Ebook Rhinology and skull base surgery: Part 1

(BQ) Part 1 book “Rhinology and skull base surgery” has contents: Nasal and paranasal sinus anatomy and embryology, nasal and paranasal sinus physiology, investigations in nasal disease, recent advances in understanding the pathophysiology of rhinosinusitis,… and other contents.

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Christos Georgalas, PhD, DLO, FRCS (ORL-HNS)

Director, Endoscopic Skull Base Center

Department of Otorhinolaryngology

Academic Medical Center

Amsterdam, The Netherlands

Wytske Fokkens, MD, PhD

Professor

Rhinology and

Skull Base Surgery

From the Lab to the Operating Room:

C Fernandez-Miranda, Wytske Fokkens, Nicole J M Freling, Paul A Gardner, Christos Georgalas, Philippe Gevaert, Mitchell

R Gore, Jan Gosepath, Haralampos Gouveris, Hakon Hakonarson, Samuel Heimgartner, Peter W Hellings, Philippe Herman, Claire Hopkins, Nick S Jones, Amin B Kassam, Robert M Kellman, Daniel F Kelly, Bhik Kotecha, Stilianos E Kountakis, Haytham Kubba, Jean-Silvain Lacroix, Basile Nicolas Landis, Donald C Lanza, Annie S Lee, Sarah Lovell, Tim C Lueth, Franklin Mariño-Sánchez, Nancy McLaughlin, Ralph Metson, Joaquim Mullol, Piero Nicolai, Gilbert J Nolst Trenité, Reza Nouraei, James N Palmer, Vasileios Papanikolaou, Kalpesh S Patel, Santdeep H Paun, Oliver Pfaar, Daniel M Prevedello, Emmanuel Prokopakis, Susanne M Reinartz, Herbert Riechelmann, Peerooz Saeed, Hesham Saleh, Glenis K Scadding, Rodney J Schlosser, Brent Senior, Jian-Bo Shi, Li Shi, Daniel Simmen, Ameet Singh, Elisabeth Victoria Sjoegren, Carl H Snyderman, Zachary M Soler, Alla Y Solyar, Gero Strauss, Andrew C Swift, Ingrid Terreehorst, Timoleon F Terzis, Marc A Tewfi k, Matthew J Tormenti, Elina Toskala, Bert van der Baan, Wouter R van Furth, Cornelius M van Drunen, Thibaut Van Zele, Carel D A Verwoerd, Henriette L Verwoerd-Verhoef, De-Yun Wang, Stefan Weber, William Ignace Wei, Ronald B Willemse, Peter-John Wormald, Giannis Yiotakis, Bing Zhou

979 illustrations

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Library of Congress Cataloging-in-Publication Data

Rhinology and skull base surgery : from the lab to the operating

room : an evidence-based approach / edited by Christos

Georga-las, Wytske Fokkens.

p ; cm.

Includes bibliographical references and index.

ISBN 978-3-13-153541-2

I Georgalas, Christos II Fokkens, Wytske J.

[DNLM: 1 Rhinitis surgery 2 Sinusitis surgery 3 Nose

Diseases physiopathology 4 Nose Neoplasms surgery

5 Rhinoplasty 6 Skull Base surgery WV 335]

617.5’1059 dc23

2012032355

Rüdigerstrasse 14, 70469 Stuttgart, Germany

http://www.thieme.de

Thieme Medical Publishers, Inc., 333 Seventh Avenue,

New York, NY 10001, USA

http://www.thieme.com

Cover design: Thieme Publishing Group

Typesetting by Maryland Composition, USA

Printed in China by Everbest Printing Ltd, Hong Kong

ISBN 978-3-13-153541-2

Also available as e-book:

eISBN 978-3-13-164461-9

Important note: Medicine is an ever-changing science

undergo-ing continual development Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every eﬀ ort

to ensure that such references are in accordance with the state of knowledge at the time of production of the book

Nevertheless, this does not involve, imply, or express any antee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the

guar-book Every user is requested to examine carefully the

manu-facturers’ leafl ets accompanying each drug and to check, if sary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers diﬀ er from the statements made

neces-in the present book Such examneces-ination is particularly tant with drugs that are either rarely used or have been newly released on the market Every dosage schedule or every form of application used is entirely at the user’s own risk and responsibility The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed If errors

impor-in this work are found after publication, errata will be posted at www.thieme.com on the product description page

Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specifi c reference to this fact is not always made in the text Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain This book, including all parts thereof, is legally protected by copyright Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation, without the publisher’s consent, is illegal and liable to prosecution This applies

in particular to photostat reproduction, copying, ing, preparation of microfi lms, and electronic data processing and storage

mimeograph-Illustrator: Katja Dalkowski, MD, Buckenhof, Germany

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To my parents, Eleni and Kostas, to whom I owe everything.

To my wife, Amanda, for embarking with me on this journey

To those who cross borders, by choice or need: our collective past, present, and future

Christos Georgalas

To my beloved parents, Onno and Joke, who taught me, among many other things, to enjoy questioning and

exploring; and my teacher Carel Verwoerd who taught me a lot more than rhinology

To the loves of my life, my husband Casper and my three children Sybren, Anne, and Lywke,

who lovingly and courageously try to keep me in line

Wytske Fokkens

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To access additional material or resources available with this e-book, please visit

http://www.thieme.com/bonuscontent After completing a short form to verify your e-book purchase, you will be provided with the instructions and access codes necessary to retrieve any bonus content.

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vii

Foreword

Over the last 20 years there have been a number of books

broadly covering the many facets of the nose and sinuses

However, such is the interest in this area and the pace of

progress in its investigation and treatment that this major

work is a welcome addition to the fi eld Underpinned by

the wide-ranging expertise of Professor Wytske Fokkens

and Christos Georgalas at the Academic Medical Center,

this multinational collaboration covers the full range of

rhinology, from basic anatomy and physiology, through

diagnostic techniques, to the entirety of sinonasal

pathol-ogy The international authorship guarantees a balanced

approach and includes many well-known contributors in

the fi eld as well as some “new blood” providing a fresh

view on old problems

As well as the usual topics, consideration is given to

some less well-understood but expanding areas of

in-terest in the nose and sinuses, such as genetics and rare

disorders such as the silent sinus syndrome and sinus dilatans The concept of “one airway” is now gener-ally accepted, but the importance of this in understanding the pathophysiology and management of rhinosinusitis

pneumo-is emphasized by authors able to authoratively consider both the upper and lower respiratory tract Despite this,

we often struggle to improve the lot of our patients with recalcitrant CRS and welcome practical advice oﬀ ered on the management of these patients

Rhinology, of course, is a multifaceted subject and,

in addition to the full range of sinonasal pathology, the editors have commendably included rhinoplasty and all of the well-established, extended applications of endoscopic surgery to adjacent structures of the orbit and skull base This comprehensive and holistic approach is to

be applauded, making this a “must have” text for anyone interested in the nose and sinuses

Valerie J Lund, CBE

Professor of Rhinology, University College London

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Preface

“ .When you set sail for Ithaca,

wish for the road to be long,

full of adventures, full of knowledge .”

Constantin P Cavafy

“The Road to Ithaca,” Collected Poems

It is fair to say that, if the fi fties and sixties were the

decades of otology and the seventies and eighties those

of head and neck surgery, the last 20 years have

wit-nessed an unprecedented boom in rhinology Advances

in basic science leading to better understanding of

dis-ease pathophysiology, improved phenotyping, advances

in endoscopic sinonasal and skull base surgery, and an

increasingly multidisciplinary outlook have all brought a

(r)evolution in rhinology Today, the nose is aptly regarded

as an anatomic and physiologic interface that mirrors our

professional interfacing with neurosurgeons and

neu-rologists, allergists and chest physicians, opthalmologists

and orbital surgeons This book aims to refl ect this by

presenting all the facets of this dynamic subspecialty

We believe that any real progress in medicine, or

rhi-nology for that matter, can only be the result of creative

integration of basic science and clinical medicine With

this in mind, we have brought together some of the

brightest clinicians and researchers of our generation

We are humbled by the enthusiasm of our contributors;

indeed, they testify to the dynamic and extrovert

out-look of current rhinology Over 90 world-class experts,

presenting the most up-to-date and authoritative

infor-mation from 17 countries and 4 continents The writing

of this book started in 2010 and continued throughout

2012, resulting in chapters that are current and date, with both the European Position Paper on the En-doscopic Management of Tumors of the Nose, Paranasal Sinuses and the Skull Base from 2010 as well as the Eu-ropean Position Paper on Rhinosinusitis and Nasal Polyps from 2012 given consideration It is intended as a study and reference book for young and experienced rhinolo-gists alike, with questions and answers, key points, tips and tricks, and notes included in every chapter The DVD included, with almost 80 videos, constitutes an integral part of the textbook, illustrating the pathology described

up-to-in various chapters, demonstratup-to-ing surgical approaches step-by-step, as well as providing a wealth of other mate-rial including data fi les for use in statistical exercises and three-dimensional imaging reconstructions

Nevertheless, in a rapidly changing world, every book should come with a health warning: “Consume with moderation, for 50% of what you know to be correct today

text-in medictext-ine may be proven to be untrue tomorrow.” Although all the information we provide is accepted to

be correct and accurate at the time of writing, we do not claim to provide eternal certainties

If this textbook makes you search the internet, debate with colleagues, and even email the authors, then we have succeeded Do not accept anything written in here

at face value—“nullis in verba”—challenge authority, or as Socrates already taught us:

“True wisdom comes to each of us when we realize how little we understand about life, ourselves, and the world around us.”

(Socrates, 469–399 BC)

Wytske Fokkens, MD, PhD Christos Georgalas, PhD, DLO, FRCS (ORL-HNS)

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ix

Acknowledgments

Although it is not possible to list all the great individuals

who contributed to this book, we would like to express

our sincere gratitude to everybody involved in the

cre-ation of this work

Special recognition goes to the contributors, as we

sin-cerely appreciate the time, expertise, and dedication you

gave to this book We hope you are as proud as we are of

the fi nal result

We thank Mr Stephan Konnry and his team for

be-lieving in and supporting this project from the very

beginning, for always guiding and being open for sion, and for their unique and valuable dedication—this book would have been impossible without them

discus-We thank Mrs Storz for supporting our illustrator; Jaap Tuyp, IC-Audiovisual Centre of the AMC, for his kind sup-port of the DVD production; Artur Gevorgyan for proofread-ing the book and for his numerous valuable suggestions; Susanne Reinartz and Dirk Jan Menger, our rhinology col-leagues, and Wouter van Furth, neurosurgeon, for their sup-port; and Katja Dalkowski, MD, for the beautiful illustrations

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Nithin D Adappa, MD

Department of Otorhinolaryngology–Head and

Neck Surgery

Hospital of the University of Pennsylvania

University of Pennsylvania School of Medicine

Philadelphia, Pennsylvania, USA

Robert V Almeyda

ENT Specialist Registrar

John Radcliﬀ Hospital

Oxford, UK

Isam Alobid, MD, PhD

Hospital Clinic

Institut d’Investigacions Biomèdiques

August Pi i Sunyer (IDIBAPS)

Director, Division of Rhinology

St Louis, Missouri, USA

Becker Nose and Sinus Center

Vanderbilt University Medical Center

Voorhees, New Jersey, USA

Brett Bell, PhD

Postdoctoral Researcher

Center for Computer-Aided Surgery

Institute of Surgical Technology and Biomechanics

University of Bern

Bern, Switzerland

Rajiv K Bhalla, BSc (Hons), FRCS (ORL-HNS), MD

Consultant, ENT Surgeon, and Rhinologist Department of Otorhinolaryngology–Head and Neck Surgery

Manchester Royal Infi rmary Manchester, UK

Benjamin S Bleier, MD

Clinical Instructor Department of Otology and Laryngology Massachusetts Eye and Ear Infi rmary Harvard Medical School

Boston, Massachusetts, USA

Ulrike Bockmühl, MD, PhD, MA

Professor Department of Otorhinolaryngology, Head and Neck Surgery

Kassel Hospital Kassel, Germany

Andrea Bolzoni Villaret, MD

Department of Otorhinolaryngology University of Brescia

Brescia, Italy

Cornelius Jan Brenkman, MD

Diaconessenhuis Leiden Leidern, The Netherlands

Hans Rudolf Briner, MD

Clinical Instructor ORL-Center for Otology, Skull Base Surgery, Rhinology, and Facial Plastic Surgery Hirslanden Clinic

Zurich, Switzerland

Ricardo L Carrau, MD, FACS

Director Skull Base Program Department of Otolaryngology–Head and Neck Surgery Ohio State University Medical Center

Columbus, Ohio, USA

List of Contributors

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xi List of Contributors

Professor and Director

University Clinic for ENT, Head and Neck Surgery

Inselspital

Bern, Switzerland

Daniel T T Chua, MD, FRCR

Consultant, Clinical Oncologist

Comprehensive Oncology Center

Department of Medicine

Hong Kong Sanatorium and Hospital

Hong Kong SAR, China

Roxana Cobo, MD

Coordinator, Service of Otolaryngology

Centro Médico Imbanaco

Hospital of the University of Pennsylvania

Leo F S Ditzel Filho, MD

Department of Neurological Surgery

Ohio State University Medical Center

Columbus, Ohio , USA

Wolfgang Draf, MD, PhD, FR

Former Director Department of Ear, Nose and Throat Diseases, Head and Neck Surgery

International Neuroscience Institute University of Magdeburg

Hannover, Germany

Patrick Dubach, MD

Department of Otorhinolaryngology, Head and Neck Surgery

Inselspital University Hospital University of Bern Bern, Switzerland

Nicolas Dulguerov, MD

Senior Fellow in ENT/Facial Plastic Surgery

St Mary’s Hospital London, UK

Davide Farina, MD

Department of Radiology University of Brescia Brescia, Italy

Berrylin J Ferguson, MD

Director Division of Sino-nasal Disorders and Allergy Professor of Otolaryngology

University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania, USA

Juan C Fernandez-Miranda, MD

Assistant Professor Department of Neurological Surgery University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania, USA

Wytske Fokkens, MD, PhD

Professor Department of Otorhinolaryngology Academic Medical Center

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xii List of Contributors

Christos Georgalas, PhD, DLO, FRCS (ORL-HNS)

Director, Endoscopic Skull Base Center

University of North Carolina at Chapel Hill

Chapel Hill, North Carolina, USA

Jan Gosepath, MD, PhD

Director

Department of Otolaryngology, Head and Neck Surgery

Dr Horst Schmidt Kliniken

Center for Applied Genomics

Children’s Hospital of Philadelphia

Associate Professor

Department of Pediatrics

Samuel Heimgartner, MD

Supervising Physician

Department of Otorhinolaryngology,

Head and Neck Surgery

University Hospital Bern, Inselspital

Claire Hopkins, MA(Oxon), DM, FRCS (OR-LHNS)

Guy’s and St Thomas’ Hospital London, UK

Nick S Jones, MD, BDS, FRCS, FRCS (ORL)

Professor Department of Otorhinolaryngology, Head and Neck Surgery

Queens Medical Center University Hospital University of Nottingham Nottingham, UK

Amin B Kassam, MD

Director Neurosciences Neurosciences Institute John Wayne Cancer Institute

St John’s Health Center Santa Monica, California, USA

Robert M Kellman, MD

Professor and Chair Department of Otolaryngology and Communication Sciences State University of New York Upstate Medical University Syracuse, New York, USA

Daniel F Kelly, MD

Medical Director John Wayne Cancer Institute

St John’s Health Center Santa Monica, California, USA

Bhik Kotecha, MPhil, FRCS, DLO

Consultant, Otolaryngologist Royal National Throat, Nose, and Ear Hospital London, UK

Stilianos E Kountakis, MD, PhD

Professor and Vice-Chairman Department of Otolaryngology Chief, Division of Rhinology Medical College of Georgia Augusta, Georgia, USA

Haytham Kubba, MD

Consultant, Pediatric Otolaryngologist Royal Hospital for Sick Children Yorkhill

Glasgow, Scotland, UK

Jean-Silvain Lacroix, MD, PhD

Professor Geneva University Hospital and Geneva Medical School Geneva, Switzerland

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xiii List of Contributors

Basile Nicolas Landis, MD

Smell and Taste Outpatient Clinic

Department of Otolaryngology–Head and Neck Surgery

Bern University Hospital, Inselspital

Bern, Switzerland

Donald C Lanza, MD, MS

Director

Sinus and Nasal Institute of Florida Foundation

St Petersburg, Florida, USA

Annie S Lee, MD

Lahey Clinic Medical Center

Burlington, Massachusetts, USA

Sarah Lovell

National University Hospital

Barcelona, Spain

Nancy McLaughlin, MD, PhD, FRCSC

Fellow in Neurosurgery

John Wayne Cancer Institute

St John’s Health Center

Santa Monica, California, USA

Ralph Metson, MD

Clinical Professor of Otolaryngology

Department of Otology and Laryngology

Harvard Medical School

Boston, Massachusetts, USA

Joaquim Mullol, MD, PhD

Professor

Hospital Clinic

Barcelona, Spain

Piero Nicolai, MD

Professor, Chairman Department of Otorhinolaryngology University of Brescia

Brescia, Italy

Gilbert J Nolst Trenité, MD, PhD

Professor ENT Department Academic Hospital Amsterdam, The Netherlands

Reza Nouraei

Special RegistrarAcademic ENT SurgeryImperial College Healthcare NHS TrustThe Royal National Throat, Nose, and Ear HospitalLondon, UK

Vasileios Papanikolaou, MD

Consultant in Otorhinolaryngology First University Department of Otorhinolaryngology Ippokation Hospital

Athens, Greece

Kalpesh S Patel, BSc (Hons), FRCS (ORL)

Consultant, ENT/Facial Plastic Surgeon Honorary Senior Lecturer

Imperial College of Science

St Mary’s Hospital London, UK

Santdeep H Paun, MBBS, FRCS (ORL-HNS)

Consultant, Nasal/Facial Plastic Surgeon Head, Department of Otorhinolaryngology–Head and Neck Surgery

St Bartholomew’s and the Royal London Hospitals London, UK

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xiv List of Contributors

Emmanuel Prokopakis, MD

Assistant Professor

Neck Surgery

University of Crete School of Medicine

Heraklio, Crete, Greece

Susanne M Reinartz, MD

Herbert Riechelmann, MD, PhD

Chairman and Professor

Hesham Saleh, FRCS (ORL-HNS)

Consultant, Rhinologist, and Facial Plastic Surgeon

Honorary Senior Lecturer

Charing Cross and Royal Brompton Hospitals

Imperial College of Medicine

Medical University of South Carolina

Mt Pleasant, South Carolina, USA

Brent Senior, MD

Professor and Vice Chair

Otolaryngology/Head and Neck Surgery

University of North Carolina at Chapel Hill

Chapel Hill, North Carolina, USA

Daniel Simmen, MD

Professor ORL Center Hirslanden Clinic Zurich, Switzerland

Ameet Singh, MD

Assistant Professor of Surgery and Neurosurgery Director, Rhinology and Skull Base Surgery George Washington University

Washington, DC, USA

Elisabeth Victoria Sjoegren, MD, PhD

Department of Otolaryngology–Head and Neck Surgery Leiden University Medical Center

Leiden, The Netherlands

Carl H Snyderman, MD, MBA

Professor Departments of Otolaryngology and Neurological Surgery

University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania, USA

Zachary M Soler, MD

Rhinology Fellow Harvard Medical School Boston, Massachusetts, USA

Alla Y Solyar, MD

Rhinology Fellow Sinus and Nasal Institute of Florida Foundation

St Petersburg, Florida, USA

Gero Strauss, MD, PD

Supervising Physician Clinic for ENT/Surgery/Plastic Surgery University Clinic Leipzig

Leipzig, Germany

Andrew C Swift, ChM, FRCS, FRCSEd

Consultant, ENT Surgeon, and Rhinologist Aintree University Hospital NHS Foundation Trust Liverpool, UK

Ingrid Terreehorst, MD, PhD

Department of Otorhinolaryngology Academic Medical Center

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xv List of Contributors

Timoleon F Terzis MD, PhD

Head, Athens Rhinology Center

Visiting Consultant, Otorhinolaryngologist

Onassis Cardiac Surgery Center

Athens, Greece

Marc A Tewfi k, MD, MSc, FRCSC

Assistant Professor

McGill University

Royal Victoria Hospital

Montreal, Quebec, Canada

Matthew J Tormenti, MD

Neurosurgery Resident

Department of Neurological Surgery

University of Pittsburgh School of Medicine

Pittsburgh, Pennsylvania, USA

Elina Toskala, MD, PhD

Professor

Finnish Institute of Occupational Health

Helsinki, Finland

Center for Applied Genomics

Children’s Hospital of Philadelphia

Bert van der Baan, MD

ENT Department

Cornelis M van Drunen, PhD

Wouter R van Furth, MD, PhD

Endoscopic Skull Base Center

Thibaut Van Zele, MD, PhD

Upper Airways Research Laboratory

Ghent University Hospital

Ghent, Belgium

Carel D A Verwoerd, MD, PhD

Emeritus Professor of Otolaryngology

Erasmus University Medical Center

Rotterdam, The Netherlands

Stefan Weber, PhD

Professor ARTORG Center for Biomedical Engineering Research University of Bern

Hong Kong Sanatorium and Hospital Hong Kong SAR, China

Ronald B Willemse, MD

Department of Neurosurgery Endoscopic Skull Base Center Academic Medical Center Amsterdam, The Netherlands

Peter-John Wormald, MD, FRCS, FRACS, FCS (SA)

Professor of Otolaryngology Adelaide and Flinders Universities Queen Elizabeth Hospital Department of Otolaryngology–Head and Neck Surgery Woodville South, Australia

Giannis Yiotakis, MD, PhD

Associate Professor First University Department of Otorhinolaryngology Ippokation Hospital

Athens, Greece

Bing Zhou, MD

Professor and Vice Chairman Department of Otolaryngology Tongren Hospital

Beijing, China

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Contents

Factors Associated with Recurrent

Acute Rhinosinusitis 53

Factors Associated with Chronic Rhinosinusitis 54

Factors Associated with Nasal Polyps 57

Therapeutic Consequences of the Complex Pathophysiology of Rhinosinusitis 58

Key Points 59

Review Questions 59

References 59

4 Immunology and the Nose: From Basic Science to Clinical 62

Cornelius M van Drunen and Wytske Fokkens Summary 62

Introduction 62

Dangers Lurking in the Outside World 62

Autoimmune Diseases and Allergy: Cases of Mistaken Identity 73

Investigating Diseases and the Immune System 75

Key Points 75

Review Questions 76

References 76

5 Genetics in Rhinology 77

Elina Toskala and Hakon Hakonarson Summary 77

Introduction 77

Allergic Rhinitis 78

Chronic Rhinosinusitis 79

Asthma 80

Cystic Fibrosis 81

Mucin Disorders 82

Key Points 82

Review Questions 82

References 83

6 Investigations in Nasal Disease 85

Glenis K Scadding and Susanne M Reinartz Summary 85

Introduction 85

Allergy Tests 86

Nasal Sampling 89

Foreword .vii

Preface .viii

Acknowledgments .ix

List of Contributors .x

I Basic Science and Patient Assessment 1

1 Nasal and Paranasal Sinus Anatomy and Embryology 3

Annie S Lee, Alla Y Solyar, Donald C Lanza, and Christos Georgalas Summary 3

Introduction 3

Development of the Nose and Paranasal Sinuses 4

The External Nose 6

The Nasal Cavity 8

The Paranasal Sinuses 16

Key Points 24

Acknowledgments 24

Review Questions 24

References 25

2 Nasal and Paranasal Sinus Physiology 27

Vassilios Danielides, Haralampos Gouveris, Sarah Lovell, and De-Yun Wang Summary 27

Physiologic Function of the Nasal Airfl ow 27

Physiologic Functions of the Nasal Epithelium 38

Special Issues on Physiology of the Paranasal Sinuses 46

Key Points 46

Review Questions 47

References 47

3 Recent Advances in Understanding the Pathophysiology of Rhinosinusitis 50

Peter W Hellings Summary 50

Introduction 50

Infl ammation in Rhinosinusitis 52

Factors Associated with Acute Rhinosinusitis 53

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xvii Contents

Evaluation of Nasal Patency 92

Microbiology 96

Evaluation of Mucociliary Clearance 97

Blood and Other Tests 99

Key Points 100

Review Questions 100

References 101

7 Imaging as a Diagnostic Tool and Surgical Instrument in Rhinology 103

Timoleon F Terzis and Nicole J M Freling Summary 103

Introduction 103

From Plain X-Ray Films to Computed Tomography 104

Computed Tomography and Magnetic Resonance Imaging 104

Other Imaging Modalities 106

Evaluation of Pathology 108

Infl ammatory Disease 109

Neoplastic Disease 113

Study of the Anatomy on Computed Tomography 116

Virtual Surgery Based on Computed Tomography 126

Do We Need Image Guidance? 126

Acknowledgment 127

Key Points 127

References 128

8 Clinical Examination and Diﬀ erential Diagnosis in Rhinology 130

Joaquim Mullol, Franklin Mariño-Sánchez, Isam Alobid, and Christos Georgalas Summary 130

Introduction 130

Clinical Diagnosis 130

Examination and Complementary Diagnostic Tools 138

Referral and Consultation Criteria 144

Steps in Diﬀ erential Diagnosis 144

Key Points 150

References 151

9 Patient-reported Outcome Measures and Measurement Tools in Rhinology 152

Claire Hopkins and Christos Georgalas Summary 152

Introduction 152

Why Measure Outcome? 152

Clinical versus Patient-reported Outcomes 153

Clinician-reported Outcome Measures in Rhinology 154

Patient-reported Outcome Measures in Rhinology 154

How to Choose an Appropriate Patient-rated Outcome Tool 164

Data Collection and Storage 166

Developing an Outcome Tool When None Are Available 167

Why Are We Not Routinely Measuring PROMs? 168

Limitations of PROMs 170

Cost-eﬀ ectiveness Analysis 171

Publishing Outcomes 171

Key Points 171

References 172

10 Facial Pain 175

Nick S Jones Summary 175

Introduction 175

Sinogenic Facial Pain 175

Main Categories of Nonsinogenic Facial Pain 178

Indomethacin-responsive Headaches 182

“Sinus Headaches” 182

Specifi c Neurologic Conditions 187

The Overlap between Conditions 188

Comment on Contact Points 188

Key Points 191

References 192

11 Olfaction and Its Disorders 195

Basile Nicolas Landis, Hans Rudolf Briner, Jean-Silvain Lacroix, and Daniel Simmen Summary 195

Olfaction 195

Olfactory Disorders 199

Key Points 209

References 210

12 The Relation between the Upper and Lower Airways: The United Airway Concept 212

Bert van der Baan, Peter W Hellings, and Wytske Fokkens Summary 212

Introduction 212

Epidemiology 213

Interaction between the Upper and Lower Airways 214

Management of the United Airways 217

Key Points 222

References 223

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xviii Contents

II Rhinitis and Rhinosinusitis 227

13 Nonallergic Rhinitis: Defi nition, Classifi cation, and Management 229

Wytske Fokkens, Hesham Saleh, and Christos Georgalas Summary 229

Introduction 229

Defi nition and Diﬀ erential Diagnosis 229

Epidemiology 232

Considerations on Possible Pathophysiologic Mechanisms 232

Diagnosis 235

Treatment Modalities 239

Conclusion 243

Key Points 244

References 244

14 Allergic Rhinitis: Defi nition, Classifi cation, and Management, Including Immunotherapy 246

Pascal Demoly, Wytske Fokkens, and Ingrid Terreehorst Summary 246

Introduction 246

Defi nition of Allergic Rhinitis 247

Epidemiology 248

Etiology: Allergens and Nonspecifi c Factors 249

Clinical Features 254

Diﬀ erential Diagnosis 255

Diagnostic Work-up 255

Management 257

Key Points 262

References 263

15 Acute Rhinosinusitis and Infections of the Nose 264

De-Yun Wang, Li Shi, Bing Zhou, and Jian-Bo Shi Summary 264

Defi nition 264

Physiologic and Immunologic Functions of the Nose and Sinuses 266

Acute Viral Rhinitis (or Viral Rhinosinusitis)/ Common Cold 267

Acute Rhinosinusitis 268

Nasal Vestibulitis 270

Diagnosis 271

Treatment 272

Conclusion 274

Key Points 274

References 275

16 Chronic Rhinosinusitis with and without Nasal Polyps 276

Jan Gosepath and Oliver Pfaar Summary 276

Chronic Rhinosinusitis: Epidemiological Burden 276

Clinical Defi nition 277

Clinical Characteristics and Associated Factors 277

Therapeutic Options Deriving from Diﬀ erent Clinical Parameters 279

Eﬃ cacy of Endoscopic Sinus Surgery 281

Evaluation of Endoscopic Sinus Surgery 282

Key Points 282

References 283

17 Evidence-based Medical Management of Chronic Rhinosinusitis 285

Philippe Gevaert, Humera Babar-Craig, Thibaut Van Zele, and Robert V Almeyda Summary 285

Introduction 285

Defi nition 286

Management Algorithm 286

Current Medical Management Options 286

Evidence for Medical Management versus Surgical Management 292

Future Therapy 292

Long-term Management 293

Key Points 293

References 294

18 Evidence-based Surgery for Rhinosinusitis 296

Christos Georgalas and Wytske Fokkens Summary 296

Introduction 296

Measuring the Eﬃ cacy of Sinus Surgery 298

Functional Endoscopic Sinus Surgery in Acute Recurrent Rhinosinusitis 298

Functional Endoscopic Sinus Surgery in Chronic Rhinosinusitis with and without Nasal Polyps 299

Functional Endoscopic Sinus Surgery versus Conventional Surgery 303

Endoscopic Sinus Surgery Modifi cations 303

Predictors of Outcome in Endoscopic Sinus Surgery 304

Revision Sinus Surgery 307

Key Points 308

References 308

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xix Contents

19 Basic Surgical Techniques in

Endoscopic Sinus Surgery 311

Hesham Saleh and Reza Nouraei Summary 311

Introduction 311

Indications/Patient Selection 312

Patient Information/Consent 312

Patient Positioning and Anesthesia 312

Basic Surgical Instruments for Endoscopic Sinus Surgery 312

Operative Steps 314

Postoperative Care 323

Complications 323

Outcome 323

Future Directions 323

Key Points 324

References 325

20 The Patient with Diﬃ cult-to-Treat Chronic Rhinosinusitis 326

Emmanuel Prokopakis, Berrylin J Ferguson, Christos Georgalas, and Wytske Fokkens Summary 326

Introduction 326

Diﬃ cult-to-Treat Disease 326

The Diﬃ cult Host 341

Treatment Suggestions 342

Conclusion 345

Key Points 346

References 346

21 Fungal Rhinosinusitis 349

Herbert Riechelmann, Marc A Tewfi k, and Peter-John Wormald Summary 349

Introduction 349

Fungus Biology 350

Fungus-related Sinus Disease 352

Medical Management 362

Surgical Management 366

Conclusion 373

Key Points 373

References 373

22 Approaches to the Frontal Sinus 376

Christos Georgalas and Wytske Fokkens Summary 376

Introduction 376

Classifi cation of Frontal Sinus Approaches/ Nomenclature 378

Indications 378

Surgical Anatomy of the Frontal Recess 381

Instrumentation 385

Approaches: Anatomical and Technical Description 386

Specifi c Anatomical Considerations 392

Specifi c Pathological Considerations 393

Preoperative and Postoperative Management 404

Outcomes 405

Key Points 407

References 407

III Rhinoplasty and Nasal Framework Surgery 411

23 Assessment of the Rhinoplasty Patient 413

Christos Georgalas Summary 413

Rhinoplasty: Social and Ethical Issues 414

Patient Selection and the Rhinoplasty Consultation 414

Surgical Anatomy of the External Nose 417

Nasal Aesthetics and Assessment 422

Documentation in Rhinoplasty: Photography and Computer Imaging 427

Key Points 433

References 433

24 Cosmetic Rhinoplasty 436

Roxana Cobo Summary 436

Introduction 436

Approach to the Nasal Septum/ Graft Harvesting 436

Approaches in Rhinoplasty 437

Management of the Upper Third of the Nose: The Bony Nasal Vault 440

Management of the Middle Third of the Nose: The Cartilaginous Vault 443

Management of the Lower Third of the Nose: The Nasal Tip 445

Alar Base Reduction 452

Skin–Soft Tissue Envelope 453

Postsurgical Follow-up 454

Conclusion 454

Key Points 454

References 455

25 Revision Rhinoplasty 456

Santdeep H Paun and Gilbert J Nolst Trenité Summary 456

Introduction 456

Psychological Issues 456

Nasal Anatomy 457

Timing of Revision Operation 457

Assessment 458

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26 Functional Nasal Surgery 478

Kalpesh S Patel and Nicolas Dulguerov

Summary 478

Introduction 478

Relevant Nasal Anatomy 478

Tip Support 480

Internal Nasal Valve 481

External Nasal Valve 482

Etiology of Nasal Obstruction 483

Aging of the Nose 483

Cartilage Considerations 483

Investigations 484

Structural Causes of Nasal Obstruction 486

Management of Septal Deviation 488

Nasal Bone Deviation 493

Nasal Valve Incompetence 493

Andrew C Swift, Benjamin S Bleier,

Rajiv K Bhalla, and Rodney J Schlosser

28 Complications of Acute Rhinosinusitis 527

Mitchell R Gore, Philippe Herman,

Brent Senior, and Wytske Fokkens

29 Nasal and Paranasal Sinus Trauma 545

Robert M Kellman

Summary 545Classifi cation of Nasal and Paranasal

Sinus Trauma 545Epidemiology of Nasal and Paranasal

Sinus Trauma 549Paranasal Sinuses as a Protective

Crumple Zone 549Clinical Features 549Diagnostic Studies 550Management 551Outcomes 560Key Points 562Review Questions 562References 563

V Rhinology: The Multidisciplinary Interface 565

30 Anesthesia for Nasal Surgery, Pre- and Postoperative Care 567

Ameet Singh, Elisabeth Victoria Sjoegren, Samuel S Becker, and Cornelius Jan Brenkman

Summary 567Introduction 567Preoperative Planning in Sinus Surgery 567General Anesthesia in Sinus Surgery 570Local Anesthesia in Sinus Surgery 570Preparation of the Surgical Field 573Preparation of the Surgical Field: Evidence of Substance Eﬀ ect and Safety 576Postoperative Management of Sinus

Surgery 578Key Points 582Review Questions 582References 582

31 Technological Advances in Rhinology and Anterior Skull Base 585

Brett Bell, Patrick Dubach, Samuel Heimgartner, Tim C Lueth, Gero Strauss, Stefan Weber, and Marco D Caversaccio

Summary 585Computer-assisted Surgery 585Modern Surgical Instrumentation 593Robotic Manipulation and Support 597Operating Room Integration 601Clinical Applications 602Key Points 603Review Questions 603References 604

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xxi

32 Acquired Noninfectious, Nonneoplastic

Disorders of the Nose and Paranasal Sinuses 606

Nithin D Adappa, Noam A Cohen,

and James N Palmer

33 Pediatric Rhinology: Developmental

Aspects and Surgery 626

Carel D A Verwoerd, Haytham Kubba,

and Henriette L Verwoerd-Verhoef

Summary 626

Introduction 627

Postnatal Growth of the Nose 627

Morphogenetic Processes and Nasal Growth:

34 Nasal Pathology in Snoring and

Obstructive Sleep Apnea 663

Bhik Kotecha and Christos Georgalas

Summary 663

Introduction 663

Pathophysiology of Nasal Obstruction and

Breathing During Sleep 664

Clinical Correlation Between Nasal Pathology

and Sleep-Disordered Breathing 665

Implications for Management 666

Key Points 670

References 671

35 Systemic Disease and the Nose 673

Jastin Antisdel and Stilianos E Kountakis

VI Sinonasal Oncology and Extended Applications of Endoscopic Surgery 693

36 Closure of Cerebrospinal Fluid Leaks and Repair of Meningoceles/Encephaloceles 695

Wytske Fokkens and Christos Georgalas

Summary 695Introduction 695Diagnosis of Leaks 698Important Surgical Anatomy and

Operative Steps 703Postoperative Care 710Outcomes 711Key Points 711Review Questions 712References 712

37 Into and Around the Orbit:

Endoscopic Dacryocystorhinostomy, Orbital Decompression, Optic Nerve Decompression, and Endoscopic Management of Orbital Tumors 713

Peerooz Saeed, Zachary M Soler, Christos Georgalas, and Ralph Metson

Summary 713Endoscopic Dacryocystorhinostomy 713Endoscopic Orbital Decompression 719Optic Nerve Decompression 725Orbital Tumors: An Endoscopic Approach 727Benign Tumors 727Key Points 735Review Questions 736References 736

38 Endoscopic Approach to the Sella 738

Ronald B Willemse, Wouter R van Furth, Wytske Fokkens, and Christos Georgalas

Summary 738Introduction 738Indications/Patient Selection 739Preoperative Planning 741Patient Information/Informed Consent 745Anesthesia and Positioning 745Operative Steps 746Complications 751Postoperative Care 753Outcomes 754Key Points 756Review Questions 756References 756

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2 Nasal and Paranasal Sinus Physiology

xxii

39 Sella and Beyond: Approaches to

the Clivus and Posterior Fossa,

Petrous Apex, and Cavernous Sinus 758

Carl H Snyderman, Paul A Gardner,

Matthew J Tormenti, and

Juan C Fernandez-Miranda

Summary 758

Introduction 758

Terminology: Defi nition of Parasellar Areas 758

Principles of Endoscopic Endonasal Surgery

of the Skull Base 759

Classifi cation of Skull Base Approaches 759

Transplanum, and Transcribriform 772

Nancy McLaughlin, Daniel M Prevedello,

Leo F S Ditzel Filho, Daniel F Kelly,

Amin B Kassam, and Ricardo L Carrau

Summary 772

Introduction 772

Indications/Patient Selection 772

Preoperative Planning 773

Patient Counseling, Informed Consent 775

Anesthesia and Positioning 775

41 Reconstruction of the Skull Base

and Management of Skull Base

Surgery Complications 791

Nancy McLaughlin, Ricardo L Carrau,

Amin B Kassam, Daniel F Kelly,

Daniel M Prevedello, and

Juan C Fernandez-Miranda

Summary 791

Introduction 791

Generalities of Skull Base Reconstruction in

Endonasal Skull Base Surgery 791

Pedicled Flaps 792

Other Reconstruction Techniques for

Large Skull Base Defects 804

Postoperative Cerebrospinal Fluid Leak 804

Key Points 807

Review Questions 807References 808

42 Benign and Malignant Tumors of the Nose and Paranasal Sinuses, Including External Approaches to Paranasal Sinuses 810

Ulrike Bockmühl, Giannis Yiotakis, Vasileios Papanikolaou, and Wolfgang Draf

Summary 810Introduction 810General Remarks 810Endonasal Approach 813External Approaches 815Outcome 832Key Points 832Review Questions 832References 833

43 The Role of Endoscopy in the Management of Benign and Malignant Sinonasal Tumors 835

Piero Nicolai, Paolo Castelnuovo, Andrea Bolzoni Villaret, and Davide Farina

Summary 835Introduction 835

A Quick Look at Epidemiology, Symptoms, Diagnosis, and Staging 836Patient Selection and Information 841Anesthesia and Positioning 844Operative Steps 846Complications 852Perioperative Management 853Adjuvant Therapy 854Outcome 855Postoperative Surveillance 857Key Points 858Review Questions 859References 859

44 Nasopharyngeal Carcinoma 862

William Ignace Wei and Daniel T T Chua

Summary 862Epidemiology 862Pathology 863Etiology 863Diagnosis 863Treatment 866Management of Residual or Recurrent

Disease 869Key Points 876Review Questions 876References 877

Appendix 879 Index .885

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Basic Science and Patient Assessment

Section I

1 Nasal and Paranasal Sinus Anatomy and Embryology 3

2 Nasal and Paranasal Sinus Physiology 28

3 Recent Advances in Understanding the Pathophysiology of Rhinosinusitis 52

4 Immunology and the Nose:

From Basic Science to Clinical 64

5 Genetics in Rhinology 79

6 Investigations in Nasal Disease 87

7 Imaging as a Diagnostic Tool and Surgical Instrument in Rhinology 105

8 Clinical Examination and Diﬀ erential Diagnosis in Rhinology 132

9 Patient-reported Outcome Measures and Measurement Tools in Rhinology 154

10 Facial Pain 177

11 Olfaction and Its Disorders 197

12 The Relation between the Upper and Lower Airways: The United Airway Concept 214

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Summary 3

Introduction 3

Development of the Nose and Paranasal Sinuses 4

Embryology of the Nose 4

Embryology of the Paranasal Sinuses 4

The External Nose 6

Surface Anatomy 6

Nasal Framework 6

Nasal Musculature 8

Blood Supply to the External Nose 8

Innervation of the External Nose 8

The Nasal Cavity 8

Nasal Vestibule and Nasal Valve 8

Nasal Septum 9Lateral Nasal Wall 10Blood Supply to the Nasal Cavity 13Innervation of the Nasal Cavity 14Pterygopalatine Fossa 15

The Paranasal Sinuses 16Maxillary Sinuses 17Sphenoid Sinuses 17Frontal Sinuses 20Ethmoid Sinuses 22

Key Points 24

Review Questions 25

Summary

Understanding the anatomy and embryology is the

founda-tion for understanding funcfounda-tion, disease, and treatment The

nose and paranasal sinuses serve important functions for

our safety and comfort Their intricate anatomy and

physi-ology must be maintained for our general health Diseases

aﬀ ecting them can readily lead to symptoms and

complica-tions Common symptoms of disease include nasal

obstruc-tion, facial pain, cough, bleeding, swelling, and olfactory

loss, but these symptoms can also be associated with poorly

controlled asthma and pneumonia, as well as orbital and

in-tracranial complications As demonstrated throughout this

chapter, surgeons interested in this area must be intimately

familiar with anatomy to safely improve quality of life

Introduction

The nose and paranasal sinuses serve important

func-tions for our general health, safety, and comfort Evidence

of the anatomical importance of these structures is seen

in the fact that respiration normally occurs through the

nasal airway as opposed to the larger oral airway Thus,

simply stated, the primary function of the nose and nasal sinuses is to couple the lungs to the external envi-ronment through a variety of important functions

Because of their intricate anatomical design, the nose and paranasal sinuses condition the air that we breathe and pre-pare it for delivery to the lungs The nasal passage’s ciliated respiratory epithelial lining, referred to as mucosa, produces

a mucous blanket that is distributed across an undulated surface area From an evolutionary point of view, this results

in an eﬀ ective system of humidifi cation and temperature control that permits humans to comfortably inhabit arid as well as frigid climates The mucosa of the nasal passages and its mucous blanket also aids with our host defense mecha-nisms The mucous blanket traps foreign particles, such as bacteria, mold, and toxic substances, so that they can be imperceptibly swallowed into the stomach, where they are neutralized by acid This mucous blanket contains immuno-globulin A (IgA) and antimicrobial peptides, such as beta-de-fensin-2, produced by the innate immunity of the mucosa The nasal passages house the nerve endings that help with early detection of toxic substances, as well as enjoyment of odors that embellish gustation (e.g., the aroma of coﬀ ee, the bouquet of wine, and the fl avor of beef)

Although the importance of nasal resistance is still debated as it relates to obstructive sleep apnea, nasal resistance appears to play an important role in normal

Annie S Lee, Alla Y Solyar, Donald C Lanza, and Christos Georgalas

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1 Nasal and Paranasal Sinus Anatomy and Embryology

The precise embryology of the lateral nasal wall and ranasal sinuses is somewhat disputed in the literature 3–7 However, the traditional teaching is that there are a series

pa-of folds on the lateral nasal wall called the binals that appear during the eighth week of gestation

ethmotur-( Fig 1.1b ) Five to seven folds initially appear, but after

a process of fusion and regression, three or four folds remain by week 15 These folds are considered ethmoid

in origin, and they ultimately become upper turbinates in the lateral nasal wall 8 The fi rst ethmoturbinal regresses during the development period and remains at its rudi-mentary form; the ascending portion becomes the agger nasi, and the descending portion forms the uncinate pro-cess The second ethmoturbinal eventually develops into the middle turbinate, and the third ethmoturbinal forms the superior turbinate The fourth and fi fth ethmoturbi-nals are thought to fuse and become the supreme turbi-nate A separate ridge of maxillary origin known as the maxilloturbinal is formed inferior to the ethmoturbinals, giving rise to the eventual inferior turbinate Interest-ingly, some researchers hold that the inferior, middle, and superior turbinates are identifi able at week 8 and that they develop directly from the cartilaginous nasal cap-sule; therefore, they propose that the embryologic terms used above are unnecessary 5 ( Fig 1.1c )

The primary furrows that form between the turbinals ultimately give rise to the various meatuses and recesses The fi rst primary furrow is formed between the

ethmo-fi rst and second ethmoturbinals The descending portion

of the fi rst primary furrow forms the ethmoid lum, hiatus semilunaris, and middle meatus The ascend-ing portion participates in the formation of the frontal recess The second and third primary furrows become the superior and supreme meatus, respectively

In addition to the development from the ridges and furrows, the paranasal sinuses receive contribution from

a cartilaginous capsule that surrounds the nasal cavity Some investigators proposed that this cartilaginous nasal capsule plays the main role in the development of the paranasal sinuses and lateral nasal wall structures, and that the development of the ridges and furrows is a secondary phenomenon 5 The detailed mechanism of the development of the paranasal sinuses is still debated, but

it is clear that all the paranasal sinuses originate from the ethmoid region 9

pulmonary function There is evidence that nasal

resis-tance is involved in adequate diaphragmatic excursion

during inspiration and that it is necessary to slow

expira-tion, thereby permitting proper oxygen and carbon

diox-ide exchange in the lungs 1

Critical to understanding nasal and paranasal

patho-physiology is a review of nasal and paranasal sinus

anatomy and embryology In this chapter we fi rst review

embryology, then review the surface anatomy of the

ex-ternal nose, the nasal framework, and the nasal

muscula-ture, along with their blood supply and innervation Next,

we present the anatomy of the nasal cavity, nasal septum,

and lateral nasal wall with their blood supply and

inner-vation Lastly, we review the anatomy of the paranasal

sinuses especially as it is relevant to sinus surgery

Development of the Nose and

Paranasal Sinuses

At the end of the fourth week of fetal development,

mes-enchymal cells of neural crest origin start to aggregate to

form the facial prominences in the midface On either side

of the frontonasal prominences, nasal placodes, bilateral

thickening of surface ectoderm, are formed During the

fi fth week, the nasal placodes invaginate to form the nasal

pits, and the tissue ridges surrounding the pits form the

lateral and medial nasal prominences The maxillary

prominences continue to expand medially, shifting the

medial nasal prominences toward the midline in the

fol-lowing 2 weeks The two medial nasal prominences

even-tually fuse, giving rise to the medial portion of the upper

lip and anterior palate ( Fig 1.1a ) Cleft lip is associated

with inadequate contact between the maxillary

promi-nences and the intermaxillary segment Cleft palate

oc-curs secondary to failure of the lateral palatine processes

to properly fuse The furrow between the lateral nasal

prominence and the maxillary prominence involutes to

become the nasolacrimal duct Ultimately, the external

nose is derived from fi ve diﬀ erent facial prominences; the

frontal prominence forms the nasal bridge, the fused

me-dial nasal prominences give rise to the tip, and the lateral

nasal prominences become the alae 2,3

Note

Cleft lip is associated with inadequate contact between the

maxillary prominences and the intermaxillary segment Cleft

palate occurs secondary to failure of the lateral palatine

pro-cesses to properly fuse

!

During the sixth week of development, the nasal pits

deepen to form a primitive nasal cavity The oronasal

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Development of the Nose and Paranasal Sinuses 5

The maxillary sinus develops as an outpouching

between the middle and inferior turbinates It is the

fi rst sinus to develop, beginning its invagination process

during the third gestational month It continues to

un-dergo growth after birth, with periods of rapid growth

typically at the times of dental development 10 The

eth-moid sinus is thought to start out as multiple

invagina-tions from the lateral wall of the nasal capsule around

the fi fth month of development 10 The sphenoid sinus

originates from an outpouching from the posterior

as-pect of the nasal capsule during the third month of

gestation Though minimal in size at birth, the sphenoid bone undergoes pneumatization during childhood, and the sinus reaches its adult size between the ages of 9 and

12 8 The development of the frontal sinus starts with the anterior pneumatization of the frontal recess into the frontal bone around week 16 of gestation Several folds and furrows develop within the frontal recess that even-tually give rise to the agger nasi cell (fi rst frontal furrow), frontal sinus proper ( second frontal furrow), and ante-rior ethmoid cells (third and fourth frontal furrows) 11 Pneumatization into the frontal bone does not start until

Nasolacrimalgroove

Stomodeum

Nasal pitNasal pit

a Coronal depictions of embryologic

de-velopments of the midface and the nose

at 5, 6, 7, and 30 weeks Yellow, medial nasal prominence; green, lateral nasal prominence; blue, maxillary prominence; light tan, mandibular prominence

b Sagittal schematic drawing

represent-ing the regions of the ethmoturbinals, maxilloturbinal, and nasoturbinal in an 8-week-old embryo

c Coronal histomicrograph of 8-week-old

embryo that demonstrates early

devel-opment of the inferior turbinate (purple

triangle), middle turbinate (aqua circle),

brain (green trapezoid), left eye (white

O), and nasal septum (blue square)

(Carnegie Collection stage 23, courtesy

of David H Henick, MD.)

Trang 30

ante-surface landmarks are shown in Fig 1.2, along with other

anatomical landmarks of the face, and their defi nitions

are found in Table 1.1

The nose is a pyramidal structure that consists of bony, tilaginous, and membranous elements It sits on an almond-shaped bony opening into the skull called the pyriform aperture, which is bounded by the alveolar processes of the

car-maxillae ( Fig 1.3 ) The alveolar processes come together in

the midline and project upward to form the anterior nasal spine This fusion of the alveolar processes is where the nasal septum attaches to the fl oor of the nasal airway 15 The nasal pyramid consists of two nasal bones that articulate with both the nasal process of the frontal bone superiorly at the nasion and with the ascending processes of the maxilla laterally The deepest point along the nasal profi le ascending toward the glabella is called the radix The nasion is the midline point deep

6 months to 2 years after birth, and radiologic evidence

of the sinus is not usually seen until the age of 6 or 7 The

two frontal sinuses are typically asymmetric, with 10 to

12% of the adult population displaying only one

pneuma-tized frontal sinus 12 Up to 4% of the population lacks both

frontal sinuses 13

Beyond the scope of this chapter, but worth noting, is

that there are a variety of congenital malformations that

can occur as a result of abnormal nasal and paranasal

sinus development Notable abnormalities include

con-genital midline masses such as encephaloceles, nasal

gli-omas, and dermoid cysts Also observable at the midline

of the posterior nasal airway in the nasopharynx are

Thornwaldt cysts

The External Nose

Familiarizing oneself with the surface anatomy of the

nose and its relationship to the facial contours is essential

not only for aesthetic nasal surgery, but also for eﬀ ective

communication with other physicians Traditionally, the

ideal face is thought to be divided into aesthetic thirds

of approximately equal length: upper, middle, and lower

thirds 14 ( Fig 1.2 ) The upper third spans from the trichion

to the glabella, where the trichion is the junction between

Table 1.1 Terms and defi nitions of surface landmarks of the

nose

Trichion Midline point at the junction between the

hairline and forehead skin

Glabella Midline point of the most prominent portion

of the forehead

Radix Deepest point of the surface anatomy of the

lateral nasal profi le just inferior to the glabella; often used interchangeably with nasion

Nasion Midline point where nasal bones meet with the

nasal process of the frontal bone; often used interchangeably with radix

Rhinion Junction of the bony and cartilaginous dorsum

Nasal tip Anteriormost point of the nose

Subnasale Midline point where the columella merges with

the upper lip

Pogonion Anteriormost point of the chin

Menton Inferiormost point of the chin

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The External Nose 7

to the radix that represents the suture line between the

nasal and frontal bones ( Figs 1.2 and 1.4 ) The terms

radix and nasion are often used interchangeably, but

they technically represent two distinct anatomical marks The ascending processes of the maxilla are bev-eled laterally in an interlocking fashion with the nasal process of the frontal bone, anchoring them fi rmly to the pyriform aperture 16 ( Fig 1.3 ) Internally, this is also

land-the approximate area known as land-the agger nasi, or nasal mound (see below)

The lower half of the nasal pyramid consists mostly

of paired cartilages: upper lateral cartilages and lower lateral cartilages, along with several smaller sesamoid

cartilages (also known as accessory cartilages) ( Fig 1.4 )

The triangular upper lateral cartilages articulate with the nasal and maxillary bones superiorly and overlap with the lower lateral cartilages inferiorly They are contiguous with the septal cartilage superiorly, adding to the integ-rity of the cartilaginous nasal dorsum 16

The lower lateral cartilages are thin, curved structures that form the shape of the nasal tip and defi ne the integ-rity of the nostrils Each lower lateral cartilage is divided into the medial crus and the lateral crus The broader lateral crus extends posterolaterally into the ala of the nose, maintaining the patency of the nostril, whereas the narrower medial crus extends caudally along the free edge of the nasal septum, delineating the projection of the nasal tip There is dense connective tissue binding the upper lateral cartilages to the lower lateral cartilages, and the multiple small accessory (sesamoid) cartilages em-bedded within fi broareolar tissue add to the integrity of the nasal alar structure 16

Frontal sinus

Ethmoidcells

MaxillarysinusNasal spine

Fig 1.3 Schematic drawing of the human skull

de-monstrating the relationship of bones to one another Blue,

maxilla; yellow, frontal bone; green, zygoma; purple,

sphe-noid; red midline, nasal bone; Day-Glo pink, lacrimal bone;

Day-Glo green, lamina papyracea; Day-Glo yellow, palatine

bone On the left half of the drawing, observe the relative

po-sitioning of the maxillary, frontal, and ethmoid sinuses Note

the ascending (frontal) process of the maxilla, nasal bones,

and frontal bone along the pyriform aperture

Fig 1.4a, b Schematic drawing of nasal framework.

RadixNasal boneRhinionNasion

Upper lateral cartilageAccessory/sesamoid cartilages

Pronasalae

lateral(alar)cartilage

Lateral crusMedial crusColumella

Supratip breakpointSupratip lobuleInfratip lobule

Fibro-areolar tissueAnterior nasal

spine of maxilla

Alar marginTip-defining point

Alar cartilageRhinion

Nasal boneMedial canthus

Soft triangleInfratip lobule

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The muscles of the nose can be categorized into elevators,

depressors, dilators, and compressors 17 The elevators are

the procerus, the levator muscle of the upper lip and ala

(levator labii superioris and levator labii superioris

alae-que nasi), and the anomalous nasi The depressor muscles

of the nose are the alar portion of the nasalis muscle and

the depressor nasi septi labii The anterior dilator naris

works to dilate the nostrils, whereas the transverse

por-tion of the nasalis and the compressor narium minor are

the compressors 15 ( Fig 1.5 ) All the nasal muscles are

innervated by the zygomatic and buccal branches of the

facial nerve (cranial nerve [CN] VII), although the

pro-cerus receives contribution from the frontal branch of the

facial nerve as well 17

The blood supply to the external nose varies, but it

re-ceives contributions from the external carotid via the

facial artery and the infraorbital artery, and the internal

carotid via the ophthalmic artery 15,16 The lateral nasal

artery arises from the angular artery (from the facial

artery) that anastomoses with the dorsal nasal artery

(from the ophthalmic artery) This arcade receives

addi-tional contributions from the infraorbital branch of the

internal maxillary artery and the external nasal artery,

which is the terminal branch of the anterior ethmoid

ar-tery ( Fig 1.6 ) The venous drainage of the external nose is

performed by the angular vein and the ophthalmic vein,

which in turn can communicate with the cavernous sinus

Compressor nariumminor m

Depressor septi m

Alar nasalis m

Orbicularis oris m

Fig 1.5 Schematic drawing of nasal musculature.

Fig 1.6 Schematic drawing demonstrating the blood supply

and innervation of the external nose Note that the external nasal artery is the distalmost branch of the anterior ethmoid artery, which arises within the orbit and courses intracranially before emerging externally

The skin of the external nose is innervated by the nal nerve system The supratrochlear and infratrochlear branches of the ophthalmic nerve (CN V 1 ) supply the skin

trigemi-of the root, bridge, and upper half trigemi-of the side trigemi-of the nose The infraorbital branch of the maxillary nerve (CN V 2 ) supplies the skin of the lower half of the side of the nose The external nasal branch of the anterior ethmoid nerve exits between the nasal bone and the upper lateral cartilages to supply the skin over the dorsum of the nose

(Fig 1.6) 16

The Nasal Cavity

The nasal vestibule is a dilation inside the nostril that corresponds to the ala of the external nose It is lined with skin that contains hair (vibrissae), sweat glands, and sebaceous glands Separating the nasal vestibule from the rest of the nasal cavity is a ridge along the lat-eral nasal wall called the limen nasi (limen vestibuli)

Trang 33

The Nasal Cavity 9

Note

The external nasal valve is defi ned as the area in the nasal vestibule under the nasal ala, formed by the caudal septum, the medial crura of the alar cartilages, the alar rim, and the nasal sill The internal nasal valve is located ⬃1.3 cm from the nares (nostril opening) and corresponds to the region under the upper lateral cartilages, bound medially by the dorsal septum, inferiorly by the head of the inferior turbinate, and laterally by the upper lateral cartilage.18

!

The nasal septum serves as both a functional and an thetic unit, dividing the nasal cavity into right and left sides and providing major support for the external nose and an extended surface area for the mucosa The sep-tum extends from the columella to the rostrum of the sphenoid sinus, where the posterior choanae open into the nasopharynx The septum has three components: the membranous septum, the cartilaginous septum, and the bony septum The majority of the septum is formed

aes-by the perpendicular plate of the ethmoid bone orly and the quadrangular (also known as quadrilateral) cartilage anteriorly The vomer (Latin for “plowshare”)

posteri-is a wedge-shaped bone situated in the posteroinferior portion of the septum In the inferior portion of the sep-tum, the nasal crests of the maxillary and palatine bones attach to the cartilaginous and bony septum at the fl oor

of the nasal cavity ( Fig 1.8 )

It corresponds to the caudal end of the upper lateral

cartilage and marks the transition from the

keratin-izing squamous epithelium to the pseudostratifi ed

co-lumnar ciliated epithelium of the mucous membrane 16

The mucous membrane contains numerous mucous and

serous glands

The nasal valve itself is a slitlike structure associated

with the entrance to the nasal passages The nasal valve

has both external and internal components It has been

described anatomically as the cross-sectional area of

the nasal cavity with the greatest overall resistance to

airfl ow, thus acting as the dominant determinant for

nasal inspiration Even the smallest lesion in the area can

substantially aﬀ ect the overall airfl ow through the nasal

passage ( Fig 1.7a ) The external nasal valve is defi ned as

the area in the nasal vestibule under the nasal ala, formed

by the caudal septum, the medial crura of the alar

carti-lages, the alar rim, and the nasal sill The internal nasal

valve is located ⬃1.3 cm from the nares (nostril opening)

and corresponds to the region under the upper lateral

car-tilages, bound medially by the dorsal septum, inferiorly

by the head of the inferior turbinate, and laterally by the

upper lateral cartilage 18 ( Fig 1.7b )

Although the exact teleological reason for the nasal

valve is still debated, several theories exist Inhalation

against resistance in the upper airway yields higher

intrathoracic pressure, which in turn promotes the

alveo-lar gas exchange by prolonging the expiratory phase of

breathing Also, the nasal valve disrupts laminar airfl ow

within the nasal cavity, and the resulting turbulent fl ow

increases the interface time between odorants and the

olfactory neuroepithelium

Fig 1.7a, b Schematic coronal drawing of the external and

internal nasal valve Note shading, which represents the region

of the internal nasal valve

Upper lateralcartilage

b

Trang 34

to as the olfactory cleft (see below) Additionally, sensory

fi bers of CN V descend through the cribriform plate to supply the nasal cavity and even more important through the sphenopalatine fossa

Note

Septal deviation is very common and has a variety of shapes

In one anatomical study of adult skulls, only 21% of the nasal septa were straight; 37% were deviated and 42% kinked

!

Whereas the medial wall of the nasal cavity is relatively simple in its anatomy, the lateral nasal wall displays com-plicated anatomy with multiple raised structures, clefts, and openings, working as the interface between the pa-ranasal sinus cavities and the nasal cavity The osteology

The membranous portion of the septum, the

caudal-most portion, is composed of skin and connective

tis-sue It is supported anteriorly by the medial crura of the

lower lateral cartilages The cartilaginous septum, which

sits just posterior to the membranous septum, is formed

predominantly by the quadrangular cartilage The

quad-rangular cartilage fl ares superiorly to fuse with the upper

lateral cartilages at the nasal dorsum Posteriorly, it gives

rise to a thin, tail-like process that inserts between the

vomer and the ethmoid bone The cartilage widens

infe-riorly at the base as it articulates with the maxillary crest

and the anterior septal body 17 ( Fig 1.9 ) The anterior

sep-tal body is an area of thickened mucosa with underlying

pseudoerectile tissue that is located just anterior to the

leading edge of the middle turbinate The pseudoerectile

tissue of the nasal airway appears to have an important

role in the “nasal cycle” that helps maintain normal nasal

physiology The bony septum lies posterior to the

carti-laginous septum and consists of the perpendicular plate

of the ethmoid bone and the vomer It is a common site

of septal deviation and septal spurs Septal deviation is

very common and has a variety of shapes In one

ana-tomical study of adult skulls, only 21% of the nasal septa

were straight; 37% were deviated and 42% kinked 19 The

perpendicular plate of the ethmoid complex articulates

with the frontal and nasal bones superiorly and with the

sphenoid bone posteriorly As seen in Fig 1.8, it

articu-lates with the vomer and the quadrangular cartilage as

well The alae of the vomer rest on the sphenoid rostrum

Along the inferior border of the quadrangular cartilage

lies a small bar of cartilage called the vomeronasal

car-tilage, which is the site of the rudimentary vomeronasal

organ (of Jacobson) 17 The superior aspect of the septum

Fig 1.9 Coronal computed tomography (CT) image

demon-strating the anterior septal body (yellow circle) and the illary crest where septal cartilage is inserted inferiorly (red

arrow) Note the position of the infraorbital nerves below each

orbit (green circle) G, globe; B, brain; IT, inferior turbinate.

Anterior ethmoid artery

Posterior ethmoid nerve CP

Anterior ethmoid nerve

Fig 1.8 Schematic sagittal drawing of the nasal septum and

its blood supply/innervation Square, quadrilateral cartilage;

circle, perpendicular plate of the ethmoid; triangle, vomer

Note that the stippled blue area known as Kiesselbach plexus is

susceptible to epistaxis and tissue necrosis CP, cribiform plate

Trang 35

Fig 1.10a, b

a Schematic sagittal drawing

show-ing the lateral nasal wall ogy Note that the nasal concha/turbinates are cut away and that the middle turbinate divides the anterior from the posterior eth-moid sinuses Note also that the position of the crista ethmoidalis can vary depending on the loca-tion of the sphenopalatine fora-men The ascending process of the maxilla correlates with the agger nasi, observed on the endo-scopic view From anterior to pos-terior (right to left): faint yellow, nasal bone; orange, maxilla; red, lacrimal bone; green, ethmoid; purple, inferior turbinate; dark blue, palatine bone

osteol-b Schematic coronal image of the

nasal cavity and sinuses strating the relationships of in-tact turbinates to one another The ethmoid complex is circled

demon-in red Note the schematic tion of orbital musculature and the centrally positioned optic

depic-nerve (orange) relative to the

eth-moid (clockwise): superior rectus

(green), inferior oblique (yellow), lateral rectus (pink), inferior rectus (turquoise), medial rectus (blue), and superior oblique (purple) The

last two extraocular muscles are

at greatest risk for inadvertent jury during sinus surgery

in-of the lateral nasal wall is depicted schematically in

Fig 1.10a Seen on the lateral nasal wall are three or four

turbinates (or conchae) that are thin, medially

project-ing scrolls of bone ( Fig 1.10b ) covered by mucous

mem-brane 2 They are the inferior turbinate, middle turbinate,

superior turbinate, and occasionally the supreme

turbi-nate, going from inferior to superior along the wall The

space lateral and inferior to each turbinate is named

ac-cording to the structure with which it is associated For

example, the inferior meatus lies underneath the inferior

turbinate ( Figs 1.10b and 1.11 ) As stated previously, only

the inferior turbinate is embryologically a separate bone The other turbinates are part of the ethmoid complex

Like the anterior septal body, the inferior turbinate

is lined with pseudoerectile tissue and is covered by a thick mucous membrane The inferior meatus houses the opening to the nasolacrimal duct (valve of Hasner), which

is usually located superolaterally in the anterior portion

Frontal bone

Uncinate process Ascending process

Upper and lower nasal cartilages

Crista ethmoidalis ossis palatinae

Superiorturbinate

Trang 36

The superior turbinate is much smaller than the middle or the inferior turbinate and is situated di-rectly behind the middle turbinate It is identifi ed as a distinctive ridge that has a shorter vertical height com-pared with the middle turbinate as it descends from the skull base Posteriorly, it is continuous with the superior aspect of the posterior middle turbinate along

the skull base ( Fig 1.12 ) The olfactory

neuroepithe-lium extends from the cribriform plate to populate the superior portion of the superior turbinate; surgically, this is an important concept, as the turbinates, along with the nasal septum, play a signifi cant role in olfac-tion The extent and the distribution of the olfactory neuroepithelium vary from individual to individual but often appear to involve a superior portion of the medial middle turbinate as well 17

The supreme turbinate is a far less developed ture along the lateral nasal wall and is seen only as a small cleft above the superior turbinate The reported prevalence of the structure in specimens ranges from

struc-17 to 60% 3,16 When the corresponding supreme meatus is present, it drains the posterior ethmoid cells the majority

of the time

of the inferior meatus ( Fig 1.11 ) Thus, any eﬀ ort to enter

the maxillary sinus from the inferior meatus is

typi-cally advised through the thinner bone more posteriorly,

where the risk of lacrimal duct injury is less

Note

Only the inferior turbinate is embryologically a separate

bone The other turbinates are part of the ethmoid complex

!

Tips and Tricks

Any eﬀ ort to enter the maxillary sinus from the inferior

meatus is typically advised through the thinner bone more

posteriorly, where the risk of lacrimal duct injury is less

The middle turbinate attaches posterolaterally adjacent

to the crista ethmoidalis of the perpendicular process

of the palatine bone ( Fig 1.10a ) and courses anteriorly

and superiorly to attach vertically at the lateral lamella

of the cribriform plate In between, it attaches laterally

to the lamina papyracea or the medial wall of the

max-illary sinus Variations in the shape of the middle

tur-binate include the paradoxical middle turtur-binate, where

Fig 1.11 Reconstructed coronal CT scan of the paranasal

sinuses demon strating the lacrimal duct (yellow) bilaterally

draining into the inferior meatus Note the agger nasi cell

(green) and septal spur (red) adjacent to the inferior

turbi-nate in the nasal airway, which is decongested prior to the

time of imaging The left frontal sinus (FS) demonstrates the

direction of mucociliary clearance within the frontal sinus

MS, maxillary sinus; G, globe

Anterior ethmoid artery

Fila olfactoriaFrontal sinus

Posterior ethmoid artery

Posterior lateral nasalartery branches

Posterior ethmoid nerve

Sphenoidsinus

SuperiorturbinateCP

Anterior ethmoid nerveMiddleturbinate

Inferiorturbinate

palatineganglion

Spheno-Fig 1.12 Schematic sagittal drawing of lateral nasal wall

blood supply and innervation Light blue stippling indicates the approximate location of the olfactory neuroepithelium

CP, cribriform plate

Trang 37

Like the blood supply of the external nose, the blood

supply to the nasal cavity comes from both the internal

and the external carotid systems 3,15,16 The ophthalmic

artery, via the anterior and the posterior ethmoid

arter-ies, supplies the upper and anterior aspects of the nasal

cavity, whereas the internal maxillary artery, via the

sphenopalatine artery, supplies the posterior part of the

nose Branches of the facial artery, via the angular and

the superior labial arteries, deliver the blood to the nasal

vestibule (see Fig 1.6 )

The sphenopalatine artery, which derives from the

internal maxillary artery, passes through the

spheno-palatine foramen and divides into the posterior lateral

nasal and posterior septal arteries It is not unusual

for the artery to divide more proximally before

exit-ing the foramen A branch or multiple branches may

exit through separate foramina One study found that

97% of the cadaver specimens studied had two or more

branches of the artery distal to the sphenopalatine

fora-men 20 Thus, ligation of one vessel emerging from the

sphenopalatine foramen is likely to be insuﬃ cient for

the management of epistaxis The position of the

sphe-nopalatine foramen has been shown to have some

vari-ability along the lateral nasal wall as it relates to the

attachments of the turbinates to the bony lateral wall It

is bound anteriorly by a constant elevation of the

afore-mentioned palatine bone called the crista ethmoidalis

(see Fig 1.10a ) This is an important clinical fact for the

management of epistaxis According to one study, more

than 50% of the sphenopalatine foramina are situated

between the superior and middle meatus, whereas 37%

are in the superior meatus 21 An accessory foramen was

present in 50% of the population, with the majority of

these situated in the middle meatus The posterior

lat-eral nasal artery, the larger of the two branches of the

sphenopalatine artery, courses along and then supplies

the middle and inferior turbinates ( Fig 1.12 ) The

poste-rior septal artery exits the sphenopalatine foramen and

runs along the sphenoid rostrum to supply the posterior

portion of the nasal septum This artery is the source

of the blood supply for the pedicled nasoseptal fl ap

de-scribed for skull base reconstruction after endoscopic

skull base resections 22

Note

Ligation of one vessel emerging from the sphenopalatine

fora-men is likely to be insuﬃ cient for the managefora-ment of epistaxis

!

Note

The sphenopalatine foramen is bound anteriorly by a constant

elevation of the palatine bone called the crista ethmoidalis

!

Note

The posterior septal artery is the source of the blood supply for the pedicled nasoseptal fl ap described for skull base re-construction after endoscopic skull base resections

!

The descending palatine artery, which is another branch

of the internal maxillary artery, travels a short distance

in the pterygopalatine fossa and then enters the greater palatine canal As it exits via the greater palatine foramen opposite the second molar, it branches into the greater and lesser palatine arteries, which then traverse into the hard palate of the oral cavity through their respective ca-nals They supply the hard and soft palates, as well as the inferoposterior portion of the nasal cavity The greater palatine artery, as it courses along the palate, anastomo-ses with the nasopalatine branch of the sphenopalatine artery coming through the incisive foramen and supplies the anterior portion of the septum

The anterior and posterior ethmoid arteries branch from the ophthalmic artery within the orbit and then enter the nasal cavity through the lamina papyracea of the ethmoid just below the horizontal plate of the frontal bone They course across the skull base at variable heights toward the cribriform plate 23 and penetrate the lateral lamella of the cribriform plate before traveling anteriorly in the ethmoid sulcus There they both provide a meningeal branch to the dura mater and occasionally to the falx cerebri, prior to passing into the nasal cavity 24 After exiting the orbit, the anterior ethmoid artery enters the anterior cranial fossa through the cribriform plate before sending branches back intranasally to the nasal septum and externally to the nasal dorsum as the external nasal artery The position of the an-terior ethmoid artery relative to the skull base is of clinical importance during endoscopic anterior ethmoidectomy,

as its injury could theoretically cause it to retract into the orbit, leading to a retro-orbital hematoma and resulting in

blindness or even cerebrospinal fl uid (CSF) leak ( Fig 1.13 )

Stammberger found that in 29 of 40 skulls, the anterior moid artery was surrounded by dura along its entire eth-moidal portion, whereas it entered the dura only during its passage through the ethmoid sulcus in 8 of the 40 skulls In only 3 of 40 cases did the artery remain extradural along its entire course 23 This fi nding once again suggests that an injury to the anterior ethmoid artery poses two obvious risks–CSF leak and hemorrhage that results in poor surgi-cal visualization or orbital hematoma The anterior eth-moid artery supplies the anterior portions of the middle and inferior turbinates, as well as the c orresponding por-tion of the anterior septum The posterior ethmoid artery, the smaller of the two, supplies the superior turbinate and the corresponding posterior portion of the septum The positions of these arteries along the skull base are variable, but the ratio of 24–12–6 mm is commonly quoted as the average distance from the anterior lacrimal crest to the an-terior ethmoid artery, from the anterior ethmoid artery to

Trang 38

eth-1 Nasal and Paranasal Sinus Anatomy and Embryology

trauma, or even septoplasty (see Fig 1.8 )

The venous drainage of the nasal cavity parallels the terial supply The veins that drain through the sphenopa-latine foramen empty into the pterygoid plexus, whereas the ethmoid veins drain into the superior ophthalmic vein, which in turn drains into the cavernous sinus One notable plexus of veins is the so-called Woodruﬀ plexus, found in the posteroinferior meatus, which is clinically associated with posterior epistaxis

ar-Note

The anterior portion of the nasal septum is particularly nerable to ischemia with its terminal blood supply; therefore, Little area is a common site of nasal septal perforation with cocaine use, trauma, or even septoplasty

vul-The Woodruﬀ plexus, found in the posterior inferior meatus,

is clinically associated with posterior epistaxis

!

In addition to the special sensory function provided by the olfactory nerve (CN I), the nasal cavity is the site for general sensory function associated with the ophthalmic and maxillary divisions of the trigeminal nerve, as well as autonomic innervation via the facial nerve and the sym-pathetic chain Although CN 0 and the vomeronasal organ are present and have functions for pheromone sensing in lower life forms, their existence and function in humans are viewed skeptically by most anatomists 3

The general sensory fi bers to the mucous membrane of the nasal cavity are provided by multiple branches derived from the ophthalmic and maxillary divisions of the trigemi-nal nerve The ophthalmic division of the trigeminal nerve enters the posterior orbit via the superior orbital fi ssure, giving rise to the nasociliary nerve This nerve in turn di-vides into the anterior and posterior ethmoid nerves, which travel alongside the anterior and posterior ethmoid arter-ies, respectively The anterior ethmoid nerve further divides into internal and external branches that descend along the anterior septum They supply the anterior lateral nasal wall and the dorsum of the external nose, respectively The pos-terior ethmoid nerve innervates the posterior and superior portions of the septum, as well as the corresponding lateral nasal wall 17 (see Figs 1.6, 1.8, 1.12, and 23.11 )

The maxillary division of the trigeminal system passes through the inferior orbital fi ssure, travels across the roof of the pterygopalatine fossa, and then enters the infraorbital canal to deliver innervation to the middle third of the face, including a portion of the lining of the vestibule A branch known as the anterosuperior alveolar nerve comes oﬀ the infraorbital nerve within the canal This descends within the anterior wall of the maxillary sinus and gives oﬀ a nasal

the posterior ethmoid artery, and then from the posterior

ethmoid artery to the optic canal, respectively 25 However,

a more recent study of dry bones shows a wider range of

distances among the frontomaxillary suture, anterior

eth-moid foramen, posterior etheth-moid foramen, and optic canal

than previously described 26 Having basic knowledge of

the distances between these important structures will be

of great benefi t in the operating room

Note

The position of the anterior ethmoid artery relative to the

skull base is of clinical importance during endoscopic

ante-rior ethmoidectomy, as its injury could theoretically cause it

to retract into the orbit, leading to a retro-orbital hematoma

and resulting in blindness or even cerebrospinal fl uid leak

!

The superior labial artery arises from the distal portion

of the facial artery and supplies the nasal vestibule and

the anterior septum after anastomosing with the septal

tributaries from the sphenopalatine system The anterior

portion of the nasal septum where the arterial supplies

aggregate is known as Kiesselbach plexus, or Little area 15

It receives contributions from the anterior ethmoid,

supe-rior labial, sphenopalatine, and greater palatine arteries

It is recognized as the source of epistaxis in 90% of cases 27

This is also a watershed area, referring to the fact that

this area receives dual blood supply from the most distal

branches of the internal (via ethmoid arteries) and

exter-nal carotid arteries (via facial artery and sphenopalatine

Fig 1.13 Reconstructed coronal CT scan of the paranasal

sinuses demon strating the course of the anterior ethmoid

neurovascular bundle (blue) across the skull base Note the

pneumatization of the supraorbital ethmoid cell (SOE) above

the anterior ethmoid artery, which is typically partially

cov-ered by dura mater Inferior turbinate (yellow), middle

turbi-nate (red), superior turbiturbi-nate (green).

Trang 39

nucleus in the brainstem At the fi rst genu, the pathetic fi bers to the nose travel past the geniculate gan-glion as the greater superfi cial petrosal nerve, and upon being joined by the deep petrosal nerve, which contains the sympathetic fi bers from the superior cervical ganglion, traverse the vidian (pterygoid) canal and enter the ptery-gopalatine fossa as the vidian nerve The preganglionic

parasym-fi bers of the vidian nerve synapse in the pterygopalatine ganglion; the postsynaptic postganglionic fi bers innervate the mucous membranes of the nose and the hard palate They have vasodilatory and secretory eﬀ ects within the nasal cavity and innervate the lacrimal gland to control lacrimation 16,17 Damage to the vidian nerve can occur during the surgical approach to the lateral pterygoid re-cess of the sphenoid sinus for encephaloceles descending through a congenital dehiscence of Sternberg canal or in the management of juvenile nasopharyngeal angiofi broma and such injury can lead to the unintended consequence

of dry eye 28,29 Alternatively, some experts have advocated endoscopic vidian neurectomy as a treatment for rhinitis 30

Caution

The anterosuperior alveolar nerve is of clinical importance during tumor removal from the maxillary sinus, Caldwell-Luc approaches, or orbital decompression surgery when the maxillary nerve is at greatest risk for injury As a result of such nerve injury, patients can develop permanent paresthesias, numbness, or pain that can be debilitating

The pterygopalatine fossa is a space located lateral to the nasal cavity and posterior to the maxillary sinus It is situated medial to the infratemporal fossa and anteroinferior to the middle cranial fossa It houses various vascular and neural structures and serves as a conduit to adjacent structures via multiple fi ssures, canals, and foramina Contained within the fossa are the maxillary division of the trigeminal nerve (CN V 2 ), the pterygopalatine ganglion, and the third part of the internal maxillary artery The pterygoplatine fossa can

be thought of as a box with openings on fi ve sides In the posterior wall, the vidian canal and foramen rotundum, which contain the vidian nerve and the maxillary nerve (CN

V 2 ), respectively, open to the middle cranial fossa, and the pharyngeal canal opens to the nasopharynx The pharyn-geal canal (also known as the palatovaginal canal) contains

a branch of CN V 2 called the pharyngeal nerve In the medial wall lies the previously mentioned sphenopalatine foramen, which connects to the nasal cavity and contains the spheno-palatine artery and nerve The inferior orbital fi ssure in the anterior wall of the “box” connects the pterygopalatine fossa

to the orbit and contains the infraorbital artery and nerve Inferiorly, the pterygopalatine fossa continues into the pterygopalatine canal, which connects to the roof of the oral cavity This canal contains the descending palatine artery and

branch that supplies the upper incisors and canine teeth,

as well as the anterior portions of the inferior meatus and

the nasal cavity fl oor 17 This is of clinical importance during

tumor removal from the maxillary sinus, Caldwell-Luc

ap-proaches, or orbital decompression surgery when the

max-illary nerve is at greatest risk for injury As a result of such

nerve injury, patients can develop permanent paresthesias,

numbness, or pain that can be debilitating (see Fig 1.9 )

Caution

Damage to the vidian nerve can occur during the surgical

ap-proach to the lateral pterygoid recess of the sphenoid sinus for

encephaloceles descending through a congenital dehiscence of

Sternberg canal or in the management of juvenile

nasopharyn-geal angiofi broma and such injury can lead to the unintended

consequence of dry eye Alternatively, some experts have

advo-cated endoscopic vidian neurectomy as a treatment for rhinitis

Sensory innervation to the internal lining of the nasal

cav-ity that derives from the maxillary division of the

trigemi-nal nerve is supplied via the pterygopalatine ganglion,

which lies within the pterygopalatine fossa The nasal

branches from the ganglion pass through the

sphenopal-atine foramen along with the sphenopalsphenopal-atine artery and

give oﬀ multiple branches that supply temperature, pain,

and touch sensations to the mucosa of the nasal cavity The

lateral posterosuperior nasal branches emerge from the

sphenopalatine foramen and supply the middle and

infe-rior turbinates The medial posterosupeinfe-rior nasal branches

cross the face of the sphenoid and the roof of the nose, then

descend along the septum as the nasopalatine nerve

in-nervating the posterior septum This nerve travels parallel

to the nasal fl oor through a bony canal, eventually exiting

through the incisive foramen Vigorous reduction of the

maxillary crest during septoplasty may put the

nasopala-tine nerve at risk, resulting in postoperative anesthesia or

paresthesia of the portion of the palate behind the central

incisors Other maxillary nerve branches pass through the

fl oor of the pterygopalatine fossa to enter the oral cavity as

the greater palatine nerve This nerve also provides

sensa-tion to the mucous membrane over the posterior part of

the inferior turbinate and the inferior meatus 16,17

Caution

Vigorous reduction of the maxillary crest during septoplasty

may put the nasopalatine nerve at risk, resulting in

postop-erative anesthesia or paresthesia of the portion of the palate

behind the central incisors

Both sympathetic and parasympathetic nerve fi bers

con-trol the vascular and glandular structures of the nasal

mucosa Although some sympathetic fi bers reach the

nasal cavity via the nasociliary nerve, the main autonomic

pathway is through the pterygopalatine ganglion and its

branches Most of the parasympathetic fi bers are derived

from the facial nerve originating from the superior salivary

Trang 40

at either end—the pyriform aperture and the choana–with

a roof, a fl oor, and two side walls The center piece of the

“box” is the ethmoid complex, with which all other sinuses

border and are intimately related (see Figs 1.3, 1.13, and 1.14 ) Development of the paranasal sinuses varies from

individual to individual and can be aﬀ ected by disease states For example, patients with cystic fi brosis often have underdeveloped paranasal sinuses in comparison to age- and gender-matched controls 31 Anatomical nomenclature for the paranasal sinuses has been the subject of great discussion, as there is global variation for terminology 32 Along with their function of warming and humidifying

of the inspired air, the sinuses may theoretically serve an evolutionary purpose by acting as a protective barrier for the brain Another theory regarding the role of the sinuses

in evolutionary development is that the pneumatization of the facial skeleton made the head lighter, allowing human

nerve and eventually leads to the greater and lesser palatine

foramina Lastly, through the lateral wall of the “box,” the

pterygopalatine fossa communicates with the

infratempo-ral fossa through the pterygomaxillary fi ssure The internal

maxillary artery passes through the fi ssure

The Paranasal Sinuses

There are four paired sinus cavities that arise and

pneu-matize at diﬀ erent times during development They are

the maxillary, sphenoid, frontal, and ethmoid sinuses

The ethmoid sinuses are further divided into anterior and

posterior sinuses by the basal lamella of the middle

turbi-nate The nasal cavity can be viewed as a box that is open

Fig 1.14a–c The ethmoid complex.

a Schematic drawing in the coronal plane of the

anterior ethmoid sinus Note the star-shaped tern of mucociliary clearance emanating from the

pat-fl oor of the maxillary sinus against gravity to the natural ostial region

b Reformatted coronal CT scan demonstrating the

anterior ethmoid complex (yellow) at the middle

turbinate attachment to the cribriform plate

with bilateral concha bullosa (red); EI, ethmoid

infundibulum; and small infraorbital ethmoid cell

(Haller cell) (green arrow) IN, infraorbital nerve;

B, brain; red star, concha bullosa

c Axial CT scan of the ethmoid complex in the

supe-rior nasal cavity Note the left postesupe-rior moid cell pneumatizing posteriorly into the face of

sphenoeth-the left sphenoid sinus (red oval) RS, right

sphe-noid; LP, lamina papyracea; OF, optic foramen; G,

globe; olfactory cleft (blue) at cribriform plate; PPE,

perpendicular plate of the ethmoid Note the soft tissue swelling consistent with chronic rhinosinus-itis in the right anterior ethmoid

EthmoidbullaHiatussemilunaris

Uncinate

process

Ethmoidalinfundibulum

a

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