(BQ) Part 2 book “Rhinology and skull base surgery” has contents: Cosmetic rhinoplasty, revision rhinoplasty, functional nasal surgery, nasal and paranasal sinus trauma, systemic disease and the nose, endoscopic approach to the sella, nasopharyngeal carcinoma,… and other contents.
Section III Rhinoplasty and Nasal Framework Surgery 23 Assessment of the Rhinoplasty Patient 413 24 Cosmetic Rhinoplasty 436 25 Revision Rhinoplasty 456 26 Functional Nasal Surgery 478 413 23 Assessment of the Rhinoplasty Patient Christos Georgalas Summary 413 Skin/Subcutaneous Tissue/SMAS Layer 421 Rhinoplasty: Social and Ethical Issues 414 Muscles of the Nose: Dynamic Anatomy 422 Value and Meaning of Beauty 414 Nasal Aesthetics and Assessment 422 Meaning and Range of the Principle of Autonomy 414 Surface Anatomical Landmarks 422 Proper Goals of Medicine 414 Facial Proportions 422 Issue of Publicly Funded Health Care 414 Frontal View .424 Patient Selection and the Rhinoplasty Consultation 414 Patient’s Motivation for Surgery, Stability, and Overall Psychological Profile 415 Lateral View .424 Smiling Lateral Views .426 Oblique View 426 Body Dysmorphic Disorder 415 Basal View 426 The Defect .417 Documentation in Rhinoplasty: Photography and Computer Imaging 427 Patient’s Wishes and the Surgeon’s Capabilities .417 Written Material/Web Site Referral/ Second Consultation 417 Image Acquisition 428 Image Storing 429 Surgical Anatomy of the External Nose 417 Image Viewing 429 Anatomy of the Bony Pyramid 417 Image-manipulating Software 429 Anatomy of the Cartilaginous Pyramid 418 The Future 431 Blood Supply to the Nose 420 Key Points 433 Review Questions 433 Innervation of the Nose 421 Beauty is a form of genius—is higher, indeed, than genius, as it needs no explanation It is of the great facts in the world like sunlight, or springtime, or the reflection in dark water of that silver shell we call the moon Oscar Wilde1 Beauty is a currency system like the gold standard Like any economy, it is determined by politics, and in the modern age in the West it is the last, best belief system that keeps male dominance intact Naomi Wolf2 Summary The preoperative assessment of a rhinoplasty patient includes several considerations that are unique in this type of surgery Social and ethical issues must be taken into account, while during the outpatient consultation the patient’s motivation for surgery, his or her stability and overall psychological assessment, with a special emphasis on body dysmorphic disorder (BDD) must be assessed BDD is an increasingly recognized disorder of self-perception associated with significant psychiatric comorbidity, high rates of suicide and self-harm, and following cosmetic surgery, high rates of dissatisfaction, occasionally manifesting as aggressiveness Assessment of the defect (both objectively and subjectively) should be complemented with a clear and honest discussion of the patient’s wishes and the surgeon’s capabilities The use of imaging and image-manipulating software can enhance communication as well as provide useful medicolegal documentation and facilitate audit and self-improvement Several software programs, including shareware and widely available photo-editing software, can be used for this purpose 23 Assessment of the Rhinoplasty Patient Rhinoplasty: Social and Ethical Issues By virtue of being a (primarily) aesthetic rather than functional procedure, rhinoplasty is unique among rhinologic operations As such, it raises moral, philosophical, and social issues that no other procedure does There has been an exponential increase in the number of cosmetic procedures performed over the last decades (a 162% increase since 1997 in the United States), with over 1.3 million procedures performed in 2009,3 and a 300% increase in the United Kingdom since 2002 with 34,000 aesthetic plastic surgery procedures performed in 2008,4 while 17 million cosmetic procedures were performed worldwide in 2009.5 These data reflect the wider availability of surgical interventions but equally testify to a universal culture increasingly focused on appearance In modern societies, where mobility and large networks of short-time acquaintances are the norm, “first impression” becomes crucial.6 Men as much as women are realizing the importance of an appealing external appearance in social life, work, and personal relations, and are more likely to use cosmetic surgery to achieve it However, although it would be wrong to dismiss some well-established universal, “objective” norms of beauty, it would be equally naive to ignore the context within which specific ideals of beauty are created and circulated, that is, our mass media culture Within this context, the concept of patient empowerment becomes controversial As the European Union Bioethics Commission report established,7 there are four important elements to be considered: the value and meaning of beauty, the meaning and range of the principle of autonomy, the proper goals of medicine, and the issue of publicly funded health care ! III Rhinoplasty and Nasal Framework Surgery 414 Note Core ethical issues in aesthetic surgery: The value and meaning of beauty The meaning and range of the principle of autonomy The proper goals of medicine The issue of publicly funded health care ■ Value and Meaning of Beauty Although a cross-cultural, universal typology of beauty undoubtedly exists, there is equally a broader context within which this is applied; this includes the character, performance, and relational capabilities of the person assessed ■ Meaning and Range of the Principle of Autonomy Although most patients with chronic rhinosinusitis (CRS) will seek medical help, the same is not true of patients with a less than ideal nose There are external and social factors at play for patients who decide to undergo an aesthetic procedure, including social norms and the dominant ideal of beauty These underline the importance of the promotion of diverse beauty ideals, by governments and the media Of course, one can argue that it is not external factors per se but the way the individual interacts with them that define whether the patient’s decision is a fully autonomous one Healthy, mature patients possess this autonomy, whereas vulnerable, psychologically unstable patients not ■ Proper Goals of Medicine Medicine is supposed to be about treatment and disease, whereas aesthetic surgery is about nondisease and enhancement However, the drawing of clear lines between medicine and aesthetic surgery has been shown to be philosophically impossible Serious suffering that deserves treatment is within the domain of aesthetic surgery as much as in traditional medicine ■ Issue of Publicly Funded Health Care All systems have limitations, and in an era of rationing, what criteria can be used to justify a procedure? Different countries have different guidelines, and there is an urgent need of harmonization of procedures within the European Union (EU) Purely aesthetic surgery is theoretically not covered by the social health care system of any country in the EU However, there are many exceptions that differ from country to country and that are not always clear In summary, however, appearance that falls outside some range of what is socially acceptable, that hampers the possibilities to get a job, or that causes dysfunction is covered (United Kingdom, Germany, Belgium, and the Netherlands) In countries where health insurance is primarily provided by the private sector (e.g., the United States), the issue is less acute, although similar issues exist within the private insurance framework What emerges in this way as one single criterion underlying these exceptions is patient suffering, often but not exclusively caused by social norms Patient Selection and the Rhinoplasty Consultation The wider social and moral context of rhinoplasty raises considerable issues However, for the average rhinoplasty surgeon, these issues are often distilled into a single decision—to operate or not—that he or she has to make in a relatively limited time frame: the rhinoplasty Patient Selection and the Rhinoplasty Consultation Tips and Tricks An initial rhinoplasty consultation should include the following: • Assessment of the patient’s motivation for surgery, stability, and overall psychological profile • Objective assessment of the real or perceived defect itself • Discussion of the patient’s wishes and the surgeon’s capabilities • Offering of informative printed material and/or Web site referral, as well as arrangement for a second consultation ■ Patient’s Motivation for Surgery, Stability, and Overall Psychological Profile (How can I help you? What brought you here today? How long have you been thinking about surgery? What caused you to begin thinking about surgery? Why you want to the operation at this particular time? What is the attitude of your family to your operation? Whose idea was it to have the surgery? How many previous operations have you had? Were you happy with the results of the previous operations? What you think this operation will for you?8) The surgeon has the duty to assess the patient’s motivation for the operation and his or her mental and physical ability to deal with the stress of surgery and potential complications, as well the stress of a nonreversible change in his or her appearance (including that brought about by a successful result) Only a patient who fully understands the goals, risks, and limitations of the operation can provide real informed consent Although several studies have shown improvement in patients’ quality of life, as well as improvement on many psychosocial wellbeing indicators after rhinoplasty,9–11 recent large-scale observational studies have also shown that there is a higher risk of suicide in patients who undergo cosmetic surgery and a vastly increased rate of psychiatric disorders.6 Although this is not to say that all cosmetic surgery patients have psychological problems, it does mean that a disproportionately larger number of such patients tend to undergo cosmetic surgery ■ Body Dysmorphic Disorder Thus, it is vital to screen potential rhinoplasty candidates; indeed, several studies have been performed using various psychological criteria What is emerging as a major issue in many (if not most) problematic patients is body dysmorphic disorder (BDD), or dysmorphophobia BDD is a relatively common obsessive-compulsive spectrum disorder defined by a constant, impairing preoccupation with imagined or slight defects in appearance.12 It is associated with poor quality of life, high rates of suicide, and, following cosmetic surgery, increased rates of dissatisfaction, occasionally manifesting as aggressiveness An algorithm has been suggested by Jakubietz et al for screening plastic surgery candidates for BDD.13 According to this algorithm, patients are divided into three groups: Those with a correctable deformity and reasonable expectations who can be treated by plastic surgery Those with no deformity and unreasonable behavior who would be inappropriate candidates for surgery and instead should be referred for psychiatric evaluation Those with minimal deformity and inadequate behavior who should be considered for referral and rescheduled for a second appointment and reevaluation The diagnosis of BDD is established after psychiatric consultation, where a 34-item Body Dysmorphic Disorder Examination may be used For screening purposes, the Body Dysmorphic Diagnosis Questionnaire (BDDQ) can be used.14 The BDDQ has been shown to have, depending on the sample, a sensitivity of 100% and specificity of 89 to 93%.15 Body Dysmporphic Diagnosis Questionnaire Are you very worried about your appearance in any way? Does this concern preoccupy you? That is, you think about it a lot and wish you could worry about it less? How much time you spend thinking about it? (More than hour per day is suggestive and more than hours highly specific for BDD.) What effect has this preoccupation with your appearance had on your life? Has it a Significantly interfered with your social life, schoolwork, job, other activities or other aspects of your life? b Caused you a lot of distress? c Affected your family or friends? For the busy clinician, the Dysmorphic Concern Questionnaire (DCQ), a seven-item screening questionnaire, can be used for the initial assessment of patients DCQ has good psychometric properties, including internal consistency, unidimensional factor structure, and strong correlations with distress and work and social impairment;16 a cutoff value of has been shown to have excellent discriminative validity, correctly classifying 92% of patients and controls.17 ! consultation During this consultation, the surgeon must make an objective assessment of the real or perceived defect, understand how the patient views it and what he or she wants to be done about it, decide and explain to the patient what can be accomplished, and, most importantly, assess the patient’s motivations, inner stability, and overall psychological profile Note Using the DCQ in the outpatient setting can be an easy and convenient way of screening patients for BDD 415 III Rhinoplasty and Nasal Framework Surgery 416 23 Assessment of the Rhinoplasty Patient Table 23.1 Characteristics of body dysmorphic disorder Prevalence Community: 0.7–1.1%18 Cosmetic surgery: 6–15% Rhinoplasty: 20.7% Mean age of onset/ Gender distribution Clinical: 16.2 years Subclinical: 13.1 years Ratio, female to male: 1.5:1 to 1:1 Comorbidity Obsessive-compulsive disorder: 6–30% Depression (lifetime): 80% Social phobia (lifetime): 39.3% Suicidal ideation: 78% 45-fold increased risk of suicide (twice as much as for major depression)19 Areas of concern20 Skin: 80% Hair: 57% Nose: 39% Stomach: 32% Teeth: 29% Use of surgical cosmetic interventions 23–40% Success of cosmetic surgery 0.7–1.5% Rates of dissatisfaction with cosmetic surgery 48–76%21,22 Other risks High rates of aggressiveness toward treating surgeon21,23 The characteristics of BDD are shown in Table 23.1 Although 80% of plastic surgeons in the United States report that they would not operate on a patient with BDD, 84% also state that they had unwillingly operated on at least one.24 Several studies22,25 have shown that up to 66% of patients with BDD undergo cosmetic interventions, with the most common being rhinoplasty.22 Indeed, in a U.K rhinoplasty practice, the use of a screening questionnaire for BDD identified a 20.7% prevalence rate.26 Cosmetic surgery is unlikely to be helpful in such patients In a study of 26 patients undergoing 46 procedures in the United Kingdom, rhinoplasty was associated with marked dissatisfaction and an increase in the degree of preoccupation and handicap, with the worst outcome in those with repeated operations.22 Phillips et al23 reported on 58 patients with BDD seeking cosmetic surgery The large majority (82.6%) reported that symptoms of BDD were the same or worse after cosmetic surgery Although 31% of patients with BDD reported an appearance improvement following the procedure, only 1% reported a decrease in their preoccupation with the defect What is potentially alarming is that these patients, who may belong in the delusional spectrum of this obsessive-compulsive disorder, may become threatening; 40% of plastic surgeons report that they have been threatened by a patient with BDD.24 Although patients with BDD may have trouble accepting it, often choosing instead to self-refer to another surgeon, their management should be psychiatric, not surgical A recent Cochrane review showed that cognitive behavioral treatment and selective serotonin reuptake inhibitors (SSRIs; fluoxetine/clomipramine) are effective and should be the treatment of choice.27 Tips and Tricks Failing to recognize and operating on patients with BDD can be a reason for litigation Interestingly, a recent study26 showed that psychiatric patients with BDD seeking rhinoplasty are different from “normal” (or mild BDD) rhinoplasty patients in a variety of ways: they are significantly younger, more depressed, more anxious, more preoccupied by their nose, and have more compulsive behaviors (e.g., mirror checking, feeling their nose with their fingers, and even self-mutilation) It also appears that they are significantly handicapped in their occupation, social life, and intimate relationships Patients with BDD are especially more likely to have been discouraged from surgery by friends or relatives, more likely to believe that there will be dramatic changes in their life after surgery, and have dissatisfaction with other areas of their body All of these characteristics are not new Before the description of BDD, several surgeons used similar terms to describe bad rhinoplasty candidates The mnemonic SIMON (single, immature, male, overexpectant or obsessive, and narcissistic) was coined for the male high-risk patient who was more likely to be dangerous, whereas SYLVIA (secure, young, listens, verbal, intelligent, and attractive) applied to a good candidate.28 Similarly, Adamson and Chen29 noted several categories of inappropriate patients for rhinoplasty: 10 11 12 Patients having a life crisis Unhappy patients Cross-cultural patients (with family friction) Psychologically estranged patients (those with obsesive-compulsive and borderline personality disorders) Patients with BDD (dysmorphophobia) Sexually dysfunctional patients Patients with “package of pictures” syndrome (unrealistic expectations) Patients with exceptionalism syndrome (narcissistic personality) Patients with “my theory” syndrome (poor listeners) Patients with Goldilocks syndrome (perfectionists) Patients with “exhausted surgeon” syndrome (patients who go “doctor shopping”) Patients with unfocused personality A recent systematic review of 37 studies on the psychosocial aspects of aesthetic surgery showed that there is Surgical Anatomy of the External Nose a distinction between expectations regarding the self (e.g., to improve body image) and expectations in terms of external parameters (e.g., enhancement of one’s social network, establishing a relationship, or getting a job).30 Patients with external motivation are less likely to be satisfied The same study, after pooling the results from all assessed studies, found that common factors associated with dissatisfaction and poor psychosocial outcome include • • • • • • • • • Young Male Unrealistic expectations of the procedure Previous unsatisfactory cosmetic surgery Minimal deformity Motivation based on relationship issues History of depression Anxiety Personality disorder The common threads in all of these appear to be difficulty to engage meaningfully and lack of mental stability The bottom line, as expressed succinctly by Goode,31 could be distilled as follows: listen to your gut feelings and to your staff—a patient who appears unsuitable for rhinoplasty during the first minutes of the consultation most likely is ■ The Defect (When you look [in] the mirror, what is it that you don’t like? What view of your nose bothers you the most? What specific feature you want corrected? If you can have only one thing changed, what would it be?8) During the initial consultation, there should be enough time for the patient to describe the defect It is said that 80% of patients require less than minutes to express their main concern6 (although this may not be strictly true for rhinoplasty patients) Open-ended questions are preferable The use of a mirror and/or photographs is vital Clear and specific complaints are easier to deal with, especially if they are based on observations shared by the doctor Computer imaging may be useful to screen patients with unrealistic expectations Patients who are not satisfied with a reasonable computer-produced manipulated image are unlikely to be satisfied with surgical results.32 There are objective and universal canons of facial beauty, and we know that what the rhinoplasty patient perceives as an “ideal” nose does not differ from what is perceived as such by the surgeon and the general public.33 However, the surgeon should be careful to avoid suggestive questioning It is counterproductive, and some patients may be insulted if the discrepancy between their nose and the ideal nose is analytically described Although a surgeon must be able to perform an objective aesthetic facial analysis, this analysis should not always be shared with the patient ■ Patient’s Wishes and the Surgeon’s Capabilities At this stage, the surgeon must explain to the patient what can and cannot be achieved by surgery on the basis of his or her expertise This can be complemented with computerimaging analysis and manipulation, as discussed later The goals and limitations of surgery should be made clear Preand postoperative photographs of previous patients may be helpful, although the surgeon must resist the temptation of focusing exclusively on “poster patients”; indeed, the cases where he or she achieved a less than ideal result, and even cases of patients who were unsatisfied and underwent revision surgery, should be shown and discussed The patient should be informed of all the potential complications of surgery, including the risk of revision surgery, and the rates quoted should not come from literature reviews but from the surgeon’s own audit ■ Written Material/Web Site Referral/ Second Consultation Patients tend to use the Internet to gather information, both before and after their consultation.34 A referral to useful rhinoplasty/facial plastic surgery Web sites, including the surgeon’s personal Web site and reliable sources of information (e.g., the European Academy of Facial Plastic Surgery, www.eafps.org, and the American Academy of Facial Plastic and Reconstructive Surgery, www.aafprs org), can complement the information provided by the surgeon Printed material and handouts with information that the patient can absorb at home are also important Indeed, in a recent study, the quality of printed handouts and the information gathered from the Internet were the factors most strongly correlated with overall patient satisfaction with the consent process.35 Surgical Anatomy of the External Nose The external nose consists of the bony pyramid (the bridge of the nose), complemented by the lateral (upper) and alar (lower) nasal cartilages, supported in the midline by the nasal septum It is divided into the bony vault, the cartilaginous vault, and the lobule ■ Anatomy of the Bony Pyramid The bony vault or pyramid is the upper one-third of the nose and is formed by the nasal bones and the ascending (frontonasal) process of the maxilla 417 III Rhinoplasty and Nasal Framework Surgery 418 23 Assessment of the Rhinoplasty Patient Nasal bone Radix Medial canthus Nasal bone Ascending process of maxilla Rhinion Upper lateral cartilage Rhinion Sesamoid cartilages Accessory cartilages Pyriform aperture Supratip breakpoint Supratip lobule Pronasalae Upper lateral cartilage Infratip lobule Middle crus Lateral crus Medial crus Alar cartilage Columella Tip-defining point Alar margin Infratip lobule Soft triangle Fig 23.1 Skeleton of the external nose Visible are the bony vault, consisting of the nasal bones and the frontonasal process of the maxilla, and the cartilaginous pyramid, consisting of upper and lower lateral (alar) cartilages Lower lateral (alar) cartilage Anterior nasal Fibroareolar tissue spine of maxilla Fig 23.2 Skeleton of the external nose, lateral view Nasal Bones The nasal bones are cephalically attached to the frontal bone, laterally to the ascending process of the maxilla, medially to each other, and posteriorly to the septum Their caudal end overlaps for a few millimeters the upper lateral cartilage, like a roof tile Caudally and laterally, they form, together with the ascending process of the maxilla, the pyriform aperture (Figs 23.1, 23.2, and 23.3) ■ Anatomy of the Cartilaginous Pyramid The lower two-thirds of the nose are formed by the cartilaginous pyramid This is a unified, winged structure that includes the upper lateral cartilage and the cartilaginous septum, which articulate with each other in a T- or Yshaped configuration.36 1a 1c Tips and Tricks Excision of a cartilaginous hump should include the septum, as well as the upper lateral cartilage, in a T configuration 1b 1d Upper Lateral Cartilages The articulation of the septum with the upper lateral cartilage forms an angle, usually 10 to 15 degrees, that is very important functionally, as it forms (at their cephalic edge and Fig 23.3 External rhinoplasty approach: ϭ lower lateral (alar) cartilage consisting of 1a ϭ lateral crus, 1b ϭ lobular segment of middle crus, 1c ϭ domal segment of middle crus, 1d ϭ medial crus, ϭ upper lateral cartilage, ϭ scroll area Surgical Anatomy of the External Nose Scroll of cephalic edge of lateral crus of alar cartilage Fig 23.4 The internal valve as seen endoscopically in a patient presenting with nasal obstruction: A, head of inferior turbinate; B, septum; C, upper lateral cartilage; IV, internal valve The internal valve is created by the convergence of the septum with the upper lateral cartilage at the level of the head of the inferior turbinate corresponding to the supratip breakpoint or depression (see Fig 23.2) together with the head of the inferior turbinate) the internal nasal valve area This is the narrowest part of the upper airway, and any degree of narrowing of this angle can lead to nasal obstruction This area is also significant histologically, as it constitutes the interface between the (external) squamous epithelium and the (internal) nasal mucosa (Fig 23.4) Tips and Tricks One of the roles of spreader grafts is the widening of the angle formed by the articulation of the septum with the upper lateral cartilage Caudally, the upper lateral cartilage articulates with the alar cartilage in the scroll area Usually the cephalic edge of the alar cartilage overlaps the caudal edge of the upper lateral cartilage, although several configurations have been described (Fig 23.5) Alar (Lower Lateral) Cartilage Although in traditional anatomical textbooks the alar cartilage was divided in medial and lateral crura, a third part is increasingly recognized: the middle or intermediate crura The alar cartilage is thus comprised of the medial, middle or intermediate, and lateral crura They form two arches, with the medial crus converging in the midline and thus forming the columella, and the lateral crus supporting the lateral wall of the nasal vestibule The medial crura converge in the midline (columellar segment of the medial crura) and diverge more inferiorly, toward the nasal spine (medial crural footplates) Posterior to their convergence Scroll of caudal edge of upper lateral crus Fig 23.5 Articulation of the alar with the upper lateral cartilage (scroll area) and between them and the upper lateral cartilage there is an area not supported by cartilage (the weak triangle of Converse) corresponding to the supratip breakpoint or depression (see Fig 23.1) Lateral and caudally to the lateral crura, fibroareolar tissue lies between them and the pyriform aperture, while laterally and cephalically, there are a few small accessory cartilages More cephalically (between the nasal bones and the pyriform aperture), there are a few sesamoid cartilages The lateral crus is the widest part of the alar cartilage and is tightly adherent to the overlying nostril skin The intermediate crus is divided into a domal and a lobular segment (Figs 23.6 and 23.7) MIDDLE OR INTERMEDIATE CRUS: Domal segment Lobular segment Tip-defining point Lateral genu Medial genu LATERAL CRUS MEDIAL CRUS: Columellar segment Footplate segment c Fig 23.6 Anatomy of the alar cartilage: frontal view The lateral and medial crura articulate through the middle crus The middle crus consists of the domal segment, containing the tip-defining point, and the lobular segment 419 23 Assessment of the Rhinoplasty Patient LATERAL CRUS MIDDLE CRUS: Domal segment Lobular segment MEDIAL CRUS: Footplate segment Columellar segment Fig 23.7 Anatomy of the alar cartilage: anterior view Tips and Tricks The domal segment of the intermediate crus of the alar cartilage can take various shapes, and its configuration defines to a large extent the shape of the nasal tip (boxy, bifid, etc.) The nasal tip is defined as the most prominent part of the nasal lobule The area cephalic to the tip is called the supratip area and the area just under it, the infratip The domal segment of the intermediate crus and the angle of the medial crura and their approximation of the domes are all important factors that define the tip shape, rotation, and projection ! III Rhinoplasty and Nasal Framework Surgery 420 Fig 23.8 Tripod theory of tip support The projection and rotation of the tip are regulated by the relative length of the medial crura (anterior stand, A) and the two lateral crura (lateral stands, B) Tips and Tricks Endonasal rhinoplasty may result in loss of tip support by disruption of the scroll area through an intercartilaginous incision, while external rhinoplasty disrupts the attachment of medial crura to the septum, the interdomal ligaments, and the soft tissue envelope Note There are several major and minor tip support mechanisms: • Major tip support mechanisms – Attachment of medial crura to the septum – Resilience of the alar cartilage – Attachment of cephalic alar cartilage to caudal upper lateral cartilage (scroll area) • Minor tip support mechanisms – Interdomal ligaments – Cartilaginous and membranous septum – Anterior nasal spine – Skin and soft tissue envelope – Lateral crural attachment to the pyriform aperture A way to understand the support of the tip and how different techniques can produce different results in terms of positioning of the tip is the tripod theory, as described by McCollough and Mangat in 198137 and further refined using the cantilever model recently.38 According to this model, the position of the tip is defined by the length and support provided by the three legs of the tripod formed by the two lateral crura and the (fused) medial crura in the midline, as shown in Fig 23.8 Shortening or loss of support of any of the above can lead to predictable movements of the tip Anatomy of the Septum The nasal septum consists of a bony part posterosuperiorly (perpendicular plate of the ethmoid bone and vomer) and a cartilaginous part anteroinferiorly (quadrilateral cartilage) The bony septum is attached to the palatine bone by the maxillary crest, while posterosuperiorly, it is attached to the sphenoid via the rostrum; posteroinferiorly, between the two choanae lies its free edge Superiorly, it is attached to the cribriform plate Only the cartilaginous part plays a role in the support of the nose It is attached posteriorly to the bony septum and posterosuperiorly to the nasal bones Caudally, it is connected with the medial crura of the alar cartilage, lying either between them (tongue in groove) or just cephalically to them (Fig 23.9) ■ Blood Supply to the Nose Blood supply to the nose comes from two main sources: via the external carotid, through the facial artery, that 910 Index nonallergic rhinitis (NAR) (continued) nasal endoscopy of 144 occupational 230 pathophysiology of 232–235 chronic inflammatory disorder 233 nasal entopy 233 neurogenic mechanisms 233–235, 234, 235 rhinorrhea in 133, 133 as SCUAD 216 smoking 231 summary of 229 tests for 99 treatment of 239, 239–243 sympathicomimetics 239–240 nonallergic rhinitis with eosinophilia syndrome (NARES) 231 noncholinergic neural system, in nonallergic rhinitis 233–235, 234 nonsinogenic facial pain 178–182 cluster headache 180, 181 hemicrania continua 181–182 migraine 178–180, 179 paroxysmal hemicrania 180–181 SUNCT syndrome 182 nonspecific nasal challenge 89 norepinephrine 42–44 norm-based scoring (NBS) algorithms 155 normosmia 199 nose aging 483, 484 airflow in 27–34 anatomical models of 28 assessment of 28–34 objective measurements of 28 particle image velocimetry of 28–29 anatomy of blood supply 8, innervation of 8, introduction 3–4 musculature 8, nasal framework 6–7, summary surface 6, vascular 511, 511–512 vascular anastomoses 512, 512–513 embryology of 4, introduction 3–4 summary immunology and 62–75 environment and 62–73 infections of 264 multiple functions of 62–63, 64 physiologic and immunologic functions of 266–267 physiology of 27–46 endonasal sensory nerve activation 44 inspired air conditioning 37–38 intranasal substance delivery and 38 mucociliary functions 38–41, 40 nasal cycle 36–37 nasal epithelium 38–46 nasal reflexes 45–46 nasal valve 34, 36 neuropeptides 44 parasympathetic system 43, 43–44 summary of 27 sympathetic/adrenergic system 42–43 vascular 41–42, 42 tumors of anatomical considerations 815, 815 anesthesia and patient positioning 812–813 endonasal approach to 813–814, 814 external approaches to 815–832 introduction to 810 outcomes for 832 preoperative management of 810–812, 811, 812 summary for 810 NOSE see Nasal Obstruction Septoplasty Effectiveness NPC see nasopharyngeal carcinoma NPs see nasal polyps NPY see neuropeptide Y nuchal rigidity 537–538 O obstructive sleep apnea (OSA) introduction to 663 management of medical treatment 666–668 nasal dilators 668 research problems 666 surgical treatment 668, 668–670, 670 nasal pathology and 665, 665–666 pathophysiology of 664, 664–665 pediatric 650–651 summary for 663 occupational airway disease 213, 248 occupational allergens 251–252 occupational asthma 213 occupational nonallergic rhinitis 230 occupational rhinitis 213, 251–252 OCR see opticocarotid recess oculomotor dysfunction 532 olfaction accessory chemosensory organs 198, 198–199 anatomy of 195–196, 196 chemical senses 197–198 nasal airflow and 33, 35 nasal obstruction and 33 orthonasal 200, 200 physiology of 196–197 retronasal 200, 200 olfactometries 146–147 olfactory aplasia 649 Index olfactory bulbs 22 olfactory bulb volumetry 206 olfactory cleft 10, 196, 196 olfactory disorders and 203, 203 retronasal olfaction and 200 olfactory disorders causes/etiologies of 200–204 congenital 202 drug-induced/toxic 203 endocrine diseases 202 endonasal surgery scars 203, 204 epilepsy 202 idiopathic 202 neurodegenerative causes 202 olfactory cleft disease 203, 203 postoperative 203 posttraumatic 201 sinonasal causes 201, 202 tumors 203–204 URTI 201 classification of 199 consequences of 206 CRS and 330 frequency of 200, 200 measurement of 204–206 objective methods 205–206 psychophysical methods 204–205, 205 retronasal olfaction 200, 200 summary of 195 treatment of 206–209 medical 207, 209 surgical 208 olfactory epithelium 196, 196 olfactory esthesioblastoma 140 olfactory fossa, imaging of 121, 121 olfactory neuroblastoma imaging of 845 outcome with 857 staging system for 842 olfactory neuroepithelium 10, 12, 12, 22 olfactory receptor (OR) 195, 197 olfactory receptor neurons (ORNs) 195 Oliver pedicled palatal flap (OPPF) 798, 803, 804 omalizumab, for rhinitis and asthma 220–221 Onodi cell see sphenoethmoid cell operating room integration 601, 601–602 ophthalmic artery 13 ophthalmoplegia, with ARS 532 OPPF see Oliver pedicled palatal flap optical tracking systems 589, 589 optic nerve decompression 725 complications with 727 patient selection for 725 results of 727 surgical anatomy for 725 technique for 725–727, 726 optic nerve gliomas 729 opticocarotid recess (OCR) 18 OR see olfactory receptor oral allergy syndrome 254 orbital abscess with ARS 530, 531 pediatric 656–658, 657, 658 orbital cellulitis with ARS 529–530, 530 pediatric 656–658, 657, 658 treatment of 534 orbital complications, of acute rhinosinusitis 527–534, 528, 530, 531 orbital decompression see endoscopic orbital decompression orbital epidermoids 729 orbital exenteration, with total maxillectomy 827 orbital extension, in frontal sinus surgery 393 of benign tumors 398–399, 399 orbital fracture 547 outcomes with 561 stabilization of 557, 557–558 orbital meningiomas 729 orbital pain 188 orbital sling technique 724, 724 orbital tumors 727, 728 dermoids 729 malignant lymphoid tumors 729 rhabdomyosarcoma 729 metastatic 731–732 neurogenic optic nerve gliomas 729 orbital meningiomas 729 schwannoma 729 orbital epidermoids 729 paranasal sinus masses 730 inverted papilloma 730–731 squamous cell carcinoma 731 secondary fibrous dysplasia 730, 731 osteomas 730, 730 signs and symptoms of 732 surgical anatomy for 732–733 surgical technique for larger lesions 735 potential complications with 735 transcaruncular approach 733, 735 transnasal endoscopy 733, 734, 735 vascular 727 capillary hemangiomas 728 cavernous hemangiomas 728 lymphangiomas 728, 728–729 orbitary cellulitis, CT of 149 organ-specific PROMs 163–164 ORNs see olfactory receptor neurons 911 912 Index orthonasal olfaction 200, 200 OSA see obstructive sleep apnea Osler-Weber-Rendu syndrome see hereditary hemorrhagic telangiectasias osteitis in CRS 56, 338, 338, 339 ESS outcome and 307, 307 osteomas 730, 730 ESS for 849–850, 851 complications with 853 outcome of 855 frontal sinus surgery for 395–398 anterior extension 399, 399 intracranial extension 399 large tumors 398, 398 lateral extent of 398 orbital extension 398–399, 399 pathological considerations 395–398 imaging of 114, 114, 843, 844 osteoplastic frontal sinus approach for 828, 829 osteomyelitis, with subcranial approach according to Raveh 832 osteoplastic flap, for frontal sinus surgery 390–392, 391, 392 revision after 393–394 osteoplastic frontal sinus approach 828 complications of 830 contraindications for 828 indications for 828, 828, 829 postoperative care for 829–830 surgical steps for 828–829 osteotomy 442, 442–443, 443 deformities 462, 462–463, 463 ostiomeatal complex (OMC), access to, in ESS 316, 316 ostiomeatal unit 24 otitis media allergic rhinitis and 254–255 with effusion 82 otorhinolaryngology specialist, referral to 144 outcome measures 152–171 clinical vs patient-reported 153, 153–154 clinician-reported 154 cost-effectiveness analysis 171 data collection and storage 166–167 missing data 167 introduction to 152 nasal obstruction 485 PROMs 154–164 in children 166 disease-specific 155, 158, 158–164, 163 generic 154–155, 156–157 generic vs disease-specific 164 limitations of 170–171 organ-specific 163–164 validity assessment 164–166 publishing of 171 purpose of 152–153 reasons for lack of use 168–170, 169, 170 summary of 152 tool development for 167 tool selection for 164–166 overresection, revision rhinoplasty for 463, 463, 464, 465 oxymetazoline 575 for allergic rhinitis 260 effect and safety of 577–578 P palatal fractures 546 stabilization of 555 palatine arteries 13, 512, 512 palatovaginal canal see pharyngeal canal palpation 141 PAMPs see pathogen-associated molecular patterns PAN see polyarteritis nodosa p-ANCA see perinuclear ANCA PAR see perennial allergic rhinitis paranasal sinuses airflow in 27–34 anatomical models of 28 assessment of 28–34 objective measurements of 28 particle image velocimetry of 28–29 anatomy of 14, 16, 16–17 ethmoid sinuses 22–24, 23 frontal sinuses 20, 20–22, 21, 22 introduction 3–4 maxillary sinuses 16, 17 sphenoid sinuses 17–20, 18, 19 summary embryology of 4–6, 5, 16 introduction 3–4 summary nasal endoscopy of 142 physiology of 27–38, 46 endonasal sensory nerve activation 44 inspired air conditioning 37–38 intranasal substance delivery and 38 nasal cycle 36–37 nasal valve 34, 36 nitric oxide production 46 sinus gas exchange 46 summary of 27 as protective crumple zone 549 regional blocks in 574, 574 tumors of anatomical considerations 815, 815 anesthesia and patient positioning 812–813 endonasal approach to 813–814, 814 external approaches to 815–832 introduction to 810 outcomes for 832 Index preoperative management of 810–812, 811, 812 summary for 810 paranasal sinus trauma classification of 545–546 midface 546, 546–547, 548 skull base/frontal bone/frontal sinuses 547–549 clinical features of 549–550, 550 diagnostic studies of 550–551 epidemiology of 549 management of antibiotics with 551 approaches to 551–553, 552, 553, 554 timing of 551 outcomes with 560–562 reduction of Le Fort III fractures 559, 559 maxillary alveolar fractures 555, 555–556, 556 maxillary fractures 553–555, 554, 555 nasal fractures 556, 556–557 orbital fractures 557, 557–558 palatal fractures 555 skull base/frontal bone/frontal sinus fracture 559–560, 560 zygomatic fractures 558–559 summary for 545 parasympathetic system 43, 43–44 in nonallergic rhinitis 233 parosmia 199 paroxysmal hemicrania 180–181 cluster headache compared with 181 treatment of 181 particle image velocimetry (PIV), of nasal airflow 28–29 particulate matter (PM) 253 pathogen-associated molecular patterns (PAMPs) 65 pathology, evaluation of 108–109 patient-reported outcome measures (PROMs) 152–153, 154–164 in children 166 clinical outcomes vs 153, 153–154 data collection and storage for 166–167 missing data 167 disease-specific 155, 158, 158–164, 163 characteristics and criteria for 160 key features of studies on 159 nasal obstruction and septal surgery 160 rhinitis and rhinoconjunctivitis 158, 160–161 rhinoplasty and facial appearance 162 rhinosinusitis 158–159, 161 selection of 161 sinonasal malignancy 162 skull base surgery 162–163, 163 for ESS 298, 299 generic 154–155, 156–157 disease-specific vs 164 generic outcome measures vs 164 limitations of 170–171 objective measures compared with 168–169, 169 organ-specific 163–164 outcome prediction and 169 reasons for lack of use 168–170, 169, 170 tool development for 167 tool selection for 164–166 unreliability of 168 validity assessment of 164–166 pattern recognition receptors (PRRs) 65–66 disease and 66 PBMCs see peripheral blood mononuclear cells PCD see primary ciliary dyskinesia PD see pneumosinus dilatans PDS see polydioxanone foil peak nasal expiratory flow (PNEF) 93 peak nasal inspiratory flow (PNIF) 93, 94, 146 meter for 93, 93 in nonallergic rhinitis 237, 238 pediatric rhinology acquired conditions acute sinusitis complications 656–658, 657, 658 adenoid hypertrophy 649–651, 650 allergic rhinitis 651 antrochoanal polyp 655–656, 656 cystic fibrosis 651–652, 652 epistaxis 652–653, 653 foreign bodies 659 juvenile nasopharyngeal angiofibroma 655 nasal symptoms 649 nasopharyngeal stenosis 652 sinonasal malignancy 653–655, 654 congenital anomalies arrhinia 637 choanal atresia 639, 639–640, 640 hemangiomas 643–644, 644, 645, 646 meningoencephaloceles and gliomas 641–643, 642, 643 midline facial clefting 637, 638, 639 midline nasal dermoid cysts 645–649, 647, 648 nasal obstruction in neonates 637, 638 nasopharyngeal stenosis 639 neonatal rhinitis 645 olfactory aplasia 649 piriform aperture stenosis 641, 641 introduction to 627 nasal growth after injury or surgery 632–635, 633, 634, 635 postnatal nose growth anatomical development 629, 629–630, 630 dimensional aspects 627, 627 newborn anatomy 628, 628 rhinosurgery closed reduction 635–636 as elective procedure 636–637 913 914 Index pediatric rhinology (continued) for hematoma of nasal dorsum 636 indications for 635 for recent nasal trauma 635 summary for 626 pedicled flaps, for skull base reconstruction 792–793 Hadad-Bassagasteguy flap 793–798, 794, 795, 796, 797, 799 Oliver pedicled palatal flap 798, 803, 804 posterior pedicle inferior turbinate flap 797–799, 800 posterior pedicle middle turbinate flap 798–800, 801 temporoparietal fascia flap 798, 800–802, 802 transfrontal pericranial flap 798, 802, 803 peptidergic neural system, in nonallergic rhinitis 233–235, 234 perennial allergic rhinitis (PAR) 247–248 fluticasone propionate for 28 perennial noneosinophilic nonallergic rhinitis (NENAR) 43–44 periciliary layer 40 perinuclear ANCA (p-ANCA) 100 periorbital cellulitis 139, 188 periorbital infection 656–657 peripheral blood mononuclear cells (PBMCs) 360, 360 persistent rhinitis 248, 248 PET see positron emission tomography petrous apex 768–769, 770 PHA see phytohemagglutinin phagocytes, fungal spores and 359 phantosmia 199 pharyngeal canal 15 phenoxybenzamine, nasal mucosa temperature with 37, 43 phenylephrine, for nonallergic rhinitis 240 pheromone 198 phorbol myristate acetate (PMA) 360, 360 photic sneeze reflex 45 phytohemagglutinin (PHA) 360, 360 piriform aperture 34 piriform aperture stenosis 641, 641 pituitary adenomas, sellar surgery for 739–740 pituitary apoplexy 740 pituitary transposition anatomy for 762, 762 case example of 763, 763 indications for 762 risks/complications with 763 technique for 762–763 PIV see particle image velocimetry pizotifen, for migraine headaches 180 plain X-ray films 104 plasma cells 69 PM see particulate matter PMA see phorbol myristate acetate PNEF see peak nasal expiratory flow pneumoceles 621 clinical features of 622 diagnostic work-up for 622, 622 epidemiology of 621 outcomes with 622 pathophysiology of 621–622 treatment for 622 pneumosinus dilatans (PD) 621 clinical features of 622 diagnostic work-up for 622, 622 epidemiology of 621 outcomes with 622 pathophysiology of 621–622 treatment for 622 PNIF see peak nasal inspiratory flow pogonion 6, pollen 250, 250 pollutants allergic rhinitis and 253 CRS and 57 pollybeak deformity 463–464, 465 polyarteritis nodosa (PAN) 684–685 clinical features of 685 diagnostic work-up for 685, 685 epidemiology and etiology of 685 outcomes and prognosis for 685–686 treatment of 685 polydioxanone (PDS) foil 489 polyenes 362–363 polypectomy 322, 322, 323 posaconazole 363 positional cloning 78 position-sensing and -tracking systems 588, 588–589, 589 positron emission tomography (PET) 106–107, 107 of NPC 866, 866 of olfactory disorders 206 posterior ethmoidectomy 320, 321 posterior pedicle inferior turbinate flap (PPITF) 797–799, 800 posterior pedicle middle turbinate flap (PPMTF) 798–800, 801 posterior rhinomanometry, in nonallergic rhinitis 237 posterior septal artery 13 posterosuperior nasal branches 15 postherpetic neuralgia 187 postnasal drip 330–331 postsurgical pain 186–187 posttraumatic olfactory loss 201 treatment for 209 Pott’s puffy tumor 539 clinical features of 539–540 definition of 539 diagnostic work-up for 540 epidemiology and etiology of 539, 539, 540 treatment of 541 powered instruments 596 Index PPITF see posterior pedicle inferior turbinate flap PPMTF see posterior pedicle middle turbinate flap pregnancy, CRS and 55 premalignant inverted papilloma 140 preseptal cellulitis with ARS 529–530, 530 treatment of 533–534 primary cilia 40 primary ciliary dyskinesia (PCD) 63 ciliogenesis in vitro for 98 CRS and 336, 336–337, 337 diagnosis of 98 dynein arms in 98 nNO in 91–92 primary spontaneous epistaxis 508 principle of autonomy 414 prolactinoma 740 PROMs see patient-reported outcome measures propranolol, for migraine headaches 180 proteases 66 PRRs see pattern recognition receptors pterygomaxillary fissure 16 pterygopalatine canal 15–16 pterygopalatine fossa 15–16 regional blocks in 574–575, 575 pterygopalatine fossa syndrome 178 pterygopalatine ganglion 15 publicly funded health care, issues of 414 puncture forces 595–596 pyogenic infections 70 pyriform aperture 6–7, Q QALY see quality-adjusted life-year QLQ-C30 tool 162 qualitative olfactory disorders 199 quality-adjusted life-year (QALY) 171 quality of life with airway disease 216 with allergic rhinitis 254 ESS for CRS and 302–303 quantitative olfactory disorders 199 R radioallergosorbent test (RAST) 86, 88 radiographic imaging 104 of ARS endocranial complications of 536 orbital complications of 532–533 for CSF leak diagnosis 699–700, 701–702 of fungal rhinosinusitis 355–356, 356, 357 of nasal and paranasal sinus trauma 550 radiotherapy intensity-modulated 862 for NPC 866–868, 867, 868, 876 with sellar surgery 755 radix 6, 6–7, Raeder paratrigeminal syndrome 178 RAST see radioallergosorbent test Rathke cleft cysts, sellar surgery for 739 Re see Reynolds number recalcitrant polypoid sinus disease 368 recurrent acute rhinosinusitis 53–54, 177 ESS for 298–299 regional blocks 573–575, 574, 575 remodeling, in AR 214 retronasal olfaction 200, 200 revision rhinoplasty assessment for documentation 459 history and examination 458, 458–459 conclusion for 475 deformities and corrective procedures 461 introduction to 456 for lower third deformities 468, 468 alar base widening 475 alar retraction 471, 473 boss formation 470–471, 472, 473 hanging columella and retraction 474, 474 pinched deformity 469–470, 471 projection deformities 469, 469, 470 rotation deformities 468, 468–469 vestibular stenosis 474–475, 475 for middle third deformities inverted V deformity 466–468, 467 pollybeak deformity 463–464, 465 saddle nose 464, 466, 467 nasal anatomy for 457, 457 psychological issues in 456–457 for skin-soft tissue envelope deformities 461, 461 summary for 456 surgical planning for 459–461 approaches to 459–460 grafting for 460–461 septal considerations 460 unpredictability 460 timing of 457–458 for upper third deformities osteotomy deformities 462, 462–463, 463 overresection 463, 463, 464, 465 underresection 462 Reynolds number (Re), in nasal airflow 27 rhabdomyosarcoma 729 rhinion 6, 6, rhinitis see also allergic rhinitis; nonallergic rhinitis allergic march and 221–222 asthma and 213–214, 217 combination of therapies for 222 course of 221 treatment of 218–221 CDA-induced 43 classification of 229–230 915 916 Index rhinitis (continued) control of 138 definitions of 138 lower airway and 217, 218 nasal endoscopy of 143 nasal obstruction and 134 neonatal 645 nonspecific bronchial hyperreactivity and 213 occupational 213 PROMs for 158, 160–161 severity of 138 summary of 212 symptoms of 51, 132 rhinorrhea 13, 133, 133 united airway concept and treatment of 217 rhinitis medicamentosa 230 rhinoconjunctivitis 252 PROMs for 158, 160 Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) 158–160 rhinology see also pediatric rhinology clinical diagnosis control 138 definition and classification 138 etiology 138 history taking 130–138, 133, 134, 135, 137, 138 introduction to 130 severity 138 summary of 130 differential diagnosis introduction to 130–132 steps in 144–145, 145, 150, 150 summary of 130 examination and complementary diagnostic tools 138–142, 139, 140, 142, 143, 144 genetics in 77–82 allergic rhinitis 78–79 asthma 80–81 CRS 79–80 cystic fibrosis 81–82 introduction to 77–78, 79 mucin disorders 82 summary of 77 imaging in 103–127, 148, 149 of anatomy 116–126, 117, 118, 119, 120, 121, 122, 123, 124, 125 angiography 107 CT 104–105, 105, 106 CT/MRI fusion 106, 106 dacryocystography 107, 108 high-resolution CT 107 image guidance systems 106 of inflammatory disease 109, 109–112, 110, 111, 112, 113 introduction to 103–104 MRI 104–105, 105, 106 neoplastic disease 113–116, 114, 115, 116 pathology evaluation 108–109 PET 106–107, 107 plain X-ray films 104 summary of 103 ultrasonography 107 virtual surgery with CT 126, 127 outcome measures for 152–171 clinical vs patient-reported 153, 153–154 clinician-reported 154 cost-effectiveness analysis 171 data collection and storage 166–167 introduction to 152 PROMs 154–164, 156–157, 158, 163, 170–171 publishing of 171 purpose of 152–153 reasons for lack of use 168–170, 169, 170 summary of 152 tool development for 167 tool selection for 164–166 referral and consultation criteria 144 rhinomanometry 28 acoustic 28 CFD compared with 31, 33 for functional nasal surgery 482 anterior 146 in nonallergic rhinitis 237 CFD compared with 31, 33 for nasal patency 95, 96 posterior, in nonallergic rhinitis 237 rhinoplasty see also cosmetic rhinoplasty; Functional nasal surgery; revision rhinoplasty aesthetics and assessment for basal views 426–427, 427 facial proportions 422–424, 424 frontal view 424, 424, 425 lateral view 424–426, 425, 426 oblique views 426 smiling lateral views 426 surface anatomical landmarks 422, 423 documentation in 427–431 future of 431, 432 image acquisition 423, 428–429 image-manipulating software 429–431, 430, 431, 432 image storing 429 image viewing 429 purposes of 427–428 patient selection and consultation for body dysmorphic disorder 415–417 defect 417 information sources 417 motivation for 415 wishes and surgeon’s capabilities 417 PROMs for 162 social and ethical issues of 414 summary for 413 Index surgical anatomy for blood supply 420–421, 421 bony pyramid 417–418, 418 cartilaginous pyramid 418–420, 419, 420, 421 innervation 421, 422 muscles 422, 422 skin/subcutaneous tissue/SMAS layer 421–422 Rhinoplasty Outcomes Evaluation (ROE) 162 Rhinoprobe 91 rhinorrhea continuous 63 as symptom 13, 133, 133 rhinoscleroma 682–683 rhinoscopy see anterior rhinoscopy rhinosinusitis see also acute rhinosinusitis; chronic rhinosinusitis; fungal rhinosinusitis; nasal polyps allergic rhinitis and 53–54 with asthma, treatment of 222 clinical definition of 26, 51–52, 96, 138 control of 138 diagnosis of 311 ESS for introduction to 296–299 measuring efficacy of 298 summary for 296 INCSs for 38 inflammation in 52–53 lower airway and 217, 218 microbiology assessment for colonization vs infection 96 recommendations for 96 sensitivity and specificity for 97 testing for 96–97 nasal endoscopy of 143 nasal obstruction and 134 pathophysiology of 50–58, 51 phenotypes of 51–52 prevalence of 50–51, 51 PROMs for 158–159, 161 severity of 138 sinus headaches with 182–183 summary of 50, 606 symptoms of 132–133 tests for 99 therapeutic approach to 58, 58 Rhinosinusitis Outcome Measure (RSOM-31) 158–159 rhinovirus infection 267–268 robotic manipulation and support 597 computer-aided robotic surgery 600–601 interaction methods 597–598 telemanipulation 598–600, 599, 600 rodents 251 ROE see Rhinoplasty Outcomes Evaluation RQLQ see Rhinoconjunctivitis Quality of Life Questionnaire RSOM-31 see Rhinosinusitis Outcome Measure S saccharin transportation test 40–41, 98 saddle nose 137, 139 revision rhinoplasty for 464, 466, 467 saline for EFRS 365 hyperosmolar 44 Samter triad 58, 80, 278, 686 see also aspirinexacerbated respiratory diseases clinical features of 686, 687 diagnostic work-up for 686–687, 687 epidemiology and etiology of 686, 686 outcomes and prognosis for 688 treatment for 687 sarcoidosis 137–138, 138, 673 clinical features of 674–675, 675 CRS and 334–335, 335 diagnostic work-up for 675–676 epidemiology and etiology of 673–674, 674 outcomes and prognosis for 676 rhinorrhea in 133 tests for 99 treatment of 676 scar formation, excessive 338, 338 SCCs see solitary chemosensory cells SCD see secondary ciliary dyskinesia schwannoma 729 SCUAD see severe chronic upper airway disease seasonal allergic rhinitis 247–248 secondary ciliary dyskinesia (SCD) 54, 63, 65 ciliogenesis in vitro for 98 dynein arms in 98 secondary epistaxis 509 selective arterial embolization for acute epistaxis 519–520 for HHT 522 sellar lesions 739–740 differential diagnosis of 739 sellar surgery anatomy for 746–747 anesthesia and positioning for 745–746, 746 complications with 751–753, 753 goals of 740–741, 741 hypopituitarism after 754 indications/patient selection for 739–740 introduction to 738–739 operative steps for 746, 746 cavernous sinus/intercavernous sinus 747, 747 image guidance for 747 nasal phase 747, 747–748, 748 sellar phase 748–750, 749, 750, 751, 752 sphenoidal phase 748, 749 outcomes with 753, 754–755, 755, 756 patient information/informed consent for 745 postoperative care for 753–754 917 918 Index sellar surgery (continued) preoperative planning for 741 endocrinological assessment 741–742 imaging 742, 742–745, 743, 744, 745 ophthalmological assessment 741 radiotherapy with 755 summary for 738 water balance disorders after 754 senile rhinitis 231 septal deviation 10 anterior rhinoscopy of 141 CFD model of 34 classes of 486, 487 in CRS 55–56, 338 epistaxis and 509 management of 488–493, 490, 491, 492, 493 nasal obstruction and 134, 135 prevalence of 487 snoring and 665, 665 surgical treatment of 488 septal dislocation 139 septal surgery, PROMs for 160 septodermoplasty, for HHT 523 septoplasty 488–493, 490, 491, 492, 493 for acute epistaxis 517 snoring and 668 serum-specific IgE 357 serum-specific IgG 358 serum total IgE 87–88, 357–358 severe chronic upper airway disease (SCUAD) 248, 328 asthma and 216–217 severe mucosal disease 327–328, 328, 329 SF-36 see Short Form 36 Health Survey shield graft 450–452, 451 Short Form 36 Health Survey (SF-36) 155 SIDS see sudden infant death syndrome silent sinus syndrome (SSS) 119, 119, 615 clinical features of 615–616 diagnostic work-up of 616, 616–617, 617 epidemiology of 615 outcomes with 618 pathophysiology of 615 treatment of 617–618 silver nitrate, for HHT 521–522 simulation 592, 592–593 single nucleotide polymorphisms (SNPs) 78 for AR 79 for asthma 80 sinogenic facial pain 175–178 bacterial rhinosinusitis and 176–177 other diseases causing 177–178, 178 sinonasal malignancy pediatric 653–655, 654 PROMs for 162 Sinonasal Outcome Test (SNOT-22, SNOT-16) 158, 158–159 sinonasal tumors anesthesia and patient positioning 812–813 classification of 837 endonasal approach to 813–814, 814 epidemiology of 836–837 ESS for adjuvant therapy for 854–855 anesthesia and positioning for 844–846 complications with 852–853 inverted papilloma 846, 846–849, 847, 848 juvenile angiofibroma 849, 849, 850 malignant tumors 850–852, 851, 852 operative steps for 846 osteoma/fibrous dysplasia 849–850, 851 outcome of 855–857 patient selection and information for 841–844, 842, 843, 844, 845 perioperative management of 853–854 postoperative surveillance 857, 857–858, 858 external approaches to 815–832 anatomical considerations 815, 815 lateral rhinotomy with medial maxillectomy 816, 816–820, 817, 818, 820 midfacial degloving 820–823, 821–822 osteoplastic frontal sinus approach 828, 828–830, 829 subcranial approach according to Raveh 830–832, 831, 832 total maxillectomy 823–827, 824, 825–826 facial pain with 177–178, 178 frontal sinus surgery for 379 imaging of 115, 836–838, 839 introduction to 810, 835–836 olfactory disorders with 203–204 outcomes for 832 preoperative management of 810–812, 811, 812 rhinorrhea in 133 staging of 838, 840–842 summary for 810, 835 symptoms of 836, 838 sinus cholesteatomas 618 clinical features of 619 diagnostic work-up for 619 epidemiology of 618 outcomes with 621 pathophysiology of 618–619 treatment of 619, 619–621, 620 sinus gas exchange, in paranasal sinuses 46 sinus headaches 182–187 analgesic-dependent headache 185 midfacial segment pain 184, 184–185 postsurgical/neuropathic 186–187 surgery and 185, 185–186 tension-type 183, 183 Index sinusitis see also maxillary sinusitis acute, complications 656–658, 657, 658 allergic fungal 99–100 frontal 176–177 sinus packs 90–91 SIT see specific immunotherapy Sjögren syndrome, tests for 99 skin prick test 86–88, 87, 357 aeroallergen 253 skin-soft tissue envelope (S-STE) 442, 446 cosmetic rhinoplasty of 453–454 revision rhinoplasty for 461, 461 skull base fractures 547–549 outcomes with 561 stabilization of 559–560, 560 skull base reconstruction generalities of 791–793 introduction to 791 other techniques for 804 abdominal fat graft 804, 805 collagen sponge 804, 804 pedicled flaps for 792–793 Hadad-Bassagasteguy flap 793–798, 794, 795, 796, 797, 799 Oliver pedicled palatal flap 798, 803, 804 posterior pedicle inferior turbinate flap 797–799, 800 posterior pedicle middle turbinate flap 798–800, 801 temporoparietal fascia flap 798, 800–802, 802 transfrontal pericranial flap 798, 802, 803 postoperative CSF leak identification of 805–807 management of 807 postoperative precautions 804–805 summary for 791 skull base surgery endonasal approaches to 759 frontal sinus surgery for 379 for fungal rhinosinusitis 371 PROMs for 162–163, 163 sleep apnea syndrome 663 see also obstructive sleep apnea nasal obstruction and 134 sleep-related breathing disorder (SRBD) 663 smell dysfunction, rhinosinusitis and 51 smell identification test 204–205, 205 smoking allergic rhinitis and 253 CRS and 57 in difficult-to-treat 342 glucocorticosteroids and 342 smoking rhinitis 231 sneeze reflex 45 sneezing, as symptom 137 snoring introduction to 663 management of medical treatment 666–668 nasal dilators 668 research problems 666 surgical treatment 668, 668–670, 670 nasal pathology and 665, 665–666 pathophysiology of 664, 664–665 summary for 663 SNOT-16 see Sinonasal Outcome Test SNOT-22 see Sinonasal Outcome Test SNPs see single nucleotide polymorphisms SNPT see specific nasal provocation test sodium valproate, for migraine headaches 180 SOE see supraorbital ethmoid cell soft tissue mass, imaging of 105, 106, 115 solitary chemosensory cells (SCCs) 45–46 SPA see sphenopalatine artery specific immunotherapy (SIT), for rhinitis and asthma 219–220 specific nasal provocation test (SNPT) 88 sphenochoanal polyps, imaging of 109–110 sphenoethmoid cell 19, 19f imaging of 119, 120 sphenoethmoidectomy for endoscopic orbital decompression 720 for optic nerve decompression 725 sphenoethmoid recess 22 imaging of 117, 119 sphenoid bone 17–18, 18, 19 embryology 5, sphenoidotomy, for acute epistaxis 519, 520 sphenoid sinuses anatomy of 17–20, 18, 19 embryology 5, ESS in 320, 322 fungal rhinosinusitis in, surgery for 371 imaging of 119, 120, 121 mucoceles 612, 613, 614 regional blocks in 574, 574 sphenopalatine artery 13, 15 occlusion, for acute epistaxis 518, 518–519 sphenopalatine artery (SPA) 511 sphenopalatine foramen 11, 13, 15 splay graft 496–497 spontaneous epistaxis 508 spreader grafts technique 493, 495, 495–496, 496 squamous cell carcinoma facial pain with 178, 178 orbital 731 squamous papilloma 135, 135 SRBD see sleep-related breathing disorder SSS see silent sinus syndrome S-STE see skin-soft tissue envelope 919 920 Index Staphylococcus aureus in CRS 56 in CRSwNP 279 in NPs 53 Starling resistor model 664, 664 steroids see also intranasal steroids for Churg-Strauss syndrome 335 for CRS 280–281 for EFRS 364 in OSA 666–667 preoperative use of 569 for sarcoidosis 335 for sinonasal disease-related olfactory loss 207 steroid-dependent anosmia 201 subcranial approach according to Raveh 830 complications of 831–832 indications for 830, 830 postoperative care for 831 surgical steps for 830–831, 831 subdural empyema 535, 535, 536 subnasale 6, subperiosteal abscess with ARS 530, 530, 531 treatment of 534 substance P 44 sudden infant death syndrome (SIDS) 45 SUNCT syndrome 182 superantigens 68 superior labial artery 14 superior meatus 13, 22–23 superior turbinate 11, 11–12, 12 lamella of 22, 23 supplementary maxillary ostia, in CRS 338 supplements, bleeding and 567–568 suprabullar area, imaging of 122–123, 124 suprabullar cell, in frontal recess surgical anatomy 381, 382, 382 supraorbital cell in frontal sinus surgery 392 imaging of 123, 124 supraorbital ethmoid cell (SOE) 14, 22 supraorbital ethmoid mucoceles 22 supraspinal pain 190 supreme meatus 12, 22–23 supreme turbinate 11, 11–12 surgery see also endoscopic sinus surgery; frontal sinus surgery; rhinoplasty; sellar surgery; skull base surgery for acute epistaxis 517 for allergic rhinitis 262 for chronic epistaxis 520–521 for CRS 281 medical management vs 292 ESS vs 303 for fungal rhinosinusitis 366–373 causes of failure 368 ethmoid and sphenoid sinuses 371 frontal sinus 371, 372, 372 general principles for 367–369 goals for 367 maxillary sinus 369–371, 370, 371 poor landmarks 368–369 postoperative care 372–373 tailoring to severity 367, 367–368, 368 for HHT 522–523 multiple prior 340–341 for nonallergic rhinitis 241–243, 242, 243 for OSA 668, 668–670, 670 for rhinosinusitis 58, 58 septal, PROMs for 160 for sinus cholesteatomas 619, 619–621, 620 sinus headaches and 185, 185–186 for SSS 617–618 virtual, with CT 126, 127 swallowing reflex 45 sweat test 99 sympathetic system 42–43 in nonallergic rhinitis 233 sympathicomimetics, for nonallergic rhinitis 239–240 symptom severity score rating, for airflow assessment 28 synechia, postoperative care of 581, 581 systemic diseases Churg-Strauss syndrome 679 clinical features of 679 diagnostic work-up for 679–680, 680 epidemiology and etiology of 679 outcomes and prognosis for 680 treatment of 680 cocaine abuse 680 clinical features of 680, 680–681, 681 diagnostic work-up for 681 epidemiology and etiology of 680 outcomes and prognosis for 681 treatment for 681 CRS and 332–336 immunodeficiency 688 clinical features of 688–689 diagnostic work-up for 689, 689 epidemiology and etiology of 688 outcomes and prognosis for 689–690 treatment of 689 infectious 681–683, 682 introduction to 673 Langerhans cell histiocytosis 675–676 clinical features of 677, 677 diagnostic work-up for 677 epidemiology and etiology of 676–677 outcomes and prognosis for 678 treatment for 677–678 leprosy 682, 682 midline granulomas 675, 678 clinical features of 678 diagnostic work-up for 678 Index epidemiology and etiology 678 outcomes and prognosis of 679 treatment for 678–679, 679 PAN and MPA 684–685 clinical features of 685 diagnostic work-up for 685, 685 epidemiology and etiology of 685 outcomes and prognosis for 685–686 treatment of 685 rhinoscleroma 682–683 Samter triad 686 clinical features of 686, 687 diagnostic work-up for 686–687, 687 epidemiology and etiology of 686, 686 outcomes and prognosis for 688 treatment for 687 sarcoidosis 673 clinical features of 674–675, 675 diagnostic work-up for 675–676 epidemiology and etiology of 673–674, 674 outcomes and prognosis for 676 treatment of 676 summary for 673 tuberculosis 682, 682 Wegener granulomatosis 683 clinical features of 683, 684 diagnostic work-up for 683–684 epidemiology and etiology of 683 outcomes and prognosis for 684 treatment of 684 systemic symptoms 137, 137–138, 138 T taste receptors 197–198 TB see tuberculosis T cell receptor (TCRs) 66, 69 TCR see trigeminocardiac reflex TCRs see T cell receptor technological advances clinical applications of balloon sinuplasty 602, 602 FESS 603 computer-assisted surgery clinical application of 591, 591–593, 592 history of 585–586 image data registration with anatomy 590, 590–591 imaging in 586, 586–588, 587, 588 position-sensing and -tracking systems 588, 588–589, 589 terminology for 585 modern surgical instrumentation force-sensing instruments 595–596, 596 lasers 593–594, 594 navigated FESS 594–595, 595 powered instruments 596 operating room integration 601, 601–602 robotic manipulation and support 597 computer-aided robotic surgery 600–601 interaction methods 597–598 telemanipulation 598–600, 599, 600 summary for 585 telecanthus, with subcranial approach according to Raveh 832 telemanipulation 598–600, 599, 600 temporoparietal fascia flap (TPFF) 798, 800–802, 802 tension headache 136 tension-type headache 183, 183 testing for allergies 86, 86–89 allergen-specific IgE 88 nasal provocation tests 88–89 serum total IgE 87–88 skin prick test 86–88, 87 T helper subsets 67–69, 68 Thornwaldt cysts Th1 pathway, in fungi defense 361 Th2 pathway, in fungi defense 361–362 Th17 pathway, in fungi defense 362 threshold testing 205 thyroid dysfunction, CRS and 55 thyrotropin-producing adenoma 740 tip elevation test 141 TLRs see toll-like receptors T lymphocytes 66–69, 68, 73 toll-like receptors (TLRs) 65 Tolosa-Hunt syndrome 178 total maxillectomy complications with 827 contraindications for 823 indications for 823 orbital exenteration in 827 postoperative care for 827 surgical steps for 823–827, 824, 825–826 toxins CRS and 57 olfactory disorders and 203 TPFF see temporoparietal fascia flap transclival approach anatomy for 760, 760 case example for 761, 761 indications for 760 risks/complications with 761–762 technique for 760–761 transcolumellar incision 440, 440, 441 transdomal suture-narrowing technique 449, 449 transfrontal pericranial flap 798, 802, 803 transnasal craniotomy 404, 404 transseptal frontal sinusotomy 378 tree pollen 250 triazoles 363 trichion 6, tricyclic antidepressants, skin prick tests and 87 trigeminal nerve system 8, 8, 14–15 921 922 Index trigeminal neuralgia 136, 187 trigeminocardiac reflex (TCR) 45–46 triptans, for migraine headaches 180 trisomy 21, CRS and 339 Trotter triad 178 T2Rs see type bitter taste receptors tuberculosis (TB) 682, 682 tumors see benign tumors; bone tumors; malignant tumors; orbital tumors; sinonasal tumors turbinates see also inferior turbinate; middle turbinate; superior turbinate; supreme turbinate air conditioning at 37–38 micron particle deposition at 38 nasal airflow and 27 turbinate reduction, for nonallergic rhinitis 241 turbulence in nasal airflow 27 at nasal valve 36 turbulent kinetic energy 31 type A ultrasonography 107 type bitter taste receptors (T2Rs) 45–46 type cell, in frontal sinus surgery 381, 381 type cell, in frontal sinus surgery 381, 382 type cell, in frontal sinus surgery 381, 382, 392 type cell, in frontal sinus surgery 381, 383, 392 U UARS see upper airway resistance syndrome ultrasonography 107 of ARS, orbital complications of 533 uncinate process 22–24, 23 in CRS 55–56 in Draf IIa 386, 386 in frontal recess surgery anatomy of 381, 381 curette insertion 382, 383 removal of 382, 383 imaging of 123–125, 124 uncinate process bulla 117, 117 uncinectomy 316–317, 317, 318 for Draf IIa 386, 386 underresection, revision rhinoplasty for 462 united airway concept 85–86 asthma treatment in 218–219 epidemiology for 213–214 interaction between airways 214–217 diagnosis and assessment of severity 216–217 pathophysiologic mechanisms 214–216, 215, 216 introduction to 212–213 management of 217–222, 218 rhinitis treatment in 217 summary of 212 upper airway see also severe chronic upper airway disease; united airway concept asthma and 217 impaired air conditioning in 215 inflammation in 54, 54 prevalence of 50–51, 51 lower airway disorders and 85 lower airway interaction with 214–217 diagnosis and assessment of severity 216–217 direct contamination 215 pathophysiologic mechanisms 214–216, 215, 216 NO and patency of 664–665 upper airway resistance syndrome (UARS) 663 upper lateral cartilages 7, 7, 418–419, 419 in cosmetic rhinoplasty 443–445, 444, 445, 446 upper respiratory tract infection (URTI) acute rhinosinusitis and 269–270 olfactory disorders with 201 treatment for 209 upper third see bony nasal vault URTI see upper respiratory tract infection V VAS see visual analogue scale vascular anastomoses 512, 512–513 vascular pain 178–182, 190 migraine 178–180, 179 vasoactive intestinal peptide (VIP) 44 vasoconstrictors 575 for allergic rhinitis 259–260 velocity fields 30 venous drainage system 512 vernal keratoconjunctivitis 254 vestibular stenosis 474–475, 475 vidian nerve anatomy of 241, 242 synapse 15 vidian neurectomy, for nonallergic rhinitis 241–243, 242, 243 VIP see vasoactive intestinal peptide viral infections, bronchial hyperreactivity and 215 viral rhinosinusitis ARS and 269 cilia in 53 diagnosis of 271, 271–272, 272 epidemiology of 267 pathogenesis and putative mechanisms of 267–268 treatment for 272–274, 273 virtual reality 592, 592–593 virtual surgery, with CT 126, 127 viscoelasticity, of mucus 39 visual analogue scale (VAS), for airflow assessment 28 VNO see vomeronasal organ vomer 9–10, 10 vomeronasal organ (VNO) 198, 198–199 von Willebrand disease (vWF) 568 voriconazole 363 vWF see von Willebrand disease Index W wall shear stress CFD models of 33–34 with different obstructions 36 of nasal cavity 31 Weber-Rendu-Osler syndrome 133, 134 weeds 250, 251 Wegener granulomatosis 99, 137, 683 clinical features of 683, 684 CRS and 333–334, 335 diagnostic work-up for 683–684 epidemiology and etiology of 683 imaging of 149 outcomes and prognosis for 684 rhinorrhea in 133, 133 treatment of 684 Woodruff plexus 14, 512, 512–513 X xerophthalmia, with total maxillectomy 827 xylometazoline 575 for allergic rhinitis 260 for CRS 289 effect and safety of 577–578 for nonallergic rhinitis 240 Y Youlten peak flow meter 93 Young procedure, for HHT 523 Z zygomatic fractures 547 outcomes with 561 stabilization of 558–559 923 DVD Contents Video Video Video Video Video Video Video Video Video Video 10 Video 11 Video 12 Video 13 Video 14 Video 15 Video 16 Video 17 Video 18 Video 19 Video 20 Video 21 Video 22 Video 23 Video 24 Video 25 Video 26 Video 27 Video 28 Video 29 Video 30 Video 31 Video 32 Video 33 Video 34 Video 35 Video 36 Video 37 Video 38 Video 39 Historic Video of Professor Walter Messerklinger Mucus Circulation from Inferior Meatal Antrostomy to Natural Maxillary Ostium Reconstruction of DICOM-CTA Using OsiriX 4.1 Rhinitis Medicamentosa Cocaine-induced Rhinitis, Early Stage Encephalocele with CSF Rhinorrhea Rendu-Osler-Weber Syndrome with Septal Button Churg-Strauss Syndrome Stage Sarcoidosis Normal Three-pass Endoscopy Nonallergic Rhinitis, Nasal Endoscopy Cocaine Abuse, Late Phase Valve Insufficiency Nonallergic Rhinitis, Nasal Endoscopy of Hyperactive Patient Vidian Neurectomy Endoscopic-powered Right Ethmoidectomy, Narrated Primary Ciliary Dyskinesia Revision FESS in CRSwNP Revision FESS Using Stable Anatomical Landmarks Medial Maxillectomy, Postoperative View Left Full House FESS and Canine Fossa Trephine for Fungal Rhinosinusitis Draf IIa Marsupialization of a Two-lobed Frontal Mucocele Medial of Middle Turbinate Draf IIb for Frontal Inverted Papilloma Draf III for Large Frontal Sinus Osteoma Removed Endoscopically Draf III for Crista Galli/Posterior Frontal Plate Defect and Encephalocele Repair Draf III for Frontocutaneous Sinus Fistula Three-dimensional Surface Rendering from Standard DICOM CT Scans, for Normal Viewing Three-dimensional Surface Rendering from Standard DICOM CT Scans, for 3D Viewing with Special Glasses The Crooked Nose The Up-rotated Tip, Revision Surgery Alar Collapse External Nasal Valve Collapse and Lateral Crus Pull-up Patient with Severe Refractory HHT, Young’s Procedure Sphenopalatine Artery Ligation Endoscopic Drainage of Subperiosteal Orbital Abscess Pott’s Puffy Tumor, Endoscopic Management Multiple CSF Leaks Following Trauma Placement of Cocaine/Epinephrine on Six Cotton-tipped Metal Rods Video 40 Video 41 Video 42 Video 43 Video 44 Video 45 Video 46 Video 47 Video 48 Video 49 Video 50 Video 51 Video 52 Video 53 Video 54 Video 55 Video 56 Video 57 Video 58 Video 59 Video 60 Video 61 Video 62 Video 63 Video 64 Video 65 Video 66 Video 67 Video 68 Video 69 Video 70 Video 71 Video 72 Video 73 Video 74 Video 75 Video 76 Video 77 Video 78 Registering and Testing the Brainlab Navigation System Endonasal Microscopic Dacryocystorhinostomy Using a Fiberoptic Erbium Laser Cases of Balloon Sinuplasty Giant Intracranial Mucocele Treated by Marsupialization Silent Sinus Syndrome Draf IIa for Frontal Pneumocele Revision of Recurrent Choanal Polyp in 6-year-old Boy Sedated, Snoring, Supine Patient, Pure Palatal Tongue Base Snorer Palatal Snoring and Effect of Jaw Lift CPAP-induced Rhinitis Sarcoidosis with Mediastinal Lymphadenopathy Cocaine-induced Midline Nasal Necrosis Wegener Granulomatosis, Nasal Manifestations Patient with ASA Triad and Sphenoid Mucocele CRSwNP in Patient with Alpha-1 Antitrypsin Deficiency Closure of Difficult-to-find CSF Leak in Patient with Previous FESS Closure of CSF Leak in the Lateral Lamella Endoscopic Dacryocystorhinostomy Endoscopic Orbital Decompression for Graves Orbitopathy Pediatric Ethmoid Orbital Ewing Sarcoma Large Frontal Osteoma in Frontal Sinus, Ethmoid, and Orbit Endoscopic Removal of Retrochiasmatic Craniopharyngioma, Pituitary Transposition Pituitary Surgery, Nasal Phase Pituitary Surgery, Sphenoid Phase Pituitary Surgery Sellar Phase 1, Extradural Pituitary Surgery Sellar Phase 2, Intradural Cerebellopontine Angle Epidermoid, Transclival Approach Cholesterol Granuloma of the Petrous Apex Tuberculum Sellae Meningioma Nasoseptal (Hadad) Flap Reconstruction Reconstruction Following Removal of Tuberculum Sellae Meningioma Juvenile Angiofibroma Medial Maxillectomy for Inverted Papilloma Residual Inverted Papilloma in Frontal, Ethmoid, and Maxillary Sinuses—Draf IIb, Ethmoidectomy, and Exploration of the Maxillary Sinus Endoscopic Excision of Sinonasal Squamous Cell Carcinoma Ossifying Fibroma in Young Woman Fibrous Dysplasia of the Sphenoid Nasopharyngectomy for Nasopharyngeal Carcinoma ... columellar strut graft, and interdomal and transdomal suturing alar sidewalls, for symmetry and for concavity/convexity (Figs 23 .23 , 23 .24 , and 23 .25 ) The use of digital imaging and morphing software... Anatomy 422 Value and Meaning of Beauty 414 Nasal Aesthetics and Assessment 422 Meaning and Range of the Principle of Autonomy 414 Surface Anatomical Landmarks 422 Proper Goals... image An example of a manipulated image is presented in Figs 23 .26 , 23 .27 , and 23 .28 , and the actual postoperative result in Fig 23 .29 An excellent online tutorial for the use of Photoshop for