Ebook Rhinology and skull base surgery: Part 1

Rhinology and
Skull Base Surgery
From the Lab to the Operating Room:
An Evidence-based Approach

Christos Georgalas, PhD, DLO, FRCS (ORL-HNS)
Director, Endoscopic Skull Base Center
Department of Otorhinolaryngology
Academic Medical Center
Amsterdam, The Netherlands

Wytske Fokkens, MD, PhD
Professor
Department of Otorhinolaryngology
Academic Medical Center
Amsterdam, The Netherlands
With contributions by
Nithin D. Adappa, Robert V. Almeyda, Isam Alobid, Jastin Antisdel, Humera Babar-Craig, Samuel S. Becker, Brett Bell, Rajiv K.
Bhalla, Benjamin S. Bleier, Ulrike Bockmühl, Andrea Bolzoni Villaret, Cornelius Jan Brenkman, Hans Rudolf Briner, Ricardo L.
Carrau, Paolo Castelnuovo, Marco D. Caversaccio, Daniel T. T. Chua, Roxana Cobo, Noam A. Cohen, Vassilios Danielides, Pascal
Demoly, Leo F. S. Ditzel Filho, Wolfgang Draf, Patrick Dubach, Nicolas Dulguerov, Davide Farina, Berrylin J. Ferguson, Juan
C. Fernandez-Miranda, Wytske Fokkens, Nicole J. M. Freling, Paul A. Gardner, Christos Georgalas, Philippe Gevaert, Mitchell
R. Gore, Jan Gosepath, Haralampos Gouveris, Hakon Hakonarson, Samuel Heimgartner, Peter W. Hellings, Philippe Herman,
Claire Hopkins, Nick S. Jones, Amin B. Kassam, Robert M. Kellman, Daniel F. Kelly, Bhik Kotecha, Stilianos E. Kountakis,
Haytham Kubba, Jean-Silvain Lacroix, Basile Nicolas Landis, Donald C. Lanza, Annie S. Lee, Sarah Lovell, Tim C. Lueth, Franklin
Mariño-Sánchez, Nancy McLaughlin, Ralph Metson, Joaquim Mullol, Piero Nicolai, Gilbert J. Nolst Trenité, Reza Nouraei,
James N. Palmer, Vasileios Papanikolaou, Kalpesh S. Patel, Santdeep H. Paun, Oliver Pfaar, Daniel M. Prevedello, Emmanuel

Prokopakis, Susanne M. Reinartz, Herbert Riechelmann, Peerooz Saeed, Hesham Saleh, Glenis K. Scadding, Rodney J. Schlosser,
Brent Senior, Jian-Bo Shi, Li Shi, Daniel Simmen, Ameet Singh, Elisabeth Victoria Sjoegren, Carl H. Snyderman, Zachary M.
Soler, Alla Y. Solyar, Gero Strauss, Andrew C. Swift, Ingrid Terreehorst, Timoleon F. Terzis, Marc A. Tewfik, Matthew J. Tormenti,
Elina Toskala, Bert van der Baan, Wouter R. van Furth, Cornelius M. van Drunen, Thibaut Van Zele, Carel D. A. Verwoerd,
Henriette L. Verwoerd-Verhoef, De-Yun Wang, Stefan Weber, William Ignace Wei, Ronald B. Willemse, Peter-John Wormald,
Giannis Yiotakis, Bing Zhou

979 illustrations

Thieme
Stuttgart • New York


Library of Congress Cataloging-in-Publication Data
Rhinology and skull base surgery : from the lab to the operating
room : an evidence-based approach / edited by Christos Georgalas, Wytske Fokkens.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-3-13-153541-2
I. Georgalas, Christos. II. Fokkens, Wytske J.
[DNLM: 1. Rhinitis--surgery. 2. Sinusitis--surgery. 3. Nose
Diseases--physiopathology. 4. Nose Neoplasms--surgery.
5. Rhinoplasty. 6. Skull Base--surgery. WV 335]
617.5’1059--dc23
2012032355

Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are
continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book
mentions any dosage or application, readers may rest assured
that the authors, editors, and publishers have made every effort

to ensure that such references are in accordance with the state of
knowledge at the time of production of the book.
Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to
any dosage instructions and forms of applications stated in the
book. Every user is requested to examine carefully the manufacturers’ leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the
dosage schedules mentioned therein or the contraindications
stated by the manufacturers differ from the statements made
in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly
released on the market. Every dosage schedule or every form of
application used is entirely at the user’s own risk and responsibility. The authors and publishers request every user to report to
the publishers any discrepancies or inaccuracies noticed. If errors
in this work are found after publication, errata will be posted at
www.thieme.com on the product description page.

Illustrator: Katja Dalkowski, MD, Buckenhof, Germany

© 2013 Georg Thieme Verlag KG,
Rüdigerstrasse 14, 70469 Stuttgart, Germany

Thieme Medical Publishers, Inc., 333 Seventh Avenue,
New York, NY 10001, USA

Cover design: Thieme Publishing Group
Typesetting by Maryland Composition, USA
Printed in China by Everbest Printing Ltd, Hong Kong
ISBN 978-3-13-153541-2
Also available as e-book:
eISBN 978-3-13-164461-9

Some of the product names, patents, and registered designs

referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not
always made in the text. Therefore, the appearance of a name
without designation as proprietary is not to be construed as a
representation by the publisher that it is in the public domain.
This book, including all parts thereof, is legally protected by
copyright. Any use, exploitation, or commercialization outside
the narrow limits set by copyright legislation, without the publisher’s consent, is illegal and liable to prosecution. This applies
in particular to photostat reproduction, copying, mimeographing, preparation of microfilms, and electronic data processing
and storage.


To my parents, Eleni and Kostas, to whom I owe everything.
To my wife, Amanda, for embarking with me on this journey.
To those who cross borders, by choice or need: our collective past, present, and future.
Christos Georgalas

To my beloved parents, Onno and Joke, who taught me, among many other things, to enjoy questioning and
exploring; and my teacher Carel Verwoerd who taught me a lot more than rhinology.
To the loves of my life, my husband Casper and my three children Sybren, Anne, and Lywke,
who lovingly and courageously try to keep me in line.
Wytske Fokkens


To access additional material or resources available with this e-book, please visit
After completing a short form to verify your e-book
purchase, you will be provided with the instructions and access codes necessary to retrieve
any bonus content.


vii

Foreword

Over the last 20 years there have been a number of books
broadly covering the many facets of the nose and sinuses.
However, such is the interest in this area and the pace of
progress in its investigation and treatment that this major
work is a welcome addition to the field. Underpinned by
the wide-ranging expertise of Professor Wytske Fokkens
and Christos Georgalas at the Academic Medical Center,
this multinational collaboration covers the full range of
rhinology, from basic anatomy and physiology, through
diagnostic techniques, to the entirety of sinonasal pathology. The international authorship guarantees a balanced
approach and includes many well-known contributors in
the field as well as some “new blood” providing a fresh
view on old problems.
As well as the usual topics, consideration is given to
some less well-understood but expanding areas of interest in the nose and sinuses, such as genetics and rare

disorders such as the silent sinus syndrome and pneumosinus dilatans. The concept of “one airway” is now generally accepted, but the importance of this in understanding
the pathophysiology and management of rhinosinusitis
is emphasized by authors able to authoratively consider
both the upper and lower respiratory tract. Despite this,
we often struggle to improve the lot of our patients with
recalcitrant CRS and welcome practical advice offered on
the management of these patients.
Rhinology, of course, is a multifaceted subject and,
in addition to the full range of sinonasal pathology, the
editors have commendably included rhinoplasty and
all of the well-established, extended applications of

endoscopic surgery to adjacent structures of the orbit and
skull base. This comprehensive and holistic approach is to
be applauded, making this a “must have” text for anyone
interested in the nose and sinuses.
Valerie J. Lund, CBE
Professor of Rhinology, University College London


viii

Preface

“. . .When you set sail for Ithaca,
wish for the road to be long,
full of adventures, full of knowledge. . .”
Constantin P. Cavafy
“The Road to Ithaca,” Collected Poems
It is fair to say that, if the fifties and sixties were the
decades of otology and the seventies and eighties those
of head and neck surgery, the last 20 years have witnessed an unprecedented boom in rhinology. Advances
in basic science leading to better understanding of disease pathophysiology, improved phenotyping, advances
in endoscopic sinonasal and skull base surgery, and an
increasingly multidisciplinary outlook have all brought a
(r)evolution in rhinology. Today, the nose is aptly regarded
as an anatomic and physiologic interface that mirrors our
professional interfacing with neurosurgeons and neurologists, allergists and chest physicians, opthalmologists
and orbital surgeons. This book aims to reflect this by
presenting all the facets of this dynamic subspecialty.
We believe that any real progress in medicine, or rhinology for that matter, can only be the result of creative
integration of basic science and clinical medicine. With

this in mind, we have brought together some of the
brightest clinicians and researchers of our generation.
We are humbled by the enthusiasm of our contributors;
indeed, they testify to the dynamic and extrovert outlook of current rhinology. Over 90 world-class experts,
presenting the most up-to-date and authoritative information from 17 countries and 4 continents. The writing
of this book started in 2010 and continued throughout

2012, resulting in chapters that are current and up-todate, with both the European Position Paper on the Endoscopic Management of Tumors of the Nose, Paranasal
Sinuses and the Skull Base from 2010 as well as the European Position Paper on Rhinosinusitis and Nasal Polyps
from 2012 given consideration. It is intended as a study
and reference book for young and experienced rhinologists alike, with questions and answers, key points, tips
and tricks, and notes included in every chapter. The DVD
included, with almost 80 videos, constitutes an integral
part of the textbook, illustrating the pathology described
in various chapters, demonstrating surgical approaches
step-by-step, as well as providing a wealth of other material including data files for use in statistical exercises and
three-dimensional imaging reconstructions.
Nevertheless, in a rapidly changing world, every textbook should come with a health warning: “Consume with
moderation, for 50% of what you know to be correct today
in medicine may be proven to be untrue tomorrow.”
Although all the information we provide is accepted to
be correct and accurate at the time of writing, we do not
claim to provide eternal certainties.
If this textbook makes you search the internet, debate
with colleagues, and even email the authors, then we
have succeeded. Do not accept anything written in here
at face value—“nullis in verba”—challenge authority, or as
Socrates already taught us:
“True wisdom comes to each of us when we realize how
little we understand about life, ourselves, and the world

around us.”
(Socrates, 469–399 BC)
Wytske Fokkens, MD, PhD
Christos Georgalas, PhD, DLO, FRCS (ORL-HNS)


ix

Acknowledgments

Although it is not possible to list all the great individuals
who contributed to this book, we would like to express
our sincere gratitude to everybody involved in the creation of this work.
Special recognition goes to the contributors, as we sincerely appreciate the time, expertise, and dedication you
gave to this book. We hope you are as proud as we are of
the final result.
We thank Mr. Stephan Konnry and his team for believing in and supporting this project from the very

beginning, for always guiding and being open for discussion, and for their unique and valuable dedication—this
book would have been impossible without them.
We thank Mrs. Storz for supporting our illustrator; Jaap
Tuyp, IC-Audiovisual Centre of the AMC, for his kind support of the DVD production; Artur Gevorgyan for proofreading the book and for his numerous valuable suggestions;
Susanne Reinartz and Dirk Jan Menger, our rhinology colleagues, and Wouter van Furth, neurosurgeon, for their support; and Katja Dalkowski, MD, for the beautiful illustrations.


x

List of Contributors

Nithin D. Adappa, MD

Department of Otorhinolaryngology–Head and
Neck Surgery
Hospital of the University of Pennsylvania
University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania, USA

Rajiv K. Bhalla, BSc (Hons), FRCS (ORL-HNS), MD
Consultant, ENT Surgeon, and Rhinologist
Department of Otorhinolaryngology–Head and
Neck Surgery
Manchester Royal Infirmary
Manchester, UK

Robert V. Almeyda
ENT Specialist Registrar
John Radcliff Hospital
Oxford, UK

Benjamin S. Bleier, MD
Clinical Instructor
Department of Otology and Laryngology
Massachusetts Eye and Ear Infirmary
Harvard Medical School
Boston, Massachusetts, USA

Isam Alobid, MD, PhD
Department of Otorhinolaryngology
Hospital Clinic
Institut d’Investigacions Biomèdiques
August Pi i Sunyer (IDIBAPS)

Barcelona, Spain
Jastin Antisdel, MD
Assistant Professor
St. Louis University School of Medicine
Department of Otolaryngology
Director, Division of Rhinology
St. Louis, Missouri, USA

Ulrike Bockmühl, MD, PhD, MA
Professor
Department of Otorhinolaryngology,
Head and Neck Surgery
Kassel Hospital
Kassel, Germany
Andrea Bolzoni Villaret, MD
Department of Otorhinolaryngology
University of Brescia
Brescia, Italy

Humera Babar-Craig
Royal Surrey County Hospital
London, UK

Cornelius Jan Brenkman, MD
Diaconessenhuis Leiden
Leidern, The Netherlands

Samuel S. Becker, MD
Director of Rhinology
Becker Nose and Sinus Center

Vanderbilt University Medical Center
Voorhees, New Jersey, USA

Hans Rudolf Briner, MD
Clinical Instructor
ORL-Center for Otology, Skull Base Surgery,
Rhinology, and Facial Plastic Surgery
Hirslanden Clinic
Zurich, Switzerland

Brett Bell, PhD
Postdoctoral Researcher
Center for Computer-Aided Surgery
Institute of Surgical Technology and Biomechanics
University of Bern
Bern, Switzerland

Ricardo L. Carrau, MD, FACS
Director Skull Base Program
Department of Otolaryngology–Head and Neck Surgery
Ohio State University Medical Center
Columbus, Ohio, USA


List of Contributors

Paolo Castelnuovo, MD, PhD
Professor and Chairman
Department of Otorhinolaryngology,
Head and Neck Surgery

University of Insubria
Varese, Italy
Marco D. Caversaccio, MD
Professor and Director
University Clinic for ENT, Head and Neck Surgery
Inselspital
Bern, Switzerland
Daniel T. T. Chua, MD, FRCR
Consultant, Clinical Oncologist
Comprehensive Oncology Center
Department of Medicine
Hong Kong Sanatorium and Hospital
Hong Kong SAR, China
Roxana Cobo, MD
Coordinator, Service of Otolaryngology
Centro Médico Imbanaco
Private Practice
Cali, Colombia
Noam A. Cohen, MD, PhD
Assistant Professor
Department of Otorhinolaryngology–Head and
Neck Surgery
Hospital of the University of Pennsylvania
University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania, USA
Vassilios Danielides, MD, PhD
Professor of Otorhinolaryngology
School of Medicine
Democritus University of Thrace
Chair

Department of Otorhinolaryngology
Alexandroupolis University Hospital
Alexandroupolis, Greece
Pascal Demoly MD, PhD
Professor, Head
Allergy Department
University Hospital of Montpellier U657
Montpellier, France
Leo F. S. Ditzel Filho, MD
Department of Neurological Surgery
Ohio State University Medical Center
Columbus, Ohio, USA

Wolfgang Draf, MD, PhD, FR
Former Director
Department of Ear, Nose and Throat Diseases,
Head and Neck Surgery
International Neuroscience Institute
University of Magdeburg
Hannover, Germany
Patrick Dubach, MD
Department of Otorhinolaryngology,
Head and Neck Surgery
Inselspital
University Hospital
University of Bern
Bern, Switzerland
Nicolas Dulguerov, MD
Senior Fellow in ENT/Facial Plastic Surgery
St. Mary’s Hospital

London, UK
Davide Farina, MD
Department of Radiology
University of Brescia
Brescia, Italy
Berrylin J. Ferguson, MD
Director
Division of Sino-nasal Disorders and Allergy
Professor of Otolaryngology
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania, USA
Juan C. Fernandez-Miranda, MD
Assistant Professor
Department of Neurological Surgery
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania, USA
Wytske Fokkens, MD, PhD
Professor
Department of Otorhinolaryngology
Academic Medical Center
Amsterdam, The Netherlands
Nicole J. M. Freling, MD, PhD
Department of Diagnostic Radiology
Academic Medical Center
Amsterdam, The Netherlands
Paul A. Gardner, MD
Assistant Professor
Department of Neurological Surgery
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania, USA

xi


xii

List of Contributors

Christos Georgalas, PhD, DLO, FRCS (ORL-HNS)
Director, Endoscopic Skull Base Center
Department of Otorhinolaryngology
Academic Medical Center
Amsterdam, The Netherlands
Philippe Gevaert, MD, PhD
Department of Otorhinolaryngology
Ghent, Belgium
Mitchell R. Gore
Resident Physician
Department of Otolaryngology
University of North Carolina at Chapel Hill
Chapel Hill, North Carolina, USA
Jan Gosepath, MD, PhD
Director
Department of Otolaryngology, Head and Neck Surgery
Dr. Horst Schmidt Kliniken
Wiesbaden, Germany
Haralampos Gouveris, MD, PhD
Assistant Professor
Department of Otorhinolaryngology–Head and
Neck Surgery

University of Mainz Medical Center
Mainz, Germany
Hakon Hakonarson, MD, PhD
Director
Center for Applied Genomics
Children’s Hospital of Philadelphia
Associate Professor
Department of Pediatrics
University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania, USA
Samuel Heimgartner, MD
Supervising Physician
Department of Otorhinolaryngology,
Head and Neck Surgery
University Hospital Bern, Inselspital
Bern, Switzerland
Peter W. Hellings, MD, PhD
Associate Professor of Otorhinolaryngology
Department of Otorhinolaryngology
University Hospitals Leuven
Leuven, Belgium
Philippe Herman, MD, PhD
Professor
ENT Department
Hôpital Lariboisière
Paris, France

Claire Hopkins, MA(Oxon), DM, FRCS (OR-LHNS)
Guy’s and St. Thomas’ Hospital
London, UK

Nick S. Jones, MD, BDS, FRCS, FRCS (ORL)
Professor
Department of Otorhinolaryngology,
Head and Neck Surgery
Queens Medical Center
University Hospital
University of Nottingham
Nottingham, UK
Amin B. Kassam, MD
Director Neurosciences
Neurosciences Institute
John Wayne Cancer Institute
St. John’s Health Center
Santa Monica, California, USA
Robert M. Kellman, MD
Professor and Chair
Department of Otolaryngology and
Communication Sciences
State University of New York Upstate Medical University
Syracuse, New York, USA
Daniel F. Kelly, MD
Medical Director
John Wayne Cancer Institute
St. John’s Health Center
Santa Monica, California, USA
Bhik Kotecha, MPhil, FRCS, DLO
Consultant, Otolaryngologist
Royal National Throat, Nose, and Ear Hospital
London, UK
Stilianos E. Kountakis, MD, PhD

Professor and Vice-Chairman
Department of Otolaryngology
Chief, Division of Rhinology
Medical College of Georgia
Augusta, Georgia, USA
Haytham Kubba, MD
Consultant, Pediatric Otolaryngologist
Royal Hospital for Sick Children
Yorkhill
Glasgow, Scotland, UK
Jean-Silvain Lacroix, MD, PhD
Professor
Geneva University Hospital and Geneva Medical School
Geneva, Switzerland


List of Contributors

Basile Nicolas Landis, MD
Smell and Taste Outpatient Clinic
Department of Otolaryngology–Head and Neck Surgery
Bern University Hospital, Inselspital
Bern, Switzerland

Piero Nicolai, MD
Professor, Chairman
Department of Otorhinolaryngology
University of Brescia
Brescia, Italy

Donald C. Lanza, MD, MS
Director
Sinus and Nasal Institute of Florida Foundation
St. Petersburg, Florida, USA

Gilbert J. Nolst Trenité, MD, PhD
Professor
ENT Department
Academic Hospital
Amsterdam, The Netherlands

Annie S. Lee, MD
Department of Otolaryngology–Head and Neck Surgery
Lahey Clinic Medical Center
Burlington, Massachusetts, USA
Sarah Lovell
Department of Otolaryngology–Head and Neck Surgery
National University Hospital
Singapore
Tim C. Lueth
Director
Institute for Micro Technology and Medical Device
Technology
Technical University of Munich
Munich, Germany
Franklin Mariño-Sánchez, MD
Department of Otorhinolaryngology
Hospital Clinic
Institut d’Investigacions Biomèdiques
August Pi i Sunyer (IDIBAPS)

Barcelona, Spain
Nancy McLaughlin, MD, PhD, FRCSC
Fellow in Neurosurgery
John Wayne Cancer Institute
St. John’s Health Center
Santa Monica, California, USA
Ralph Metson, MD
Clinical Professor of Otolaryngology
Department of Otology and Laryngology
Harvard Medical School
Boston, Massachusetts, USA
Joaquim Mullol, MD, PhD
Professor
Department of Otorhinolaryngology
Hospital Clinic
Institut d’Investigacions Biomèdiques
August Pi i Sunyer (IDIBAPS)
Barcelona, Spain

Reza Nouraei
Special Registrar
Academic ENT Surgery
Imperial College Healthcare NHS Trust
The Royal National Throat, Nose, and Ear Hospital
London, UK
James N. Palmer, MD
Department of Otorhinolaryngology–Head and Neck
Surgery
Hospital of the University of Pennsylvania
University of Pennsylvania School of Medicine

Philadelphia, Pennsylvania, USA
Vasileios Papanikolaou, MD
Consultant in Otorhinolaryngology
First University Department of Otorhinolaryngology
Ippokation Hospital
Athens, Greece
Kalpesh S. Patel, BSc (Hons), FRCS (ORL)
Consultant, ENT/Facial Plastic Surgeon
Honorary Senior Lecturer
Imperial College of Science
St. Mary’s Hospital
London, UK
Santdeep H. Paun, MBBS, FRCS (ORL-HNS)
Consultant, Nasal/Facial Plastic Surgeon
Head, Department of Otorhinolaryngology–Head and
Neck Surgery
St. Bartholomew’s and the Royal London Hospitals
London, UK
Oliver Pfaar, MD, PhD
Department of Otorhinolaryngology, Head and Neck Surgery
Center for Rhinology and Allergology
University Hospital Mannheim
Wiesbaden, Germany
Daniel M. Prevedello, MD
Assistant Professor
Neurological Surgery
Ohio State University
Columbus, Ohio, USA

xiii

xiv

List of Contributors

Emmanuel Prokopakis, MD
Assistant Professor
Department of Otorhinolaryngology–Head and
Neck Surgery
University of Crete School of Medicine
Heraklio, Crete, Greece
Susanne M. Reinartz, MD
Department of Otorhinolaryngology
Academic Medical Center
Amsterdam, The Netherlands
Herbert Riechelmann, MD, PhD
Chairman and Professor
Department of Otorhinolaryngology–Head and
Neck Surgery
Medical University Innsbruck
Innsbruck, Austria
Peerooz Saeed, MD
Professor of Ophthalmology
Orbital Center/Department of Ophthalmology
University of Amsterdam
Amsterdam, The Netherlands
Hesham Saleh, FRCS (ORL-HNS)
Consultant, Rhinologist, and Facial Plastic Surgeon
Honorary Senior Lecturer

Charing Cross and Royal Brompton Hospitals
Imperial College of Medicine
London, UK
Glenis K. Scadding, MD
Consultant, Allergist/Rhinologist
Royal National Throat, Nose, and Ear Hospital
London, UK
Rodney J. Schlosser, MD
Professor
Department of Otolaryngology–Head and Neck Surgery
Medical University of South Carolina
Mt. Pleasant, South Carolina, USA
Brent Senior, MD
Professor and Vice Chair
Otolaryngology/Head and Neck Surgery
University of North Carolina at Chapel Hill
Chapel Hill, North Carolina, USA
Jian-Bo Shi, MD
Professor
Otorhinolaryngology Hospital
First Affiliated Hospital of Sun Yat-sen University
Guangdong, China

Li Shi, MD
Professor
Department of Otolaryngology
Qilu Hospital, Shandong University
Shandong, China
Daniel Simmen, MD
Professor

ORL Center
Hirslanden Clinic
Zurich, Switzerland
Ameet Singh, MD
Assistant Professor of Surgery and Neurosurgery
Director, Rhinology and Skull Base Surgery
George Washington University
Washington, DC, USA
Elisabeth Victoria Sjoegren, MD, PhD
Department of Otolaryngology–Head and Neck Surgery
Leiden University Medical Center
Leiden, The Netherlands
Carl H. Snyderman, MD, MBA
Professor
Departments of Otolaryngology and
Neurological Surgery
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania, USA
Zachary M. Soler, MD
Rhinology Fellow
Harvard Medical School
Boston, Massachusetts, USA
Alla Y. Solyar, MD
Rhinology Fellow
Sinus and Nasal Institute of Florida Foundation
St. Petersburg, Florida, USA
Gero Strauss, MD, PD
Supervising Physician
Clinic for ENT/Surgery/Plastic Surgery
University Clinic Leipzig

Leipzig, Germany
Andrew C. Swift, ChM, FRCS, FRCSEd
Consultant, ENT Surgeon, and Rhinologist
Aintree University Hospital NHS Foundation Trust
Liverpool, UK
Ingrid Terreehorst, MD, PhD
Department of Otorhinolaryngology
Academic Medical Center
Amsterdam, The Netherlands


List of Contributors

Timoleon F. Terzis MD, PhD
Head, Athens Rhinology Center
Visiting Consultant, Otorhinolaryngologist
Onassis Cardiac Surgery Center
Athens, Greece
Marc A. Tewfik, MD, MSc, FRCSC
Assistant Professor
McGill University
Department of Otolaryngology–Head and Neck Surgery
Royal Victoria Hospital
Montreal, Quebec, Canada
Matthew J. Tormenti, MD
Neurosurgery Resident
Department of Neurological Surgery
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania, USA
Elina Toskala, MD, PhD

Professor
Finnish Institute of Occupational Health
Helsinki, Finland
Center for Applied Genomics
Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania, USA
Bert van der Baan, MD
ENT Department
Academic Medical Center
Amsterdam, The Netherlands
Cornelis M. van Drunen, PhD
Department of Otorhinolaryngology
Academic Medical Center
Amsterdam, The Netherlands
Wouter R. van Furth, MD, PhD
Department of Otorhinolaryngology
Endoscopic Skull Base Center
Academic Medical Center
Amsterdam, The Netherlands
Thibaut Van Zele, MD, PhD
Upper Airways Research Laboratory
Department of Otorhinolaryngology
Ghent University Hospital
Ghent, Belgium
Carel D. A. Verwoerd, MD, PhD
Emeritus Professor of Otolaryngology
Erasmus University Medical Center
Rotterdam, The Netherlands

Henriette L. Verwoerd-Verhoef, MD, PhD

Erasmus University Medical Center
Rotterdam, The Netherlands
De-Yun Wang, MD, PhD
Associate Professor
Department of Otolaryngology
Yong Loo Lin School of Medicine
National University of Singapore
Singapore
Stefan Weber, PhD
Professor
ARTORG Center for Biomedical Engineering Research
University of Bern
Bern, Switzerland
William Ignace Wei, MS, FRCS, FRCSE,
FRACS (Hon.), FACS (Hon.)
Head, Department of Surgery
Director, Li Shu Pui Center of Otorhinolaryngology, Head
and Neck Surgery
Hong Kong Sanatorium and Hospital
Hong Kong SAR, China
Ronald B. Willemse, MD
Department of Neurosurgery
Endoscopic Skull Base Center
Academic Medical Center
Amsterdam, The Netherlands
Peter-John Wormald, MD, FRCS, FRACS, FCS (SA)
Professor of Otolaryngology
Adelaide and Flinders Universities
Queen Elizabeth Hospital
Department of Otolaryngology–Head and Neck Surgery

Woodville South, Australia
Giannis Yiotakis, MD, PhD
Associate Professor
First University Department of Otorhinolaryngology
Ippokation Hospital
Athens, Greece
Bing Zhou, MD
Professor and Vice Chairman
Department of Otolaryngology
Tongren Hospital
Beijing, China

xv


xvi

Contents

Foreword ..........................................................................vii

Factors Associated with Recurrent
Acute Rhinosinusitis .......................................................53
Factors Associated with Chronic
Rhinosinusitis ...................................................................54
Factors Associated with Nasal Polyps ............................57
Therapeutic Consequences of the Complex
Pathophysiology of Rhinosinusitis.............................58
Key Points ...............................................................................59
Review Questions .................................................................59

References...............................................................................59

Preface .............................................................................viii
Acknowledgments ............................................................ix
List of Contributors ............................................................x
I Basic Science and Patient Assessment..........................1
1 Nasal and Paranasal Sinus Anatomy
and Embryology ...........................................................3
Annie S. Lee, Alla Y. Solyar, Donald C. Lanza, and
Christos Georgalas
Summary .................................................................................. 3
Introduction............................................................................. 3
Development of the Nose and Paranasal
Sinuses .................................................................................. 4
The External Nose .................................................................. 6
The Nasal Cavity ..................................................................... 8
The Paranasal Sinuses .........................................................16
Key Points ...............................................................................24
Acknowledgments ...............................................................24
Review Questions .................................................................24
References...............................................................................25

4

Immunology and the Nose:
From Basic Science to Clinical ....................................62
Cornelius M. van Drunen and Wytske Fokkens
Summary ................................................................................62
Introduction...........................................................................62
Dangers Lurking in the Outside World ..........................62

Autoimmune Diseases and Allergy:
Cases of Mistaken Identity ...........................................73
Investigating Diseases and the
Immune System ...............................................................75
Key Points ...............................................................................75
Review Questions .................................................................76
References...............................................................................76

2 Nasal and Paranasal Sinus Physiology .......................27
Vassilios Danielides, Haralampos Gouveris,
Sarah Lovell, and De-Yun Wang
Summary ................................................................................27
Physiologic Function of the Nasal Airflow....................27
Physiologic Functions of the Nasal
Epithelium .........................................................................38
Special Issues on Physiology of the Paranasal
Sinuses ................................................................................46
Key Points ...............................................................................46
Review Questions .................................................................47
References...............................................................................47

5

Genetics in Rhinology .................................................77
Elina Toskala and Hakon Hakonarson
Summary ................................................................................77
Introduction...........................................................................77
Allergic Rhinitis ....................................................................78
Chronic Rhinosinusitis .......................................................79
Asthma ....................................................................................80

Cystic Fibrosis........................................................................81
Mucin Disorders ...................................................................82
Key Points ...............................................................................82
Review Questions .................................................................82
References...............................................................................83

3 Recent Advances in Understanding
the Pathophysiology of Rhinosinusitis ......................50
Peter W. Hellings
Summary ................................................................................50
Introduction...........................................................................50
Inflammation in Rhinosinusitis .......................................52
Factors Associated with Acute Rhinosinusitis ............53

6 Investigations in Nasal Disease ..................................85
Glenis K. Scadding and
Susanne M. Reinartz
Summary ................................................................................85
Introduction...........................................................................85
Allergy Tests...........................................................................86
Nasal Sampling .....................................................................89


Contents

Evaluation of Nasal Patency ..............................................92
Microbiology .........................................................................96
Evaluation of Mucociliary Clearance ..............................97
Blood and Other Tests .........................................................99
Key Points ............................................................................ 100

Review Questions .............................................................. 100
References............................................................................ 101
7

8

9

Imaging as a Diagnostic Tool and
Surgical Instrument in Rhinology ............................103
Timoleon F. Terzis and Nicole J. M. Freling
Summary ............................................................................. 103
Introduction........................................................................ 103
From Plain X-Ray Films to Computed
Tomography ................................................................... 104
Computed Tomography and Magnetic
Resonance Imaging ...................................................... 104
Other Imaging Modalities............................................... 106
Evaluation of Pathology .................................................. 108
Inflammatory Disease...................................................... 109
Neoplastic Disease ............................................................ 113
Study of the Anatomy on Computed
Tomography ................................................................... 116
Virtual Surgery Based on Computed
Tomography ................................................................... 126
Do We Need Image Guidance? ...................................... 126
Acknowledgment .............................................................. 127
Key Points ............................................................................ 127
Review Questions .............................................................. 128
References............................................................................ 128

Clinical Examination and
Differential Diagnosis in Rhinology .........................130
Joaquim Mullol, Franklin Mariño-Sánchez,
Isam Alobid, and Christos Georgalas
Summary ............................................................................. 130
Introduction........................................................................ 130
Clinical Diagnosis .............................................................. 130
Examination and Complementary
Diagnostic Tools ............................................................ 138
Referral and Consultation Criteria ............................... 144
Steps in Differential Diagnosis ...................................... 144
Key Points ............................................................................ 150
Review Questions .............................................................. 150
References............................................................................ 151
Patient-reported Outcome Measures
and Measurement Tools in Rhinology .....................152
Claire Hopkins and Christos Georgalas
Summary ............................................................................. 152
Introduction........................................................................ 152
Why Measure Outcome? ................................................ 152
Clinical versus Patient-reported Outcomes .............. 153
Clinician-reported Outcome Measures in
Rhinology ........................................................................ 154

Patient-reported Outcome Measures
in Rhinology ................................................................... 154
How to Choose an Appropriate
Patient-rated Outcome Tool ...................................... 164
Data Collection and Storage ........................................... 166
Developing an Outcome Tool When

None Are Available ....................................................... 167
Why Are We Not Routinely
Measuring PROMs? ...................................................... 168
Limitations of PROMs ...................................................... 170
Cost-effectiveness Analysis ............................................ 171
Publishing Outcomes ....................................................... 171
Key Points ............................................................................ 171
Review Questions .............................................................. 171
References............................................................................ 172
10 Facial Pain ...............................................................175
Nick S. Jones
Summary........................................................................... 175
Introduction ..................................................................... 175
Sinogenic Facial Pain...................................................... 175
Main Categories of Nonsinogenic
Facial Pain ..................................................................... 178
Indomethacin-responsive Headaches ...................... 182
“Sinus Headaches” .......................................................... 182
Specific Neurologic Conditions .................................. 187
The Overlap between Conditions .............................. 188
Comment on Contact Points ....................................... 188
Key Points ......................................................................... 191
Review Questions ........................................................... 192
References ......................................................................... 192
11 Olfaction and Its Disorders ....................................195
Basile Nicolas Landis, Hans Rudolf Briner,
Jean-Silvain Lacroix, and Daniel Simmen
Summary........................................................................... 195
Olfaction ............................................................................ 195
Olfactory Disorders ........................................................ 199

Key Points ......................................................................... 209
Review Questions ........................................................... 210
References ......................................................................... 210
12 The Relation between the Upper and
Lower Airways: The United Airway Concept .........212
Bert van der Baan, Peter W. Hellings,
and Wytske Fokkens
Summary........................................................................... 212
Introduction ..................................................................... 212
Epidemiology ................................................................... 213
Interaction between the Upper and
Lower Airways ............................................................ 214
Management of the United Airways ......................... 217
Key Points ......................................................................... 222
Review Questions ........................................................... 223
References ......................................................................... 223

xvii


xviii

Contents

II

Rhinitis and Rhinosinusitis .......................................227

13

Nonallergic Rhinitis: Definition,
Classification, and Management ...........................229
Wytske Fokkens, Hesham Saleh, and
Christos Georgalas
Summary........................................................................... 229
Introduction ..................................................................... 229
Definition and Differential Diagnosis....................... 229
Epidemiology ................................................................... 232
Considerations on Possible
Pathophysiologic Mechanisms .............................. 232
Diagnosis ........................................................................... 235
Treatment Modalities .................................................... 239
Conclusion ........................................................................ 243
Key Points ......................................................................... 244
Review Questions ........................................................... 244
References ......................................................................... 244

14

15

Allergic Rhinitis: Definition,
Classification, and Management,
Including Immunotherapy .....................................246
Pascal Demoly, Wytske Fokkens,
and Ingrid Terreehorst
Summary........................................................................... 246
Introduction ..................................................................... 246
Definition of Allergic Rhinitis ..................................... 247
Epidemiology ................................................................... 248

Etiology: Allergens and Nonspecific
Factors ........................................................................... 249
Clinical Features .............................................................. 254
Differential Diagnosis .................................................... 255
Diagnostic Work-up....................................................... 255
Management .................................................................... 257
Key Points ......................................................................... 262
Review Questions ........................................................... 262
References ......................................................................... 263
Acute Rhinosinusitis and
Infections of the Nose ............................................264
De-Yun Wang, Li Shi, Bing Zhou,
and Jian-Bo Shi
Summary........................................................................... 264
Definition .......................................................................... 264
Physiologic and Immunologic Functions
of the Nose and Sinuses ........................................... 266
Acute Viral Rhinitis (or Viral Rhinosinusitis)/
Common Cold ............................................................. 267
Acute Rhinosinusitis ...................................................... 268
Nasal Vestibulitis ............................................................ 270
Diagnosis ........................................................................... 271
Treatment.......................................................................... 272
Conclusion ........................................................................ 274
Key Points ......................................................................... 274
Review Questions ........................................................... 274
References ......................................................................... 275

16 Chronic Rhinosinusitis with and
without Nasal Polyps..............................................276

Jan Gosepath and Oliver Pfaar
Summary........................................................................... 276
Chronic Rhinosinusitis: Epidemiological
Burden ........................................................................... 276
Clinical Definition........................................................... 277
Clinical Characteristics and Associated
Factors ........................................................................... 277
Therapeutic Options Deriving from Different
Clinical Parameters.................................................... 279
Efficacy of Endoscopic Sinus Surgery ....................... 281
Evaluation of Endoscopic Sinus Surgery ................. 282
Key Points ......................................................................... 282
Review Questions ........................................................... 282
References ......................................................................... 283
17

Evidence-based Medical Management of
Chronic Rhinosinusitis ............................................285
Philippe Gevaert, Humera Babar-Craig,
Thibaut Van Zele, and Robert V. Almeyda
Summary........................................................................... 285
Introduction ..................................................................... 285
Definition .......................................................................... 286
Management Algorithm ............................................... 286
Current Medical Management Options ................... 286
Evidence for Medical Management
versus Surgical Management ................................. 292
Future Therapy ................................................................ 292
Long-term Management .............................................. 293
Key Points ......................................................................... 293

Review Questions ........................................................... 293
References ......................................................................... 294

18

Evidence-based Surgery for Rhinosinusitis ...........296
Christos Georgalas and Wytske Fokkens
Summary........................................................................... 296
Introduction ..................................................................... 296
Measuring the Efficacy of Sinus Surgery ................. 298
Functional Endoscopic Sinus Surgery
in Acute Recurrent Rhinosinusitis ........................ 298
Functional Endoscopic Sinus Surgery in
Chronic Rhinosinusitis with and
without Nasal Polyps ................................................ 299
Functional Endoscopic Sinus Surgery versus
Conventional Surgery ............................................... 303
Endoscopic Sinus Surgery Modifications ................ 303
Predictors of Outcome in Endoscopic
Sinus Surgery .............................................................. 304
Revision Sinus Surgery ................................................. 307
Key Points ......................................................................... 308
Review Questions ........................................................... 308
References ......................................................................... 308


Contents

19

20

Basic Surgical Techniques in
Endoscopic Sinus Surgery ......................................311
Hesham Saleh and Reza Nouraei
Summary........................................................................... 311
Introduction ..................................................................... 311
Indications/Patient Selection ...................................... 312
Patient Information/Consent ...................................... 312
Patient Positioning and Anesthesia .......................... 312
Basic Surgical Instruments for
Endoscopic Sinus Surgery ....................................... 312
Operative Steps ............................................................... 314
Postoperative Care ......................................................... 323
Complications .................................................................. 323
Outcome ............................................................................ 323
Future Directions ............................................................ 323
Key Points ......................................................................... 324
Review Questions ........................................................... 324
References ......................................................................... 325
The Patient with Difficult-to-Treat
Chronic Rhinosinusitis ............................................326
Emmanuel Prokopakis, Berrylin J. Ferguson,
Christos Georgalas, and Wytske Fokkens
Summary........................................................................... 326
Introduction ..................................................................... 326
Difficult-to-Treat Disease ............................................. 326
The Difficult Host............................................................ 341
Treatment Suggestions ................................................. 342
Conclusion ........................................................................ 345

Key Points ......................................................................... 346
Review Questions ........................................................... 346
References ......................................................................... 346

21

Fungal Rhinosinusitis..............................................349
Herbert Riechelmann, Marc A. Tewfik,
and Peter-John Wormald
Summary........................................................................... 349
Introduction ..................................................................... 349
Fungus Biology ................................................................ 350
Fungus-related Sinus Disease ..................................... 352
Medical Management ................................................... 362
Surgical Management ................................................... 366
Conclusion ........................................................................ 373
Key Points ......................................................................... 373
Review Questions ........................................................... 373
References ......................................................................... 373

22

Approaches to the Frontal Sinus ............................376
Christos Georgalas and Wytske Fokkens
Summary........................................................................... 376
Introduction ..................................................................... 376
Classification of Frontal Sinus Approaches/
Nomenclature ............................................................. 378
Indications ........................................................................ 378
Surgical Anatomy of the Frontal Recess .................. 381

Instrumentation.............................................................. 385

Approaches: Anatomical and
Technical Description ............................................... 386
Specific Anatomical Considerations ......................... 392
Specific Pathological Considerations........................ 393
Preoperative and Postoperative
Management ............................................................... 404
Outcomes .......................................................................... 405
Key Points ......................................................................... 407
Review Questions ........................................................... 407
References ......................................................................... 407
III Rhinoplasty and Nasal Framework Surgery ...........411
23 Assessment of the Rhinoplasty Patient .................413
Christos Georgalas
Summary........................................................................... 413
Rhinoplasty: Social and Ethical Issues ..................... 414
Patient Selection and the Rhinoplasty
Consultation ................................................................ 414
Surgical Anatomy of the External Nose ................... 417
Nasal Aesthetics and Assessment .............................. 422
Documentation in Rhinoplasty:
Photography and Computer Imaging................... 427
Key Points ......................................................................... 433
Review Questions ........................................................... 433
References ......................................................................... 433
24

Cosmetic Rhinoplasty .............................................436
Roxana Cobo

Summary........................................................................... 436
Introduction ..................................................................... 436
Approach to the Nasal Septum/
Graft Harvesting ......................................................... 436
Approaches in Rhinoplasty.......................................... 437
Management of the Upper Third of
the Nose: The Bony Nasal Vault............................. 440
Management of the Middle Third of
the Nose: The Cartilaginous Vault ........................ 443
Management of the Lower Third of
the Nose: The Nasal Tip ........................................... 445
Alar Base Reduction ....................................................... 452
Skin–Soft Tissue Envelope ........................................... 453
Postsurgical Follow-up ................................................. 454
Conclusion ........................................................................ 454
Key Points ......................................................................... 454
Review Questions ........................................................... 454
References ......................................................................... 455

25

Revision Rhinoplasty ..............................................456
Santdeep H. Paun and Gilbert J. Nolst Trenité
Summary........................................................................... 456
Introduction ..................................................................... 456
Psychological Issues ....................................................... 456
Nasal Anatomy ................................................................ 457
Timing of Revision Operation ..................................... 457
Assessment ....................................................................... 458

xix


xx

Contents

Surgical Planning ............................................................ 459
Surgical Deformities and Corrective
Procedures.................................................................... 461
Conclusion ........................................................................ 475
Key Points ......................................................................... 475
Review Questions ........................................................... 476
References ......................................................................... 476
26

Functional Nasal Surgery .......................................478
Kalpesh S. Patel and Nicolas Dulguerov
Summary........................................................................... 478
Introduction ..................................................................... 478
Relevant Nasal Anatomy ............................................... 478
Tip Support ....................................................................... 480
Internal Nasal Valve ....................................................... 481
External Nasal Valve ...................................................... 482
Etiology of Nasal Obstruction ..................................... 483
Aging of the Nose ........................................................... 483
Cartilage Considerations .............................................. 483
Investigations ................................................................... 484
Structural Causes of Nasal Obstruction ................... 486
Management of Septal Deviation .............................. 488

Nasal Bone Deviation .................................................... 493
Nasal Valve Incompetence ........................................... 493
Turbinate Hypertrophy ................................................. 499
Nasal Septal Perforation ............................................... 499
Key Points ......................................................................... 501
Review Questions ........................................................... 501
References ......................................................................... 501

IV Acute Rhinology ......................................................505
27

28

Epistaxis: Etiology, Investigations,
and Management ...................................................507
Andrew C. Swift, Benjamin S. Bleier,
Rajiv K. Bhalla, and Rodney J. Schlosser
Summary........................................................................... 507
Epidemiology ................................................................... 507
Etiology .............................................................................. 508
Evidence-based Treatment and Outcomes ............. 513
Key Points ......................................................................... 523
Review Questions ........................................................... 523
References ......................................................................... 524
Complications of Acute Rhinosinusitis ..................527
Mitchell R. Gore, Philippe Herman,
Brent Senior, and Wytske Fokkens
Summary........................................................................... 527
Introduction ..................................................................... 527
Orbital Complications ................................................... 527

Endocranial Complications .......................................... 535
Special Case: Meningitis as a Complication
of Acute Sinusitis........................................................ 537
Osseous Complications ................................................. 539
Key Points ......................................................................... 541

Review Questions ........................................................... 542
References ......................................................................... 542
29 Nasal and Paranasal Sinus Trauma ........................545
Robert M. Kellman
Summary........................................................................... 545
Classification of Nasal and Paranasal
Sinus Trauma ............................................................... 545
Epidemiology of Nasal and Paranasal
Sinus Trauma ............................................................... 549
Paranasal Sinuses as a Protective
Crumple Zone.............................................................. 549
Clinical Features .............................................................. 549
Diagnostic Studies .......................................................... 550
Management .................................................................... 551
Outcomes .......................................................................... 560
Key Points ......................................................................... 562
Review Questions ........................................................... 562
References ......................................................................... 563
V

Rhinology: The Multidisciplinary Interface .............565

30

Anesthesia for Nasal Surgery,
Pre- and Postoperative Care ..................................567
Ameet Singh, Elisabeth Victoria Sjoegren,
Samuel S. Becker, and Cornelius Jan Brenkman
Summary........................................................................... 567
Introduction ..................................................................... 567
Preoperative Planning in Sinus Surgery .................. 567
General Anesthesia in Sinus Surgery........................ 570
Local Anesthesia in Sinus Surgery ............................. 570
Preparation of the Surgical Field ............................... 573
Preparation of the Surgical Field: Evidence of
Substance Effect and Safety .................................... 576
Postoperative Management of Sinus
Surgery .......................................................................... 578
Key Points ......................................................................... 582
Review Questions ........................................................... 582
References ......................................................................... 582

31 Technological Advances in Rhinology
and Anterior Skull Base ..........................................585
Brett Bell, Patrick Dubach, Samuel Heimgartner,
Tim C. Lueth, Gero Strauss, Stefan Weber, and
Marco D. Caversaccio
Summary........................................................................... 585
Computer-assisted Surgery ......................................... 585
Modern Surgical Instrumentation ............................ 593
Robotic Manipulation and Support .......................... 597
Operating Room Integration ....................................... 601
Clinical Applications ...................................................... 602
Key Points ......................................................................... 603

Review Questions ........................................................... 603
References ......................................................................... 604


xxi

32

33

34

35

Acquired Noninfectious, Nonneoplastic
Disorders of the Nose and Paranasal Sinuses .......606
Nithin D. Adappa, Noam A. Cohen,
and James N. Palmer
Summary........................................................................... 606
Mucoceles ......................................................................... 606
Silent Sinus Syndrome .................................................. 615
Sinus Cholesteatomas.................................................... 618
Pneumoceles and Pneumosinus Dilatans ............... 621
Barotrauma....................................................................... 622
Conclusion ........................................................................ 624
Key Points ......................................................................... 624
Review Questions ........................................................... 624
References ......................................................................... 624
Pediatric Rhinology: Developmental
Aspects and Surgery...............................................626

Carel D. A. Verwoerd, Haytham Kubba,
and Henriette L. Verwoerd-Verhoef
Summary........................................................................... 626
Introduction ..................................................................... 627
Postnatal Growth of the Nose..................................... 627
Morphogenetic Processes and Nasal Growth:
Surgical Aspects ......................................................... 631
Nasal Growth in Children after Injury
or Surgery..................................................................... 632
Indications, Diagnosis, and Treatment..................... 635
Congenital Anomalies ................................................... 637
Acquired Conditions ...................................................... 649
Key Points ......................................................................... 659
Review Questions ........................................................... 659
References ......................................................................... 660
Nasal Pathology in Snoring and
Obstructive Sleep Apnea ........................................663
Bhik Kotecha and Christos Georgalas
Summary........................................................................... 663
Introduction ..................................................................... 663
Pathophysiology of Nasal Obstruction and
Breathing During Sleep ............................................ 664
Clinical Correlation Between Nasal Pathology
and Sleep-Disordered Breathing ........................... 665
Implications for Management .................................... 666
Key Points ......................................................................... 670
Review Questions ........................................................... 670
References ......................................................................... 671
Systemic Disease and the Nose ..............................673
Jastin Antisdel and Stilianos E. Kountakis

Summary........................................................................... 673
Introduction ..................................................................... 673
Granulomatous Disorders ............................................ 673
Key Points ......................................................................... 690

Review Questions ........................................................... 690
References ......................................................................... 690
VI

Sinonasal Oncology and Extended Applications of
Endoscopic Surgery ................................................ 693

36

Closure of Cerebrospinal Fluid Leaks
and Repair of Meningoceles/Encephaloceles ........695
Wytske Fokkens and Christos Georgalas
Summary........................................................................... 695
Introduction ..................................................................... 695
Diagnosis of Leaks .......................................................... 698
Important Surgical Anatomy and
Operative Steps ........................................................... 703
Postoperative Care ......................................................... 710
Outcomes .......................................................................... 711
Key Points ......................................................................... 711
Review Questions ........................................................... 712
References ......................................................................... 712

37

Into and Around the Orbit:
Endoscopic Dacryocystorhinostomy,
Orbital Decompression, Optic Nerve
Decompression, and Endoscopic
Management of Orbital Tumors ............................713
Peerooz Saeed, Zachary M. Soler,
Christos Georgalas, and Ralph Metson
Summary........................................................................... 713
Endoscopic Dacryocystorhinostomy ........................ 713
Endoscopic Orbital Decompression .......................... 719
Optic Nerve Decompression........................................ 725
Orbital Tumors: An Endoscopic Approach.............. 727
Benign Tumors ................................................................. 727
Key Points ......................................................................... 735
Review Questions ........................................................... 736
References ......................................................................... 736

38

Endoscopic Approach to the Sella .........................738
Ronald B. Willemse, Wouter R. van Furth,
Wytske Fokkens, and Christos Georgalas
Summary........................................................................... 738
Introduction ..................................................................... 738
Indications/Patient Selection ...................................... 739
Preoperative Planning ................................................... 741
Patient Information/Informed Consent ................... 745
Anesthesia and Positioning ......................................... 745
Operative Steps ............................................................... 746
Complications .................................................................. 751

Postoperative Care ......................................................... 753
Outcomes .......................................................................... 754
Key Points ......................................................................... 756
Review Questions ........................................................... 756
References ......................................................................... 756


xxii

2 Nasal and Paranasal Sinus Physiology

39

Sella and Beyond: Approaches to
the Clivus and Posterior Fossa,
Petrous Apex, and Cavernous Sinus ......................758
Carl H. Snyderman, Paul A. Gardner,
Matthew J. Tormenti, and
Juan C. Fernandez-Miranda
Summary........................................................................... 758
Introduction ..................................................................... 758
Terminology: Definition of Parasellar Areas .......... 758
Principles of Endoscopic Endonasal Surgery
of the Skull Base ......................................................... 759
Classification of Skull Base Approaches .................. 759
Operative Preparation ................................................... 759
Surgical Approaches ...................................................... 760
Reconstruction ................................................................ 769
Postoperative Care ......................................................... 769
Key Points ......................................................................... 771

Review Questions ........................................................... 771
References ......................................................................... 771

40

Anterior Skull Base Tumors and
Approaches: Transtuberculum,
Transplanum, and Transcribriform ........................772
Nancy McLaughlin, Daniel M. Prevedello,
Leo F. S. Ditzel Filho, Daniel F. Kelly,
Amin B. Kassam, and Ricardo L. Carrau
Summary........................................................................... 772
Introduction ..................................................................... 772
Indications/Patient Selection ...................................... 772
Preoperative Planning ................................................... 773
Patient Counseling, Informed Consent .................... 775
Anesthesia and Positioning ......................................... 775
Anatomy ............................................................................ 776
Operative Steps ............................................................... 777
Complications .................................................................. 784
Postoperative Care ......................................................... 785
Outcome ............................................................................ 785
Key Points ......................................................................... 787
Review Questions ........................................................... 788
References ......................................................................... 789

41

Reconstruction of the Skull Base
and Management of Skull Base

Surgery Complications ...........................................791
Nancy McLaughlin, Ricardo L. Carrau,
Amin B. Kassam, Daniel F. Kelly,
Daniel M. Prevedello, and
Juan C. Fernandez-Miranda
Summary........................................................................... 791
Introduction ..................................................................... 791
Generalities of Skull Base Reconstruction in
Endonasal Skull Base Surgery ................................ 791
Pedicled Flaps .................................................................. 792
Other Reconstruction Techniques for
Large Skull Base Defects .......................................... 804
Postoperative Cerebrospinal Fluid Leak .................. 804
Key Points ......................................................................... 807

Review Questions ........................................................... 807
References ......................................................................... 808
42 Benign and Malignant Tumors of
the Nose and Paranasal Sinuses,
Including External Approaches to
Paranasal Sinuses....................................................810
Ulrike Bockmühl, Giannis Yiotakis,
Vasileios Papanikolaou, and Wolfgang Draf
Summary........................................................................... 810
Introduction ..................................................................... 810
General Remarks ............................................................ 810
Endonasal Approach ...................................................... 813
External Approaches ..................................................... 815
Outcome ............................................................................ 832
Key Points ......................................................................... 832

Review Questions ........................................................... 832
References ......................................................................... 833
43

The Role of Endoscopy in the
Management of Benign and Malignant
Sinonasal Tumors....................................................835
Piero Nicolai, Paolo Castelnuovo,
Andrea Bolzoni Villaret, and Davide Farina
Summary........................................................................... 835
Introduction ..................................................................... 835
A Quick Look at Epidemiology, Symptoms,
Diagnosis, and Staging.............................................. 836
Patient Selection and Information ............................ 841
Anesthesia and Positioning ......................................... 844
Operative Steps ............................................................... 846
Complications .................................................................. 852
Perioperative Management ......................................... 853
Adjuvant Therapy ........................................................... 854
Outcome ............................................................................ 855
Postoperative Surveillance .......................................... 857
Key Points ......................................................................... 858
Review Questions ........................................................... 859
References ......................................................................... 859

44

Nasopharyngeal Carcinoma ...................................862
William Ignace Wei and Daniel T. T. Chua
Summary........................................................................... 862

Epidemiology ................................................................... 862
Pathology .......................................................................... 863
Etiology .............................................................................. 863
Diagnosis ........................................................................... 863
Treatment.......................................................................... 866
Management of Residual or Recurrent
Disease .......................................................................... 869
Key Points ......................................................................... 876
Review Questions ........................................................... 876
References ......................................................................... 877

Appendix.........................................................................879
Index ...............................................................................885


Section I Basic Science and Patient
Assessment
1

Nasal and Paranasal Sinus Anatomy and
Embryology..........................................................

3

2 Nasal and Paranasal Sinus Physiology ................ 28
3

Recent Advances in Understanding the
Pathophysiology of Rhinosinusitis...................... 52

4

Immunology and the Nose:
From Basic Science to Clinical ............................. 64

5

Genetics in Rhinology .......................................... 79

6 Investigations in Nasal Disease ........................... 87
7

Imaging as a Diagnostic Tool and Surgical
Instrument in Rhinology ..................................... 105

8

Clinical Examination and Differential
Diagnosis in Rhinology ........................................ 132

9

Patient-reported Outcome Measures and
Measurement Tools in Rhinology ....................... 154

10

Facial Pain ............................................................ 177

11

Olfaction and Its Disorders ................................. 197

12

The Relation between the Upper and
Lower Airways: The United Airway Concept ...... 214