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358
Table 32.3 Comparison between SMR and septoplasty
[9, 11]
Submucosal resection Septoplasty
The L-strut is not
addressed
Killian incision: placed
about 1cm cephalad
from the caudal end of
the septum
Radical surgery Conservative surgery
Higher probability of
complications
The L-strut is addressed
Hemitransxation incision:
placed at the caudal edge of
the septum and exposes the
L-strut.
Lower probability of
complications
Septoplasty may be required to correct a deviated nasal septum for the following:
• Irreversible symptomatic nasal obstruction
• Improving access for endoscopic sinus or
skull base surgery
• Septal spurs causing epistaxis
32.10 Complications
ofSeptoplasty
• Septal hematoma.
• Epistaxis from raw mucosal edges.
• Septal perforation: Bilateral opposing mucosal
tears, excessive packing and septal hematoma.
• Nasal obstruction can be caused due to inade-
quate correction of septal deformity and syn-
echiae from opposing, traumatized septal and
inferior turbinate mucosal surfaces.
• Nasal deformity occurs from excessive
removal of cartilage and preserving too little
dorsal or caudal cartilage struts.
32.11 Nasal Septal Perforation
M. Al Sulaiti et al.
Fig. 32.3 Nasal septal perforation
and epistaxis; these are consequences of disruption of laminar airow and its destructive effect
on the nasal tissues.
The usual mechanism for developing a septal
perforation is disruption of blood ow and ischemia of the septum. Despite its rich blood supply;
perforations most commonly involve the anterior
septum.
Treatment is mainly conservative by moisturizing the nasal mucosa with saline irrigation
and topical ointments. Surgery is necessary
only for patients who fail conservative treatment and are symptomatic. When septal perforations are related to an active disease, e.g.,
vasculitis, malignancy, or infection, treatment
should be directed at the underlying disease
process. Only once the etiology is controlled
the treatment can be tailored to the extent of the
symptomatology.
The most common causes of nasal septal perforations are trauma, iatrogenic, e.g., septoplasty, and
pharmacologic, e.g., intranasal corticosteroids
and cocaine abuse. Other etiologies such as vasculitis, malignancy, and infection should be considered when investigating a patient when a cause
is not apparent (Fig.32.3).
The majority of septal perforations are asymptomatic. Some of the most troublesome signs and
symptoms include a whistling sound, crusting,
32.12 Indications forSurgery
Include
Symptomatic perforations
• Crusting
• Whistling
• Nasal congestion
• Recurrent epistaxis
32 The Nasal Septum andTurbinates
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359
Perforations refractory to conservative
management:
• Nasal moisturizers
• Septal button
32.13 Contraindications toSurgery
Include
An active underlying cause such as:
• Vasculitis
• Malignancy
• Infection
• Diameter/location precluding harvesting of
adequate tissue for reconstruction (approximately >3cm)
32.14 The Turbinates
The inferior turbinate is an embryologically independent structure.
The inferior turbinate consists of a supporting
cancellous conchal bone which is attached along
the inferolateral aspect of the nasal cavity and
extending from the interior nasal valve to just
anterior to the Eustachian tube. The turbinate is
covered by a ciliated pseudostratied respiratory
mucosa that is supported by a lamina propria and
specialized erectile mucosa with vascular channels and venous sinusoids which serve to warm
and humidify air, modify nasal airow resistance
and maintain linear rather than turbulent air ow
within the nose.
The blood supply to the inferior turbinates is
from the lateral branch of the sphenopalatine
artery that enters the posterior aspect of the turbinate. Sensation is supplied by the trigeminal
nerve; sympathetic nerves travel along the feeding arterial blood vessels; the parasympathetic
supply also travels along the vascular supply but
travels along the vidian nerve before entering the
nose through the sphenopalatine foramen.
The normal inferior turbinate is a dynamic
structure that varies in size according to the
degree of congestion. Congestion is determined
by the control of blood owing through the specialized erectile tissue. This change is governed
by the autonomic neural supply:
• The sympathetic nerves induce reduction of
blood ow and a decrease in volume.
• The parasympathetic supply congests the
erectile tissue of the turbinate.
The degree of congestion varies in a cyclical
manner in a healthy nose every few hours and is
coordinated so that when one side is congested
the other is constricted. This phenomenon is
known as the nasal cycle.
The septum deviation itself gives rise for com-
pensatory changes in the nose; an atrophy of the
nasal turbinate on the convex side while the nasal
turbinates on the concave side enlarge. The turbinates regulate the nasal air stream in a way that
further functions like warming up and moistening are fullled even in the deviated nose.
Three different variations of inferior turbi-
nates are often encountered; these include [13]:
• Bony: Bony turbinate hypertrophy is usually
caused by a prominent (broad) inferolateral
turn of the turbinate; it is very large but normally shaped obstructing inferior turbinates
are also described.
• Soft tissue: very common and represents the
majority of cases of inferior turbinate hypertrophy. The common underlying pathophysiology in soft tissue hypertrophy is chronic
rhinitis and other conditions that cause chronic
mucosal inammation.
• Mixed hypertrophy: involves anatomic bony
hypertrophy in the setting of chronic rhinitis.
Pneumatization of the inferior turbinate may
cause inferior turbinate hypertrophy, which leads
to nasal obstruction.
32.15 Management ofthe
Hypertrophy oftheInferior
Turbinates (Table32.4)
AL GRAWANY
360
Table 32.4 Methods of treatment of the inferior turbinates hypertrophy [14–16]
Method
Turbinates
lateralization
Turbinates
soft tissue
reduction
Soft tissue
resection of
the turbinates
Bone
resection of
the turbinates
Turbinates
resection
Not sufcient as a stand-alone procedure for the management of signicant turbinate hypertrophy
The creation of an area of submucosal thermal injury, which ultimately heals by brosis and scar
contracture
• Monopolar
• Bipolar
• Radiofrequency:
– The temperature generated is signicantly lower than electrocautery
– The distribution of the heat is limited, allowing for a more focused reduction of the deeper
components of the inferior turbinate tissue
Can be done using specialized microdebrider blades
• Allows for precise and targeted removal which aims to reduce the bulk of the submucosal erectile
tissue of the turbinate without injury to the epithelium
• Reduction focused on the anterior half of the turbinates (nasal valve) which contributes mostly to
the air ow resistance
• Resection of the posterior part associated with higher risks of bleeding due to the arterial supply
by the sphenopalatine artery
• Indicated when the bony component is the major contributor to the patient’s turbinate hypertrophy
• Submucosal resection of the bone
• Ranges from limited resection of the anterior aspect of the turbinate to total resections
• Extensive subtotal or total resections have been suspected to predispose one to a paradoxic nasal
obstruction or atrophic rhinitis
M. Al Sulaiti et al.
Take Home Messages
• The nasal cavity is highly vascular, and
this serves multiple functions.
• A nasal septal deviation is considered
pathological once it has subjective reduction of the nasal breathing, so not all deviations need to be assessed surgically.
• Multiple approaches can be used to
address nasal blockage and it is different
from one patient to another.
• Nasal septal and turbinates surgeries are
simple procedures but can carry devastating complications.
References
1. Bridger GP. Physiology of the nasal valve. Arch
Otolaryngol. 1970;92:543–53.
2. Kern EB, Arbour P.The phenomenon of paradoxical
nasal obstruction. Arch Otolaryngol. 1976;102:669.
3. Proetz A.Applied physiology of the nose. St Louis:
Annals Publishing; 1941.
4. Sheen JH. Spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg. 1984;
73:230.
5. Glam T, Ahmad SK.Physiology of the nose and paranasal sinuses. In: Scott Brown Otorhinolaryngology
head and neck surgery. 8th ed. Boca Raton: CRC
Press; 2018. p.1025–34.
6. Yigit O, Akgul G, Alkan S, Uslu B, Dadas B.Changes
occurring in the nasal mucociliary transport in
patients with one-sided septum deviation. Rhinology.
2005;43:257–60.
7. Maran AGD, Lund VJ. Nasal anatomy. In: Maran
AGD, Lund VJ, editors. Clinical rhinology. Stuttgart:
Thieme; 1990. p.5.
8. Moore KL, Persaud TVN. The developing human.
Clinically oriented embryology. 6th ed. Philadelphia:
WB Saunders; 1998.
9. Dalgorf DM, Harvey RJ.Anatomy of the nose and
paranasal sinuses. In: Scott Brown otorhinolaryngology head and neck surgery. 8th ed. Boca Raton: CRC
Press; 2018. p.1025–34.
10. Mladina R, Čujić E, Šubarić M, et al. Nasal septal
deformities in ear, nose, and throat patients: an international study. Am J Otol. 2008;29(2):75–82.
32 The Nasal Septum andTurbinates
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11. Iqbal K, Khan MI, Amanullah A.Submucous resection versus septoplasty: complications and functional outcome in adult patients. Gomal J Med Sci.
2011;9(1):23–7.
12. Gray LP.Deviated nasal septum. Incidence and etiology. Ann Otol Rhinol Laryngol. 1978;87(3 Pt 3 Suppl
50):3–20.
13. Neskey D, Eloy J, Casiano R.Nasal, septal, and turbinate anatomy and embryology. Otolaryngol Clin N
Am. 2009;42:193–205, vii. https://doi.org/10.1016/j.
otc.2009.01.008.1
.
14. Cavaliere M, Mottola G, Iemma M.Comparison of
the effectiveness and safety of radiofrequency turbinoplasty and traditional surgical technique in treatment
of inferior turbinate hypertrophy. Otolaryngol Head
Neck Surg. 2005;133(6):972–8.
15. Swift AC, Leong SC.Management of enlarged turbinates.
In: Scott Brown otorhinolaryngology head and neck surgery. 8th ed. Boca Raton: CRC Press; 2018. p.1025–34.
16. Hol M, Huizing E. Treatment of inferior turbinate
pathology: a review and critical evaluation of the different techniques. Rhinology. 2001;38:157–66.
AL GRAWANY
Pitfalls andPearls inEndoscopic
Sinus Surgery
OmarM.Bargas andAhmadAbuAlsoud
33
33.1 Introduction
The history of endoscopic sinus surgery return to
early 1901 when HIRSCHMANN started using a
modied cystoscope after that Maltz bring the
name of the sinocopy to the world. The surgery
started to improve and clarify year by year with the
appearance of many interested rhinologist in the
USA and Europe like Messerklinger, Stammberger,
and Kennedy. Most of them assume that the endoscopic sinus surgery should be directed toward
dealing with the diseased mucosa and preserving
the normal tissue as much as possible. With further
advancement of technology and continuous study
of the anatomy and physiology of sinonasal region,
the surgery started to be tailored according to the
site of disease. Many nomenclatures then appear
like MIST (minimal invasive sinus technique) and
FESS (functional endoscopic sinus surgery), all of
which directed toward mucosal preservation and
avoidance of any unwanted mucosal stripping.
Anteroposterior and posteroanterior dissection are
the most followed technique in endoscopic sinus
surgery. The presence of new instruments, powered devices like microdebrider, various angled
telescopes, and navigation system make the sur-
O. M. Bargas
Anbar College of Medicine, Ramadi, Iraq
A. AbuAlsoud (*)
Union Memorial Hospital, Baltimore, MD, USA
gery more interesting and challenging, with the
proximity of vital structures like skull base, optic
nerve, and carotid artery. It is now necessary for
the surgeon to be familiar with anatomical variations and instrumentation to avoid injury to these
vital structures.
33.2 Position ofthePatient
andtheSurgeon
Each step in the patient and surgeon positioning
is important and designed to make the surgery
smooth. First of all, the surgeon has to sit or
stand at the right side of the patient. The surgeon can use a mayo stand to rest his arm. The
patient should be laying on a supine position
while the operating table is tilted 30° anti-Trendelenburg. Patient’s head has to be in a neutral
position. The monitor, patient’s head, and the
surgeon have to be in a straight line. It is not a
routine to sterilize the nose before the ESS;
however, sterile drape is recommended with
leaving the eyes exposed (it’s advisable to use
topical eye ointment to avoid dryness during
surgery). The surgeon can turn the head of the
patient to either direction for better angle and
eld. The scrub nurse should position their
instrument table parallel to the head.
© Springer Nature Switzerland AG 2021
A. Al-Qahtani et al. (eds.), Textbook of Clinical Otolaryngology,
https://doi.org/10.1007/978-3-030-54088-3_33
363
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33.3 Nasal Preparation
andVasoconstriction
There are different materials and medications used
in nasal preparation. The choice depends on the
surgeon preference, patient’s allergic history or
comorbidities, and medications availability. For
the nasal preparation, different packing can be
used, e.g., neurosurgical patties or cotton ball. The
communication with the anesthetist about the
medications is the most important thing to do prior
to the packing. Nasal preparation can be started by
using a counted number of packs soaked with 1%
oxymetazoline or cocaine in the nose for few minutes. If no contraindications, the lidocaine-adrenaline combination is drug of choice for inltration;
however, the concentration will be adjusted
according to the patient. The area above the anterior end of the middle turbinate and the back end
of the middle turbinate in the region of the sphenopalatine artery are injected. Another injections can
be done in the anterior wall of the bulla, greater
palatine foramen, and even the polyps itself.
O. M. Bargas and A. AbuAlsoud
Fig. 33.1 CT scan of paranasal sinuses demonstrate the
uncinate process (white arrow) and the Maxillary ostium
(yellow asterisk)
33.4 Surgical Steps
33.4.1 Uncinectomy
The entrance to the endoscopic sinus surgery usually occurs from the uncinate door. Uncinectomy
(aka infundibulotomy) usually began with identication of the posterior free border of this
sickle shaped structure by an angled ball probe
or curette at the same time the probe is advanced
superiorly to identify the variable attachment of
the superior end of the uncinate. The whole uncinate (Fig.33.1 white arrow) should be removed
otherwise there is risk of ESS failure and orbital
injury. The techniques of uncinate removal are
variable, all of them are aimed to complete excision of the uncinate and identication of the
natural maxillary ostium. Swing door technique
is our favorable technique [1] which began with
making a cut in the middle 1/3 of the anterior
attachment of the uncinate by the sickle knife or
by size 11 blade, then it is advanced superiorly
and inferiorly to free the attachment of uncinate,
Fig. 33.2 Endoscopic picture explaining how the back-
bitter engage the posterior border of the uncinate process
by the sickle itself or by freer’s dissector; the
uncinate slightly moved medially away from the
lamina papyracea; here a pediatric (or adult size)
backbiter introduced in the middle meatus and
opened to engage the free posterior border of the
uncinate (Fig.33.2) and remove part of the uncinate to free it from the horizontal part and again
make another cut near its superior attachment;
here the orbit is guarded by the frontal process
AL GRAWANY
33 Pitfalls andPearls inEndoscopic Sinus Surgery
of maxilla [2] which is a hard bone, then remove
the remaining part of the uncinate between the
two cuts by straight Blakesley forceps. The bone
of the horizontal part of the uncinate which
passes inferiorly to natural maxillary ostium is
dissected free from the mucosa. Now the natural maxillary ostium (Fig. 33.1 yellow asterisk)
can be easily identied by angled degree or even
by zero degree endoscope. Another technique to
remove the uncinate is by removing a small portion of the uncinate by through-cutting backbiter
to create a raw edge, then completely removing
the bone either by microdebrider or upward and
downward angled through-cutting Blakesley forceps. Using microdebrider allows trimming these
edges without exposing the bone and thus allows
healing by primary intention without scaring.
Pitfalls in Uncinectomy
• Take care of the variable attachment of
superior end of the uncinate.
• Be aware of the atelectatic uncinate as
in case of silent maxillary syndrome
where the risk of orbital injury is high,
so try retrograde excision rather than
anterior one.
• Palpate the lateral nasal wall to identify
the uncinate which considered a slightly
mobile bone unlike the frontal process
of maxilla to avoid injury to nasolacrimal duct.
365
Fig. 33.3 Endoscopic picture after performing infundib-
ulotomy showing the natural maxillary ostium (NO),
uncinate (U) and middle turbinate (MT)
33.4.2 Middle Meatal Antrostomy
After completing dissection of the horizontal part
of the uncinate process, the natural maxillary
ostium can now be easily visualized in the opened
infundibulum (Fig. 33.3); it is an oval shaped
mucosal opening with oblique orientation; its
superior margin marks the junction between
orbital oor and the lamina papyracea. In case of
minimal sinus disease, the natural ostium can be
only stretched with ball probe of sucker without
removing the mucosa while if there is extensive
mucosal disease or in presence of accessory max-
Fig. 33.4 Endoscopic picture of the nose showing the
accessory ostium (AO), bulla ethmoidalis (B) and the
middle turbinate (MT)
illary ostium (Fig. 33.4); here it should be
enlarged and connected to the accessory ostium
to avoid the chance of circular mucus ow. The
optimal size of the enlarged ostium is variable
and may be tailored to the severity of the disease.
The enlargement can be started with using backbiter forceps which engage the anterior lip of the
ostium and start cutting till fell a hard bone which
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represents the nasolacrimal duct system, then the
ostium can be enlarged posteriorly but take care
of the sphenopalatine artery which may be
injured far posteriorly [3]. Inferior enlargement
can also be done by down-biting forceps; here
also avoid injury to superior surface of inferior
turbinate which may lead to more bleeding. Now
with angled endoscope the interior of the maxillary sinus can be visualized entirely.
Pitfalls on MMA
• Don’t widen the maxillary ostium far
posteriorly or far anteriorly.
• Keep the orbital oor your superior
limit.
• Try to distinguish between accessory
and the natural maxillary ostium.
33.4.3 Anterior Ethmoidectomy
Ethmoidal bulla (Figs.33.5 and 33.6) is the largest and the most constant anterior ethmoidal cell.
Its size and degree of pneumatization is variable
so as its superior extension, its roof may be continuous with the skull base and may house the
Fig. 33.5 Bulla red asterisk. Yellow arrow head: hiatus
semilunaris inferior
O. M. Bargas and A. AbuAlsoud
Fig. 33.6 Endoscopic picture of the nose after opening
of the bulla (B) and the natural maxillary ostium (NO)
anterior ethmoidal artery or it may leave as a
space above it known as suprabullar recess and
here the anterior ethmoidal artery may run within
the skull base or in isolated mesentery hanging
downward. Rarely the anterior ethmoidal artery
runs on the anterior surface of the bulla. Ethmoidal
bulla located posterior to uncinate process and
separated from it by hiatus semilunaris inferior
(Fig. 33.5). Its natural ostium opens posteromedially [4] and it can be identied after excision
of the anterior wall. Entrance to the bulla starts
with puncturing it infero-medially to be away
from the roof and the lateral wall which is represented by the lamina papyracea by using angled
ball probe, angled curette, or even a suction tube.
Then start removal of the remaining walls by
either angled through-cutting Blakesley or shaver
and try to stay away from the lamina papyracea
which marks the lateral limit of dissection. It is
recommended to compress the eyeball gently and
dissect the bulla to highlight the lamina papyracea and to be sure you are away from the eye. At
the same time you may leave a thin rim on the
antero-lateral junction which may be used as
landmark for dissection if you lost during dissection as it represents second ethmoturbinals after
the rst one (uncinate process). After completing
the excision of the uncinate and the bulla, now the
natural maxillary ostium, the basal lamella, and
the frontal recess will be demonstrated clearly.
AL GRAWANY
33 Pitfalls andPearls inEndoscopic Sinus Surgery
Pitfalls on Anterior Ethmoidectomy
• Puncture the bulla infero-medially.
• Read the CT scan well before surgery to
know the expected location of AEA.
• Take care of the haller cell.
33.4.4 Posterior Ethmoidectomy
The transition between anterior (frontal, maxillary,
and anterior ethmoidal) sinuses to the posterior
(posterior ethmoid and sphenoid) sinuses considered the cornerstone of endoscopic sinus surgery.
The basal lamella or the ground lamella can be
regarded as the second oblique part of the middle
turbinate and represent the bridge between the anterior and posterior ethmoidal cells (Figs.33.7 and
33.8). After dissecting the bulla, the basal lamella
will be the next block to be dissected. The entrance
to the posterior ethmoidal cells start with opening
the basal lamella infero- medially just above the
junction between the vertical and horizontal part of
the lamella to achieve that the endoscope is passed
under the middle turbinate till reaching its end, then
it is brought anteriorly under the horizontal part
till it turns vertically and just above this point and
enters the sinus by angled curette or suction tube,
then complete dissecting the posterior ethmoidal
cells by using through-cutting Blakesley, mushroom forceps, or by microdebrider. Here also the
367
Fig. 33.8 Endoscopic Picture after completing anterior
ethmoidectomy showing the basal lamina (BL), maxillary
sinus (MS), Frontal recess (FR) and the asterisk refer to
the site of penetration the posterior ethmoid aircells
lateral limit is represented by the lamina papyracea.
Keeping dissection below the level of antral roof is
a safe way to avoid the slopping skull base [5].
Pitfalls on Posterior Ethmoidectomy
• The posterior ethmoidal air cells are
larger than the anterior ones.
• Look for onodi cells on CT to avoid
injury of optic nerve and carotid artery.
• The PEA is larger than AEA and locate
on the skull base just anterior to the
sphenoid face.
• Entrance to posterior ethmoid via this
way minimizes the risk of skull base
injury, which may result if entrance
occurs far above the point of junction
between the horizontal and vertical part
of ground lamella.
33.4.5 Sphenoidotomy
Sphenoid sinus (Figs.33.9 and 33.10) represents
the posterior room of the endoscopic sinus surgery; behind it the cranial cavity is located and
the sphenoid ostium is located medial to superior
turbinate in 83% of the patients [6]. Approach to
sphenoid sinus is a step-up in endoscopic sinus
surgery requiring good knowledge and excellent Fig. 33.7 The posterior ethmoidal cells (yellow asterisk)
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Fig. 33.9 SS sphenoid sinus, blue arrow represents the
frontal recess
O. M. Bargas and A. AbuAlsoud
Transnasal: Sometimes approaching the sphe-
•
noid sinus can be done via nasal cavity rather
than through ethmoidal sinuses and this is
mostly chosen when the disease is isolated to
sphenoid sinus like mycetoma, mucocele or
even isolated sphenoiditis. To do this, the
endoscope is passed medial to middle turbinate and this may require reduction in middle
turbinate, then identify the sphenoethmoidal
recess between the superior turbinate tail and
the nasal septum; here the natural ostium can
be visualized by careful palpation of the anterior sphenoidal wall by the suction tip or blunt
instrument. The natural ostium looks like a
slit, then start widening it in four directions.
Another method for transnasal approaching of
the sphenoid sinus is by locating the choana
which considered a xed and important landmark to reach the sphenoid sinus; here advance
the endoscope toward the choana, then move it
slightly upward on the anterior sphenoidal
wall for 1–1.5 cm and start palpating with
blunt instrument to reveal the natural ostium if
failed to do so, then articial opening can be
done in this area then start widening. Widening
of the sphenoidotomy can be done by mushroom forceps or the through-cutting forceps
and try to avoid microdebrider in this area.
Fig. 33.10 Endoscopic picture after completing poste-
rior ethmoidectomy showing the maxillary sinus posterior
ethmoidal cell (PE), sphenoid sinus (SS) and the maxillary sinus (MS)
Pitfalls in Sphenoidotomy
• Sphenoid sinus opening considered
advanced step in sinoscopic surgery.
• The sphenoid sinus can house multiple
complete and incomplete septa which
orientation of the normal anatomy and anatomical variation to avoid damage to nearby vital
structures like optic nerve and carotid artery.
Entry to sphenoid sinus can be done endoscopically by one of the following two techniques:
may be attached to carotid artery so take
care in resecting it.
• Don’t widen the ostium more inferiorly to
avoid injury to a branch of sphenopalatine
artery which may result in troublesome
bleeding also don’t go more laterally to
• Transethmoidal: After completing the dissec-
tion of the posterior ethmoidal cells, the
ground lamella of the superior turbinate perforated infero-medially to avoid skull base superiorly and lamina papyracea laterally. Then
this entry is widened medially to engage the
avoid optic and carotid artery injury.
• Don’t remove the mucosal lining of the
sphenoid sinus; try just wash, suction,
and leave it clean.
• Don’t be deceived by onodi cell which
may house the optic nerve.
natural ostium, superiorly and inferiorly.
AL GRAWANY
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