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"The key steps in the minimally invasive approach are designed to assure the drainage
of offending sinus cavities without injury to any drainage pathways."
David S. Parsons, MD, FAAP, FACS
Philosophy
Every sinus cavity has a drainage pathway for mucus to exit the sinus and be
transported to the nasopharynx. Sinus surgery techniques that do not
advocate the total preservation of the ciliated membrane-covered pathways
cannot be termed "minimally invasive." All surgical steps in this technique
are directed toward assuring unobstructed drainage of natural ostia. The
purpose for the design of the described instruments is to provide precise
dissection with optimal visualization. The XPS® System, used in combination
with these instruments, provides the finest state-of-the-art capability to
enhance all minimally invasive sinus surgery.
Surgical Technique
Step 1:
Addressing the Middle Turbinate
The initial step
in the minimally invasive approach is to deal
with obstructive concha bullae, if present. The
removal of the lateral wall of the middle
turbinate must be extensive enough to include
the natural ostium of the concha. Failure to
address this ostium can lead to a very deceptive
recirculation that is difficult to see in
postoperative office examinations.
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| Follow-up CT scans
can be mistakenly read as primary frontal
recess/frontal sinus disease (FR/FS) when, in
fact, it is mucosal edema at the recirculation
site causing secondary FR/FS disease. After
incising the anterior/inferior wall of the
concha, removal of its lateral wall is augmented using the sharp
suction freer to dissect tissue to find the natural
ostium. Complete removal is accomplished using the XPS System
(Figures 1 and 2). |
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| Step 2: Creating the "Uncinate Window"
The next step is removal of the uncinate process. If the FR/FS disease is
non-existent, or only the sinus has mucosal edema, the FR/FS does not
require any surgical debridement. The lower portion of the uncinate that
covers the maxillary sinus ostium is all that needs removal. A preferred
method of resection is to utilize the "window"
technique. A 135° probe specifically designed to reach into the infundibulum is positioned, then
pulled toward the surgeon. A flattened 135° probe provides easier access
to the infundibulum and greater elevation of the uncinate. This elevates the
uncinate away from the lateral nasal wall and prepares it for precise removal
with the backbiter.
(Figure 3) |
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The backbiter (MCEN27-2) removes the uncinate from
posterior to anterior. It is critical that the entire
uncinate be removed in this line of dissection. Any of the anterior portion of the uncinate
process which is not removed can obscure visualization of the natural
maxillary ostium. (Figure 4)
Author's Note: The MicroFrance® Pediatric Backbiter (MCEN27-2) is inserted into the middle
meatus with the cutting jaw in the closed position. The jaw is opened in a near vertical
orientation, then rolled behind the free edge of the uncinate. It is optimally positioned with
gentle opening and closing of the jaw; the posterior to anterior dissection now begins.
This is best achieved using a controlled, consecutive series of bites in a retrograde fashion to
form a window in the uncinate. |
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Step 3: Enlarging the Uncinate Window
This window is then enlarged with the XPS® System at 3,000 RPM in
oscillate mode for optimal visualization of the maxillary sinus
ostium. Using an angled telescope with the XPS System assures continuous
protection of the ciliated mucosa of the maxillary sinus outflow tract
and the final common pathway. (Figure 5)
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The bony portion of the most inferior uncinate is positioned for removal by shaving off some of its medial mucosa with the XPS System.
The flattened 90° probe (MCEN763) is then used to dissect the lateral mucosa and remaining medial mucosa from the uncinate bone. The
bone is then elevated from the surgical field with the 90° probe. The XPS System gently shaves the remaining inferior uncinate mucosa under
telescopic vision with care not to touch the membrane of either the maxillary sinus outflow tract or final common pathway.
(Figure 6) |
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| Step 4: Inspecting the Maxillary Ostium
The 110° olive tip suctions (MCEN766 and MCEN767) are designed to
cleanse the operative site of blood, allowing the best possible view of
the natural maxillary sinus ostium. (Figure 7)
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| If an accessory ostium is found in the final common pathway, it
may be connected to the natural ostium using either the push or the pull
end of the antrostomy blade (MCEN761 and MCEN760). The push blade
is inserted into the natural ostium and, with a sawing motion, a cut is
made to the accessory ostium. Sometimes it is easier to use a pull blade
sawing from the accessory to the natural ostium. (Figure 8) |
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| The mucosa between the two ostia is then removed with the XPS System.
(Figure 9) |
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| Step 5: Dissection of the Ethmoid Bulla
The bulla ethmoidalis is then opened on its anterior/inferior surface
using the sharp suction elevator (MCEN764) and dissection is continued
until its natural ostium is identified on its posterior surface.
(Figure 10)
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| The medial wall of the bulla is then completely removed
with the XPS System (Figure 11). When the posterior medial wall is
completely removed, the natural ostium of the bulla is adequately dealt
with and recirculation will not occur. In the majority of the patients, this
is all the surgery that is required.
Secondary FR/FS, posterior ethmoid or sphenoid disease will usually resolve with typical
postoperative care having effectively drained the ostiomeatal
complex.
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Other uses for these instruments:
Endoscopic Septoplasty
Secondary FR/FS, posterior ethmoid or sphenoid disease will usually resolve with typical
postoperative care having effectively drained the ostiomeatal
complex.
(Figure 12) |
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Use of the Suction Curettes
When the basal lamella or anterior wall of the sphenoid sinus requires
removal, the 60° or 90° suction curette (MCEN769 or MCEN768) can
be placed in the surgical opening made in the inframedial quadrant. A
pulling motion resects bone and this is repeated to the base of the skull.
The suction provides clear visualization during this dissection.
(Figure 13)
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The same technique can be
used in adolescent and adult patients. These instruments
are designed to sharply transect and not strip mucosa
form its underlying bone.
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MCEN7600
MicroFrance® Parsons Minimally Invasive Sinus Instruments Set
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MCEN27-2
Backbiter |
MCEN760
Push-Pull Antrostomy Blade, 10 mm
MCEN761
Push-Pull Antrostomy Blade, 7 mm |
MCEN762
Sinus Probe, 50°/90°
MCEN763
Sinus Probe, Flat, 50°/90° |
MCEN764
Suction Elevator, Sharp
MCEN765
Suction Elevator, Dull |
MCEN766
Sinus Suction Tube, 3 mm
MCEN767
Sinus Suction Tube, 4 mm |
MCEN768
Suction Curette, 90° |
MCEN769
Suction Curette, 60° |
Ordering
Information |
| SKU
# |
Description |
| MCEN7600 |
MicroFrance® Parsons Minimally Invasive Sinus Instruments Set |
| Set Includes: |
| MCEN27-2 |
MicroFrance® Pediatric Backbiting Forceps, Curved Down
Overall Length 105 mm (4.1")
Working Length 90 mm (3.5")
1.5 mm x 3.0 mm Bite |
| MCEN760 |
Push-Pull Antrostomy Blade, 10 mm
Overall Length 240 mm (9.4")
Working Length 75 mm (3") |
| MCEN761 |
Push-Pull Antrostomy Blade, 7 mm
Overall Length 247 mm (9.7")
Working Length 75 mm (3") |
| MCEN762 |
Sinus Probe, 50/90°, 7 mm
Overall Length 245 mm (9.6")
Working Length 75 mm (3") |
| MCEN763 |
Sinus Probe, 50/90° Flat, 7 mm
Overall Length 245 mm (9.6")
Working Length 75 mm (3") |
| MCEN764 |
Suction Elevator, Sharp, 3 mm x 8 mm Tip
Overall Length 190 mm (7.5")
Working Length 84 mm (3.3") |
| MCEN765 |
Suction Elevator, Dull, 3 mm x 8 mm Tip
Overall Length 190 mm (7.5")
Working Length 84 mm (3.3") |
| MCEN766 |
Sinus Suction Tube, 3 mm Diameter
Overall Length 150 mm (5.9")
Working Length 90 mm (3.5") |
| MCEN767 |
Sinus Suction Tube, 4 mm Diameter
Overall Length 150 mm (5.9")
Working Length 90 mm (3.5") |
| MCEN768 |
Suction Curette, 90°, 2 mm x 3 mm Cup
Length 150 mm (5.9") |
| MCEN769 |
Suction Curette, 60°, 2 mm x 3 mm Cup
Length 150 mm (5.9") |
| 3717010 |
One-Level Instrument Tray, 25 cm Wide x 53 cm Long x 4 cm Deep |
| Parsons Minimally-Invasive Sinus Instrument Accessories (Not Pictured): |
| MCEN720 |
Sharp Hockey Stick Seeker |
| MCEN721 |
Uncinate Seeker, Angled |
| MCEN723 |
Maxillary Seeker, Angled |
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Nota Bene: The technique description herein and the use of instructions for the related procedures are
made available by Medtronic ENT to the healthcare professional to illustrate the author's suggested
treatment for the uncomplicated procedure. In the final analysis, the preferred treatment is that which, in
the healthcare professional's judgment, addresses the needs of the individual patient.
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Important Safety Information
