Coakley trocar used in this procedure. Above - the cannula, below - the sharp end of the device use to prick and make the opening of the medial wall of the antrum.
Attached cannula sleeved into the trocar. The trocar will be removed and the sleeve left in place for irrigation once antral cavity placement of the tip confirmed.
Snapshot of Coakley trocar in-situ (arrow) with its tip inside the maxillary sinus.
(S - septum, IT - inferior turbinate)
The puncture wound (arrow) at completion of procedure which will close naturally upon healing. (S - septum, IT -inferior turbinate)
Figure 1: Endoscopic view prior to balloon procedure.
Figure 2: Balloon sinuplasty being performed using SPIN system and LUMA guidewire.
Figure 3: Mucopus and infectious material being flushed out.
Figure 4: Procedure completed once the exited saline from dilated ostium becomes clear.
MT - middle turbinate, S - nasal septum, dashed line - uncinate process surface anatomy, star - mucopus, X - saline irrigation exited from dilated ostium. NB: this patient had endoscopic sinus surgery years ago and has recurrent infection.
An illumination of right maxillary sinus for confirmation of correct entry and positioning before the balloon andvancement and inflation. Similar illumination is seen in frontal sinus but least visible in sphenoid sinus.
Septal Deviation to The Right Initial Incision on The Septum
Raising Subperichondrial Flap The Contralateral
Subperichondrial Flap Separated
with Septal Cartilage seen
Between The Nasal Speculum
[Credit of these images to Dr AW Chong
from University of Malaya Medical Centre]
Fragments and pieces of cartilage and bones removed from a patient with severe nasal septum deviation.
An example of suction elevator used to separate mucoperichondrium from cartilage or bony segment of nasal septum whilst achieving a blood-free operating field.
Suction elevator in used during septoplasty. Noted dry field achieved with improved visualization of surgical anatomy while right mucoperichondrial flap being raised. (F - mucoperichondrial flap, SC - septal cartilage, SE - suction elevation with the hollow end facing medially)
Absorbable septal sutures secured at incision line of nasal septum to appose the wound edges. Alternatively, an absorbable suture stapler can be used. Arrows - vicryl sutures (top left - view from right nasal cavity, top right - view from left nasal cavity), S - nasal septum (after cartilage removed), IT - inferior turbinate.
Septal deviation with spurring to right in another patient.
Absorbable septal sutures in-situ at completion of surgery.
[Credit of this image to Dr AW Chong
from University of Malaya Medical Centre]
Figure shows the postoperative appearance of healed left inferior turbinate
after partial turbinectomy performed. The tail of inferior turbinate (white arrow)
was left untouched. Some degree of mucosal hyperplasia can still recur.
[S- nasal septum, stars mucosal cover of turbinate remnant,
red arrow- nasolacrimal duct opening (covered by mucosa- valve of Hassner].
Thin mucosal cover of inferior concha after right subtotal inferior turbinectomy.
Inferior tubinate tail preservation in partial turbinectomy as this part
can potentially bleed as the vessel feeders are in proximity distally.
[ITT- inferior turbinate tail, MT- middle turbinate, N- nasopharynx]
Honour of this surgery to Professor Prepageran Narayanan
from University of Malaya Medical Centre
Endoscopic appearance of left middle turbinate concha bullosa (CB). (S - septum)
Endoscopic view of left middle turbinate concha bullosa showing its pneumatized cavity. Its lateral-halve will be excised leaving its cavity wide open and epithelialized naturally while preserving the medial attached side as natural landmark. (S - septum)
Figures showing an introperative endoscopic view of left concha bullosa after it was uncapped. The mucosa appeared hyperplastic and this will revert
to normal upon healing.
Watch video of concha bullosa surgery @ YouTube
PC - posterior choana, V - vomer, MT - middle turbinate, F - flap raised, A - maxillary antrum, arrow - sphenopalatine artery.
F - flap raised, A - maxillary antrum, arrow - sphenopalatine artery,
The artery can be ligated using Liga clip or cauterized using bipolar diathermy device as shown below.
An example of microdebrider by Medtronic
This device is has becomes widely-used during endoscopic nasal surgery and very useful in removing mass lesions including polyps. Specimen can be collected by siphoning the debrided materials into a collector bottle attached to the suction tube. It is an alternative biopsy method to cold instrument usage.
Microdebrider tip showing the inner rotating serrated blade
in "close" [left figure] and "open" position [right figure].
Biopsy was taken prior to polyps removal.
Video showing biopsy of nasal polyps. Prior local infiltration
with marcain/adrenaline was given. Adequate tissue and deeper biopsy
need to be taken especially in suspected malignancy and inverted papilloma.
Video showing polypectomy by using microdebrider. This device sucks and cut the polyps at the same time whenever the foot paddle pressed. The direction of the cutting blade must be seen to ensure safety. The speed can be varied depending on how much pressure exerted on the foot paddle.
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