Endoscopic view of a trans-middle turbinate ethmoidectomy.

[FIGURE OMITTED]

An 82-year-old man presented with right facial discomfort medial and inferior to the right eye. He had been experiencing recurring bouts of ethmoid sinusitis over a 3-year period. Computed tomography (CT) showed an opacified right ethmoid sinus. Endoscopic examination revealed that the anterior portion of the middle turbinate had an unusual shape (figure, A). The patient elected to undergo right endoscopic ethmoidectomy under local anesthesia. He explained that he had experienced a difficult time during a previous right sinus operation 30 years earlier.

At surgery, the patient was found to have a concavity of the right anterior and middle portions of the middle turbinate (figure, B). Closer inspection revealed the presence of an oval membranous area in the frontal plane of the middle turbinate (figure, C). This membranous area was opened with a microdebrider (figure, D), and polypoid tissue was extracted from the opening (figure, E). The polypoid tissue was removed, and the ethmoid labyrinth was found to have more polypoid tissue. Ethmoidectomy was carefully carried out through the previously created middle turbinate defect (figure, F).

During the operation 30 years earlier, the ethmoid sinus had obviously been drained and ventilated via this trans-middle turbinate route. Since it had remained functional throughout most of the intervening years and would probably remain patent for many more years, we felt that our ethmoid procedure had been adequate and that no further surgery was needed. Indeed, at 6 years of follow-up, the patient remained symptom-free and the trans-middle turbinate ethmoidectomy remained patent.

Endoscopic ethmoidectomy is usually performed through the middle meatus and then through the ethmoid bulla in a technique that was introduced by Kennedy in 1985. (1) An earlier technique developed by Wigand involves approaching the ethmoid sinus medially from the posterior ethmoid and sphenoid sinuses. (2,3) A retrograde posterior-to-anterior dissection was the described procedure at the time.

A trans-middle turbinate approach medially through the anterior and middle portions of the middle turbinate has not been described as a conventional approach to the ethmoid labyrinth. However, in our patient, this nontraditional approach provided adequate ethmoid sinus drainage and ventilation for almost 30 years.

References

(1.) Kennedy DW. Functional endoscopic sinus surgery. Technique. Arch Otolaryngol 1985;111(10):643-9.

(2.) Wigand ME. Transnasal ethmoidectomy under endoscopical control. Rhinology 1981;19(1):7-15.

(3.) Wigand ME, Steiner W, Jaumann MP. Endonasal sinus surgery with endoscopical control: From radical operation to rehabilitation of the mucosa. Endoscopy 1978;10(4):255-60.

Dewey A. Christmas, MD; Joseph P. Mirante, MD, FACS; Eiji Yanagisawa, MD, FACS

From the Department of Otolaryngology, University of South Florida College of Medicine, Tampa, and the Halifax Medical Center, Daytona Beach, Fla. (Dr. Christmas and Dr. Mirante); and the Southern New England Ear, Nose, Throat, and Facial Plastic Surgery Group; the Section of Otolaryngology, Hospital of St. Raphael; and the Section of Otolaryngology, Yale University School of Medicine, New Haven, Conn. (Dr. Yanagisawa).