Chapter
Some Psychological Aspects of Nasal Symptoms
Optimize Medical Treatment
Tailor the Surgery to Fit the Extent of the Problem
Minimize Surgical Morbidity
How Can This Be Achieved?
Sense of Smell Should Be Preserved at All Costs
The Importance of Postoperative Treatment
2 Pathophysiology of Rhinosinusitis
Limited Evidence Associated with Anatomical Factors
Comments on Specific Conditions
A Note on the Term “Nasal Polyposis”
Chronic Rhinosinusitis Without Nasal Polyps
3 Who? Optimizing Diagnosis and Selection of Patients for Surgery
Symptom-oriented Patient Selection
Which are the Cardinal Symptoms? What Criteria in the History are Best to Focus on?
History—Interpreting Nasal Symptoms
Catarrh and Postnasal Drip
Total or Specific Immunoglobulin E Tests
Ciliary Motility/Structural Studies
Sweat Sodium Concentration
Who Will Most Likely Benefit from Surgery? .
Disease-oriented Patient Selection
Chronic Infective Rhinosinusitis
Aspergillosis/Fungal Disease
Mycetoma/Saprophytic Fungal Disease
Chronic Invasive Fungal Sinusitis
Maxillary Sinusitis Secondary to Dental Disease
Unilateral Nasal Polyps Associated with Neoplasia
Benign and Malignant Tumors
Endoscopic Sinus Surgery in Children
Who Not to Select for Surgery
4 When? Medical Treatment and Timing of Surgery
Optimizing Medical Treatment Before Surgery
The Management of Chronic Rhinosinusitis with Polyposis
The Management of Chronic Rhinosinusitis without Polyposis
The Management of Infective Rhinosinusitis
The Management of Fungal Rhinosinusitis
Optimizing the Timing of Surgery
5 Preserving and Improving the Sense of Smell
Why Should We Focus on the Sense of Smell?
Surgical Strategy to Preserve and Improve Olfaction
Concept of the “Controlled Moderate Lateralization of the Middle Turbinate”
How to Prevent Loss of Olfaction
6 Why? The Goals of Surgery
Why Surgery Can Help the Diseased Mucosa
Rationale and Goals of Surgery in Specific Conditions
Distal Nasolacrimal Duct Obstruction
Repair of Dural and Skull Base Defects
Decompression of the Orbit
Decompression of the Optic Nerve
Penetrating Injuries of the Skull Base
7 Applied Anatomy for Endoscopic Sinus and Skull Base Surgery
8 How? Operative Procedures: A Step-by-Step Safe and Logical Approach
Infundibulotomy (Uncinectomy) ± Maxillary Sinusotomy (I, II, III)
Terminology and Classification
Indications for Infundibulotomy and Maxillary Sinusotomy
Alternative Surgical Techniques
Endoscopic Transnasal Anterior Approach to the Maxillary Sinus Ostium
Partial Anterior Ethmoidectomy
Terminology and Classification
Alternative Surgical Techniques
Frontoethmoidectomy ± Frontal Sinusotomy (I, II, III)
Terminology and Classfication
Alternative Surgical Techniques
Sphenoethmoidectomy ± Sphenoidal Sinusotomy (I, II, III)
Terminology and Classfication
Alternative Surgical Techniques
Frontosphenoethmoidectomy ± Frontal Sinusotomy (I, II, III) ± Maxillary Sinusotomy (I, II, III) ± Sphenoidal Sinusotomy (I, II, III)
Terminology and Classification
Sphenoidal Sinusotomy (I, II, III)
Terminology and Classification
A Comment on the Management of the Middle and Superior Turbinates
Alternative Surgical Techniques
A Comment on the Management of the Inferior Turbinate
9 An Endoscopic Tour: Endoscopic Examination, Anatomical Variations, and Specific Conditions
Endoscopic Evidence of Mucosal Disease
A Paradoxical Middle Turbinate
A Polypoid Anterior End of the Middle Turbinate
A Paradoxical Uncinate Process
Pneumatized Uncinate Process
Accessory Ostia of the Maxillary Sinus Posterior to the Uncinate Process
Defect in the Uncinate Process
An Atlas of Specific Conditions To Help Recognize Variations in Anatomy and Different Pathologic Conditions
10 The Place of Radiology
Cross-sectional CT and Cone-beam CT
The Role of Computed Tomography
When to Request CT in the Management of Rhinosinusitis
When Should MRI be Requested?
Magnetic Resonance Angiography
Digital Subtraction Angiography and Embolization
Interdisciplinary Cooperation
11 Preoperative Checklist
Reviewing the Effect of Maximum Medical Treatment Helps in Determining Prognosis
Optimize the Immediate Preoperative Condition
Check That Relevant Investigations Have Been Done
Review the Relevant Medical History
Preoperative CT Checklist
Planning and Staging the Procedure
Review Medication That May Affect Anesthesia or Surgery
12 Patient Consent and Information
How to Communicate the Benefits and Risks of Surgery to the Patient
Time Off Work and Advice About Flying
Specific Surgical Complications
Shortfall in Doctor–Patient Communication
Psychology and the Surgeon
Position of the Anesthesiologist
Curved Olive-ended Suckers
Through-cutting Instruments (Rhinoforce Blakesley/Mackay–Grunewald Forceps)
Rhinoforce Stammberger Antrum Punch (“Back-biters”)
Hajek–Kofler Punch and Kerrison Punches
Stammberger Cutting Mushroom Punch
Belluci and Zurich Microscissors
Stammberger Side-biting Punch Forceps
Heuwieser Antrum Grasping Forceps
Giraffe Forceps (Kuhn–Bolger)
Frontal Sinus Punch: Curved Modified Hajek Punches for the Frontal Sinus (Bachert, Hosemann)
Computer-aided Surgery—Navigation Technology
Positioning of the Patient, Surgeon, and Equipment
Real-time Computer-aided Surgery
Before Starting the Operation
Objectives of the Operation
15 Preventing and Dealing with Complications
Peroperative Complications
Fat Herniation and Violation of the Orbit
Postoperative Complications
16 Postoperative Management
Outpatient Visit at One Week
17 Extended Endoscopic Procedures
Dacryocystorhinostomy and Surgery of the Nasolacrimal System
Terminology and Classification
Principles of Surgical Technique in DCR
Alternative Surgical Techniques
The Treatment of Common Canalicular Pathology
Management of the Sphenopalatine Artery
Terminology and Classification
Alternative Surgical Techniques
Management of the Anterior Ethmoidal Artery
Terminology and Classification
Alternative Surgical Techniques
Median Frontal Sinus Drainage Procedure
Terminology and Classification
Alternative Surgical Techniques
Terminology and Classification
Optic Nerve Decompression
Terminology and Classification
Terminology and Classification
Alternative Surgical Techniques
Terminology and Classification
Management of Cerebrospinal Fluid Leaks
Terminology and Classification
Modifications and Alternatives
Management of Encephaloceles
Terminology and Classification
Alternative Surgical Techniques
Langerhans Cell Histiocytosis
Other Benign Pathological Lesions
Lesions of the Cribriform Plate and Fovea Ethmoidalis
Ethmoidal Complex, Lateral Nasal Wall, and Orbit
Sphenoidal Sinus, Clivus, and Cavernous Sinus
Endoscopic Resection of Malignant Anterior Skull Base Tumors
Combined Craniofacial and Endoscopic Resection
Recurrent or Residual Malignant Disease
Preoperative Embolization
Juvenile Nasopharyngeal Angiofibroma
Postfunctional Endoscopic Sinus Surgery
Complications of Embolization
18 The Endoscopically Assisted Bimanual Operating Technique
From Basic Endoscopic Sinus Surgery to More Extended and Advanced Skull Base Surgery
Advantages of the Endoscopically Assisted Bimanual Operating Technique
Operating with Both Hands
Suction Tip Stays in the Operative Field: Fewer Instrument Changes
Theater Setup and Technical Aspects
Ergonomic Handling of the Endoscope
Stabilizing the Endoscope in the Nasal Vestibule
Retraction of Structures and Tissue
Modifications of the Standard “One-nostril Approach”
19 Transnasal Endoscopic Approaches to the Skull Base
Transnasal Surgical Approaches to the Skull Base
Transseptal/Transnasal (Bi-nostril Approach) for the Sphenoidal Sinus
Transmaxillary/Transpterygoid/Infratemporal
Approaches to the Cavernous Sinus
20 Interdisciplinary Teamwork in Transnasal Endoscopic Skull Base Surgery
Operating Theater and Patient Preparation
The Role of Navigation and Intraoperative Imaging
Rhino-/Neurosurgical Instrumentation
Surgical Technique—General Hints
21 Transnasal Endoscopic Surgery of Pituitary Tumors
Planning for Pituitary Surgery
Transnasal Approaches to the Pituitary Gland
Removal of Pituitary Tumors—General Hints
Sella Reconstruction and Closure
22 Transorbital Surgery of the Skull Base
Important Incisions and Approaches
Medial Orbit: Precaruncular
Inferior Orbit: Lower Lid Preseptal Transconjunctival
Lateral Orbit: Lateral Retrocanthal
Superior Orbit: Superior Lid Crease/Blepharoplasty
Repair of Cerebrospinal Fluid Leak
Access to the Frontal Sinus
Orbital and Optic Nerve Decompression
Useful Equipment and Setup
23 Evidence Base in Rhinosinusitis and Endoscopic Sinus Surgery
Chronic Bacterial Rhinosinusitis
Chronic Rhinosinusitis Without Nasal Polyposis
Chronic Rhinosinusitis with Nasal Polyposis
The Effect of Type I Hypersensitivity or IgEmediated Disease
Ciliary Dyskinesia and Immunodeficiencies
Recalcitrant Chronic Rhinosinusitis
Allergic and Nonallergic Rhinitis
Appendix: Information for Patients Undergoing Endoscopic Sinus Surgery
What is Endoscopic Sinus Surgery?
What Can I Expect When I Have This Operation?
What Complications Can Occur?
Pharyngeal/Laryngeal Hypersensitivity
Regimen to Break the Cycle
Conditions Associated with Nasal Polyps
Unilateral (One-sided) Polyps
Advice for Patients after Endoscopic Surgery for Nasal Polyps
The Complications of Endoscopic Surgery for Nasal Polyps
“Telephone Consultations”
Manual of Endoscopic Sinus and Skull Base Surgery
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