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Figure 3. A sagittal section of the head demonstrating lateral structures of the nasal cavity and pharynx.
Figure 4. Cartilaginous and bony structures of the Nasal Septum; The Quadrangular septal cartilage and the vomer articulate
with bones of the nasal floor; The thin perpendicular plate of the ethmoid extends upward to the cribriform plate.
bone anteriorly and the crest of the palatine bone posteriorly. The perpendicular plate of the ethmoid
extends superiorly, attaching to the cribriform plate (lamina cribosa). A superior projection of the
hard palate, the maxillary ridge (crista nasalis maxillae; the nasal crest of maxilla) often forms a “T”
anteriorly at the base of the septum. The lateral wings of the “T” may project into the nasal cavity.
Turbinates
Three or four turbinates provide filtration, heating and cooling and humidification of inspired air
and offer resistance to airflow. The turbinates are comprised of a scroll-shaped bony supporting
structure, called a concha and overlying mucosa. Clefting or segmentalization of the turbinates
may occur both horizontally and sagittally, and clefting of a middle turbinate may be difficult to
distinguish from a nasal polyp on anterior examination. The space created by a turbinate and the
lateral wall of the nose is called a meatus.
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Inferior Turbinate and Inferior Meatus
The inferior concha is a separate bone sitting in an opening in the maxilla and resting in the lateral
wall of the nasal passage. It is attached to the palate and maxilla by membranous soft tissue. The
turbinate follows the lower lateral wall of the nose in a course parallel to that of the nasal floor. In
patients with nasal septal deviation, the inferior turbinates are not the same size. The only structure
opening into the inferior meatus is the nasolacrimal duct which drains tears through a large opening
in the anterior roof of the meatus (Figure 5), located about 1 cm from the anterior margin of the
turbinate. The orifice is rarely seen by fiberoptic rhinoscopy. An opening found in the lateral wall
at this location is most likely an antral window surgically placed in the inferior meatus to provide
drainage for the maxillary sinus.
Middle Turbinate and Middle Meatus
The middle turbinate, like the superior turbinate, is part of the ethmoid bone and is suspended from
the roof of the nose rather than from the lateral wall. The anterior edge is superior and posterior to
that of the inferior turbinate.
The semilunar hiatus (hiatus semilunaris) is a crescent-shaped cleft located in the middle
meatus (Figure 5). The ostium of the nasofrontal duct and the anterior ethmoid sinus ostia typically
are located in the anterior and midportions of the hiatus. The nasofrontal duct may have a separate
opening anterior to the semilunar hiatus. The maxillary sinuses open into the posteroinferior portion
of the semilunar hiatus. The ostium of the maxillary sinus varies in size in normal individuals from
pinpoint to several millimeters in diameter and large accessory ostia may be present. The ethmoid
bulla (bulla ethmoidalis) is a bulge containing anterior and middle ethmoid air cells, located posterior
and superior to the semilunar hiatus.
Superior and Supreme Turbinates
The superior turbinate is a short, oblique structure located superior and posterior to the middle
turbinate. The posterior ethmoid sinuses drain into the superior meatus (Figure 5). A supreme
turbinate medial to the superior turbinate is occasionally noted.
Sphenoethmoidal Recess
The sphenoethmoidal recess is a deep groove located superior, posterior and medial to the superior
turbinate. It contains the ostium of the sphenoid sinus (Figure 5).
Figure 5. A sagittal section of the head with the turbinates removed to demonstrate ostia of the paranasal sinuses and
nasolacrimal duct.
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Nasopharynx
The torus tubarius is located on the lateral wall of the nasopharynx, defining and protecting the
Eustachian tube orifice (Figure 5). Rosenmueller’s fossa is a vertical cleft, a potential space, between
the posterior lip of the torus tubarius and the adenoidal pad. Many of the insidious malignancies
of the pharynx have their origin in this space. The adenoid or pharyngeal tonsil is a primary lymph
node of first-line defense against inflammation involving the upper airway.
Oropharynx
The lingual tonsils are located on either side of the dorsum of the tongue anterior to the epiglottis
(Figure 6). The median glossoepiglottic fold and the two lateral glossoepiglottic folds attach the
epiglottis to the base of the tongue.
Figure 6. The larynx as viewed from above and oriented as it would be seen with a fiberoptic endoscope.
Hypopharynx
The valleculae are cup-shaped spaces, separated by the median glossoepiglottic fold, posterior to
the base of the tongue and anterior to the epiglottis. To the right and to the left of the larynx are the
piriform sinuses, gutter-like structures that direct food to the esophagus.
Larynx
The framework of the larynx is formed by the thyroid, cricoid and epiglottic cartilages and by pairs
of arytenoid, corniculate and cuneiform cartilages. The aryepiglottic folds and the arytenoids are
located immediately behind the epiglottis. The aperture of the glottis (rima glottidis) is formed
by the true vocal folds (plicae vocales) and the posterior commissure between the arytenoids. The
anterior ligament of the true vocal folds is located at the anterior angle of the vocal folds. Between
the true vocal folds and the false vocal folds (vestibular folds; plicae ventriculares) is the laryngeal
ventricle. The nodular swellings located medially in the aryepiglottic folds are the corniculate
cartilages which sit on top of the arytenoid cartilages. Lateral to the corniculate cartilages are the
cuneiform cartilages.
The true vocal folds are anteriorly attached to the thyroid cartilage. The posterior attachment
is to the vocal processes of the arytenoid cartilages. The true vocal folds often reflect light in such
a manner that they appear whiter than the surrounding mucosa. The strong vocal ligaments are
covered by connective tissue and a thin layer of epithelium. Reinke’s space is the potential space
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between the vocal ligaments and the subepithelial connective tissue layer. The mobile arytenoid
cartilages move in and out with respiration and phonation.
Examination Procedure
Preparation for Examination
Other than the explanation of the procedure to the patient, the only special preparation usually
required is decongestion and anesthesia; the patient is not fasted.
After the procedure has been explained to the patient, the patient is seated in an examining
chair, preferably an ENT-type chair with an adjustable headrest. A small child may sit in a parent’s
lap. The examiner should perform a preliminary nasal examination to determine nasal patency and
to identify pathology which might be visible on routine examination.
The patient is asked to clear secretions by the gentle blowing of the nose. If necessary, saline
irrigation may be used to clear the nasal passage of mucus and debris.
To shrink the nasal mucosa, topical decongestants, such as phenylephrine or oxymetazoline,
may be delivered by a standard nasal atomizer. Xylocaine solution (4%), also delivered by a nasal
atomizer, may be used for nasal anesthesia. The examiner should remember that this requires a few
minutes to take effect. Pharyngeal and laryngeal anesthesia is not necessary. One or two sprays of
each drug should be directed posteriorly, with the same amount directed superiorly and posteriorly
at about a 45-degree angle. If desired, the rhinoscope may be lubricated with a water-based lubricant
or with 2% viscous xylocaine.
With proper anesthesia, the procedure is not painful. The patient may talk to the examiner
during the examination and should be asked to communicate any discomfort (other than pressure) to
the examiner so that the endoscope may be withdrawn from that area.
Examination Sequence
The examination should proceed in a consistent, logical sequence that can be varied if needed
in individual patients. The examination sequence is the same for children and adults, although a
complete examination might not be possible in an uncooperative child. It is usually convenient to
examine structures of the anterior nasal cavity first, followed by an examination of the pharynx and
larynx. Because the sphenoethmoidal recess and middle meatus are more difficult to examine and
may be less well anesthetized than other structures, they are generally examined last.
Examination of the nasal cavity begins with the nasal vestibule. It is usually possible to examine
the nasal floor by slowly and gently advancing the endoscope into the nasal cavity. The inferior
turbinate, floor of the nose, and septum will be in view (Figure 7). Deformities of the septum include
septal spurs (Figure 8). If the endoscope tip is flexed slightly upward, the middle turbinate will be
seen in the distance and with upward flexion to 60–90 degrees, the superior portion of the anterior
nose can be evaluated. If the inferior turbinate is large or swollen, it may be necessary to advance
the tip of the endoscope over the anterior margin of the inferior turbinate in order to view the
middle turbinate. To view the anterior portion of the middle turbinate, the tip of the endoscope
is directed over the inferior turbinate. In this position, a polyp exiting the middle turbinate might
be seen (Figure 9). The endoscope is usually advanced to the choana along the floor of the nose,
but this position may be used if the lower route is obstructed. With the endoscope positioned at
the posterior choana, it is usually possible to direct the endoscope superiorly and laterally into the
middle meatus either at this point in the examination or later after the examination of the larynx and
sphenoethmoidal recess.
With the endoscope tip on the nasal floor at the level of the posterior choana, structures of
the nasopharynx may be viewed through the choana (Figure 10). Enlarged adenoidal tissue might
obscure other structures of the nasopharynx (Figure 11). The endoscope is then advanced into the
nasopharynx. The endoscope is advanced into the oropharynx. Structures of the posterior tongue,
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Figure 7. A normal right anterior nasal cavity. The septum is on the right. the inferior turbinate and the inferior meatus are
on the left.
Figure 8. In this view of the superior portion of the mid-nasal passage, a septal spur is seen impinging on the medial surface
of the middle turbinate; at some point in the past, this patient had received a direct blow to the nose, causing the posterior
portion of the septal (quadrangular) cartilage to displace from its articulation with the bony structures of the septum; this
results in facial pain when the patient develops nasal congestion—a symptom complex sometimes called sluder syndrome.
Figure 9. The left middle meatus is occupied by a single ethmoid polyp which displaces the middle turbinate toward the
septum located at 9 o’clock; characteristic features of a polyp, distinguishing it from nasal mucosa, include the slightly
yellow or translucent coloring of a smooth relatively avascular structure; this polyp can be moved with a cotton-tipped
the epiglottis, the valleculae and glosso-epiglottic and lateral epiglottic folds are examined. Here,
the examiner can view abnormalities such as enlarged lingual tonsils (Figure 12) or other enlarged
lymphoid structures (Figure 13).
The endoscope tip is kept close to the posterior wall of the pharynx as it is directed into the
hypopharynx. The patient is encouraged to breathe quietly and asked not to swallow but reassured
that swallowing will merely result in the sensation of attempting to swallow the endoscope, not in
discomfort. The endoscope is directed along the posterior pharyngeal wall in the midline, over the
.
applicator, indicating its origin from the middle meatus.
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Figure 10. In this view of a normal right posterior nasal passage; the adenoidal pad is seen posteriorly; the eustachian tube
orifice; surrounded by the torus tubarius is on the left at 9 o’clock; rosenmüller’s fossa is the potential space between the
posterior torus and the adenoidal pad.
Figure 11. Partial obstruction of the right nasal cavity by adenoidal hyperplasia; the small aperture inferiorly may disappear
when the child is sleeping and the palate moves superiorly; this can result in snoring with apnea and mouth breathing with
maxillofacial and dental growth abnormalities.
Figure 12. Prominent lingual tonsils.
epiglottis. In this position, the arytenoids, the superior projections of the corniculate and cuneiform
cartilages, the aryepiglottic folds, the true and false vocal folds and the ventricles are well visualized
(Figure 14). With the endoscope in this position, patients with vocal cord dysfunction syndrome
can be identified (Figure 15). Laryngeal edema will also be obvious (Figure 16). Slight rotations of
the endoscope in this position will very clearly reveal the piriform sinuses. From this position, the
examiner often will see well into the trachea.
To examine the sphenoethmoidal recess, the endoscope is withdrawn under direct visualization
to a position just anterior to the choana. As the endoscope is directed superiorly, the anterior margin
of the sphenoid bone comes into view.
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Figure 13. A patient with long standing chronic rhinosinusitis. The tip of the examining scope is in the nasopharynx and is
directed inferiorly; at 12 o’clock is the posterior pharyngeal wall. The tip of the epiglottis is seen in the distance in the center
of the slide; prominent lymphoid nodularity can be readily visualized on the posterior wall; the palatine tonsils protrude from
the lateral walls at 4 o’clock and 9 o’clock.
Figure 14. A normal larynx; the true and false vocal folds are clearly seen.
Figure 15. In patients with vocal cord dysfunction syndrome; the vocal folds adduct, forming a posterior diamond-shaped
opening as seen on the left figure; this finding is not present in asthma (right figure).
Figure 16. Laryngeal edema.
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If structures of the middle meatus were not previously examined, they are studied at this time. It
is usually easier to examine the middle meatus from posterior to anterior. Following the withdrawal
of the endoscope under direct visualization, an examination of the other side of the nose is carried
out. Afterward, the equipment is cleaned and disinfected in preparation for the next examination.
Summary
The endoscopist can quickly and thoroughly examine most areas of the upper airway without
discomfort to the patient. Once the endoscopist becomes familiar with the anatomy variations from
normal and pathology becomes readily apparent. Examinations may be recorded for permanent
record keeping and may be replayed and explained to patients. The use of rhinoscopy will enhance
the diagnosis and treatment of upper airway disease.
Acknowledgments
Text, illustrations, and photographs in this chapter are from Selner J.C., Dolen W.K., Spofford B.,
Koepke J.W. Rhinolaryngoscopy. 2nd ed. Denver, CO; Allergy Respiratory Institute of Colorado;
1989. An updated online version of the text, images and instructional videos may be found at
http://www.augusta.edu/mcg/pediatrics/allergy/rhino/. Used with permission. In memoriam, John
Canty Selner, MD (1936–2006).
Chapter 3E
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Bronchial Thermoplasty
Nishil Dalsania, Sandeep Jewani and Ali Musani*
Introduction
Severe uncontrolled asthma in patients maximized on pharmacologic therapy accounts for a
majority of morbidity and mortality associated with asthma. Bronchial Thermoplasty (BT) is a
non-pharmacological FDA-approved bronchoscopic intervention that delivers thermal energy via
endobronchial radio frequency wave catheter to the bronchial airways. BT was designed prior to the
advent of biologic therapy to assist in controlling severely uncontrolled asthmatics. The principal
goal of this procedure is to reduce airway smooth muscle in the bronchial airways. The benefits of
bronchial thermoplasty can be in reducing airway hyper-responsiveness, optimizing asthma control,
decreasing asthma exacerbations, and stepping down on asthma therapy, including steroids. A crucial
component prior to relegating a patient to the procedure is ensuring appropriate patient selection
in efforts to maximize benefits and minimize risks associated with the procedure. Complications
after bronchial thermoplasty are often seen and predominately involve exacerbation of underlying
asthma, atelectasis, respiratory tract infection, and hemoptysis.
Bronchial Thermoplasty (BT) is a non-pharmacological FDA-approved bronchoscopic intervention
that delivers thermal energy via endobronchial radio frequency (RF) wave catheter to the bronchial
airways. The principal goal of this procedure is to reduce airway smooth muscle (ASM) in
the bronchial airways (Facciolongo et al. 2018). The benefits of BT can be in reducing airway
hyper-responsiveness, optimizing asthma control, decreasing asthma exacerbations and stepping
down on asthma therapy, including steroids.
There are a growing number of patients worldwide affected by asthma. More than 235 million
patients suffer from asthma, of which only approximately 5% have severe uncontrolled disease and
are on maximal conventional inhaled therapy with a high dose inhaled corticosteroid and long-acting
inhaled beta agonist. This minority of asthmatics with severely uncontrolled patients have continued
symptoms that affect their daily activity and life choices. However, they account for the majority
Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, 12700 East 19th Avenue, 9C03,
Aurora, CO 80045.
Emails: nishil.dalsania@cuanschutz.edu; sandeep.jewani@cuanschutz.edu
* Corresponding author: ali.musani@cuanschutz.edu
Principals of Bronchial Thermoplasty
Overview of Asthma and BT
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of morbidity and mortality associated with asthma. Chronic obstructive disease caused by severe
asthma is due to the remodeling and thickening of the airway wall via various mechanisms. Asthma
treatment is mainly pharmacological based on relaxing ASM and reducing airway inflammation.
Bronchothermoplastic intervention was designed prior to the advent of biologic therapy to assist
in controlling severe asthmatics on maximal therapy with the intent to decrease the morbidity and
mortality associated with severely uncontrolled asthmatics. BT is carried out by controlled RF
thermal energy to the airway wall to reduce ASM, decreasing oral or inhaled glucocorticoid dose
and decreasing long-term morphological changes associated with asthma.
Rationale/Data
Clinical trials on bronchial thermoplasty as a treatment for severe uncontrolled asthma began with
a single-arm, prospective feasibility study to evaluate the safety of BT in 16 patients with mild
to moderate asthma (Cox et al. 2006). Results demonstrated that BT was well tolerated, and all
procedure-related adverse events occurred within one week of the procedure. Most of these events
are commonly seen in asthmatics after any bronchoscopic procedures. All adverse events resolved
spontaneously with antibiotics or a temporary increase in asthma medications.
A randomized controlled trial (AIR Trial) from 2002–2010 was conducted on 112 patients to
evaluate the efficacy and safety of BT in moderate to severe asthma (Cox et al. 2007). The primary
outcome of this study was the frequency of mild exacerbations, calculated during three scheduled
two-week periods of abstinence from LABA at 3, 6 and 12 months. In patients treated with inhaled
corticosteroids alone, BT reduced the frequency of mild exacerbations (−0.16 ± 0.37 vs. 0.04 ± 0.29;
P = 0.005) at a rate equivalent to ten exacerbations per subject per year and provided 86 additional
symptom-free days per patient per year. There was no significant difference in FEV1 or airway
hyper-responsiveness by methacholine challenge. The adverse events noted were more common in
BT than control group immediately after treatment and at less than six weeks; however, were similar
from 6 weeks to 12 months after treatment.
Concomitantly, the non-blinded randomized controlled RISA (Research In Severe Asthma)
Trial from 2004–2019 was conducted with 32 patients to assess safety, reduction in medications and
asthma symptoms in severe refractory asthmatics (Pavord et al. 2007). In this trial, BT resulted in a
transient worsening of asthma symptoms. Seven hospitalizations for respiratory symptoms occurred
in 4 of 15 BT subjects during the treatment period. BT was associated with a short-term increase in
asthma-related morbidity. Also noted in this trial was a slight improvement in FEV1 (14.9 ± 17.4
vs. 0.9 ± 22.3; P = 0.04) at 22 weeks, although non-significant improvement in FEV1 at 52 weeks.
After safety analysis from the AIR Trial, the AIR2 Trial (2005–2019), a prospective, randomized
multi-site, double-blind, sham-controlled trial with 288 patients, assessed the effectiveness and
safety in severe persistent asthma of BT vs. sham procedure (Castro et al. 2010). The primary
outcome was the difference in Asthma Quality of Life Questionnaire (AQLQ) scores from baseline
at 6, 9 and 12 months, which showed improvement from baseline in the BT group compared with
sham (1.35 +/– 1.10 vs. 1.16 +/– 1.23 [PPS, 96.0% ITT and 97.9% per protocol]). Seventy-nine
percent of BT and 64% of sham subjects achieved changes in AQLQ of 0.5 or greater (PPS, 99.6%).
Six percent more BT subjects were hospitalized in the treatment period (up to 6 weeks after BT).
From 2011–2018 the PAS2 Trial, a prospective open-label observational multi-site trial with
190 patients, assessed the effectiveness and safety of BT in clinical practice (Chupp et al. 2017).
At three years, patients had a reduction in severe exacerbations, ED visits and hospitalizations by
45%, 55%, and 40%, respectively. FEV1 remained unchanged. Although, the mean daily ICS dose
was reduced to 2070 from 2300 μg/day (p = 0.003), and the percentage of subjects taking daily OCS
reduced from 18.9% to 10.2% (p = 0.0004).
A meta-analysis published in 2015 reviewed the five years follow-up of patients who had
undergone BT (Zhou et al. 2015). This review consolidated an unchanged FEV1 in BT patients
between years 1 and 5 (p = 0.57, p = 0.65), significance for a reduced frequency of asthma
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