Allergy Tests

Skin Prick Test Chart

Skin-prick tests have good sensitivity and relatively good specificity. They not only define the allergens whose avoidance may help the patient, they also demonstrate to the patient that part of their problem is their own reaction to the environment and that surgery on its own may not be the whole solution. Total IgE is not very specific or sensitive, being positive in only approximately 60 of patients with allergic rhinitis. It has a role as an adjunct to history, clini- Fig. 8.5 If a patient...

Advice for Patients after Endoscopic Surgery for Nasal Polyps

An endoscope is often used to help see the polyps and sinuses better and this type of surgery is called endoscopic sinus surgery. 2 Do not blow your nose hard for two days, even though your nose may feel blocked sniff 3 Nasal drops and or steam inhalation may be advised for you by the doctors. Medical or nursing staff will give you instructions on how to do this if it is necessary. 4 It is normal to feel blocked for several days and, while this improves over one to two weeks, it may take 6...

General Anesthetic Technique

A topical vasoconstrictor such as xylometazoline can be given on the ward 20 minutes prior to surgery. A vasoconstrictor on a swab pledget or as liquid can be placed in the nose in the same way as under local anesthesia. If a liquid is applied, the patient is positioned with their head extended and their shoulders being supported by a pillow. In this position with the head very extended, the solution inserted will bathe the spheno- palatine artery this appears to reduce the amount of...

Adenoid Hypertrophy Ct Scan

Bilateral Nasal Specific

Fig. 2.14 A harmless-looking polyp medial to the middle turbinate and an infective-looking polyp at the origin of the turbinate at histology an adenocarcinoma. Fig. 2.15 Children below the age of 6 years average eight upper respiratory tract infections a year. Clear periods between infections will help distinguish upper respiratory tract infections from other causes of rhinosinusitis. Fig. 2.15 Children below the age of 6 years average eight upper respiratory tract infections a year. Clear...

Anatomical Variations

Pneumatized Agger Nasi Cell

The prevalence of anatomical variations is well documented, and it appears that they are not consistently different between asymptomatic groups and those with proven rhinosinusitis. This is contrary to early reports that labeled them as anatomical abnormalities, for they now appear to be normal variations. This implies that anatomical variations play a minor role, if Fig. 6.18 a A well-pneumatized agger nasi cell producing a bulge in the lateral nasal wall near the origin of the middle Fig....

Goals of Surgery in Patients with Rhinosinusitis

Imaging Traumatic Csf Leaks

Why Surgery Can Help the Diseased Mucosa Surgery in patients with rhinosinusitis can have several goals. These goals very much depend on the nature of the underlying pathology Table 4.1 Opening sinus ostia to help restore mucociliary function. Removing diseased tissue to relieve the symptoms of nasal obstruction. Aiding the delivery and distribution of topical nasal treatment to any diseased mucosa, and in particular to the paranasal sinuses. Reducing the surface area from which diseased...

Optimizing Diagnosis Medical Treatment and Timing of Surgery

Treatment Hyper Turbinates

The decision to operate is often made when medical treatment has failed or has only provided a small or temporary improvement in the patient's symptoms. This does not mean that medical treatment should be put to one side because it has not cured the patient. For the timing of surgery, it is important to maximize medical treatment just before operating so that the patient's mucosa is as healthy as possible. For example, ensuring that any allergic component is fully treated will minimize the...

Novel Therapeutic Strategies

Mucociliary Transport Rhinitis

Therapeutic attempts to reduce the action of cytokines and chemokines offer promise. The chemokine receptor CCR3 is expressed on mast cells, eosinophils, basophils and IL-2-activated T lymphocytes. It appears that activation of these receptor sites can influence the migration of these cells into mucosa Murdoch and Finn, 2000 . Chemokine receptor antagonists have the potential to inhibit eosinophilia in particular. Other chemokine receptor antagonists that offer promise are CXCR1 and 2. The...

Fat Herniation and Violation of the Orbit

Periorbital Cellulitis

The orthodox anterior approach to an uncinectomy is potentially one of the most dangerous procedures in endoscopic sinus surgery and we now recommend a retrograde removal of the uncinate process for those who are just starting ESS. Not infrequently there are no ethmoid air cells to act as a cushion between the unci-nate process and the lamina papyracea and an incision Fig. 12.6 A line diagram to show the plane of the medial walls of the orbits. Fig. 12.6 A line diagram to show the plane of the...

Simmend Disease

Adelroth E, Rak S, Haahtela T, Aasand G, Rosenhall L, Zetterstrom O, Byrne A, Champain K, Thirlwell J, Della C 2000 Recombinant humanised mAb-E25, an anti-IgE mAb, in birch pollen-induced seasonal allergic rhinitis. Journal of Allergy and Clinical Immunology 106 2 253-259. Albritton FD, Kingdom TT, DelGaudio JM 2001 Malleable registration mask application of a novel registration method in image guided sinus surgery. American Journal of Rhinology 15 4 219-224. Anand VK, Kacker A 2000 Value of...

Nasal Polyps

The cause of most inflammatory polyps remains a mystery in spite of extensive work describing their cell morphology, IgE, and cytokine profiles Kramer et al., 2000 , as well as exploring some possible genetic associations Irving et al., 1997 . Why nasal polyps present more than twice as frequently in men is unknown. It is often said that polyps are caused by allergy, although atopy is no more prevalent in patients with nasal polyps than in the whole population Slavin, 1997 . However, a higher...

Mucoceles

Mucocele Scar Tissue

The majority of mucoceles can be marsupialized en-doscopically with minimal morbidity and with long-term results that are as good as, if not better than, those done by a conventional external approach. Concerns that the marsupialization of mucoceles may not halt their expansion have been found to be unwarranted. Mucoceles accessible with the endoscope should be opened as widely as possible using through-cutting forceps in order to minimize the amount of scar tissue that forms around the edges,...

Alternative Surgical Techniques

Revision Maxillary Antrostomy

Occasionally, in a very narrow nose, where access is restricted by a narrow pyriform aperture, finding the maxillary ostia can be difficult, particularly if there is active purulent disease and a great deal of bleeding with any instrumentation in the middle meatus. While Fig. 5.19 a Zurich scissors or through-cutting forceps are used process. d A line diagram of c. e Blakesley forceps can be used to divide any remaining superior attachment of the uncinate to grasp the uncinate and rotate it...

Malignant Melanoma

Reconstruction Turbinate

The management of malignant melanoma suggests that an initial en bloc resection with radiotherapy is associated with a lower local recurrence and meta-static rate in spite of its relatively low radiosensitivity. Fig. 15.55 a A right hemorrhagic polyp in the olfactory cleft an olfactory neuroblastoma. b Reconstructed coronal CT scan Fig. 15.55 a A right hemorrhagic polyp in the olfactory cleft an olfactory neuroblastoma. b Reconstructed coronal CT scan However, the prognosis is poor, with...

Surgical Technique

Sphenopalatine Artery

The posterior ethmoidal cells are entered through the basal lamella and it is safest to enter these medially and inferiorly Fig. 5.72 a-u . Enlarge access to these Fig. 5.67 A sphenoethmoid air cell above the sphenoid sinus note the optic nerve in its lateral wall arrow . Fig. 5.68 The sphenoid ostia can be seen high on the anterior wall of the sphenoid note that the bone becomes thin about 1 cm above the shoulder of the posterior choana. Fig. 5.68 The sphenoid ostia can be seen high on the...

Osteoma

Endoscopic Osteoma

Approximately 3 of people have paranasal sinus osteomas according to Earwacker 1993 . In his series of 1500 CT scans, only two patients were symptomatic. This is the authors' experience. Many osteomas are found incidentally and are blamed for causing headaches or excision is recommended before they cause symptoms Hehar and Jones, 1997 . In practice, osteomas rarely cause any problems other than cosmetic. If they do cause symptoms by obstructing the frontal recess, their history should include...

Laser DCR

Endoscopic Dcr

The laser is first used to ablate mucosa around the area where the light-pipe is most readily seen. The bone is then ablated over an area of 0.5-0.8 cm Fig. 14.14 . It is important to be guided by the light in the sac and not to follow the reflection of the aiming beam, which could potentially lead to the creation of a false passage. Fig. 14.11 A lacrimal probe is placed within the sac this will help tent it medially to help incise the length of the exposed sac. Fig. 14.11 A lacrimal probe is...

Paradoxical Middle Turbinate

Bifid Middle Turbinate

This is a middle turbinate that has a concave medial surface facing the septum. This occurs in approximately 11 of normal people and is a normal variation Fig. 6.20a, b . The middle turbinate is often thin and frail and should be gently mobilized by pressing it medially with a Freer's elevator to help access to the middle meatus. Fig. 6.21 a A right bifid middle turbinate and b its appearance on CT. Fig. 6.21 a A right bifid middle turbinate and b its appearance on CT. Fig. 6.22a, b Posterior...

Sinonasal Papilloma Images

Uncinate Process Middle Turbinate

To understand the frontal recess, you need first of all to know the different relationships of the uncinate process and then the variation in pneumatization of the air cells that extend into it. Access to the frontal recess may be altered by the attachment of the uncinate process. If the uncinate process is attached to the lamina papyracea, the agger nasi air cells, or the lateral wall, it will not get in the way of the frontal recess type A, where the uncinate process attaches to the lateral...

Lateral Canthotomy and Inferior Cantholysis

Lateral Orbital Canthotomy

It is important to have practiced this procedure on a cadaver in order to have the confidence to do it in vivo. Local anesthetic should be placed around the lateral canthus of the eye. Small straight scissors should be used to divide the lateral canthus down to the bone of the orbital rim and to the depth of the lateral sulcus of the conjunctiva. It is important to protect the globe in order to avoid a corneal abrasion or conjunctival damage Fig. 12.18a-d . The lower lid is then retracted...

Inverted Papilloma

Inverted Papilloma

It is important to exclude any coexisting malignancy or atypia present at diagnosis as these occur in 8-15 of cases on presentation, and these justify an en bloc resection with possible radiotherapy, depending on the histology and degree of invasion Fig. 15.34a, b . It is Fig. 15.33 Laterally placed mucocele not accessible with an endoscope. Fig. 15.33 Laterally placed mucocele not accessible with an endoscope. important that all macroscopically diseased tissue is examined in order to avoid...

Symptoms

Acute sinusitis causes pain over the affected sinus, usually the cheek, or on one side of the forehead, a blocked nose and or a discharge, feeling unwell, and a temperature. Facial pain alone without any nasal symptoms is rarely due to sinus disease and is often caused by other types of pain such as midfacial segment pain, tension-type headaches, migraine, dental pain, or trigeminal neuralgia. Sinusitis is chronic when the symptoms have persisted for longer than three months. The features are...

Accessory Ostia of the Maxillary Sinus Anterior to the Uncinate Process

Maxillary Sinus Ostium

If an ostium to the maxillary sinus can readily be seen by endoscopy in outpatients, it is probably an accessory ostia. The accessory ostium that is most readily seen lies anterior to the edge of the uncinate process Fig. 6.26a-d . Such ostia are said to be the result of recurrent acute maxillary infections, but this is conjectural. Fig.6.26a-d Anterior accessory ostium and its appearance on CT. Fig.6.26a-d Anterior accessory ostium and its appearance on CT. Fig. 6.27 a An endoscopic view of a...

Anatomy

Paradoxical Turbinate

The uncinate process is shaped like a rudder Fig. 5.9 its superior extension can do one of the following Merge with an agger nasi air cell or the lateral nasal wall to form a blind-ended pocket called the sulcus terminalis. Insert into the skull base, forming an overhang that can limit anterior access to the frontal recess. Insert into the middle turbinate and form a web that guards the frontal recess. Fig. 5.3 Line diagram showing the area to be removed in a maxillary sinusotomy Fig. 5.3 Line...

Preoperative CT Checklist

Recessus Frontalis

Like an airline pilot before preparing for take-off, you must go through a systematic check of the CT scan before surgery so as to avoid the surgical equivalent of a crash. Particular problems occur in the absence of the middle turbinate or where there is a hypoplastic maxillary sinus, a sphenoethmoidal air cell, or an asymmetrical skull base. It is vital to systematically check the CT scan. You must do this or you will be more likely to miss a danger area or a relevant variation in the anatomy...

Who Patient Selection

Who Will Most Likely Profit from Surgery In determining which patients to select for surgery, the decision must be founded on the likelihood that surgical treatment is capable of offering the desired improvement. Patients with a diagnosis of rhi-nosinusitis and nasal polyposis who have not become symptom-free after maximum medical treatment are most likely to profit from surgery. These patients may have had a very good response to oral steroids, but their symptoms of hyposmia and congestion...

Principles of Practice

Nasal Polyps Before And After

Accurate Diagnosis Is the Key to Success A good surgeon is also a good physician. The best surgical results are often obtained by optimizing medical treatment both preoperatively and postoperatively Fig. 1.1a, b . Optimizing medical treatment before surgery makes it less traumatic, reduces the chances of complications, and helps preserve olfactory mucosa. In order to optimize medical treatment, the surgeon needs to have an understanding of the mucosal disease. Postoperative medical treatment...