Sphenoidotomy Technique

Updated: Mar 19, 2015
  • Author: Thomas S Higgins, Jr, MD, MSPH; Chief Editor: Arlen D Meyers, MD, MBA  more...
  • Print
Technique

Approach Considerations

Several specific sphenoid procedures may be performed. Some procedures, including lavage of the sphenoid sinus and diagnostic sinuscopy, provide access to the sphenoid sinus without requiring surgical sphenoidotomy. Surgical dilation of the sphenoid ostium is a minimally invasive approach to widen the sinus ostium without removing tissue. [4, 5]

Sphenoidotomy is the surgical opening of the sphenoid sinus. Sphenoidotomy may be performed without (CPT#31287) or with (CPT#31288) tissue removal. The designation of "tissue removal" has been defined by the American Academy of Otolaryngology-Head and Neck Surgery as removal of material or tissue, not just suctioning of mucus or pus.

The techniques for endoscopic sphenoidotomy may be divided into (1) transethmoidal versus transnasal approach and (2) opening via the natural os versus through the anterior sinus wall.

The image below demonstrates a sphenoidotomy site 6 weeks postoperatively.

Left-sided sphenoidotomy site at 6 weeks postopera Left-sided sphenoidotomy site at 6 weeks postoperatively from removal of sphenoid sinus fungal ball.

The size limitations of the sphenoidotomy depend on the size of the sphenoid sinus. The optimal size of the sphenoidotomy is unknown; however, it is generally considered important to perform wider sphenoidotomies in obstructive sinonasal disease such as polyposis and allergic fungal sinusitis. Expanded endonasal approaches via the sphenoid sinus often require extended procedures, including concomitant posterior septectomy, removal of the intersinus septum, and drilling away a portion of the rostrum and inferior portion of the anterior sphenoid sinus wall.

Next:

Lavage of the Sphenoid Sinus

The least invasive procedure of the sphenoid sinus is a lavage of the sphenoid sinus (CPT#31002), in which the sphenoid sinus is accessed either via the natural opening or through the sphenoid sinus face. The sinus is irrigated with saline and aspirated. The contents can then be cultured or evaluated by a pathologist.

Previous
Next:

Nasal/Sinus Endoscopy, Diagnostic with Sphenoid Sinuscopy

A nasal/sinus endoscopy, diagnostic with sphenoid sinuscopy (CPT#31235) is a procedure in which a puncture is created or cannulation is performed of a nonsurgically opened ostium. The contents can then be irrigated, aspirated, cultured, or biopsied.

Previous
Next:

Nasal/Sinus Endoscopy, Surgical; With Dilation of Sphenoid Sinus Ostium

A nasal/sinus endoscopy with dilation of the sphenoid sinus ostium (CPT#31297) is procedure in which the sphenoid sinus ostium is dilated mechanically to allow improved drainage and access to the sphenoid sinus. The procedure can be performed in the office setting or the operating room. Topical anesthesia and decongestion is performed.

In an unoperated sinus, the natural ostium is typically identified medial to the superior turbinate. Depending on the style of catheter used, a probe or a wire is gently inserted into the ostium. Once the sinus is successfully cannulated, the dilation device or balloon is advanced into the sinus ostium. The balloon is then inflated to dilate the sinus ostium. The sinus contents may then be irrigated, aspirated, cultured, or biopsied.

Previous
Next:

Endoscopic Sphenoidotomy, Transnasal via the Natural Ostium

Endoscopic transnasal sphenoidotomy without ethmoidectomy via the natural ostium can be considered in cases of isolated sphenoid sinus disease. [2] This approach has the advantage of being minimally destructive of nasal mucosa and can result in shorter operative and recovery times; however, access to the sphenoidotomy site postoperatively may be limited because the ethmoid sinus cavity has not been opened.

A 30° nasal endoscope is often beneficial to provide visualization of the sphenoid sinus opening. Removal of part of the superior turbinate may be necessary to access the ostium and to facilitate postoperative care and inspection. The natural ostium of the sphenoid sinus usually lies just posterior to the superior turbinate. The anatomic landmarks that may be used to locate the natural ostium of the sphenoid sinus include the following: [6]

  • Posterior to the superior turbinate in the sphenoethmoid recess; the natural ostium is medial to the superior turbinate in 80% of cases
  • Approximately 6 cm from the nasal sill at an angle of 30° from the nasal cavity floor
  • Approximately 1 cm above the superior extend of the choana
  • At the approximate level of the maxillary sinus roof

Once the sphenoid ostium is identified, it is enlarged using a sphenoid sinus mushroom punch or a small Kerrison punch. The contents within the sphenoid sinus are then cultured, biopsied, irrigated, or removed. Care should be taken to avoid manipulation of the posterior wall of the sphenoid sinus, which could risk injury to the internal carotid artery, optic nerve, or skull base.

Previous
Next:

Endoscopic Sphenoidotomy, Transethmoidal via the Natural Ostium

Endoscopic transethmoidal sphenoidotomy is a sphenoidotomy performed through the passageway of an ethmoidectomy. This approach is the most commonly performed method, as it gives the widest view of the sphenoid sinus from lamina papyracea to rostrum. A total ethmoidectomy is first performed until the anterior face of the sphenoid sinus, skull base, and superior turbinate are identified. A decision can then be made to approach the sphenoid via the natural os or through a puncture into a thin section of bone of the anterior face of the sphenoid sinus. Although no comparison trials have evaluated these two methods, each has theoretical and anecdotal advantages and disadvantages.

Performing a sphenoidotomy via the natural os is theorized to limit postoperative recirculation of mucus and may be safer, as the sphenoid sinus is opened via a known opening in the sinus. In contrast, a sphenoidotomy via the anterior sinus wall avoids removing a potentially healthy superior turbinate and may lessen the risk of olfactory dysfunction. The comparative complication and patency rates between these two procedures are unknown.

A 0° nasal endoscope is typically used for the procedure. Angled endoscopes (30°, 45°, or 70°) are occasionally used to visualize the corners or floor of the large sphenoid sinus cavities once a sphenoidotomy has been performed. When identifying the natural ostium, the inferior one third to half of the superior turbinate is often resected using a straight thru-cutting forceps. It is not advisable to resect the superior turbinate too superiorly because of risks to olfactory dysfunction and skull base injury with cerebrospinal fluid leak. The natural ostium of the sphenoid sinus usually lies just posterior to the superior turbinate. The anatomic landmarks that may be used to locate the natural ostium of the sphenoid sinus include the following: [6]

  • Posterior to the superior turbinate in the sphenoethmoid recess; the natural ostium is medial to the superior turbinate in 80% of cases
  • Approximately 6 cm from the nasal sill at an angle of 30° from the nasal cavity floor
  • Approximately 1 cm above the superior extend of the choana
  • At the approximate level of the maxillary sinus roof

A J-curette or image guidance probe are helpful to bluntly palpate and identify the os when it cannot be visualized initially. [7] Once the natural os is identified, a straight mushroom punch, Kerrison punch, or other instrumentation may be used to enlarge the opening laterally and superiorly. The image below demonstrates an endoscopic transethmoidal sphenoidotomy performed via the natural ostium at 6 weeks postoperatively.

Left-sided sphenoidotomy site at 6 weeks postopera Left-sided sphenoidotomy site at 6 weeks postoperatively from removal of sphenoid sinus fungal ball.
Previous
Next:

Endoscopic Sphenoidotomy, Transethmoidal via Anterior Sinus Wall

Endoscopic transethmoidal sphenoidotomy via the anterior sinus wall avoids removing a potentially healthy superior turbinate and may lessen the risk of olfactory dysfunction.

A total ethmoidectomy is first performed until the anterior face of the sphenoid sinus, skull base, and superior turbinate are identified. A 0° nasal endoscope is typically used for this approach. Angled endoscopes (30°, 45°, or 70°) may be used to visualize the corners or the floor of the large sphenoid sinus cavities once a sphenoidotomy has been performed.

The superior turbinate is usually not resected unless the surgeon decides to incorporate the natural os. The image guidance system may be used to locate a safe location for entering the sinus. If no image guidance is available, the surgeon should choose a location that is somewhat inferior and medial with palpably evident thin bone to avoid skull base injury. A blunt sickle knife or J-curette is used to puncture through a thin section of bone in the anterior face of the sphenoid sinus. The sphenoid sinus mushroom punch, Kerrison punch, or other instrumentation can then be used to widen the sphenoidotomy.

Previous