Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4518_Библиотеки_им_академика_М_И_Перельмана
.pdf
6 Rhinology
https://t.me/medicina_free
• Foreign bodies (local irritation or secondary to attempts at removal).
• Tumors (secondary to erosion into vessels).
• Carotid aneurysm (rare, usually a late complication occurring several
Systemic.
• TB, Wegener’s granulomatosis (respiratory tract granulomas, vasculitis,
• Hypertension—association between epistaxis and hypertension is con-
• Hereditary hemorrhagic telangiectasia.
75
years after trauma accompanied by monocular blindness).
and glomerulonephritis), sarcoidosis (noncaseating granulomas),
syphilis.
– Symptoms=crusting, friable mucosa, septal perforation.
troversial; recent systematic review and meta-analysis did support this
association.
– Autosomal dominant, numerous small vascular malformations of the
skin and mucosal linings of the aerodigestive tract, AVMs of larger
organs (lung, liver, brain).
– Epistaxis and GI bleeding common, onset at puberty and worsens
with age.
– Lack of normal vascular smooth muscle, impairs ability to contract.
– Treated with bipolar cautery or laser ablation, septodermoplasty, or
nasal closure as a last resort.
– Use of bevacizumab (Avastin), a VEGF inhibitor, has had increasing
use as an intranasal injection.
Blood dyscrasias.
• Thrombocytopenia which has a broad differential diagnosis and can be
classied by a production, destruction, or redistribution problem.
• Alcoholism, malnutrition, malignancy, immunodeciency, liver or kidney failure.
– Characterized by reduced platelet aggregation, prolonged bleeding
time; treat with platelet transfusion for severe bleeds.
• von Willebrand disease.
– Deciency of von Willebrand protein leads to defective platelet adhe-
sion and decreased activity of clotting factor VIII; treat with DDAVP,
cryoprecipitate, or von Willebrand protein concentrate for
severe bleeds.
• Hemophilia.
– Deciency in clotting factor VIII (type A) or IX (type B); treat with
factor VIII or IX concentrate.
76
https://t.me/medicina_free
K. Phillips et al.
• Drugs (i.e., NSAIDs, anticoagulants).
– NSAIDs, ASA, and clopidogrel characterized by reduced platelet
function; treat with platelet transfusion.
– Coumadin inhibits formation of multiple clotting factors; reverse
with vitamin K and FFP.
– Other anticoagulants include heparin, enoxaparin, rivaroxaban, dabi-
gatran, apixaban, edoxaban, and fondaparinux, whose all mechanisms of action target the clotting cascade at different levels.
– Management: Determine acuity, and remember ABCs; ensure patient is sta-
ble, and address any systemic disease or obvious associated comorbidity.
Topical vasoconstriction (e.g., oxymetazoline) and manual pressure at the
lower 1/3 of the nose for minor bleeds.
Cauterization (silver nitrate, electric, or KTP/argon laser).
Nasal packing can be absorbable or non-absorbable and can place pressure either anteriorly or posteriorly, ranging from a variety of nasal tampon devices to Vaseline gauze packing to absorbable hemostatic
materials.
• Absorbable packing:
– Does not necessarily need to be removed.
– Useful in patients on anticoagulation, with thrombocytopenia, or
other blood dyscrasias or in other systemic illness predisposing to
epistaxis
• Anterior packing:
– Removed after 2–5days, depending on severity and etiology
– Can be managed outpatient unless patient is frail or has underlying
coagulopathy, which requires treatment
– Complications: toxic shock syndrome (give anti-staphylococcal anti-
biotic while packing in place), sinusitis from blockage of sinus ostia,
septal necrosis/perforation
• Posterior packing:
– Often requires sedation due to discomfort.
– Requires inpatient stay to monitor airway; elderly or frail patients
and those with underlying cardiopulmonary disease should be monitored in intensive care unit with low threshold for intubation.
– Complications: airway compromise, nasal-vagal reex (hypotension
and bradycardia), alar necrosis.
Greater palatine foramen injection (local anesthetic 1% lidocaine 1:100,000
epinephrine inltrated into foramen—must aspirate prior to injection to
ensure not in the vessel) helps control posterior bleeds.
Surgical evaluation with ligation of bleeding vessel(s):
6 Rhinology
https://t.me/medicina_free
• Internal maxillary artery (IMA): open posterior maxillary sinus wall;
• Sphenopalatine artery (SPA): endoscopically dissect in a subperiosteal
• Anterior/posterior ethmoid arteries (AEA/PEA): can either identify
Angiography and embolization:
• Angiography identies site of active bleed; interventional radiologist
• Complications: blindness (more common with internal carotid branches,
77
identify branches of IMA in pterygopalatine foramen and ligate
with clips.
plane along the medial inferior maxillary wall just anterior to lamellar
attachment of middle turbinate; identify SPA as it exits at crista ethmoidalis, and ligate with clip or cauterize.
endoscopically and cauterize with bipolar cautery within the nasal cavity or perform Lynch incision and dissect periorbita off medial orbital
wall; AEA located 8–12mm from lacrimal crest, PEA 10–12mm from
AEA, and optic nerve 4–6mm from PEA.
performs embolization of specic branch or branches of external
carotid.
and embolization of these branches would only be undertaken in a lifesaving procedure), necrosis, stroke, facial pain, paresthesia.
Benign Masses/Abnormalities
• Nasopharyngeal cysts
– Rathke’s pouch cyst or craniopharyngioma
Remnant of ectodermal tissue precursor of anterior pituitary gland
Tx=reassurance versus endoscopic marsupialization if symptomatic
– Tornwaldt cyst
Remnant of caudal notochord
Tx=reassurance versus endoscopic marsupialization if symptomatic
• Midline nasal masses
– Arise as a result of failure of closure of anterior nasopore
– Persistence of fonticulus frontalis (opening between nasal and frontal bones
in the embryo) allows for intracranial connection to prenasal space
– MRI=allows for assessment of intracranial extension (IC)
– Biopsy of midline nasal mass in children contraindicated due to risk of IC
extension
– Tx = open vs. endoscopic surgical excision, depending on whether or not
external nasal structures involved
– Glioma
78
https://t.me/medicina_free
60% Extranasal, 30% intranasal, 10% combined
“Pinched off” glial tissue; can appear red and be confused with
hemangioma
Symptoms=rm, nontender, noncompressible mass that does not transilluminate or change in size
– Encephalocele, meningocele, meningoencephalocele
Herniation of meninges (meningocele), meninges + brain (meningoencephalocele), or meninges+brain+part of ventricular system (meningoencephalocytocele) through skull base defect.
Sac of glial tissue lined with ependymal cells.
25% Anterior (sincipital/external versus basal/internal) and 75% posterior,
or occipital inlocation.
• Sincipital/external: herniation occurs anterior to crista galli between
frontal and ethmoid bones, presenting as external mass over nose or
glabella.
• Basal/internal (less common): herniation occurs posterior to cribriform
plate, presenting as an intranasal mass.
Symptoms: soft, compressible mass that transilluminates and increases in
size with crying (positive Furstenberg test)
– Dermoid Cyst
K. Phillips et al.
Sequestration of ectodermal and mesodermal elements anywhere along a
tract extending from foramen cecum to nasal tip
Symptoms=Fistulous tract, nasal pit with tuft of hair
– Fibro-osseous lesions (nd also in Systemic Diseases chapter)
Osteoma=most common benign sinonasal lesion
• Frontal sinus most common
• Gardner’s syndrome = skull osteomas, colonic polyps, and soft tissue tumors
Fibrous dysplasia
• Two types: Monostotic (most common, 70–80%) and polyostotic
McCune-Albright syndrome=polyostotic lesions, precocious puberty,
pigmented skin lesions
• CT ndings: Early = radiolucent; Late = “ground
glass”+calcications
• Tx=surgery only if symptomatic (debilitating pain or cosmetic deformity effecting quality of life), bisphosphonates
Ossifying broma
• Solitary encapsulated slow-growing monostotic tumor
• CT ndings=central lucency with eggshell rim
• Tx=surgery
6 Rhinology
https://t.me/medicina_free
Aneurysmal bone cyst
• Often seen in rst and second decades of life
• Osteolytic lesion consisting of blood-lled spaces separated by osteoid
tissue and containing osteoclast giant cells
– Cerebrospinal uid (CSF) rhinorrhea, may be associated with encephaloceles
or other midline nasal masses
Can present with unilateral rhinorrhea, postnasal drip, metallic or salty
taste, pulsatile tinnitus, headaches, balance disturbance, visual change,
headaches, or history of recurrent meningitis.
Workup includes testing of rhinorrhea for beta-2 transferrin positivity and
imaging of the skull base (thin-cut CT to evaluate for bony dehiscence,
thinning, or scalloping of the skull base and MRI to evaluate for encephalocele and associated intracranial ndings of elevated intracranial pressure) and may need CT cisternogram for occult cases.
Classied into four categories, congenital, traumatic/iatrogenic, neoplastic, or spontaneous:
• Congenital CSF leaks are often associated with malformations or the
meningoencephalocele spectrum; repair is dictated by location and particular local expertise of treating otolaryngologist and neurosurgeon.
• Traumatic CSF leaks complicates 2% of head trauma and 12–30% of
basilar skull fractures; can be treated conservatively with strict bedrest,
head-of-bed elevation, restriction of straining with the aid of antiemetics and stool softeners, and CSF diversion procedures. If the leak fails to
respond to conservative management or depending on clinical status, it
can be repaired either endoscopically or open (techniques described
below in the “Major Complications of Sinus Surgery” section).
• Iatrogenic CSF leaks are often repaired at time of injury and are
described below in the “Major Complications of Sinus Surgery” section.
• Neoplastic CSF leaks are managed in the context of malignancy.
• Idiopathic CSF leaks are often associated with idiopathic intracranial
hypertension (IIH) and present spontaneously; more common in obese
middle-aged women; associated ndings on imaging include broadly
attenuated or scalloping of the skull base, arachnoid pits, multiple skull
base defects, or empty sella syndrome. It often requires multidisciplinary approach including evaluation by otolaryngology, ophthalmology, neurology, and neurosurgery. Treatment includes repair of skull
base defect (techniques described below) and then possible trial of acetazolamide (carbonic anhydrase inhibitor), weight loss, bariatric surgery,
or CSF diversion techniques depending on the clinical situation.
79
– Inverted papilloma—most common benign epithelial tumor of the nose and
paranasal sinuses
Arises from the Schneiderian membrane (transition between the endodermderived respiratory epithelium and the ectoderm-derived squamous epithelium), association with HPV (usually types 6 and 11).
80
https://t.me/medicina_free
Histologically, the epithelium inverts into underlying stroma but does not
cross the basement membrane.
Appears as a unilateral exophytic pink to tan mass.
Most common sites of attachment include the lateral nasal wall and maxillary sinus (may see bony thickening at site of attachment on CT).
Can be locally destructive with tendency to reoccur and associated 10%
malignancy rate and therefore treated with aggressive surgical resection
with close surveillance after resection.
In addition to inverted papilloma, other intranasal papillomas arising from
the Schneiderian membrane include fungiform/exophytic papillomas
(most commonly on nasal septum) and oncocytic/cylindrical papillomas.
– Antrochonal polyp
Benign unilateral lesion arising from a cyst in the maxillary sinus growing
into the nasal cavity to the choana, often presenting with nasal obstruction
Treatment with surgical resection including attachment site in the maxillary sinus to prevent reoccurrence
– Vascular lesions
Hemangioma—often along septum or inferior turbinate, present with epistaxis; if symptomatic, treat surgically (+/− perioperative embolization);
can be associated with pregnancy and should be treated conservatively in
pregnancy if able
Hamartomas
K. Phillips et al.
• Respiratory epithelial adenomatoid hamartoma, which often originates
in the olfactory cleft; can be associated with nasal polyposis
• Seromucinous hamartoma, which shows haphazard proliferation of
seromucinous glands
Sinonasal Malignancy
See Head and Neck chapter.
Surgical Approaches
• Endoscopic approach (endoscopic sinus surgery or ESS)
– Technique=Rigid nasal endoscopy+/−stereotactic image guidance; typical
steps include medialization of middle turbinate, removal of uncinate process,
maxillary antrostomy, ethmoidectomy, sphenoidotomy, and frontal recess
exploration with sinosotomy as needed.
6 Rhinology
https://t.me/medicina_free
Consider mega-antrostomy or pre-lacrimal approach in patients with cystic
brosis, recalcitrant inammatory disease, tumor access, or need for better
visualization/monitoring of the maxillary sinus.
– Four lamellae encountered (anterior → posterior)=uncinate process → eth-
moid bulla → vertical portion of middle turbinate basal lamella → vertical
portion of superior turbinate basal lamella.
– Should be considered for any lesion or disease process (congenital, inamma-
tory, neoplastic, traumatic, etc.), which can be accessed endoscopically, but
the rhinologic surgeon must be familiar with open approaches for lesions that
are inaccessible or incompletely addressed via this approach.
– Complications=bleeding, synechiae, injury to the eye including blindness,
CSF leak, nasolacrimal duct injury, hyposmia, and brain injury.
– Specic endoscopic approaches to the frontal sinus:
Draf I: complete removal of the anterior ethmoid cells and uncinate process within the frontal recess leading to the frontal ostium. Obstructing
frontal cells, if present, are removed. The frontal sinus ostium may then
drain into a patent frontal recess, but the frontal sinus ostium itself is not
instrumented.
Draf IIa: resecting all included in Draf I with the addition of widening the
frontal sinus ostium itself, resecting all of the frontal sinus oor from lamina to the insertion of the middle turbinate medially.
Draf IIb: resecting all included in Draf IIa with the addition of resecting
the middle turbinate up to skull base and widening the frontal sinus medially to the septum.
Draf III (aka modied Lothrop): resecting all included in Draf II, with the
addition of a superior anterior septectomy, removing the intersinus septum,
and connecting bilateral frontal sinuses into one horseshoe-shaped sinus
with a common drainage pathway.
81
– Specic endoscopic approaches to the maxillary sinus:
Medial maxillectomy (aka mega-antrostomy).
• Indications include intractable maxillary sinus inammatory disease,
benign tumors of the maxillary sinus, maxillary sinus malignancies that
have not invaded into surrounding soft tissue, and access to the pterygopalatine fossa, infratemporal fossa, and middle cranial fossa.
• Steps include maxillary antrostomy, identication of Hasner valve, and
resection of the posterior 2/3 of the inferior turbinate just posterior to
the valve (unless the nasolacrimal duct is involved in which case a dacryocystorhinostomy would also be indicated) and of the medial wall of
the maxillary sinus until nasal oor is ushed.
• For anterior/lateral maxillary sinus access, other modications may be
needed (pre-lacrimal approach).
• If there is ethmoid involvement, the lamina papyracea may need to be
removed with care to leave the periorbital intact.
82
https://t.me/medicina_free
– Specic endoscopic approaches to the ventral skull base:
Transphenoidal
• Indications—approach to lesions within clivus, sella, tuberculum, or
planum, e.g., pituitary lesions, meningomas, Rathke’s cleft cyst,
craniopharyngiomas.
• Steps include lateralization of turbinates, bilateral sphenoidectomy,
posterior septectomy, preservation of bilateral rescue aps, creating
common sphenoid cavity by taking down the rostrum, and expanding
the opening to visualize bilateral optico-carotid recess as well as other
landmarks depending on the level and size of the lesion.
Transpterygoid
• Indications—endonasal access to the lateral recess of the sphenoid
sinus, middle cranial fossa (petrous apex, Meckel’s cave, cavernous
sinus), infratemporal fossa, or the eustachian tube and nasopharynx.
• Steps include raising the contralateral nasoseptal ap if a CSF leak is
anticipated or possible (as the ipsilateral SPA will likely be sacriced), ranssphenoidal approach, modied medial maxillectomy,
removal of the posterior wall of the maxillary sinus with care to leave
the posterior periosteum intact to prevent spilling the fat of the PPF,
ligation of SPA, retraction of PPF contents, and inferior and lateral+/−removal of the pterygoid plates depending on specic region
needed for access.
K. Phillips et al.
Transclival
• Indication—endonasal access to clivus, posterior cranial fossa; same
anterior approach as for nasopharyngectomy.
• Steps include inferior posterior septectomy, drilling down of maxillary
crest, identication of medial pterygoid plates, and identication of
where eustachian tubes may need to be transected. Finding
buccopharyngeal and pharyngobasilar fascia, either using to create a
plane or transecting to move past to skull base. For posterior cranial
fossa, approaches involving the upper cervical spine may need to consider C-spine xation rst.
Open Approaches
• Caldwell Luc
– Used most often to gain access to the anterior wall of the maxillary sinus
– Performed through canine fossa with incision at gingivobuccal sulcus
6 Rhinology
https://t.me/medicina_free
– Can augment endoscopic surgery; good for anteriorly attached IP or other
tumors, broader access to orbital oor and PPF
– Complications = cheek edema/ecchymosis, numbness or pain with infraor-
bital nerve injury, oroantral stula, epiphora if damage to nasolacrimal duct
• External ethmoidectomy
– Provides access to ethmoid cavity, medial orbit, cribriform plate, and fronto-
nasal area if endoscopy is not an option; can be employed to decompress
subperiosteal abscess
– Complications=eye injury including blindness and corneal abrasions, CSF
leak, skull base injury, bleeding from AEA+/−retraction of vessel into the eye
• External frontoethmoidectomy (Lynch procedure) or frontal trephine
– Indications: uncommonly used now, when endoscopic approach is for any
reason insufcient to address frontoethmoid mucocele, mucopyocele, rhinosinusitis with orbital complications, frontoethmoid or anterior skull base
tumor, CSF leak repair, acute sinusitis with intracranial or orbital complications or not responsive to medical management and unable to access endoscopically, lateral frontal mucocele
– Complications = bleeding, epiphora, frontal sinusitis, diplopia, blindness,
CSF leak, intracranial hemorrhage
• Osteoplastic ap with frontal sinus obliteration or cranialization
83
– Indications = when endoscopic approaches are insufcient or have failed to
address osteomyelitis, mucocele, frontal sinus tumor, osteoma, recurrent persistent frontal sinusitis, trauma with comminuted anterior or posterior table fractures
• Open approaches to sphenoid sinus (historically used by neurosurgeons in pituitary surgery)
– Transseptal: incision can be endonasal, sublabial, or transcolumellar
• Transfacial incisions
– Lateral rhinotomy (incision made in naso-facial crease for small lesions of
nasal cavity and medial maxilla), historically used for IP, no longer “gold
standard”
– Weber-Ferguson (incision for lateral rhinotomy extended laterally in subcili-
ary crease and inferiorly along philtrum through vermilion border to split lip,
provides wide access for most sinonasal tumors)
• Craniofacial resection
– Bifrontal craniotomy with transfacial exposure of sinonasal cavity and orbits,
allows for access to anterior cranial fossa
– Used to approach skull base pathology including malignancy that cannot, for
whatever reason, be accessed via the endoscopic approach
84
https://t.me/medicina_free
K. Phillips et al.
Major Complications ofSinus Surgery
• Orbital
– Includes blindness (direct injury or hematoma), penetration of orbit (may see
fat herniation), diplopia (muscle injury—often medial rectus or superior
oblique muscle), and epiphora (damage to lacrimal system).
– Retrobulbar hematoma is an acute complication which must be recognized
immediately and treated to avoid blindness.
Cause = most commonly from venous injury near lamina papyracea or
arterial injury to AEA during endoscopic surgery → retraction of vessel
into orbit where pressure from hematoma compresses optic nerve.
Sx=proptosis, chemosis, ecchymosis, and vision change (if awake).
Treatment = immediate ophthalmology consult; ice packs; mannitol;
remove any nasal packing if it has been placed; surgical intervention (lateral canthotomy+/−medial orbital wall decompression).
Prevention=keep eyes visible during surgery, and evaluate any imaging
preoperatively to identify AEAs which run below skull base.
• Major vascular injury to carotid artery
– Place enough pressure with pledgets to staunch blood ow but not compress
artery fully, preserving blood ow to the brain.
– Can harvest muscle patch, crush and place to repair minor injuries.
– Regardless of whether muscle patch is placed, patient needs to then undergo
interventional angiography to evaluate the vessel and branches.
• CSF leak.
– If identied at the time of surgery, the defect should be repaired at that time
(most common site of iatrogenic injury = lateral lamella of ethmoid roof)
depending on surgeon comfort or immediate referral to rhinologist.
– If identied postoperatively (beta-2 transferrin positive thin watery rhinor-
rhea) conservative management can be tried rst, although many surgeons
would opt to go straight to surgery for repair.
– Conservative treatment=7–10days of bed rest, head elevation, stool soften-
ers to avoid straining, and lumbar drain for diversion (+/− antibiotics (pro-
phylaxis for meningitis)—no evidence to support use; however most continue
to use).
– Surgical repair:
Intracranial approach (50–70% success rate) requires a coronal approach
and carries risks of frontal lobe dysfunction, cerebral edema, seizures, and
anosmia.
Extracranial approach (80% success rate) uses transfacial incisions, providing better visualization of the site of CSF leak but resulting in facial
scarring.
Соседние файлы в папке Библиотека им академика М.И. Перельмана