Atlas of Endoscopic Sinus and Skull Base Surgery E-Book

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Improve your surgical outcomes with Atlas of Endoscopic Sinus and Skull Base Surgery by James N. Palmer, MD and Alexander G. Chiu, MD. Ideal for every otolaryngologist who performs basic or advanced rhinologic procedures, this beautifully illustrated atlas takes you step by step through endoscopic sinus and skull base surgeries as if the chapter authors were right there with you in the operating room.

  • Consult this title on your favorite e-reader with intuitive search tools and adjustable font sizes. Elsevier eBooks provide instant portable access to your entire library, no matter what device you're using or where you're located.
  • Benefit from the extensive knowledge and experience of leaders in the field as they walk you through endoscopic approaches to chronic sinus disease, nasal polyps, pituitary tumors, cerebrospinal fluid leaks, sinonasal tumors, and much more.
  • Employ state-of-the-art techniques in your practice, from septoplasty and sphenoethmoidectomy to extended frontal sinus procedures, endoscopic craniofacial resections, balloon dilation, and complex skull base reconstructions.
  • Visualize every step of each procedure thanks to high-definition, intraoperative endoscopic photos paired with detailed, labeled anatomic illustrations.
  • Achieve optimal patient care before, during, and after surgery with detailed information on relevant anatomy and surgical indications, instrumentation, potential pitfalls, and post-operative considerations.

Sujets

Livres
Savoirs
Medecine
Rongeur
Clivus
Functional endoscopic sinus surgery
Dacryocystorhinostomy
Uncinate process
Sphenoidal sinuses
Ligation
Osteitis
Frontal sinus
Rhinology
Encephalocele
Electrocoagulation
Maxillary sinus
Surgical instrument
Neoplasm
Decompression
Traumatic brain injury
Acute pancreatitis
Pituitary adenoma
Balloon catheter
Choanal atresia
Skin grafting
Hereditary hemorrhagic telangiectasia
Debridement
Nasal polyp
Epistaxis
Hypertrophy
Nasal concha
Osteotomy
Fluorescein
Optic Nerve
Physician assistant
Caucasian race
Daughter
Allergic rhinitis
Device
Lesion
Inferior nasal concha
Cauterization
Nasopharynx
Maxilla
Tetralogy of Fallot
Alopecia
Papilledema
Endoscopy
Trepanning
List of surgical procedures
Bleeding
Médecine
Surgical incision
Nasal
Oncology
Contract
Angiofibroma
Inverted papilloma
The Only Son
Cerebrospinal fluid rhinorrhoea
Surgical suture
Surfactant protein A
LMNA
Blood transfusion
Anemia
Hypertension
Headache
Ophthalmology
X-ray computed tomography
Philadelphia
Atlas (anatomy)
Surgery
Artery
Sinusitis
Sleep apnea
Data storage device
Radiation therapy
Idiopathic intracranial hypertension
Paranasal sinuses
Otolaryngology
Mechanics
Magnetic resonance imaging
General surgery
Chemotherapy
Bipolar disorder
Antibacterial
Fractures
Cicatrices
Collection
Mandrillus leucophaeus
Trust
Neck
Dissection
Crib
Diffusion
Punch
Format
Blister
Planning
Cartilage
Electronic
Forceps
Son
Copyright
Air

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Date de parution 07 juin 2012
Nombre de lectures 0
EAN13 9781455751822
Langue English
Poids de l'ouvrage 2 Mo

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Atlas of Endoscopic Sinus
and Skull Base Surgery
Editors:
James N. Palmer, MD
Associate Professor and Director, Division of Rhinology, Department of
Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania, Philadelphia,
Pennsylvania
Alexander G. Chiu, MD
Professor and Chief, Division of Otolaryngology, Department of Surgery, University of
Arizona, Tucson, Arizona
Associate Editor:
Nithin D. Adappa, MD
Assistant Professor, Division of Rhinology, Department of Otorhinolaryngology–Head and
Neck Surgery, University of Pennsylvania, Philadelphia, PennsylvaniaTable of Contents
Cover image
Title page
Copyright
Dedication
Contributors
Foreword
Preface
Part 1: Nasal Surgery
Chapter 1. Septoplasty
Introduction
Anatomy
Preoperative Considerations
Instrumentation (Figure 1-3)
Pearls And Potential Pitfalls
Surgical Procedures
Postoperative Considerations
Special Considerations
References
Chapter 2. Septodermoplasty
Introduction
AnatomyPreoperative Considerations
Instrumentation
Pearls And Potential Pitfalls
Surgical Procedure
Postoperative Considerations
Chapter 3. Middle and Inferior Turbinates
Introduction
Anatomy And Physiology
Preoperative Considerations
Instrumentation
Pearls And Potential Pitfalls
Surgical Procedures
Postoperative Considerations
References
Chapter 4. Sphenopalatine Artery Ligation
Introduction
Anatomy
Preoperative Considerations
Instrumentation (Figure 4-3)
Pearls And Potential Pitfalls
Surgical Procedure
Postoperative Considerations
Conclusions
References
Chapter 5. Endoscopic and Open Anterior/Posterior Ethmoid Artery Ligation
Introduction
Anatomy—Endoscopic Perspective
Preoperative Considerations
InstrumentationPearls And Potential Pitfalls
Surgical Procedures
Postoperative Considerations
Special Considerations
References
Chapter 6. Endoscopic Repair of Choanal Atresia
Introduction
Anatomy
Preoperative Considerations
Instrumentation
Pearls And Potential Pitfalls
Surgical Procedure
Unilateral Left-Sided Atresia
Special Considerations
References
Part 2: Basics of Primary Endoscopic Sinus Surgery
Chapter 7. Maximal Medical Management of Chronic Rhinosinusitis: Preoperative
Preparation and Positioning
Introduction
Mainstays Of Medical Therapy For Chronic Rhinosinusitis
Adjunct Medical Therapy For Chronic Rhinosinusitis
Guidelines For Maximal Medical Therapy
Preoperative Preparation And Positioning
References
Chapter 8. Maxillary Antrostomy
Introduction
Anatomy (Figures 8-1, 8-2, And 8-3)
Preoperative Considerations
Instrumentation (Figure 8-7)Pearls And Potential Pitfalls
Surgical Procedure
Postoperative Considerations
Special Considerations
Chapter 9. Partial and Complete Ethmoidectomy
Introduction
Anatomy
Preoperative Considerations
Instrumentation (Figure 9-7)
Pearls And Potential Pitfalls
Surgical Procedure
Postoperative Considerations
Chapter 10. Sphenoidotomy
Introduction
Anatomy
Preoperative Considerations
Instrumentation
Pearls And Potential Pitfalls
Surgical Procedures
Special Considerations—Onodi Cell
Chapter 11. Frontal Sinusotomy
Introduction
Anatomy
Preoperative Considerations
Instrumentation
Pearls And Potential Pitfalls
Surgical Procedure
Chapter 12. Postoperative Debridement
IntroductionAnatomy
Preoperative Considerations
Instrumentation
Pearls And Potential Pitfalls
Surgical Procedure
Postoperative Considerations
Special Considerations
References
Chapter 13. Balloon Dilatation of the Maxillary, Frontal, and Sphenoid Sinuses
Introduction
Preoperative Considerations
Instrumentation
Pearls And Potential Pitfalls
Surgical Procedures
Postoperative Considerations
Special Considerations
Part 3: Revision Endoscopic Sinus Surgery for Inflammatory Disease
Chapter 14. Revision Functional Endoscopic Sinus Surgery: Completion
Sphenoethmoidectomy
Introduction
Anatomy
Preoperative Considerations
Instrumentation
Surgical Procedure
Postoperative Considerations
References
Chapter 15. Extended Frontal Recess Dissections: Draf IIb and Draf III Approaches
Introduction
AnatomyIndications And Contraindications For Extended Frontal Sinus Surgery
Preoperative Considerations
Instrumentation
Surgical Procedure
Pearls And Potential Pitfalls
Postoperative Considerations
Special Considerations
References
Chapter 16. Modified Medial Maxillectomy for Recalcitrant Maxillary Sinusitis
Introduction
Anatomy
Preoperative Considerations
Instrumentation
Pearls And Potential Pitfalls
Surgical Procedure
Postoperative Considerations
Special Considerations
References
Chapter 17. Extended Sphenoid Sinus Antrostomy
Introduction
Anatomy
Preoperative Considerations
Instrumentation
Pearls And Potential Pitfalls
Surgical Procedures
Postoperative Considerations
References
Part 4: Orbital Surgery
Chapter 18. Endoscopic DacryocystorhinostomyIntroduction
Anatomy
Preoperative Considerations
Instrumentation
Pearls And Potential Pitfalls
Surgical Procedure
Postoperative Considerations
Special Considerations
References
Chapter 19. Endoscopic Orbital Decompression
Introduction
Anatomy
Preoperative Considerations
Instrumentation (Figure 19-2)
Pearls And Potential Pitfalls
Surgical Procedure
Postoperative Considerations
Special Considerations
Conclusions
References
Chapter 20. Optic Nerve Decompression
Introduction
Anatomy
Indications And Contraindications For Optic Nerve Decompression
Preoperative Considerations
Instrumentation (Figure 20-8)
Pearls And Potential Pitfalls
Surgical Procedure
Postoperative Considerations
ReferencesPart 5: Sinonasal Tumors
Chapter 21. Endoscopic Medial Maxillectomy for Inverted Papilloma
Introduction
Anatomy
Preoperative Considerations
Instrumentation (Figure 21-4)
Pearls And Potential Pitfalls
Surgical Procedure
Postoperative Considerations
References
Chapter 22. Pterygopalatine/Pterygomaxillary Space Approaches and Internal
Maxillary Artery Ligation
Introduction
Anatomy
Preoperative Considerations
Instrumentation
Pearls And Potential Pitfalls
Surgical Procedure
Postoperative Considerations
Conclusion
References
Chapter 23. Approach for Juvenile Nasopharyngeal Angiofibroma
Introduction
Anatomy
Preoperative Considerations
Instrumentation
Pearls And Potential Pitfalls
Surgical Procedure
Postoperative ConsiderationsReferences
Chapter 24. Endoscopic Craniofacial Resection
Introduction
Anatomy
Preoperative Considerations
Instrumentation
Pearls And Potential Pitfalls
Surgical Procedure
Postoperative Considerations
Special Considerations
References
Part 6: Skull Base Reconstruction
Chapter 25. Repair of Cerebrospinal Fluid Leak and Encephalocele of the Cribriform
Plate
Introduction
Anatomy
Preoperative Considerations
Instrumentation
Pearls And Potential Pitfalls
Surgical Procedure
Postoperative Considerations
Special Considerations
References
Chapter 26. Sphenoid Sinus Cerebrospinal Fluid Leak and Encephalocele Repair
Introduction
Anatomy
Preoperative Considerations
Instrumentation
Pearls And Potential PitfallsSurgical Procedure
Postoperative Considerations
Special Considerations
References
Chapter 27. Large Skull Base Defect Reconstruction with and without Pedicled Flaps
Introduction
Anatomy
Preoperative Considerations
Instrumentation
Pearls And Potential Pitfalls
Surgical Procedures
Postoperative Considerations
Special Considerations
References
Part 7: Anterior and Central Skull Base Approaches
Chapter 28. Endoscopic Resection of Pituitary Tumors
Introduction
Anatomy
Preoperative Considerations
Instrumentation (Figure 28-5)
Surgical Procedure
Postoperative Considerations
Special Considerations
References
Chapter 29. Endoscopic Transplanum and Sellar Approach
Introduction
Anatomy
Preoperative Considerations
Instrumentation (Figure 29-7)Pearls And Potential Pitfalls
Surgical Procedures
Postoperative Considerations
References
Chapter 30. The Clivus
Introduction
Anatomy And Physiology
Preoperative Considerations
Instrumentation
Pearls And Potential Pitfalls
Surgical Procedure
Postoperative Considerations
Special Considerations
References
Part 8: Combined Endoscopic and Open Approaches—Frontal Sinus
Chapter 31. Frontal Sinus Trephination
Introduction
Anatomy
Preoperative Considerations
Instrumentation
Pearls And Potential Pitfalls
Surgical Procedure
Postoperative Considerations
Conclusion
References
Chapter 32. Osteoplastic Flaps with and without Obliteration
Introduction
Anatomy
Preoperative ConsiderationsInstrumentation
Pearls And Potential Pitfalls
Surgical Procedure
Postoperative Considerations
References
Chapter 33. Frontal Sinus Fractures
Introduction
Anatomy
Preoperative Considerations
Instrumentation
Pearls And Potential Pitfalls
Surgical Procedures
Open Reduction And Internal Fixation Of The Anterior Table With Exploration Of
The Frontal Sinus Without Obliteration
Endoscopic Reduction And Internal Fixation Of Anterior Table Fractures
Delayed Endoscopic Camouflage Of Anterior Frontal Sinus Fractures
Open Reduction And Internal Fixation With Obliteration Of The Frontal Sinus
Cranialization Of The Frontal Sinus
Postoperative Considerations
Special Considerations
References
IndexCopyright
1600 John F. Kennedy Blvd.
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ATLAS OF ENDOSCOPIC SINUS AND SKULL BASE SURGERY ISBN:
978-0-32304408-0
Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
No part of this publication may be reproduced or transmitted in any form or by any
means, electronic or mechanical, including photocopying, recording, or any
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This book and the individual contributions contained in it are protected under
copyright by the Publisher (other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new
research and experience broaden our understanding, changes in research
methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience
and knowledge in evaluating and using any information, methods,
compounds, or experiments described herein. In using such information
or methods they should be mindful of their own safety and the safety of
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With respect to any drug or pharmaceutical products identified, readers
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Library of Congress Cataloging-in-Publication Data
Atlas of endoscopic sinus and skull base surgery / editors, James N. Palmer,
Alexander G. Chiu; associate editor, Nithin D. Adappa.
p. ; cm.
“Expert consult basic.”
Includes bibliographical references and index.
ISBN 978-0-323-04408-0 (hardcover : alk. paper)
I. Palmer, James N., 1967 - II. Chiu, Alexander G. III. Adappa, Nithin D.
[DNLM: 1. Paranasal Sinuses—surgery—Atlases. 2. Endoscopy—methods—Atlases.
3. Otorhinolaryngologic Surgical Procedures—Atlases. 4. Paranasal Sinuses—
anatomy & histology—Atlases. 5. Skull Base—anatomy & histology—Atlases. 6. Skull
Base—surgery—Atlases. WV 17]
617.5’140597—dc23 2012037410
Senior Content Strategist: Stefanie Jewell-Thomas
Content Development Specialist: Rachel Miller
Publishing Services Manager: Anne Altepeter
Project Manager: Cindy Thoms
Design Direction: Lou Forgione
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1D e d i c a t i o n
Without the love and support of my beautiful wife, Amy,
the book simply does not happen, all the way from the
original contract(s) to the final edition. To think the
planning began at the same time my son Sam was born – I
have worked on some version of this text his entire life –
and he is now in second grade! I dedicate this book to my
entire family – especially Amy, Sam, and my daughter Zoe.
They make it all worth it. To my work family – especially
my brothers Alex, Noam, and Nithin - thank you so much
for your friendship, guidance, and making academic
rhinology such an exciting, satisfying field.
—James N. Palmer, MD
First and foremost, this book is dedicated to my lovely
wife, Michelle, who has allowed me to move her from the
city (New York City) to the suburbs (Philadelphia) and
now to what must feel like the moon (Tucson). To my
parents, Paul and Elizabeth, for showing me what it takes
to be great parents, and to my children, Nicolas and Aidan,
who always bring a smile to my face. And last but not least,
this book would not be possible without the friendship I
have with Noam Cohen and Jim Palmer—it truly was a
special seven and a half years.
—Alexander G. Chiu, MDTo my wonderful wife and daughter, Jyoti and Maya, for
their love and support, my parents, Vijay and Usha, for
their understanding and dedication, and my mentors, too
many to name, for their knowledge and guidance.
—Nithin D. Adappa, MD$
Contributors
Nithin D . A dappa, MD , A ssistant Professor, D ivision of Rhinology, D epartment of
Otorhinolaryngology–Head and N eck S urgery, University of Pennsylvania,
Philadelphia, Pennsylvania
Robert T. Adelson, MD, Division of Rhinology, Department of Otorhinolaryngology–
Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
Marcelo B. A ntunes, MD , Resident, D epartment of Otorhinolaryngology–Head and
Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
D aniel G. Becker, MD , FA C,S Clinical A ssociate Professor, D epartment of
Otorhinolaryngology–Head and N eck S urgery, University of Pennsylvania,
Philadelphia, Pennsylvania
Samuel S. Becker, MD , Clinical A ssistant Professor, D epartment of
Otorhinolaryngology–Head and N eck S urgery, University of Pennsylvania,
Philadelphia, Pennsylvania
Benjamin S. Bleier, MD , A ssistant Professor, D epartment of Otology and
Laryngology, Massachuse s Eye and Ear I nfirmary, Harvard Medical S chool, Boston,
Massachusetts
Angela Blount, MD, Resident, D ivision of Otolaryngology–Head and N eck S urgery,
University of Alabama at Birmingham, Birmingham, Alabama
Rakesh K. Chandra, MD , A ssociate Professor, N orthwestern S inus and A llergy
Center, D epartment of Otolaryngology–Head and N eck S urgery, N orthwestern
University Feinberg School of Medicine, Chicago, Illinois
A lexander G. Chiu, MD , Professor and Chief, D ivision of Otolaryngology,
Department of Surgery, University of Arizona, Tucson, Arizona
Martin Citardi, MD, Professor and Chair, Department of Otorhinolaryngology–Head
and N eck S urgery, University of Texas Medical S chool at Housto,n Chief of
Otorhinolaryngology, Memorial Hermann-Texas Medical Center, Houston, Texas
Noam Cohen, MD, PhD, Assistant Professor of Otorhinolaryngology–Head and Neck
S urgery, Veterans A dministration Medical Cente,r D irector, Rhinology Research,
University of Pennsylvania, Philadelphia, Pennsylvania
David B. Conley, MD, Associate Professor of Otolaryngology, Otolaryngology–Head
and N eck S urgery, N orthwestern University Feinberg S chool of Medicine, Chicago,
Illinois
Samer Fakhri, MD , A ssociate Professor and Program D irector, D epartment of
Otorhinolaryngology–Head and N eck S urgery, University of Texas Medical S chool at
Houston, Houston, TexasFrancisca I. Fernandez, MD , Professor and Chair, D epartment of Psychiatry and
Behavioral N eurosciences, D irector, I nstitute for Research in Psychiatry, Head, S ilver
Child D evelopment Center, University of S outh Florida, Health Morsani College of
Medicine, Tampa, Florida
Leonardo Lopes Balsalobre Filho, MD, Fellow, Rhinology, D epartment of
Otolaryngology–Head and N eck S urgery, Federal University of S ão Paulo, S ão Paulo,
Brazil
Satish Govindaraj, MD, FACS, Assistant Professor, Department of Otolaryngology–
Head and Neck Surgery, Mount Sinai Medical Center, New York, New York
Richard J. Harvey, MD , A ssociate Professor, D ivision of Rhinology/S kull Base
S urgery, D epartment of Otolaryngology, S t. Vincent’s Hospital, S ydney, N ew S outh
Wales, Australia
Peter H. Hwang, MD , Professor, D epartment of Otolaryngology–Head and N eck
Surgery, Stanford University School of Medicine, Palo Alto, California
A lfred Marc C. Iloreta, MD, Physician, D epartment of Otolaryngology–Head and
Neck Surgery, Mount Sinai Medical Center, New York, New York
James J. Jaber, MD , PhD, Fellow, D epartment of Otolaryngology–Head and N eck
Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
Stephanie A . Joe, MD , A ssociate Professor and D irector, S inus and N asal A llergy
Center, Co-D irector, S kull Base S urgery, D epartment of Otolaryngology–Head and
Neck Surgery, University of Illinois at Chicago, Chicago, Illinois
T odd T. Kingdom, MD , Professor and Vice Chairman, D epartment of
Otolaryngology–Head and N eck S urgery, University of Colorado D enver, D enver,
Colorado
Jivianne T. Lee, MD , Co-D irector, Orange County S inus I nstitute, S CPMG, I rvine,
California, Clinical A ssistant Professor, D epartment of Otolaryngology–Head and
Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
John M. Lee, MD , FRCS,C D epartment of Otolaryngology–Head and N eck S urgery,
University of Toronto, Toronto, Ontario, Canada
Randy Leung, MD, FRCSC, Department of Otolaryngology–Head and Neck Surgery,
Royal Victoria Hospital, Barrie, Ontario, Canada
Amber Luong, MD, PhD, Assistant Professor, Otorhinolaryngology–Head and Neck
Surgery, University of Texas Medical School at Houston, Houston, Texas
Li-Xing Man, MSc, MD, MPA, Assistant Professor, Department of Otolaryngology–
Head and N eck S urgery, University of Rochester S chool of Medicine and D entistry,
University of Rochester Medical Center, Rochester, New York
Avinash V. Mantravadi, MD, A ssistant Professor, D epartment of Otolaryngology–
Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana
Y uresh Naidoo, BEng(Hons), MBBS, FRA C, S Rhinology and S kull Base S urgeon,
D epartment of Otolaryngology, Concord Hospital, S ydney, N ew S outh Wales, S outh
Australia
Jayakar V. Nayak, MD , PhD, A ssistant Professor, D epartment of Otolaryngology–
Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California$
Bert W. O’Malley, Jr. MD, Gabriel Tucker Professor and Chairman, D epartment of
Otorhinolaryngology–Head and N eck S urgery, University of Pennsylvania,
Philadelphia, Pennsylvania
Richard R. Orlandi, MD , FA C,S Executive Medical D irector, S outh J ordan Health
Center, Professor, D epartment of Otolaryngology–Head and N eck S urgery, University
of Utah, Salt Lake City, Utah
James N. Palmer, MD , A ssociate Professor and D irector, D ivision of Rhinology,
D epartment of Otorhinolaryngology–Head and N eck S urgery, University of
Pennsylvania, Philadelphia, Pennsylvania
A aron N. Pearlman, MD , A ssistant Professor of Otolaryngology, Weill Cornell
Medical College, A ssistant A ending Otolaryngologist, N ew York–Presbyterian
Hospital, New York, New York
P. Seamus Phillips, MD , BM, D OHNS, FRCS (ORL-HNS), ,M SScydney Rhinology
Fellow, D epartment of Rhinology/S kull Base S urgery, S t. Vincent’s Hospital, S ydney,
New South Wales, Australia
Shirley Shizue Nagata Pignatari, MD, PhD, Professor and Head, Division of Pediatric
Otolaryngology, Federal University of São Paulo, São Paulo, Brazil
Amy L. Pittman, MD, Chief Resident, Department of Otolaryngology–Head and Neck
Surgery, Loyola University Medical Center, Maywood, Illinois
Vijay R. Ramakrishnan, MD , A ssistant Professor, D epartment of Otolaryngology,
University of Colorado School of Medicine, Aurora, Colorado
Jeremy Reed, MD, Division of Rhinology, Department of Otorhinolaryngology–Head
and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
Raymond Sacks, MBBCh, FCS(SA)ORL, FRACS, Associate Professor and Chairman,
D epartment of Otolaryngology–Head and N eck S urgery, Macquarie Universit,y
Clinical A ssociate Professor, D epartment of S urgery, University of S ydney, S ydney,
New South Wales, Australia
Rodney J. Schlosser, MD, Professor, Department of Otolaryngology–Head and Neck
Surgery, Medical University of South Carolina, Charleston, South Carolina
Andrew R. Simonsen, DO, Department of Otolaryngology–Head and Neck Surgery,
University of Medicine and Dentistry of New Jersey, Stratford, New Jersey
Raj Sindwani, MD , FA CS, FRC , S S ection Head, Rhinology, S inus and S kull Base
Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
Hwa J. Son, MD , N orthwestern S inus and A llergy Center, D epartment of
Otolaryngology–Head and N eck S urgery, N orthwestern University Feinberg S chool of
Medicine, Chicago, Illinois
Aldo Cassol Stamm, MD, PhD, A ffiliated Professor, D epartment of Otolaryngology
and Head and Neck Surgery, Federal University of São Paulo, Director, ENT Center of
São Paulo, São Paulo, Brazil
Jeffrey D . Suh, MD , A ssistant Professor, D ivision of Head and N eck S urgery,
University of California Los Angeles, Los Angeles, California
Gabriel J. Tsao, MD, Otolaryngology Resident, Department of Otolaryngology–Head
and Neck Surgery, Stanford University School of Medicine, Palo Alto, CaliforniaJustin H. Turner, MD , PhD, A ssistant Professor, D epartment of Otolaryngology–
Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California
William A lexander Vandergrift III., MD, A ssistant Professor, D ivision of
N eurological S urgery, D epartment of N eurosciences, Medical University of S outh
Carolina, Charleston, South Carolina
Eric W. Wang, MD, Assistant Professor, Department of Otolaryngology, University of
Pittsburgh, Pittsburgh, Pennsylvania
Heather H. Waters, MD, Department of Otolaryngology, Cleveland Clinic, Cleveland,
Ohio
Calvin Wei, MD, Fellow, Division of Rhinology, Department of Otorhinolaryngology,
University of Pennsylvania, Philadelphia, Pennsylvania
Kevin C. Welch, MD, A ssistant Professor, D ivision of Rhinology and A nterior S kull
Base S urgery, D epartment of Otolaryngology–Head and N eck S urgery, Loyola
University Medical Center, Maywood, Illinois
Bradford A . Woodworth, MD , A ssistant Professor of S urgery and J ames J . Hicks
Endowed Chair of Otolaryngology, D ivision of Otolaryngology–Head and N eck
Surgery, Associate Scientist, Gregory Fleming James Cystic Fibrosis Research Center,
University of Alabama at Birmingham, Birmingham, Alabama
P.J. Wormald, MD , FRCS, FCS(SA), MB, C , hB Professor and Chairman,
Otolaryngology–Head and N eck S urgery, University of A delaide, A delaide, S outh
AustraliaForeword
This is the book we wished we had. A s we progressed through our rhinology
fellowship, we spent countless hours recording video of surgical cases, capturing
video stills, and photographing external sinus procedures. I nitially, it seemed the
reason for this work was because D rs. Palmer and Chiu kept after us to document our
surgery–but we realized that we were acquiring, step by step, an incredible collection
of images of endoscopic sinus surgery. I t would have saved us a great deal of time
and effort had the steps been in some published format for easy reference. A lthough
there were many great texts available to assist each of us with learning, there was no
satisfactory atlas of rhinologic and skull base procedures.
I n the first edition of Atlas of Endoscopic Sinus and Skull Base Surger,y D rs. Palmer
and Chiu gather an ensemble of premier surgeons, each of whom has gone to great
lengths to provide readers with beautifully illustrated drawings, high-quality digital
images, and straight-forward instructions for a plethora of rhinologic procedures.
This is the rhinology and skull base atlas that we wish we had been able to read
during our fellowship, and we are proud to say that it is as useful to us now as it
would have been during those earlier years. We believe this text will be well-suited for
the medical student all the way to the experienced Rhinologic surgeon–as an
introduction to endoscopic procedures and a manual to refresh experienced surgeons
on complex techniques.
We remain indebted to D rs. Palmer and Chiu for the mentorship they provide, and
we are honored to have contributed to this atlas. I hope you enjoy reading this atlas as
much as we did writing chapters and that it will enlighten and inspire you.
Nithin D. Adappa, MD; Robert T. Adelson, MD; Rakesh K. Chandra, MD; Noam
Cohen, MD, PhD; Satish Govindaraj, MD, FACS; Jivianne T. Lee, MD; John M.
Lee, MD, FRCSC; Jayakar V. Nayak, MD, PhD; Vijay R. Ramakrishnan, MD;
Jeremy Reed, MD; Rodney J. Schlosser, MD; Jeffery D. Suh, MD; Calvin Wei,
MD; Kevin C. Welch, MD; and Bradford A. Woodworth, MD./
/
Preface
A fter seven and a half years together in adjoining offices at the University of
Pennsylvania, training 11 rhinology fellows and 32 otolaryngology residents,
bouncing ideas and interesting cases off each other, and collaborating on nearly 50
peer-reviewed publications, we decided that we spent too much time talking about
writing a book and needed to actually accomplish writing a book. Thanks to our
associate editor, N ithin A dappa; our developmental editor, Rachel Miller; artist,
Devon Stuart; and our trusted chapter writers, many of whom were former fellows, we
have provided you with a comprehensive atlas for endoscopic sinus and skull base
surgery.
Pairing high-definition endoscopic photos with beautiful illustrations, our goal was
to take you through each surgical procedure as if we were in your operating room
assisting you with the case. Each surgical chapter starts with the relevant anatomy
and surgical indications, instrumentation needed, and potential pitfalls to look out
for. The chapters take the reader through the procedure step by step, with special
a ention to surgical anatomy and postoperative considerations. We have a empted
to cover the entire spectrum of modern rhinology and anterior skull base surgery,
from septoplasty and sphenoethmoidectomy to extended frontal sinus procedures,
endoscopic craniofacial resections, and complex skull base reconstructions.
Atlas of Endoscopic Sinus and Skull Base Surger yis suited for medical students
interested in otolaryngology, otolaryngology residents, and practicing
otolaryngologists who perform rhinologic procedures, simple or complex. We have
had some great success in training excellent rhinologic surgeons and hope this book
and our experience can benefit you as well.
—James N. Palmer, MD
—Alexander G. Chiu, MDPA RT 1
Nasal Surgery
Chapter 1 Septoplasty
Chapter 2 Septodermoplasty
Chapter 3 Middle and Inferior Turbinates
Chapter 4 Sphenopalatine Artery Ligation
Chapter 5 Endoscopic and Open Anterior/Posterior Ethmoid Artery Ligation
Chapter 6 Endoscopic Repair of Choanal AtresiaC H A P T E R 1
Septoplasty
Samuel S. Becker, Daniel G. Becker, Marcelo B. Antunes and
Andrew R. Simonsen
Introduction
The nasal septum plays a key role in the form and function of the nose, nasal cavity, and
1paranasal sinuses.
Septal deformities are common and occur in nearly 77% to 90% of the general
2,3population worldwide.
Even small deviations in key areas have been shown to adversely affect nasal airflow,
4,5mucociliary clearance, and the external appearance of the nose.
Improving nasal airflow continues to be the primary goal of nasal septal surgery. Other
4indications include epistaxis, sinusitis, obstructive sleep apnea, and headaches.
This chapter focuses on three commonly used septoplasty techniques: traditional
septoplasty, septoplasty addressing caudal deformities, and endoscopically directed
septoplasty.
6,7Anatomy
The nasal septum is a mucosa-covered bony and cartilaginous structure located in the
rough midline of the nose, which separates the right nostril from the left nostril (Figure
1-1).FIGURE 1-1 Drawing of the nasal septum in sagittal view.
The nasal septum is situated in a sagittal plane extending from the skull base superiorly
to the hard palate inferiorly and the nasal tip anteriorly to the sphenoid sinus and
nasopharynx posteriorly.
The bony portion of the septum includes the perpendicular plate of the ethmoid bone,
the vomer, and the maxillary crest, which has contributions from the maxillary and
palatine bones. The quadrangular cartilage forms the caudal portion of the septum.
The nasal septum forms the medial wall of each nasal cavity and contributes to the
internal and external nasal valves.
Preoperative Considerations
Patient history is important in establishing an operative plan. Preoperative history
taking should elicit information regarding subjective nasal airway obstruction, prior
trauma, epistaxis, nasal decongestant use, and drug use.
Adequate mucosal decongestion and vasoconstriction are essential in reducing
intraoperative bleeding and optimizing visualization during the procedure.
Choice of septoplasty technique should be based on the nature and location of the
deformity, patient history including prior septoplasty, and surgeon skill and
8preference.
Radiographic Considerations
Radiographic evaluation is not always necessary but is often available when septoplasty
is performed in conjunction with other rhinologic procedures.
When available, coronal computed tomographic (CT) scan of the sinuses is the
9preferred study to evaluate the course of the nasal septum (Figure 1-2).FIGURE 1-2 Coronal computed tomographic scan of the sinuses demonstrating a
large posterior septal deformity.
When a septoplasty is performed to treat airway obstruction, the coronal CT scan may
assist in identifying posterior deflections not visualized on anterior rhinoscopy or other
9sources of obstruction such as a concha bullosa.
Instrumentation (Figure 1-3)
Nasal specula of multiple lengths
FIGURE 1-3 Photograph of suggested instruments for septoplasty.
Bayonet forceps
Scalpel with a No. 15 or 15C blade
Small curved, sharp-pointed scissors
Cottle elevator
Freer elevator
Takahashi forceps
Open and closed double-action rongeur (Jansen-Middleton type)
0-degree endoscope (endoscopic technique)
Pearls and Potential Pitfalls
Establishing the proper subperichondrial plane before elevating the mucoperichondrialflap is essential to ensure a bloodless dissection and minimize the risk of tearing the
mucosa.
– Bare cartilage is identified by its pearly white appearance and somewhat gritty feel.
Septal perforations are an uncommon complication following septoplasty. The risk is
10-12increased when bilateral opposing mucosal tears occur during flap elevation.
It is important to maintain a generous L-strut of at least 15 mm along the dorsal and
caudal margins of the quadrangular cartilage to avoid long-term nasal tip and dorsal
10-12deformities (Figure 1-4).
FIGURE 1-4 Drawing of septal cartilage resection showing the remaining L-strut
(orange shading).
Care should be taken when separating the perpendicular plate of the ethmoid bone
10-12from the skull base to avoid a cerebrospinal fluid leak.
Surgical Procedures
4,6,8Traditional Septoplasty
After adequate nasal decongestion is achieved using a topical agent, inject local
anesthetic with a vasoconstrictor (1% lidocaine with 1:100,000 epinephrine) into the
septal mucosa. Allow approximately 15 minutes for the anesthetic to take full effect.Step 1: Initial Incision
Retract the columella to the opposite side using a small nasal speculum, columellar
retractor, or large two-prong hook and expose the caudal margin of the septum.
Use a No. 15 blade or No. 15C blade to make a hemitransfixion incision along the caudal
margin of the septum extending from the anterior septal angle to the posterior septal
angle.
A modified Killian incision may be used when more posterior deflections are wanted or
when less exposure is necessary (Figure 1-5).
FIGURE 1-5 Drawing of hemitransfixion, Killian, and modified Killian incisions.
Step 2: Elevation Of Mucoperichondrial Flaps
Use a No. 15 blade, sharp-pointed scissors, or Cottle elevator to incise the
perichondrium at or adjacent to the caudal septum.
Perform a submucoperichondrial dissection along the inferior portion of the septum.
– Flap elevation should extend to include all areas of deflection including bony spurs.
A mucoperichondrial flap is then raised on the contralateral side of the septum
beginning at the caudal margin if a hemitransfixion incision was used.
– If a modified Killian incision was used, gain access to the opposite side by incising the
cartilage just anterior to the deflected portion.Step 3: Removal Of Offending Cartilage And Bone
Using a No. 15 blade or sharp elevator, excise and remove the offending (deflected)
portion of cartilage, again maintaining a generous L-strut.
– A portion of the resected cartilage may be morselized or otherwise straightened and
replaced into the septal pocket before the incision is closed.
Any bony spurs can now be excised using controlled osteotomies.
– A double-action rongeur works well for areas of the perpendicular plate of the
ethmoid or vomer.
– A septal chisel may be used for abnormalities of the maxillary crest.
Step 4: Closure Of The Septal Pocket And Incision
It is important to close the septal pocket to prevent the development of a septal
hematoma postoperatively. Multiple methods have been described to accomplish this.
– A running or interrupted quilting stitch can be placed using absorbable suture such as
4-0 plain gut on a straight needle.
– Internal Silastic splints are often used in addition to further stabilize the septum and
prevent fluid accumulation.
– Additional nasal packing is often unnecessary.
Close the hemitransfixion or Killian incision in a single layer using absorbable suture.
4,6,8Caudal Septal Deformities
Step 1: Initial Incision And Elevation Of Mucoperichondrial Flaps
Complete Steps 1 and 2 as described earlier for traditional septoplasty.
Step 2: Reduction Of Cartilage Memory
Use a No. 15 blade to score the deflected cartilage on the concave side.
The direction of scoring should be vertical or along the axis of the deflection.
Step 3: Swinging Door/Doorstop Techniques
Use a Cottle elevator to elevate the quadrangular cartilage out of the maxillary crest
groove inferiorly.
Using a knife excise the inferior strip of cartilage that had been resting in the maxillary
crest groove.
– This should allow the remaining cartilage, attached only superiorly, to swing freely to
the midline, where it can be secured caudally to the nasal spine with absorbable
suture. Use a figure eight of 3-0 polyglactin 910 (Vicryl) from septum to periosteum,
overlying the anterior maxillary crest (Figure 1-6).FIGURE 1-6 A, Drawing of a nasal septum with caudal septal deformity. B, Nasal
septum following septoplasty using the “doorstop technique.” C and D, Nasal
septum following septoplasty with figure-eight suture.
A modification of this technique (doorstop method) eliminates the step of excising a
strip of cartilage.
After elevating the cartilage off of the maxillary crest, displace it to the side of the crest
opposite the obstruction and again suture it in place.
Step 4: Closure Of The Septal Pocket And Incision
Complete Step 4 as described for traditional septoplasty.
6,8,13,14Directed Endoscopic Septoplasty
After adequate nasal decongestion is achieved using a topical agent, inject local
anesthetic with a vasoconstrictor (1% lidocaine with 1:100,000 epinephrine) into the
septal mucosa. Allow approximately 15 minutes for the anesthetic to take full effect.
Step 1: Incision And Elevation Of Flaps
Advance the 0-degree endoscope into the nasal cavity on the side of the deflection.
Using a No. 15 blade or sharp elevator make a horizontal incision directly over the apex
of the spur or deflection.
Raise mucosal flaps superiorly and inferiorly (Figures 1-7 and 1-8).FIGURE 1-7 Drawing depicting correct placement of the incision (dashed line)
parallel to and directly over the apex of the spur. (From Friedman M, Schalch P.
Endoscopic septoplasty. Oper Tech Otolaryngol Head Neck Surg.
2006;17[2]:139-142.)
FIGURE 1-8 Drawing showing the mucoperiosteal flaps raised superiorly and
inferiorly. (From Friedman M, Schalch P. Endoscopic septoplasty. Oper Tech
Otolaryngol Head Neck Surg. 2006;17[2]:139-142.)
Step 2: Removal Of Offending Cartilage Or Bone A bony spur may be excised simply using a micro-debrider or through-cutting
instrument.
Alternatively, the septum may be incised anteriorly to the deflected cartilage or bony
spur with a small flap raised on the opposite side.
The deformed segment is then resected entirely as described for the traditional
septoplasty.
Step 3: Replacement Of Flaps
The flaps are simply redraped to their anatomic positions (Figure 1-9).
FIGURE 1-9 Drawing of the septum after replacement of the flaps. (From
Friedman M, Schalch P. Endoscopic septoplasty. Oper Tech Otolaryngol Head
Neck Surg. 2006;17[2]:139-142.)
Postoperative Considerations
While nasal packing or splints are in place, the patient should receive an antibiotic with
4adequate coverage for Staphylococcus aureus to prevent toxic shock syndrome.
4 Splints are removed 2 to 7 days after surgery.
Special Considerations
If spreader grafts are going to be used, initial mucoperichondrial flap elevation should
remain low. This will facilitate the formation of precise pockets dorsally to accept and
8stabilize the grafted cartilage.
An open approach via a columellar incision may be used when severe caudal
deformities are encountered or when the septoplasty is performed in conjunction with a
rhinoplasty.References
1. Walsh WE, Kern RC. Sinonasal anatomy, function, and evaluation. In: Bailey BJ,
Johnson JT, Newlands SD, eds. Head and Neck Surgery—Otolaryngology. 4th ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 2006;307–318.
2. Gray LP. Deviated nasal septum: incidence and etiology. Ann Otol Rhinol Laryngol.
1978;87(3 pt 3 suppl 50):3–20.
3. Mladina R, Cujic E, Subaric M, et al. Nasal septal deformities in ear, nose and throat
patients: an international study. Am J Otol. 2008;29:75–82.
4. Fettman N, Thomas S, Raj S. Surgical Management of the deviated septum: techniques
in Septoplasty. Otolaryngol Clin N Am. 2009;42:241–252.
5. Ulusoy B, Arbag H, Sari O, et al. Evaluation of the effects of nasal septal deviation and
its surgery on nasal mucociliary clearance in both nasal cavities. Am J Rhinol.
2007;21:180–183.
6. Toriumi DM, Becker DG. Rhinoplasty dissection manual. Philadelphia, PA: Lippincott
Williams & Wilkins; 1999.
7. Neskey N, Eloy J, Casiano R. Nasal, septal, and turbinate anatomy and embryology.
Otolaryngol Clin N Am. 2009;42:193–205.
8. Becker DG. Septoplasty and turbinate surgery. Aesthetic Surg J. 2003;23:393–403.
9. Chandra RK, Patadia MO, Raviv J. Diagnosis of nasal airway obstruction. Otolaryngol
Clin North Am. 2009;42:207–225.
10. Rettinger G, Kirsche H. Complications in septoplasty. Arch Otolaryngol Head Neck
Surg. 1995;121:681–684.
11. Schwab JA, Pirsig W. Complications of septal surgery. Facial Plast Surg. 1997;13:3–14.
12. Muhammad IA, Rahman N. Complications of the surgery for deviated nasal septum. J
Coll Physicians Surg Pak. 2003;13:565–568.
13. Sautter NB, Smith TL. Endoscopic septoplasty. Otolaryngol Clin N Am. 2009;42:253–
260.
14. Friedmen M, Schalch P. Endoscopic septoplasty. Oper Tech Otolaryngol Head Neck Surg.
2006;17:139–142.C H A P T E R 2
Septodermoplasty
Alexander G. Chiu
Introduction
Septodermoplasty is a procedure for the treatment of epistaxis secondary to
hereditary hemorrhagic telangiectasia (HHT).
HHT is an autosomal dominant disease with incomplete penetrance. The clinical
hallmark of disease is the presence of arteriovenous (AV) malformations in the
sinonasal mucosa, lungs, brain, skin, and gastrointestinal tract.
AV malformations in the sinonasal tract are seen in nearly 100% of patients with
HHT. Symptoms mainly consist of nosebleeds and nasal obstruction secondary to
blood clots in the nose. In mild cases, nosebleeds may be unilateral and occur
sporadically, but in severe cases, bilateral nosebleeds can occur multiple times
throughout the day resulting in anemia and requiring blood transfusion.
Initial treatment for epistaxis secondary to HHT is prophylactic: avoidance of blood
thinners, humidification of nasal mucosa, and application of nasal pressure.
Nosebleeds are often short-lived and frequently do not require nasal packing. For
nosebleeds that begin to interfere with quality of life, nasal endoscopy with laser
cauterization may be indicated (Figure 2-1).
FIGURE 2-1 A, Zero-degree endoscopic view of arteriovenous malformations
along the right nasal septum. B, A potassium-titanyl-phosphate laser was used
to cauterize the lesions, which resulted in areas of mucosal ischemia. I T ,
Inferior turbinate; S , septum. For those patients who continue to have severe nosebleeds, who require blood
transfusions, and for whom previous laser cauterization attempts have failed,
septodermoplasty may be indicated.
Septodermoplasty is not a cure for HHT epistaxis—AV malformations will often
grow back in time, and long-term results vary from patient to patient.
Anatomy
Please see Chapter 1 for an anatomic description of the nasal septum.
AV malformations associated with HHT are most commonly located on the nasal
septum, anterior head of the middle turbinate, inferior turbinate, and floor of the
nasal mucosa.
AV malformations can be variable in their appearance: they may be either
superficial and flat or broad and raised. Those lesions that are raised are more
resistant to the effects of laser cauterization and often require septodermoplasty.
Preoperative Considerations
Septodermoplasty procedures are performed under general anesthesia. A screening
work-up, including chest radiography, should be performed to rule out large
pulmonary AV malformations that may cause problems during general anesthesia.
A large amount of blood is often lost during the operation. Preoperative blood
transfusions should be considered in patients with a hemoglobin level below 8
mg/dL.
Patients should be counseled preoperatively on the side effects of having a
septodermoplasty before undergoing the procedure. Nasal congestion, decreased
sense of smell, and fetid crusting are common nasal sequelae of the procedure.
Instrumentation
Straight microdebrider
Suction Freer elevator
Dermotome
Suction monopolar cautery
2 bayonet forceps
Pearls and Potential Pitfalls
Pearls
When removing the AV malformations, work briskly to limit overall blood loss.
Subtotal resection of both inferior turbinates will often allow better draping of the
skin graft over the floor of the nasal cavity when there are a large number of
malformations along the floor.
Use the microdebrider to shave away the nasal mucosa while keeping the underlying
perichondrium intact.
Topical epinephrine mixed in thrombin is a quick and effective intraoperative
hemostatic agent.
Potential Pitfalls Make sure to tack the skin graft as high up on the nasal septum as possible. This will
prevent the graft from sliding down the septum in the immediately postoperative
period.
The graft must be immobilized for at least 10 days. Ensure that packing material is
sutured to the nasal septum to prevent displacement down the nasopharynx during
the postoperative period.
Surgical Procedure
Step 1
Use a dermotome to obtain a split-thickness skin graft. Obtain a 12-cm × 6-cm graft
with a thickness of 0.28 inches.
Once the graft is taken, divided it in two, using a 6-cm × 3-cm graft for each side of
the nasal septum.
The skin graft should be long enough to reach the anterior head of the middle
turbinate (Figure 2-2).
FIGURE 2-2 Photograph of a split-thickness skin graft taken to measure
roughly 12 cm by 6 cm.
Step 2
Make a marginal incision bilaterally along the nasal vestibule at the
squamocolumnar junction using a No. 15 blade.
The incision should start lateral to the head of the inferior turbinate and run along
the floor of the nasal cavity and then up along the nasal septum to end at the top ofthe septum (Figure 2-3).
FIGURE 2-3 Drawing of the incision point and area of septal mucosa to be
removed for graft placement. Note U-shaped marginal incision from lateral
nasal wall, across floor, and up to septum in the nose. It is important to remove
all mucosa leading to these incisions to ensure graft integration.
Step 3
Use a straight microdebrider to debride the AV malformations and mucosa off the
nasal septum and nasal cavity floor posterior to the marginal incisions bilaterally.
Take care to debride the mucosa but preserve the perichondrium of the nasal
septum. An intact perichondrium provides a better recipient bed for the skin graft
than exposed cartilage and bone.
This step of the procedure can be quite bloody—work briskly to remove the mucosa
and limit overall blood loss (Figure 2-4).FIGURE 2-4 Zero-degree endoscopic view of debridement of the septal
mucosa using a straight microdebrider. The underlying perichondrium is
preserved. I T , Inferior turbinate; S , septum.
Step 4 (Optional)
If there are a large number of AV malformations along the floor of the nasal cavity
or inferior turbinate, perform total resection of the inferior turbinate.
Medialize the inferior turbinate with a Freer elevator and resect the turbinate to its
attachment to the lateral nasal wall using endoscopic scissors.
Use monopolar cautery to cauterize the posterior attachment to the lateral nasal
wall.
Step 5
Use monopolar cautery to cauterize any AV malformations located along the
anterior head of the middle turbinates.
Step 6
Sew the skin grafts into place.
Starting at the top of the nasal septum, approximate the skin graft to the nasal
vestibule using 5-0 chromic suture.
Begin by placing the skin graft epidermis side down and arranging the graft in front of
the nasal vestibule to rest on a blue towel covering the patient’s mouth.
Use interrupted stitches around the nasal vestibule (Figure 2-5).FIGURE 2-5 Photograph of skin grafts sewn in place around the nasal
vestibule. Note that the epidermis is down.
Step 7
Once both skin grafts are sewn in place, use bayonet forceps in each hand to place
the grafts into the nasal cavity.
A large nasal speculum is useful to help smooth the skin graft against the septum
and nasal floor.
A nasal endoscope is useful to help ensure that the graft drapes over the nasal
septum posteriorly (Figure 2-6).FIGURE 2-6 Photograph showing the use of two bayonet forceps to invert
the skin grafts into the nose and along the nasal septum and floor.
Step 8
Use 3-0 chromic suture on a cutting needle straightened out with hemostat to
mattress the skin grafts to the nasal septum.
A medium-sized nasal speculum is useful to hold the skin grafts against the septum
while the stitch is being placed.
Make sure to place a tacking stitch as high up on the septum as possible. Use
multiple stitches along the height of the nasal septum to tack the skin graft in
multiple locations.
Step 9
Cut a thick sheet of silicone elastomer (Silastic) to fit the nasal septum and then
place it against the grafts to help immobilize the grafts. Use size 2-0 polypropylene
(Prolene) suture to fix the splints in place.
Cut size 28F nasal trumpets to 5 cm in length and place them into the nasal cavity.
Sew them in place across the nasal columella to provide additional immobilization
of the grafts while providing a nasal airway for the patient. Make sure there is space
between the flange of the trumpet and the skin of the nasal vestibule to avoid
pressure necrosis.
These are kept in place for 14 days after the procedure and are removed in the clinic
(Figure 2-7).FIGURE 2-7 Zero-degree endoscopic view of the placement of silicone
elastomer (Silastic) stents and cut nasal trumpets inserted as packing material.
No other packing is used. S , Septum.
Postoperative Considerations
The patient is admitted to the hospital overnight, where hemoglobin level is checked
and the patient is monitored for bleeding.
Antibiotics are prescribed to cover the duration of the nasal packing, and a fresh
dressing is applied to the skin graft donor site.
The trumpets and nasal Silastic stents are removed on postoperative day 14.
Following their removal, the patient is instructed to resume using saline nasal sprays
four times daily.
A nasal septum 4 months after septodermoplasty is shown in Figure 2-8.FIGURE 2-8 Zero-degree endoscopic view of the left nasal septum 4 months
after septodermoplasty. Note healed non–mucus-bearing skin in nasal cavity.
I T , Inferior turbinate; S , septum.C H A P T E R 3
Middle and Inferior Turbinates
Richard R. Orlandi, Justin H. Turner and Peter H. Hwang
Introduction
Turbinate surgery is performed most commonly to treat obstruction. Examples are nasal airway
obstruction caused by oversized inferior turbinates and obstruction of sinus drainage by a lateralized
middle turbinate.
The middle and inferior turbinates are dynamic functional structures within the nasal cavity and sinuses.
Anatomic variations and/or dysfunction commonly lead to the need for turbinate reduction or resection.
Total resection of an inferior turbinate is the extreme and is generally not recommended in most cases
except for neoplasm resection (Figure 3-1).
FIGURE 3-1 Endoscopic view of the right nasal cavity after near total inferior turbinectomy. Patients
with such extensive turbinate resection are at risk for atrophic rhinitis.
Anatomy and Physiology
The turbinates comprise a set of three paired laminar structures that arise from the lateral wall and roof of
the nasal cavity.
The inferior turbinate is its own laminar structure, whereas the middle and superior turbinates form part
of the ethmoid bone.
Each turbinate is composed of a bony base covered by respiratory epithelium with an intervening
submucosal layer.
Although the functions of the turbinates are not completely understood, it is known that they help to
optimize oxygen exchange in the lungs by warming, humidifying, and filtering inspired air.
The turbinates also assist in maintaining directional and laminar airflow in the nose and contribute to
olfaction by directing air toward the olfactory cleft.
The submucosa of the inferior turbinate contains a complex system of capacitance vessels that allow for
selective engorgement or decongestion of the submucosal tissue. This change in turbinate thickness alters
both the cross-sectional diameter of the nasal airway and the surface area of the turbinate.
These anatomic variations change based on the temperature and humidity of inspired air and overall
sympathetic tone of the individual.
The cross-sectional area of the nasal cavity can also be altered by inflammatory swelling of turbinate softtissue.
Preoperative Considerations
When considering turbinate surgery, the surgeon should always remember that the turbinates are
functional organs.
Techniques should target the submucosal tissue, while leaving the functional mucosa intact and
undisturbed.
Bleeding can be minimized by timely injection of 1:100,000 epinephrine (usually in combination with an
anesthetic such as 1% lidocaine).
Inferior turbinate outfracture does not address the vasoactive components of turbinate hypertrophy and is
generally not sufficient as a standalone procedure.
The surgeon should remember that the anterior-most 2 cm of the inferior turbinate account for the
majority of its impact on the nasal airway.
Dissection posteriorly can injure larger vessels branching off the sphenopalatine artery as they enter the
turbinates posteriorly.
Radiographic Considerations
Radiologic imaging is not necessary to assess the inferior turbinates.
For the middle turbinates, closely evaluate the axial and coronal computed tomographic scans.
Identify the inferior and middle turbinates. Identify the nasolacrimal duct and take note of its location in
relation to the inferior turbinate and inferior meatus.
Identify the presence of any concha bullosa and note the anatomy of the middle turbinate as it inserts on
the skull base. Evidence of previous surgical manipulation of the middle turbinate and its effects on the
frontal, ethmoid, and maxillary sinuses should be assessed.
Assess the size and patency of the nasal cavity, as well as the possible contributions of the inferior and
middle turbinates, nasal septum, and other anatomic structures on nasal obstruction.
Instrumentation
0- and 30-degree endoscopes
Boies-Goldman elevator
Freer elevator
Straight microdebrider with or without turbinate blade
Monopolar or bipolar radiofrequency ablation device (optional)
Monopolar needle electrocautery device (optional)
Sickle knife or scalpel
Straight and angled through-cutting forceps
Endoscopic scissors
Pearls and Potential Pitfalls
Care should be taken when operating on the turbinates, with the goal being to preserve or restore normal
function.
The most conservative procedure that can accomplish this goal is the best option, with more destructive
techniques reserved for treatment failures, which are uncommon.
Thermal injury caused by aggressive soft tissue reduction of the inferior turbinate can result in
problematic complications such as mucosal sloughing and crusting.
Surgery directed at the more posterior portions of the inferior or middle turbinate do little to address the
nasal airway but can dramatically increase the risk of substantial bleeding.
Surgical Procedures
Surgery Of The Inferior Turbinate
Nasal obstruction is the primary indication for inferior turbinate surgery.
Some evidence exists to support the use of inferior turbinate surgery to improve the symptoms of allergic
rhinitis.
Surgery of the inferior turbinate can be classified into a sequence ranging from least invasive to most
invasive: outfracture, soft tissue resection, resection of bone and soft tissue, and full-thickness resection ofthe anterior portion.
Inferior Turbinate Outfracture
Outfracture is the simplest and least invasive of the inferior turbinate procedures because no tissue is
removed.
Because outfracture does not modify soft tissue, the vasoactive components of turbinate hypertrophy are
not addressed by this technique.
The inferior turbinate bone attaches to the lateral nasal wall at an angle, so that outfracture requires
pressure on the bone in an inferior-lateral, not just lateral, direction.
Gentle technique is necessary to avoid injury to the orifice of the nasolacrimal duct in the lateral wall of
the inferior meatus.
Step 1
Under direct visualization, place a Freer or similar elevator within the inferior meatus and fracture the
turbinate upward and medially (Figure 3-2, A).
FIGURE 3-2 Artist’s depiction of inferior turbinate outfracture in endoscopic view. A, Inferior
turbinate is medialized so that the fracture point of the bore is at the attachment of the lateral nasal
wall. B, Inferior turbinate is lateralized with a Freer or Boies-Goldman elevator to create a larger
inferior airway.
Step 2
Place a Boies-Goldman or Freer elevator on the superior and medial surface of the turbinate and
outfracture it laterally and inferiorly (Figure 3-2, B).
Inferior Turbinate Soft Tissue Resection
Many techniques can be used to address the soft tissue of the inferior turbinates.
Some devices that use thermal or radiofrequency energy remove tissue to some degree but work largely by
causing wound contraction.
Most, but not all, techniques target the submucosal tissue while leaving the functional mucosa intact.
Submucosal needle electrocautery is, in many ways, the simplest of these techniques but is also very
imprecise.
Laser ablation essentially resurfaces the mucosa, with some ablation of the submucosa as well. The
equipment costs can be substantial.
Ablation and electrocautery both subject the overlying mucosa to thermal injury, which sometimes results
1in mucosal sloughing and crusting. Radiofrequency devices for performing inferior turbinate reduction can be either unipolar or bipolar, and
2no appreciable difference in outcomes is seen with the two methods.
The impact of soft tissue reduction on the nasal airway is largely due to alterations in the anterior portion
of the inferior turbinate. Reduction posteriorly does not significantly improve the nasal airway and can
significantly increase the risk of bleeding.
Several careful analyses of outcomes following inferior turbinate surgery have been performed over the
last few years.
– A large study comparing subtotal turbinectomy, laser cautery, electrocautery, cryotherapy, submucosal
resection, and submucosal resection combined with outfracture found the best outcome at 6 years of
3follow-up in patients treated with submucosal resection combined with outfracture. This is the
preferred technique.
– Comparisons between bipolar radiofrequency ablation and microdebrider submucosal resection have
shown improvement in symptoms with both techniques, with the microdebrider technique yielding
4,5greater improvement over a longer period of time.
Step 1
Under direct visualization, either with a nasal speculum or 0-degree endoscope, inject the inferior
turbinate with 1% lidocaine with 1:100,000 epinephrine.
Step 2
Using a scalpel or similar leading edge of the microdebrider device, make a stab incision just posterior to
the mucocutaneous junction of the inferior turbinate (Figure 3-3).
FIGURE 3-3 Artist’s depiction of the incision point into the left inferior turbinate submucosa in
endoscopic view.
Step 3
Elevate soft tissue off of the underlying bone by subperiosteal dissection with a Freer or Cottle elevator or
elevator portion of the microdebrider device (Figure 3-4).FIGURE 3-4 Endoscopic view of the left inferior turbinate bone exposed by incising the anterior soft
tissue.
Step 4
Once the tissue is elevated off of the bone, insert the oscillating microdebrider blade into the soft tissue
pocket and engage the blade with soft tissue in a circular direction. Direct the active face of the
microdebrider blade away from the turbinate bone.
A slow oscillation speed facilitates controlled resection of the submucosal tissue without injuring the
overlying mucosa.
Direct soft tissue reduction toward the anterior two thirds of the inferior turbinate.
Step 5
Sculpt the soft tissue until adequate reduction is achieved.
Preserve the overlying mucosa.
Bleeding from the stab incision can be controlled, if necessary, using unipolar or bipolar electrocautery.
Other Methods
Other techniques for soft tissue reduction, including electrocautery, radiofrequency ablation, and laser
ablation, are implemented in accordance with the device manufacturer’s instructions.
In general, the device is inserted into the anterior surface of the turbinate, and multiple passes are made
while the device is activated.
The tip of the submucosal energy-delivering device should remain as far as possible below the surface to
prevent mucosal injury.
Submucosal Resection of Bone and Soft Tissue of the Inferior Turbinate
Submucosal resection of the inferior turbinate is indicated when the bone is significantly hypertrophic.
This technique is often combined with other soft tissue procedures.
The flaps can be partially resected, if necessary, to shorten the turbinate’s height.
Step 1
Follow the steps for inferior turbinate soft tissue resection outlined earlier.
Step 2
Remove the underlying bone sharply using a combination of backbiters, through-cut instruments, andmicrodebrider. Ensure that all resected bone is removed from the soft tissue pocket (Figure 3-5).
FIGURE 3-5 Artist’s depiction of the dissection of the pocket of the inferior turbinate bone in
endoscopic view. Grasping with Blakesley forceps and using a twisting motion is a good method of
removal.
Step 3
Replace the mucosal flap and place packing, if necessary, to keep the flap in place.
Full-Thickness Resection of the Anterior Portion of the Inferior Turbinate
Conservative resection of the anterior 1 to 2 cm of the inferior turbinate is usually well tolerated.
The bone exposure resulting from this technique can sometimes lead to longer healing times and extensive
crusting.
Extensive removal of the inferior turbinate may lead to atrophic rhinitis, characterized by a paradoxical
sense of obstruction due to loss of laminar airflow, and is therefore discouraged.
Step 1
Inject the anterior end of the inferior turbinate with 1% lidocaine with 1:100,000 epinephrine.
Step 2
Under direct visualization with a 0-degree endoscope, place a Freer elevator into the inferior meatus and
infracture the inferior turbinate medially and superiorly.
Step 3
Remove the soft tissue overlying the lateral surface of the inferior turbinate either by using a
microdebrider or by incising the mucosa and elevating it sharply off of the bone.
Step 4
Remove the bone of the lateral and anterior surface of the inferior turbinate using through-cutting
instruments and backbiters (Figure 3-6).FIGURE 3-6 Artist’s depiction of an endoscopic view of resection of the anterior head of the left
inferior turbinate using scissors.
Step 5
Redrape the mucosa over the resected surface and lateral surface of the inferior turbinate and place
packing, if necessary.
Surgery Of The Middle Turbinate
Resection of a Concha Bullosa
A concha bullosa is an enlargement of the middle turbinate caused by pneumatization of the turbinate
bone.
6 Concha bullosa of the middle turbinate is found more commonly in patients with chronic rhinosinusitis.
During the course of surgical treatment for chronic ethmoid sinusitis, it is typically necessary to partially
resect this cell to ensure its drainage and facilitate access into the remainder of the ethmoid cavity.
It is important to recognize that the concha bullosa represents a functioning ethmoid sinus cell. Surgical
resection should consequently adhere to the same principles of mucosal preservation and promotion of
physiologic drainage that are followed in other types of functional endoscopic sinus surgery.
In nearly all cases, the medial aspect of the concha bullosa attaches to the cribriform plate, so that typically
the lateral wall is removed during resection (Figure 3-7).