Endoscopic Complete Sinus Surgery for Chronic Sinusitis with Nasal Polyps - Front to Back Approach

This is a demonstration of a front to back approach to the paranasal sinuses using the vertical lamellas concept. After taking some polyps and preparing the sinus cavity, the very first step in ESS is to identify, the uncinate process and the hiatus semilunaris. The uncinate process is the first vertical lamella to be opened in order to access the first space, which contains the maxillary natural ostium and the frontal recess. Now, with a Kerrison forceps, we are taking out part of the frontal process of the maxillary bone, In order to get better exposure to the agger nasi and the fronto-ethmoidal cells. Now we can see fully the ethmoid bulla which is the second vertical lamella, and it’s anterior aspect will take us directly to the frontal recess. Now we are using a patty to access the frontal recess, the patty is slowly accessing the frontal recess. And we will leave the patty there while we continue the approach. The next step would be to enlarge the maxillary natural ostium, to do that we are fracturing the inferior part of the remaining uncinate process which articulates directly with the inferior turbinate. The next step is to open the face of the bulla, this is usually done with a couple of bites or a curette. The microdebrider is a very useful tool, we use it only as “running the ridge”, it means that is used for taking out bone debris and redundant mucosa. Never for dissection or inside a sinus cavity for safety reasons. Now, it can be seen that the anterior ethmoidal complex is completely opened, as the basal lamella of the middle turbinate can be fully identified, this is the third vertical lamella. To access the posterior ethmoidal complex, we will safely from the inferior portion of the coronal plate of the basal lamella. The posterior ethmoidal complex has from 3 to 5 cells, which are bigger than the ones on the anterior complex. More “running the ridge” with the microdebrider. To expose the sphenoid sinus natural ostium, we are going to take out the sagittal portion of the basal lamella with a Kerrison forceps. As you can see, the natural ostium is exposed and enlarged, also with a Kerrison forceps. The face of the sphenoid corresponds to the fifth basal lamella. The forth is not constant and corresponds to the basal lamella of the superior turbinate. Remember that the objective of this procedure is to create a single sinus cavity, in order to facilitate local/ topical treatment.