The uncinate process (UP) can be identified in both coronal and axial CT scans with attention to its length, inclination (medial or lateral) and its relation to middle turbinate (MT) anterior end. The uncinate superior attachment determines the pattern of frontal sinus drainage into the ethmoid infundibulum (UP attaches to fovea ethmoidalis or MT) or directly into the middle meatus (UP attaches laterally to lamina papyracea or ethmoid cell). Therefore, the antrosuperior attachment of UP is a good landmark to frontal sinus ostium.
During surgery, the uncinate process can be identified with gentle pressure revealing its resilience or palpated with a curved probe.
Uncinate Palpation: Video 4 & Video 5
Video 4 "Uncinate Palpation 1" Video 5 "Uncinate Palpation 2"
Uncinate Palpation with a probe: Video 6
Video 6 "Uncinate Palpation with probe"
2- Uncinectomy with Sickle Knife
The sickle knife is the traditional instrument for uncinectomy. However, it has some disadvantages such as frequent injury to the inferior turbinate with the proximal part of its cutting edge and the ethmoid bulla with its tip. Its main advantage is being one of the thru cutting instruments.
Video 7 shows uncinectomy with sickle knife in a patient with left antrochoanal polyp.
Video 8 illustrates uncinectomy with sickle knife together with the use of the knife as a thru cutting instrument shaving polyps from the middle turbinate.
Video 7 "Uncinectomy with Sickle Knife" Video 8 "Uncinectomy with Sickle Knife plus Shaving Polyps"
3- Uncinectomy with Suction Dissector
The septal semi-sharp slightly bent suction dissector is a useful instrument for uncinectomy. It has many advantages such as clear view due to suction and no tendency to injury to the inferior turbinate or the ethmoid bulla.
Video 9 illustrates uncinectomy with suction dissector.
Video 9 "Uncinectomy with Suction Dissector"
4- Uncinectomy with Reverse Cutting Forceps
The reverse cutting (back biting) forceps is an excellent instrument for uncinectomy. It has many advantages such as precise or selective thru cutting of the uncinate free edge with no tendency to injure the inferior turbinate or the ethmoid bulla. The risk to injure the nasolacrimal duct is not realistic as the newly developed forceps are too delicate to injure the thick nasolacrimal duct bone. One can realize how much thick this bone from coronal and axial CT scans. Moreover with precise technique the tip of the cutting blade can easily be seen while cutting.
Video 10 illustrates uncinectomy with reverse cutting forceps.
Video 10 "Uncinectomy with Reverse Cutting Forceps"
5- Uncinectomy with Powered Instruments
Since 1994, the concept of a power driven, suction based rotating surgical systems have become widely accepted for removal of polyps and soft tissue masses (soft tissue shavers or microdebriders). Newer developments including irrigation and angled cutters for both soft tissue and bones have further improved their utility.
Unlike conventional non-powered suction thru-cutting instruments, sinonasal soft tissue shavers (microdebriders) have the advantage of evacuating the tissue from the surgical site without the need to remove the instrument, providing potentially continuous suction of blood and resected tissue from the field with the opportunity for improved visualization and precision and less frequent interruption during the procedure. They provide much less mucosal trauma and less denuding of the bone, as a result of this decreased trauma and more mucosal preservation, healing time is reduced and reepithelization of the denuded surface occurs much more rapidly with less crusting, less need for postoperative care and a reduced incidence of persistent disease.
A bite to engage the debrider blade is made in the uncinate process with the reverse cutting forceps or a probe. The uncinate is then precisely resected giving the opportunity to visualize the maxillary natural ostium at the depth of the infundibulum (INF).
Video 11 illustrates powered uncinectomy in a grossly polypoid disease.
Video 11 "Powered Uncinectomy 1"
It is advisable to shave the uncinate mucosa with the debrider, dissect the bony uncinate submucosally with a probe and remove bone with a forceps. This adds to the finesse of surgery and protects clogging of the shaver blade.
Video 12 illustrates this in a patient with huge sphenoid mucocele pressing on right middle turbinates and causing maxillary sinusitis.
Video 12 "Powered Uncinectomy 2"
To dissect the bony uncinate submucosally with a probe and remove bone with a forceps has many advantages such as mucosal preservation and the chance to cut nasal mucosa and antral mucosa at the same level therefore helping cross epithelialization and rapid healing with no or minimal chance for stenosis of MMA.
Video 13 illustrates submucosal dissection of UP with cold instruments.
Video 14 illustrates submucosal dissection of UP with powered instruments.
Video 13 "Submucosal Uncinectomy" Video 14 "Powered Submucosal Uncinectomy"
