Surgical Anatomy

The lacrimal sac is located in the fossa lacrimalis. The fossa lacrimalis lies in the medial orbital wall behind the orbital rim and is 15-mm high, 4-8-mm wide, and 2-mm deep. The lacrimal bone and the nasal process of the maxilla make the fossa. Rarely, the maxilla may form the entire lacrimal fossa. The anterior edge of the lacrimal fossa is the anterior lacrimal crest which is continuous with the inferior orbital rim. The anterior lacrimal crest is thick and protects the lacrimal sac from...

Conservative UPPP

The indication is narrow maxilla with a sharp angle between the tonsils and in cases where muscular hypotonia during sleep is the major problem. Children with Down syndrome are always candidates. Perform a tonsillectomy or if there is a fossa supra-tonsillaris a partial intracapsular tonsillectomy (Fig. 43.5). Remove the mucus membrane in the fossa su-pratonsillaris all the way to the root of the uvula. Ex tirpate a half-moon-shaped piece of the mucus membrane above the uvula (Fig. 43.5c)....

Upper Pharyngeal Airway Surgery

Velopharyngeal surgery is the cornerstone of surgical management of patients with SRBD, although major complications may occur (Fig. 48.4). There are very few prospective and randomized trials reported in the literature for palatal operations in patients with SRBD, and current management is mainly based on retrospective data and uncontrolled case series 2, 3, 7, 11, 13, 16, 21, 31, 35, 37, 39, 41, 45, 47, 51, 54 . Recently, Sundaram et al. 49 with the Cochrane collaboration tried to assess the...

Info

ProSeal laryngeal mask airway Patients with extreme anatomical anomalies should be intubated in alert condition with optimal local anesthesia 10 . Fig 28.5. Laryngeal tube suction with an additional lumen allowing placement of a gastric tube and suctioning Fig 28.4. Laryngeal mask airway with a curved steel shaft guiding the fiberscope towards the glottis Fig 28.5. Laryngeal tube suction with an additional lumen allowing placement of a gastric tube and suctioning glottic alternative...

Turbinate Reduction

A variety of techniques have been used for inferior turbinate reduction. These include Turbinate lateralization via outfracture Caudal and anterior septal deviations can be readily seen on anterior rhinoscopy however, in patients with significant turbinate hypertrophy or septal deviation, nasal endoscopy may be required to visualize the full extent of septal and turbinate anatomy. Rigid nasal endoscopy is an important part of the routine evaluation of patients with nasal obstruction. In...

Violation of the Skull Base with CSF Leak andor Brain Parenchymal Injury

A comprehensive discussion of skull base injuries is beyond the scope of this chapter (see Chap. 14). Important concepts to remember when dealing with these injuries include recognizing the extent of the injury during surgery, improving visualization of the surrounding defect by minimizing bleeding, and gently manipulating the skull base during repair to prevent worsening of the defect. The surgeon should chose whichever of the many published methods he she is comfortable with to repair the...

Intraoral Greater Palatine Block

The authors utilize bilateral greater palatine blocks (Fig. 4.1, Video 4.1) in nearly all cases as previously described 2 . A 3-ml aliquot of 1 lidocaine with 1 100,000 epinephrine is drawn into a 3-ml Luer-lock syringe. Before obtaining this fluid, the expiration date and the proper concentration of the li-docaine and epinephrine on the stock container are confirmed by the surgeon. A 1.5-in. 25 gauge needle is measured with a ruler and bent at a 60 angle at a length of 25 mm for all adults....

Postoperative Care

For patients with extensive hyperplastic rhinosinus-itis with nasal polyposis, oral steroids are provided in the immediate postoperative period with a gradual taper over a 1-week period. Patients with obvious fungal disease should be considered for long-term steroid tapers over a 3-4-week period. Postoperative pain medication is provided as well as antibiotic coverage for those patients with nasal packing or for those with evidence of acute infection at the time of surgery. Nasal packing is...

Preoperative Workup

The feasibility of the endoscopic medial maxillectomy is dependent upon three important factors. These are the determination of the extent of the tumor, the location and origin of tumor attachment, and the presence of malignancy 5 . In terms of location, involvement of ethmoid and maxillary sinuses occurs in the majority of cases 16 . Preoperative nasal endoscopy is important in determining the location and origin of tumor attachment as well as the extent of tumor involvement. With larger...

Sphenoid Sinus

The sphenoid sinus serves as a critical structure to be identified in the revision sinus surgery case. It anatomically defines the lowest point of the skull base, marks the posterior extent of the dissection and serves as a posterior landmark for the medial orbital wall. The most common iatrogenic sequela of the sphenoid sinus is scarring of the ostium. At times the ostium may be densely osteitic, requiring a drill for entry. In these cases, stereotactic navigation is very helpful. A typical...

Surgical Technique

The procedure is demonstrated in Video 37.2 Palatal advancement pharyngoplasty is an evolving technique that advances the soft palate forward to enlarge the pharyngeal isthmus. The procedure may be divided conceptually into steps including (1) incision, (2) flap elevation, (3) palatal osteotomy, (3) ten-dinolysis, (4) palate advancement, (5) wound closure, and if needed (6) distal palatopharyngoplasty or ton-silectomy. The procedure is performed under general anesthesia delivered...

Inverted Papilloma

Patients with inverted papilloma are taken to the operating under two different circumstances biopsy-proven inverted papilloma or unilateral polyposis with a high index of suspicion. Distinctive CT and MRI characteristics can aid preoperative diagnosis 20 . In either circumstance, it is helpful to have the ability for intraoperative frozen section. Though the reported incidence of unsuspected diagnosis is less than 1 during routine histological examination of nasal polyp specimens, clinically...

Tips and Pearls

Fractured frontal recess cell walls must be manipulated and removed in a careful and meticulous fashion in order to maximize the functional result and minimize scarring and mucosal injury to surrounding structures. Fig. 3.7. Kuhn suction frontal sinus curettes Fig. 3.7. Kuhn suction frontal sinus curettes Frontal sinus seekers were designed to fit the anatomy around the corner and manipulate bone and mucosa with their fine ball-ended tips. These seekers were created in two angles, 77 and 90 ,...

The Goal of Surgery in Children with OSA and the Methods Used

The goal of surgery in children with OSA is to increase the diameter of the upper airway in order to decrease the tissue collapse by the Bernoulli effect and thereby resolve snoring and other obstructive symptoms. The surgery should always allow for normal future growth and development. be tried first and later orthodontic maxillo-facial surgery can be involved, if necessary. Distraction treatment of the mandible and expansion of the maxillary suture are often very effective treatments in...

Ethmoid Sinus

The ethmoid region is a common area for residual bony partitions along the skull base and medial orbital wall. These areas may be sources of persistent inflammation and cellular obstruction with secondary neo-osteogenesis. In addition, if prior surgery has removed or perforated the middle turbinate, clearing the skull base of bony partitions or polyps becomes dangerous as the site of attachment of the middle tur-binate and the dural invagination which occurs at this site may be difficult to...

References

Feldman D, Hultman S, Colaizzo R, et al. Electron microscope investigation of soft tissue in growth into Dacron velour with dogs. Biomaterials 1983 4 105. 2. Greenwald D, Shumway S, Albear P, et al. Mechanical comparison of 10 suture materials before and after in vivo incubation. J Surg Res 1994 56 372-77. 3. Kuhnel TS, Hein G, Hohenhorst W. Maurer JT. Soft palate implants a new option for treating habitual snoring. Eur Arch Otorhinolaryngol 2005 262(4) 277-80. 4. Ho WK, Wei WI, Chung KF....

Caudal Septal Deviation

Deviation of the caudal septum can contribute significantly to nasal obstruction. Deviations in this area can be difficult to manage, and generally cannot be addressed adequately via endoscopic techniques 3 . Caudal septal deviations are best treated using traditional septoplasty techniques, sometimes in conjunction with endonasal or open rhinoplasty approaches. Fig. 5.3. In order to decrease the likelihood of flap perforation at the site of a septal spur, separate superior (a) and inferior (b)...

Type IIaIIb Extended Drainage

Extended drainage is achieved after ethmoidectomy by resecting the floor of the frontal sinus between the lamina papyracea and the middle turbinate (type Ila Fig. 8.2b) or the nasal septum (type IIb (Fig. 8.2c, d)) anterior the ventral margin of the olfactory fossa. Hosemann et al. 10, 11 showed in a detailed anatomical study that the maximum diameter of a neo-ostium of the frontal sinus (type IIa), which could be gained using a spoon or a curette, was 11 mm, with an average of 5.6 mm. They...

Localization of the Lacrimal Sac and Duct

The key initial landmark is the posterior border of the frontal process of the maxilla, which is usually identifiable as a ridge or an indentation into the nasal airway just anterior to the middle turbinate 47 . This ridge extends from the highest point of the inferior turbinate upwards and ends immediately in front of the middle turbinate attachment. The nasolacri-mal duct and sac lie immediately lateral and posterior to this ridge. Superiorly the duct joins the sac halfway between the...

Surgical Approaches

Currently, there are many available surgical approaches to the sphenoid sinus, endoscopic and nonendoscop-ic. The decision as to which approach to use depends on factors such as the nature of the lesion, the exact location of the lesion, the extent of the lesion, coexisting pathologic processes, the goal of the surgery (e.g., complete tumor removal vs. biopsy), and the experience and comfort of the surgeon with the different approaches. For example, a polypoid process that involves also the...

Osteoplastic Flap

The indications are intractable frontal sinus inflammatory disease not amenable to a transseptal frontal sinusotomy, failure of Draf III frontal sinusotomy, and for resection of selected frontal sinus tumors. The technique is a standard coronal incision typically extending from each helical crus. A subgaleal plane is identified and elevated to 2 cm above the supraorbital rims. At this point blunt dissection is used to further elevate the flap and identify the supraorbital neurovascular bundles....

Velopharyngeal Insufficiency

A number of near-fatalities due to inability to establish an airway during UPPP have been described. The first 5-10 min following extubation is critical as this is when airway emergencies due to premature extu-bation manifest. In this situation, the patient must be paralyzed to afford the team a chance to reintu-bate the patient. Failure to respond swiftly may result in death. Avoidance of this complication is the best strategy. The surgeon should be present during intubation and equipment for...

Nasopharyngeal Stenosis

Nasopharyngeal stenosis (NPS) involves partial or complete obstruction between the nasopharynx and oropharynx due to concentric scar contracture of the tonsillar pillars and posterior pharyngeal wall (Fig. 44.1) 16 . NPS results from excessive resection of mucosa. Management of bleeding with nasopharyngeal packing and electrocautery has also been cited as a cause of NPS. Other technical errors resulting in NPS include excessive excision and cautery of the posterior tonsillar pillars or...

Indications and Patient Selection

Failure of UPPP may be multidimensional. Diagnostic reevaluation confirms the systems with which the patient presents. Prior testing should be reviewed and, if inadequate, testing should be repeated. A comprehensive head and neck examination focusing on the upper airway should be performed. This includes sitting and supine endoscopy. Additional special test ing may include cephalometry, pharyngoesopha-gram (swallow study), sinus imaging studies, other head and neck imaging, sedated endoscopy,...

Physical Examination

The revision sinus surgery patient should undergo complete reassessment, especially in those cases where the prior surgery or surgeries were performed by another surgeon. It is important to secure the patient's initial complaints prior to the first surgery and the operative records. It is critical to understand whether the patient's complaints prior to the first surgery were truly of sinus origin, the evaluations and medical treatment performed prior to the surgery, the extent of the initial...

Uvulopalatal Flap Under Local Anesthesia

The UPF procedure is performed as described in the preceding section, using the modification in which the procedure is performed under local anesthesia (Fig. 32.2). The patients are given prophylactic antibiotics 1 h before surgery. Diazepam (5 mg) is administered only for patients with a significant gag reflex. The UPF procedure is performed with the patient in an upright sitting position in an examination chair. The patient is monitored with pulse oximetry during the procedure. Basic life...

Contents

Of the Paranasal Sinuses 3 Surgical Anatomy of the Paranasal Sinuses . . . 17 Frontal Sinus Instrumentation 27 Frederick A. Kuhn, Christopher T. Melroy, Marc G. Dubin, Shridhar Ventrapragada Injection and Anesthetic Techniques 41 Septal and Turbinate Surgery 49 and Seth J. Kanowitz, Joseph B. Jacobs, Richard A. Lebowitz Surgical Approaches to the Sphenoid Sinus . . 73 Frontal Sinus Surgery 83 Endoscopic Modified Lothrop Procedure 93 Francis T.K. Ling, Ioannis G. Skoulas, Stilianos E. Kountakis...

Weber Ferguson Approach

For maxillectomy with or without orbital exenteration in the treatment of neoplasia of the maxillary sinus In the treatment of acute mucormycosis of the sinonasal cavities As part of a facial translocation approach to the anterior and or central skull base The Weber-Ferguson approach combines the lateral rhinotomy with an upper lip splitting incision and a lateral horizontal incision below the orbit at the level of the inferior orbital rim. This creates a large cheek flap that is displaced...

Frontal Sinus Obliteration

The most common method of frontal sinus obliteration today is the osteoplastic flap procedure. This method exposes the interior of the frontal sinus by elevating a flap of the anterior table hinged inferior-ly on pericranium (osteoplastic flap) 15 . The mucosa of the frontal sinus is removed with a burr, and the duct is plugged with one of several different materials and sealed with fibrin glue. The ducts may be obdu-rated with autogenous bone graft, temporalis muscle plugs 15, 24 or...

Advantages and Disadvantages

Functional approach with restoration of frontal sinus drainage Permits mucosal preservation of the frontal recess Note that the frontal recess is located posteriorly relative to the midline frontal sinus floor and, thus, drilling directly across from one frontal recess to the other should be avoided. Uses inherent anatomic landmarks to facilitate surgery Allows for endoscopic and radiographic surveillance postoperatively Improved cosmesis through avoidance of facial incisions Decreased...

Laboratory Studies

Diagnostic workup of children with chronic rhinosinusitis should include an allergy evaluation, immune deficiency testing, cilia biopsy and reflux evaluation. Fig. 21.2. Endoscopic view with a 4-mm 0 scope of the left nasal cavity of a child showing complete blockage of the choa-na by adenoid tissue Fig. 21.2. Endoscopic view with a 4-mm 0 scope of the left nasal cavity of a child showing complete blockage of the choa-na by adenoid tissue Fig. 21.3. Coronal computed tomography scan of the...

The Lothrop Procedure

Indications are chronic frontal sinusitis unresponsive to conservative intranasal procedures where hope still exists of reconstructing the nasofrontal drainage system. Fig. 22.4. A frontal sinus trephination and lynch procedure for acute frontal and ethmoid sinusitis complicated by cerebritis and brain abscess Fig. 22.4. A frontal sinus trephination and lynch procedure for acute frontal and ethmoid sinusitis complicated by cerebritis and brain abscess The Lothrop procedure is performed via a...

Inferior Turbinate Lateralization

While typically insufficient as a standalone procedure, turbinate lateralization by outfracture can be an excellent complement to soft-tissue reduction in improving nasal airway patency. A Boies elevator is It may be beneficial to reserve full-thickness resection techniques for patients who have failed more conservative methods of reduction. sociated with a prior history of partial or complete inferior turbinectomy. High success rates have been reported using the entire gamut of turbinate...

The Uncinate Process and the Maxillary Sinus

The uncinate process is a very important surgical landmark in the lateral nasal wall for endonasal sinus surgery. Although considered part of the ethmoid labyrinth since it derives from the descending portion of the first ethmoturbinal, the uncinate process is typically discussed when addressing the maxillary sinus because of its intimate relationship with the maxillary ostium. The uncinate process is a crescent-shaped bony structure that typically projects from posteroin-ferior (at the...

Indications and Contraindications of Tracheostomy for OSA

Failure of CPAP or upper-airway expansion surgery Temporary airway bypass during recovery from maxillary-mandibular surgery or bariat-ric surgery Upper-airway obstruction in difficult intubation patients Aggressive airway surgery requiring temporary airway control Refusal of the patient or family to accept the surgery Patient self-destructive behavior Medical or anesthesia contraindications

Technique

The technique is demonstrated in Video 6.1. 1. Review the preoperative PNS CT scans. (a) Identify the superior attachment of the uncinate process (skull base, lamina papyracea, or middle turbinate). (b) Identify the position of orbital floor relative to the maxillary ostium, and the attachment of the inferior turbinate (i.e., the height of the infundibulum). (c) If there is previous trauma, be mindful of a dehiscent or displaced infraorbital nerve. (d) Identify the anterior ethmoid artery...

Hardware

Each IGS system includes these individual components Computer workstation. The computer workstation serves to integrate the other hardware components and provides the central functionality of IGS. Standard input devices include a computer mouse and keyboard. Most workstations are also connected to a computer network. Display system. A computer monitor obviously is necessary for the output of visual information. Today, high-resolution flat-panel monitors have supplanted older, cathode ray tube...

General Concepts

Maxillary sinus extends medially into the nasal cavity, entrapment of airflow occurs with mucosal drying and secondary impairment of mucociliary clearance. The following are typical problems, the instruments used and the technique employed Residual uncinate process. The instruments used are a Backbiter, a ball-tip seeker and a Stammberger downbiter. Most commonly the residual uncinate process is anterior to the an-trostomy and a 45 endoscope will be required to obtain a better view of the area...

Systemic Disease

Daytime sleepiness and sleep apneas can be observed in various endocrine, neuromuscular and other types of disorders 2, 29, 42, 44, 52 . Examples are hypothyroidism, acromegaly, diabetic neuropathy with autonomic dysfunction, Parkinsonism, Alzheimer's disease, stroke, epilepsy, metabolic abnormalities such as hyponatremia and hypoglycemia due to adrenal insufficiency, Cushing's syndrome, brainstem abnormalities due to inflammation, hemorrhage, trauma, encephalitis, acute bulbar poliomyelitis,...

Approaches to the Ethmoid and Sphenoid Sinuses

Trephination

For external ethmoidectomy sphenoidotomy indications are Chronic ethmoid sinusitis unresponsive to conservative intranasal procedures. As an approach to the orbital apex for optic nerve decompression. As an approach to the anterior skull base or sphenoid sinus in the treatment of CSF rhinor rhea or other abnormality, such as encephalo-cele. As an approach to the lacrimal sac for dacryo-cystorhinostomy. As an approach to the anterior and posterior ethmoid arteries in the treatment of refractory...

Surgical Procedure

The child is placed supine with the head of table slightly elevated. The results of a CT scan should always be in the operating suite to be used as a road map. The surgeon should be facing the patient with the monitor facing the surgeon. The surgeon can operate looking through the scope using a beam-splitter camera, or, if so trained, can operate by looking at the monitor. If the surgeon is skilled in the procedure, the eyes do not need to stay uncovered. A small tape can be used to cover them....

Sphenoid Sinus and Sinonasal Anatomy

The sphenoid sinus starts developing at about the 12th week of gestation. The sinus is not present at birth, with pneumatization beginning at about 5-7 years of age, while the adult size is usually reached by 15-18 years. 8 The sphenoid sinus is variably pneumatized into the sphenoid bone. Three types of sphenoid sinuses are described according to the degree of pneumatization in relation to the sella 1. Conchal sphenoid is one which has pneumatized only to a small degree with thick bone still...

Other Instrumentation

There are several other instruments commonly used during frontal recess dissections that were not detailed in the previous sections. The frontal mushroom developed by Stammberger (Fig. 3.13) has a handle, shaft, and overall appearance similar to the frontal sinus giraffes however, the distal tip is a mushroom punch. This is a through-cutting instrument that has the advantage of being able to work circumferentially, Fig. 3.11. Forty-five-degree Fried and 90 Kuhn Instatrak suctions Fig. 3.12....

Results Outcomes

There is a delicate balance between the pharyngeal biomechanics and the anatomical structure that contribute to airway collapse in patients suffering from OSA. It would be rather simplistic to attribute the pathophysiology of OSA to the small box (craniofacial skeleton jaw) or the crowded contents (oropharyngeal tongue soft tissue). Nevertheless, most oto- Fig. 33.2. Insertion of the implant with the implant device Fig. 33.2. Insertion of the implant with the implant device laryngologists have...

Maxillomadibular Widening

Maxillomandibular widening can be performed in the adult as well as in the pediatric population. In the pediatric population, maxillary widening usually does not require surgical intervention since the mid-palatal suture is not yet ossified. However, with fusion of the midpalatal suture after adolescence, osteotomy is required to facilitate the expansion. The surgical technique is as follows. The procedure is performed in the operating room under general anesthesia technique. Maxillary widening...

Core Messages

Obstructive sleep apnea (OSA) is a significant health problem. The cardinal symptoms of OSA are heavy habitual snoring, witnessed intermittent apneas, and excessive daytime sleepiness. Patients with OSA are at high risk of developing postoperative complications when undergoing surgery under general anesthesia. This holds true for surgery to cure OSA and for any other surgery. Surgeons of all specialties, and especially anesthetists, should be aware that undiag-nosed OSA is common. They should...

Septoplasty

Nasal septal deviation is a frequent cause of nasal obstruction. Surgical correction by means of a septo-plasty allows for definitive treatment. An adequate knowledge of nasal and septal anatomy is very important in understanding the surgical techniques used for correction. The nasal septum consists of cartilaginous and bony components. The anterior aspect of the nasal septum is composed of the quadrangular cartilage. The bony components of the septum include the perpendicular plate of the...

Ethmoid Infundibulum

The ethmoid infundibulum is a true three-dimensional space and is defined (Fig. 1.5a) Laterally by the lamina papyracea Anteromedially by the uncinate process Posteriorly by the bulla ethmoidalis It opens medially into the middle meatus across the hiatus semilunaris inferioris, a cleftlike opening between the free posterior margin of the uncinate process and the corresponding anterior face of the bulla ethmoidalis (Fig. 1.5b). This is the functional common pathway of mucociliary drainage for...

Frontal Recess Agger Nasi and Uncinate Process

The Anatomic Terminology Group defined the frontal recess as the most anterior and superior part of the anterior ethmoid complex from where the frontal bone becomes pneumatized, resulting in a frontal sinus 9 . The frontal recess frequently looks like an inverted funnel (Fig. 1.3a) on sagittal images, opening superiorly towards the frontal sinus ostium, with its anatomic boundary dictated by the walls of surrounding structures. The boundaries of the frontal recess are as follows The lateral...

Incision Flap Elevation and Mobilization

A palatal incision is outlined beginning at the central hard palate posterior to the alveolus (Fig. 37.3a). The tip should extend 5-10 mm anterior to the planned osteotomy. The incision is outlined immediately medial to the greater palatine foramen. At the junction of the hard palate and the soft palate, it is flaired laterally over the hamulus. This results in a curvilinear O-arch appearance. Anteriorly, a midline vertical incision is extended up the midline of the hard palate (T incision)....

Of the Sphenoethmoid Recess Region

Onodi cells are hyperpneumatized posterior ethmoid air cells that grow posteriorly on the planum sphenoidale above the sphenoid sinuses, typically towards the clinoid processes. Onodi cells frequently have associated de-hiscence of the optic nerves whenever the cli-noid process is pneumatized. It is a surgical danger zone as a potential site for iatrogenic endoscopic optic nerve injury or intracranial penetration (Fig. 1.12a, b). Dehiscent internal carotid arteries can occur whenever there is...

Introduction

Owing to its limited success in curing obstructive sleep apnea-hypopnea syndrome (OSAHS) 1 , many adjunctive procedures and modifications were proposed after the introduction of the classic uvulopalatopharyngoplasty (UPPP) by Fujita et al. 2 in 1981. However, its role as part of a comprehensive treatment plan remains solidly accepted in most situations in which the palate, with or without the tonsils, is contributing to airway turbulence and obstruction. The goal of UPPP is to widen the...

Is Silicone Tubing Necessary in All Cases

After the bone has been removed, the sac is identified. The vascularized white color of the sac is characteristic and can easily be identified. A lacrimal probe may be used to identify the lacrimal sac. A lacrimal probe is passed through a canaliculus and directed medially into the obstructed sac. The tenting of medial sac wall by the probe is visualized endonasally. While it is tented by the lacrimal probe, the sac mucosa is incised by a sickle knife. Mucopus, residual contrast material may...

Kuhn Frontal Sinus Punches

The frontal sinus punches were designed in conjunction with Karl Storz to allow more removal of frontal recess sinus cell walls while preserving the mucous membranes. Although upon cursory inspection these punches appear similar to the frontal sinus giraffes, their use is very different. Their tips are through-cut ting and allow accurate and precise cutting of bony partitions without stripping the surrounding mucosa. Similar to the giraffes, the set includes six instruments, three each in 77...

Clinical Presentation

AFRS is characteristically associated with nasal pol-yposis and allergic mucin 25 (Fig. 11.1). AFRS typically affects young adults (mean age 21.9) 23 , and atopy and asthma are frequent comorbid findings 1, 6, 8, 23 . The incidence of AFRS varies geographically, with the majority of cases centered in temperate regions of the world with high humidity 8, 12 . In the USA, the majority of cases are found in the southern states 25 . The majority of patients with AFRS present with gradual progressive...

Sella Turcica Anatomy

The pituitary gland sits in the sella turcica, a deep depression on the superior aspect of the body of the sphenoid bone. The posterior boundary of the sella is defined by the dorsum sellae and the posterior cli-noid processes. Below the dorsum sellae is the clivus, which slopes inferiorly and is continuous with the occipital bone. The roof of the fossa is formed by the diaphragm, which is a dural fold traversed by the pituitary stalk. The lateral extension of the diaphragm forms the roof of...

How to Examine a Child with Suspected OSA

Waldeyer's ring is poorly developed at birth, but then starts to grow, as a consequence of a normal immun-ological development. At the age of 2 years, the adenoid is usually well developed and can create breathing problems for children with a narrow face. At the age of 4 years, many children also have a relative hyperplasia of the pharyngeal tonsils. These organs are necessary as a first line of defense both for the breathing and eating functions and for the development of B and T cells. In...

Frontal Recess Anatomy

Frontal Recess

Using endoscopic methods, surgeons treat chronic inflammatory disease in a functional manner rather than in an extirpative or ob-literative manner. They seek to preserve the anatomy and enhance the natural drainage pathways of the paranasal sinuses. Frontal sinus instrumentation has evolved symbiotically with endoscopic management of the paranasal sinus disorders. Specialized instruments allow the surgeon to follow the tenets of functional frontal sinus surgery complete removal of the frontal...

Tongue Suspension Effects

Tongue-base approaches range from radiofrequency ablation to reduce tongue-base volume, to genioglos-sus advancement, which entails mandibular osteotomies to reposition the genial tubercle, and thus the ge-nioglossus muscle, anteriorly. A recent advance is the development of the Repose lingual suspension procedure for genioglossus advancement. This is the authors' preferred approach to tongue-base suspension and is performed using commercially available instrumentation (Influ-ENT Medical) (Fig....

Epidemiology

Mucoceles have no sex predilection and can occur at any age although most are diagnosed in patients between the ages of 40 to 60 years old 1 . Those occurring in children are usually idiopathic although many may be associated with cystic fibrosis and some authors have even advocated cystic fibrosis screening in any child found to have a mucocele 5, 7 . While mucoceles can form within any sinus cavity, the first series of 14 patients noted the frontal sinus to be the most common location 12 ....

Type III Endonasal Median Drainage

The extended type lib opening is enlarged by removing portions of the superior nasal septum in the neighborhood of the frontal sinus floor (Fig. 8.2e, f, Video 8.1). The diameter of this opening should be about 1.5 cm. This is followed by resection of the frontal sinus septum or septa, if there is more than one. Starting on one side of the patient, one crosses the midline until the contralateral lamina papyracea is reached. To achieve the maximum possible opening of the frontal sinus, it is...

Advancement

In the first reports of the procedure, mobilization of the soft palate was done by fracturing the hamulus in order to release stress on the tensor tendon. The occasional complication of serous otitis media with effusion was observed and new techniques were developed. The hamulus is now left undisturbed, and mobilization is achieved by bilaterally cutting and freeing the tensor tendon just medial to the hamu-lus. Complete incision of the tensor tendon medial to the hamulus markedly increased the...

The Nasal Cavity

Basal Lamella Sinuses

The nasal cavity is the first cavity encountered by the surgeon during ESS. Its lateral and posterior-superior walls contain the openings for the paranasal sinuses, and its posterior-inferior wall leads to the nasopharynx through the choana. The identification of the choana and its relations to the posterior nasal septum and the eustachian tube opening (torus tubarius) in the nasopharynx is very important at the beginning of every ESS (Fig. 2.1). When polyps obstruct the nasal airway in its...

Intracapsular Partial Tonsillectomy with the ellman Surgitron dual RF 40 MHz Device

The ellman Surgitron dual-RF 4.0 MHz device is shown in Fig. 43.3 and the procedure is demontrated in Video 43.2. The patient is anesthetized, orally intubated and a David-Meyers mouth gag inserted to get a good overview of the tonsils all the way down to the lower pole Two neutral electrodes (antennas) are placed one under each shoulder. One of the electrodes is connected to the machine. The tonsils are inspected and checked for superficial blood vessels. On the posterior side you should also...

Pituitary Apoplexy

MRI CT fusion image for intraoperative stereotactic image guidance atomic details such as the presence of Onodi (sphe-noethmoid) cells, asymmetry of the sphenoid sinuses, or possible dehiscence of the carotid arteries and or optic nerves (Fig. 18.4b). The operative plan and potential variations are discussed by the two operative teams. At our institution, all patients have a fine-cut CT scan for use with the computer-guided navigation system. In the setting of revision surgery, the...

Operative Procedure

Prior to any operative procedure, a valid and explicit informed consent discussion should occur 29 . Within this discussion, all risks of surgery should be clear and understood by the patient. After establishment of informed consent, and prior to preparation in the operating room, an intranasal vasoconstrictive agent such as oxymetazoline begins the operative preparation. The choice of anesthetic used is up to the surgeon and patient. While endo-scopic sinus surgery can be performed under local...

The Superior Turbinectomy Approach

Fastest, least invasive and overall the best approach for management of isolated sphenoid sinus disease and for approaching lesions adjacent to the sphenoid sinus 6-11 . Under general anesthesia and under direct vision, cottonoids soaked with a vasoconstricting solution are inserted between the middle turbinate and the septum on both sides. After 10 min, the cot- This approach does not involve transseptal surgery , , .,,, . . , Fig. 7.1. Rarely, partial middle turbinectomy may be required. and...

Partial Intracapsular Tonsil Resection Tonsillotomy

When the child's main problem is caused by hyper-trophied tonsils possibly in combination with hypertrophy of the adenoid, one should always consider how much of the tonsils have to be removed 1. What degree of reduction of the size of the tonsils is enough for the specific child 2. Which technique is most suitable for the purpose 3. Are there differences in the outcome of different surgical techniques pared with complete tonsillectomy. However, studies have not reported any differences with...

Training Upper Airway Sleep

Tonsillar Mass Adult

Continuous narrowing of upper airway. UARS upper-airway resistance syndrome, OSA obstructive sleep apnea. (Modified after 15 ) sleep, based on current experiences and data, one begins to consider the possibility of so-called multilevel surgery. Also in this case, the appropriate surgical technique depends upon the severity of disease and the anatomic disposition. Figure 29.3 illustrates the indications for the surgical techniques preferred in Mannheim and Hamburg, in relationship to...

Fibrous Dysplasia Of Frontal Bone

With appropriate endoscopic skills and instrumentation and routine endoscopic surveillance, patients with benign sinonasal neoplasms can be treated safely and effectively. Certain benign neoplasms such as inverted papilloma can be locally aggressive and have a risk for malignant degeneration and should not be underestimated in treatment planning. Multimodality imaging with CT and MRI is important to evaluate the extent of the benign sinonasal neoplasms. In the management of benign sinonasal...

And Antrostomy Nasoantral Window

Chronic polypoid maxillary sinusitis unresponsive to conservative intranasal procedures Acute complicated maxillary sinusitis In the treatment of oroantral fistulae As a route to biopsy Infraorbital nerve Maxillary sinus mass As an approach to the orbital floor To treat fracture For orbital decompression of Grave's ophthal-mopathy The Caldwell-Luc procedure is a sublabial approach to the maxillary sinus through the anterior wall under the upper lip. Traditionally it was used to treat chronic...

Long Term Effectiveness of UPPP for SDB

Eight groups of authors reported on long-term results after UPPP for primary snoring in 868 patients with follow-ups between 1.5 and 10 years 12 . No snoring was found in 29.8 of patients, reduced snoring in 43.1 , no change in 29.4 and worse snoring in 8.1 . Combining the values for snoring reduced and no snoring results in a long-term success rate of 73 for isolated UPPP in the treatment of primary snoring. But these data have to be considered with caution, owing to the fact that the diverse...

Ulm Procedure of UPPP

The procedure is demonstrated in Video 35.1. On the basis of the anatomy and function of the soft palate, we markedly modified the technique of Fujita at al. 9 in 1986 28 and returned to a more tissue-preserving technique in 1996 1 based on Ikematsu's 15 procedure from 1964. UPPP with or without T is performed under general anesthesia with the patient in the Rose position (supine with head hanging). After orotracheal intubation has been performed, a self-retaining mouth gag is inserted. The gag...

Uvulopalatal Flap For

The uvulopalatal flap (UPF) is recommended as a surgical option for oropharyngeal obstruction in patients with sleep-related breathing disorders. The procedure is a mucosal procedure thus, swelling and swallowing problems are moderate and transient. The success of the UPF depends on carefully selected patients and it is performed as a one-stage surgery. Patients with sleep-related breathing disorders pose a significant anesthetic risk and are generally deemed as difficult intubations. Sedating...

Frontal Sinus

Etmoidectomia Anteriore

Revision endoscopic frontal sinus surgery has been an area of significant recent advancement. With the appropriate anatomy, frontal sinus inflammatory disease can be treated endoscopically (Video 20.1), with only a select few cases requiring open approaches such as trephination or an osteoplastic flap. The main iat-rogenic sequelae causing frontal sinus obstruction are residual uncinate process, bulla ethmoidalis or agger nasi cells obstructing the frontal recess region. In addition, mucosal...

Structures and Spaces

The ethmoid infundibulum is the key element to understand the anatomy and physiology of the ostiome- atal complex (Fig. 1.5a). The ethmoid infundibulum is a sickle-shaped sagittally oriented three-dimensional space extending from the agger nasi frontal recess region towards the middle meatus, running downwards and posteriorly between the lamina papyracea of the ipsilateral orbit laterally and the uncinate process medially. This resulting V-shaped drainage channel collects the mucociliary output...

General Principles

The operative technique for a combined endoscopic and open approach was initially described by Wigand et al. 11 . Subsequent publications reported utilization of a similar variation or modifications of this technique 1-3, 5-7 . Trephination is quick, technically-straightforward and does not require extensive endoscopic training. It is done using standard and readily available surgical instruments and often without image-guidance systems. Frontal sinus trephination results in a small external...

The Ethmoid Labyrinth

Located lateral to the olfactory cleft and fossa, between the lateral nasal wall and the medial orbital wall, the ethmoid sinus is the most compartmentalized paranasal sinus. At birth, only a few cells are pneuma-tized, but in adulthood their number can go beyond 15 cells. The frontal bone in its posterior extension covers the roof of the ethmoid sinus, forming the so-called fovea, or foveolae ethmoidales 18 . The anterior and posterior ethmoid arteries, terminal branches of the internal...

Nasal Obstruction and Its Medical BD and Surgical Management in Sleep Related Breathing Disorders

Septorhino Turbinoplasty

Bernard Bertrand, Philippe Rombaux, Daniel Rodenstein Although an increased nasal resistance does not always correlate with symptoms of congestion, nasal congestion typically results in a switch to mouth breathing. Nasal airway resistance is responsible for approximately two thirds of the total airway resistance in wakefulness. Nasal reflexes play an important role in modulating upper-airway patency during sleep. The presence of a high Mallampati score with concomitant nasal obstruction is...

Modified Mallampati

Modified Mallampati Grades Mmp

There is no standardized system to describe the anatomical features associated with snoring and obstructive sleep apnea OSA . The most common clinical features in a patient with snoring or OSA are a long uvula, a high tongue base and lateral narrowing of the pharyngeal walls. In children, tonsil hypertrophy is the most common risk factor for OSA. The assessment of the snoring patient should include a fiberoptic examination with a M ller maneuver. Surgical alterations of the palate and...

Indications for Genioplasty

Genioplasty is indicated for the treatment of patients suffering from OSAS with a respiratory disturbance index above 15 per hour of sleep and oxyhemoglobin desaturation to less than 87 that failed CPAP or are unwilling to use CPAP on a long-term basis. Documentation of hypopharyngeal airway obstruction contributing to OSAS based on the physical examination including fiberoptic laryngoscopy and or imaging typically cephalometry is needed. The operation may be performed as a same-stage operation...

Bert Schmelzer

Department of Otorhinolaryngology General Hospital Middelheim Lindendreef 1, 2020 Antwerp Belgium E-mail bert.schmelzer belgacom.net Brent A. Senior Department of Otolaryngology -Head and Neck Surgery The University of North Carolina at Chapel Hill G0412 Neurosciences Hospital, CB 7070 Chapel Hill, NC 27599 USA E-mail brent_senior med.unc.edu Michael J. Sillers Alabama Nasal and Sinus Center, Suite 301 7191 Cahaba Valley Road, Birmingham AL 35242 USA

Indications and Contraindications for Palatal Advancement Pharyngoplasty

Retropalatal narrowing proximal to the free margin of the soft palate. Retropalatal narrowing following failed UPPP. Approach to benign midline nasopharyngeal masses with or without sleep apnea . Choanal narrowing. Combined with other procedures to enlarge the retropalatal airway for cases of nasopha-ryngeal stenosis. Partial or complete cleft palate Large torus palatinus requires removal first Maxillary advancement surgery relative Impaired palatal blood flow such as with radiation therapy or...

Lower Pharyngeal Airway Surgery

Clinical evaluation, sleep nasendoscopy and surgical failures after velopharyngeal procedures have underlined the importance of the retrobasilingual area in the pathophysiology and management of SRBD. The primary aims of these techniques are to reduce the tongue size and increase the retrolingual space. RFTVR was used to reduce the size of the tongue as a single procedure utilizing intraoral or external approaches 22, 46, 48 . The preference is to use the intraoral dorsal approach since it...

Indications and Contraindications for Isolated UPPP

Velum snorer with airway obstruction at the level of the soft palate by redundant tissue Velum snorer on the basis of analyzing snoring noises Hypertrophy of palatine tonsils No malocclusion in need of treatment BMI lt 30 kg m2 None or minor daytime sleepiness Primary snoring, mild OSA AHI lt 25 For moderate or severe OSA as part of a multilevel surgery concept Contraindications are Chronic heart and or lung diseases Neurological psychiatric illnesses in need of treatment High anesthesia risk...

The Frontal Sinus

Embryology Turbinate

Frontal sinus orientation. The correct trajectory into the frontal sinus is along a line dotted line parallel to the convexity of the nasolacrimal apparatus small arrows , starting at the maxillary natural ostium area, and extending several millimeters behind the anterior attachment of the middle turbinate asterisk Fig. 2.11. Frontal sinus orientation. The correct trajectory into the frontal sinus is along a line dotted line parallel to the convexity of the nasolacrimal apparatus...

Transnasal Transseptal Approach

The transseptal route provides an excellent approach to the sphenoid sinus. It is a safe, avascular and easy to learn procedure. During the last decade of the nineteenth century and the fist decade of the twentieth century, this approach was introduced for management of pituitary lesions. Soon after, this procedure fell into disfavor because of the limited surgical exposure obtained in the absence of surgical microscopes. Hardy, in the 1950s, introduced microsurgical techniques and...