Ebook Office-Based rhinology: Principles and techniques (Part 2)

Part 2 book “Office-Based rhinology: Principles and techniques” has contents: In-Office treatment of post-endoscopic sinus surgery issues, office-based management of mucoceles, nasal fractures - closed reduction in the office setting, office-based nasal polypectomy, office-based evaluation and treatment of epiphora,… and other contents.

8 In-Office Treatment of Post-Endoscopic Sinus Surgery Issues

Robert T Adelson James N Palmer

Introduction

Endoscopic sinus surgery (ESS) that preserves

native anatomy and sinonasal mucosa to the

greatest degree possible has become the

uni-versally accepted surgical modality by which

chronic rhinosinusitis (CRS) is addressed

Inherent to this operation is the

understand-ing, by both patient and surgeon, that

opera-tive procedures are adjuncopera-tive to the medical

management of an underlying inflammatory

disorder Similarly, the postoperative care

of patients undergoing ESS remains akin

to a moving target The idealized

postop-erative sinus cavity can only be achieved by

active participation in medical management

and office-based minor surgical procedures

Medical management includes both topical

and oral route corticosteroids and antibiotics

whereas surgical procedures are focused on

the removal of material that may predispose

to either cicatricial occlusion of sinus ostia or

re-infection of a paranasal sinus Our

postop-erative procedures are aligned with the current

concept of functional ESS that emphasizes not just improving the patency of sinus ostia

to facilitate the egress of mucus, but, more importantly, to enhance the penetration of medicated topical irrigations

Although ESS is the widely established standard of care for the surgical management

of CRS, its postoperative management is less well characterized There are wide variances between surgeons with regard to both medi-cal and surgical therapy Common to all is the understanding that the inflammatory nature

of CRS requires long-term follow-up and occasional medical or surgical interventions

to control the underlying disease process In the absence of blinded, prospective, disease-matched, controlled studies with validated out-come measures at long-term follow-up, there

is no substantial evidence to guide tive debridements.1,2

postopera-Our routine postoperative care involves

a regimen of weekly debridements until the endoscopic examination normalizes Adjust-ment of the timing, degree, and frequency

of debridements is best relegated to clinical

assessment of patient factors, anatomic

find-ings, extent of the operation, and the

inflam-matory state at the time of surgery and

during recovery.3 Mucosal preservation

dur-ing debridements is a guiddur-ing principle, while

maximizing the removal of retained

secre-tions, bone chips, bridging clots, and early

synechiae Patients are followed over time and

both the medical management of the

underly-ing inflammatory disorder is modified

accord-ing to patient symptoms and the endoscopic

evidence of disease Office-based surgical

interventions are introduced when surgically

created ostia become critically narrowed or the

natural course of healing deviates from desired

goals Inherent to achieving postoperative

success is that the goals of the surgeon and

patient remain mutually aligned, as

postopera-tive office-based procedures require a degree of

cooperation by both parties

Areas of Exposed Bone

When sinonasal mucosa is inadvertently

stripped, areas of denuded bone will require a

prolonged period for complete healing

Cau-tion should be exerted during routine

postop-erative debridements to avoid extending an area

of epithelial loss It has been demonstrated that

avulsion of epithelium beneath mucous crusts

occurs in 23% of specimens studied during the

first postoperative week, yet similar

debride-ment in the second postoperative week did not

result in epithelial loss beneath removed crusts.4

Nasal irrigations are emphasized during the first

postoperative week, and crusts that obstruct

ostia or may lead to synechiae at critical

loca-tions are gently removed Areas of exposed

bone or firmly adherent crusts along the medial

orbital wall are typically removed during the

second postoperative week or later, when

epi-theliazation is more likely to have occurred

Maxillary Sinus Natural Ostium

Although there remains some disagreement regarding the optimal size of a maxillary antros-tomy, the necessity for the surgical antrostomy

to connect with the natural ostium is sally accepted Despite this straightforward surgical goal, failure to connect the natural ostium with the surgical antrostomy at the time of operation or as a result of postopera-tive synechiae formation is among the most common etiologies for failure at the maxillary sinus.5 Retention of parts of the uncinate pro-cess involved with osteitis or failure to open the natural ostium will result in continued obstruction of the normal mucociliary clear-ance Maxillary antrostomies that do not connect with the natural ostium can lead to recirculation and recurrent infection of the maxillary sinus as normal mucociliary flow out

univer-of the maxillary sinus natural ostium results in re-introduction of mucous through the poste-riorly located surgical antrostomy (Figure 8–1) Currently, our preference is to perform a large maxillary antrostomy that extends from the natural ostium anteriorly to the posterior wall

of the maxillary sinus, including the vertical and horizontal portions of the uncinate pro-cess and the medial maxillary wall superior to the inferior turbinate The general shape of this antrostomy comes to resemble that of a

“pear,” with the natural ostium located more anteriorly and superiorly (Figure 8–2).6

Preserving normal mucociliary flow at the natural ostium is a critical step in ensuring good postoperative maxillary sinus outcomes Scar bands, clots, frayed mucosa, or granula-tion tissue that could develop into synechiae at this location are visualized and removed in the office setting using angled scopes and topical anesthesia

In-Office Treatment of Post-Endoscopic Sinus Surgery Issues 69

Instrumentation

n Lusk probe

n Rotating back-biting forcep (allows management of left and right maxillary sinuses with a single instrument)

Postoperative care of the maxillary sinus requires the use of rigid sinus endoscopes with angled views The natural ostium of the maxil-lary sinus cannot be visualized with a 0-degree scope and small synechiae in this location will not be detected (Figure 8–3) The use of a 30-degree scope for a complete postoperative examination is required (Figure 8–4), whereas 45-degree and 70-degree (Figure 8–5) rigid endoscopes will facilitate postoperative surgi-cal interventions

Figure 8–1. recirculation at the right

maxillary sinus is a result of an iatrogenic

synechiae posterior to the natural ostium

thick mucopurulence is noted to leave

the natural ostium and flow into the more

posteriorly located surgical antrostomy

Graphic Representation of Idealized Maxillary Antrostomy

Natural ostrium of maxillary sinus

Surgical antrostomy

The surgical antrostomy includes the posterior half of the natural ostium

of the maxillary sinus This techinique enlarges the ostium while avoiding

operative trauma to the mucosa of the anterior half of the ostium and

decreasing the risk of postoperative circumferential synechiae.

Figure 8–2. Graphic representation of an idealized maxillary antrostomy in which the surgical antrostomy overlaps the posterior 50% of the natural ostium circumference, leaving uninterrupted mucosa of the natural ostium at the anterior 50% of the natural ostium

Topical anesthesia is titrated with

con-sideration for both the patient’s pain

thresh-old and the degree of surgical intervention

required Atomized 4%

lidocaine/oxymetazo-line is usually adequate followed by

applica-tion of 4% cocaine soluapplica-tion and, if necessary,

injection of 1% lidocaine with 1:100,000 epinephrine into the operative site Severe discomfort could be addressed with pterygo-palatine fossa injection with local anesthesia, although this is rarely required

Curved ball-tipped probes or maxillary sinus seekers are adequate for palpation of the natural ostium, and can confirm the pres-ence of scarring that has involved the natural ostium Backbiting and through-cutting for-ceps are vital instruments for cleanly cutting and removing natural ostium synechiae in the postoperative setting (Figure 8–6) The avoid-ance of mucosal stripping at this critical loca-tion during postoperative care is emphasized,

as in all endoscopic sinus procedures

At present, the large size of the surgical antrostomy performed at our institution pre-cludes the use of balloon catheter technology for postoperative dilation of a narrowed maxil-lary sinus ostium This technology remains a management option for postoperatively nar-

Figure 8–3. a rigid 0-degree scope allows

mucus to be seen entering the surgical

antrostomy from an anterior location;

however, the natural ostium is not visualized

Figure 8–4. the 30-degree rigid endoscope

provides an improved view of the natural

ostium of the maxillary sinus

Figure 8–5. the angle afforded by a 70-degree rigid endoscope enhances the view of the natural ostium of the maxillary sinus and allows back-biting instruments

to remove the scar tissue resulting in iatrogenic recirculation phenomenon and recurrent infection of the maxillary sinus

In-Office Treatment of Post-Endoscopic Sinus Surgery Issues 71

rowed maxillary antrostomy, although the

surgeon must ensure that the natural ostium

is incorporated by the surgical fenestration to

produce the desired results

On DVD: Video 1 —

Maxillary Recirculation

This video demonstrates a sequence of

increas-ingly angled scopes and backbiting instruments

used in the office-based management of a

patient with isolated, bilateral maxillary sinus

disease who underwent surgery at an outside

institution Although mature synechiae are

addressed in this video, the visualization,

surgi-cal maneuvers, and operative goals are identisurgi-cal

to postoperative debridement of early synechiae

Tips and Pearls

n Avoid mucosal stripping, as

this would further compromise

mucociliary clearance from the maxillary sinus

n Angled scopes are required for the postoperative evaluation and surgical management of the natural ostium

n The removal of postoperative clots and thick mucocrusts from the natural ostium will help decrease the risk of developing synechiae in this critical site

Sphenoid Sinus Ostium

Postoperative office-based care of the noid sinus is largely dependent on the size of the sphenoidotomy performed at surgery As with any circumferential wound, the tendency for cicatricial narrowing is great and the need for postoperative care seems inversely propor-tional to the size of the initial opening It is our practice to remove nearly the entire anterior

sphe-Figure 8–6. the double-ball-tipped Lusk probe and rotating,

through-cutting back-biting forceps are useful in palpating

the natural ostium of the maxillary sinus and removing any

scar tissue that obstructs normal mucociliary flow

wall of the sphenoid sinus during

sphenoid-otomy, thereby allowing removal of retained

material, easy postoperative examination, and

wide exposure for postoperative irrigation

with medicated washes We have found that

the rate of sphenoidotomy stenosis is small

to nonexistent when removing the entire face

of the sphenoid sinus More common goals

for postoperative management include

resec-tion of scar tissue at the anterior wall that

precludes complete endoscopic examination

in tumor cases or if postoperative

accumula-tions of material is noted In the

postopera-tive period, the sphenoid sinus tends to collect

large quantities of mucous and blood in that

produces occipital or vertex pain and provides

a culture medium that is ripe for re-infection

Typically, postoperative procedures for the

sphenoid sinus requires removal of that blood

and mucus Postoperative stenosis of a surgical

sphenoidotomy with retention of mucous, CT

scan evidence of sphenoid inflammation and

symptoms referable to the sphenoid sinus could

potentially be addressed with balloon catheter

technology; however, it is our preference to

maximally widen a narrow sphenoid ostium

by using hand instruments for bone removal

Instrumentation

n 30-degree rigid endoscope

n Cutting instruments: straight

mushroom punch, small

Kerrison-Rongeur or Hajek-Koffler punch

Tips and Pearls

n The septal branch of the posterior

nasal artery runs along the anterior

face of the sphenoid sinus inferior to

the natural ostium, and is frequently

encountered and coagulated during

sphenoidotomy Caution should be

exerted in postoperative removal of additional anterior inferior sphenoid wall, as this maneuver can result in arterial bleeding that is difficult to control in the office setting

n Palpate for ledges at the anterior sphenoid face and remove only that bone that enters the instrument This allows a clean tissue cut, and avoids rocking, grasping, or twisting motions during bone removal, which has the potential for serious complications within the sphenoid sinus

n Review the preoperative CT scan before considering the additional removal of bone in the office setting, as the optic nerve and carotid artery will be dehiscent in a small percentage of patients

Middle Turbinate

It is difficult to affect large changes in the postoperative position of the middle turbi-nate Our surgical approach favors preserva-tion and medialization of the middle turbinate with creation of controlled synechiae from the middle turbinate to the nasal septum7 or the use of a middle turbinate suture.8 These meth-ods enlarge the middle meatus during surgery, facilitate postoperative inspection and inter-vention as well as the penetration of medicated irrigations into the paranasal sinuses Medial-ization of the middle turbinate to the nasal septum helps decrease the risk for synechiae

at a common area for postoperative scarring.Although multiple studies have demon-strated that middle turbinate medialization does not impair olfaction,9,10 patient com-plaints of diminished olfaction or headache that cannot otherwise be explained by endo-scopic findings or CT scan, can be treated

In-Office Treatment of Post-Endoscopic Sinus Surgery Issues 73

in the office setting by release of the synechiae

or suture retaining the turbinate in a

medial-ized position

More problematic is lateralization of

the middle turbinate such that postoperative

inspection is hindered and instrumentation

of the paranasal sinuses following surgery is

impossible We have used a variety of material

as postoperative spacers to preserve the middle

meatus: Gelfilm, Gelfoam, Merocel Although

lateralization of the middle turbinate can make

postoperative endoscopic examinations

frus-trating, in and of itself, the condition does not

require operative intervention If the frontal

recess becomes obstructed and inflammation

persists as a result of lateralization, revision

surgery can be performed, although this is not

recommended as an office-based procedure

Retained Cells / Retained

Bone Fragments

Although every effort is made during surgery

to remove all ethmoid partitions through the

combined advantages of frameless stereotactic

navigation and high quality endoscopic

visu-alization, partitions can be found

postopera-tively and these may require removal in the

postoperative setting Before proceeding with

removal, a review of the preoperative CT scan

is recommended, both for self-evaluation and

to remind the surgeon of the location of the

anterior ethmoidal arteries and position of the

skull base and medial orbital wall Retained

partitions that obstruct the egress of normal

sinonasal secretions or prevent instillation of

medicated irrigations should be addressed

Common locations are the supraorbital

eth-moid cells, the posterior frontal recess and,

to a lesser degree, the inferior aspect of the

anterior face of the sphenoid sinus Small

par-titions that do not meet these criteria

prob-ably should be left undisturbed unless mucosal

edema persists or osteitic changes become apparent on future CT scans

Instrumentation

n 45-degree through-cut forceps

n Frontal sinus through-cut forceps

n Giraffe grasping forceps

n Blakesley grasping forcepsTopical anesthesia and vasoconstriction can

be provided as described above for other cedures necessitating bone removal Palpation

pro-of ledges with through cutting instruments are critical to ensure that only obstructing prominences of bone are removed and that inadvertent entry into the orbit or skull base does not occur

More commonly, a retained fragment

of bone resulting from intraoperative surgical cuts can become embedded within the healing mucosa Isolated fragments of bone will serve

as a nidus for infection and when detected, should be removed Routine atomized topi-cal anesthetic is sufficient and grasping for-ceps will release the bone from surrounding mucosa Care should be taken to avoid includ-ing mucosa in the forceps when grasping bone fragments, so as to prevent further insult to the surrounding mucosa

Frontal Sinusotomy

Surgery of the frontal recess is among the most challenging endoscopic sinus procedures, and similarly, the maintenance of a patent and functional frontal sinus ostium postop-eratively can be fraught with difficulty The most important steps in maintaining the long term patency of a frontal sinusotomy occur at the time of surgery: removal of all obstruct-ing anterior ethmoidal cells, clearing and

defining the frontal recess boundaries, and

avoiding injury to the mucosa of the frontal

sinus drainage pathway (FSDP)

Preserva-tion of the FSDP is enhanced by placement

of a temporary frontal sinus dressing at the

conclusion of every frontal sinus operation,

which, at our institution, involves Draf IIa/IIb

for routine frontal sinusotomy and Draf III

for revision operations and tumor resection

A 0.5-mm thick piece of Silastic sheeting is

cut into the shape of rectangle (15 to 20-mm

wide x 30-mm long) with two darts removed

at the “shoulders” of the stent (Figure 8–7)

The stent is rolled tightly and inserted into

the frontal sinusotomy with a pediatric

fron-tal sinus giraffe (see Video 2) The stent acts

in much the same way as a semi-occlusive

dressing applied to traumatized or recently

operated soft tissue Light pressure is exerted

against the mucosa of the FSDP and a clear

pathway for suctioning of the frontal sinus

is provided in the early postoperative period

(see Video 3)

The frontal sinus dressing is removed

14 days after surgery and a well-mucosalized

sinusotomy noted (see Video 4) At this time, maneuvers to address any residual parti-tions are performed with topical anesthesia (see above) and standard frontal sinus hand instruments Although image guidance and angled scopes are helpful in decreasing the incidence of retained partitions, even widely patent Draf IIa/IIb and III sinusotomies can succumb to the vagaries of wound healing and an unchecked inflammatory response In these instances, the surgeon must be prepared

to revise the compromised frontal sinusotomy and, in a compliant patient, this can be per-formed in the office setting

Instruments

n 45-degree and 70-degree rigid endoscopes

n 90-degree frontal sinus curette

n Frontal sinus punch with link chain sheath, backward cutting (Figure 8–8)

n Upturned mushroom punch

n Small malleable suction

Early Frontal Sinus Synechiae

Clots, thick mucus, and mucosal injury within the frontal recess can result in bridging of this narrow drainage pathway and lead to sub-sequent formation of cicatricial bands with potential to obstruct the frontal sinus The early identification of obstructing tissue within the frontal recess allows cutting and removal

of this soft, fibrinous tissue and prevention of more mature and surgically recalcitrant cica-trix Although a 30-degree rigid endoscope is useful for inspection, most complete frontal sinusotomies will benefit from careful inspec-tion with a more angled scope Instrumenta-tion of the frontal recess should be performed under the guidance of a 45- or 70-degree rigid

Figure 8–7. the frontal sinus dressing

is fashioned from 0.5-mm thick Silastic

sheeting, rolled into the shape of a tube,

and best inserted with a pediatric frontal

sinus instrument

In-Office Treatment of Post-Endoscopic Sinus Surgery Issues 75

endoscope Early synechiae in this location

are soft and routinely removed without

pre-procedure CT scans The posterior wall of the

frontal recess can be visualized and backward

biting instruments will direct surgical injury

away from the skull base, enlarging the FSDP

Video 5

Resection of an early synechiae from the left

frontal sinusotomy site

Mature Frontal Sinus

Synechiae

Despite performing a wide frontal sinusotomy,

circumferential surgical injury and persistent

inflammatory disease can result in narrowing

or obliteration of the FSDP In these cases,

revision is required or obstruction of the

fron-tal sinus and recurrent infection will result

The surgeon should maintain a low threshold for obtaining CT scans of the postoperative anatomy and review these triplanar images to better understand the anatomy of the FSDP prior to instrumentation Patient compliance with office-based procedures is critical and, if unlikely, revision in the operating room set-ting may be necessary

Commonly, inspection of the frontal recess with a 70-degree angled endoscope will identify an obvious, though narrowed, FSDP

A frontal sinus instrument is useful for ing the stenosis and confirming the relation-ship to the frontal sinus A small, malleable suction can be contoured to fit into this loca-tion providing both tactile feedback regarding the nature of the stenosis as well as confirma-tion of a connection into the frontal sinus Backward-biting instruments and upturned mushroom punches are used in sequence to safely remove surrounding cicatrix and enlarge the FSDP When a large percentage of the circumference of the FSDP is traumatized,

palpat-a customized piece of 0.5-mm thick Silpalpat-astic

Figure 8–8. heavily angled, backward-facing instruments

that complement the angles afforded by 45-degree and

70-degree endoscopes are used to address the frontal

recess

sheeting is placed as a dressing into the

opera-tive site for two weeks Oral and topical

cor-ticosteroids are initiated and postoperative

endoscopic debridements are undertaken in

earnest on a weekly basis Those patients with

stenosis of large Draf IIa/IIb frontal

sinusoto-mies that require surgical revision may benefit

from longer than average courses of

corticoste-roids postoperatively

There may be room for the addition

of balloon catheter technology to the

office-based surgical options for treating stenosis of

a frontal sinusotomy Although this technique

is not used in our practice at the present time,

one can envision the application of

endo-scopic dilation techniques for minimally

inva-sive dilation of narrowed drainage pathways

Video 6

Mature frontal stenosis in a patient with

Sam-ter’s triad who was noncompliant with

post-operative medical therapy following revision

endoscopic sinus surgery

Video 7

Surgical revision of a mature frontal sinus

ste-nosis in a patient with suboptimal

postopera-tive endoscopic inspection and debridements

Tips and Pearls

n A narrow frontal sinusotomy can

be revised in the office setting

under local anesthesia with hand

instruments, provided the surgeon

has excellent understanding of the

particular frontal recess anatomy

and has reviewed appropriate CT

scans

n When possible, limit the surgical injury to areas of a scarred frontal recess to prevent further cicatricial changes within the frontal sinus drainage pathway

References

1 Thaler, ER Postoperative care after

endo-scopic sinus surgery Arch Otolaryngol Head

Neck Surg 2002;128:1204–1206.

2 Ramakrishnan VR, Suh JD How necessary are postoperative debridements after endoscopic

sinus surgery Laryngoscope 2011;121:8–9.

3 Senior, BA, Kennedy DW, Tanabodee J, et al Long-term results of functional endoscopic

sinus surgery Laryngoscope 1998;108: 151–157.

4 Kuhnel T, Hosemann W, Wagner W, et al How traumatizing is mechanical mucous membrane care after interventions on paranasal sinuses?

A histological immunohistochemical study

Laryngorhinootologie 1996;75(10):575–579.

5 Richtsmeier WJ Top 10 reasons for

endo-scopic maxillary sinus surgery failure

Mid-echiae technique Laryngoscope 1999;109:

9 Office-Based Inferior Turbinate Reduction

Praveen Duggal John M DelGaudio

Introduction

Nasal obstruction is a common patient

com-plaint resulting from anatomic

abnormali-ties or mucosal disease of the nose and nasal

cavities Hypertrophy of the turbinates is one

of the most common causes of nasal

obstruc-tion Turbinate hypertrophy is often seen in

conditions such as allergic rhinitis,

vasomo-tor rhinitis, or chronic hypertrophic rhinitis

Compensatory hypertrophy of the turbinates

can also be observed in the setting of nasal

septal deviation In addition, dependent

turbi-nate engorgement in the recumbent position

is a common cause of nasal congestion with

increasing age This tends to manifest as

noc-turnal congestion that alternates sides, with

the dependent side being congested

Epide-miologic investigations have noted that up to

20% of the population of various European

countries has chronic nasal obstruction

sec-ondary to turbinate hypertrophy.1

The goal of surgical intervention in

tur-binate surgery is to obtain an improvement

in nasal breathing by reducing the size of

hypertrophied turbinates while maintaining normal nasal physiology Although there are many options for turbinate reduction, there

is no consensus on the best and most effective technique However, despite the method used, most inferior turbinate procedures appear to

be effective in treating symptoms of nasal obstruction not relieved by medical therapy

In addition, office-based procedures targeted

at turbinate reduction can be a useful tool

to help relieve nasal obstruction without the need of general anesthesia and the cost of the operating room

Anatomy

The nasal turbinates (or conchae) are long, thin, curved bones that vary in size and are covered by adherent mucoperiosteum They arise as three bony shelves that project from the lateral wall of the nasal cavity (Figure 9–1) The turbinates develop as outgrowths from the lateral wall between the 7th and 12th weeks of fetal life The embryologic

maxilloturbinal forms the inferior turbinate,

whereas the second and third ethmoturbinals

form the middle and superior turbinates,

respec-tively.2 Each turbinate has a corresponding space

beneath it called a meatus, which receives

drain-age from specific structures The inferior meatus

drains the nasolacrimal duct The middle meatus

receives drainage from the maxillary sinus,

anterior ethmoids, and frontal sinuses The

superior meatus drains the posterior ethmoids

Histologically, there are three layers to

the turbinates Medially there is thick mucosa

overlying a basement membrane, then

lam-ina propria, followed by bone.3 The medial

aspect of the inferior turbinate mucosal layer

is thicker and has more surface area Stratified

squamous epithelium is found on the anterior

tip of the inferior turbinate The mucosa of all

other surfaces of the turbinates is

pseudostrati-fied columnar, ciliated, respiratory

epithe-lium Within the epithelium are goblet cells,

glycoproteins, polysaccharides, and lysozymes

The lamina propria contains a complex array

of arteries, veins, and venous sinusoids The continually beating ciliated mucosa provides constant motion to the mucous blanket within the nose This acts as a cleaning and filtering system while helping to maintain nasal mois-ture The cilia beat in unison to move mucus from the front of the nasal cavity toward the nasopharynx

The arterial blood supply of the nates is primarily from branches of the sphe-nopalatine artery.4 Numerous arteriovenous anastomoses are present in the deeper mucosa and around the mucus glands in the epithe-lium A rich submucosal cavernous plexus is especially dense in the middle and inferior turbinates Numerous arteriovenous anasto-moses are also present in the deeper aspects

turbi-of the mucosa These cavernous plexuses and venous sinusoids within the turbinates resem-ble erectile tissue The venous erectile tissue

of the nasal epithelium is well developed at the anterior end of the inferior turbinate, and swelling of the tissue contributes to nasal air-way resistance Engorgement of this tissue can lead to symptoms of nasal obstruction.5

In the nasal cavity, vasomotor function is modulated by the autonomic nervous system

to control secretions and nasal airway tance The flow of blood to the nasal mucosa,

resis-in particular the venous plexus of the nates, is regulated by the nerves originating from the pterygopalatine ganglion, and func-tions to heat or cool the air flowing through the nose The nasal epithelium is innervated by both sympathetic and parasympathetic nerve fibers, with the parasympathetic fibers sup-plying nasal glands and the sympathetic fibers controlling nasal blood flow and venous erec-tile tissue Decreased sympathetic activity or increased parasympathetic activity, separately

turbi-or in combination, result in nasal congestion and obstruction.6 Various environmental, infectious, allergic, and pharmacologic stimuli can lead to such changes

Figure 9–1. Cadaveric specimen showing

lateral nasal wall with inferior (It), middle

(Mt), and superior turbinates (St) along

with their corresponding meatus (inferior —

IM, medial — MM, superior — SM) also

pictured: sphenoid sinus (Sph), pituitary

gland (pit), clivus (Cl), and eustachian tube

(et)

Office-Based Inferior Turbinate Reduction 79

Physiology

The nasal valve is the narrowest point of the

nasal passage and determines the nasal

resis-tance to airflow.5 The nasal valve is dynamic

and not a fixed anatomic narrowing The

internal nasal valve is defined by the upper

lateral cartilage, the nasal septum, and the

anterior face of the inferior turbinate The

nasal airway resistance is determined by the

swelling and constriction of the venous

sinu-soids within the anterior inferior turbinate

and nasal septum

Airflow dynamics play a key role in

warming, humidifying, and filtering inspired

air Airflow within the nose is both laminar

and turbulent Inspired air must first pass

through the nasal valve in order to enter the

nasal cavity Changes in speed and pressure

produce turbulent flow in the nose The

degree of congestion of the tip of the inferior

turbinate determines the dynamic

cross-sec-tional area of the nasal valve and subsequently

nasal airway resistance Minor changes in

tur-binate congestion can significantly decrease

the airflow and resistance Turbulent airflow

can give a sensation of obstruction If nasal

airway resistance is increased or even decreased

out of the limits of normal perceived

breath-ing, a sensation of obstruction can also occur

Finally, the perception of nasal blockage can

be secondary to compromised function of the

overlying mucosa due to underlying disease

or edema

Nasal Cycle

The nasal cycle describes the spontaneous and

reciprocal change in unilateral nasal airflow

associated with changes in congestion and

decongestion of the turbinate erectile tissue.5

These changes of nasal engorgement

occur-ring in the nasal venous sinuses are dictated by the autonomic nervous system An increase in sympathetic tone to the venous erectile tissue causes a vasoconstriction of the tissue and a decrease in nasal airflow resistance This cycle alternates between the left and right nasal cav-ity with lengths ranging from 2 to 4 hours The cycle is hypothesized to be driven by the suprachiasmatic nucleus

The nasal cycle aids in the natural tenance and functioning of the nose to warm, humidify, and filter nasally inspired air These humidifying and filtering functions are depen-dent on the presence of moist respiratory epi-thelium, mucus-producing goblet cells and properly functioning cilia Both nasal pas-sages function in an alternating pattern that prevents excessive drying, crusting, and infec-tion, which are the likely results of a static passage that is continuously open to airflow When one nasal passage is congested, its cilia slow in beat frequency or even stop in order for moisture to accumulate in preparation for resuming the nasal functions when that side decongests The turbinates can slow the flow

main-of air through the nose by causing turbulence, allowing more time for these beneficial func-tions to take place

Turbinate Dysfunction

There are various causes of turbinate tion, which include upper respiratory infec-tion, allergic rhinitis, vasomotor rhinitis, and nasal polyposis Drugs or hormones may also induce turbinate dysfunction Nasal obstruc-tion is the most common symptom associated with turbinate dysfunction Symptoms can vary depending on the more common infec-tious or inflammatory causes Often, the eti-ology is multifactorial Allergic rhinitis is the most common cause Allergic rhinitis is due to

dysfunc-environmental allergens that cause an

inflam-matory reaction once in contact with nasal

mucosa, resulting in congestion and

obstruc-tion Vasomotor rhinitis is a non-allergic cause

of turbinate dysfunction leading to symptoms

similar to allergic rhinitis such as rhinorrhea

and nasal congestion Hormones such as

pro-gesterone and other medications can alter the

sympathetic/parasympathetic nervous system

and lead to turbinate dysfunction

Hypertro-phy of the turbinates can be mucosal, bony,

or both (Figure 9–2A and 9–2B) Bony

turbi-nate hypertrophy covered with a thin layer of

mucosa is less likely to improve with thermal

or microdebrider assisted techniques, but this

is a less common form of turbinate

hypertro-phy Nasal polyps are hyperplastic edematous

mucosa often originating in the paranasal

sinuses Polypoid degeneration of the

turbi-nates is less common, especially of the inferior

turbinates Isolated polypoid degeneration is

uncommon in the absence of diffuse nasal

pol-yps, but can be seen in all of the turbinates

The middle turbinate is often affected by this

polypoid change (Figure 9–3) This polypoid

degeneration of the turbinate can alter

natu-ral nasal airway flow resistance and the nasal cycle, leading to significant nasal obstruction.Dependent engorgement of the inferior turbinates is a significant cause of nocturnal nasal congestion in adults, especially with increasing age The side of the nose that is more dependent (ie, toward the pillow) is con-

Figure 9–2. A Left inferior turbinate hypertrophy B right inferior turbinate hypertrophy.

Figure 9–3. polypoid degeneration of the left middle turbinate

Office-Based Inferior Turbinate Reduction 81

gested while the other side decongests This

alternates with changing positions The reason

for this may be related to decreased vascular

tone in the submucosal vessels within the

infe-rior turbinates, causing increased engorgement

of the erectile tissue and resultant obstruction

Symptoms tend to resolve within a short time

of assuming a nonrecumbent position

Medical Therapy

Medical management is used as a first line

treatment for turbinate hypertrophy Various

medications can be attempted to decrease the

burden of nasal obstruction Many of them

differ in their mechanisms of action as well as

their side effects Medical therapy should be

attempted first if not contraindicated, before

surgical intervention, for patients suffering

from turbinate hypertrophy, allergic rhinitis,

vasomotor rhinitis, or patients with chronic

sinusitis with or without polyposis

The nasal blood vessels are extremely

sensitive to sympathomimetic medications

that mimic the vasoconstrictor effects of

norepinephrine and epinephrine

Sympatho-mimetic medications cause decongestion of

nasal venous sinuses and a decrease in nasal

resistance by acting on alpha-1 and alpha-2

receptors Topical sprays such as

oxymeta-zoline and phenylephrine are extremely

powerful alpha-agonists However, repeated

application of topical sympathomimetics can

cause rebound vasodilation and nasal

conges-tion, also known as rhinitis medicamentosa or

rebound rhinitis Pseudoephedrine and

phen-ylephrine are common forms of oral

decon-gestants The main concerns regarding their

use include elevation of blood pressure in

hypertensive patients Histamine is a potent

vasodilator in the nose Antihistamines act on

the H1 receptors in the nose, preventing the

binding of histamine This prevents dilation

of the venous sinuses and decreases sneezing, itching, rhinnorhea, and nasal congestion.5

Urinary retention in patients with benign prostatic hypertrophy is a concern with anti-histamine use Adverse effects are drug specific and range from sedation and memory effects (with the earlier generation antihistamines that cross the blood-brain barrier) to excessive dryness Many of these systemic side effects can be avoided by giving antihistamines in the form of a nasal spray The leukotriene receptor antagonist montelukast is also approved for use in cases of seasonal and perennial allergic rhinitis and is relatively safe This is consid-ered a third-line therapy for allergic rhinitis Leuokotriene receptor antagonists have shown improvement in daytime symptom scores of nasal congestion, rhinorrhea, and sneezing.Corticosteroids are potent anti-inflammatory medications that can reduce nasal swelling, congestion, and mucus pro-duction Intranasal steroids are currently the first line treatment for allergic rhinitis Topi-cal nasal steroids reduce nasal airway resistance that is associated with allergens Intranasal ste-roids are administered every day and require continued daily use for any significant ben-efits Proper direction of the spray nozzle is to the lateral nasal wall Systemic corticosteroids can be used in cases of severe allergic rhinitis

or patients with nasal polyposis and polypoid degeneration of the nasal mucosa with signifi-cant obstruction of the nasal passages; however the significant short and long-term side effects need to be explained to the patient, and repeti-tive courses of systemic steroids within short time periods should be avoided In patients with significant allergies, long-term control can be achieved with immunotherapy to treat the offending allergens However, if medical therapy fails to alleviate obstructive symp-toms, surgical intervention can be attempted

to reduce the size of the turbinates

Surgical Treatment

Surgical therapy is reserved for symptomatic

patients with persistent dysfunction of the

turbinates who are not responding to

medi-cal management or in whom medimedi-cal

man-agement is contraindicated The goals of

turbinate surgery are to maximize turbinate

volume reduction, improve nasal obstruction,

and maintain nasal function and physiology.7

Effective turbinate surgery should balance

conservative reduction in the volume of the

turbinate with mucosal preservation and

main-tenance of mucociliary function The ideal

method of turbinate reduction performed in

the office setting under local anesthesia would

be efficient and easy to use, require minimal

postoperative care, and preserve the mucosal

and glandular anatomy of the turbinate

There are many options for treating

tur-binate hypertrophy One of the most

impor-tant decisions in method of treatment is

determining if the hypertrophy is mucosal or

bony Bony hypertrophy often requires part, or

all, of the turbinate bone to be removed Soft

tissue hypertrophy can be treated by

decreas-ing the bulk and thickness of the submucosal

tissue of the inferior turbinate Although there

are many different techniques for

decreas-ing turbinate hypertrophy, only some have

shown to be tolerated in an office setting For

example, submucosal resection of the

infe-rior turbinates using a microdebrider or cold

instrumentation is a highly effective method

of treating turbinate hypertrophy while

pre-serving mucosal function.8,9 However, it is

not performed in an office-based setting due

to the pain and bleeding associated with the

procedure The advantage is clear for a

blood-less therapy in an outpatient setting with high

patient acceptance and satisfactory results, as

compared to several operating room based

surgical techniques The following are

mini-mally invasive techniques that can treat

tur-binate dysfunction in an office setting under local anesthesia

for-Electrocautery

Electrocautery can be done directly on the mucosa or in a submucosal plane Surface cauterization involves a wire or needle used

in a linear fashion on the turbinate mucosal surface Submucosal cauterization can be per-formed with a monopolar or bipolar electrode through a stab incision to induce a reduction

in volume by creating fibrosis and wound tracture The monopolar acts by coagulating

con-in a circumferential fashion around the tip of the electrode The bipolar coagulates specifi-cally between the tips of the electrodes The electrodes can be passed into the anterior head

of the turbinate and advanced to the posterior end Fradis et al12 showed that 87% of their patients were symptom free at one year using

Office-Based Inferior Turbinate Reduction 83

submucosal diathermy in an office setting The

use of electrocautery can produce very high

temperatures approaching 800°C Although

this can lead to eventual fibrosis and wound

contracture, the damage to the

surround-ing tissue and mucosa can be significant and

can lead to decreased mucocilliary clearance,

altered nasal airflow physiology, and chronic

inflammation.13

Laser Surgery

Lasers function by projecting a beam of

coher-ent light that is absorbed by tissue Various laser

systems have been studied to reduce the volume

of turbinate hypertrophy; specifically CO2,

argon, KTP, Nd:YAG, Ho:YAG, and diode lasers

have been evaluated The fundamental difference

between these laser systems is the wavelength

of the emitted light, which then provokes

differ-ent interactions between laser light and tissue

Lasers with deeper tissue penetration may

have varying ablative and coagulative

proper-ties Often, the laser is used in one or multiple

pass attempts at different spots from posterior

to anterior along the inferior turbinate Heat from

the laser leads to coagulation of the

surround-ing tissue and creatsurround-ing intact mucosal islands

between treated areas and scarring of the

turbi-nates leading to a reduction in size The laser is

an excellent tool for a controlled coagulopathy

of soft tissue with good hemostasis The CO2

laser has shown to be efficacious and efficient

as an in-office procedure when used to ablate

the medial and inferior surfaces of the inferior

turbinates.14 The laser has shown a decrease in

symptoms of postnasal drip, nasal congestion/

obstruction, and rhinorrhea The diode and

Ho:YAG laser have shown good long term

re-sults as well.15 Although the use of lasers may

show a relief of symptoms months after the

procedure, the first 2 to 4 weeks may show early

crusting, moderate to severe nasal obstruction,

and nasal hypersecretion The laser also has a

questionable and possible irreversible effect on nasal epithelium as some studies have shown a decrease in mucocilliary function,8,13 whereas other studies have no long-term effect on the epithelium or mucocilliary clearance.16,17 One noted disadvantage of the laser is the financial burden and expense of the equipment as well

as the training, certification, and maintenance

of the system

Radiofrequency Ablation

Radiofrequency tissue reduction is based

on the local submucosal delivery of frequency energy by means of a specifically adapted electrode.18 The electrode is inserted into the inferior turbinate at one or more points and energy is delivered to a set energy level and/or duration.19 This energy induces ion agitation within the tissue and increases the local tissue temperature as well as causes tissue vaporization Radiofrequency heat-ing induces submucosal tissue destruction.20

low-Thermal lesions (2–4 mm by 1 cm around the active electrode) occur in the deep mucosa, preferably without damaging the superficial layers Fibrosis replaces the vascular, expansile tissue, and wound contraction can then occur leading to tissue volume reduction The tar-get temperature can be controlled at 60°C to 90°C to prevent surrounding tissue damage.21

Radiofrequency turbinate reduction is a mally invasive surgical option that reduces tis-sue volume in a precise and targeted manner.Coblation is a form of radiofrequency ablation that uses a plasma field created by radiofrequency current generated between bipolar electrodes to ablate soft tissues As the instrument is placed into the turbinate, it creates channels by ablating tissue Submuco-sal lesions are created in seconds Coblation-based plasma devices are designed to operate

mini-at a relmini-atively low tempermini-ature to gently solve and/or shrink target tissue with minimal

dis-thermal damage to surrounding healthy tissue

The clinical effectiveness and safety have been

tested and show coblation to be an effective

procedure for turbinate reduction.22 A

com-parison by Cavaliere et al23 compared the

monopolar and bipolar radiofrequency

abla-tion technologies Both techniques showed

similar long-term results at 20 months and

decreased nasal resistance, obstructive nasal

symptoms, and maintained nasal function

Radiofrequency inferior turbinate

reduc-tion can be used in patients with nasal

conges-tion and rhinorrhea associated with inferior

turbinate mucosal hypertrophy, sleep apnea

with increased nasal resistance and difficulty

wearing a nasal CPAP mask, in conjunction

with septoplasty and/or endoscopic sinus

surgery, and in rhinitis medicamentosa

requir-ing adjunctive treatment Contraindications

include patients with pacemakers, turbinate

hypertrophy from bony overgrowth, and

patients on active anticoagulation therapy

Patients on anticoagulation medications

should stop those medicines at least 5 days

prior to the procedure

The procedure of submucosal

radiofre-quency reduction of the inferior turbinates

is performed with the patient in the sitting

position The anterior portion of the inferior

turbinate is topically anesthetized with

ponto-caine on a cotton-tipped applicator These are

left in contact with the anterior portion of the

inferior turbinate for several minutes

Topi-cal anesthetic spray can be used, but this can result in pharyngeal numbness and a feeling of dyspnea or anxiety Local anesthetic (1% lido-caine) is then injected into the leading edge

of the inferior turbinate for anesthetic effect and also to “inflate” the turbinate to provide

a larger volume to treat (see Video 9–1) This

“inflation” of the turbinate also helps to tect the mucosa by providing a greater volume

pro-of submucosal tissue to incorporate the size pro-of the lesion Only the anterior portion of the turbinate needs to be anesthetized because that is the where the entry points are located.Our technique for radiofrequency reduc-tion (also known as Somnoplasty) of the infe-rior turbinates, begins with placement of the probe anterior and inferior in the leading edge

of the inferior turbinate, ideally equidistant between the mucosal surface and the bone (Figure 9–4) A lesion is created submucosally

by delivering 300 joules of energy The needle

is advanced about one centimeter and a ond lesion is created The needle is removed and then reinserted anterior and superior into the leading edge of the inferior turbinate Once again, an anterior lesion is created and a second one created after the probe is advanced about one centimeter Care is taken not to burn the mucosa Patients may report a feel-ing of heat during the procedure If there is significant discomfort despite adequate local anesthetic then the lesion is too superficial and

sec-is causing mucosal injury A feeling of

throb-Figure 9–4. the Somnoplasty turbinate probe

Office-Based Inferior Turbinate Reduction 85

bing in the teeth can occur when the probe is

close to the turbinate bone Additional lesions

can be created if the turbinate is larger, but

four lesions is adequate in most situations

Bleeding from the probe insertion site is

minimal, and is easily controlled with topical

decongestant-soaked cotton patties

For inferior turbinate reduction via

coblation, the procedure is performed as with

radiofrequency, but the lesions are created

based on time rather than energy We use an

ablation setting of 6 and a coagulation

set-ting of 2 Each lesion is created for

approxi-mately ten seconds The probe insertion site

can be cauterized when the probe is removed

Coblation inferior turbinate reduction has the

advantage of being a faster procedure than

Somnoplasty, and has the advantage of

remov-ing a small core of tissue The disadvantage

is that the amount of energy delivered is less

precise than with Somnoplasty, and the higher

temperature and larger probe make mucosal

injury slightly more common

(See Video 9–2: Coblation technique

on hypertrophied left inferior turbinate and

Video 9–3: Coblation technique on

hypertro-phied right inferior turbinate.)

Microdebrider Reduction

The inferior or middle turbinates can

infre-quently present as polypoid in appearance In

these cases the mucosa is significantly diseased

and poorly functional Treatment of these

tur-binates should involve resection of the

polyp-oid mucosa with preservation of a significant

amount of submucosal tissue and care not to

expose the underlying bone This will reduce

the volume of the turbinate and allow for

regeneration of healthier mucosa This can

easily be performed in the office under

topi-cal or lotopi-cal anesthesia with a microdebrider

(See Video 9–4: Microdebrider used on

polypoid inferior turbinate.)

Middle Turbinate

Middle turbinate pathology causing nasal obstruction is less common than inferior tur-binate pathology The two conditions that can affect the middle turbinate are a muco-cele of a concha bullosa and islolated polyps

or polypoid degeneration of the middle binate Mucoceles of the middle turbinate are rare These may present with nasal obstruc-tion or with orbital findings due to erosion

tur-of the orbital wall (Figure 9–5) These can

be drained in the office, as discussed in the chapter on mucocele drainage Isolated polyps

of the middle turbinate are uncommon, with diffuse sinonasal polyposis with middle turbi-nate involvement being much more common Isolated polyposis of the middle turbinate

Figure 9–5. Concha bullosa mucocele of left middle turbinate

almost always involves the leading edge of

the middle turbinate (Figures 9–6A, 9–6B,

9–6C, and 9–6D).When the polyps become

large enough to cause obstruction they can be

removed in the office using through cutting

instruments or a microdebrider, as described

in Chapter 11 on office polypectomy

Postoperative Care

Postoperative care for all of these turbinate procedures are directed at keeping the mucosa moist and the nose decongested Frequent nasal saline spray application is recommended

A

C

B

D

Figure 9–6. A and B.: polypoid right and left middle turbinates C and D.: right and left

middle turbinates post removal of polypoid degeneration with microdebrider

Office-Based Inferior Turbinate Reduction 87

after these procedures, and continued until

the nose is completely healed Topical

decon-gestant sprays are used sparing for the first 3

or 4 days after the procedures for nasal

con-gestion as needed Topical steroid sprays are

discontinued in the early postoperative period

to avoid excessive drying Postoperative nasal

congestion due to edema may last for up to

a week after radiofrequency reduction of the

inferior turbinates, but then resolves and the

patients notice an improvement of their nasal

breathing Patients are seen in follow-up about

a month after the procedure to assure

muco-sal healing Occasionally, there may be some

mucosal loss and exposed turbinate bone This

is rare after Somnoplasty but may be seen after

coblation Exposed bone becomes osteitic and

serves as a nidus for infection This bone should

be debrided, which will allow mucosalization

and resolve the crusting Saline spray should be

continued until remucosalization is complete

References

1 Seeger J, Zenev E, Gundlach P, Stein T, Muller

G Bipolar radiofrequency-induced

thermo-therapy of turbinate hypertrophy: pilot study

and 20 months’ follow-up Laryngoscope

2003; 113(1):130–135

2 Lee KJ, ed Essential Otolaryngology-Head and

Neck Surgery 9th ed New York, NY:

McGraw-Hill Medical; 2008

3 Berger G, Hammel I, Berger R, Avraham S,

Ophir D Histopathology of the inferior

tur-binate with compensatory hypertrophy in

patients with deviated nasal septum

Laryngo-scope 2000;110(12):2100–2105.

4 Gray H, Standring S, Ellis H, Berkovitz BKB

Gray’s Anatomy: The Anatomical Basis of

Clini-cal Practice 39th ed Edinburgh; New York:

Elsevier Churchill Livingstone; 2005

5 Adkinson NF, Middleton E Middleton’s

Allergy: Principles and Practice 7th ed

Phila-delphia, PA: Mosby/Elsevier; 2009

6 Younger RA Illusions in rhinoplasty

Otolar-yngol Clin North Am 1999;32(4):637–651.

7 Nurse LA, Duncavage JA Surgery of the

infe-rior and middle turbinates Otolaryngol Clin

North Am 2009;42(2):295–309, ix.

8 Passali D, Passali FM, Damiani V, Passali GC, Bellussi L Treatment of inferior turbinate

hypertrophy: a randomized clinical trial Ann

Otol Rhinol Laryngol 2003;112(8):683–688.

9 Cingi C, Ure B, Cakli H, Ozudogru E Microdebrider-assisted versus radiofrequency-assisted inferior turbinoplasty: a prospective study with objective and subjective outcome

measures Acta Otorhinolaryngol Ital 2010;

30(3):138–143

10 Elwany S, Harrison R Inferior turbinectomy:

comparison of four techniques J Laryngol

ment Am J Otolaryngol 2002;23(6):332–336.

13 Salzano FA, Mora R, Dellepiane M, et al Radiofrequency, high-frequency, and electro-cautery treatments vs partial inferior turbi-notomy: microscopic and macroscopic effects

on nasal mucosa Arch Otolaryngol Head Neck

Surg 2009;135(8):752–758.

14 Siegel GJ, Seiberling KA, Haines KG, Aguado

AS Office CO2 laser turbinoplasty Ear Nose

Throat J 2008;87(7):386–390.

15 Sroka R, Janda P, Killian T, Vaz F, Betz CS, Leunig A Comparison of long-term results after Ho:YAG and diode laser treatment of

hyperplastic inferior nasal turbinates Lasers

17 Janda P, Sroka R, Betz CS, Grevers G, Leunig

A [Ho:YAG and diode laser treatment of

hyperplastic inferior nasal turbinates]

Laryn-gorhinootologie 2002;81(7):484–490.

18 Coste A, Yona L, Blumen M, et al

Radio-frequency is a safe and effective treatment of

turbinate hypertrophy Laryngoscope 2001;

111(5): 894–899

19 Bhandarkar ND, Smith TL Outcomes of

surgery for inferior turbinate hypertrophy

Curr Opin Otolaryngol Head Neck Surg 2010;

18(1):49–53

20 Li KK, Powell NB, Riley RW, Troell RJ,

Guil-leminault C Radiofrequency volumetric

tissue reduction for treatment of turbinate

hypertrophy: a pilot study Otolaryngol Head

Neck Surg 1998;119(6):569–573.

21 Sapci T, Sahin B, Karavus A, Akbulut UG

Comparison of the effects of quency tissue ablation, CO2 laser ablation, and partial turbinectomy applications on

radiofre-nasal mucociliary functions Laryngoscope

Mono-follow-up Otolaryngol Head Neck Surg 2007;

137(2):256–263

10 Office-Based Management of

Septal Pathologies

Ethan Soudry Reza Vaezeafshar Peter H Hwang

In this chapter we present common nasal

septal pathologies encountered in the office

setting and discuss their evaluation, diagnosis

and in-office management

Anatomy

Understanding the anatomy of the nasal

sep-tum is crucial to the evaluation of nasal septal

pathologies The septum divides the nasal

cav-ity into two and provides structural support

for the external nose The septum consists

of cartilage and bone at its core, covered by

respiratory mucosa The quadrangular

carti-lage comprises the anterior and caudal aspect

of the septum, whereas the bony components

of the septum are located more posteriorly and

inferiorly: the perpendicular plate of the

eth-moid, the vomer, the nasal crest of the palatine

bone, the nasal crest of the maxilla and

pre-maxilla, the nasal crest of the frontal bone, and

the nasal spine The quadrangular cartilage

forms osseous attachments posteriorly at the

perpendicular plate of the ethmoid, and

infe-riorly at the vomer and maxillary crest sally, the cartilaginous septum is fused to the paired upper lateral cartilages at the midline, forming the internal nasal valve Caudally, the cartilaginous septum has ligamentous attach-ments to the medial crura of the lower lateral cartilages, forming the membranous septum The septal mucosa is predominantly pseu-dostratified ciliated columnar epithelium, but in the posterosuperior septum, olfactory neuroepithelium has significant representa-tion in the olfactory cleft region The septal body is an area of bilateral mucosal promi-nence located at the superior aspect of the septum just anterior to the middle turbinate Composed of loose venous submucosal spaces and erectile tissue, the septal body is some-times referred to as the septal turbinate When hypertrophied, the septal body can contribute

Dor-to nasal obstruction

The blood supply of the nasal septum derives from the septal branch of the supe-rior labial artery, the anterior and posterior ethmoidal arteries, the septal branch of the sphenopalatine artery, and the descending and greater palatine arteries The anterior part

of the septum, known as Little’s area, is rich

with blood vessels and is an area of confluence

of the labial, sphenopalatine, and ethmoidal

arteries known as Kiesselbach’s plexus

The innervation of the nasal septum

originates from the trigeminal nerve (CN V)

The posteroinferior half of nasal mucosa

is innervated by the nasopalatine nerve, a

branch of the maxillary nerve (CN V2) The

anterosuperior half of nasal mucosa is

inner-vated by the branches of the nasociliary nerve

which originates from the ophthalmic nerve

(CN V1) Posterosuperiorly in the region of

the olfactory cleft, olfactory filae originating

from the olfactory nerve (CN I) traverse the

cribriform plate to supply the septal mucosa

in this region

Evaluation and

Differential Diagnosis

The differential diagnosis for diseases affecting

the septum is wide, including structural,

infec-tious, inflammatory, neoplastic, and vascular

etiologies Some of the common pathologies

are listed in Table 10–1 History should include

a thorough investigation of local, regional, and

systemic symptoms Patients with septal lesions

typically present with nasal obstruction,

dis-charge, epistaxis, pain, or swelling However,

some lesions may be asymptomatic, and thus

careful consideration of the septum should be

part of any nasal evaluation

Evaluation of the nasal septum begins by

inspection and palpation of the external nose

Swelling, erythema and tenderness may

sug-gest a septal hematoma, abscess, or

autoim-mune process Saddling of the nasal dorsum

indicates a loss of septal cartilage suggestive

of past trauma or an ongoing destructive

pro-cess Examination of the nasal septum should

include anterior rhinoscopy with speculum

and/or otoscope, as well as fiberoptic nasal

Table 10–1. Common Septal pathologies

Pathology

Inflammatory

Wegener’s granulomatosisSarcoidosis

Churg-Strauss

Infectious

tuberculosisSyphillisrhinoscleromaLeprosyOzenahistoplasmosis

Neoplasms

Benign

Inverted papilloma pyogenic granuloma hemangioma hamartoma

Malignant

Squamous cell carcinoma Basal cell carcinoma Melanoma

Chondrosarcoma

t cell lymphoma adenocarcinoma hemangiopericytoma

Traumatic/Iatrogenic

Septal hematomaSeptal abscessepistaxisperforation

Structural

Septal deviation/spur

Office-Based Management of Septal Pathologies 91

endoscopy so that the entirety of the septum

can be evaluated The integrity and character

of the septal mucosa should be noted

Pres-ence of erythema, edema, or purulPres-ence may

suggest an inflammatory or infectious process

Severe crusting or tissue friability should raise

concern for a granulomatous disease process

The presence of a necrotic or ulcerative mass

or a perforation may suggest a neoplastic or

granulomatous process (Figures 10–1, 10–2,

and 10–3) The septum should also be

evalu-ated for any deviations, spurs and contact

points with the inferior, middle, or superior

turbinates Endoscopically guided palpation of

the septum with a probe provides additional

tactile characterization of swelling, fluid

col-lections, or loss of underlying cartilage or bone

Physical examination of the patient with

a septal lesion should also include a

comprehen-sive head and neck and cranial nerve

examina-tion Peripheral examination may reveal clues

to systemic disease with septal manifestations

For example, multiple telangiectasias of the

digits and oral mucosa in a patient with

epi-staxis would suggest hereditary hemorrhagic telangiectasia (HHT) syndrome Additional examination of other body systems should be guided by differential diagnosis

Adjunctive laboratory or radiologic ing should be guided by the findings in the history and physical examination Elevated

test-Figure 10–1. Squamous cell carcinoma of

the left anterior septum presenting as an

ulcerative lesion

Figure 10–2. a small septal hemangioma

Figure 10–3. pyogenic granuloma of the septum in a young adult male patient Note that the lesion had previously bled and there is an old blood clot attached to it

erythrocyte sedimentation rate (ESR) is

com-mon in systemic inflammatory conditions

but is nonspecific Elevated antineutrophil

cytoplasmic autoantibody (c-ANCA) and

anti-serine protease 3 levels are associated

with Wegener’s granulomatosis, although

patients with limited forms of head and neck

Wegener’s granulomatosis may have negative

c-ANCA tests Elevated

perinuclear-stain-ing antineutrophil cytoplasmic antibodies

(p-ANCA) and peripheral blood eosinophilia

suggest Churg-Strauss syndrome The serum

angiotensin-converting enzyme (ACE) level

and serum calcium level are typically elevated

in patients with sarcoidosis A sinus CT or

MRI scan can be helpful in characterizing

suspected neoplasms, co-existing sinusitis, and

involvement/erosion of adjacent structures

Management of Selected

Septal Pathologies

Septal Masses

Septal masses require careful endoscopic

char-acterization before consideration of biopsy

Superiorly based masses should also be

evalu-ated by CT or MRI prior to biopsy to ensure

that the mass does not involve or originate

from the skull base If radiologic imaging

sug-gests the possibility of meningoencephalocele

or a lesion with extensive skull

base/intracra-nial extent, office-based biopsy may be

con-traindicated A high degree of vascularity of

the lesion may also be a contraindication for

office biopsy

For the patient requiring septal biopsy,

careful attention to anesthesia of the nasal

septum will ensure greater patient satisfaction

as well as clinical accuracy of biopsy Topical

anesthesia may be sufficient for minor

proce-dures, but locally injected anesthesia should

also be considered, depending on the degree

of tissue manipulation planned Common topical anesthetics in use are lidocaine 4%, tetracaine 0.5 to 2%, typically combined with

a topical vasoconstrictor such as line, phenylephrine or epinephrine Cocaine 4%, another alternative, has both anesthetic and vasoconstrictive effects In patients aller-gic to lidocaine (an amide class of anesthetic), tetracaine or cocaine (ester class) may be used and vice versa Cotton pledgets or applicators soaked in the anesthetic/vasoconstrictor solu-tion should be placed gently under endoscopic visualization over the site of the planned pro-cedure After allowing several minutes for the topical anesthetic to take effect, the mucosa can be locally infiltrated with 1% lidocaine with 1:100,000 epinephrine Regional blocks such as a sphenopalatine ganglion block can

xylometazo-be considered as well but are generally not required for most septal procedures

Septal biopsy is best performed with endoscopic guidance, which allows greater precision, illumination, and visualization, especially for posteriorly based lesions Either

a 0-degree or 30-degree scope can be used For soft and friable lesions, noncutting cup for-ceps can be used to obtain an adequate tissue sample For lesions with firmer consistency, the biopsy should be taken with through-cutting forceps or by incising the lesion with

a scalpel For ulcerative lesions, the biopsy should be directed at the margin rather than the center of the ulcerated region, in order to minimize the amount of necrotic tissue that may contribute to a nondiagnostic result Straight Frazier suctions should be available for clearing of any secretions obstructing clear visualization of the lesion and for clearing of any bleeding caused by the biopsy Hemostasis typically can be achieved with 5 to 10 minutes

of local packing (such as a cottonoid/pledget) soaked in a topical vasoconstrictor In cases of continued bleeding, cauterization using either silver nitrate or bipolar cautery can be useful

Office-Based Management of Septal Pathologies 93

For smaller, well-defined lesions such as

septal fungiform papilloma, it may be possible

to perform excisional biopsy with adequate

mucosal margins in the office (Figure 10–4)

Additional instrumentation such as Freer or

Cottle elevators may be useful for dissection

of the deep margin of the tumor in either a

supraperichondrial or subperichondrial plane,

as necessary to secure adequate resection In

general, the septal mucosal defect resulting

from such procedures will heal satisfactorily

by secondary intention, and therefore no

wound closure is required

Once the biopsy has been procured, it

should be decided whether the biopsied tissue

be sent fixed in formalin or fresh in saline,

the latter being preferable when lymphoma is

a potential diagnosis Culture of the biopsied

tissue should also be considered, including

testing for aerobic and anaerobic bacteria, acid

fast bacilli, and fungi where indicated

Epistaxis

Epistaxis is discussed elsewhere in this text

(see Chapter 13), but we briefly outline its

management, as it is often from a septal tion Epistaxis is generally classified as either anterior or posterior Anterior epistaxis, the predominant form of epistaxis, typically arises from Kiesselbach’s plexus and can be con-trolled with common first-line interventions such as local pressure, chemical or electrical cautery, the application of hemostatic agents,

loca-or shloca-ort-term anteriloca-or nasal packs Posteriloca-or epistaxis, arising from branches of the sphe-nopalatine or posterior ethmoidal arteries, tends to be more severe and is more likely to require more aggressive packing or surgical intervention

Clinical history is important in the diagnosis and management of epistaxis Both local and systemic factors should be sought

as contributing factors for epistaxis Relevant medical history includes hypertension, liver disease, and the use of anticoagulant or anti-platelet medications The examination begins with anterior rhinoscopy with a nasal specu-lum and suction, which should reveal the most common origins of anterior hemorrhage Nasal endoscopy provides more comprehen-sive evaluation of both anterior and posterior bleeding sources and should be used if the bleeding source remains in question The use

of topical anesthetic combined with a constrictor will enhance the examination and slow some of the bleeding

vaso-For anterior epistaxis, initial treatment includes local pressure and placement of a cot-tonoid or a pledget soaked in a vascoconstric-tor In many cases these measures may suffice Nonetheless, otolaryngologists will most often encounter patients in whom these measures have already failed In these cases the first line

of treatment should be cautery (chemical, electrical, or thermal) Chemical cautery can

be achieved using silver nitrate sticks, which are available in several concentrations As the concentration of silver nitrate increases, the depth of penetration and coagulation also increases, potentially increasing the risk of

Figure 10–4. a small squamous papilloma

of the right caudal septum

complications.1 Regardless of the

concentra-tion of the silver nitrate, the general

princi-ples are the same The application begins with

the proper visualization of the bleeding area;

once identified, application should begin at

the periphery and slowly moved toward the

center of the bleed Care must be exercised

not to overcauterize to avoid post treatment

rhinorrhea or excessive tissue necrosis.2 Care

should also be taken as to avoid cauterizing

the opposing lateral nasal wall to minimize

the risk of synechia formation Cauterization

should be limited to one side of the nasal

sep-tum, or separated by 4 to 6 weeks to avoid

septal perforation.3

A variety of electrocautery devices can also

be used to cauterize the bleeding sites when

the source has been identified It has been

shown that these devices are at least as

effec-tive as silver nitrate applicators in the initial

management of epistaxis.4 A bipolar cautery

is preferable to unipolar cautery in providing

more focal treatment and minimizing thermal

injury to nearby healthy mucosa

The majority of posterior bleeding sites

can be identified by endoscopy in the office.5

Another useful adjunct for diagnosis of

signifi-cant posterior bleeding is a transpalatal

injec-tion of the sphenopalatine artery A 25-gauge

needle is bent at 2.5 cm and inserted

tran-sorally into the greater palatine foramen to

the bend After withdrawing slightly to ensure

the needle is not within a vessel, 1.5 to 2 mL

of a 1:100,000 epinephrine solution is then

injected slowly.6 This vasoconstrictive

injec-tion will slow bleeding from the

sphenopala-tine artery branches, effectively making the

diagnosis of posterior epistaxis

The key to treatment of posterior

epi-staxis is identification and control of the site

of the bleeding using suction diathermy The

majority of posterior idiopathic bleeds

origi-nate from the septal branch of the

spheno-palatine artery Controlling the bleeding

avoids the discomfort associated with nasal

packing and also avoids hospital admission Endoscopic cauterization achieves hemostasis

in more than 80% of patients with posterior epistaxis at the first attempt and more than 90% after a second attempt.7

When cauterization fails to control the bleeding, packing or thrombin dressings/gels should be considered as the next treat-ment option Many different types of packs have been developed over the years, includ-ing absorbable, nonabsorbable, anterior, and posterior packs Selective placement of nasal packing directed to the site of bleeding will provide effective control of bleeding while optimizing patient comfort

Septal Perforation

Nasal septal perforation is a pathologic or rogenically produced direct communication between the two nasal cavities that results from a traumatic, inflammatory, neoplastic, or autoimmune process (Table 10–2) Nasal sep-tal perforations are relatively common, affect-ing up to 0.9% of the general population.8

iat-Perforations can be asymptomatic, especially smaller posterior lesions; however, anterior and large perforations are more likely to dis-rupt laminar nasal airflow and cause symp-toms such as bleeding, crusting, or whistling during nasal breathing (Figures 10–5A and 10–5B) Advanced cases may present with a saddle-nose deformity It is extremely impor-tant to determine the etiology and stability

of a perforation before considering surgical repair At times, the etiology remains obscure despite careful evaluation

After a complete head and neck nation, nasal endoscopy should be performed

exami-to assess the character and size of the tion Presence of active ulceration or necrosis may indicate malignancy or systemic disease, requiring biopsy prior to proceeding with any intervention The size of the perforation

perfora-Office-Based Management of Septal Pathologies 95

should be determined as this can influence the

selection of repair technique The

anterior-posterior diameter can be measured using a

centimeter-etched Cottle elevator, or

alterna-tively a cotton applicator or suction Finally,

a trained eye can provide a close estimate of

the defect

Patients with symptomatic septal

perfo-rations may elect to have surgical repair, but

an office-based alternative is placement of a septal button Prefabricated buttons are typi-cally made of soft silicone and are comprised

of a flexible hub connecting two pliable discs, which allow them to adapt to the curvatures and irregularities of the septum These buttons are commercially available in various sizes The button can be inserted during an office visit with the aid of local or topical anesthesia and

Table 10–2. Differential Diagnosis for Septal Perforation

Renal Failure

decongestant To facilitate proper placement,

one side of the disk is folded and passed or

pulled through the perforation with cup

for-ceps or bayonet forfor-ceps An endoscopic view

of the nasal cavity may facilitate this

maneu-ver The flanges should be seated in the region

of the internal nasal valve superiorly and

con-tact the nasal floor inferiorly After a septal

button is inserted, it can remain in place for

a long period of time with attention to good

nasal hygiene (saline irrigation) and proper

care of the prosthesis Indications for removal

include: intolerance of the button due to pain

or nasal obstruction, biofilm colonization

causing infection, degradation of the button,

excessive crusting, epistaxis, and the need to

up-size the prosthesis.9

Septal Hematoma

Septal hematoma represents the

accumula-tion of blood between septal cartilage/bone

and septal mucoperichondrium or

mucoperi-osteum It may result from facial trauma, nasal

fracture, or septal surgery Because septal

carti-lage is avascular and depends on the overlying

perichondrium for its viability, displacement

of the perichondrium by hematoma may result

in a pressure-induced avascular necrosis of the nasal cartilage Furthermore, the accumulated blood and necrotic tissue can be a nidus for infection, the end result of which may be the formation of a septal abscess.10

The most common symptoms of septal hematoma are nasal obstruction (95%), pain (50%), rhinorrhea (25%), and fever (25%) Symptoms usually appear within the first

24 to 72 hours.11 However, a delayed septal hematoma may also develop several days after trauma.12 Concern for septal hematoma should

be raised in any patient who has sustained nasal trauma, especially those presenting with nasal deformity, epistaxis, or significant pain

In patients who have had a recent septoplasty and have symptoms of acute pain and nasal obstruction, the presence of a septal hematoma must be excluded

A septal hematoma can usually be nosed by inspecting the septum with a nasal speculum or an endoscope Swelling of the septum may suggest a hematoma, but a true hematoma can be difficult to discern from simple edema Palpation using a cotton-tipped

Figure 10–5. A NK-t cell lymphoma of the nasal septum presenting as a septal

perforation with severe crusting B hard palate examination in the same patient shows

ulceration and bony destruction

Office-Based Management of Septal Pathologies 97

applicator or blunt instrument will reveal

fluc-tuance Presence of a hematoma may be

con-firmed by needle aspiration using an 18- to

20-gauge needle under topical anesthesia

Management of septal hematoma

typi-cally includes incision and drainage Simple

aspiration can be considered in selected cases

but risks the possibility of recurrence After

careful establishment of local anesthesia, the

hematoma is drained through a mucosal

incision over the area of greatest fluctuance

For bilateral hematomas, bilateral incisions

should be made in a staggered fashion to

avoid a through-and-through septal

perfo-ration Next, the hematoma is evacuated by

suctioning through the incision A small

Pen-rose drain may be placed through the

inci-sion and sutured in place Alternatively, we

prefer to broadly enlarge the incision using a

through-cutting Blakesley forceps to create a

drainage port for egress of any reaccumulated

fluid, obviating the need for drain placement

Traditionally, the nasal cavity is packed to

re-approximate the perichondrium to the

carti-lage The drain and packing remain in place

until the drainage stops for 24 hours; this

usu-ally takes 2 to 3 days.13 However, in our

prac-tice we have found that with a sufficiently large

drainage window, packing is not necessary The

patient is instructed to follow up within 1 to 3

days for re-inspection of the nasal cavity

Septal Abscess

In up to 85% of cases, septal abscess develops

secondarily to infected traumatic nasal septal

hematoma.14 Other causes include chronic

irritation and injury of the nasal septum by

nasogastric tube placement, or dissemination

of an infection within the nasal cavity The

pathway of infection is thought to be either

direct extension from the overlying infected

mucosa, or via lymphatic and/or vascular

spread.15 Bacteria are the most commonly

implicated organisms, particularly aerobic

bacteria Reports have shown that cus aureus accounts for 70% of septal abscess

Staphylococ-pathogens Other bacteria that may be found

include Hemophilus influenzae, group A hemolytic Streptococcus, Streptococcus pneumo- niae, and other Streptococcus species.16–17 Fungal and mycobacterial pathogens should also be considered in immunocompromised hosts.Examination should include vital signs, nasal examination, and central nervous system examination (to rule out intracranial compli-cations) Nasal examination should include inspection, palpation, anterior rhinoscopy, and nasal endoscopy The most common finding is bilateral nasal septal swelling obstructing the airway with or without purulent nasal dis-charge.17 Once a septal abscess is suspected, needle aspiration should be performed to con-firm the diagnosis

beta-Although septal abscess typically involves the anterior cartilaginous nasal septum, there can be isolated posterior involvement of the nasal septum, and hence nasal endoscopy is essential when anterior rhinoscopy appears normal or inconclusive in a patient with a suggestive clinical history.15 Clinically, it can

be difficult to distinguish between a septal hematoma and septal abscess Generally, a septal abscess is larger and more painful, and the external nose may appear swollen and erythematous suggesting local spread of cel-lulitis Endonasal exam of patients with septal abscess may be differentiated by the presence

of mucosal exudates, and systemically there may be fever and leukocytosis.18

Incision and drainage is the preferred method of treatment Once the incision has been made with a scalpel or sickle knife, a sample of pus should be sent for microbio-logical assessment As in septal hematoma treatment, we typically enlarge the incision with a through-cutting Blakesley to create a wide drainage port to facilitate drainage and prevent recurrence

The nose may be packed for 48 to 72

hours with the aim of preventing

re-accumula-tion Alternatively, if daily examination can be

performed, the abscess site can be re-aspirated

through the incision site and packing may be

avoided Empiric broad spectrum parenteral

antibiotic should be started immediately to

prevent intracranial complications Antibiotic

coverage can be narrowed upon culture-based

pathogen identification

Contact Point Headache

Mucosal contact point headache is a newly

added secondary headache disorder in the

International Classification of Headache

Disorders (HIS), 2nd edition and supported

by limited evidence According to the IHS,

contact point headaches are attributed to the

intranasal contact between tightly apposing

mucosal surfaces inside the nasal cavity Such

endonasal contact points are believed by some

to trigger various forms of headaches via the

trigeminovascular system and release of

sub-stance P This diagnosis should only be

con-sidered after intracranial and sinusitis-related

causes have been ruled out In-office diagnosis

is made by visualizing a contact point between

a septal spur or deviation and the adjacent

inferior or middle turbinate on the side of the

headache Next, a cottonoid or neurosurgical

pledget soaked in lidocaine and a

deconges-tant is placed at the site of the contact point

for 5 minutes and then removed Alternatively,

local injection of lidocaine at the contact point

may be placed Resolution of the pain with

local anesthesia and decongestion predicts

success in resolution of the rhinogenic

head-ache with nasal septal surgery.19 Because of the

limited evidence surrounding this diagnosis,

in our practice we have the patient return to

the office for a second trial of this local topical

application of anesthetic and assess for repeat

improvement to confirm this diagnosis

Although most septal deformities are best addressed in the operating room, an office-based laser ablation procedure has recently been introduced for the management of sep-tal spurs.20 In this technique CO2 or diode laser transmitted through flexible fibers is used

to perform a direct transmucosal ablation of anterior or posterior cartilaginous spurs with-out incisions or elevation of the mucoperi-chondrial flaps Reports indicate minimal bleeding and no need for nasal packing, and may be an option in the future

References

1 Amin M, Glynn F, Phelan S, et al Silver nitrate cauterisation, does concentration mat-

ter? Clin Otolaryngol 2007;32(3):197–199.

2 Middleton PM Epistaxis Emerg Med

Austra-las 2004;16(5–6):428–440.

3 Hanif J, Tasca RA, Frosh A, et al Silver nitrate: histological effects of cautery on epithelial sur-

faces with varying contact times Clin

Otolar-yngol Allied Sci 2003;28(4):368–370.

4 Toner JG, Walby AP Comparison of electro and chemical cautery in the treatment of ante-

rior epistaxis J Laryngol Otol 1990; 104(8):

7 Frikart L, Agrifoglio A Endoscopic treatment of

posterior epistaxis Rhinology 1998;36: 59–61.

8 Oberg D, Akerlund A, Johansson L, et al Prevalence of nasal septal perforation: the

Skövde population-based study Rhinology

2003; 41(2):72–75

9 Watson D, Barkdull G Surgical management

of the septal perforation Otolaryngol Clin

North Am 2009;42(3):483–493.

Office-Based Management of Septal Pathologies 99

10 Ginsburg CM Nasal septal hematoma

Pedi-atr Rev 1998;19(4):142–143.

11 Canty PA, Berkowitz RG Hematoma and

abscess of the nasal septum in children Arch

Otolaryngol Head Neck Surg 1996; 122(12):

1373–1376

12 Dubach P, Aebi C, Caversaccio M Late-onset

posttraumatic septal hematoma and abscess

formation in a six-year-old Tamil girl Case

report and literature review Rhinology 2008;

46:342–344

13 Kim YS, Kim YH, Kim NH, et al A

prospec-tive, randomized, single-blinded controlled

trial on biodegradable synthetic polyurethane

foam as a packing material after septoplasty

Am J Rhinol Allergy 2011;25(2):e77–79.

14 Chukuezi AB Nasal septal haematoma in

Nigeria J Laryngol Otol 1992;106;396–398.

15 George A, Smith WK, Kumar S, et al Posterior

nasal septal abscess in a healthy adult patient J

18 Ehrlich A Nasal septal abscess: an unusual

complication of nasal trauma Am J Emerg

Med 1993;11;149–150.

19 Mokbel KM, Elfattah AM, Kamal ES Nasal mucosal contact points with facial pain and/

or headache: lidocaine can predict the result

of localized endoscopic resection Eur Arch

Otorhinolaryngol 2010;267:1569–1572.

20 Kizhner V, Krespi YP, Kamami C, et al

In-office laser septal spur removal Otolaryngol

Head Neck Surg 2010;142(1):135–136.

11 Office-Based Nasal Polypectomy

Oswaldo A Henriquez John M DelGaudio

Introduction

Nasal polyposis (NPs) is a condition which

significantly impacts the quality of life of our

patients.1,2 The incidence of NPs in the

gen-eral population has been estimated to be 1 to

4%.3 However, the incidence of symptomatic

patients with NPs has been cited to be 0.627

patients per one thousand per year.4 Although

overall this is a low incidence when compared

with other chronic diseases, patients suffering

from NPs are seen quite frequently in an

oto-laryngology practice, especially in a

rhinology-based tertiary care setting

The incidence of chronic rhinosinusitis

(CRS) with NPs is reported to account for 20

to 33% of total CRS patients.3 It has been

well established that the presence or absence

of NPs in CRS patients delineates two distinct

clinical phenotypes Although they can have

some overlap, these two groups of patients do

demonstrate differing clinical presentations,

available treatments, and outcomes, and these

are used to subdivide CRS patients into two

groups: CRS with NPs (CRSwNP) and CRS without NPs (CRSsNP).5,6

Pathophysiology

It is traditionally accepted that the presence of NPs is the end product of chronic inflamma-tion The exact mechanism for the develop-ment of NPs is poorly understood and most likely multifactorial.3 Proposed factors in NPs pathogenesis include but are not limited

to inflammatory mediators (eg, eosinophils,

cytokines), bacteria (eg, biofilms, coccus aureus enterotoxin), genetics, and even

Staphylo-alterations in intercellular junctions.7–10

Special mention should be noted for patients with cystic fibrosis (CF) who pre-sent with an incidence of NPs between 33 and 57%.11 In these patients, dysfunction of mucociliary clearance is believed to play a key role in the pathophysiology of NPs Cystic fibrosis patients represent a unique clinical phenotype for presentation of NPs and require special considerations in their management

Clinical Presentation

and Diagnosis

Symptoms

Patients with CRSwNP can present with an

array of complaints that include nasal

obstruc-tion and congesobstruc-tion, anterior rhinorrhea,

olfactory dysfunction ranging from hyposmia

to anosmia, hyponasal voice, and facial pain,

fullness or pressure.5,6 Symptoms are likely

to be described as bilateral in 80 to 90% of

patients.3 Patients with CRSwNP have

sig-nificant decrease in health-related quality of

life (HRQoL); however, multiple studies have

shown that these patients tend to have better

HRQoL scores than CRSsNP.12,13

Physical Examination and

Endoscopic Examination

A comprehensive physical examination should

be performed in every patient However, nasal

endoscopic examination remains the gold

standard for the diagnosis of NPs Hence, in

order to diagnose and manage these patients in the office setting, the clinician should have the capability to perform a detailed nasal endo-scopic examination Multiple endoscopic stag-ing systems have been proposed to quantify the severity of NPs (Table 11–1).14 Their clin-ical utility rests mostly in their use for prein-tervention and postintervention comparisons.Another important endoscopic finding

to document is the presence and severity of nasal septal deviations In patients undergoing endoscopic sinus surgery (ESS) in the operat-ing room, the rate of concurrent septoplasty for access has been reported to be around 34%.15 This is a key determination to make when considering if a patient might be a can-didate for office-based polypectomy since the presence of a significant nasal septal devia-tion may limit access for proper endonasal instrumentation

Finally, an added value to performing nasal endoscopy in the office is that it helps to gauge

if a patient is a candidate for awake endonasal instrumentation As highlighted in the patient selection chapter, one could infer that if the patient does not tolerate a diagnostic nasal endoscopy, he or she will not be a good candi-date for an office-based polypectomy procedure

Table 11–1. endoscopic Staging of Nasal polyposis

Lindholt Method36 Lund and Mackay Method37

0 = no polyposis

1 = mild polyposis (small polyps not

reaching the upper edge of the inferior

turbinate)

2 = moderate polyposis (medium sized

polyps reaching between the upper and

lower edges of the inferior turbinate)

3 = severe polyposis (large polyps

reaching below the lower edge of the

inferior turbinate)

0 = none

1 = polyps confined to middle meatus

2 = polyps beyond middle meatus

Office-Based Nasal Polypectomy 103

Imaging

Radiologic evaluation of patients with NPs

is paramount for determination of the extent

of disease and selection of surgical treatment

(office vs operating room)

Computed tomography (CT) is the gold

standard primary imaging test for evaluation

of NPs (Figure 11–1) CT is superior to other

imaging modalities to determine the sinonasal

bony anatomy, extent and localization of the

disease process, and identifying complications

such as sclerotic thickening of the bone or

cortical destruction.16 CT limitations include

inability to differentiate soft-tissue masses

from inspissated secretions in the sinuses, and

radiation exposure

Magnetic resonance (MR) is superior when

evaluating soft tissue pathology, and is used to

differentiate sinus inflammatory disease from

mass lesions, brain, and orbital structures.17

Differential Diagnoses

It is imperative that when evaluating a patient

for a possible office-based polypectomy that

the clinician keeps in mind other possible

pathologies that could mimic NPs, such as

inverted papilloma and

meningoencephalo-celes Failure to do so could result in

cata-strophic complications during the procedure

Treatment

Medical Treatment

It is not within the scope of this chapter to go

into great detail about the medical

manage-ment of NPs However, medical managemanage-ment

does play an important role in the treatment

of patients with NPs A detailed review on

the current evidence and recommendations for medical management of CRSwNPs can

be found in the European position paper on Rhinosinusitis and Nasal Polyps 2012 (EPOS 2012).5 Mild to moderate polyps can be managed medically, but cure is not frequent Extensive nasal polyps are rarely treated with medical therapy alone, requiring surgical removal to reduce the mucosal inflamma-tory load and allow easier deposition of topi-cal medications into the sinus cavities Once nasal polyps have been removed surgically, the medical management of the underlying mucosal inflammatory disease is then of the utmost importance

Surgical Treatment

When the myriad of options for medical management fail, surgical resection has been proven to be effective.18–20 It is estimated that

at least 50% of patients with nasal polyps require procedural intervention, with multiple revisions being common.21

Figure 11–1. Ct scan of a candidate for office-based polypectomy Notice wide ethmoid cavity filled with soft tissues density and no bony partitions

Documentation of polyp removal by

snare methods dates to the era of Hippocrates,

but may result in painful removal of normal,

healthy mucosa.22 With the development of

current anesthetic techniques, as well as the

evolution of ESS, treatment of CRSwNP in

the operating room setting has become

stan-dard However, with the advent of specialized

instruments such as powered

microdebrid-ers, office-based polypectomy is now a viable

option for selected patients

Office-Based Polypectomy

Patient Selection

Appropriate patient selection is the first step

in any surgical procedure, but is especially

important in the awake patient This has

been discussed in a previous chapter Office

polypectomy can be utilized in several

situa-tions In the patient who has not undergone

previous sinus surgery, the indications are

lim-ited to isolated anterior polyps in the middle meatus or isolated polypoid degeneration of the middle turbinate (Figure 11–2) These are areas that can be readily accessed if there is not a significant septal deviation More poste-rior polypoid disease is much more difficult to access in the office in the unoperated patient.The most common application of office polypectomy is in the patient who has under-gone a thorough previous surgery, or multiple surgeries, for polyps and has recurrent disease that is not adequately controlled with medical management This patient has had the ostia of the maxillary and/or sphenoid sinuses opened

up and the ethmoid septations removed, so that all that needs to be addressed is the recur-rent polyps with no bony obstructions The senior author will only perform complete office polypectomy on those patients that he has previously operated upon and is assured that the sinuses have been adequately opened,

or on patients that have a CT scan strating that the disease is purely mucosal with

demon-no obstructing bone, such as in Figure 11–1 The goal of the procedure is to be as complete

Figure 11–2. A endoscopic view of nasal polyps arising from the left middle turbinate

B post-procedure view of the left middle meatus after middle turbinate polypectomy.

Office-Based Nasal Polypectomy 105

as possible with the polyp removal to give

sub-sequent medical management the best chance

to control the mucosal inflammatory process

Instrumentation

Endoscopes

The rigid endoscopes available to perform the

procedure should at least include a 0° rigid

endoscope This gives the best visualization

for the ethmoid and sphenoid sinuses A 30°

endoscope can be useful when addressing

pol-yps in the maxillary ostium and frontal recess

and frontal sinus Another consideration is the

availability of pediatric size endoscopes These

are especially helpful when the endonasal space

might be limited for instrumentation

Microdebriders

Microdebriders were initially adapted from

arthroscopy for use in the nasal cavity.23 The

sharp shearing of polyploid tissue grasped

by the device’s suction results in

consider-able decrease in both operative and healing

times when compared to conventional

instru-ments.24,25 Despite evidence of equivalent

complication rates and successful use in awake

patients, concerns about obtaining adequate

hemostasis in the office setting has limited its

use by many surgeons25–28 (see Video 11–1)

Coblation

Coblation is a recently developed

electrosurgi-cal technology that uses radiofrequency waves

to excite electrons in a conductive medium

The energized electrons then disrupt

molecu-lar bonds in the surrounding tissue, leading to

dissolution with minimal blood loss Several

studies have shown coblation instruments to

be safe and effective for tonsillectomy, with

the suggestion that it may cause less

postop-erative pain than electrocautery.29–31 nary evaluation of coblation instrumentation

Prelimi-in endoscopic sPrelimi-inus surgery has shown ising results for improved mucosal healing time in a rabbit model and decreased blood loss in human subjects when compared to the microdebrider32,33 (see Video 11–2)

prom-Informed Consent

As with any surgical procedure, adequate informed consent should be obtained from the patient prior to undergoing an awake pro-cedure A detailed discussion of the alternative treatments should be performed, including continued medical treatment and surgical treatment in the operating room All possible complications should be discussed, including but not limited to bleeding, infection, scar-ring, orbital injury with double vision or vision loss, cerebrospinal fluid leak, recurrence of NPs, and need for further surgery All patient questions and concerns should be answered The informed consent process should ideally

be documented both in the encounter note as well as the procedure note

Anesthesia

Office rhinologic surgeries are performed under topical and/or local anesthesia by the senior author No sedation is administered The administration of topical anesthetic and decongestant spray should be performed as a first step prior to any office endonasal instru-mentation In the author’s practice neosyn-ephrine and pontocaine spray is used, but oxymetazoline can be used also Following appropriate topical anesthesia and deconges-tion, injection of 1% lidocaine with 1:100,000 epinephrine is performed under endoscopic visualization As the procedure progresses, and the dissection proceeds further into the

sinus cavities, additional topical and/or local

anesthetic can be administered More

anes-thetic techniques are outlined in Chapter 6

Surgical Technique

The goal of office-based polypectomy should be

maximum removal of polyps (see Figures 11–2A

and 11–2B) The surgical technique is no

dif-ferent than in the operating room, with the

exception of the anesthetic and patient

posi-tion The senior author prefers the patient to

be sitting upright in the exam chair Topical

and local anesthetic is administered as

men-tioned above For isolated polyps of the middle

meatus or leading edge of the middle

turbi-nate, through cutting instruments can be used

to remove the localized polyps (Figures 11–3A

and 11–3B) For more extensive polyps in

previously operated sinuses the senior author

prefers to use the microdebrider Straight

and curved (40-degree) blades can be used,

depending on the sinuses addressed The

pro-cedure begins with removal of the most

acces-sible polyps in the nasal cavity and ethmoid

sinuses Polyps are removed from anterior

to posterior, and inferior to superior, just as

in the operating room Time is taken to anesthetize the sinus cavities as necessary to minimize patient discomfort This allows good visualization and maximal removal of polyps Bleeding is usually minimal, and can

re-be controlled with intermittent application of topical decongestant on cotton patties Polyp removal can proceed posterior to the sphenoid ostium and laterally to the maxillary ostium The frontal recess can be addressed with a 40-degree blade Care should be used in the frontal recess to not cause circumferential scarring Packing is not required and has not been used by the authors

Postoperative care is the same as with any other endoscopic surgery Saline irrigations are initiated the day of the procedure and con-tinued until complete healing has occurred Topical steroid preparations are begun shortly after surgery, depending on the severity of pol-yps Long-term follow-up and medical man-agement is essential to maximize outcome