Alveolar Recess Cell (ARC): A Newly Described Intra Maxillary Sinus Cell with Variable Pneumatisation of Alveolar Process of Maxilla.

Anatomical variations in the maxillary sinus pneumatisation are limited unlike the ethmoids. We present rare variations of the maxillary sinus along its floor other than septations and includes wide pneumatisation of alveolar and palatal recess with cell formation. An intra-maxillary cell that opens into the maxillary infundibulum well within the sinus is described here and our senior author has coined the new term-alveolar recess cell. Its involvement in the sinus pathologies and additional surgical approaches for the disease clearance is discussed here.

How I do it:- Endoscopic Reverse Denker's Approach.

Introduction: Endoscopic Denker's approach involves complete exposure of the anterior, inferior and lateral walls of the maxillary sinus providing access to both infratemporal and pterygopalatine fossa. Open approaches to maxillary sinus may lead to a high chance of cranial nerve dysfunction, trismus and wound healing issues. Surgical methods differ based on pathology, exposure, visualization and extent of clearance of the pathology. Method: The technique and surgical steps of Endoscopic Reverse Denker's approach are presented. Results: Critical steps include inferior turbinectomy, uncinectomy, followed by mega middle meatal antrostomy. For exposure drilling is started from the anterior margin of middle meatal antrostomy up to the pyriform aperture anteriorly till the anterior wall of the maxilla is visualized and the nasolacrimal duct can be visualized and transected. This method preserves the pyriform aperture and anterior wall similar to inside-out mastoidectomy tracing the pathology with less bone removal, faster and less morbidity. Conclusion: Endoscopic Reverse Denker's is a 2-handed or 4-handed endoscopic technique for proper exposure, visualization and clearance of the maxillary pathology of the anterolateral and anterior wall. Olfaction is preserved and crusting is less as there is less bone removal with no atrophic nasal changes. It preserves the pyriform aperture thereby preventing alar collapse.

Local Anaesthetic Nerve Blocks in Endoscopic Nasal and Sinus Surgery.

In the present era, Hemostasis in Endoscopic nasal and sinus surgeries are challenging even with appropriate use of instrumentation and surgical skills. This can be addressed with appropriate local anaesthesia and nerve blocks. Expertise in performing surgery under local anaesthesia can be acquired over years of surgical training. The objective  of this article is to define complete nerve blocks which can be used in endoscopic nasal surgeries.

Supra Maxillary Cell (SMC): An Anatomical variant of Ethmoid Sinus.

65 year old female presented with complaints of Right sided nasal obstruction of 1 year duration, intermittent nasal discharge for the past 6 months, without much significant improvement in medical management. Computerized tomography of paranasal sinuses revealed presence of supra maxillary cell (SMC) which was infected, along with sphenoid sinus (Heterodense lesion-suggestive of probable Fungal sinusitis). Patient underwent Functional Endoscopic Sinus Surgery with Septoplasty under local anesthesia. Among the paranasal sinuses, the ethmoid sinus has the largest number of anatomical variations. Important structures near the ethmoid sinus are usually in danger during the endoscopic sinus surgery due to its extreme anatomical variations. Posterior ethmoid cells can also expand towards and into the Maxillary sinus, which drains into the superior nasal meatus, referred to as the Ethmo maxillary sinus. This clinical report highlights about similar  anatomical variation in the paranasal sinuses. We report a case of similar type of cell, only difference is it drains into middle meatus, situated mostly over the maxillary sinus alone along its entire width and the senior author has coined a term for it as supra maxillary cell (SMC).

A Comparative Study between Endoscopic Prelacrimal Approach and Middle Meatal Antrostomy for Maxillary Sinus Pathologies.

Aim, To evaluate the treatment outcomes of endoscopic prelacrimal approach in managing various maxillary sinus pathologies, analyzing the associated adverse events and post treatment quality of life and also to compare surgical outcomes of prelacrimal approach with middle meatal antrostomy approach to remove various maxillary sinus pathologies. MATERIALS AND METHODS: A prospective study was conducted from January 2019 to April 2020. We took 60 patients with maxillary sinus pathologies and divided into two groups and done sinus surgery through middle meatal antrostomy approach (group A) and prelacrimal approach (group B). Post operative follow up done for one year and analyzed complications and recurrence. RESULTS: We compared the recurrence rate of antrochoanal polyp in both groups. Out of 12 patients in group A, 6 patients (50%) got recurrence of polyp. In group B, only one patient (8%) got recurrence out of 12 patients of antrochoanal polyp. CONCLUSION: We conclude that prelacrimal recess approach is a better option than middle meatal antrostomy for complete removal of pathologies in maxillary sinus.

"Fizz Sign" in Acute Sinusitis-A CT Scan Finding.

To study the Computerized Tomography (CT) Paranasal Sinus findings in patients with acute bacterial sinusitis and the clinical symptom associated with it. 120 patients were examined over 2 years with coronal CT images of paranasal sinus with clinical symptoms of acute sinusitis of 2 weeks duration from the onset. Patients with symptoms of more than 2 weeks and patients with chronic sinusitis, immunocompromised status were excluded. Air mixed with fluid is seen like a Fizz of cola drink within the maxillary, frontal or sphenoid sinus, mucosal thickening of more than 5 mm, fluid level and presence of opacifications were used as evidence of acute sinusitis. 28 patients (23.3%) had Fizz sign (Air mixed with fluid seen as bubbles) coronal CT images of the paranasal sinus. The study demonstrated great variation in the CT paranasal findings amongst patients with suspected acute sinusitis. More than one sinus subsite was affected amongst patients in whom acute sinusitis was confirmed by CT Paranasal sinus imaging. We hereby highlight a new sign of air mixed with fluid which the senior author had named as Fizz Sign because of its resemblance to the fizz of dark cola drink.

Cribriform CSF Leak: Endoscopic Surgical Repair Using Free Septal Mucosal Graft Without Postoperative Nasal Packs.

Cribriform plate is the commonest site of Cerebrospinal fluid (CSF) leak, its fragility and juxtaposition of arachnoid's investment to the bone, where the olfactory nerve pierces the skull, is a vulnerable site for CSF leak. Endoscopic transnasal approach has been the main stay for CSF leak repair over the past 2 decades. The technique and surgical steps of Endoscopic Surgical Repair of Cribriform CSF Leak using Free Septal Mucosal Graft without Postoperative Nasal packs are presented. Transnasal endoscopic CSF leak repair under General anesthesia with free mucosal graft, the critical steps include visualize the site of leak, lateralisation of middle turbinate, defect site cauterised with bipolar cautery. Free mucosal from contralateral side of the septum was placed as overlay technique. Graft stabilised with surgicel after ensuring adequate contact between the graft and the defect site. If the defect site is large then fat harvested from thigh is used as bath plug the defect, then free mucosal graft is kept supported by surgicel. Finally the middle turbinate was medialized and sutured with 3 0' Vicryl with nasal septum to support the graft and also to stabilize the middle turbinate as a quilting stich. No fibrin glue was used in our case series. No nasal packing was done. Patients discharged on 2nd or 3rd postoperative day. This technique provides consistent good results reduced operating time of 40 min, no post-operative morbidity, early mobilisation, with 100% success rate and with added advantage of no nasal packing, patient can easily breathing through the nose postoperatively & no recurrence on long follow up.

Dr. Ahila's Conchal Crusher for Concha Bullosa.

Endoscopic Sinus Surgery is evolving day by day, there is a constant need for improvisation in terms of instrumentation with clear bloodless surgical field and good postoperative results. The applications of Dr. Ahila's Conchal Crusher for managing Concha bullosa in Functional Endoscopic Sinus Surgery  (FESS) Surgery are presented. The creation/innovation of Dr. Ahila's conchal crusher will prevent raw mucosal surface area, bleeding and scope fogging with blood during FESS surgery after traditional conchoplasty. This new instrument makes it easy to reduce concha bullosa during nose and sinus surgery creating a bloodless field, no risk of destabilization or fracture of middle turbinate hence no postoperative synechiae  which may otherwise lead to iatrogenic frontal sinusitis. Surgical instruments  represent a major financial asset to the healthcare facility. Single instrumentation is essential to avoid costly replacements, surgeon satisfaction, reduce costs and delays in the Operating room and enhance patient safety. Dr. Ahila's conchal crusher may facilitate the performance of concha bullosa surgery and advance the art of Endoscopic Sinus surgery to a better level.