Anatomical Principles of Endoscopic Sinus Surgery: A Step by Step Approach Renuka Bradoo
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1Anatomical Principles of Endoscopic Sinus Surgery: A Step by Step Approach
2Anatomical Principles of Endoscopic Sinus Surgery: A Step by Step Approach
Renuka Bradoo MS DORL Professor and Head Department of ENT and Head and Neck Surgery Lokmanya Tilak Municipal Medical College and General Hospital Sion, Mumbai
3Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
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Anatomical Principles of Endoscopic Sinus Surgery: A Step by Step Approach
© 2005, Renuka Bradoo
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.
First Edition : 2005
9788180613463
Typeset at JPBMP typesetting unit
Printed at Gopsons Papers Ltd., A-14, Sector 60, Noida
4Dedicated to
Anil
For being both my anchor and the wind in my sails
Anjali and Anant Savant
My parents
For translating my dreams into reality
Mohini and Mohanlal Bradoo
My in-laws
For their unstinting support always
And
Rishi and Hriday
Who make it all worthwhile
5Foreword
Endoscopic Sinus Surgery (ESS) has progressed immensely in the last 2 decades. The interest in the subject and the desire to acquire proficiency in the surgical technique has led to enthusiastic attendance at numerous ‘workshops’ being conducted in India and abroad. The introduction of motorized instruments, laser, image guided surgery etc., and the evolving concepts of the ‘right way’ to do the surgery are steps to making this procedure as ‘functional’ as possible. The basic need of the aspiring surgeon however, is still an accurate knowledge of the anatomy of the region, a 3 dimensional concept, which will allow him to approach and clear disease from the narrow recesses of the nose and the paranasal sinuses and restore function to near normal.
Dr Renuka Bradoo, who is currently the Professor and Head, Department of ENT and Head and Neck Surgery at the Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, has been an outstanding teacher, a skilled surgeon and a brilliant speaker as evidenced by the numerous lectures and workshops she has conducted in ESS.
She has been interested in the subject for many years. This book authored by her exemplifies her methodical approach and the tremendous efforts she has put into make it as complete as possible. The book has been well planned and carries several colored illustrations of very high quality. The text in the various chapters is excellent in its clarity of presentation. I am confident that this book will be of immense value to all aspiring and established sinus surgeons.
Dr MV Kirtane
Mumbai
6Preface
This book was not planned to be written. It grew out of my experience and took on an identity of its own. Over the last few years, I have been guest faculty at various endoscopic sinus surgery workshops throughout the country besides conducting workshops at my own institution. One of the lectures I am often asked to take is the one on the anatomy of lateral nasal wall. Almost invariably, after the lecture various colleagues would approach me to know where they could access the material I had just discussed, on a regular basis. It was then, that I realized the need for a book dedicated exclusively to anatomy of the nose and paranasal sinuses as viewed by an endoscopic surgeon. It also went hand in hand with my absolute belief that to be a safe but effective endoscopic sinus surgeon one needs to have a very strong foundation of anatomy. In fact, the entire skull should be mapped in 3-dimensional form in the surgeon's brain. It is with this in mind that I have written a separate chapter on osteology.
Two chapters which complement each other include the anatomy of the Lateral Nasal Wall as seen in sagittal section and the Endoscopic Anatomy as seen by the surgeon in a live patient. These are illustrated in a stepwise manner. The chapter on Endoscopic Anatomy is accompanied by a CD-ROM.
Another prerequisite of a clinically sound surgeon is that he should be able to read the fine nuances of a CT scan of the paranasal sinuses. Anyone can say whether the sinuses are diseased or normal. What is required is to have a detailed knowledge of both normal findings and anatomical variations seen on the CT scan so that it can be used as a compass or road map during surgery. I have therefore included two chapters, one on reading the normal CT scan and a separate one on deviations from the normal.
The chapter on surgical anatomy is more of a summary of different facts that we already know or should know, put together in one comprehensive capsule.
The first chapter, very suitably, deals with embryology of the nose and paranasal sinuses because ‘….he sees things best who sees them from the beginning’. It answers in many cases- the reason why?
I have tried to illustrate the book extensively using cadaveric dissection specimens with explanatory line diagrams alongside. There are also endoscopic pictures, CT scans and schematic diagrams.
I hope this book proves to be useful to you and that you enjoy reading it as much as I have enjoyed writing it.
Renuka Bradoo
7Acknowledgements
The book has my name on its cover, but I owe this effort to many people who have touched my life in so many ways.
I would like to thank all my patients who have been my first and foremost teachers. Dr Gadre, Dr Bhargava and Dr Morwani, my teachers in the formal sense, opened up the vistas of ENT for me. I have learnt a great deal from Dr Kirtane, whom I think of as a guru. Dr Dale Rice first sparked off my interest in endoscopic sinus surgery when I watched him operate on his visit to India. I never cease to be amazed by the poetry of Dr Sethi's surgery. Watching him has helped me to fine tune many of my surgical techniques.
I have been fortunate in having an excellent faculty in my department—Dr Nerurkar, Dr Joshi and Dr Kalel. They have held the fort whenever I have been away and made valuable suggestions. I also take this opportunity to thank my residents and Dr Sujata Muranjan for the numerous times that they have burnt the midnight oil with me. Dr Mishra helped me research the first chapter of Embryology. My very special thanks to Dr Jayesh Shah, my student and now my colleague without whose hard work and persistence this book would have remained just a dream and never have seen the light of the day.
There are a myriad of technical inputs which go into making a book like this one. I would like to thank M/s Chimco Biomedical and Infometry for helping me to shoot the endoscopic images, Mr Khan and Mr Chandrakant Desai for photographing the cadaveric images and Mr Krishna Patil and Ganesh for the artwork. Dr PP Rao helped me with digitizing the images. Mrs Lakshmi Nakhawa was invaluable as always for her secretarial help and her down to earth common sense. The “other” Lakshmi, Ms Lakshmi Perla typed the manuscript many times over.
I owe my thanks to various Heads of Departments—Dr Athaviya, Head, Department of Anatomy and Dr Pathak, Head, Department of Forensic Medicine for providing me cadavers on which I could conduct my dissections and research, Dr Merchant and Dr Joshi of the Department of Radiology for letting me choose CT scans from their archives. I would also like to thank, Dr ME Yeolekar, Dean, Lokmanya Tilak Municipal Medical College and General Hospital.
On a personal note, my family and friends have always been a tremendous support system cushioning me in my setbacks and rejoicing in my triumphs.
9Abbreviations A
Atrium
AEA
Anterior ethmoid artery
AEC
Anterior ethmoid cell
Ag
Agger nasi
AO
Accessory ostium
B
Bulla ethmoidalis
CG
Crista galli
EO
Eustachian tube opening
FS
Frontal sinus
FI
Frontal infundibulum
FO
Frontal ostium
FR
Frontal recess
GL
Ground lamella
HSI
Hiatus semilunaris inferioris
HSS
Hiatus semilunaris superioris
I
Infundibulum
ICA
Internal carotid artery
IT
Inferior turbinate
LP
Lamina papyracea
MO
Maxillary ostium
MR
Medial rectus
MS
Maxillary sinus
MT
Maxillary turbinate
NLD
Nasolacrimal duct
ON
Optic nerve
PEA
Posterior ethmoid artery
PEC
Posterior ethmoid cell
Pit
Pituitary
PPF
Pterygopalatine fossa
S
Septum
SER
Sphenoethmoidal recess
SL
Sinus lateralis
SO
Sphenoid ostium
SS
Sphenoid sinus
ST
Superior turbinate
U
Uncinate process
V
Vestibule