How To: Vomer-Rostrum Mucosal Flap for Exposed Bone Coverage After Sphenoid Sinusotomy

Rostrum Drilling and Expanding the Sphenoid Opening

A high-speed drill is used to remove the sphenoid rostrum and enlarge the sphenoid sinus opening. An osteotomy is performed inferiorly toward the sphenoid floor and then medially toward the vomer. The contralateral septal mucosa is elevated off the rostrum, and the contralateral sphenoid sinus may be opened if bilateral sphenoidotomy is warranted. The posterior part of the vomer that articulates with the sphenoid rostrum is removed. Then the rostrum is removed. This last step allows wide exposure of the floor of the sphenoid. The inter-sphenoidal septation may be drilled out to ensure communication between both sphenoid sinuses. In case of bilateral sphenoidotomy, the contralateral sphenoid sinus should be widely open, with enlargement of the natural ostium. The vomer-rostrum mucosal flap is then rotated to cover the large area of exposed bone along the inferior border of the sphenoidotomy and sphenoid floor. Frequently, a mometasone-eluting stent is placed, securing the flap in place in contact with all borders of the sphenoidotomy. The absence of bone over the carotid or optic nerve should be considered. In general, a mini stent is used, and the stent should be placed so that it crosses into the sphenoid just beyond the sphenoid face and then protrudes from the sinus, while ensuring that there is no contact in the region of the internal carotid artery or optic nerve. Patients are then dismissed on steroid irrigations until follow-up debridements, which occur generally at one and four weeks (see supplemental video).

RESULTS

This technique has been used on four patients, including two sphenoid sinus fungus balls and two cases of recurrent sphenoiditis. One patient had two prior surgeries for sphenoiditis at another institution with recurrence; they each underwent the described wide sphenoidotomy with rostrum-vomer flap, and at four weeks they had well-healed and widely patent sphenoid sinuses (see Figure 1). All four patients at follow-up had widely patent sphenoid sinuses, with follow-up time ranging from two to six months.