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AshuSeithBhalla Radiology, AIIMS, New Delhi, India
e-mail: ashubhalla1@yahoo.com
Avni Jain ENT, ESIC Medical College Faridabad, Faridabad, Haryana,
India
e-mail: avanijain87@hotmail.com
BhartiDevnani Radiotherapy, AIIMS, New Delhi, India
e-mail: bhartidevnani@gmail.com
DarwinKaushal ENT, AIIMS, Jodhpur, Rajasthan, India
e-mail: drdarwin.aiims@gmail.com
DavidVictorKumarIrugu ENT, AIIMS, New Delhi, India
e-mail: irugudavid72kumar@rediffmail.com
Debesh Bhoi Anaesthesiology, Pain Medicine and Critical Care, AIIMS,
New Delhi, India
e-mail: debeshbhoi@gmail.com
DeepaliJain Pathology, AIIMS, New Delhi, India
e-mail: deepalijain76@gmail.com
GagandeepSingh Microbiology, AIIMS, New Delhi, India
e-mail: drgagandeep@gmail.com
List of Contributors
GanakalyanBehera ENT, AIIMS, Bhopal, MP, India
e-mail: drganakalyan@gmail.com
GauravGupta ENT, SP Medical College, Bikaner, Rajasthan, India
e-mail: drgauravgupta24@gmail.com
GopicaKalsotra ENT, GMC, Jammu, India
e-mail: drgopikapgimer@gmail.comm
GurbaxSingh ENT, GGS Medical College and Hospital, Faridkot, Punjab,
India
e-mail: drgurbax@gmail.com
GyanNayak ENT, PGIMER, Chandigarh, India
e-mail: gyani.nayak@gmail.com
HarpreetKocher ENT, Yatharth Superspeciality Hospital, Greater Noida,
UP, India
e-mail: hpskochar@gmail.com
HitenderGautam Microbiology, AIIMS, New Delhi, India
e-mail: drhitender@gmail.com
HiteshVerma ENT, AIIMS, New Delhi, India
Department of ENT, AIIMS, New Delhi, India
e-mail: drhitesh10@gmail.com
ImmaculataXess Microbiology, AIIMS, New Delhi, India
e-mail: immaxess@gmail.com
List of Contributors
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xv
Jaini Lodha ENT, Seven Hills Hospital, Andheri East Mumbai,
Maharashtra, India
e-mail: jainilodha@gmail.com
K.Davraj ENT, KMC, Manipal, Karnataka, India
e-mail: deardrdr@gmail.com
KapilSikka ENT, AIIMS, New Delhi, India
e-mail: kapil_sikka@yahoo.com
KrantiBhawna ENT, AIIMS, Patna, Bihar, India
e-mail: bhavana.kranti@gmail.com
KshitizCharya Indus Hospital, Mohali, Punjab, India
e-mail: charaya.k@gmail.com
KuldeepThakur ENT, AIIMS, New Delhi, India
e-mail: drkuldeep70@gmail.com
M.RaviSankar Neurootology, SGPGIMS, Lucknow, UP, India
e-mail: drravisankarpgi@gmail.com
ManishGupta ENT, MMIMSR, MMU, Ambala, Haryana, India
e-mail: manishgupta1217@gmail.com
ManjuSilu ENT, SP Medical College, Bikaner, Rajasthan, India
e-mail: manjusilu35@gmail.com
MohnishGrover ENT, SMS Medical College, Jaipur, Rajasthan, India
e-mail: drmohnish.aiims@gmail.com
MayankYadav ENT, SHKM GMC, Nalhar, Nuh, Haryana, India
e-mail: drmayankyadav@yahoo.co.in
Nagesh Tangirala Anaesthesiology, Pain Medicine and Critical Care,
AIIMS, New Delhi, India
e-mail: nag947@gmail.com
NamritaMahmi Department of ENT, AIIMS, New Delhi, India
e-mail: namritamehmi@gmail.com
NikhilSingh ENT, AIIMS, Raipur, Chhattisgarh, India
e-mail: doc.niks03@gmail.com
NitinGupta ENT, GMCH, Chandigarh, India
e-mail: nitinent123@gmail.com
NitinM.Nagarkar ENT, AIIMS, Raipur, Chhattisgarh, India
e-mail: nmnent63@gmail.com
PankuriMittal Department of ENT, AIIMS, New Delhi, India
e-mail: mamc.pankhuri@gmail.com
PoojaD.Nayak ENT, SP Medical College, Bikaner, Rajasthan, India
e-mail: poomahe2007@gmail.com
PradipKumarTiwari ENT, NIGRIMS, Shillong, Meghalaya, India
e-mail: dr.pradiptiwari@gmail.com
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PrateekSharma ENT, AIIMS, New Delhi, India
e-mail: drprateeksharma.mamc@gmail.com
PreetamChappity ENT, AIIMS, Bhubaneswar, Odisha, India
e-mail: drcpreetam@aiimsbhubaneswar.edu.in
PritySharma ENT, AIIMS, Bhubaneswar, Odisha, India
e-mail: sharmaprity21@gmail.com
R.S.Virk ENT, PGIMER, Chandigarh, India
e-mail: virkdoc@hotmail.com
Raja Pramanik Medical Oncology, Dr.B.R.A-IRCH, AIIMS, New Delhi,
India
e-mail: drrajapramanik@gmail.com
RajeshKumarMeena Neurosurgery, AIIMS, New Delhi, India
e-mail: drrajeshmeena165@gmail.com
RakeshKumar ENT, AIIMS, New Delhi, India
e-mail: winirk@hotmail.com
RameshS.Doddamani Neurosurgery, AIIMS, New Delhi, India
e-mail: drsdramesh@gmail.com
RavneetSingh ENT, GMCH, Chandigarh, India
e-mail: ravneetrverma@gmail.com
List of Contributors
RipuDamanArora ENT, AIIMS, Raipur, Chhattisgarh, India
e-mail: neelripu@gmail.com
RohitVerma ENT, DMC, Ludhiana, Punjab, India
e-mail: rohitaiims@yahoo.co.in
RupaMehta ENT, AIIMS, Raipur, Chhattisgarh, India
e-mail: rmehta0409@yahoo.com
SanjeevBhagat ENT, Rajindra Hospital Patiala, Patiala, Punjab, India
e-mail: sbent224@gmail.com
SauravSarkar ENT, AIIMS, Bhubaneswar, Odisha, India
doc.sauravsarkar@gmail.com
ShamimAhmedShamim Nuclear Medicine, AIIMS, New Delhi, India
e-mail: sashamim2002@gmail.com
ShashankNathSingh ENT, SMS Medical College, Jaipur, Rajasthan, India
e-mail: drshashanknathsingh@gmail.com
ShashikantPaul ENT, JIPMER, Pondicherry, India
e-mail: drshashikantpol@gmail.com
SheetalKumari ENT, GMC, Jammu, India
e-mail: gphonshashetal@gmail.com
ShitanshuSharma ENT, SMS Medical College, Jaipur, Rajasthan, India
e-mail: shsharma811@gmail.com
List of Contributors
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SmitaManchanda Radiology, AIIMS, New Delhi, India
e-mail: smitamanchanda@gmail.com
SmritiPanda Department of ENT, AIIMS, New Delhi, India
e-mail: smriti.panda.87@gmail.com
SonuKumariAgrawal Microbiology, AIIMS, New Delhi, India
e-mail: drhitender@gmail.com
SumanBhasker Radiotherapy, AIIMS, New Delhi, India
e-mail: drsumanbhasker@gmail.com
SunilKumar ENT, LHMC, New Delhi, India
e-mail: suku321@rediffmail.com
SureshMani ENT, CMC, Vellore, Tamil Nadu, India
e-mail: msuresh.doc@gmail.com
Surya Prakash Vadlamani Medical Oncology, Dr.B.R.A-IRCH, AIIMS,
New Delhi, India
e-mail: vadlamanisuryaprakash@gmail.com
TanmayaKataria ENT, SMS Medical College, Jaipur, Rajasthan, India
e-mail: tanmayakataria@gmail.com
VaibhavSaini ENT, AIIMS, Bhatinda, Punjab, India
e-mail: drvaibhavsaini@gmail.com
VikasGupta ENT, AIIMS, Bhopal, MP, India
e-mail: vikasmsent@gmail.com
VishalSharma ENT, Rajindra Hospital Patiala, Patiala, Punjab, India
e-mail: drvishalsharma2@gmail.com
ZareenLynrah ENT, NIGRIMS, Shillong, Meghalaya, India
e-mail: zareenalynrah@gmail.com
Endoscopic Anatomy andSurgery
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Hitesh Verma, Smita Manchanda, Sunil Kumar,
Vaibhav Saini, Debesh Bhoi, Nagesh Tangirala,
AbhaKumari, and AnanditaGupta
Contents
1.1 Part A: Anatomy ofNasal Cavity andParanasal Sinuses 2
1.1.1 Ethmoid Cells 4
1.1.2 Frontal Sinus 6
1.1.3 Maxillary Sinus 6
1.1.4 Anterior Ethmoid Artery 6
1.1.5 Sphenopalatine Artery 7
1.1.6 Cribriform Plate 7
Sphenoid Sinus 7
1.1.7
1.1.8 Optic Nerve Relationship with Paranasal Sinuses 8
1.2
Part B: Local Anesthesia and Regional Blocks in Nasal Surgery 8
1.3
Part C: General Anesthesia 13
1.3.1 Preoperative Concerns 13
1.3.2 Anesthesia Technique 14
1.3.3 Hypotensive Anesthesia 14
1.3.4 Acute Normovolemic Hemodilution 15
Juvenile Nasopharyngeal Angiobroma withIntracranial Extension 15
1.3.5
1.3.6 Emergence fromAnesthesia 15
1.3.7 Postoperative Concerns 15
1.3.8 Emergency Surgical Intervention 16
1
H. Verma (*)
ENT, AIIMS, New Delhi, India
e-mail: drhitesh10@gmail.com
S. Manchanda
Radiology, AIIMS, New Delhi, India
S. Kumar
ENT, LHMC, New Delhi, India
V. Saini
ENT, AIIMS, Bhatinda, Punjab, India
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021
H. Verma, A. Thakar (eds.), Essentials of Rhinology, https://doi.org/10.1007/978-981-33-6284-0_1
D. Bhoi · N. Tangirala
Anaesthesiology, Pain Medicine and Critical Care,
AIIMS, New Delhi, India
A. Kumari
ENT, Command Hospital, Kolkata,
West Bengal, India
A. Gupta
ENT, Army College of Medical Sciences,
New Delhi, India
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1.4 Part D: FESS 16
Diagnostic Endoscopy 16
1.4.1
1.4.2
FESS Techniques andSteps 17
NASAL POLYP andFESS 23
1.4.3
1.4.4
AFRS andFESS 23
ESS inPediatric Age Group 23
1.4.5
1.4.6
Balloon Sinuplasty 24
Conclusion 24
1.4.7
1.5
Part E: Packing Materials forNose andParanasal Sinuses 24
1.5.1
Uses ofNasal Packing 24
Types ofNasal Packing Material 25
1.5.2
Non-Absorbable Nasal Packs 25
1.5.3
1.5.4
Absorbable Nasal Packs 27
References 29
H. Verma et al.
1.1 Part A: Anatomy ofNasal
Cavity andParanasal Sinuses
The nasal cavity is the initial entry point in the
airway. It extends from anterior nares to posterior choana. Pneumatized air spaces within facial
bones are known as paranasal sinuses. They converse with the nasal cavity at various levels. The
frontal sinus is the supraorbital airspace within
the frontal bone which comes in the superior
relationship of the nasal cavity and it drains into
the middle meatus via frontal recess. The maxillary sinus is the airspace inside the maxilla bone
which communicates with the middle meatus via
ethmoid infundibulum. Ethmoid air cells are
located within the nasal cavity just below the
skull base from agger nasi cells till anterior wall
of the sphenoid sinus. The sphenoid sinus is the
airspace of the body of the sphenoid and it lies in
the superior relationship of the nasopharynx.
The nasal placode and mesenchymal processes
around the primitive mouth develop nose. A
primitive nasal cavity develops by fusion of
maxillary process of the rst brachial arch with
the medial nasal process and frontonasal process. Choana is derived by a split of bucconasal
membrane which separates the primitive oral
cavity from the nasal cavity. The nasal cavity is
divided into two half by fusion of septum with
palatine process of both sides. Failure of fusion
or split of these processes will present as congenital anomalies like cleft lip, cleft palate, choanal atresia, etc. The vestibule is the initial part
of the nasal cavity which extends from the external opening till the nasal valve. The vestibule is
a line by the skin with vibrissae, sweat, and sebaceous gland. The nasal cavity proper is the
remaining part of the nasal cavity which is a line
by pseudo-stratied columnar epithelium. The
anatomy of the nose and paranasal sinuses is
very complex. The detailed knowledge of anatomical variation is the foremost thing to overcome complications of surgery. The lateral nasal
wall contains three to four projections which are
known as turbinates [1].
A. Inferior Turbinate: Inferior turbinate is a
separate bone with an irregular surface. It is
the largest turbinate of the nasal cavity
(Fig.1.1).
B. Middle Turbinate
1. In the sagittal plane, it attaches with cribriform plate at the junction of the vertical
and horizontal lamina (Fig. 1.1).
Inadvertent pooling of middle turbinate
can lead to cribriform plate injury and iatrogenic CSF leak. The collection of air
within the lower free part of the middle
turbinate is known as concha bullosa
(Fig.1.1).
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CP
MM
MT
IM
IT
3
UP
Fig. 1.1 NCCT PNS orbit (Coronal cuts) is showing inferior turbinate (IT), inferior meatus (IM) middle turbinate
(MT), middle meatus (MM), and cribriform plate (CP).
2. In frontal and horizontal plane it attached
with lamina papyracea. It is known as
ground lamella. Ground lamella divides
ethmoid air cells into anterior and posterior ethmoid cells. Lamina papyracea is
thin at the site of attachment so that unintentional pooling of turbinate can leads to
orbital fat prolapse.
3. Normally middle turbinate is concave on
the middle meatus side. Paradoxical turbinate is the convex presentation of middle
turbinate which reduces the volume of
middle meatus (Fig. 1.1). Minimum
inammation in the middle meatus can
affect the drainage of anterior sinuses
signicantly.
Meatus is the part of the nasal cavity
which is present deep and lateral to the turbinate. Sphenoethmoidal recess and
supreme meatus are present medial to
superior turbinate (Fig. 1.7). Inferior
meatus is the largest and it is present along
the entire length of the inferior turbinate.
Nasolacrimal duct opening locates at anterior third and posterior two-third junction
of the inferior turbinate. Genu is the part of
inferior meatus which locates just below
and posterior to the nasolacrimal duct
The central picture is depicting bullosa of MT (white
arrow) and the right side picture is showing paradoxical
MT with uncinate process attachment on middle turbinate
opening. Surgical window to reach the
oor of the maxillary sinus in endoscopic
surgery, in ancient surgery like Proof
puncture and for inferior meatal antrostomy (2 × 1 cm) is performed at genu
because lateral wall bone is thinnest in this
area. The middle meatus is the space present lateral to the middle turbinate. It contains the uncinate process, hiatus
semilunaris, bulla ethmoidalis, and ethmoid infundibulum (Fig. 1.2). Anterior
ethmoid air cells, maxillary, and frontal
sinuses drains into middle meatus. Middle
turbinate along with its contents is known
as osteomeatal complex (Fig.1.2).
Superior meatus is the smallest meatus.
It is located between the middle and superior turbinate and posterior ethmoid cells
lies within it. Sphenoethmoid recess is the
space above and behind the superior
meatus. Posterior ethmoid cells and sphenoid sinus drains into it.
C. Uncinate Process
It is a boomerang shape of two-dimensional
structure. It attaches laterally with the lacrimal
bone and inferiorly with the inferior turbinate.
Superiorly, the uncinate process has three different kinds of attachments. In 70–80% cases,
4
H. Verma et al.
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it attaches with the lamina papyracea and
allows the drainage of the frontal sinus into the
middle meatus. Recess terminalis is the blind
sac formed by the attachment of the uncinate
process with the lamina papyracea. Skull base
and middle turbinate are two other attachments
and it allows the drainage of the frontal sinus
into ethmoid infundibulum (Fig. 1.1). The
presence of the frontoethmoidal cells may be
responsible for the upper attacment of the
uncinate process. Hiatus semilunaris inferior is
the space between the free posterior edge of
the uncinate process and bulla ethmoidalis
(Fig. 1.2). It allows the drainage of the ethmoid infundibulum into the middle meatus.
D. Ethmoid Infundibulum
It is a three dimensional space. It is bounded
anteriorly by the uncinate process, posteriorly
by the bulla ethmoidalis, medially by the uncinate process medial surface (Fig.1.2). It communicates with middle meatus via hiatus
semilunaris inferior. Superiorly, it is either end
as recess terminalis or it continues with frontal
recess, when the uncinate process attaches
with the middle turbinate and the skull base.
1.1.1 Ethmoid Cells
Ethmoid air cells are 3–18in number. It is broadly
divided into anterior and posterior by the ground
lamella. The anatomical variations are seen more
in and around anterior ethmoid cells.
Fig. 1.2 Osteomeatal Complex. Components of osteomeatal unit are maxillary ostium (MO), ethmoidal infundibulum (EI), uncinate process (UP), hiatus semilunaris
(HS), and bulla ethmoidalis (BE)
Type 1
AN
1. Agger Nasi Cells
(a) Anterior most ethmoidal cells locate over
the lacrimal bone (Fig.1.3). It lies anterior and superior to the axilla of the middle turbinate.
Type 3
Fig. 1.3 The NCCT PNS orbit (sagittal cut) is depicting type 1 Frontoethmoidal air cells. The coronal cut is depicting
type 3 frontoethmoidal cell
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5
2. Frontal Cells
Frontal cells (frontoethmoidal cells, anterior
ethmoid cells) are present in a 20–41% population (Fig.1.3). It is classied into four types [2].
(a) Type 1 (most common)—single cell above
the agger nasi cells (Fig.1.3)
(b) Type 2- the tier of cells above
(c) Type 3 (least common)—large cell pro-
truding more than 50% within frontal
sinus (Fig.1.3)
(d) Type 4 is found in the frontal sinus. Some-
time extended pneumatization of the bulla
ethmoidalis can presented as isolated cell
in the frontal sinus. Saggital section is the
useful tool to differentiate both type of cells
Frontal bullar cell is the single cell above bulla
ethmoidalis and it may extend anteriorly into
frontal sinus. Its infection can affect the drainage of the frontal sinus by narrowing the frontal recess area.
3. Bulla Ethmoidalis
It is the largest anterior ethmoid air cells
(Fig. 1.2). It drains into the middle meatus.
Well pneumatized bulla ethmoidalis reaches
upto skullbase and ground lamella. Lateral
sinus (suprabullar cell) is the air space found
above the bulla ethmoidalis when it is not
extent till the skullbase. Retrobullar recess is
the space between the bulla ethmoidalis and
ground lamella. Hiatus semilunaris superior is
the medial communication of the retrobullar
recess with the middle meatus. Torus ethmoidalis is the terminology used for nonpneumatized bulla ethmoidalis. Pneu
matized bulla
ethmoidalis is three types
(a) Simple bulla-single cavity
(b) Compound bulla—two–three compart-
ments communicated at hiatus
semilunaris
(c) Complex bulla—two–three compartments
communicated at hiatus semilunaris, ethmoid infundibulum
4. Heller cell
(a) It is an infraorbital anterior ethmoid cell.
It can affect the drainage of the maxillary
sinus by narrowing its outow tract.
Posterior ethmoid cells are the cells present
behind the ground lamella of the middle turbi-
nate. It extends posteriorly till the anterior
face of the sphenoid sinus. It drains into the
nasal cavity by superior meatus or by sphenoethmoidal recess. Onodi cell is the posterior
extension of the posterior ethmoid cell over
the sphenoid sinus. The optic nerve runs very
close to the lateral wall of the Onodi cell.
Fovea ethmoidalis is the part of skull bone
present over ethmoid cells. Fovea ethmoidalis
is found higher when the ratio of the vertical
height of ethmoid air cells with a vertical
height of maxillary sinus or orbit is more than
50% and when skull base angle with the horizontal lamina of the cribriform plate is more
than 55°. In such cases chances of injury to the
skull base is more at fovea ethmoidalis region.
Frontal recess is bound anteriorly by the
uncinate process, laterally by lamina papyracea, medially by middle turbinate. The posterior boundary is the anterior face of the bulla
ethmoidalis or lateral sinus in the superior part.
It continues inferiorly with the ethmoid infundibulum or the middle meatus, which depends
on the superior attachment of the uncinate process (Fig.1.4).
Fig. 1.4 Depicting frontal sinus and frontal beak at the
level of the frontal ostium. The frontal sinus is above the
frontal beak and the frontal sinus drainage pathway
(FSDP) is below the beak
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H. Verma et al.
1.1.2 Frontal Sinus
Frontal sinus dimensions are 24×20×12mm with
a volume of 6–7ml. It develops from the embryonic
infundibulum at frontal recess superior part during
the 16th week of intrauterine life. The frontal
sinuses are absent at birth and reach their full size
by the end of puberty. The anterior edge of the frontal sinus ostia is formed by the frontal beak and the
posterior edge by the skull base. Ostia is the narrowest part of the frontal outow tract. Frontal sinus is
an asymmetrically paired sinus with scalloping
margins which may loss in the frontal sinus chronic
diseases e.g mucocele. The anterior wall is thicker
than the posterior wall (Fig.1.4).
1.1.3 Maxillary Sinus
Maxillary sinus is also known as the antrum of
Highmore. It is pyramidal in shape. It is the largest paranasal sinus with a volume of approximately 10 ml. Maxillary sinus ostium is lying
high in the medial wall which opens into the ethmoid infundibulum (Fig. 1.2). Maxillary sinus
ostium is 2–3 mm oval structure. It is not visible
on routine nasal endoscopy as the ostium is covered by the uncinate process. Anterior and poste-
rior accessory maxillary sinus ostium are found
at membranous fontanelle. they are visible on
endoscopic examination. Accessory ostium is
round and it is present in up to 43% of cases. The
lining epithelium is the pseudo stratied ciliated
columnar epithelium and it is known as
Schneiderian membrane.
1.1.4 Anterior Ethmoid Artery
It is the largest branch of the ophthalmic artery. It
runs in the orbit between the superior oblique and
medial rectus muscles. It enters into the nasal
cavity via the anterior ethmoid foramen and runs
in the ethmoid roof 1–2mm behind the anterior
end of bulla ethmoidalis. The anterior ethmoid
foramen is present 24mm deep to anterior lacrimal crest. Anterior ethmoid artery runs out of
fovea ethmoidalis in the nasal cavity in 8–10% of
cases. The radiological sign for the nasal cavity
entry point is visible in the form of a point
(Kennedy nipple) the radiological features for
intranasal course of anterior ethmoid artery are
Keros 3 cribriform plate, presence of supraorbital
cell or wide antero-posterior width of frontal
recess and more than 2 cm length of cribriform
plate (Fig.1.5).
Frontal
recess
Anterior
ethmoid
artery
Fig. 1.5 (a) NCCT PNS orbit is showing bilateral soft tis-
sue density in the nose and paranasal sinus. Anterior ethmoid artery enter site is depicted by the arrow. (b) Post
operative endoscopic picture is showing the intranasal
anterior ethmoid artery
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