Part 2 book “Office-Based rhinology: Principles and techniques” has contents: In-Office treatment of post-endoscopic sinus surgery issues, office-based management of mucoceles, nasal fractures - closed reduction in the office setting, office-based nasal polypectomy, office-based evaluation and treatment of epiphora,… and other contents.
Chapter In-Office Treatment of Post-Endoscopic Sinus Surgery Issues Robert T Adelson James N Palmer Introduction Endoscopic sinus surgery (ESS) that preserves native anatomy and sinonasal mucosa to the greatest degree possible has become the universally accepted surgical modality by which chronic rhinosinusitis (CRS) is addressed Inherent to this operation is the understanding, by both patient and surgeon, that operative procedures are adjunctive to the medical management of an underlying inflammatory disorder Similarly, the postoperative care of patients undergoing ESS remains akin to a moving target The idealized postoperative sinus cavity can only be achieved by active participation in medical management and office-based minor surgical procedures Medical management includes both topical and oral route corticosteroids and antibiotics whereas surgical procedures are focused on the removal of material that may predispose to either cicatricial occlusion of sinus ostia or re-infection of a paranasal sinus Our postoperative procedures are aligned with the current concept of functional ESS that emphasizes not just improving the patency of sinus ostia to facilitate the egress of mucus, but, more importantly, to enhance the penetration of medicated topical irrigations Although ESS is the widely established standard of care for the surgical management of CRS, its postoperative management is less well characterized There are wide variances between surgeons with regard to both medical and surgical therapy Common to all is the understanding that the inflammatory nature of CRS requires long-term follow-up and occasional medical or surgical interventions to control the underlying disease process In the absence of blinded, prospective, diseasematched, controlled studies with validated outcome measures at long-term follow-up, there is no substantial evidence to guide postoperative debridements.1,2 Our routine postoperative care involves a regimen of weekly debridements until the endoscopic examination normalizes Adjustment of the timing, degree, and frequency of debridements is best relegated to clinical 68 Office-Based Rhinology: Principles and Techniques assessment of patient factors, anatomic findings, extent of the operation, and the inflammatory state at the time of surgery and during recovery.3 Mucosal preservation during debridements is a guiding principle, while maximizing the removal of retained secretions, bone chips, bridging clots, and early synechiae Patients are followed over time and both the medical management of the underlying inflammatory disorder is modified according to patient symptoms and the endoscopic evidence of disease Office-based surgical interventions are introduced when surgically created ostia become critically narrowed or the natural course of healing deviates from desired goals Inherent to achieving postoperative success is that the goals of the surgeon and patient remain mutually aligned, as postoperative office-based procedures require a degree of cooperation by both parties Areas of Exposed Bone When sinonasal mucosa is inadvertently stripped, areas of denuded bone will require a prolonged period for complete healing Caution should be exerted during routine postoperative debridements to avoid extending an area of epithelial loss It has been demonstrated that avulsion of epithelium beneath mucous crusts occurs in 23% of specimens studied during the first postoperative week, yet similar debridement in the second postoperative week did not result in epithelial loss beneath removed crusts.4 Nasal irrigations are emphasized during the first postoperative week, and crusts that obstruct ostia or may lead to synechiae at critical locations are gently removed Areas of exposed bone or firmly adherent crusts along the medial orbital wall are typically removed during the second postoperative week or later, when epitheliazation is more likely to have occurred Maxillary Sinus Natural Ostium Although there remains some disagreement regarding the optimal size of a maxillary antrostomy, the necessity for the surgical antrostomy to connect with the natural ostium is universally accepted Despite this straightforward surgical goal, failure to connect the natural ostium with the surgical antrostomy at the time of operation or as a result of postoperative synechiae formation is among the most common etiologies for failure at the maxillary sinus.5 Retention of parts of the uncinate process involved with osteitis or failure to open the natural ostium will result in continued obstruction of the normal mucociliary clearance Maxillary antrostomies that not connect with the natural ostium can lead to recirculation and recurrent infection of the maxillary sinus as normal mucociliary flow out of the maxillary sinus natural ostium results in re-introduction of mucous through the posteriorly located surgical antrostomy (Figure 8–1) Currently, our preference is to perform a large maxillary antrostomy that extends from the natural ostium anteriorly to the posterior wall of the maxillary sinus, including the vertical and horizontal portions of the uncinate process and the medial maxillary wall superior to the inferior turbinate The general shape of this antrostomy comes to resemble that of a “pear,” with the natural ostium located more anteriorly and superiorly (Figure 8–2).6 Preserving normal mucociliary flow at the natural ostium is a critical step in ensuring good postoperative maxillary sinus outcomes Scar bands, clots, frayed mucosa, or granulation tissue that could develop into synechiae at this location are visualized and removed in the office setting using angled scopes and topical anesthesia In-Office Treatment of Post-Endoscopic Sinus Surgery Issues 69 Instrumentation n Lusk probe n Rotating back-biting forcep (allows management of left and right maxillary sinuses with a single instrument) Figure 8–1. Recirculation at the right maxillary sinus is a result of an iatrogenic synechiae posterior to the natural ostium Thick mucopurulence is noted to leave the natural ostium and flow into the more posteriorly located surgical antrostomy Postoperative care of the maxillary sinus requires the use of rigid sinus endoscopes with angled views The natural ostium of the maxillary sinus cannot be visualized with a 0-degree scope and small synechiae in this location will not be detected (Figure 8–3) The use of a 30-degree scope for a complete postoperative examination is required (Figure 8–4), whereas 45-degree and 70-degree (Figure 8–5) rigid endoscopes will facilitate postoperative surgical interventions Graphic Representation of Idealized Maxillary Antrostomy Natural ostrium of maxillary sinus Surgical antrostomy The surgical antrostomy includes the posterior half of the natural ostium of the maxillary sinus This techinique enlarges the ostium while avoiding operative trauma to the mucosa of the anterior half of the ostium and decreasing the risk of postoperative circumferential synechiae Figure 8–2. Graphic representation of an idealized maxillary antrostomy in which the surgical antrostomy overlaps the posterior 50% of the natural ostium circumference, leaving uninterrupted mucosa of the natural ostium at the anterior 50% of the natural ostium 70 Office-Based Rhinology: Principles and Techniques Figure 8–3. A rigid 0-degree scope allows mucus to be seen entering the surgical antrostomy from an anterior location; however, the natural ostium is not visualized Figure 8–4. The 30-degree rigid endoscope provides an improved view of the natural ostium of the maxillary sinus Topical anesthesia is titrated with consideration for both the patient’s pain threshold and the degree of surgical intervention required Atomized 4% lidocaine/oxymetazoline is usually adequate followed by application of 4% cocaine solution and, if necessary, Figure 8–5. The angle afforded by a 70-degree rigid endoscope enhances the view of the natural ostium of the maxillary sinus and allows back-biting instruments to remove the scar tissue resulting in iatrogenic recirculation phenomenon and recurrent infection of the maxillary sinus injection of 1% lidocaine with 1:100,000 epinephrine into the operative site Severe discomfort could be addressed with pterygopalatine fossa injection with local anesthesia, although this is rarely required Curved ball-tipped probes or maxillary sinus seekers are adequate for palpation of the natural ostium, and can confirm the presence of scarring that has involved the natural ostium Backbiting and through-cutting forceps are vital instruments for cleanly cutting and removing natural ostium synechiae in the postoperative setting (Figure 8–6) The avoidance of mucosal stripping at this critical location during postoperative care is emphasized, as in all endoscopic sinus procedures At present, the large size of the surgical antrostomy performed at our institution precludes the use of balloon catheter technology for postoperative dilation of a narrowed maxillary sinus ostium This technology remains a management option for postoperatively nar- In-Office Treatment of Post-Endoscopic Sinus Surgery Issues 71 Figure 8–6. The double-ball-tipped Lusk probe and rotating, through-cutting back-biting forceps are useful in palpating the natural ostium of the maxillary sinus and removing any scar tissue that obstructs normal mucociliary flow rowed maxillary antrostomy, although the surgeon must ensure that the natural ostium is incorporated by the surgical fenestration to produce the desired results On DVD: Video 1 — Maxillary Recirculation This video demonstrates a sequence of increasingly angled scopes and backbiting instruments used in the office-based management of a patient with isolated, bilateral maxillary sinus disease who underwent surgery at an outside institution Although mature synechiae are addressed in this video, the visualization, surgical maneuvers, and operative goals are identical to postoperative debridement of early synechiae Tips and Pearls n Avoid mucosal stripping, as this would further compromise mucociliary clearance from the maxillary sinus n Angled scopes are required for the postoperative evaluation and surgical management of the natural ostium n The removal of postoperative clots and thick mucocrusts from the natural ostium will help decrease the risk of developing synechiae in this critical site Sphenoid Sinus Ostium Postoperative office-based care of the sphenoid sinus is largely dependent on the size of the sphenoidotomy performed at surgery As with any circumferential wound, the tendency for cicatricial narrowing is great and the need for postoperative care seems inversely proportional to the size of the initial opening It is our practice to remove nearly the entire anterior 72 Office-Based Rhinology: Principles and Techniques wall of the sphenoid sinus during sphenoidotomy, thereby allowing removal of retained material, easy postoperative examination, and wide exposure for postoperative irrigation with medicated washes We have found that the rate of sphenoidotomy stenosis is small to nonexistent when removing the entire face of the sphenoid sinus More common goals for postoperative management include resection of scar tissue at the anterior wall that precludes complete endoscopic examination in tumor cases or if postoperative accumulations of material is noted In the postoperative period, the sphenoid sinus tends to collect large quantities of mucous and blood in that produces occipital or vertex pain and provides a culture medium that is ripe for re-infection Typically, postoperative procedures for the sphenoid sinus requires removal of that blood and mucus Postoperative stenosis of a surgical sphenoidotomy with retention of mucous, CT scan evidence of sphenoid inflammation and symptoms referable to the sphenoid sinus could potentially be addressed with balloon catheter technology; however, it is our preference to maximally widen a narrow sphenoid ostium by using hand instruments for bone removal Instrumentation n 30-degree rigid endoscope n Cutting instruments: straight mushroom punch, small KerrisonRongeur or Hajek-Koffler punch Tips and Pearls n The septal branch of the posterior nasal artery runs along the anterior face of the sphenoid sinus inferior to the natural ostium, and is frequently encountered and coagulated during sphenoidotomy Caution should be exerted in postoperative removal of additional anterior inferior sphenoid wall, as this maneuver can result in arterial bleeding that is difficult to control in the office setting n Palpate for ledges at the anterior sphenoid face and remove only that bone that enters the instrument This allows a clean tissue cut, and avoids rocking, grasping, or twisting motions during bone removal, which has the potential for serious complications within the sphenoid sinus n Review the preoperative CT scan before considering the additional removal of bone in the office setting, as the optic nerve and carotid artery will be dehiscent in a small percentage of patients Middle Turbinate It is difficult to affect large changes in the postoperative position of the middle turbinate Our surgical approach favors preservation and medialization of the middle turbinate with creation of controlled synechiae from the middle turbinate to the nasal septum7 or the use of a middle turbinate suture.8 These methods enlarge the middle meatus during surgery, facilitate postoperative inspection and intervention as well as the penetration of medicated irrigations into the paranasal sinuses Medialization of the middle turbinate to the nasal septum helps decrease the risk for synechiae at a common area for postoperative scarring Although multiple studies have demonstrated that middle turbinate medialization does not impair olfaction,9,10 patient complaints of diminished olfaction or headache that cannot otherwise be explained by endoscopic findings or CT scan, can be treated In-Office Treatment of Post-Endoscopic Sinus Surgery Issues 73 in the office setting by release of the synechiae or suture retaining the turbinate in a medialized position More problematic is lateralization of the middle turbinate such that postoperative inspection is hindered and instrumentation of the paranasal sinuses following surgery is impossible We have used a variety of material as postoperative spacers to preserve the middle meatus: Gelfilm, Gelfoam, Merocel Although lateralization of the middle turbinate can make postoperative endoscopic examinations frustrating, in and of itself, the condition does not require operative intervention If the frontal recess becomes obstructed and inflammation persists as a result of lateralization, revision surgery can be performed, although this is not recommended as an office-based procedure Retained Cells / Retained Bone Fragments Although every effort is made during surgery to remove all ethmoid partitions through the combined advantages of frameless stereotactic navigation and high quality endoscopic visualization, partitions can be found postoperatively and these may require removal in the postoperative setting Before proceeding with removal, a review of the preoperative CT scan is recommended, both for self-evaluation and to remind the surgeon of the location of the anterior ethmoidal arteries and position of the skull base and medial orbital wall Retained partitions that obstruct the egress of normal sinonasal secretions or prevent instillation of medicated irrigations should be addressed Common locations are the supraorbital ethmoid cells, the posterior frontal recess and, to a lesser degree, the inferior aspect of the anterior face of the sphenoid sinus Small partitions that not meet these criteria probably should be left undisturbed unless mucosal edema persists or osteitic changes become apparent on future CT scans Instrumentation n 45-degree through-cut forceps n Frontal sinus through-cut forceps n Giraffe grasping forceps n Blakesley grasping forceps Topical anesthesia and vasoconstriction can be provided as described above for other procedures necessitating bone removal Palpation of ledges with through cutting instruments are critical to ensure that only obstructing prominences of bone are removed and that inadvertent entry into the orbit or skull base does not occur More commonly, a retained fragment of bone resulting from intraoperative surgical cuts can become embedded within the healing mucosa Isolated fragments of bone will serve as a nidus for infection and when detected, should be removed Routine atomized topical anesthetic is sufficient and grasping forceps will release the bone from surrounding mucosa Care should be taken to avoid including mucosa in the forceps when grasping bone fragments, so as to prevent further insult to the surrounding mucosa Frontal Sinusotomy Surgery of the frontal recess is among the most challenging endoscopic sinus procedures, and similarly, the maintenance of a patent and functional frontal sinus ostium postoperatively can be fraught with difficulty The most important steps in maintaining the long term patency of a frontal sinusotomy occur at the time of surgery: removal of all obstructing anterior ethmoidal cells, clearing and 74 Office-Based Rhinology: Principles and Techniques defining the frontal recess boundaries, and avoiding injury to the mucosa of the frontal sinus drainage pathway (FSDP) Preservation of the FSDP is enhanced by placement of a temporary frontal sinus dressing at the conclusion of every frontal sinus operation, which, at our institution, involves Draf IIa/IIb for routine frontal sinusotomy and Draf III for revision operations and tumor resection A 0.5-mm thick piece of Silastic sheeting is cut into the shape of rectangle (15 to 20-mm wide x 30-mm long) with two darts removed at the “shoulders” of the stent (Figure 8–7) The stent is rolled tightly and inserted into the frontal sinusotomy with a pediatric frontal sinus giraffe (see Video 2) The stent acts in much the same way as a semi-occlusive dressing applied to traumatized or recently operated soft tissue Light pressure is exerted against the mucosa of the FSDP and a clear pathway for suctioning of the frontal sinus is provided in the early postoperative period (see Video 3) The frontal sinus dressing is removed 14 days after surgery and a well-mucosalized sinusotomy noted (see Video 4) At this time, maneuvers to address any residual partitions are performed with topical anesthesia (see above) and standard frontal sinus hand instruments Although image guidance and angled scopes are helpful in decreasing the incidence of retained partitions, even widely patent Draf IIa/IIb and III sinusotomies can succumb to the vagaries of wound healing and an unchecked inflammatory response In these instances, the surgeon must be prepared to revise the compromised frontal sinusotomy and, in a compliant patient, this can be performed in the office setting Instruments n 45-degree and 70-degree rigid endoscopes n 90-degree frontal sinus curette n Frontal sinus punch with link chain sheath, backward cutting (Figure 8–8) n Upturned mushroom punch n Small malleable suction Early Frontal Sinus Synechiae Figure 8–7. The frontal sinus dressing is fashioned from 0.5-mm thick Silastic sheeting, rolled into the shape of a tube, and best inserted with a pediatric frontal sinus instrument Clots, thick mucus, and mucosal injury within the frontal recess can result in bridging of this narrow drainage pathway and lead to subsequent formation of cicatricial bands with potential to obstruct the frontal sinus The early identification of obstructing tissue within the frontal recess allows cutting and removal of this soft, fibrinous tissue and prevention of more mature and surgically recalcitrant cicatrix Although a 30-degree rigid endoscope is useful for inspection, most complete frontal sinusotomies will benefit from careful inspection with a more angled scope Instrumentation of the frontal recess should be performed under the guidance of a 45- or 70-degree rigid In-Office Treatment of Post-Endoscopic Sinus Surgery Issues 75 Figure 8–8. Heavily angled, backward-facing instruments that complement the angles afforded by 45-degree and 70-degree endoscopes are used to address the frontal recess endoscope Early synechiae in this location are soft and routinely removed without preprocedure CT scans The posterior wall of the frontal recess can be visualized and backward biting instruments will direct surgical injury away from the skull base, enlarging the FSDP Video Resection of an early synechiae from the left frontal sinusotomy site Mature Frontal Sinus Synechiae Despite performing a wide frontal sinusotomy, circumferential surgical injury and persistent inflammatory disease can result in narrowing or obliteration of the FSDP In these cases, revision is required or obstruction of the frontal sinus and recurrent infection will result The surgeon should maintain a low threshold for obtaining CT scans of the postoperative anatomy and review these triplanar images to better understand the anatomy of the FSDP prior to instrumentation Patient compliance with office-based procedures is critical and, if unlikely, revision in the operating room setting may be necessary Commonly, inspection of the frontal recess with a 70-degree angled endoscope will identify an obvious, though narrowed, FSDP A frontal sinus instrument is useful for palpating the stenosis and confirming the relationship to the frontal sinus A small, malleable suction can be contoured to fit into this location providing both tactile feedback regarding the nature of the stenosis as well as confirmation of a connection into the frontal sinus Backward-biting instruments and upturned mushroom punches are used in sequence to safely remove surrounding cicatrix and enlarge the FSDP When a large percentage of the circumference of the FSDP is traumatized, a customized piece of 0.5-mm thick Silastic 76 Office-Based Rhinology: Principles and Techniques sheeting is placed as a dressing into the operative site for two weeks Oral and topical corticosteroids are initiated and postoperative endoscopic debridements are undertaken in earnest on a weekly basis Those patients with stenosis of large Draf IIa/IIb frontal sinusotomies that require surgical revision may benefit from longer than average courses of corticosteroids postoperatively There may be room for the addition of balloon catheter technology to the officebased surgical options for treating stenosis of a frontal sinusotomy Although this technique is not used in our practice at the present time, one can envision the application of endoscopic dilation techniques for minimally invasive dilation of narrowed drainage pathways Video Mature frontal stenosis in a patient with Samter’s triad who was noncompliant with postoperative medical therapy following revision endoscopic sinus surgery Video Surgical revision of a mature frontal sinus stenosis in a patient with suboptimal postoperative endoscopic inspection and debridements Tips and Pearls n A narrow frontal sinusotomy can be revised in the office setting under local anesthesia with hand instruments, provided the surgeon has excellent understanding of the particular frontal recess anatomy and has reviewed appropriate CT scans n When possible, limit the surgical injury to areas of a scarred frontal recess to prevent further cicatricial changes within the frontal sinus drainage pathway References Thaler, ER Postoperative care after endoscopic sinus surgery Arch Otolaryngol Head Neck Surg 2002;128:1204–1206 Ramakrishnan VR, Suh JD How necessary are postoperative debridements after endoscopic sinus surgery Laryngoscope 2011;121:8–9 Senior, BA, Kennedy DW, Tanabodee J, et al Long-term results of functional endoscopic sinus surgery Laryngoscope 1998;108:151–157 Kuhnel T, Hosemann W, Wagner W, et al How traumatizing is mechanical mucous membrane care after interventions on paranasal sinuses? A histological immunohistochemical study Laryngorhinootologie 1996;75(10):575–579 Richtsmeier WJ Top 10 reasons for endoscopic maxillary sinus surgery failure Laryngo scope 2001;111(11 pt 1):1952–1956 Adappa ND, Kennedy DW Endoscopic maxillary antrostomy: not just a simple procedure Laryngoscope 2011;121 (10):2142–2145 Bolger WE, Kuhn FA, Kennedy DW: Middle turbinate stabilization after functional endoscopic sinus surgery: the controlled synechiae technique Laryngoscope 1999;109: 1852–1853 Lee MR, Marple BF Middle turbinate medialization for improved access during endoscopic sinus surgery Int Forum Allergy Rhinol 2011; 1(3):187–190 Friedman M, Landsberg R, Tanyeri H Middle turbinate medialization and preservation in endoscopic sinus surgery Otolaryngol Head Neck Surg 2000;123:76–80 10 Duton JM, Hinton MJ Middle turbinate suture conchopexy during endoscpic sinus surgery does not impair olfaction Am J Rhinol Allergy 2011;25(1):125–127 142 Office-Based Rhinology: Principles and Techniques irrigated If the nasolacrimal duct is patent, the irrigant will pass down to the nose and the throat Partial or complete obstruction will result in some degree of resistance and reflux of the irrigant Once the cause of the tearing is determined, the appropriate management can then be performed A CT scan can be valuable when evaluating patients with NLDO This is especially valuable if there is likely obstruction in the lacrimal sac, duct, or in the inferior meatus CT can identify pathologies such as nasolacrimal duct orifice cysts, polypoid edema of the inferior meatus, tumors and other invasive processes, and nasolacrimal duct pathology from previous surgery (Figure 15–12) Inferior Meatus Endoscopy The otolaryngologist has the unique capability to endoscopically evaluate the nasal and sinus cavities for causes of epiphora This Figure 15–12. Coronal CT scan showing bilateral polypoid tissue causing nasolacrimal duct obstruction mainly involves endoscopic evaluation of the inferior meatus Endoscopic evaluation of the inferior meatus can be easily performed in the office setting Topical anesthetic and decongestant spray is used to shrink and anesthetize the inferior turbinate This opens up the inferior meatus As the inferior meatus is a very small space, it is preferable to use a smaller endoscope, such as a 30-degree 2.8-mm rigid endoscope This allows a more inferior placement of the scope in the inferior meatus with an upward angle of view to get a good view of the superolateral wall, where the nasolacrimal duct orifice is located If the inferior turbinate is positioned laterally it can be displaced medially Additional anesthetic and decongestant can be applied to the inferior meatus on a cotton pledget The inferior turbinate can then be gently displaced medially with a Freer elevator, taking care not to damage the mucosa and cause bleeding that will obscure visualization Visualization of the nasolacrimal duct orifice is straightforward The nasolacrimal duct orifice is located on the lateral wall of the inferior meatus on a vertical plane with the medial canthus The nasolacrimal duct orifice can appear as an umbilicus type opening or a circular opening, depending on where it is located (see Videos 15–1 and 15–2) If there is NLDO the area may appear edematous or as a bulge, which may represent a nasolacrimal duct orifice cyst Palpation of the lacrimal sac while endoscopically visualizing the nasolacrimal duct orifice area will reveal tears draining from a normal nasolacrimal duct orifice, or in a patient with a distal obstruction may result in a bulging of the lateral wall of the inferior meatus due to compressing the tear column against an obstructed nasolacrimal duct orifice (see Video 15–3) Determining the patency of the lacrimal system requires more than just endoscopic observation in many instances Irrigating saline through the inferior canaliculus while Office-Based Evaluation and Treatment of Epiphora 143 endoscopically visualizing the inferior meatus can also help determine if there is a patent or obstructed nasolacrimal duct orifice Obstruction of the nasolacrimal duct orifice in the inferior meatus has recently been reported Causes include inverted papilloma, dacryolith (Figure 15–13), nasolacrimal duct orifice cysts (Figure 15–14), and mucosal edema (Figure 15–15).1–4 Additional causes that have been identified are inferior meatal scarring (Figure 15–16), polypoid inferior turbinates (see Video 15–4), invasive fungal infections, granulomatous diseases, and previous inferior meatal antrostomy (Figure 15–17) A B Figure 15–13. A A right nasolacrimal duct orifice dacryolith B Same right nasolacrimal duct orifice after dacryolith removal Figure 15–14. Right inferior meatus endoscopy reveals a nasolacrimal duct orifice cyst Figure 15–15. Mucosal edema of the inferior meatus with previous inferior turbinate reduction Coronal CT in Figure 15–12 is from the same patient 144 Office-Based Rhinology: Principles and Techniques Figure 15–16. Left inferior meatus scarring after radiation therapy Figure 15–17. Nasolacrimal duct obstruction as a result of a large inferior meatal antrostomy Inferior meatus pathology has been reported to be very common in patients with epiphora Surgery directed at the inferior meatus is a viable option if pathology is identified at the nasolacrimal duct orifice The results of inferior meatus surgery for nasolacrimal duct orifice obstruction are reported to be very good, with success rates of 90% for distal obstruction only.5 Golub JS, Parikh SL, Bernardino CR, DelGaudio JM Inverted papilloma of the nasolacrimal system invading the orbit Ophth Plast Recon Surg 2007;23:151–153 DelGaudio JM, Wojno T Nasolacrimal duct orifice cysts in adults: a previously unrecognized, easily treatable cause of epiphora Laryngoscope 2007;117(10):1830–1833 Rogers GA, Murchison AP, Wojno TH, DelGaudio JM Inferior meatus endoscopy and directed treatment for epiphora: early experience with a novel approach Otolaryngol Head Neck Surg 2009;140:579–584 Nerad J Techniques in Ophthalmic Plastic Surgery with DVD: A Personal Tutorial Philadelphia, PA: Elsevier; 2009 References Rogers GA, DelGaudio JM Inferior meatus dacryolith: an easily managed cause of epiphora Arch Otolaryngol 2008;134:1110–1111 Index Note: Page numbers in bold reference non-text material A B Abscesses, nasal septum, 97–98 Adenocarcinoma, 32 AFRS (Allergic fungal rhinosinusitis) See Allergic fungal rhinosinusitis (AFRS) Agger nasi cells, 7, 11, 22 Allergic fungal rhinosinusitis (AFRS), CT and, 27–28 Allergic rhinitis, 79–80 American Academy of Otolaryngology chronic rhinosinusitis defined by, 64–65 on image guided surgery, 16 American College of Obstetrics and Gynecology, Anesthesia, 37–38 agents, 52–54 indications/contraindications, 50 inhalation, 57 intravenous, 57–58 local, 51–52, 54–55 NPs and, 105 oral, 57 regional, 55–56 systemic, 56–58 topical, 54 Angled endoscopes, 40–42 ethmoid air cells, 24 artery, 23 complex, fontanelles, 10 frontoethmoid cells, 22 Arterial ligation, epistaxis, 127 Arteries anterior ethmoid, 23 ethmoid, 12 Balloon catheters, 40 Biopsy, nasal, 64–65 Blakesley forceps, 38, 39, 41 Bone exposed, post surgery in-office treatment, 68 fragments, post surgery in-office treatment, 73 Bozzini, Phillip, C Canaliculitis, 139 Cartilage quadrangular, 5, 89 upper/lower lateral, Catheters, balloon, 40 Cells, retained, post surgery in-office treatment, 73 Children, paranasal sinuses and, 10 Chondrosarcoma, 32 Chronic rhinosinustis (CRS) NPs and, 101 post surgery in-office treatment, 67–76 Churg-Strauss syndrome, 92 Clinoidectomy, CSF leaks and, 25 Coblation, 83–85, 105 Cocaine as anesthesia, 92 as anesthetic, 38, 54 Computer tomography (CT) See CT (Computer tomography) Concha bullosa, Conchae See Turbinates Contrast CT and, 16 ordering with MRIs, 27 Co-phenylcaine Forte™, 54 146 Office-Based Rhinology: Principles and Techniques Cribriform plates, 24 CRS (Chronic rhinosinustis) See Chronic rhinosinustis (CRS) CRSwNP, 102 Cryotherapy, 82 CSF leaks, 24–25 clinoidectomy and, 25 fibro-osseous lesions and, 29–30 CSF rhinorrhea, image guided surgery and, 16 CT (Computer tomography), 15–16, 32–34 allergic fungal rhinosinusitis (AFRS) and, 27–28 encephalocele and, 28–29 ethmoid sinuses, 24–25 fibro-osseous lesions and, 29–30 frontal sinus, 21–23 maxillary sinus, 20–21 mucocele and, 27, 110 NPs and, 103 nasal cavity, 17–20 review of, 16–26 sinonasal malignancies and, 32–34 sphenoid sinuses, 25–26 tumors/tumor like conditions, 26–34 use of contrast with, 16 vascular tumors and, 31 Cystic fibrosis, 22 sphenoid sinuses and, 25 D Dacrocystitis, 139 DDT (Dye disappearance test) See Dye disappearance test (DDT) Decongestion, 54 Desormeaux, Antoine Jean, Distorted sinus surgery, image guided, 16 Drug-eluting stents, 40 Dye disappearance test (DDT), 140 E Early frontal sinus synechiae, post surgery in-office treatment, 73–74 Ectropion, 139 Edison, Thomas, Electrocautery, 82–83 EMLA™, 53 Encephalocele, CT and, 28–29 Endoscopes, 40–42, 105 Endoscopic sinus surgery (ESS), 67, 102 Endoscopy history of nose/paranasal sinuses, 2–3 inferior meatus, 142–144 nasal, 61–65 NPs and, 102 Entropion, 140 Epinephrine, 54, 92 Epiphora defined, 137 diagnostic tests, 140–142 examination and, 139–140 treatment of, 137–144 Epistaxis, 42, 120 anatomy of surgical relevant, 118–119 vascular, 117–118 arterial ligation, 127 causes of, 120 childhood, 126 etiology of, 119–122 management of, 122–127 examination, 123 hospital based, 126–127 office-based, 123–126 positioning, 123 nasal septum, 93–94 posterior, 118 potentiation factors, 119–122 treatments direct, 124–125 indirect, 125–126 Equipment, 38–43 ESS (Endoscopic sinus surgery) See Endoscopic sinus surgery (ESS) Esthesioneuroblastoma, 32 Ethmoid air cells, 24 arteries, 12 bone, Ethoid bulla, 8, 22 cells, infraorbital, 10 complex, 8–9 infundibulum, mucoceles, 112–113 roof, 24 sinuses, CT of, 24–25 Index 147 Eutectic measures of local anesthetics (EMLA) See EMLA™ External nerve block, 55 Eye, examination, 140 F FESS (Functional endoscopic sinus surgery) See Functional endoscopic sinus surgery (FESS) Fibro-osseous lesions, CT and, 29–30 Forceps, 38 Fovea ethmoidalis, 24 Fractures, nose, 129–134 Frazier suctions, 38, 39, 92 Frontal bone, bulla cells, 11, 23 cells, 11 intersinus septal cell, 11 mucoceles, 114 recess, 10–11 anatomy of, 21–22 sinus, 10–11 CT of, 21–23 ostium, synechiae, post surgery in-office treatment, 73–76 sinusotomy, post surgery in-office treatment, 73–74 Frontoethmoid cells, 22 Functional endoscopic sinus surgery (FESS), Fungal rhinosinusitis, allergic, 27–28 G Gardner’s syndrome, 29 German Society of Physicians, Goetze, Otto, Greater palatine nerve block, 56 H Haller cells, 8, 10 Hartmann forceps, 38 Hasson, H M., Headaches contact point, 98 fibro-osseous lesions and, 29–30 Hematoma, nasal septum, 96–97 Hemophilus influenzae, 97 Hemostasis, NPs and, 105 Hiatus semilunaris, Hirschmann, Alfred, HIS (International Classification of Headache Disorders) See International Classification of Headache Disorders (HIS) Hopkins, Harold H., Hypertrophy of turbinates medical treatment of, 81 surgical treatment of, 82–85 I Image guided surgery, American Academy of Otolaryngology and, 16 Imaging mucoceles, 110 NPs and, 103 Infections, septal, 90 Inferior meatus endoscopy, 142–144 Inferior turbinate, reduction, office-based, 77–87 Inflammations, septal, 90 Informed consent, 47–48, 105 Infraorbital ethmoid cells, 8, 10 Infraorbital nerve block, 55–56 Infundibulum, maxillary bone and, Inhalation anesthesia, 57 In-office treatment, post surgery, 67–76 Instruments, 38–39 International Classification of Headache Disorders (HIS), 98 Intralamellar cell, Intravenous anesthesia, 57–58 Inverted papilloma, CT and, 32 J Jacobaeus, Hans Christian, K Kalk, Heinz, Kennedy, David, Keros classification system, 12 Kiesselbach’s plexus, 90 148 Office-Based Rhinology: Principles and Techniques L Lacrimal bones, Lacrimal system anatomy of, 137–138 probing/irrigation, 140 Lamina papyracea, 8, 24 Laparascopy, “Laparathorakoskopie,” Laser surgery, 83 Lateral lamella, thin, 24 Lesions, fibro-osseous, CT and, 29–30 Lespinasse, Victor Darwin, Lichtleiter, Lidocaine, 52, 92 pellets, 53–54 Lignocaine, 52 Lindholt Method, 102 Local anesthesia, 51–52, 54–55 Lower lateral cartilage, Lund and Mackay Method, 102 Lund-Kennedy scoring system, 63, 64 Lymphoma, 32 pneumatization of, post surgery in-office treatment, 72–73 Mouret, Phillip, MRI (magnetic resonance imaging), 16 mucoceles, 110 NPs and, 103 ordering with contrast, 27 Mucoceles CT and 27 defined, 109 diagnosis of, 109–110 drainage of advantages, 114 disadvantages of, 116 ethmoid, 112–113 frontal, 114 imaging, 110 management of, 109–116 maxillary, 110–112 sphenoid, 113–114 Mucosal contact point headache, 98 Mushroom punch, 38, 41 Mycobacterium tuberculosis, M N Magnetic resonance imaging (MRI) See MRI (magnetic resonance imaging) Malignancies, sinonasal, CT and, 32–34 Mature frontal sinus synechiae, post surgery in-office treatment, 75–76 Maxilla, Maxillary bone, infundibulum and, mucoceles, 110–112 sinus, 9–10 CT of, 20–21 post surgery in-office treatment, 68–71 Medial turbinate, Melanoma, sinonasal, 32 Messerklinger, Walter, Methoxyflurane, 57 Microdebrider reduction, 85 Microdebriders, 105 Middle meatus, 6–7 Middle turbinate, 5–6, 85–86 ethmoid arteries and, 12 ethmoid complex and, Nasal biopsy, 64–65 bones, cavity CT of, 17–20 structural framework of, 5–6 cycle, 79 endoscopy, 61–65 ervous system, 49–51 obstructions, 79 packs, anesthetic-soaked, 54 polypectomy, 101–107 polyposis (NPs) chronic rhinosinustis (CRS) and, 101 described, 101 endoscopic staging of, 102 pathophysiology of, 101 presentation/diagnosis, 102 treatment of, 103–104 polyps, 80 septum, abscess, 97–98 Index 149 anatomy of, 89–90 biopsy, 92 contact point headache, 98 epistaxis, 93–94 evaluation/diagnosis of, 90–92 hematoma, 96–97 masses, 92–93 medical management of, 89–98 pathologies of, 90 perforation, 94–96 Natural ostium, post surgery in-office treatment, 68–71 Neoplasms septal, 90 sinonasal, image guided surgery and, 16 Nerve block external, 55 greater palatine, 56 infraorbital, 55–56 Nervous system, nasal, 49–51 Nitze, Maximilian, Nodal disease, 32 Nose anatomy of, 130 fractures, 129–134 complications, 134 management of, 131–134 history of endoscopy of, 2–3 NPs (Nasal polyposis) See Nasal polyposis (NPs) O Office procedures, 37–43 Olive-tipped suctions, 39, 41 Onodi cell, 9, 25 Oral anesthesia, 57 Orbital fat, herniation of, 24 Ostium, 25–26 Otologic suctions, 39 Otologic wax curettes, 39 Oxycodone, 57 Oxymetazoline, 54 P Packing epistaxis absorbable/degradable, 125–126 nonabsorbable, 125 Palatine nerve block, 56 Palmer, Raoul, Papilloma, CT and, 32 Paranasal sinus mucocele See Mucoceles Paranasal sinuses children and, 10 history of endoscopy of, 2–3 structural framework of, 5–6 Patient selection, 45–47 Penthro™, 57 Perforation, nasal septum, 94–96 Phenylephrine, 54, 92 Pneumatization of middle turbinate, sphenoid sinuses and, 25 Pneumocephalus, fibro-osseous lesions and, 29–30 Pneumoperitoneum, Polypoid degeneration, 80 Post surgery in-office treatment, 67–76 exposed bone, 68 Posterior ethmoid air cells, 24 cell, complex, superior turbinate and, image guided surgery and, 16 fontanelles, 10 frontoethmoid cells, 24 Q Quadrangular cartilage, 5, 89 R Radiofrequency ablation, 83–85 Regional anesthesia, 55–56 Reichert, M., Reiner, Carl, Retraction, 139 Revision sinus surgery, image guided, 16 Rhinosinusitis defined by American Academy of Otolaryngology, 64–65 grading of, 63–64 post surgery in-office treatment, 67–76 150 Office-Based Rhinology: Principles and Techniques Room setup, 42–43 Ropivacaine, 53 S Semm, Kurt, Septum, nasal See Nasal septum Sinonasal endoscopy, melanoma, 32 neoplasms image guided surgery and, 16 malignant, CT and, 32–34 polyposis, image guided surgery and, 16 Sinus obstruction, fibro-osseous lesions and, 29–30 Sinus surgery, image guided, 16 Sinuses early frontal synechiae, post surgery in-office treatment, 73–74 ethmoid, 9–10 frontal, 10–11 ostium, maxillary, 9–10 paranasal, history of endoscopy of, 2–3 sphenoid, 11–12 Sinusotomy, frontal, post surgery in-office treatment, 73–74 Skull, base of, 12, 24 Sphenoethmoidal cell, 9, 25 Sphenoid bone, mucoceles, 113–114 sinus, 11–12 sinuses CT of, 25–26 image guided surgery and, 16 ostium, post surgery in-office treatment, 71–72 Sphenopalatine artery, 118 Spiess, Kremer M., Squamous cell carcinoma, 32 Stammberger, Heinz, Staphylococcus aureus, 97, 101 Stents, drug-eluting, 40 Storz, Karl, Streptococcus, 97 Streptococcus pneumoniae, 97 Superior turbinate, 5–6 Suprabullar cells, 11, 23 recess, 11 Supraorbital ethmoid cells, 8, 23 Supreme turbinate, Surgery, image guided, 16 Synechiae early frontal sinus, post surgery in-office treatment, 73–74 mature frontal sinus, post surgery in-office treatment, 75–76 Systemic anesthesia, 56–58 T Tetracaine, 52, 92 Topical anesthesia, 54 Trendelenburg position, Tumors, CT and, 26–34 Turbinates, 5–6 anatomy of, 77–78 dysfunction, 79–81 hypertrophy of, 80 medical treatment of, 81 surgical treatment of, 82–85 inferior, reduction, 77–87 middle, 5–6, 85–86 post surgery in-office treatment, 72–73 physiology, 79 post operative care, 86–87 U Uncinate process, 6–7 Upper lateral cartilage, V Vascular tumors, CT and, 31 Vasoconstriction, 54 Vasomotor rhinitis, 80 Veress, Janos, Vomer bone, W Wegener’s granulomatosis, 92 Woodruff ’s plexus, 118 Index 151 X Z Xylocaine, 52 Xylometazoline, 92 Zero degree endoscopes, 40–42 Zygomatic bones, ...68 Office-Based Rhinology: Principles and Techniques assessment of patient factors, anatomic findings, extent of the operation, and the inflammatory state at the time of surgery and during... obstructing anterior ethmoidal cells, clearing and 74 Office-Based Rhinology: Principles and Techniques defining the frontal recess boundaries, and avoiding injury to the mucosa of the frontal... Silastic 76 Office-Based Rhinology: Principles and Techniques sheeting is placed as a dressing into the operative site for two weeks Oral and topical corticosteroids are initiated and postoperative