Part 1 book “Office-Based rhinology: Principles and techniques” has contents: History of nasal endoscopy, endoscopic anatomy for office-based rhinology procedures, radiology of the nose and paranasal sinuses, room setup and equipment for office procedures, patient selection and informed consent for office-based procedures,… and other contents.
Office-Based Rhinology Principles and Techniques Office-Based Rhinology Principles and Techniques Zara M Patel, MD Sarah K Wise, MD, MSCR John M DelGaudio, MD, FACS Division of Rhinology Department of Otolaryngology-Head and Neck Surgery Emory University of School of Medicine 5521 Ruffin Road San Diego, CA 92123 e-mail: info@pluralpublishing.com Web site: http://www.pluralpublishing.com Copyright © by Plural Publishing, Inc 2013 Typeset in 11/13 Adobe Garamond by Flanagan’s Publishing Services, Inc Printed in the United States of America by Bang Printing All rights, including that of translation, reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording, or otherwise, including photocopying, recording, taping, Web distribution, or information storage and retrieval systems without the prior written consent of the publisher For permission to use material from this text, contact us by Telephone: (866) 758-7251 Fax: (888) 758-7255 e-mail: permissions@pluralpublishing.com NOTICE TO THE READER Care has been taken to confirm the accuracy of the indications, procedures, drug dosages, and diagnosis and remediation protocols presented in this book and to ensure that they conform to the practices of the general medical and health services communities However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication The diagnostic and remediation protocols and the medications described not necessarily have specific approval by the Food and Drug administration for use in the disorders and/or diseases and dosages for which they are recommended Application of this information in a particular situation remains the professional responsibility of the practitioner Because standards of practice and usage change, it is the responsibility of the practitioner to keep abreast of revised recommendations, dosages, and procedures Every attempt has been made to contact the copyright holders for material originally printed in another source If any have been inadvertently overlooked, the publishers will gladly make the necessary arrangements at the first opportunity Library of Congress Cataloging-in-Publication Data Office-based rhinology : principles and techniques / Zara M Patel, co-editor, Sarah K Wise, co-editor, John M DelGaudio, co-editor p ; cm Includes bibliographical references and index ISBN-13: 978-1-59756-475-5 (alk paper) ISBN-10: 1-59756-475-3 (alk paper) I Patel, Zara M II Wise, Sarah K III DelGaudio, John M [DNLM: Nose Diseases — surgery Ambulatory Surgical Procedures — methods Nasal Surgical Procedures — methods Nose surgery WV 300] 617.5'23 — dc23 2012042898 Contents Introduction vii Contributors ix 10 11 12 13 14 15 History of Nasal Endoscopy Endoscopic Anatomy for Office-Based Rhinology Procedures Radiology of the Nose and Paranasal Sinuses 15 Room Setup and Equipment for Office Procedures 37 Patient Selection and Informed Consent for Office-Based Procedures 45 Nasal and Sinus Anesthesia for Office Procedures 49 Basic Nasal Endoscopy and Biopsy 61 In-Office Treatment of Post-Endoscopic Sinus Surgery Issues 67 Office-Based Inferior Turbinate Reduction 77 Office-Based Management of Septal Pathologies 89 Office-Based Nasal Polypectomy 101 Office-Based Management of Mucoceles 109 Epistaxis: Office-Based Management 117 Nasal Fractures: Closed Reduction in the Office Setting 129 Office-Based Evaluation and Treatment of Epiphora 137 Index 145 Introduction As otolaryngology has moved toward minimally invasive procedures in every subspecialty, there has been a parallel trend to perform these procedures in the office setting, when possible Physicians and patients alike can derive benefits from moving procedures from the hospital operating room to the office exam room Physicians have more flexibility in scheduling, delays associated with staff shift changes and equipment turnover are eliminated, time can be used more efficiently, and more patients can be seen Patients are more comfortable in a familiar environment, require less time away from their regular schedules, have decreased anesthesia requirements, are not exposed to hospital acquired infectious organisms, and often have a lower insurance copay for officebased procedures In this text, we cover the foundation of knowledge a surgeon must have to prepare for office-based procedures, including anatomy, radiology, and basic endoscopic skills We review the basic preparatory steps involved such as proper patient selection, room setup, and local anesthetic techniques, and then present multiple rhinologic procedures that can be performed in the office setting We have asked expert rhinologists across the subspecialty to share their techniques in this text, and we thank them for their excellent contributions We have also compiled a DVD of selected surgical procedures to help the reader obtain a more complete and thorough understanding of these procedures We hope this book will educate surgeons at all stages of their career, whether otolaryngology residents or those who have been practicing for many years, and allow them to develop a new and fulfilling aspect of their practice as otolaryngologists Zara M Patel Sarah K Wise John M DelGaudio Department of Otolaryngology— Head and Neck Surgery Emory University School of Medicine Contributors Robert T Adelson, MD Department of Otolaryngology-Head and Neck Surgery University of Pennsylvania School of Medicine Philadelphia, Pennsylvania Chapter Kristen Lloyd Baugnon, MD Department of Radiology Emory University School of Medicine Atlanta, Georgia Chapter John M DelGaudio, MD, FACS Division of Rhinology Department of Otolaryngology-Head and Neck Surgery Emory University of School of Medicine Atlanta, Georgia Chapters 1, 2, 9, 11, 12, and 15 Praveen Duggal, MD Department of Otolaryngology-Head and Neck Surgery Emory University School of Medicine Atlanta, Georgia Chapter Richard J Harvey, MD Australian School of Advanced Medicine Macquarie University Faculty of Medicine University of New South Wales Sydney, Australia Chapter Oswaldo A Henriquez, MD Department of Otolaryngology-Head and Neck Surgery Emory University School of Medicine Atlanta, Georgia Chapter 11 Elizabeth K Hoddeson, MD Department of Otolaryngology-Head and Neck Surgery Emory University School of Medicine Atlanta, Georgia Chapter Peter H Hwang, MD Department of Otolaryngology-Head and Neck Surgery Stanford University School of Medicine Stanford, California Chapter 10 H Joon Kim, MD Department of Ophthalmology Emory University School of Medicine Atlanta, Georgia Chapter 15 Todd T Kingdom, MD Department of Otolaryngology-Head and Neck Surgery University of Colorado School of Medicine Denver, Colorado Chapter Adrienne Laury, MD Department of Otolaryngology-Head and Neck Surgery Emory University School of Medicine Atlanta, Georgia Chapter 12 Basic Nasal Endoscopy and Biopsy 63 overall health of the nasal mucosa and an indication of any anatomic abnormalities such as severe septal deviation, which would impair further visualization The inferior meatus is examined on this pass If Hasner’s valve, the opening of the nasolacrimal duct is not readily visible and one desires to view it in order to better evaluate a patient with epiphora, a smaller scope along with a freer elevator to gently retract the inferior turbinate may be used to improve visualization The scope should then be passed into the nasopharynx and the opening of the eustachian tube and the torus tubarias should be visualized This view is facilitated by using an angled scope and rotating the angle toward these structures Drainage from the sinuses may be visualized along the lateral wall during this portion of the exam Drainage from the posterior ethmoids and sphenoid characteristically passes superior to the torus tubarias whereas secretions from the ethmoid infundibulum typically pass inferior to the torus.4 The next pass is between the inferior and middle turbinate The inferior portion of the middle meatus is assessed for the possible presence of a thinned posterior fontanelle and the presence or absence of accessory maxillary ostia To examine the sphenoethmoid recess the scope should be passed medial to the middle turbinate and then rotated allowing for visualization of the superior turbinate and meatus, and in some cases, the ostia of the sphenoid sinus (Figure 7–2) On withdrawing the scope, one can often rotate the scope under the middle turbinate and visualize the posterior portion of the middle meatus including the ethmoid bulla, hiatus semiluminaris, and uncinate with its surrounding mucosa The third and final pass should be undertaken to examine the olfactory cleft and assess whether any polyps or other pathology are present in this area The septum can often obscure one side due to deviation and the examination may only be possible unilaterally Figure 7–2. View of sphenoethmoid recess These three passes are usually performed in one fluid continuous movement of the endoscope within the nose along the pathways of least resistance Endoscopy in Staging and Grading of Rhinosinusitis Endoscopic findings, along with imaging, are key pieces of information in most staging systems for the severity of sinusitis The Lund-Kennedy scoring system quantifies the pathologic states of the nose and paranasal sinuses, focusing on the presence of crusting, polyps, discharge, edema, and scarring or adhesions2 (Table 7–1) The system as described provides a consistent means to follow a patient’s disease over time and past any surgical or medical intervention It also provides an extremely useful tool for objectively describing outcomes in clinical research The 2007 American Academy of Otolaryngology guidelines for the definition of chronic rhinosinusitis (CRS) include endoscopic findings such as edema of the middle meatus or ethmoids, presence of purulent 64 Office-Based Rhinology: Principles and Techniques Table 7–1. Lund-Kennedy Endoscopic Scoring System Characteristic Baseline mo mo year years Polpy, left (0,1,2) Polyp, right (0,1,2) Edema, left (0,1,2) Edema, right (0,1,2) Discharge, left (0,1,2) Discharge, right (01,2) Postoperative scores to be used for outcome assessment Scarring, left (01,2) Scarring, right (01,2) Crusting, left (0,1,2) Crusting, right (0,1,2) Total Points Polyps: 0 — absence of polyps; 1 — polyps in middle meatus only; 2 — polyps beyond the middle meatus Edema: 0 — absent; 1 — mild; 2-severe Discharge: 0 — no discharge; 1 — clear thin discharge; 2 — thick, purulent discharge Scarring: 0 — absent; 1 — mild; 2 — severe Crusting; 0 — absent; 1 — mild; 2 — severe Source: Lund VH, Kennedy DW Quantification for staging sinusitis The Staging and Therapy Group Ann Otol Rhinol Laryngol Suppl 1995;167:17–21 secretions or polyps, as one of the objective findings necessary for the diagnosis of CRS.3 The addition of objective endoscopic findings to the clinical symptom criteria in making the diagnosis of CRS was found by Bhattacharyya and Lee4 to increase the specificity of diagnosis significantly from 12.3 to 84.1%, with both the positive and negative predictive values for the presence of disease with CT scan findings being taken as the gold standard for diagnosis They concluded that endoscopy improves diagnostic accuracy and may decrease the need for CT scanning to make a diagnosis of CRS.4 Endoscopic Biopsy The most basic of nasal endoscopic interventions is the endoscopic biopsy There are myriad sinonasal masses and lesions, benign and malignant, which can present on endoscopic examination The ability to obtain tissue for pathologic diagnosis in the office is the most convenient and efficient method of hastening patient counseling and treatment planning The list of possible sinonasal masses is long and varied, including benign epithelial Basic Nasal Endoscopy and Biopsy 65 tumors, malignant epithelial tumors, neuroendocrine tumors, soft tissue tumors, tumors of bone and cartilage, hematologic and lymphomatous tumors, neuroectodermal tumors, germ cell tumors, and metastases There are also various lesions that can arise from systemic disorders, such as sarcoidosis, Wegener’s granulomatosis, or leprosy If the mass or lesion appears in any way to be pulsatile or vascular, it is not a good idea to biopsy it in the office without imaging Imaging is also important to obtain in almost all masses extending from the superior or posterior skull base to rule out meningoencephalocele As noted in the chapter on radiology, there are important things to note about a sinonasal mass on imaging before biopsying On a CT, one should look for bony defects of the skull base in association with the mass On an MRI, in addition to being able to clearly determine any association with the brain or meninges, if postcontrast images demonstrate avid enhancement, and T2w MRI images demonstrate curvilinear hypointense vascular flow voids, the mass is likely too vascular to biopsy in the office After using topical anesthetic spray (pontocaine with neosynephrine works well, as other preparations that are discussed at length in Chapter 6), the proper instrumentation should be selected Through-cutting instrumentation is the safest to use, as it will not pull on the tissue and cause inadvertent damage or bleeding If bleeding does occur, this can usually be controlled with silver nitrate cautery Placing pledgets soaked in neosynephrine or oxymetazoline for a few minutes can also help The office should be stocked with absorbable and nonabsorbable packing options as well, in the event the more conservative measures are not enough Enough tissue should be obtained so as to be able can be sent in both formalin and in saline (“fresh”), so lymphomatous diagnoses can be more easily identified alongside the more common carcinomas Conclusions The addition of nasal endoscopy to otolaryngologic practice provides essential information for the diagnosis and treatment of sinonasal disease Taking the care to perform a systematic exam each time ensures a maximum of information is obtained and no sinonasal pathology is missed In-office endoscopic biopsy is also an extremely important tool in the diagnosis and expedition of treatment for sinonasal masses and lesions References Joe SA Nasal Endoscopy: Diagnosis and Staging of Inflammatory Sinus Disease, in Diseases of the Sinuses Diagnosis and Management London, UK: BC Decker Inc; 2001;119–128 Lund VJ, Kennedy DW Quantification for staging sinusitis The Staging and Therapy Group Ann Otol Rhinol Laryngol Suppl 1995; 167:17–21 Rosenfeld RM, Andes D, Bhattacharyya N, et al Clinical practice guideline: adult sinusitis Otolaryngol Head Neck Surg 2007;137(3 suppl):S1–31 Bhattacharyya N, Lee LN Evaluating the diagnosis of chronic rhinosinusitis based on clinical guidelines and endoscopy Otolaryngol Head Neck Surg 2010;143(1):147–151 .. .Office-Based Rhinology Principles and Techniques Office-Based Rhinology Principles and Techniques Zara M Patel, MD Sarah K Wise, MD, MSCR John... their bony attachment sites The middle and superior turbinates are especially important landmarks for endoscopic 6 Office-Based Rhinology: Principles and Techniques Figure 2–1. Endoscopic view... invented a needle that could be used to create a pneumoperitoneum, and had the foresight 2 Office-Based Rhinology: Principles and Techniques to describe its potential applications to facilitate