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242
N. Mat Lazim et al.
Fig. 9.21 The recurrent laryngeal nerve is passing
obliquely on the trachea and adherent at Berry’s ligament
posterior to the thyroid mass
Fig. 9.22 Recurrent laryngeal nerve shown under the
thyroid mass and is tested for its functionality with a
probe of nerve stimulator
Similar techniques are used for lobectomy as
in total thyroidectomy. Once the skin ap is elevated, strap muscle is identied and retracted laterally. This exposes the thyroid lobe. The lobe is
dissected superiorly or inferiorly depending on
the surgeon’s decision on where to start the dissection around the glands. The ITA can be identied in a similar manner, as in total thyroidectomy.
The Berry’s ligament is the toughest tissue to dissect at the posterior part of the thyroid lobes
(Figs. 9.23 and 9.24). Meticulous dissection is
needed in order to avoid inadvertent injury to the
RLN. Once the thyroid lobes are removed, the
RLN is tested with the stimulator to assess its
function (Figs.9.25 and 9.26).
Fig. 9.23 The area of Berry’s ligament which consists of
a dense tissue which poses difcult dissection during thyroid surgery
Fig. 9.24 Two separate masses are visualized, the bigger
left thyroid lobes and smaller inferior part of thyroid
isthmus
Fig. 9.25 Post removal of thyroid lobes, the recurrent
laryngeal nerve is restimulated with nerve probe to ensure
its patency
9 Thyroid Gland Tumour andSurgical Approach withCase Illustration
Fig. 9.26 Both of the thyroid lobes removed measuring 3.0cm × 5.0cm and 2.0cm × 1.0cm
243
Fig. 9.27 The carotid sheath is exposed where recurrent
laryngeal nerve (rln) is located more medially than carotid
artery (ca). The vagus nerve is in between IJV and carotid
artery
Once the surgical bed is irrigated with warm
saline, a whitish colour of the nerve becomes
more visible. The RLN lies medial to the carotid
sheath, i.e. the carotid artery and IJV (Figs.9.27
and 9.28).
Fig. 9.28 The carotid sheath is exposed where recurrent
laryngeal nerve (rln) is located more medially than carotid
artery (ca). The vagus nerve is in between IJV and carotid
artery. The recurrent laryngeal nerve is tested with a nerve
stimulator (ns) and is intact
9.9.1 Case Illustration 1: Completion Hemithyroidectomy
This is the case of a young lady with a history of
thyroidectomy 15years ago, represented with left
244
N. Mat Lazim et al.
Fig. 9.29 Patient lies supine with oral intubation tube (it)
in situ for anaesthesia. The nerve monitoring (ns) has been
applied. Previous thyroid scar (ts) is visible, and left thyroid mass (ltm) is visualized
thyroid mass mimicking a branchial cyst
(Fig.9.29). A FNAC evaluation and CT scan conrmed that it was a recurrent benign thyroid
tumour. The case indicated for a completion
thyroidectomy.
A normal preparation for total thyroidectomy
is intubation with the EMLT tube that is designed
for recurrent laryngeal nerve monitoring
(Fig. 9.29). This tube should be inserted where
the marker for electrode monitoring is at the level
of glottic. If the tube is inserted too inferiorly
below the glottic level, the nerve monitoring will
not be functioning.
A common skin incision is midway between
the sternal notch and cricoid cartilage. In this
case, however, since the recurrent tumour is lateral and more superiorly located at the left level
II, III, and IV neck node region (Fig.9.30), the
designed skin incision is at the epicentre of the
mass, following the normal skin crease, and
placed below two nger breadths of the angle of
mandible.
The subplatysmal skip ap is elevated, superiorly to the level of hyoid bone and inferiorly to
the inferior-most border of the mass (Fig.9.31).
This will facilitate better dissection with wide
surgical access. It is critical to anticipate the
carotid artery, IJV, and vagus nerve deep to the
Fig. 9.30 The outermost margin of thyroid mass (tm) has
been outlined, which abuts mandible (m) superiorly and
close to midline (an) anteriorly
Fig. 9.31 The subplatysmal skin ap (sf) has been raised
exposing the thyroid mass (tm) and its capsule. Superior
ap is retracted towards mandible (m), and the inferior
ap is raised down to the inferior border of the mass
mass, which need to be identied and preserved.
A wide surgical access will allow safer dissection
in the carotid sheath area and ensure the preservation of the carotid sheath and its content.
Retraction of the mass superomedially with
meticulous dissection of tissue around the carotid
sheath ensures preservation of IJV, vagus nerve,
and carotid artery (Fig. 9.32). The dissection
should be continued on the mass capsule, so as to
avoid unnecessary tissue trauma to adjacent
tissue.
9 Thyroid Gland Tumour andSurgical Approach withCase Illustration
245
Fig. 9.32 The lateral dissection of the mass (tm) has
been completed, and retraction of mass medially exposed
the carotid artery (ca), vagus nerve (vn), and internal jugular vein (ijv). The mass is able to be dissected away from
the carotid sheath as it has a well-formed capsule
Fig. 9.33 The mass (tm) is retracted superiorly while
deep dissection continues. The recurrent laryngeal nerve
(rln) is tested with a nerve stimulator and is intact. The
sternocleidomastoid muscle (SCM) is also shown
Fig. 9.34 The left thyroid mass (tm) which is removed
measuring 8.0cm × 5.0 cm. The dissected thyroid gland
(tg) tissue is also shown
9.10 Conclusion
Thyroid gland surgery can cause signicant
morbidity to the patient. The complication of
recurrent laryngeal nerve paralysis and hypocalcaemia poses critical management challenges.
Sufcient knowledge of the anatomy and surgical landmarks together with experience ensure a
safe and effective thyroidectomy. The surgeon
also needs to understand the factors that underpin the types of thyroidectomy and their indication for the patients. Each patient has distinct
tumour factors and preference that need to be
considered meticulously during surgical
planning.
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Further dissection deep to the mass and traction on the mass superiorly will allow a safe
tumoural mass removal (Fig.9.33). Any residual
bleeding can be controlled with bipolar diathermy. Irrigation of tumour bed with warm normal saline allows bleeding control better.
The mass is excised in total together with its
capsule which is intact (Fig.9.34). The specimen
is labelled and sent to the histopathology for
analysis.
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Endoscopic Nasal andParanasal
Sinus Surgery
RamizaRamzaRamli, SakinahMohamad,
andNorasniedaMdShukri
10
10.1 Introduction
The endoscopic sinus surgery (ESS) has greatly
evolved over the past few decades. It was originally started with the attempt at nasal endoscopy
in 1901 by Hirschman by using a modied cystoscope to assess the nasal cavity [1]. Following
that, Reichert introduced a 7 mm endoscope
through an oro-antral stula, and this was
regarded as the rst endoscopic procedure [1].
Later on, in 1925, the term ‘sinuscopy’ was
coined by Maltz. The turning point in nasoendoscopy was when Hopkins introduced the rod optic
endoscope system together with the inventions of
a bre-optic gastroscope and zoom camera lens
[1]. Subsequently, Messerklinger utilized this
innovation and performed a cadaveric study on
mucociliary clearance [1]. From his observation,
the mucociliary clearance in the paranasal sinuses
was draining towards their respective natural
ostium. Then, Stammberger and Kennedy popularized the philosophy of widening the natural
ostium of the diseased paranasal sinuses [2].
Following that onwards, with the advancement in
the instrumentation and technological progress,
the use of the endoscopic technique is extended
to other procedures such as endoscopic dacryo-
R. R. Ramli (*) · S. Mohamad · N. M. Shukri
Department of Otorhinolaryngology—Head and
Neck Surgery, School of Medical Sciences, Universiti
Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
e-mail: ramizaramza@usm.my
cystorhinostomy, orbital/optic nerve decompression, and anterior skull base surgery via
transsphenoidal route.
10.2 Surgical Anatomy
It is of utmost importance to thoroughly know
and understand the surgical landmarks involved
during the endoscopic sinus surgery for surgical
planning to achieve complete clearance of the
disease and to avoid complications. The nose is
divided internally into two nasal cavities by the
nasal septum. The nasal septum is composed of
membranous, cartilaginous, and bony components as shown in Fig.10.1 [3].
The membranous component consists of connective tissues located between the columella and
the caudal part of the cartilaginous septum. The
cartilaginous septum is comprised of septal cartilage or also known as quadrilateral cartilage. On
the other hand, the bony septum is composed of
superiorly the perpendicular plate of the ethmoid
bone and inferiorly the vomer, crest of maxilla
bone, and crest of palatine bone. The Little’s area
is located at the anterior part of the nasal septum
and supplied by branches from the anterior ethmoid artery, sphenopalatine artery, greater palatine artery, and superior labial artery, which
anastomose forming the Kiesselbach’s plexus.
This region is the commonest site of anterior epistaxis as it is very rich in capillary loops and
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
N. Mat Lazim et al. (eds.), Head and Neck Surgery : Surgical Landmark and Dissection Guide,
https://doi.org/10.1007/978-981-19-3854-2_10
249
Frontal sinus
Palatine crest
Nasal spine of
250
Fig. 10.1 Components
of nasal septum
frontal bone
Nasal bone
Frontal sinus
Septal
cartilage
Membranous
septum
Vomeronasal
cartilage
Fig. 10.2 Coronal view of the CT scan of the paranasal
sinuses showed some degree of bony septal deviation to
the right. The septal deviation in this case is not in contact
with the mucosa of the structures in the lateral wall of the
nose
susceptible to injury such as digital trauma. The
nasal septum deviation may cause narrowing of
the nasal airway passage leading to some degree
of nasal blockage for the patient (Fig.10.2).
Along the lateral nasal wall, there are 3–4
types of turbinates, namely inferior turbinate,
middle turbinate, superior turbinate, and supreme
turbinate occasionally. These turbinates play
R. R. Ramli et al.
Crista galli
PPE
Frontal sinus
Sphenoid
rostrum
Vomer
some role in the regulation of the inhaled nasal
airow, humidication, and ltration. The nasal
passage inferior to each turbinate is called the
meatus. The nasolacrimal duct drains into the
inferior meatus via some mucosal folds named
Hasner’s valve, which is about 1cm posterior to
the caudal end of the inferior turbinate. The middle meatus is a complex region whereby it acts as
a common drainage from the maxillary sinus,
anterior ethmoid sinus, and frontal sinus.
Meanwhile, the posterior ethmoid air cells drain
into sphenoethmoidal recess of the superior
meatus.
From anterior to posterior, there are a series of
4–5 bony partitions or lamellae separating the
ethmoid sinuses, namely uncinate process (rst
lamella), bulla ethmoidalis (second lamella),
ground or basal lamella of the middle turbinate
(third lamella), superior turbinate (fourth
lamella), and occasionally supreme turbinate
(fth lamella) [4]. The basal lamella of middle
turbinate marks the division between anterior and
posterior ethmoid sinuses. Posterior ethmoid air
cells are fewer in number but larger in size compared to anterior ethmoid air cells. The uncinate
process is a boomerang-shaped bone that runs
from anterosuperior to posteroinferior direction.
Superiorly, it can attach to the lamina papyracea
(85% of cases), middle turbinate, or skull base
(both account for 15% of cases). Interestingly, in
more than 50% of cases, it has multiple
ab cd
10 Endoscopic Nasal andParanasal Sinus Surgery
Fig. 10.3 Different attachment of uncinate process: (a) single attachment to lamina papyracea, (b) middle turbinate,
(c) skull base, or (d) multiple attachment
251
attachments in the nasal cavity. Figure 10.3
shows different attachment of the uncinate process in the nasal cavity [3].
The uncinate process has a horizontal and a
vertical component, whereby the latter is closely
related to the frontal recess. When the uncinate
process attaches to the lamina papyracea, the
frontal recess will drain medially to the uncinate
process into the middle meatus, and vice versa; if
lamina papyracea, and medially by the middle turbinate. Agger nasi cell is the most anterior ethmoid
air cell. If it enlarges, it can encroach the frontal
recess resulting in a narrower frontal recess drainage pathway. Besides that, the size of the drainage
pathway of frontal recess is also determined by
other cells. According to the International Frontal
Sinus Anatomy Classication, there are three
types of cells related to the frontal recess [5]:
the uncinate process attaches to the middle turbinate or skull base, then the drainage pathway of
the frontal recess will be lateral to the uncinate
process, hence draining into the ethmoid infundibulum. The ethmoid infundibulum is a threedimensional space located lateral to the uncinate
process. Bulla ethmoidalis is the largest and the
most prominent anterior ethmoid air cell on the
lateral nasal wall. It is bounded anteriorly by the
frontal recess and uncinate process, posteriorly
1. Anterior cells (push the drainage pathway of
frontal sinus medially, posteriorly, or posteromedially): agger nasi cell, supra agger cell,
and supra agger frontal cell
2. Posterior cells (push the drainage pathway
anteriorly): supra bulla cell, supra bulla frontal cell, supraorbital ethmoid cell
3. Medial cells (push the drainage pathway laterally): frontal septal cells
by the basal lamella of the middle turbinate,
medially by the lamina papyracea, and laterally
by the middle turbinate.
The outow tract of the frontal sinus resembles
an hourglass appearance in the sagittal plane. The
wider upper part of the hourglass (oor of the frontal sinus) drains into the wider lower part (frontal
recess) via the narrowest segment in the middle
(frontal ostium). Frontal recess is bounded anteriorly by the agger nasi cell, posteriorly by the bulla
ethmoidalis and supra bulla air cells, laterally by
The maxillary sinus is bounded by orbital
oor superiorly, alveolar process inferiorly, facial
surface of the maxilla anteriorly, infratemporal
fossa posteriorly, and lateral wall of nasal cavity
medially. The infraorbital nerve runs in the roof
of maxillary sinus to exit via infraorbital foramen
at the anterior surface of maxilla. About 14% of
cases have a dehiscent infraorbital canal, which
may increase the risk of nerve injury intraoperatively [4]. The natural maxillary sinus ostium
252
R. R. Ramli et al.
opens into the posterior third of the ethmoid
infundibulum on the superior part of the medial
wall of the maxillary sinus. On the other hand,
the accessory sinus ostium can be found in either
anterior or posterior nasal fontanelle. It is important to differentiate between the true and the
accessory sinus ostium so that we can enlarge the
true ostium and restore the drainage pathway of
the maxillary sinus. Occasionally, the anterior
ethmoid air cells can expand laterally into the
maxillary sinus, known as infraorbital ethmoid
cells or Haller cells.
Sphenoid sinus ostium can be found within
1cm behind the posteroinferior end of the superior turbinate, and most of the time the sphenoid
ostium (SO) is medial to it [6]. Besides that, the
roof of the maxillary sinus can be used as a reference point when looking for the SO.A horizontal
imaginary line is drawn at the level of the roof of
the maxillary sinus to the nasal septum [7], and
the SO is usually within 1cm medial to the nasal
septum [6]. Posterior choana can also be one of
the landmarks for SO as the SO is located about
1.5 cm above the posterior choana. Sphenoid
sinuses are surrounded by important neurovascular structures, namely internal carotid arteries
(ICA), optic nerves, cavernous sinuses, and other
nerves such as oculomotor, trochlear, maxillary,
vidian, and abducens nerves. Bony canal dehiscence for ICA and optic nerve were found to be
in approximately 25% and 6% of cases, respectively [8]. Onodi cells or sphenoethmoidal cells,
which are located at the superolateral part of
sphenoid sinuses, can also be seen occasionally.
10.3 Indications
The term ‘functional’ in functional endoscopic
sinus surgery (FESS) refers to the restoration of
the function of the sinonasal cavity, i.e. trying to
preserve as much mucosa as possible. The most
common indication for FESS is for chronic rhinosinusitis with or without polyp when maximal
medical therapy has failed. The goals for this procedure are to remove the diseased sinonasal
mucosa, allow adequate sinus drainage and ventilation, facilitate topical drug deliverance, and
facilitate the surveillance of disease recurrence
post-operatively.
Other indications include:
• Sphenopalatine artery ligation
• Orbital/optic nerve decompression
• Mucocele
• Invasive and non-invasive fungal rhinosinusitis
• Benign and malignant sinonasal tumour
• Cerebrospinal uid leaks
• Lesions involving pituitary fossa, petrous
apex, and pterygomaxillary fossa
10.4 Preoperative Evaluation
andSurgical Preparation
Optimizing the surgical eld in patients prior to
endoscopic sinus surgery increases the chances
for a safe and efcient surgery. Preoperative medical management, anaesthetic choice, patient
positioning, and topical vasoconstrictors are
methods currently used to mitigate cumbersome
bleeding during surgery. Decreased bleeding
improves the quality of the optical cavity, thereby
enhancing visualization of nearby critical
structures.
10.4.1 Patient Preparation
Before we proceed with endoscopic sinus surgery, one of the most crucial aspects that we need
to deal with is stabilizing the patient’s current
medical condition. We need to optimize patient
health, especially for those who had diabetes and
hypertension. Early referral to physician for
blood sugar monitoring and blood pressure control is mandatory.
The patient was also advised to stop smoking
for at least 1 month before the surgery. A study on
smoking habits in endoscopic sinus surgery
found an association between exposure to cigarette smoke and potentially severe surgical site
infections in the 30-day post-operative period
after ESS [9].
All the blood-thinning products such as garlic
and ginkgo biloba need to be stopped. Blood