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Endoscopic Endonasal Surgery: Sinuses & Beyond
Milind V Kirtane
CHAPTER 1:
Lateral Nasal Wall
INTRODUCTION
OVERVIEW
VESTIBULE AND ATRIUM
TURBINATES
OSTIOMEATAL UNIT
MAXILLARY OSTIUM
FRONTAL RECESS
Uncinate Process
ETHMOID LABYRINTH
SPHENOETHMOIDAL RECESS AND SPHENOID SINUS
CONCLUSION
CHAPTER 2:
Endoscopic Surgical Anatomy
INTRODUCTION
DIAGNOSTIC ENDOSCOPY
First Pass
Second Pass
Third Pass
TURBINATES
Middle Turbinate
DISSECTION OF FRONTAL RECESS
DISSECTION OF THE ETHMOID SINUS AND THE OSTIOMEATAL UNIT
DISSECTION OF POSTERIOR ETHMOID CELLS
“WANDERING” CELLS
DISSECTION OF SPHENOID SINUS
CHAPTER 3:
Imaging for Paranasal Sinuses
INTRODUCTION
PRE-FESS CT CHECKLIST
Coronal View
Structures Better seen on the Coronal Scan
Axial View
Structures Better seen on the Axial Scan
Sagittal View
Structures Better seen on Sagittal Scan
HOW TO APPROACH CT SCAN READING?
Step 1
Step 2
Discussion of Surgical Approach with Respect to CT Scan Reading
Frontal Sinus Approach and Role of CT Scan
From the Above Scans
Approach to Maxillary Sinus Ostium and Role of CT Scan (Figs 3.4A and B)
From the Scans Below
Approach to the Ethmoid Sinus and Role of CT Scan (Figs 3.5 and 3.6)
From the Above Scans
Approach to the Sphenoid Sinus and Role of CT Scan (Figs 3.7 and 3.8)
From the Below Scans
CONCLUSION
CHAPTER 4:
Preoperative Preparation of Functional Endoscopic Sinus Surgery
INTRODUCTION
INDICATIONS OF SURGERY
GOALS OF SURGERY
PATIENT MANAGEMENT BEFORE SURGERY
Preoperative Evaluation
Key Points
Preoperative Medical Treatment
Anesthesia for Endoscopic Sinus Surgery
Preparation of Nasal Cavity
Preoperative CT Scan Checklist
POSTOPERATIVE MANAGEMENT
CHAPTER 5:
Postoperative Management after Functional Endoscopic Sinus Surgery
INTRODUCTION
NEED FOR POSTOPERATIVE CARE
PATIENT COUNSELING AND ADVICE
RESUMING ACTIVITIES5
NASAL IRRIGATION
MEDICAL TREATMENT
CLEANING AND DEBRIDEMENT
Treatment in First Postoperative Week
Treatment in Second Postoperative Week
Treatment in Third Postoperative Week
Treatment During the Late Postoperative Phase
CONCLUSION
CHAPTER 6:
Endoscopic Ethmoid Sinus Surgery
INDICATIONS OF ETHMOIDECTOMY
PRESURGICAL CONSIDERATIONS
STEPS OF ETHMOIDECTOMY
Uncinectomy (Infundibulotomy)
Resection of Ethmoid Bulla (Anterior Ethmoidectomy)
Posterior Ethmoidectomy
REVISION SURGERY
CLEANING AND PACKING
MUCOSAL PRESERVATION AND PREVENTION OF ADHESIONS
OPTIMIZING THE SURGICAL FIELD
MANAGEMENT OF COMPLICATIONS
Anterior or Posterior Ethmoid Artery Transection
Management of Damage to the Lamina Papyracea
Intraoperative CSF Leak
POSTOPERATIVE CARE
SUMMARY
CHAPTER 7:
Endoscopic Surgery for the Frontal Sinus
INTRODUCTION
Why is it so Difficult?
EMBRYOLOGY
ENDOSCOPIC ANATOMY
Supraorbital Cell (Figs 7.5A and B)
Frontal Bullar Cell (Fig. 7.6)
Interfrontal Sinus Septal Cell (Fig. 7.7)
Recessus Terminalis
OTHER FACTORS AFFECTING THE FRONTAL SINUS OUTFLOW TRACT17
Thickness of the Frontal Beak
Anteroposterior Diameter of the Frontal Isthmus
Anteroposterior Diameter of the Frontal Recess
PATHOLOGIES AFFECTING THE FRONTAL SINUS
Rhinosinusitis
Acute Rhinosinusitis
Chronic Sinusitis19,20
IMAGING FOR THE FRONTAL SINUS
Computed Tomography (CT)
MAGNETIC RESONANCE IMAGING
Three-dimensional Reconstructed Images
APPROACHES TO THE FRONTAL SINUS
Endoscopic Frontal Sinusotomy
Axillary Flap Technique (Fig. 7.11)
ENDONASAL FRONTAL SINUS SURGERY TYPE I–III
Type I
Type II
Indications for a Draf Type II
Type III/Median Drainage
Indications for Draf Type III
Outcomes of Frontal Sinus Drilling
FRONTAL SINUS TREPHINATION
Causes of Failure
STENTING IN THE FRONTAL RECESS
Material for Stenting
Indication for Stenting
Duration of Stenting
Postoperative Care of the Stent
CONCLUSION
CHAPTER 8:
Endoscopic Maxillary Sinus Surgery
HISTORY
ANATOMY
PNEUMATIZATION AND GROWTH
CLINICAL ANATOMY
PHYSIOLOGY OF SINUS DRAINAGE
PATHOLOGY
CLINICAL FEATURES OF RHINOSINUSITIS
MEDICAL MANAGEMENT OF RHINOSINUSITIS
PREOPERATIVE EVALUATION OF PATIENT
INDICATIONS OF MAXILLARY SINUS SURGERY
PREOPERATIVE PREPARATION OF PATIENT
STEPS OF SURGERY
TIPS FOR COMPLETE CLEARANCE OF ANTROCHOANAL POLYP
POSTOPERATIVE CARE
COMPLICATIONS
DIFFICULTIES ARISING IN ENDOSCOPIC MAXILLARY SINUS SURGERY
CHAPTER 9:
Approach to the Sphenoid Sinus
INTRODUCTION
ANATOMY
SURGICAL APPROACHES
Trans-septal Sphenoidotomy
Sublabial Trans-septal Approach
External Rhinoplasty Approach
Columellar Flap Modification
Transantral Sphenoidotomy
External Transorbital Transethmoidal Sphenoidotomy
Transpalatal Sphenoidotomy
Endoscopic Endonasal Sphenoidotomy
Paraseptal Approach
Intermediate Approach
Lateral Approach
Endoscopic Transnasal with Posterior Septectomy
PATHOLOGIES
COMPLICATIONS OF SPHENOID SURGERY
Epistaxis
Carotid Artery Damage
LANDMARKS AND PRECAUTIONS DURING SPHENOID SURGERY
SPHENOID AS A ROUTE
CHAPTER 10:
Sinonasal Polyposis
INTRODUCTION
PATHOPHYSIOLOGY AND THEORIES
OTHER DISEASES ASSOCIATED WITH NASAL POLYPOSIS
SYMPTOMS
SIGNS
DIFFERENTIAL DIAGNOSIS
INVESTIGATIONS
Radiological Investigations
MEDICAL MANAGEMENT
Dosage
Newer Drugs
Immunomodulators
Surgical Treatment
RECURRENCE
Management of Recurrences
SUMMARY
CHAPTER 11:
Rhinosinusitis
DEFINITION
DURATION OF THE DISEASE IN ADULTS
ACUTE RHINOSINUSITIS
Definition
Classification of Acute Rhinosinusitis
Predisposing Factors: Rhinosinusitis
Pathophysiology of Acute Rhinosinusitis
Diagnosis and Management of Acute Rhinosinusitis
Treatment Strategy
Antimicrobial Therapy
Role of Intranasal Steroids
Decongestant Therapy
Antihistaminics
Saline Administration
CHRONIC RHINOSINUSITIS
Definition
Diagnosis
Investigations
Primary Investigations
Medical Management of Chronic Rhinosinusitis
Aim of Treatment
Nasal Saline Irrigation and Saline Nasal Spray
SUMMARY
CHAPTER 12:
Invasive Fungal Sinusitis
INTRODUCTION
CLASSIFICATION
Acute Fulminant Invasive Fungal Sinusitis
Chronic Invasive Fungal Sinusitis
Granulomatous Invasive Fungal Sinusitis
MICROBIOLOGY5,6,8,11,12
PATHOGENESIS
CLINICAL FEATURES
Symptoms
Examination
INVESTIGATIONS
Microbiology
Fungal Stains and Microscopy22
Fungal Cultures
Histopathology
Imaging
Computed Tomography
Magnetic Resonance Imaging
Magnetic Resonance Angiography
Cerebrospinal Fluid Examination
Nonculture-based Tests
TREATMENT
Medical Management
Antifungal Therapy
Surgical Management
Adjunctive Treatment
Desferroxamine
Hyperbaric Oxygen
Other Adjunctive Therapies
PROGNOSIS
CHAPTER 13:
Instrumentation in Functional Endoscopy Sinus Surgery
INTRODUCTION
OPERATION THEATER LAYOUT
ENDOSCOPES
Cyclops
CAMERA
SUCTION TIPS
SICKLE KNIFE
FREER ELEVATOR
BALL PROBES
CURETTES: STRAIGHT AND CURVED CURETTES
BLAKESLEY FORCEPS
THROUGH-CUTTING INSTRUMENTS: RHINOFORCE BLAKESLEY
TOBEY REVERSE CUTTING FORCEPS AND STAMMBERGER ANTRUM PUNCH
STAMMBERGER MUSHROOM PUNCH
KERRISON PUNCH
BELLUCCI SCISSORS
HEUWIESER ANTRUM GRASPING FORCEPS
GIRAFFE FORCEPS (KUHN)
STAMMBERGER SIDE-BITING PUNCH FORCEPS
MICRODEBRIDER POWER SHAVERS
NASAL PACKING
DISSOLVABLE NASAL PACKING
SUCTION DIATHERMY
Unipolar Cautery
Bipolar Suction Diathermy
BALLOON CATHETER
IMAGE-GUIDANCE SYSTEMS
PROCEDURE
CHAPTER 14:
Endoscopic Sinus Surgery in Orbital Lesions
INTRODUCTION
ENDOSCOPIC APPROACH
ORBITAL ABSCESS
ORBITAL DECOMPRESSION OF GRAVES' ORBITOPATHY
ORBITAL HEMATOMA
Iatrogenic Orbital Hematoma
BLOW OUT FRACTURE OF THE ORBIT
FOREIGN BODY OF THE ORBIT
ORBITAL TUMOR
ENDOSCOPIC ASSISTED ORBITAL LESION
TIPS AND PEARLS
LIMITATIONS
CONCLUSION
CHAPTER 15:
Endoscopic Decompression for Post-traumatic Optic Neuropathy
INTRODUCTION
HISTORICAL ASPECTS
SURGICAL ANATOMY
PATHOPHYSIOLOGY
PREOPERATIVE WORK-UP
OPHTHALMIC EXAMINATION
IMAGING
MEDICAL THERAPY
SURGICAL MANAGEMENT
Preoperative Care
Procedure
Postoperative Care
COMPLICATIONS
CHAPTER 16:
Endoscopic Dacryocystorhinostomy
HISTORY
ANATOMY
Lacrimal Gland
Lacrimal Ducts
Lacrimal Sac
Valves (Fig. 16.2)
Dimensions
ENDOSCOPIC ANATOMY (FIG. 16.4)
PHYSIOLOGY OF LACRIMATION
Neural Supply
CLINICAL FEATURES OF DACRYOCYSTITIS
Preoperative Evaluation of the Patient
DIAGNOSTIC NASAL ENDOSCOPY
PREOPERATIVE PATIENT PREPARATION
ANESTHESIA
STEPS OF SURGERY
CHALLENGES FACED IN SURGERY
STEPS TO ENHANCE SUCCESS RATES IN ENDOSCOPIC DACRYOCYSTORHINOSTOMY
PACK REMOVAL AND TREATMENT
STENT REMOVAL AND RESULTS
ADVANTAGES OF ENDOSCOPIC DACRYOCYSTORHINOSTOMY
COMPLICATIONS
Complications of Surgery
Intraoperative
Postoperative
Complications of Stent (Silicone)
CONCLUSION
CHAPTER 17:
Endoscopic Management of Epistaxis
INTRODUCTION
ANATOMY
CAUSES OF EPISTAXIS
PATHOPHYSIOLOGY
MANAGEMENT
ENDOSCOPIC ELECTROCAUTERIZATION
ENDOSCOPIC LIGATION OF SPHENOPALATINE ARTERY
CHAPTER 18:
Juvenile Nasopharyngeal Angiofibroma
INTRODUCTION
EPIDEMIOLOGY
ETIOPATHOGENESIS
PATHOLOGY
MODE OF SPREAD
CLASSIFICATION
Andrew-Fisch Classification (1989)
Radkowski Classification
BLOOD SUPPLY
CLINICAL FEATURES
DIAGNOSIS
TREATMENT
Surgical Management
Open Surgical Approaches
Endoscopic Approach
Radiotherapy
Medical Treatment
COMPLICATIONS
PROGNOSIS
CHAPTER 19:
Pituitary Tumors
INTRODUCTION
Histological Classification
Classification by Size
Classification as Per Function
EPIDEMIOLOGY
CLINICAL FEATURES
Endocrine Effects
MASS EFFECT OF TUMOR
INVESTIGATIONS
Radiological Investigations
Perimetry
MANAGEMENT (FLOW CHART 19.1)
Medical Management
Radiotherapy
Gamma Knife
Surgical Management
Trans-septal Approach
Transethmoidal Approach
Transcranial Approach
Trans-sphenoidal Endoscopic Approach
EQUIPMENT
ANESTHESIA AND POSITION
SURGICAL TECHNIQUE
COMPLICATIONS
Intraoperative
Postoperative Complications
Endocrine Complications
Recurrence
OTHER LESIONS IN THE PITUITARY
Craniopharyngioma
Rathke's Pouch Cyst
Chordomas
MALIGNANT TUMORS OF THE PITUITARY
CHAPTER 20:
Endoscopic Approach to Sinonasal and Anterior Skull-Base Tumors
INTRODUCTION
PROGRESS
BIOLOGY OF TUMORS
EVALUATION
TREATMENT
WHY TRANSNASAL SURGICAL ACCESS?
IS ENDONASAL ACCESS SUITABLE?
CONTRAINDICATIONS
Oncologic Results
Preservation of Uninvolved Structures
Steps of Resection
Endonasal Endoscopic Resection
Combined Approach
Combined Endoscopic with Orbital Resection
Combined Endoscopic and Craniotomy Access (Cranioendoscopic Resection)
DEBATE: ENDOSCOPIC SURGERY VERSUS CONVENTIONAL SURGERY
AUTHOR'S EXPERIENCE
CONCLUSION
CHAPTER 21:
Endoscopic Management of Cerebrospinal Fluid Rhinorrhea
INTRODUCTION
HISTORICAL ASPECTS
PATHOPHYSIOLOGY
Physiology of Cerebrospinal Fluid Production
Sites of Cerebrospinal Fluid Production
Classification of Cerebrospinal Fluid Leaks
Congenital
Acquired
Sites of Cerebrospinal Fluid Leaks
CLINICAL PRESENTATION
MANAGEMENT
Preoperative Assessment
Nasal Endoscopy
Biochemical Tests
Imaging
Intrathecal Fluorescein
CONSERVATIVE MANAGEMENT
SURGICAL MANAGEMENT
Indications for Surgery
Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea
Principles of Endoscopic Repair
Approaches to the Defect Site
Sphenoid Sinus
Frontal Recess and Frontal Sinus
Types of Reconstruction
Underlay Technique
Overlay Technique
Combined Underlay-Overlay Technique
Bath Plug Technique48
Fascia, Cartilage, Fascia “Sandwich” Technique
Drawbacks of Various Grafting Materials
Nasal Packing
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATIONS
Limitations of Endoscopic Techniques
Failure of Endoscopic Repair32,55–57
CHAPTER 22:
Complications of Endoscopic Sinus Surgery
INTRODUCTION
CLASSIFICATION OF COMPLICATIONS OF ENDOSCOPIC SINUS SURGERY
RISK FACTORS FOR COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY
ORBITAL COMPLICATIONS
Nasolacrimal Duct Injury
Periorbital Ecchymosis
Management
Intraorbital Hemorrhage
Management
Extraocular Muscle Injury
Management
Periorbital Emphysema
Management
Optic Nerve Injury
Assessment of Optic Nerve Injury
Management
PREVENTION OF ORBITAL COMPLICATIONS
Preoperative Steps to Prevent Complications
Intraoperative Steps to Prevent Complications
INTRACRANIAL COMPLICATIONS IN ENDOSCOPIC SINUS SURGERY
Cerebrospinal Fluid Rhinorrhea
Risk Factors for Cerebrospinal Fluid Rhinorrhea
Management of Cerebrospinal Fluid Leaks
Pneumocephalus
Management
Injury to Great Vessels/Hemorrhage
Implications of Carotid Injury
Meningitis
Routes of Spread of Infection
Common Presenting Features
Commonly Involved Organisms
Diagnosis
Management
Common Sequelae
Brain Abscess
Frontal Lobe Damage
Anosmia
INTRANASAL COMPLICATIONS OF ENDOSCOPIC SINUS SURGERY
Bleeding
Adhesions and Synechia Formation
Crusting
Osteitis
PEARLS AND PERILS FOR SAFE ENDOSCOPIC SINUS SURGERY
Preoperative Management for Optimal Surgical Field
Study the CT Scan Diligently
Prepare the Intraoperative Field
Identify Landmarks
Be Meticulous in your Surgery
Learn from your Mistakes
CHAPTER 23:
Image-guided Sinus Surgery
INTRODUCTION
HISTORY
TECHNOLOGY AND PRACTICAL USE
STEPS TO GET STARTED WITH THE NAVIGATION SYSTEM
CLINICAL INDICATIONS FOR NAVIGATION SURGERY
Revision Surgery
Anatomical Variants
Extended Procedures
SURGICAL ADVANTAGES
LIMITATIONS
CHAPTER 24:
Nasal Packing Materials
INTRODUCTION
Difference between Dissolvable and Removable Nasal Packing
NONABSORBABLE NASAL PACKING MATERIALS
Vaseline or Paraffin Ribbon Gauze Packing
BIPP Ribbon Gauze Packing
Merocel Packing
Features
ABSORBABLE NASAL PACKING MATERIALS
Gelfoam
Surgicel and Fibrillar
FloSeal
Fibrin Glue
Merogel
NEWER ABSORBABLE NASAL PACKS
NasoPore
PosiSep and PosiSepX (Chitosan Nasal Packing)
Description
Indications for Use
NexStat, NexFoam and NexPak
NexStat Topical Hemostat Powder
NexFoam Topical Hemostat Sponge
NexPak Topical Hemostat Sponge (Fig. 24.5)
ACKNOWLEDGMENTS
CHAPTER 25:
Revision Endoscopic Sinus Surgery
INTRODUCTION
INDICATIONS FOR REVISION SINUS SURGERY2
DIAGNOSIS AND PREOPERATIVE EVALUATION
Diagnostic Nasal Endoscopy
Imaging Studies
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
CT-MRI Fusion
Three-dimensional Computed Tomography Angiography (3DCTA)
TECHNIQUES OF REVISION SURGERY
General Considerations
Anatomical Landmarks for Revision Surgery11
Maxillary Sinus Revision Surgery
Frontal Sinus Revision Surgery
Draf Procedures17
Frontal Sinus Rescue Procedure
Revision Surgery of the Ethmoid Sinuses
Causes for Recurrence of Ethmoid Disease2
Revision Surgery of the Sphenoid Sinus
Causes for a Revision Sphenoid Sinus Surgery
Image Guidance
POSTOPERATIVE CARE
CONCLUSION
CHAPTER 26:
Balloon Sinuplasty
INTRODUCTION
BALLOON SINUPLASTY SYSTEM
Guidewire (Fig. 26.1)
Cannula (Fig. 26.2)
Balloon (Fig. 26.3)
Balloon Sizes
Relieva® Stratus (Fig. 26.5)
Frontal Deployment Guide (Fig. 26.6)
Vortex (Fig. 26.7)
PROCEDURE
Balloon Introduction
Hybrid Procedure
Procedure
Frontal Sinus
Maxillary Sinus
Sphenoid Sinus
CLINICAL STUDIES FOR SAFETY AND EFFICACY
RECENT ADVANCES
SUMMARY
ACKNOWLEDGMENTS
CHAPTER 27:
Pediatric Endoscopic Sinus Surgery
INTRODUCTION
ANTROCHOANAL POLYP
ETHMOIDAL POLYPI
MENINGOCELE
DEVIATED NASAL SEPTUM
CONGENITAL DACRYOCYSTOCELE
CHOANAL ATRESIA (CA)
JUVENILE ANGIOFIBROMA
HEMANGIOMA
NASAL GLIOMA
PREOPERATIVE WORK-UP
ANESTHESIA
INSTRUMENTS
TIPS AND PEARLS
CONCLUSION
CHAPTER 28:
Imaging of Paranasal Sinuses Pathologies
INTRODUCTION
GENERAL CONSIDERATIONS
CT Scan
MRI
PET CT
COMMON PATHOLOGICAL CONDITIONS
Silent Sinus Syndrome
Acute Sinusitis
Chronic Rhinosinusitis (CRS)
Infundibular Pattern
Ostiomeatal Unit Pattern
Sphenoethmoid Recess Pattern
Nasal Polyposis Pattern
Sporadic Pattern
Aggressive Inflammatory Lesions
Allergic Fungal Rhinosinusitis
Acute Invasive Fungal Sinusitis
Chronic Invasive and Granulomatous Invasive Fungal Sinusitis
Granulomatous Disease of Sinonasal Cavities
CT-MRI CISTERNOGRAPHY
Sinonasal Tumors
Special Issues
Orbital Invasion
Perineural Spread
Lymphatic Spread
BENIGN SINONASAL NEOPLASMS
Juvenile Nasopharyngeal Angiofibroma
Schneiderian Papillomas
Hemangioma
Osteoma
Ossifying Fibroma
Fibrous Dysplasia
Peripheral Nerve Sheath Tumors
Midline Nasofrontal Masses in Children
MALIGNANT SINONASAL NEOPLASMS
Squamous Cell Carcinoma
TNM Staging of Sinonasal Carcinomas
Nasal Cavity and Ethmoid Sinus Carcinoma
Metastatic Regional Lymph Node Staging
Adenocarcinoma
Olfactory Neuroblastoma
Lymphoma
Melanoma
Metastasis
Sarcomas
Rhabdomyosarcoma
CONCLUSION
INDEX
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