Ethmoidectomy Surgical Coaching with narration

Kaiser Permanente Surgical Coaching Ethmoidectomy: Step 1) Local anesthetic injection - Use 0-degree endoscope and 25 gauge spinal needle to inject 1-2 mL of 1% lidocaine with 1:100,000 epinephrine at sphenopalatine artery (1cm above the inferior border of the inferior attachment of the middle turbinate to the lateral nasal wall). Best practice – 2 bend technique of spinal needle Step 2) Medialize middle turbinate and identify the medial border of the ethmoid bulla - Use freer elevator or back end of J-curette Step 3) Fracture ethmoid bulla in an anterolateral direction - Use J-curette Step 4) Remove all bony fragments of ethmoid bulla - Remove with straight microdebrider or blakesley forceps. Fragments along the lamina papyracea can be removed with angled through cutting instruments. Step 5) Identify roof of maxillary sinus. Perforate the medial-inferior basal lamellae with J-curette at this height Step 6) Open basal lamella inferiorly to the horizontal portion and superiorly to the height of the roof of the maxillary sinus - Remove partitions with straight microdebrider or straight through cutters. Bony partitions along the medial orbital wall can be removed with angled through cutting instruments. Step 7) Dissect the posterior ethmoids until the anterior face of the sphenoid sinus. Identify skull base. - Confirm with image guidance if available - Remember that the skull base generally slants downward from front to back, so as you dissect the ethmoids posteriorly, the skull base will be much lower Step 8) Dissect posterior to anterior removing ethmoid partitions - Switch to angled endoscope (30 or 45 degree). Use curved suction/image guidance to visualize around bony partitions. Use upbiting through cutters to take down partitions. If you can see in front and feel behind it, then it is generally safe to cut with a through cutter. Step 9) Dissect anteriorly until roof of the ethmoid bulla and suprabullar recess - This marks area of the anterior ethmoid artery and beginning of frontal recess dissection