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Five New Landmarks for Better Sinus Surgery

In an Expert Series presentation today, Ralph B. Metson, MD, is back with his 2017 popular session to introduce a set of five new landmarks that can be invaluable visual tools for both beginning and seasoned sinus surgeons.

Ralph B. Metson, MD

“In medical school and residency, we learn anatomy, and when it comes to sinus surgery, there are certain nasal- and sinus-specific landmarks that we use to perform the surgery. But many of these are based on cadaver dissections and old, time-honored surgical techniques,” explained Dr. Metson, professor of otolaryngology at Harvard Medical School and program director for the rhinology fellowship at Massachusetts Eye and Ear and Harvard Medical School. “With the advent of endoscopic instrumentation, our whole orientation has changed.”

When Dr. Metson started doing endoscopic surgery in the 1980s, he was surprised at how many anatomic structures there were that he’d never seen and that had no names. So, he began to name them, coming up with dozens of landmarks and teaching these over the past three decades.

Another Five Landmarks to Make You a Better Sinus Surgeon

Today, 1:15 – 2:15 pm

GWCC, Building A, Rooms 313-314

“I use these landmarks as novel teaching points to help physicians learn sinus surgery and to give them a fresh perspective of the anatomy of the nose and sinuses. My goal is to help them to become better surgeons,” he said. “This approach appeals to sinus surgeons all over the world, no matter what their level.”

The first landmark he named—and described at last year’s session—was the maxillary line.

“When I started doing this surgery in the 1980s, I would look inside the nose and see this curved line along the lateral wall of the nose. I used it to be a guide for where I should inject the nose at the start of nasal surgery.” That line also showed him where to make the initial incision in order to avoid bleeding when opening up blocked sinuses.

Another landmark he discussed last year is the Canary Island Sign, which came about because of the colors a surgeon sees during endoscopic surgery. There are three shades of bone in the nose: white (because dura is behind it), yellow (because yellow fat is behind the orbital bone), and blue (because the air behind it looks blue). Where those three colors meet is the orbital apex, providing another surgical landmark. Dr. Metson and one of his fellows gave the sign its name after the flag of Canary Island, which has blue, yellow, and white stripes. 

The other three landmarks discussed last year were the Spheno-Ethmoid Angle, Frontal OMC, and Frontal Wishbone.

This year’s session will emphasize landmarks that help surgeons identify and open up blocked frontal sinuses, which can be one of the most challenging sinus surgeries.

Dr. Metson provided a teaser to his presentation: “If you have a problem with visualization at the start of sinus surgery because of a large turbinate, I have a special technique or trick that is based upon a little-known anatomic landmark that can shrink down or decrease the size of a turbinate surprisingly quickly at the start of surgery,” he said. The “turbinate pump” is an area where the blood vessels and nerves meet.

Attend today’s session to learn what these landmarks are and how these visual tools can help sinus surgeons.

  • Turbinate Pump
  • Maxillary-Ethmoid Plate
  • Sphenoid Line
  • Ting’s Triangle
  • El Toro Sign