was used in less than 2% of operations. All ethmoidal, lacrimal sac, and epistaxis surgery is performed intranasally. In 1984 frontal sinus surgery was performed in 59 cases with an intranasal and in 11 cases with an osteoplastic procedure. For a larger defect of the ethmoidal roof in severe injuries, conically trimmed rib cartilage is wedged into the defect from above. Having performed more than 4,000 ethmoidal operations we have never experienced an iatrogenic CSF leakage, or persisting postoperative visual or ocular disturbance. In order to achieve the necessary skill, training on 50 cadavers is required.