Table of Contents

Principles of Practice

■ Accurate Diagnosis Is the Key to Success 1

■ Dealing with the Patient's Expectations . 5

■ Optimize Medical Treatment 5

■ Tailor the Surgery to Fit the Extent of the Problem 6

Minimize Surgical Morbidity 6

How Can This Be Achieved? 8

Sense of Smell Should Be Preserved at All Costs 8

The Importance of Postoperative

Treatment 9

Who?

Patient Selection

■ Who Will Most Likely Profit from Surgery? 10

■ Symptom-oriented Patient Selection 10

Nasal Obstruction 11

Facial Pain and Pressure 11

Disordered Sense of Smell 11

Anterior Rhinorrhea 12

Posterior Rhinorrhea 12

■ Disease-oriented Patient Selection 12

Chronic Infective Rhinosinusitis 12

Aspergillosis/Fungal Disease 12

Maxillary Sinusitis Secondary to Dental Disease 15

Antrochoanal Polyp 15

Inverted Papilloma 17

Unilateral Nasal Polyps Associated with Neoplasia 17

Benign and Malignant Tumors 17

Pediatric Rhinosinusitis 17

Who Not to Select for Surgery 18

Patient Expectations 20

When?

Optimizing Diagnosis, Medical Treatment, and Timing of Surgery 22

Optimizing the Diagnosis 22

Patient History 22

Examination 3G

Investigations 31

Response to Treatment 32

Optimizing Medical Treatment 32

The Management of Allergic Rhinitis 32

The Management of Nonallergic Rhinitis . . 33

The Management of Infective

Rhinosinusitis 34

The Management of Fungal

Rhinosinusitis 35

The Management of Chronic

Rhinosinusitis with Polyposis 35

The Use of Systemic Steroids 35

Optimizing the Timing of Surgery 37

Why?

Goals of Surgery in Patients with Rhinosinusitis

■ Why Surgery Can Help the Diseased Mucosa 40

■ Rationale and Goals of Surgery in Specific Conditions 40

Unknown Pathology/Biopsy 40

Mucoceles 42

Antrochoanal Polyp 42

Benign and Malignant Tumors 42

Inverted Papilloma 44

Periorbital Abscess 44

Barotrauma 44

Choanal Atresia 44

Epistaxis 44

Distal Nasolacrimal Duct Obstruction 44

Repair of Dural and Skull Base Defects 46

Pituitary Surgery 46

Decompression of the Orbit 46

Decompression of the Optic Nerve 46

Quality of Life 46

Operative Procedures: A Step-by-Step Safe and Logical Approach

Procedures 50

Infundibulotomy (Uncinectomy)

Terminology and Classification 50

Indications 51

Anatomy 51

Surgical Technique 55

Alternative Surgical Techniques 58

Useful Instruments 63

Partial Anterior Ethmoidectomy 65

Terminology and Classification 65

Indications 65

Anatomy 66

Surgical Technique 67

Alternative Surgical Techniques 68

Frontoethmoidectomy

Terminology and Classification 69

Indications 70

Anatomy 71

Surgical Technique 78

Alternative Surgical Techniques 84

Useful Instruments 87

Sphenoethmoidectomy

Terminology and Classification 87

Indications 88

Anatomy 88

Surgical Technique 88

Alternative Surgical Techniques 94

Useful Instruments 97

Frontosphenoethmoidectomy ± Frontal Sinusotomy (I, II, III) ± Maxillary Sinusotomy (I, II, III)

Terminology and Classification 98

Indications 98

Sphenoid Sinusotomy (I, II, III) 100

Terminology and Classification 100

Indications 100

Anatomy 100

Surgical Technique 100

A Comment on the Management of the

Middle and Superior Turbinates 102

Surgical Technique 102

Alternative Surgical Techniques 103

An Endoscopic Tour:

Endoscopic Examination, Anatomical Variations, and Specific Conditions 106

Outpatient Examination 106

The Endoscopic Tour 107

Endoscopic Evidence of Mucosal Disease . 109

Anatomical Variations 111

Agger Nasi Air Cells 111

Concha Bullosa 112

A Paradoxical Middle Turbinate 112

A Bifid Middle Turbinate 113

A Polypoidal Anterior End of the Middle

Turbinate 113

A Paradoxical Uncinate Process 114

Pneumatized Uncinate Process 114

Accessory Ostia of the Maxillary Sinus

Anterior to the Uncinate Process 114

Accessory Ostium of the Maxillary Sinus in the Posterior Fontanelle 116

An Atlas of Specific Conditions To Help

Recognize Variations in Anatomy and Different Pathological Conditions ... 116

Allergy 116

Infection 116

Inflammatory Diseases 116

Benign Tumors 118

Malignant Tumors 118

Miscellaneous 120

7 The Place of Radiology

The Role of Conventional Radiology 121

The Role of Computed Tomography 121

When to Request CT in the Management of Rhinosinusitis 122

■ Radiation Exposure 124

■ Indications for MRI 125

■ Digital Subtraction Angiography 128

■ Interdisciplinary Cooperation 128

■ Points to Mention on a CT Request 129

Preoperative Checklist

■ Confirm the Diagnosis 130

■ Reviewing the Effect of Maximum Medical Treatment Helps in Determining Prognosis 131

■ Optimize the Immediate Preoperative Condition 131

■ Check That Relevant Investigations

Have Been Done 132

Allergy Tests 132

Immune Status 132

Hematological Parameters 133

Olfaction 133

Vision 133

Review the Relevant Medical History 134

Preoperative CT Checklist 134

Planning and Staging the Procedure 141

Informed Consent 142

9 Patient Consent and Information

How To Communicate the Benefits and Risks of Surgery to the Patient 144

Time Off Work and Advice about Flying . 145

Complications

Specific Complications

10 Perioperative Aids

Local Anesthesia 148

Local Anesthetic Technique 148

General Anesthesia 148

General Anesthetic Technique 149

■ Operating Room Setup 150

Operating Table 150

Surgeon's Seat 150

Position of the Anesthetist 150

Setup for One Surgeon 150

Setup for Two Surgeons 151

Video Stack/Cameras 151

Cables 152

Lighting 154

Radiograph Screen 154

Ancillary Staff 154

■ Instruments 154

Endoscopes 154

Camera Systems 154

Suckers 155

Curved Olive-ended Suckers 155

Ball Probes 156

Curettes 156

Blakesley Forceps 157

Through-cutting Instruments (Rhinoforce

Blakesley/Mackay-Grunewald Forceps) 157 Rhinoforce Stammberger Antrum Punch

("Back-biters") 158

Hajek-Kofler (Rotating) Punch 158

Stammberger Cutting Mushroom Punch .. 159

Kerrison Antrum Punch 159

Freer Elevator 159

Sickle Knife 159

Belluci and Zurich Scissors 159

Stammberger Side-biting Punch Forceps .. 159

Heuwieser Antrum Grasping Forceps 160

Giraffe Forceps (Kuhn-Bolger) 161

Powered Shavers 161

Drill 161

Unipolar Suction Diathermy 162

Bipolar Suction Diathermy 162

■ Computer-aided Surgery 162

Preoperative Work-up 164

Modeling 164

Positioning of the Patient, Surgeon, and Equipment 164

Registration 164

Methods of Localization 166

Display of Images 166

Accuracy 166

Operative Time 167

Economic Factors 167

Teaching 168

Real-time Computer-aided Surgery 168

Peroperative Monitoring of Optic Function 168

11 Hints

■ In the Operating Room 169

■ Anesthetist's Goals 169

■ Preparation 169

12 Preventing and Dealing with Complications

■ Peroperative Complications 171

Bleeding 171

Fat Herniation and Violation of the Orbit 173

CSF Leak 177

Dealing with an Intraoperative CSF Leak ... 180

Retro-orbital Hemorrhage 181

Lateral Canthotomy and Inferior

Cantholysis 181

Medial Rectus Damage 183

Optic Nerve Lesion 183

13 Postoperative Management

■ The Postoperative Course 189

Nasal Packs 189

Douching 190

Medical Management 191

■ Outpatient Visit at One Week 191

Debridement 191

Medical Management 192

Surgical Hints 169

Objectives of the Operation 170

Postoperative Complications 183

Bleeding 183

Adhesions 184

Epiphora 184

Periorbital Emphysema 185

Anosmia 185

Frontal Recess Stenosis 186

Crusting 187

Infection 187

Osteitis 187

Neuropathic Pain 188

Postoperative Problems 192

Crusting 192

Bleeding 192

Pain 193

Nasal Obstruction 193

14 Selected Procedures

■ Dacryocystorhinostomy (DCR) 194

Terminology and Classification 194

Indications 194

Surgical Anatomy 195

Assessment 195

Surgical Technique 196

Laser DCR 199

Principles of Surgical Technique in DCR ... 201

Alternative Surgical Techniques 201

Stents 201

Useful Instruments 202

Revision DCR 202

Common Canalicular Pathology 202

■ Management of the

Sphenopalatine Artery 202

Terminology and Classification 202

Indications 203

Anatomy 203

Surgical Technique 204

Alternative Surgical Techniques 206

Useful Instruments 207

■ Management of the

Anterior Ethmoid Artery 207

Terminology and Classification 207

Indications 207

Surgical Anatomy 207

Surgical Technique 208

Alternative Surgical Techniques 209

Useful Instruments 209

■ Median Frontal Sinus Drainage

Procedure 209

Terminology and Classification 209

Indications 209

Contraindications 210

Surgical Anatomy 210

Surgical Technique 212

Alternative Surgical Techniques 218

Useful Instruments 219

■ Orbital Decompression 221

Terminology and Classification 221

Indications 221

Surgical Anatomy 221

Surgical Technique 222

Useful instruments 225

■ Optic Nerve Decompression 225

Terminology and Classification 225

Indications 225

Surgical Anatomy 226

Surgical Technique 226

Useful Instruments 227

■ Choanal Atresia Surgery 228

Terminology and Classification 228

Indications 228

Surgical Anatomy 228

Surgical Technique 228

Alternative Surgical Techniques 230

Useful Instruments 230

15 Skull Base Surgery

■ Medial Maxillectomy 230

Terminology and Classification 230

Indications 230

Surgical Anatomy 231

Surgical Technique 231

Alternative Techniques 232

Useful Instruments 232

■ Pituitary Surgery 235

Terminology and Classification 235

Indications 235

Surgical Anatomy 236

Surgical Technique 237

Alternative Surgical Techniques 238

Useful Instruments 239

m Management of Skull Base Lesions with a CSF Leak 240

Terminology and Classification 240

Indications 240

Surgical Anatomy 240

Diagnosis 242

Surgical Technique 245

Comment 248

Modifications and Alternatives 251

■ Encephaloceles 251

Terminology and Classification 251

Indications 251

Surgical Anatomy 251

Surgical Technique 253

Alternative Surgical Techniques 253

16 The Way Forward

■ The Role of Endonasal Surgery in Benign

Tumors 254

General Principles 254

Specific Conditions 255

Surgical Approaches for Benign Paranasal and Skull Base Lesions 268

■ The Role of Endonasal Surgery in the Resection of Malignant Tumors ... 272

Surgical Technique 272

The Endoscopic Resection of Malignant

Anterior Skull Base Tumors 272

Specific Malignant Conditions 274

Other Malignant Skull Base Tumors 276

Recurrent or Residual Malignant Disease .. 279

m Advances in Medical Management 280

Nasal Polyps 280

Immunoglobulin E, Cytokines, and

Chemokines in Rhinitis 280

Nitric Oxide 280

Novel Therapeutic Strategies 281

Immunotherapy 282

The Markers of Atopy 282

Radiology 282

■ Surgical Tools 283

Optics and Camera Systems in Surgery ... 283

Surgical Training 284

Appendix

Information for Patients

■ Endoscopic Sinus Surgery 285

What is Endoscopic Sinus Surgery? 285

What Can I Expect When I Have

This Operation? 285

What Complications Can Occur? 285

Allergy 286

What is an Allergen? 286

Intermittent Allergy 286

Persistent Allergy 286

Diagnosis 286

Treatment 287

■ Sinus Infection 288

Associated Causes 288

Symptoms 288

Management 288

Complications 288

■ Nasal Polyps 289

Conditions Associated with Nasal Polyps .. 289

Symptoms and Signs 289

Unilateral (One-sided) Polyps 289

Investigations 289

Treatment 289

■ Advice for Patients after Endoscopic Surgery for Nasal Polyps 289

■ The Complications of Endoscopic Surgery for Nasal Polyps 290

References 291

Index

This page intentionally left blank

Allergic To Everything

Allergic To Everything

The human body And Todays chemical infested world. Here is a news flash You are not allergic to pollen, pet dander, or whatever it is that makes your body revolt Rather, your body just can not handle that one thing, what ever it is, anymore, due to the massive barrage of toxic chemicals you and everyone else are ingesting every single day.

Get My Free Audio and Ebook


Post a comment