Foreword
Preface
Contents
Contributors
Section I: The Basic Science of Rhinology: Understanding the Nose and Sinuses
1: Embryology of the Nose and Paranasal Sinuses
Nose Development
Turbinate Development
Paranasal Sinus Development
Maxillary Sinus
Ethmoid Sinus
Frontal Sinus
Sphenoid Sinus
Nasolacrimal Duct Development
Sinonasal Vasculature Development
Areas of Uncertainty and Controversy
References
2: Applied Anatomy of the Nose and Sinuses
The Nose
Introduction
External Structure
The Nasal Septum
The Inferior Turbinate
Sinonasal Mucosa
Olfaction
The Paranasal Sinuses
Introduction
Osteology
The Maxillary Sinus
The Ethmoid Sinuses
The Sphenoid Sinus
The Frontal Sinus
The Agger Nasi
Frontal Cells and Classification
Type 1 Cell
Type 2 Cell
Type 3 Cell
Type 4 Cell
Suprabullar Cell
Frontal Bullar Cell
Medial Intraseptal Cell
The Palatine Bone
The Nasolacrimal Apparatus
The Blood Vessels of the Nose
Internal Carotid Artery System
External Carotid Artery System
The Nerves of the Nose and Sinuses
External Nose
Internal Nose
Sinuses
Autonomic Nerve Supply to the Nose
Key Concepts
The Internal Valve
Septum Attachment Points
The Middle Turbinate
The Ostiomeatal Complex
The Surgical Lamellae
Pterygopalatine Fossa
Infratemporal Fossa
Further Reading
3: Physiology: Nasal Airflow
Introduction
Nasal Breathing, Airflow Distribution, and Physiology
Ventilation of Paranasal Sinuses and Physiology
The Nasal Cycle
Effects of Physical Activity on Nasal Airflow
Effects of Temperature and Air Humidity on Nasal Respiratory Function
Effects of Posture on Nasal Airflow
Nasal Nitric Oxide
Conclusions
References
4: Physiology of the Nose and Paranasal Sinuses: Mucociliary Clearance
Introduction
Mucus
Cilia
Assessment of Ciliary Ultrastructure and Ciliary Beat Function
Nasal Mucociliary Clearance Testing
Saccharin Test
Scintigraphy with Technetium-99
Examples of Compromised MCC
Primary Ciliary Dyskinesia
Cystic Fibrosis (CF)
Secondary Ciliary Dyskinesia
Smoking
Drugs
Gastroesophageal Reflux Disease (GERD)
Type 2 Inflammation
Improving Mucociliary Clearance (MCC)
Nasal Irrigation with Saline
Drugs
Endoscopic Sinus Surgery (ESS)
References
5: Immunology of the Nose and Paranasal Sinuses
Allergy and Specific IgE
Allergic Rhinitis
Specific IgE
Chronic Rhinosinusitis
Allergic Fungal Rhinosinusitis
Aspirin-Exacerbated Respiratory Disease (AERD) / N-ERD / Samter’s Triad
Autoimmune Sinonasal Conditions
Granulomatosis with Polyangiitis
Eosinophilic Granulomatosis with Polyangiitis
Sarcoidosis
Immunodeficiencies and Sinonasal Conditions
Chronic Rhinosinusitis (CRS) and Secondary Immune Deficiencies
Chronic Rhinosinusitis (CRS) and Secondary Fungal Sinusitis
Conclusion
References
6: Allergy and the Nose
Introduction
Allergy: Terminology
Types of Allergic Reaction
Type I
Type II
Type III
Type IV
Allergy, Intolerance and Hypersensitivity
Allergens
The Concept of the ‘United Airways’
Differences Between the Nose and the Bronchi
Allergy in the Nose
Allergic Rhinitis
Entopy or Local Allergic Rhinitis (LAR)
Classification of Allergic Rhinitis
Immunological Aspects of Allergy
Mast Cell Activity
Granulocyte Activity
End-Organ Responses
Remodelling
Clinical Assessment for Suspected Allergy
Medical History (Anamneses)
Nasal Endoscopy
Spirometry
Allergy Testing
Skin Prick Testing
Specific IgE (sIgE) Testing
Commercial Allergy Tests (Outside of Hospital Practice)
Other Aspects of Allergic Rhinitis in Clinical Practice
Children with Allergic Rhinitis
Food Allergy, Sensitivity and Intolerance
Alcoholic Drinks and the Nose
The Principles of Management
References
7: Genetics and Disorders of the Nose and Sinuses
Introduction
Genetic Testing
General Sample Information
Karyotype
Microarray
Single Gene Testing
Gene Panels
Whole Exome/Genome Sequencing
Ethics of Genetic Testing
Variant Interpretation
Inheritance Patterns
Autosomal Dominant
Autosomal Recessive
X-Linked (Dominant and Recessive)
Mitochondrial
Genetic Diagnoses to Consider
General Approach
Epistaxis
Anosmia
Nasal Polyps and Tumours
Recurrent Infections
Cystic Fibrosis
Primary Ciliary Dyskinesia
Immunodeficiency
Structural Anomalies of the Nose
Genetics of Common Diseases
References
Further Reading
8: The Current Concepts of Biofilms and Superantigens
Bacterial Biofilms: Definition
Biofilms: The Preferred Microbial Lifestyle
Bacterial Species Involved in Biofilms
The Establishment, Life Cycle, and Structure of Biofilms
The EPS Matrix: Not Just Slime
Spatial Patterns of Protein and DNA Synthesis in Biofilms
Biofilms Show Chemical and Physiological Heterogeneity
Role of Bacterial Biofilms in the Pathophysiology of Chronic Rhinosinusitis
Differences Between Planktonic Cells and Biofilms
Bacterial Biofilms as Immune Evasion Strategy
Bacterial Biofilms Show Reduced Susceptibility to Antibiotics
Superantigens
The Role of Superantigens in the Etiopathogenesis of CRS
References
9: Bacteria, Viruses and Fungi in Healthy and Diseased Paranasal Sinuses
Introduction
Bacteria, Viruses and Fungi in Healthy Paranasal Sinuses
Bacteria, Viruses and Fungi in Diseased Paranasal Sinuses
Acute Rhinosinusitis
Chronic Rhinosinusitis
Single Pathogen Hypotheses
Biofilms
Microbial Dysbiosis
Fungi
Viruses
Acute Exacerbation of Chronic Rhinosinusitis (AECRS)
Odontogenic Sinusitis
Fungal Rhinosinusitis
Cystic Fibrosis
Primary Ciliary Dyskinesia
Technology
Culture
Immunohistochemistry
Fluorescence In Situ Hybridisation
Amplicon Sequencing
Summary of Areas of Controversy or Uncertainty
References
Key References
10: Sleep Disorders and the Nose: What Is the Evidence Base?
Introduction
Pathophysiology
Nasal Breathing During the Awake State
Nasal Breathing During Sleep
How Can Nasal Obstruction Promote Upper Airway Collapse?
Starling Resistor
Increase in Oral Breathing
Loss of Nasal Reflexes
Nitric Oxide (Nitrogen Monoxide: NO)
Clinical Results
Effects of Conservative Treatment
Medication
Anti-allergic Treatments
Nasal Dilators
Results of Surgical Intervention
Nasal Surgery for OSA
Nasal Surgery and PAP
Nasal Surgery and Simple Snoring
Conclusion
References
11: The Nose and the Effects of SARS-CoV-2 Pandemic
Introduction
Evidence from Coronavirus and SARS-CoV-1 (Before the Pandemic)
The Emergence of SARS-CoV-2
Pathophysiology in SARS-CoV-2
Viral Affinity for the Nose
Neuroinvasion
Olfactory Epithelium
Parosmia
SARS-CoV-2 and Taste
Clinical Applications
Conclusion
References
Section II: The Assessment of the Nose and Sinuses
12: Clinical Assessment of the Nose and Olfaction
Clinical History
Presenting Complaint
Nasal Obstruction
Epistaxis
Rhinorrhoea
Facial Pain
Olfactory Dysfunction
Triggering Factors
Past Medical History
Social History
Smoking
Alcohol
Medication
Intranasal Drugs
Clinical Examination
External Nasal Examination
Aesthetics of the Nose and Face
Palpation of the Nose
Nasal Airflow
Internal Examination
Anterior Rhinoscopy
Intranasal Endoscopy
Investigations
Targeted Assessments [1]
Allergy Testing and Endotyping
Skin Prick Testing
Serological Tests
Nasal Allergen Challenges [6]
Markers of Type 2 Endotype
Vasculitic Screen
Olfaction
Microbiology
Nasal Patency
Biopsy
Urinalysis
Areas of Controversy or Uncertainty
References
13: Outcome Metrics and Measurement Tools for Rhinological Treatment Modalities
Introduction
Subjective Outcome Measures
Patient Reported Outcome Measures (PROMs)
Disease-Specific PROMs
22-Item Sinonasal Outcome Test (SNOT-22)
Nasal Obstruction Symptom Evaluation (NOSE) Scale
Skull Base Surgery
Other Disease-Specific PROMs
Generic Health-Related PROMs
Short Form-36 (SF-36)
EQ-5D
Objective Outcome Measures
Olfactory Testing
Olfactory Identification
Olfactory Threshold Testing
Olfactory Discrimination
Measurement of Nasal Airflow
Peak Nasal Inspiratory Flow (PNIF)
Rhinomanometry
Acoustic Rhinometry
Rhinospirometry
Computational Fluid Dynamics
Nasal Nitric Oxide
Summary of Areas of Controversy and Uncertainty
References
14: Radiological Imaging in Rhinology
Introduction
Clinically Applied Imaging Anatomy
Key Anatomic Findings and Normal Variants
Basic Anatomy of the Nasal Cavity
The Anterior Paranasal Sinus Drainage Pathway: Maxillary Sinus and Osteomeatal Complex
The Anterior Paranasal Sinus Drainage Pathway: Frontal Sinus, Frontal Sinus Drainage Pathway (FSDP) and Anterior Ethmoid Cells
The Anterior Skull Base
The Posterior Sinus Drainage Pathway: Sphenoid Sinus and Posterior Ethmoid Cells
Structures Outside the Sinonasal Cavity
Pre-operative CT Report
Radiological Imaging Techniques in the Nose and Sinuses
Multidetector CT (MDCT)
Cone Beam CT (CBCT)
Magnetic Resonance Imaging (MRI)
Other Imaging Modalities
Future Developments in Rhinology Imaging
Evolution of Image-Guided Surgery (IGS) and Intra-operative Imaging
Emerging Applications of Artificial Intelligence (AI)
References
Section III: Paediatric Sinonasal Disorders
15: Congenital Sinonasal Disorders
Introduction
Embryology of the Nose and Midface
Choanal Atresia
Clinical Presentation
Immediate Management
Investigations
Surgical Management
Neonatal Rhinitis
Pyriform Aperture Stenosis
Clinical Presentation
Management
Congenital Nasal Masses
Intracranial Masses in the Nasal Cavities
Nasal Cysts
Haemangiomas and Vascular Malformations
Classification
Clinical Presentation
Treatment
Vascular Malformations (VMs)
The Nasal Septum
Nasal Problems in Craniofacial Deformities
Cleft Lip and Palate
References
16: Paediatric Rhinosinusitis
Background
Development of the Paranasal Sinuses
Acute Rhinosinusitis (ARS) in Children
Definition
Aetiology
Microbiology of ARS
Diagnosis of ARS in Children
Management of ARS in Children
Recurrent Acute Rhinosinusitis (RARS) in Children
Chronic Rhinosinusitis in Children
Definition of Chronic Rhinosinusitis in Children
Prevalence of CRS
Predisposing Factors Associated with CRS in Children
Significant Effect
Adenoid Biofilms and Bacterial Reservoir
Immune Deficiency
Inflammatory Mechanisms in Paediatric CRS
Moderate Effect
Age
Atopy–Allergic Rhinitis–Asthma
Low Effect
Ethnic and Socioeconomic Factors
Passive/Active Smoking
Genetics
No Proven Effect
Nose and Paranasal Sinus Anatomy
Viral Infection in Children
Gastroesophageal Reflux Disease
Rare Genetic Disease in Children
Cystic Fibrosis (CF)
Primary Ciliary Dyskinesia (PCD)/Ciliopathy
Diagnosis of CRS in Children
History
Examination
Patient (Carer) Reported Outcome Measures (PROMs)
Allergy Testing
Smell Assessment
Upper Airways Physiological Tests
Miscellaneous Specialist Diagnostic Testing
Assessments of Ciliary Function
Immunological Tests
Miscellaneous
Imaging
Management of Paediatric CRS
Nasal Saline Rinses
Medical Therapy
Antibiotics
Intranasal Steroids
Systemic Steroids
Adjunctive Therapies for Paediatric CRS
Biologics in Paediatric CRS
Surgery
Complications of Rhinosinusitis in Children
Intracranial
Meningitis
Intracranial Abscesses
Extracranial
Periorbital Infections
Frontal Bone Osteomyelitis
Mucoceles
Conclusions
Controversies
References
Further Reading
17: Paediatric Nasal Masses
Introduction
Imaging in Paediatric Nasal Masses
Congenital Lesions
Dermoids
Hairy Polyp
Non-neoplastic Lesions
Pyogenic Granuloma
Haemangioma
Tornwaldt Cysts
Dentigerous Cysts
Benign Neoplastic Lesions
Juvenile Angiofibroma (Link to Juvenile Angiofibroma Chap. 33)
Teratoma
Fibrous Dysplasia
Juvenile Ossifying Fibroma
Malignant Neoplastic Lesions
Rhabdomyosarcoma
Olfactory Neuroblastoma
Nasopharyngeal Carcinoma
Lymphoma
References
18: Paediatric Nasal Deformity
Introduction
Nasal Embryology
Nasal Development Through Childhood
Development of the Nasal Septum
Development of the Nasal Dorsum
Development of the Nasal Tip
Nasal Growth Phase
Congenital Nasal Anomalies
Type I Anomalies: Hypoplasia and Atrophy
Hemi-nose
Arhinia
Hypoplasia or Absence of Parts
Craniofacial Syndromes
Nasal Cavity Atresia
Case Presentation 1
Type 2 Anomalies: Hyperplasia and Duplications
Assessment of Nasal Deformity
Nasal Trauma in Children
Septoplasty
Septal Perforation
Nasal Fracture
Rhinoplasty
Case Presentation 2
Conclusion
References
Section IV: Inflammatory Sinus Disorders
19: Non-allergic Rhinitis
Introduction
Assessment
Patient History
Clinical Examination
Special Investigations
Pathophysiology
Occupational/Irritant/Smoking-Induced Rhinitis
Drug-Induced Rhinitis
Hormonal Rhinitis
Rhinitis of the Elderly
Gustatory Rhinitis
Idiopathic Rhinitis
Therapeutic Options
Nasal Douching
Avoidance of the Causative Triggers
Corticosteroids
Ipratropium Bromide
Antihistamines
Capsaicin
Surgery
Areas of Uncertainty
References
Further Reading
20: Allergic Rhinitis
Pathophysiology
Epidemiology of AR
AR and Asthma
Clinical Presentation: Symptoms and Quality of Life
Diagnostic Tests
Differential Diagnoses
Treatment of AR (Including Immunotherapy)
Avoidance
Symptomatic Treatment
Antihistamines
Leukotriene Receptor Antagonists (LTRA)
Sodium Cromoglicate
Intranasal Glucocorticosteroids
Ipratropium
Monoclonal Antibodies
Surgery
Modification of the Disease Process
Immunotherapy
Children with AR
Areas of Controversy or Uncertainty
References
21: Current Scientific Understanding of Rhinosinusitis
Introduction
Principle I: Acute and Chronic Rhinosinusitis are Distinct Disease Entities
Acute Rhinosinusitis
Chronic Rhinosinusitis
Principle II: CRS Is a Multifactorial Disease
Host Factors
Genetics
Immunity
Environmental Factors
Bacteria
Viruses
Fungi
Pollution/Occupational Exposure
Smoking
Tissue Remodelling
Clinical Application
Principle III: CRS Is an Umbrella Term Requiring Classification
The Presence or Absence of Nasal Polyps in CRS
The New Classification of Chronic Rhinosinusitis
Primary Versus Secondary, Localized Versus Diffuse CRS
Principle IV: The Inflammatory Endotype in Primary Diffuse CRS Determines Treatment and Outcomes
Clinical Determination of Endotypes in Primary Diffuse CRS
Conclusion
Short Summary of Areas of Controversy or Uncertainty
References
22: New Innovations and Treatments for Chronic Rhinosinusitis
Primary Chronic Rhinosinusitis
Primary Localized Non-type 2 Chronic Rhinosinusitis
Primary Localized Type 2 Chronic Rhinosinusitis
Primary Diffuse Chronic Rhinosinusitis
Primary Diffuse Non-type 2 Chronic Rhinosinusitis
Xylitol
Primary Diffuse Type 2 Chronic Rhinosinusitis
Aspirin Treatment After Desensitization (ATAD)
Drug-Eluting Stents and Exhalation Delivery Systems
Exhalation Delivery Systems (EDS)
Drug-Eluting Stents
Biologicals
Indication for a Biologic
Choosing the Correct Biologic
Real-Life Experience with Biologicals
Secondary Chronic Rhinosinusitis
Localized Secondary Chronic Rhinosinusitis
Diffuse Bilateral Secondary Chronic Rhinosinusitis
Diffuse Bilateral Secondary Chronic Rhinosinusitis Due to Mechanical Reasons
Diffuse Bilateral Secondary Chronic Rhinosinusitis Due to Inflammatory Reasons
Diffuse Bilateral Secondary Chronic Rhinosinusitis Due to Immunological Reasons
Summary of Areas of Controversy or Uncertainty
References
23: Clinical Assessment and Management of Acute Rhinosinusitis
Introduction
Definitions
Epidemiology and Economic Impact
Aetiology and Pathogenesis
Cytokine Storm Syndromes
Clinical Presentation and Assessment
Background
History
Predisposing Conditions
Examination
Diagnosis
Differential Diagnosis
Complications
Investigations
Swabs
Bloods Tests
Imaging
Treatment
Viral ARS
Post-viral ARS
ABRS
Recurrent ARS
References
Papers that May Be of Interest
24: Clinical Assessment and Management of CRSsNP
Introduction
Differences Between CRSsNP and CRSwNP
Patient History
Nasal Endoscopy
Endotyping/Additional Investigations
Medical Management of CRSsNP
Appropriate Medical Therapy
Local/Intranasal
Rinsing
Intranasal Corticosteroid (INCS)
Xylitol
Systemic
Antibiotics, Including Long-Term Antibiotics/Macrolides
Oral Corticosteroids
Surgical Management of CRSsNP
Treatable Traits
Important Differential Diagnostic Considerations in CRSsNP
Secondary CRS
The Patient with Headache
Short Summary of Areas of Controversy or Uncertainty
References
25: Clinical Assessment and Management of Chronic Rhinosinusitis with Nasal Polyposis
Introduction
Risk Factors and Comorbidities
Diagnosis and Assessment
Routine Investigations
Imaging
Supplementary Investigations
Assessment of Comorbidities and Subgroups of CRSwNP
Central Compartment Allergic Disease
Allergic Fungal Rhinosinusitis
Asthma
NSAID-Exacerbated Respiratory Disease
Immunodeficiency and Mucociliary Dysfunction
Treatment of CRSwNP
Medical Management
Intranasal Treatments
Systemic Therapy
Glucocorticoids
Antibiotics
Anti-leukotrienes
Biological Therapy in CRSwNP
Surgery for CRSwNP
Post-operative Care
Controversies: Current Pathways and Position of Novel Treatments
References
Further Reading
26: Primary Atrophic Rhinitis
Introduction
Aetiology
Diagnosis
Symptoms
Signs
Blood Investigations
Mucociliary Clearance
Imaging
Management
Medical
Surgical
Reduction in Size of Nasal Cavity
Regeneration of Nasal Tissue
Conclusion
References
27: Fungal Sinus Disease
Introduction
Diagnosing Fungal (Mycotic) Infections
Mycotic Infection
How Do Fungi Cause Disease?
Pathogenesis of Inflammation from Fungal Disease
Prevention and Prophylaxis of Fungal Infection
Risk Factors
Prevention
The Environment
Prophylactic Antifungal Medications
Fungal Balls (Mycetomas)
Pathogenesis
Clinical Features
Radiological Imaging
Management
Allergic Fungal Rhinosinusitis (AFRS) or Eosinophilic Fungal Rhinosinusitis
Pathogenesis
Clinical Features
Radiological Imaging
Management
Chronic Invasive Fungal Rhinosinusitis
Pathogenesis
Clinical Features
Radiological Imaging
Management
Invasive Fungal Rhinosinusitis in the Acquired Immunodeficiency Syndrome (AIDS)
Acute Invasive Fungal Rhinosinusitis
Aspergillosis
Pathogenesis
Clinical Features
Radiological Imaging
Management
Mucormycosis
Pathogenesis
Histological Investigations
Clinical Features
Radiological Imaging
Management
References
28: Frontal Sinusitis
Introduction
Definition and Concepts
Acute Frontal Sinusitis
Chronic Frontal Sinusitis
Primary and Secondary CRS
Localised or Diffuse
Endotype Dominance
Anatomy
Surgical Technique
Draf I
Draf IIa, b, c
Draf III or the Modified Endoscopic Lothrop
Frontal Mini-Trephine for Culture
The Management of the Frontal Sinus by Sinusitis Disease Phenotype
Acute Frontal Sinusitis
Frontal Sinus Involvement in CRS
Primary-Localised CRS
Localised Type 2 Dominant Frontal CRS: Allergic Fungal Rhinosinusitis
Localised Non-type 2 Dominant Frontal CRS: Isolated or Ostial Occlusion Frontal CRS
Primary Diffuse CRS
Primary Diffuse Type 2 Dominant: Eosinophilic Chronic Rhinosinusitis (eCRS)
Primary Diffuse Type 2 Dominant: Central Compartment Atopic Disease (CCAD)
Primary Diffuse Type 2 Dominant: Allergic Fungal Rhinosinusitis (AFRS)
Primary Diffuse Non-type 2 Dominant: Non-eosinophilic Chronic Rhinosinusitis (Non-eCRS)
Frontal Sinus in the Setting of Secondary CRS
Secondary CRS: Localised
Fungal Ball
Odontogenic Sinusitis
Tumours
Secondary CRS: Diffuse
Mechanical Cause
Inflammatory Cause
Immunity/Immunodeficiency
Perioperative Care in Frontal Sinusitis
References
29: Complications of Rhinosinusitis
Introduction
Epidemiology, Microbiology and Pathophysiology
Classification Systems
Complications of Acute Rhinosinusitis
Orbital Complications
Intracranial Complications
Osseous Complications
Complications of Chronic Rhinosinusitis
Complications of Chronic Rhinosinusitis with Nasal Polyps
Complications of Chronic Rhinosinusitis Without Nasal Polyps
Diagnosis
Physical Examination
Radiology
Laboratory Tests
Treatment
Principles of Management
Surgical Management
Orbital Complications
Intracranial Complications
Clinical Examples
Areas of Controversy
References
Further Reading
Section V: Benign and Malignant Sinonasal Tumours
30: Sinonasal Papilloma
Introduction
Terminology: WHO Definition
Pathogenesis
Inverted Sinonasal Papilloma (IP) (Fig. 30.1a)
Exophytic Papilloma (Fig. 30.1b)
Oncocytic Sinonasal Papilloma (Fig. 30.1c)
Etiology
Malignant Transformation
Biomarkers of Malignant Transformation
Clinical Features
Exophytic Sinonasal Papilloma (ESP)
Inverted and Oncocytic Sinonasal Papilloma (ISP, OSP)
Association with Nasal Polyps
Imaging
Classification
Management
Exophytic Sinonasal Papilloma
Inverted Sinonasal Papilloma
External Surgical Approach Vs. Endoscopic Resection
Combined Approach Surgery
Attachment-Oriented Endoscopic Resection and Frozen Section
Categorization of Tumor and Surgery
Maxillary Sinus Surgery
Frontal Sinus Surgery
Sphenoid Sinus Surgery
Surgical Planning
Adjuvant Therapy
Recurrence
Surveillance
Conclusions
References
31: Benign Tumours of the Nose and Sinuses
Introduction
The Diagnostic Challenge
Imaging
Tumour Biopsy
Fibro-Osseous Lesions (FOLS)
Osteoma
Clinical Features
Imaging
Management of Osteomas
The Surgical Approach
The Endoscopic Approach
External Approach Surgery
Fibrous Dysplasia (FD)
Ossifying Fibroma (OF)
The Antrochoanal Polyp
Respiratory Epithelial Adenomatoid Hamartoma (REAH)
Salivary Gland Tumours
Schwannomas and Neurofibromas
Haemangioma
Solitary Fibrous Tumour (SFT)
Glomangiopericytoma
Inflammatory Myoblastic Tumour
References
32: Malignant Tumours
Introduction
Epidemiology
Clinical Features
Diagnostic Workup
CT Imaging
MRI Imaging
Additional Scanning Protocols
Staging
Histology-Driven Treatments
Squamous Cell Carcinoma (SCC)
Adenocarcinoma (ADC)
Adenoid Cystic Carcinoma (ACC)
Esthesioneuroblastoma (ENB)
Neuroendocrine Carcinoma (NEC)
Sinonasal Undifferentiated Carcinoma (SNUC)
Mucosal Melanoma (MM)
References
33: Juvenile Angiofibroma
Natural History of the Disease
Theory and Growth
Pathology
Clinical Features
Radiology
Biopsy
Staging
Preoperative Embolization
Preoperative Workup Considerations
Surgery
Endoscopic Endonasal Approach
External Approaches
Outcomes
Residual and Recurrent Angiofibroma
Role of Radiation Therapy
Cytotoxic Drugs and Hormonal Therapy
Controversies
Embolization
References
Suggested Reading
Section VI: Surgery of the Sinuses and Anterior Skull Base
34: Complications of Endoscopic Sinus Surgery
Introduction
Classification of Complications
Severity
Time Related to Surgery
Vascular Complications
Preoperative Scenario
Operative Scenario
Postoperative Scenario
Management of Specific Arteries
Anterior Ethmoidal Artery Injury
Sphenopalatine Artery Injury
Internal Carotid Artery (ICA) Injury
Management of ICA Lesions
Neurological Complications
Cerebrospinal Fluid (CSF) Leak
Preoperative Scenario
Operative Scenario
Postoperative Scenario
Associated Complications
Tension Pneumocephalus
Meningitis
Ophthalmic and Orbital Complications
Preoperative Scenario
Operative Scenario
Optic Nerve Injury
Infraorbital Nerve Injury
Orbital Injury
Extraocular Muscle Injury
Orbital Haematoma
Nasolacrimal Duct Injury
References
35: Open Approaches to the Paranasal Sinuses
Maxillary Sinus
Maxillary Antral Puncture/Washout
History
Procedure
Caldwell Luc Procedure (Anterior Antrostomy)
History
Complications
Technique
Ethmoid Sinuses
History
Complications
Transcutaneous Approach
Drainage of an Orbital Subperiosteal Abscess
Anterior Ethmoid Artery Ligation
Open-Approach Ethmoidectomy
Frontal Sinus
Frontal Trephination
Risk and Complications
Pre-procedural CT Scan Assessment
Conventional Frontal Trephination Technique
Frontal Trephination Technique Using a Mini-trephination Set
External Frontoethmoidal Surgery
Frontal Osteoplastic Flap With or Without Frontal Sinus Obliteration
Procedure
Managing Disease in the Small Frontal Sinus
Lateral Rhinotomy, Midfacial Degloving and Craniofacial Resections
Conclusion
References
36: Surgery of the Anterior Skull Base
Introduction
Anterior Skull Base Surgery
Open-Approach Surgery
Approach
Transfacial Approaches
Craniofacial and Subcranial Approaches
Resection
Reconstruction
Endoscopic Approach Surgery
Approach and Resection
Reconstruction
Combined Approach Surgery
Summary of Areas of Controversy or Uncertainty
References
37: Transorbital Endoscopic Surgery of the Paranasal Sinuses and Skull Base
Introduction
Rationale for Transorbital Surgery
Indications for the Otolaryngologist
Superior-Lateral Portal
Medial Portal
Inferior Portal
Transorbital Surgery: Surface Anatomy
Superior and Lateral Orbital Portals
Medial Orbital Portal
Inferior Portal
Preoperative Planning
Contraindications
Surgical Technique and Tips
Intraoperative Preparation
Surgical Instruments
Surgical Steps and Tips
Superior Lateral Portal
Medial Portal
Inferior Portal
Postoperative Management
Complications
Areas of Controversy
References
38: CSF Rhinorrhoea and the Anterior Skull Base
CSF Physiology
Classification of CSF Leaks
Complications of CSF Leaks
Indication for CSF Leak Closure
Clinical Features of CSF Leaks
Watery Rhinorrhoea That Mimics CSF Leaks
Clinical Examination
Investigations
Beta-2 Transferrin and Beta-Trace Protein
Imaging
Sodium Fluorescein
The Principles of Management of CSF Rhinorrhoea
The Active Leak
The Subclinical Leak
The Traumatic CSF Leak
CSF Leak as a Surgical Complication
Prevention of Meningitis by Vaccination
Timing of Surgery for Long-Term CSF Leaks
Repair of CSF Leaks
Surgical Approach
Reconstruction Material
Technique of Repair
Tips and Tricks
Lumbar Drains
Antibiotics
Miscellaneous
Idiopathic Intracranial Hypertension (IIH)
Areas of Controversy
References
Section VII: Miscellaneous Rhinological Disorders
39: Epistaxis
Introduction
Paediatric Epistaxis
Aetiology
Juvenile Angiofibroma
Clotting Disorders
Management of Paediatric Epistaxis
Management of Acute Paediatric Epistaxis
First Aid Measures
Haemostatic Agents
Nasal Tamponade
Management of Recurrent Paediatric Epistaxis
History Taking
Investigations
First-Line Treatments
Simple Measures
Intranasal Ointments
Silver Nitrate Cautery
Second-Line Treatments
Electrocautery
Surgical Treatment
Endoscopic Sphenopalatine Artery Ligation
Endoscopic Tumour Removal
Adult Epistaxis
Aetiology
Coagulopathy
Pathology
Septal Perforation
HHT
Other Vascular Abnormalities
Neoplasms
Induced Epistaxis
Facial Trauma
Iatrogenic
Pharmacological
Management of Adult Epistaxis
Management of Acute Adult Epistaxis
Initial First Aid
Medical Management
Management of Concurrent Oral Antithrombotic Agents
Blood Transfusion
Systemic Tranexamic Acid
Nasal Cautery
Intranasal Agents
Management of Recalcitrant Epistaxis
Surgery
Embolisation
Management of Hereditary Haemorrhagic Telangiectasia (HHT)
Areas of Controversy and Research
References
Further Reading
40: Olfaction, Taste and Its Disorders
Summary
Introduction
Smell
Physiology of the Olfactory System (Fig. 40.1)
Smell Impairment Classifications [4, 5]
Aetiology (Fig. 40.2)
Nasal and Sinus Disease
Upper Respiratory Tract Infections (URTI)
Head Injury
Neurodegenerative and Neurological
Medication and Chemicals [8, 9]
Surgical Trauma
Childhood Aetiology
Other Aetiology
Clinical Assessment
History
Clinical Examination
Investigations [9, 11]
Therapy and Prognosis
Taste
Anatomy and Physiology of Taste (Fig. 40.3)
Taste Disorder Classification [6, 12]
Aetiology
Age
Infective Causes
Medication/Chemicals
Cancer
Iatrogenic
Trauma
Other Causes
Taste Evaluation [12, 13]
Therapy and Management [6, 12, 13]
Conclusion
References
41: Headache and Facial Pain: Diagnosis, Evaluation and Management
Introduction
Facial Pain
Approach to a Patient with Facial Pain
Systematic Approach to Facial Pain Diagnosis
History and Examination
Examination Should Include the Following
Investigations
Sinusitis and Facial Pain
As per EPOS 2020 Guidelines
Primary Facial Pain
Migraine and Facial Pain
Trigeminal Neuralgia
Trigeminal Autonomic Cephalgias (TACs)
Cluster Headaches
Paroxysmal Hemicrania
SUNCT
Short-Lasting, Unilateral, Neuralgiform Headache Attacks with Conjunctival Injection and Tearing (SUNCT)
Tension Headache
Mid-Facial Segment Pain
Atypical Facial Pain
Giant Cell Arteritis (Temporal Arteritis)
Dental and Oral Disorders Causing Facial Pain
Temporomandibular (TMJ) Dysfunction
Sluder’s Neuralgia
Contact Point Pain
Current Developments
References
42: Trauma to the Nose
Summary
Introduction
Anatomy
Pathogenesis and Mechanism of Injury
Clinical Assessment
Clinical History
Physical Examination
Imaging
Management
Local Anaesthesia Technique
Nasal Bone Reduction Technique
Special Consideration
Paediatric Nasal Fracture
Conclusion
References
43: Septoplasty
Introduction
A Brief History of Septal Surgery
Anatomy
Assessment of the Nasal Septum
Measurements of Septal Deviation
Clinician Judgement
Patient Reported Outcome Measures (PROMS)
Tests of Nasal Airflow
Zones of the Septum
Surgical Techniques
Standard Septoplasty Technique
The Incision
Mucosal Elevation
Septal Spurs
Septal Deviation
Septal Cartilage Mobilisation
The Bony Septum
Closure
Endoscopic Techniques
L-Strut Deviations
External Open Approach Techniques
Extracorporeal Septoplasty
Iatrogenic Tears in the Mucosal Flaps
Local Anaesthetic Septoplasty
Complications of Septoplasty
Surgical Outcomes of Septoplasty
Areas of Controversy
Conclusion
References
Further Reading
44: Nasal Obstruction: The Role and Management of the Nasal Valve and Inferior Turbinates
Introduction
The Nasal Valve
Applied Anatomy
Nasal Valve Assessment
Principles of Nasal Valve Management
Surgical Treatment of the External Nasal Valve
The Lateral Crural J-Flap
Repositioning of the Lower Lateral Cartilages
Lateral Crural Strut Grafts and Alar Rim Grafts (Fig. 44.2)
Surgical Treatment of the Internal Nasal Valve
Batten Grafts (Fig. 44.2)
Spreader Grafts
Other Nasal Valve Surgical Techniques
The Inferior Nasal Turbinate
Investigation of Inferior Turbinate Hyperplasia
Management of Inferior Turbinate Hyperplasia
Surgical Management of the Inferior Turbinate
References
45: Nasal Septal Perforation
Introduction
Pathology
Pathogenesis
Clinical Features and Diagnosis
Medical History
Clinical Examination
Clinical Assessment
Investigation
Blood Tests
Urinary Drug Detection Test
Imaging
Biopsy
Clinical Management
Medical Treatment
Septal Obturators
Surgery
Indications
Surgical Techniques
Mucosal Advancement Flaps (Fig. 45.1)
Description
Indications
Surgical Technique [6, 7]
Cross-Over Flaps (Fig. 45.2)
Description
Surgical Technique
Bilateral Hadad Flap
Description
Indications
Surgical Technique [10]
Anterior Ethmoidal Artery (AEA) Flap
Description
Indications
Surgical Technique [11, 12]
Greater Palatine Artery (GPA) Flap
Description
Indications
Surgical Technique [13, 14]
Middle Turbinate Flap (Fig. 45.4)
Description
Indications
Surgical Technique [15]
Nasal Floor and Inferior Meatus Flap (Fig. 45.5)
Description
Indications
Surgical Technique [16, 17, 18]
The Extended Flap
Lateral Nasal Wall Flap (Fig. 45.6.)
Description
Indications
Surgical Technique [19]
Pericranial Flap
Description
Indications
Surgical Technique (Fig. 45.7) [20–22]
Areas of Controversy
Investigation
The Indication for Surgery
References
46: Granulomatous Disease, Vasculitides and the Cocaine Nose
Introduction
Types of Chronic Inflammatory Disorders
Specific Granulomatous Disease
Tuberculosis
Syphilis
Rhinoscleroma
Leprosy
Non-specific Chronic Inflammatory Disease
Sarcoidosis
Eosinophilic Granulomatosis with Polyangiitis (eGPA)
ANCA-Associated Vasculitis (AAV)
Granulomatosis with Polyangiitis (GPA)
Cocaine-Induced Vasculitis
Pathogenesis of Cocaine-Induced Vasculitis
The Mechanism Behind the Vasculitis
Drug-Induced Vasculitis (CIV) and Levamisole-Induced Vasculitis (LIV)
Investigation of Suspected GPA and CIV
Anti-neutrophil Cytoplasmic Antibodies (ANCA) and Vasculitis
Management of GPA and CIV
Medical Management
Surgical Management
The Nasal Septum
The Hard Palate
Saddle Deformity
Columella Reconstruction
Epiphora
Fistulae
References
47: Empty Nose Syndrome
Introduction
Pathophysiology
Diagnosis
Symptoms
Types of ENS
Symptom Scores
Signs
Diagnostic Cotton Test [2]
Imaging
Rhinomanometry
Management
Medical
Surgical
Conclusion
References
48: Management of Lacrimal and Orbital Disorders
Applied Anatomy and Physiology
Anatomy
Lacrimal Physiology
The Nasolacrimal System
Assessment of the Nasolacrimal System
Assessment of Nasolacrimal Disorders
Ophthalmological Assessment
Relevant ENT Assessment
Imaging
Disorders of the Nasolacrimal System
Epiphora and Dacryocystitis
Clinical Features
Differential Diagnosis of Dacryocystitis
Lacrimal Stones
Lacrimal Tumours
Management of Nasolacrimal Disorders
Treatment of Dacryocystitis
Management of Nasolacrimal System Obstruction
External Versus Endoscopic Dacryocystorhinostomy (DCR)
Surgical Management of Pre-saccal Obstruction
Endoscopic DCR Procedure
Local Anaesthesia and Vasoconstriction
Surgical Procedure
Placement of a Stent
Controversies in the Treatment of Epiphora Due to Saccal and Post-saccal Obstruction
The Orbit
Orbital Complications of Rhinosinusitis
Controversies in the Management of Orbital Complications
Orbital Tumours
Grave’s Orbitopathy
The Joint Lacrimal Clinic
References
49: Rhinological Dilemmas and Questions from Clinical Practice
Introduction
Steroid Use for Sinonasal Disease
Systemic Corticosteroids
Topical Nasal Steroids
Delivery Systems
Saline and the Nose
Saline Preparations
Current Research on Low-Sodium Nasal Rinses
Saline with Additives
The Anterior Localised Mucosal Atrophy and Septal Ulcer
Management of the Isolated Opaque Sinus
Osteoneogenesis: Significance and Management
Silent Sinus Syndrome
References
Index