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EPISTAXIS
Endoscopic Control
Failure to locate the bleeding point is an indication for rod lens endoscopy and targeted
haemostasis using modern single bre bipolar electrodes. Endoscopy identies the source of
posterior epistaxis in over 80% of cases. Success rates for immediate control by endoscopic
guidance are consistently reported in the 90% range.
Indirect Therapies
Lack of specialist skills is an indication for use of one of many of the following traditional
indirect strategies:
Anterior nasal packing:
•
Ribbon gauze impregnated with petroleum jelly or bismuth iodoform paran
•
paste (BIPP), tampons, resorbable packing and inatable balloon packs are used.
Removal aer 24–72 hours; antibiotic cover is required.
•
Persistent bleeding with packs in situ is observed in up to 40% of cases requiring
•
further examination of the nasal cavity.
Complications of packing include sinusitis, septal perforation, alar necrosis,
•
hypoxia and myocardial infarction.
Posterior nasal packing:
•
Largely obsolete as packing causes considerable pain, but it is indicated in extreme
•
cases or where no specialist rhinologist is available.
Posterior tamponade is achieved by endonasal insertion of Foley urethral cath-
•
eter, which is inated with water once it reached nasopharynx.
Removal aer 24–72 hours or at least until rhinologist can attend; antibiotic cover
•
is required.
Complications include hypoxia secondary to so palate oedema, sinusitis, middle
•
ear eusions and necrosis of the septum and columella.
Medical Therapy
Systemic medical therapy:
•
Tranexamic acid reduces the severity and risk of re-bleeding (oral, 1.5g, 3x/day).
•
Topical thrombin compounds (e.g. Floseal) are an additional tool for the manage-
•
ment of dicult bleeds (especially secondary).
Surgical Management
If the techniques described above fail, surgical intervention is required. Endoscopic diathermy of the bleeding point under anaesthesia may control the bleeding, but if the vessel
still cannot be controlled (or even located) indirect surgical therapy is indicated. Surgical
management for continued epistaxis consists of the following:
Ligation techniques:
•
Sphenopalatine artery
•
External carotid artery
•
Internal maxillary artery
•
Anterior/posterior ethmoidal artery
•
Embolization techniques
•
Endonasal Endoscopic Sphenopalatine Artery Ligation (ESPAL)
ESPAL has now largely replaced all other ligation procedures.
•
Under general anesthesia, incision is made 8 mm anterior to and below the posterior
•
end of the middle turbinate.
Once the artery is identied (posterior to the crista ethmoidalis), it is ligated using
•
haemostatic clips and divided/coagulated using bipolar diathermy.
208 Rhinology and Facial Plastic Surgery
NASAL FRACTURES
Table 40.1 Classication of epistaxis
Primary: no proven causal factor
Secondary: proven causal factor
Childhood: <16 years
Adult: >16 years
Anterior: bleeding anterior to piriform aperture
Posterior: bleeding point posterior to piriform aperture
Success rate is almost 100%.
•
Complications include re-bleeding (anastomoses), infection and nasal adhesions (less
•
common than with other procedures).
Anterior/Posterior Ethmoidal Artery Ligation (EAL)
Given the minimal contribution of these arteries to the nasal blood supply, this is best
reserved as an adjuvant to one of the procedures described above or in cases of conrmed
ethmoidal bleeding (e.g. ethmoidal fracture, iatrogenic tear). e arteries are approached by
a medial canthal incision (Figures 40.1 and 40.2).
Embolisation
Success rate to control severe epistaxis is 82–97%.
•
Particles (polyvinyl alcohol, tungsten or steel microcoils) are used.
•
Complication frequency depends on local expertise and includes skin necrosis,
•
paraesthesia, cerebrovascular accident, blindness and groin haematomas.
KEY POINTS
• Direct bleeding point–specic approaches are superior to indirect nasal packing
strategies.
• Epistaxis secondary to drugs or coagulopathy requires management of the underlying
cause.
• Endoscopic ligation of the sphenopalatine artery is the ligation of choice.
• The endoscope has revolutionized the treatment of epistaxis.
41. NASAL FRACTURES
Introduction
e treatment of nasal fractures was rst recorded 5000 years ago. An isolated nasal pyramid
fracture accounts for about 40% of all facial fractures. It is essential to exclude concurrent
facial fracture and neurological injury in patients presenting with nasal trauma. Delays in
management can result in signicant cosmetic and functional deformity that may result in
medicolegal action.
Young men are twice as likely to sustain a fractured nose as women. Fractures in younger
children tend to be greenstick in nature. Compound and comminuted fractures are more
common in the elderly who are prone to falls.
Relatively little force is required to fracture the nasal bones. Most fractures result from laterally applied forces (>66%). Greater force is required to fracture the nose with a blow directed
from the front as the nasal cartilages behave like shock absorbers.
Rhinology and Facial Plastic Surgery 209
NASAL FRACTURES
Clinical Presentation
History
Key issues include the following:
How and when the injury was sustained
•
Nasal obstruction (with persisting pain may indicate a septal haematoma)
•
Change in appearance (based on the patient’s own assessment)
•
Anosmia, hyposmia, watery rhinorrhoea → skull base injury
•
Visual disturbance, diplopia, ecchymosis, epiphora → orbital trauma
•
Altered bite, loo se teeth, tri smus, cheek paraes thesia → dama ge to temporomandibu lar
•
joint (TMJ), mandible or zygomaticomaxillary complex
Examination
Key issues to consider when examining a patient include
Deviation, depression, step deformities
•
Mobility, crepitus, specic areas of point tenderness
•
Generalised swelling and focal bruising
•
Skin and mucosal lacerations
•
Septal fracture/haematoma/abscess
•
Investigations
Plain facial X-rays are not required to make the diagnosis or aid subsequent reduction. If
there is clinical evidence of a more extensive facial injury, computed tomography (CT) scan
of the facial bones and brain should be acquired. Samples of any watery rhinorrhoea must be
collected and tested for beta-2 transferring.
Treatment
Timing of Initial Assessment
Ideal window for assessment is either within the rst 3 hours, or 4–7 days post-injury
•
(due to signicant swelling between these times).
In cases of septal haematoma, surgical drainage is required. Associated facial frac-
•
tures or neurological injury (uncommon) may also indicate surgical intervention.
Delayed intervention beyond 2–3 weeks post-injury makes eective reduction less
•
likely, and sometimes impossible without making osteotomies.
In children, healing can take place even more quickly and earlier intervention is indicated.
•
Some patients will have a pre-existing nasal deformity. ese patients should be advised that,
at best, their nose will only return it to its most recent appearance.
Timing of Reduction
<3 hours aer injury in adults and children has the potential for optimal results (if
•
minimal oedema is present).
OR
7–10 days aer injury in adults (aer oedema has resolved and before the setting of
•
fracture fragments)
3–7 days aer injury in children (aer oedema has resolved and before the setting of
•
fracture fragments)
Anaesthesia
It can be performed under local or general anaesthesia.
•
Local anaesthesia:
•
Suitable for simple fractures of nasal bones/naso-septal complex.
•
External inltration along the nasomaxillary groove, infraorbital nerve in its
•
foramen and around the infra-trochlear nerve.
210 Rhinology and Facial Plastic Surgery
NASAL FRACTURES
Intra-nasal local anaesthesia is also acceptable, using combinations of cocaine,
•
lignocaine, adrenaline and phenylephrine (caution in hypertension or cardiovascular disease).
ere are easily identiable groups of patients who are not suitable for reduction under local
anaesthesia. Children and patients with low pain tolerance or signicant anxiety are better
admitted for general anaesthesia. Extensive fracture-dislocation of nasal bones and septum
and open fractures are not suitable for local anaesthesia.
Technique
Closed and open technique can be utilised in reduction of nasal fractures. is nasal trauma
classication can be used to determine the optimal technique:
Injury restricted to so tissue (type I): no fracture
•
Simple, unilateral nondisplaced fracture (type IIa): no reduction
•
Simple, bilateral nondisplaced fracture (type IIb): no reduction
•
Simple, displaced fracture (type III): closed reduction
•
Closed comminuted fracture (type IV): open reduction
•
Open comminuted fracture or complicated fracture (type V): open reduction with use of
•
septorhinoplasty reconstruction techniques
Closed nasal reduction involves rst increasing and then decreasing the degree of deformity, i.e.
an initial slight increase in deformity away from the side of the blow to disimpact the fragments,
followed by steady movement back toward and oen slightly beyond the midline. Generally, this
can be achieved by rm digital pressure but sometimes instruments are necessary, particularly
in those where there has been delay in treatment. Various elevators and forceps can be used
including the Freer, Hills and Howarth elevators and Ashe and Walsham forceps (Figure 41.1).
Closed reduction alone may not achieve a satisfactory result when the nal position of the
nasal dorsum reects the deformity of the underlying septum. Segments of the fractured
perpendicular plate of the ethmoid or septal cartilage may overlap, requiring repositioning
by open reduction. If the bones are xed, especially if the fracture is old, then osteotomies are
necessary to release the fragments before manipulation.
It is advisable to refrain from contact sports for at least 6 weeks.
Occasionally, open reduction or rhinoplasty techniques may be desirable or required to provide optimal results, despite the increased time and eort involved. In indicated cases, open
Figure 41.1 (A) Instruments used in nasal fracture manipulation. (a) Howarth’s elevator, (b) Ashe’s
forceps (septum) and (c) Walsham’s forceps (nasal bones). (B) Determining depth of insertion of
instrument into nasal cavity. The instrument is held so that the index nger of the dominant hand is
placed along the instrument in the line of the nose.
Rhinology and Facial Plastic Surgery 211
NASAL FRACTURES
technique oers better exposure and precise approximation of dislocated structures. Open
technique is further described in Chapter 47.
Management of the Nasal Septum
Septal fracture is seen in almost half of nasal fractures. is is oen missed and is a major
reason for poor functional and cosmetic results. A satisfactory reduction of nasal bones is
oen not possible without improving the position of the septum.
Septal reduction can sometimes be performed with Ashe’s forceps, but oen requires a
Killian or hemitransxion incision, elevation of mucosal aps to expose the cartilage and
bone fragments and replacement and/or removal of cartilaginous and bony fragments, as in
an endonasal septoplasty. Quilting sutures may reduce the risk of haematoma.
Complications
Attempts to reduce deformity or improve obstruction are not always successful. is is multifactorial, and inuenced by pre-existing nasal injury, surgical technique, under-recognition of concurrent septal fractures and post-operative scarring. Some patients inevitably
require a septorhinoplasty, which should be delayed by 6–12 months to allow the fractures
to heal, oedema to settle completely so the underlying nasal skeleton is evident and for any
brosis to develop. Other complications include epistaxis and septal haematoma.
Management of Septal Haematoma
Septal haematoma presents with acute unilateral or bilateral nasal obstruction and, on
inspection, a reddish-purple, uctuant swelling of the caudal septum. A deviated septum
can be confused with a septal haematoma. Gentle pressure on the bulging area will ascertain
that it is uctuant if a collection is present. Untreated, an abscess may develop and the patient
becomes very unwell with a uctuating fever and severe facial and cranial pain.
e haematoma or abscess must be drained as soon as possible. is can be performed under
local or general anaesthetic. Incision and drainage is preferable to needle aspiration; oen
the collection will have become organised and impossible to aspirate fully. Once drained,
through-and-through quilting sutures are inserted to eliminate the dead space. Packs or
splints can be used to provide gentle pressure on the septum. e patient must be re-examined
within 48 hours to establish that the collection has not recurred. e management of a septal
abscess is similar, but with the addition of intravenous antibiotic therapy. If le untreated,
there is signicant risk of cartilage necrosis and/or abscess and subsequent saddle nose deformity, columellar retraction and broadened septum, as well as a risk of intracranial infection.
KEY POINTS
• Timing of initial assessment is critical and dictates optimal outcome:
• Within rst 3 hours or 4–7 days post-injury (due to signicant swelling in between)
• Timing of reduction:
• <3 hours after injury in adults and children has potential for optimal results
OR
• 7–10 days after injury in adults
• 3–7 days after injury in children
• Exclusion of septal haematoma, related injuries to face, orbit, jaws and central nervous
system at initial assessment.
• Most cases can be reduced adequately with closed techniques, unless the fractures are
complex or a signicant septal fracture-dislocation is present.
• If tolerated, local anaesthesia has comparable results with general anaesthesia in
indicated cases.
• Patients should be advised that residual cosmetic deformity and nasal obstruction are
relatively common.
212 Rhinology and Facial Plastic Surgery
SINONASAL TUMOURS
42. SINONASAL TUMOURS
Introduction
Evidence now supports endoscopic approaches as a suitable treatment option for the management of benign sinonasal tumours. e role of such approaches for malignant sinonasal
tumours has been more controversial with early concerns raised regarding the lack of en bloc
resection, diculty in addressing vascular complications and challenges in defect reconstruction. Recent studies refute these concerns with demonstrated reductions in morbidity, improved vascular control and equivalent survival outcomes to open approaches. e
endoscopic approach for sinonasal tumours is now supported by European and American
societal position papers.
Sinonasal Tumour Epidemiology
Sinonasal tumours are a rare and diverse group of lesions arising from any of the
•
structures comprising the paranasal sinuses (Table 42.1).
Sinonasal osteoma is the most reported benign lesion (radiological incidence 1%).
•
Ossif ying broma, brous dysplasia and inverted papilloma a re the next most reported
•
benign lesions of the paranasal sinuses.
Table 42.1 Summary of sinonasal tumours by tissue of origin
Tissue of origin Benign lesions Malignant lesions
Epithelial • Inverted papilloma
• Oncocytic papilloma
• Exophytic papilloma
• Respiratory epithelial
adenomatoid hamartoma
(REAH)
• Salivary gland adenomas
Neuroendocrine • Carcinoid
Soft tissue • Myxoma
• Leiomyoma
• Haemangioma
• Schwannoma
• Meningioma
• Neurobroma
• Angiobroma
• Haemangiopericytoma
Bone and cartilage • Fibrous dysplasia
• Osteoma
• Osteoblastoma
• Chondroma
• Ameloblastoma
Haematological and
lymphatic
Germ cell tumours • Dermoid cyst • Teratoma sinonasal yolk sac
Neuroectodermal tumours • Aesthesioneuroblastoma
• Squamous cell carcinoma
• Sinonasal undifferentiated
carcinoma (SNUC)
• Lymphoepithelial carcinoma
• Adenocarcinoma
• Salivary gland carcinomas
• Mucoepidermoid
• Adenoid cystic carcinoma
• Acinic cell carcinoma
• Fibrosarcoma
• Rhabdomyosarcoma
• Angiosarcoma
• Malignant peripheral nerve sheath
tumour
• Chondrosarcoma
• Osteosarcoma
• Chordoma
• Lymphoma
• Langerhans cell Histiocytosis
tumour
Rhinology and Facial Plastic Surgery 213
SINONASAL TUMOURS
Table 42.2 Concerning features on clinical examination
Clinical nding Reason for concern
Conductive hearing loss/middle ear effusion Obstruction/invasion of eustachian tube
Visual change/loss
Visual eld change diplopia/ophthalmoplegia
Pain on eye movement
Chemosis/orbital displacement
Clear rhinorrhoea Dural/intra-cranial involvement with CSF leak
Facial paraesthesia Compression/invasion of the maxillary or
Loose teeth dental paresthesia Invasion of the alveolar process and dental roots
Facial asymmetry Possible involvement of facial soft tissues
Oronasal or oroantral stula Erosion of the nasal oor or maxillary sinus oor
Palpable cervical nodal disease Possible metastatic spread
Reduced neck range of motion Paraspinal muscle involvement
Sinonasal malignancies are less common (incidence 0.5–1/100 000):
•
1% of all malignancies and 3–5% of all head and neck cancers
•
Squamous cell carcinoma is the most common subtype followed by adenoid cystic
•
carcinoma and adenocarcinoma.
Diagnosis and Pre-Operative Planning
A thorough history, examination and cranial nerve assessment should be performed in all
patients with sinonasal masses. Table 42.2 highlights concerning features that should be
looked for on clinical examination.
Optic nerve involvement
Intra-cranial extension, optic chiasm compression
Involvement of intra-orbital contents
infraorbital nerve
Endoscopy
Nasal endoscopy is important in pre-operative planning. Visualizing the likely site of origin,
along with involvement or destruction of the local anatomic structures, guides surgical planning.
Decisions regarding the likely pathology, lesion resectability, endoscopic access and approach can
also be made. Endoscopy can facilitate biopsy following review of the relevant radiology.
Radiology
High-resolution computed tomography (CT) and magnetic resonance imaging (MRI) are
critical to the management of sinonasal tumours and provide complimentary information
regarding the tumour’s nature, extent and involvement of local structures (Table 42.3):
CT is excellent for osseous margins of the skull base and sinus walls.
•
MRI is superior for so tissue resolution permitting the dierentiation of tumour from
•
retained secretions and hemorrhage. Allows appreciation of so tissue tumour margins and their interface with local structures (Figure 42.1).
Positron emission tomography (PET) is indicated for the detection of distant
•
metastases.
Biopsy
Tumour histopathology directs intra-operative decision making and adjuvant management.
Multiple representative endoscopic-guided biopsies should be taken before the deni-
•
tive surgical procedure.
Tissue should be sent both fresh and in formalin xative, for histopathology and ow
•
cytometry.
Biopsies should always be performed aer reviewing the relevant radiology to exclude
•
vascular lesions or prolapsed meningo-encephaloceles.
214 Rhinology and Facial Plastic Surgery
SINONASAL TUMOURS
Table 42.3 Radiological features on CT/MRI and their possible implications
Feature Potential clinical implication
Orbit
Breech of lamina papyracea
Loss of orbital fat planes
May indicate involvement of orbit and the need for orbital
exenteration.
Involvement of extra-ocular muscles
Septum
Erosion of septum Important implications for surgical access and repair.
Lesions crossing midline will require a septectomy and
binasal approach. Gross septal involvement may preclude
the use of the nasoseptal ap.
Skull base
Asymmetrical or low lying
Position of anterior ethmoid arteries
Skull base defect
Increase risk of inadvertent entry and CSF leak during
surgery
Mesentery suspended arteries are at increased risk of injury
Suggestive of intra-cranial extension of sinonasal
pathology or intranasal extension of intra-cranial
pathology
Sphenoid sinus
Extent of pneumatization
Onodi cells
Location of sphenoid septations
Laterally pneumatized sinuses may place the carotid at risk
May contain optic nerve and be confused with sphenoid
sinus
Septations may be closely related to carotid artery and
optic nerve, requiring great care when removing.
Paranasal sinus
Osteitic changes Possible site of tumour origin
Widened bony foramina Perineural invasion of tumour
Nerve sheath tumour
Tumour calcication See to varying degrees with aesthesioneuroblastoma,
chondroma, chondrosarcoma, osteoma, ossifying broma
and osteosarcoma
Expansion of paranasal sinus/fossae Tends to indicate the presence of a mass within the space
Figure 42.1 Coronal CT and MRI of a sinonasal tumour. Although the CT would suggest involve-
ment of the extra-ocular muscles (a), the MRI demonstrates clear preservation of the fat plane.
(b) The MRI also facilitates a differentiation of tumour from retained secretions seen in the maxillary
sinus. These images highlight the importance of obtaining both a CT and MRI for skull base tumours.
Rhinology and Facial Plastic Surgery 215
SINONASAL TUMOURS
Multidisciplinary Planning Meetings
All patients with malignant and complex pathology should be presented to a multidisciplinary team, comprising surgeons, radiologists, medical and rad iation oncologists and a llied
health professionals. Treatment recommendations should not only consider the pathology of
the tumour but also the age, health, functional status and wishes of the patient. Patients and
families should be informed of all available treatment options along with the risks, benets
and likelihood of success to enable an informed consent.
Principles of Endoscopic Management of Sinonasal Tumours
Case Selection
Appropriate case selection is critical to the success of endoscopic skull base surgery. To minimize complications and improve outcomes, surgeons should rst become procient in the
surgical management of sinonasal inammatory disease, before progressing to benign and
eventually malignant tumours.
e anatomic and technical limits of endoscopic resectability have continued to evolve as
experience builds.
Endoscopically resectable anatomical areas include the following:
Entire anterior cranial base from cribriform plate to planum sphenoidale.
•
Dura, olfactory bulbs and lamina papyracea.
•
Nasopharynx, clivus and odontoid process can now be reached, limited inferiorly at
•
the nasopalatine line.
Laterally, the pterygopalatine and infratemporal fossa can be reached, with the
•
transpterygoid approach aording additional access to the petrous temporal bone,
Meckel’s cave and middle cranial fossa.
Relative contraindications to an entirely endoscopic approach include involvement of
Skin and subcutaneous tissue
•
Nasolacrimal sac
•
Carotid artery
•
Anterior table of the frontal sinus
•
Dural and brain
•
Image Guidance Technology
Image guidance technology aids endoscopic skull base surgery, providing the surgeon with
enhanced anatomical localization. It may decrease surgical disorientation, improve surgical
completeness and potentially lower complication rates.
Principles of Oncologic Resection
Complete resection of a tumour with minimal morbidity is the primary goal of any oncological surgery. e anatomical connes of the nasal cavity prevent en bloc resection for
the vast majority of sinonasal tumours. Fortunately, many sinonasal tumours have a welldened area of origin or tissue invasion. Provided en bloc excision of the origin is performed, ideally with a cu of normal surrounding tissue, the remainder of the tumour can
be selectively debulked down to attachment points, without compromising the completeness of resection.
Surgical Access Techniques
Prior to resection or debulking the tumour, the surgeon needs to obtain maximal access.
is allows room for instrumentation and improves the approach to the peripheral aspects
of the tumour. It also facilitates early identication of tumour-free zones and aids in dening
the tumour extent.
216 Rhinology and Facial Plastic Surgery
SINONASAL TUMOURS
Improving Lateral Access
Endonasal endoscopic techniques can access tumours extending laterally as far as the infratemporal fossa. Tumours within the nasal cavity without extension beyond the infra-orbital
nerve can usually be managed through the ipsilateral nostril. ose extending further
laterally may require a transeptal approach along with removal of part or all the medial
maxillary wall.
Transeptal Approach
Non-opposing septal incisions permit use of the contralateral nostril to pass instruments or
endoscopes, increasing lateral access and allowing a second surgeons’ involvement.
Transmaxillary Approaches
Stepwise increases in maxillary sinus access allow a tailored approach to sinonasal tumours
in this region. Initially, an uncinectomy to identify the natural maxillary ostium should be
performed and enlarged accordingly. Posterior lesions medial to the infra-orbital nerve can
usually be accessed with a mega-antrostomy. Further lateral extension requires enhanced
lateral access via a modied medial max illectomy, allowing preservation of the lacrimal duct.
Access for more superiorly based lesions may require a total medial max illectomy with transection of the nasolacrimal duct. Anterolateral maxillary sinus tumours can be approached with
a pre-lacrimal approach, which preserves the structure and function of the lateral nasal wall.
Improving Posterior Access
Binasal access is useful for tumours involving the nasopharynx, sphenoid sinus, pituitary
fossa and the infra-temporal and pterygopalatine fossae. is access is facilitated by posterior septectomy.
Posterior Septectomy
A pedicled nasoseptal ap may be raised before performing the septectomy and used for later
reconstruction. A bilateral, wide sphenoidotomy to maximize visualization should extend to
the skull base superiorly and lamina papyracea laterally, helping avoid inadvertent injury of
critical neurovascular structures. e extent of the septectomy can be tailored to the extent
of access required. e septal window should extend anteriorly enough to enable complete
visualization of the entire surgical eld and limit contralateral instrument clash. Where possible, surgeons should preserve at least 1.5 cm of posterosuperior septal mucosa within the
olfactory cle for olfaction provided oncologic outcome is not compromised.
Improving Superior Access
e entire anterior skull base can be accessed endoscopically. When the intra-cranial component lies posterior to the anterior ethmoidal artery, targeted resection of the posterior
skull base is usually sucient for access. If the intra-cranial extent of the tumour lies anterior
to the anterior ethmoid arteries, an endoscopic modied Lothrop procedure (EMLP) will
typically be required to access the anterior aspect of the tumour. e EMLP also improves
lateral access to lesions within the frontal sinus.
Tumour Resection
With appropriate access obtained, the tumour can be debulked down to its site of attachment. Where possible, all tumour removed from the patient should be sent for histopathological analysis. Following debulking, the attachment site can be resected, with
attainment of clear surgical margins the goal. Frozen sections may aid intra-operative
margin assessment; however, all surgical margin specimens should undergo formal histopathological analysis.
While the ultimate goal of surgery is a complete oncological resection of the tumour, the
tumour nature and patient characteristics may, on occasion, necessitate compromise. Benign
tumours may be appropriate for subtotal resections with post-operative surveillance where
Rhinology and Facial Plastic Surgery 217
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