Rserved for the patient who do not respond to medical treatment such as ipratropium .
Reinnervation occurs within a year.
Involves either:
Excision of vidian nerve
Diathermy or division of vidian nerve
Three approaches :
Trans-nasal
Trans-antral ( Classic Golding-wood and Subperioasteal appraoch)
Trans-palatal
CLASSIC TRANS-ANTRAL APPROACH(GOLDING-WOOD)
General hypotensive anaesthesia given with oral endotracheal intubation.
Patient kept in reverse Tredelenberg position with 15 degree neck flexion.
Antiseptic dressing (betadine and spirit) done and patient drapped.
2% Lignocaine with 1 : 2lakhs Adrenaline infiltrated along the incision line . Wait for 10 minutes.
Incision: 4 cm, sublabial, horizontal incision made 3 mm above and parallel to the gingival margin, from lateral incisor to 2nd molar. Incision must be deep to bone.
Mucoperisoteal flap elevated superiorly with periosteal elevator to expose anterior wall of maxilla. Avoid injury to infraorbital nerve.
Anterior wall is opened in the canine fossa with 5 mm Jenkin’s gouge or drill. Opening is the enlarged with Kerrison’s punch or antral burruntil the entire posterior wall is visualized with microscope (300 mm focal length).
Mucosa over the posterior wall is removed and the posterior wall thinned with the burr. Posterior wall is then cracked open with Freer’s elevator and removed piece meal, under microscopic vison, to identify periosteal layer. Haemostasis is achieved.
Periosteum of the posterior wall is incised horizontally from side to side and flap retracted within the antrum to expose the fat in the pterygopalatine fossa.
Blunt dissection done in the fat with long straight artery forceps to expose the pulsating , tortuous internal maxillary artery trunk with branches ( having the configuration of H).
First clip put on the artery as close to SPF as possible. Then all branches are clipped.
Search the VERTICAL CREST of bone in postero-medial wall of pterygopalatine fossa lying in direct line with medial wall of maxillary antrum.
Opening of Pterygoid canal which lies infero-medial to this vertical crest.
Vidian nerve coming out of this opening sectioned and opening of pterygoid canal is cauterized with bipolar diathermy.
Sublabial incision closed with interrupted 3-0 catgut.
TRANS-ANTRAL SUPPERIOSTEAL APPROACH
Similar steps upto making the window in the posterior wall.
Posterior part of the medial antral wall removed with burr
Freer’s periosteal elevator is then inserted between the lateral wall of nasal cavity and the periosteum of the pterygopalatine fossa.
Periosteal envelop with its contents of pterygopalatine fossa reflected laterally to expose the openeing of pterygoid canal.
Vidian nerve coming out of this opening sectioned and opening of pterygoid canal is cauterized with bipolar diathermy.
Sublabial incision closed with interrupted 3-0 catgut.
Protection