While atlases of endoscopic sinus surgery are numerous, there is a serious knowledge gap created by the lack of a comprehensive, uptodate atlas dedicated to office diagnostic nasal endoscopy. The first and only such atlas, written in German and translated in 1978, is sadly out of date. Filling this gap, An Atlas of Diagnostic Nasal Endoscopy illustrates all variants of normal intranasal anatomy and pathologies seen through nasal endoscopy. Developed by an author with more than fifteen years of experience, the book features more than 600 pictures of normal and abnormal findings of nasal endoscopy. Captioned with arrows and legends, each photograph provides a clear and independent teaching message. This format allows the reader to easily find the information they need without wading through information they dont. The author also supplies clear, concise expository text that provides background information for each chapter. The user friendly format and comprehensive coverage of the normal variants of intranasal anatomy and the many abnormal pathologies encountered in clinical practice make An Atlas of Diagnostic Nasal Endoscopy an important resource for all trainees, practitioners, and teachers of otolaryngology, and practitioners and specialists interested in sinus disorders.
Cover Page i An Atlas of DIAGNOSTIC NASAL ENDOSCOPY Page ii This page intentionally left blank Page iii THE ENCYCLOPEDIA OF VISUAL MEDICINE SERIES An Atlas of DIAGNOSTIC NASAL ENDOSCOPY Salah D.Salman, MD, FACS Surgeon Director of the Sinus Center Massachusetts Eye and Ear Infirmary Lecturer, Department of Otology & Laryngology Harvard Medical School Boston, Massachusetts, USA Formerly Professor & Chairman, Department of Otolaryngology American University of Beirut Lebanon The Parthenon Publishing Group International Publishers in Medicine, Science & Technology A CRC PRESS COMPANY BOCA RATON LONDON NEW YORK WASHINGTON, D.C Page iv Published in the USA by The Parthenon Publishing Group Inc. 345 Park Avenue South, 10th Floor New York NY 10010 USA Published in the UK and Europe by The Parthenon Publishing Group 23–25 Blades Court Deodar Road London SW15 2NU UK Copyright © 2004 The Parthenon Publishing Group Library of Congress CataloginginPublication Data Data available on application British Library Cataloguing in Publication Data Salman, Salah D. An atlas of diagnostic nasal endoscopy.—(The encyclopedia of visual medicine series) 1. Nasoscopy—Atlases 2. Nose—Diseases—Diagnosis—Atlases I. Title 616.2′1207545 ISBN 0203490606 Master ebook ISBN ISBN 0203623932 (OEB Format) ISBN 184214233X (Print Edition) First published in 2004 This edition published in the Taylor & Francis eLibrary, 2005. To purchase your own copy of this or any of Taylor & Francis or Routledge’s collection of thousands of eBooks please go to www.eBookstore.tandf.co.uk. No part of this book may be reproduced in any form without permission from the publishers except for the quotation of brief passages for the purposes of review Composition by The Parthenon Publishing Group Page v Contents Introduction SECTION I: NORMAL AND VARIANTS Chapter 1. The nostrils and the anterior nasal cavities Chapter 2. The normal septum 13 Chapter 3. The olfactory slits Chapter 4. The floor of the nose and the inferior meati 19 23 Chapter 5. The inferior turbinates Chapter 6. The middle meati and the agger nasi 29 35 Chapter 7. The middle turbinates Chapter 8. The superior turbinates and meati 45 53 Chapter 9. The sinus ostia Chapter 10. The posterior choanae Chapter 11. The mucociliary clearance 59 65 69 Chapter 12. Peculiarities of the nasal cavities 73 83 SECTION 2: PATHOLOGY Chapter 13. The abnormal septum Chapter 14. Epistaxis 85 95 Chapter 15. Rhinosinusitis Chapter 16. Polyps 99 109 Page vi Chapter 17. Systemic diseases 121 Chapter 18. Miscellaneous 129 Chapter 19. Tumors 139 Chapter 20. Operative pictures 157 Chapter 21. Postoperative pictures 169 Chapter 22. Pathologies likely to be missed without nasal endoscopy 183 195 Index Page vii Acknowledgements I am grateful to Rich Cortese of the Department of OtolaryngologyHead and Neck Surgery at the Massachusetts Eye and Ear Infirmary for his help with image preparation This Atlas would not have been possible without Linda Sheehan, RN, Jenecia George, medical assistant, and Mary Tassy, RN, whose dedication, patience, and friendship over so many years facilitated the taking of hundreds of endoscopic pictures, even during very busy clinics I am also grateful for the editorial work graciously provided by Helena Kurban, Terry and Najla Prothro. Page viii This work is dedicated to the memory of my parents who first introduced me to the pleasure of giving. My father Dr Daoud Salman gave daily at home and in his clinical work. My mother Zahia Salman gave abundantly to six of us and later to the children of Lebanon. Page 1 Introduction The introduction of the Hopkins fiberoptic telescope into offices and operating rooms must be credited for major advances in the diagnosis and the treatment of rhinological disorders. Their routine office use, which the author strongly advocates, has permitted the appreciation of the quite variable intranasal anatomy, and the early recognition and diagnosis of abnormalities and pathologies encountered in the practice of Otolaryngology and Rhinology. Atlases of endoscopic sinus surgery and ENT endoscopy are numerous, but libraries are still lacking a comprehensive uptodate atlas dedicated to nasal endoscopy. The first and only such atlas, written in German by Walter Messerklinger of Graz, Austria, was translated into English in 1978. It is hoped that this work fills the gap and becomes a base upon which to build, so that all possible variants and pathologies seen on nasal endosopy become recognizable. The aim of this Atlas is to familiarize the readers with the numerous normal variants of intranasal anatomy, and with many abnormalities and pathologies encountered in clinical practice. The emphasis is on recognition of the normal, the normal variants, and the pathology as well as on diagnosis. This Atlas does not discuss treatment. The pictures shown were all taken by the author over a 15year period, during his practice at a major tertiary care referral center, the Massachusetts Eye and Ear Infirmary in Boston, Massachusetts. Each picture, with its concise caption, carries a clear and independent teaching message. The format adopted allows leisurely reading. Page 185 Figure 22.7 Two streaks of pus (short arrows) moving posteriorly and coming out of a right middle meatal antrostomy (long arrow), and an anterior ethmoid cell (arrowhead) Figure 22.8 A granular area (short arrow) on the medial part of the right inferior turbinate in a patient diagnosed with a common cold. The long arrow points to the middle turbinate, and the arrowhead to the septum. A week later, this area was no longer seen and the mucosa appeared normal. This picture illustrates the rare condition of a circumscribed rhinitis Figure 22.9 A soft bulge of a recurrent left frontoethmoid mucocele in a patient who had undergone, many years before, an external ethmoidectomy for a mucocele Figure 22.10 CT scans of the patient in Figure 22.9 showing the mucocele (short arrows) and the defect in the medial orbital wall (long arrows) resulting from the previously performed external ethmoidectomy Page 186 Figure 22.11 A homeless man presented with a left superior orbital swelling of 3 months’ duration Figure 22.12 A nasal endoscopy of the patient in Figure 22.11 showed a soft swelling in the left frontal recess (short arrow), and a streak of pus (long arrow) between the swelling and the middle turbinate (arrowhead) Figure 22.13 The CT scan of the same patient as in Figures 22.11 and 22.12 showed the mucocele expanding into the upper part of the left orbit Figure 22.14 Purulence (short arrow) and a crust (long arrow) blocking a left middle meatal antrostomy. The arrowhead points to the middle turbinate Figure 22.15 A fungus ball (short arrow) appearing through a right middle meatal antrostomy. The long arrow points to the inferior turbinate. Note that the middle turbinate had been resected Page 187 Figure 22.16 A cicatricial chronic ethmoiditis on the left side following multiple surgeries for chronic sinusitis. The short arrows point to the small abscesses and the long arrow to the septum. Note that the middle turbinate is missing. This patient grew methicillin resistant S. aureus repeatedly and failed to respond to the appropriate antibiotics Figure 22.17 Another patient with a cicatricial chronic ethmoiditis following multiple surgeries. The short arrow points to an obvious small abscess and the long arrow to the left middle turbinate Figure 22.18 A single polyp (short arrow) in the left frontal recess responsible for recurrent frontal sinusitis. The long arrow points to the middle turbinate Figure 22.19 A more discrete single polyp (short arrow) in the right frontal recess. The long arrow points to the middle turbinate Page 188 Figure 22.20 Two polyps (short arrows) in the left frontal recess. The long arrow points to the septum and the arrowhead to the middle turbinate Figure 22.21 A fleshy polyp (short arrow) lateral to the left middle turbinate (long arrow). A biopsy is needed to differentiate a fleshy polyp from an inverted papilloma Figure 22.22 Two polyps (short arrows) in the posterior ethmoid cavity on the left. Note the large ostium of the concha bullosa which contained a polyp (long arrow) Figure 22.23 Polyps (short arrows) in the right olfactory area, between the septum (long arrow) and the middle turbinate (arrowhead). Similar polyps were found on the left. This patient with chronic nasal allergies presented with anosmia as her only symptom. No other polyps were seen on endoscopy Figure 22.24 A small polyp (short arrow) in the left sphenoethmoid recess. The long arrow points to the natural sphenoid ostium Page 189 Figure 22.25 A sessile polyp arising from the lower border of the right inferior turbinate Figure 22.26 A polyp (short arrow) seen through a left nasoantral window. The long arrow points to the inferior turbinate Figure 22.27 A retention cyst or a polyp (short arrow) filling the right maxillary sinus and seen through a posterior accessory ostium. The long arrow points to the middle turbinate Figure 22.28 A retention cyst (short arrow) coming out of a right middle meatal antrostomy. It was opened and emptied painlessly in the office. It is not always easy to differentiate a cyst from a polyp on nasal endoscopy. The long arrow points to the middle turbinate Page 190 Figure 22.29 A patient with recurrent nasal polyposis who had undergone multiple surgeries including a right CaldwellLuc 20 years before. She presented with a dull pain over the right maxillary sinus. Endoscopy revealed a soft swelling (short arrow) over the right inferior turbinate (long arrow) Figure 22.30 The CT scan of the patient in Figure 22.29 showed that the swelling was due to a maxillary mucocele, a known very late complication of the CaldwellLuc operation Figure 22.31 A firm swelling (short arrow) below the right inferior turbinate (long arrow), discovered incidentally in a patient with no rhinological symptoms Figure 22.32 The CT scan of the patient in Figure 22.31 showed a cyst which proved to be a recurrent radicular cyst Page 191 Figure 22.33 An adult with a history of right nasal congestion and cheek discomfort. Nasal endoscopy revealed a soft bulge (short arrow) in the inferior meatus, displacing the inferior turbinate (long arrow) superiorly Figure 22.34 The CT scan of the patient in Figure 22.33 showed a cyst which proved to be odontogenic Figure 22.35 A small capillary hemangioma on the left middle turbinate Figure 22.36 A 50yearold male with a few months’ history of left epistaxis on noseblowing. Endoscopy showed a blood streak (short arrow) coming out of the lower aspect of the hiatus semilunaris. The long arrow points to the middle turbinate and the arrowhead to the uncinate process. This patient proved to be suffering from an ameloblastoma of the maxilla. (Courtesy of Dr Nicolas Busaba) Page 192 Figure 22.37 A bilobed fleshy polyp in the roof of the anterior right nasal cavity. It proved to be a hamartoma Figure 22.38 A recurrent inverted papilloma 10 years after a left medial maxillectomy Figure 22.39 An adult patient with sudden right eye blindness. She had been treated for years for allergies. A CT scan showed a mass invading the orbital apex Figure 22.40 Nasal endoscopy on the patient in Figure 22.39 revealed a fleshy polypoid mass filling the upper third of the right nasal cavity. On biopsy, it proved to be a squamous cell carcinoma arising within an inverted papilloma Page 193 Figure 22.41 Significant adhesions (short arrows) lateral to the right middle turbinate (long arrow) several weeks following endoscopic sinus surgery Figure 22.42 Moderate adhesions (short arrows) between the septum and the right middle turbinate following a septoplasty. The long arrow points to a small septal perforation Figure 22.43 Significant adhesions (short arrows) between the septum (long arrow) and the left middle turbinate (arrowhead) following a septorhinoplasty. Similar adhesions were also found on the right side. The patient’s only complaint was anosmia Page 194 Figure 22.44 A total stenosis of the right middle meatal antrostomy. The arrow points to the stump of a partially resected middle turbinate Figure 22.45 A retracted left posterior fontanelle (short arrow) in a case of maxillary atelectasis. The long arrow points to the bulla ethmoidalis, and the arrowhead to the middle turbinate Figure 22.46 An adult with a chronic and resistant left nasal blockage. Nasal endoscopy revealed a long bony structure (short arrow) hanging from the left sphenoethmoid recess toward the nasopharynx. Its lower end was polypoid (long arrow) Figure 22.47 The polypoid end (short arrow) of the bony structure in Figure 22.46 could also be seen from the right side. The long arrow points to the posterior edge of the vomer Figure 22.48 A CT scan showed the structure in Figures 22.46 and 22.47 to be tubular. It was excised. It proved to be a part of the middle turbinate which failed to be resected properly. It must have been pushed toward the nasopharynx and kept there. The patient’s nasal blockage improved after surgery Page 195 Index abscess 107, 187 adenocarcinoma, nasopharyngeal 134 adenoids 24, 65, 67 adhesions 98, 105, 170, 179–180, 193 anosmia/hyposmia and 19 prevention 162 agger nasi 20, 35–38, 132 ostia 62, 70 AIDS 140, 154 allergies 19, 29, 90, 153 allergic fungal mucin 104, 117, 160–161 polyps and 109, 119, 188 rhinosinusitis and 99 ameloblastoma 148, 191 angiofibroma 95, 148 angioma 93, 124 anosmia 19, 21, 119, 188 anticoagulants, epistaxis and 95 antrostomy inferior meatal 27, 69, 72, 101, 136, 169, 171–173 middle meatal 69, 70, 72, 105–106, 169, 171–173 obstruction 105–106, 180, 186 retention cyst 189 stenosis 105, 165, 173, 194 stenting 157, 182 aspirin 175, 181 epistaxis and 95, 97 atelectasis, maxillary sinus 75–76, 102, 194 benign mixed tumor 147 bifid uvula 18 blockage see nasal blockage blood dyscrasias 95 ‘Breath Right’ strips 7, 9 bulla ethmoidalis 35, 38–42, 49, 50 cyst 42 mucosal hypertrophy 78 ostium 63 polyp 112–113 carcinoma 140 squamous cell 77, 140, 151–153, 192 cauterization 96–98 cerebrospinal fluid leak 182 choanae atresia 65 polyp 114–115 posterior 65–67, 134 folds 65 stenosis 65, 67, 134 cleft palate 18, 23, 51, 77, 114 submucous 73, 76 cocaine abuse 77 concha bullosa 45, 47, 50, 59, 63, 158 crushed 73, 79, 157, 158 mucocele 163 ostium 63 sinusitis and 103, 157 congestion 11, 19, 30, 109, 191 allergy and 90 nasal cycle 73–74 ‘cookiebite’ deformity 33, 48 cottonoid fungus colonization 136 cranial base defects 157 cyst bulla ethmoidalis 42 Page 196 nasoalveolar 132 odontogenic 191 radicular 190 see also retention cyst cystic fibrosis 69, 86 dacryocystorhinostomy 27, 137 diplopia 151 ecchymosis 181 epistaxis 23, 95–98, 127 ameloblastoma and 148, 191 nasopharyngeal angiofibroma and 148 plasmacytoma and 153 prominent vessels and 13, 86, 95, 96, 98 pyogenic granuloma and 145 septal perforations and 86 squamous cell carcinoma and 152 esthesioneuroblastoma 19 ethmoid cell ostia 62, 64, 101 ethmoid sinus abscess 107 cavity 174–175 inverted papilloma 166 mucocele 164, 185 osteoma 142–143, 163 ostia 54, 62 polyps 109, 117, 118, 175, 188 sinusitis 103, 105, 107 ethmoidectomy 20, 105, 106, 116–117 postoperative 169, 181, 185 scarring and 167 stenting and 157 ethmoiditis, chronic cicatricial 107, 187 eustachian tube orifice 70, 71 exophthalmos 151 eyeball displacement mucocele and 107 polyps and 109 facial paralysis 7 FES stent 162, 182 fibroma, cementifying ossifying 133 floor of the nose 23–24 fontanelle anterior 38, 43 posterior 42, 43, 194 foreign body 130–131 fovea ethmoidalis 166 defect 166 fracture 11, 130 frontal recess polyps 103, 112, 116, 187–188 frontal sinus mucocele 99, 106, 107, 185 ostium 59 sinusitis 103, 133, 187 frontal sinusotomy 157, 166–167, 169–170, 181 functional endoscopic sinus surgery (FESS) 35, 69 fungus ball 104, 157, 160, 186 graft 93, 166, 182 Graves’ disease 137, 165, 180 hamartoma 139, 141, 192 Hasner’s valve 23, 25 missing/incompetent 23, 25 headache chronic 86, 164–165 following sinus surgery 107 hemangioma 139, 144–145 capillary 139, 144–145, 146, 191 cavernous 139, 145, 146 nasal pregnancy tumors 139, 146 hematoma 161 septal 91 hereditary hemorrhagic telangiectasia 124 hiatus semilunaris 35, 39 human papillomavirus 139 hypertelorism 109, 119 hypertension 95 hypohidropic ectodermal dysplasia 122 hyposmia 19, 21 infections 19, 29 sinusitis 107 Kiesselbach’s plexus 95 Klebsiella ozaenae 127 Little’s area 95 lymphoma 140, 154 Page 197 natural killer (NK) cell 154–155 Lynch procedure 107 makeup powder 136 mastocytosis 161 maxillary sinus 33–34 atelectasis 75–76, 102, 194 mucocele 190 mucociliary clearance 69 mucopyocele 159–160 osteoma 143 ostia 59, 60, 69, 159 accessory 34, 59–61, 69, 71–72, 76, 101 pneumosinus dilatans bilateral 42 unilateral 43 polyps 116, 169, 173, 189 pseudocysts 169, 173 pyocele 102, 184 retention cyst 189 sinusitis 69, 99, 104–105, 165 maxillectomy, medial 23, 27 meatus inferior 23–27, 33, 61, 173 fibrous nodularities 136 polyp 115–116 middle 35–43, 62 fibrous nodule 172 polyps 103, 110–112, 117, 118, 172 superior 53, 57 polyp 110–111 melanoma, malignant 155 mucocele 163, 165, 185, 186 ethmoid sinus 164 frontal sinus 99, 106, 107 maxillary sinus 190 mucociliary clearance 69–72 mucopyocele 157, 159–160 mucosa cranial base defect repair 157 inferior turbinate 29, 30 nasal 5, 13 olfactory 19, 20 septal 13 grooves and folds 13–15 swelling 15 mucosal contact 86 mucus 69–70, 72 nasal blockage 85–86, 194 benign mixed tumor 147 by agger nasi 37 cavernous hemangioma 146 fracture and 11 hamartoma 141 hematoma 161 mucocele 163 nasopharyngeal adenocarcinoma 134 polyps 109 pyogenic granuloma 145 septal deviation 85, 87 squamous cell carcinoma 152 nasal cavities anterior 7 peculiarities 73–80 rhinolith 131 nasal cycle 29, 73–74, 79–80 nasal mucosa 5, 13 nasal obstruction see nasal blockage nasal polyps see polyps nasal pregnancy tumors 139, 146 nasal valve 7, 9 nasoalveolar cyst 132 nasoantral window 27, 69, 72, 101, 136, 169, 173–174 nasofrontal duct blockage 133, 167–168 reconstructed 176 nasolacrimal duct 23, 25–26 nasopharyngitis 66 neoturbinate 32 nose bleeds see epistaxis nosepicking 10, 89 epistaxis and 95, 96 nostrils 7–8 obstruction see nasal blockage odontogenic cyst 191 olfactory fibers 19 olfactory mucosa 19, 20 olfactory slits 19–21 scarring 19, 21 Page 198 orbital decompression 137, 165, 180 orbital fat 137, 165 organ of Jacobson 17 OslerWeberRendu syndrome 86, 93, 124 osteoma 139, 142–144 ethmoid 142–143, 163 maxillary 143 reactive 144 osteomeatal complex (OMC) 35 packing 97 palate, cleft see cleft palate papilloma 10, 139–140, 149–151 fungiform 139, 151 inverted 83, 95, 139–140, 149–150, 166, 192 pemphigoid disease 86, 92 cicatricial 123 pemphigus 11 Penrose drain 168 plasmacytoma 153–154 plicae septi see septal turbinates pneumosinus dilatans bilateral 42 unilateral 43 polyps 19, 73, 109–119 antrochoanal 114–115 bulla ethmoidalis 112–113 ethmoid sinus 109, 117, 118, 175, 188 frontal recess 103, 112, 116, 187–188 inferior meatus 115–116 inferior turbinate 24, 30–31, 115–116, 118, 189 inflammatory 83 maxillary sinus 116, 169, 173, 189 middle meatus 103, 110–112, 117, 118, 172 middle turbinate 45, 51, 62, 112, 114 pedunculated 113, 115 pseudocystic degeneration 117 recurrent 104, 109, 116–118, 161, 190 septal 17, 92, 111 sessile 111–114, 117, 189 sphenoethmoid recess 57, 188 superior meatus 53, 57, 110–111 superior turbinate 113 uncinate process 113 pseudocysts 169, 173 Pseudomonas infection 107 pus 69–72, 136, 184–186 sinusitis and 100–101, 103, 105–107, 164 pustule 17 pyocele, maxillary 102, 184 pyogenic granuloma 139, 145 radicular cyst 190 retention cyst 53, 169, 172 ethmoid cavity 175 in polyp 110 maxillary sinus 189 middle meatal antrostomy 189 septal 92 sphenoethmoid recess 56 rhinitis atrophic 73, 85, 127 circumscribed 185 vasomotor 29, 74 rhinitis sicca 122 rhinolith 131 rhinoscleroma 127 rhinosinusitis 99 see also sinusitis S. aureus (MRSA) 107, 187 sarcoidosis 83, 91, 121, 122 scarring 134, 167, 171, 177 olfactory slit 19, 21 schneiderian membrane 139 scleroderma 86, 93, 124 septal concavity 89 septal deviation 7, 9–10, 13–14, 16, 73, 85–87, 89 septal dislocation 10, 13 septal mucosa 13 grooves and folds 13–15 swelling 15 septal perforation 73, 77, 86, 91, 193 sarcoidosis and 122 squamous cell carcinoma and 152 septal polyps 17, 92, 111 septal spurs 14, 75, 86, 87–89, 130 septal turbinates 13, 15, 77, 85, 118 septectomy 177 septoplasty 17, 91–92 septorhinoplasty complication 11 Page 199 septum 13–18 abnormalities 85–93 seroma 92 sickle cell anemia 126–127 silicone catheter 27 sinus see ethmoid sinus; frontal sinus; maxillary sinus; sphenoid sinus sinusitis 35, 41, 69, 99 acute 99, 100–101, 103–105 chronic 99, 133, 139, 163 concha bullosa and 103, 157 ethmoid 103, 105, 107 frontal 103, 133, 187 maxillary 69, 99, 104–105, 165 sphenoid 99 sphenoethmoid recess 53, 54, 56–57 polyp 57, 188 sphenoid sinus ostia 54, 55–57, 59, 64, 177 sinusitis 99, 164 sphenoidotomy 90, 169, 171, 177 spider angioma 93, 124 stenosis 11, 92, 98, 123 choanal 65, 67, 134 following frontal sinusotomy 157 middle meatal antrostomy 105, 165, 173, 194 nasofrontal duct 167–168 stenting 157, 162, 168, 182 substance abuse 77, 151–152 telangiectasias 124 thrombosis 139, 145 tumors 139–155 see also specific tumors turbinate inferior 18, 24–27, 29–34 degeneration 31 hypertrophy 29 mucosa 29, 30 ostia 33, 34 polyps 24, 30–31, 115–116, 118, 189 remodelling 73, 75–76, 87 secondary 78–79, 179 split 32 variants 32–34 middle 36–43, 45–51 cellular 45, 47, 59 ‘cookiebite’ deformity 33, 48 displaced 135, 194 mucocele 163 osteoma 144 paradoxical 45, 48 polyps 45, 51, 62, 112, 114 remodelling 73, 75–77 secondary 79 split 39, 49, 112 tail 45, 51 variability 45, 47–50 neoturbinate 32 septal 13, 15, 85, 89 secondary 15, 77–78, 90, 118, 170, 178 superior 53–55, 59 polyp 113 supreme 53, 55, 59 turbinectomy 73, 79 inferior 16, 25–27, 78, 90, 101, 168, 169, 179 middle 13, 15, 77–78, 90, 178–179, 180 ulceration 96, 97, 122, 125–127 uncinate process 35, 38–43, 49, 61 hypertrophy 179 mucosal hypertrophy 78 polyp 113 postoperative changes 170 upper respiratory tract infections 19 uvula, bifid 18 variants 5 vasoconstrictors 74 venous lake 17 vessels, prominent 17, 24, 110 epistaxis and 13, 86, 95, 96, 98 vomer 23, 51 short 18, 23, 73, 76, 114 vomerine membrane 65, 66 Wegener’s granulomatosis 83, 86, 121, 125, 133 ...Page i An? ?Atlas? ?of? ?DIAGNOSTIC? ?NASAL? ?ENDOSCOPY Page ii This page intentionally left blank Page iii THE ENCYCLOPEDIA? ?OF? ?VISUAL? ?MEDICINE? ?SERIES An? ?Atlas? ?of? ?DIAGNOSTIC? ?NASAL? ?ENDOSCOPY Salah? ?D.Salman, MD, FACS ... Figure 1.8 A ‘Breathe Right’ strip applied to the nose? ?of? ?the same subject. Note the resulting ballooning? ?of? ?the soft parts? ?of? ?the? ?nasal? ? walls Figure 1.9 The endoscopic picture? ?of? ?the left? ?nasal? ?cavity? ?of? ?the same subject, after application? ?of? ?the ‘Breathe Right’ strip. Note the ... Copyright © 2004 The Parthenon Publishing Group Library? ?of? ?Congress CataloginginPublication Data Data available on application British Library Cataloguing in Publication Data Salman,? ?Salah? ?D.? ? An? ?atlas? ?of? ?diagnostic? ?nasal? ?endoscopy.—(The encyclopedia? ?of? ?visual? ?medicine? ?series)? ?