Endoscopic Surgery of the Paranasal Sinuses and Anterior

Skull Base, 2nd Edition

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 V

List of Collaborators and Contributors

Torsten Birkholz, Dr. med. Werner Hosemann, Dr. med.

Department of Anesthesiology Professor of Otorhinolaryngology
University Hospital Erlangen University Hospital Greifswald
Erlangen, Germany Head of the Department of Otorhinolaryngology,
Head and Neck Surgery
Alessandro Bozzato, Dr. med. Greifswald, Germany
University Hospital Erlangen
Department of Otorhinolaryngology, Heinrich Iro, Dr. med.
Head and Neck Surgery Professor
Erlangen, Germany University Hospital Erlangen
Head of the Department of Otorhinolaryngology,
Klaus Bumm, Dr. med. Head and Neck Surgery
University Hospital Erlangen Erlangen, Germany
Department of Otorhinolaryngology,
Head and Neck Surgery Martin Marsch, Dr. med.
Erlangen, Germany Department of Anesthesiology
University Hospital Erlangen
Holger Greess, Dr. med., PD Erlangen, Germany
Supervising Physician
Department of Radiology Jochen Wurm
University Hospital Erlangen University Hospital Erlangen
Erlangen, Germany Department of Otorhinolaryngology,
Head and Neck Surgery
Erlangen, Germany

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 VI

Preface to the Second Edition

Seventeen years have passed since the publication of the Again, as in the first edition, the emphasis is laid on
first edition of this monograph on endoscopic sinus sur- endoscopic procedures because of their advantage of ma-
gery. The technique was fairly new for the rhinologic nipulation in angled directions. The use of a binocular
community at that time, and it was partly welcomed but microscope is stressed only where this tool offers sub-
partly rejected by many as dangerous—if not hazardous stantial help. A similar restriction is observed concerning
—and as an insufficiently solid method. In many instances external approaches, which are still justified for certain
criticism focused on what was thought to be too radical indications. These are mentioned in connection with dif-
an exenteration of the sinuses, resulting in mucosal atro- ficult-to-reach targets and with combined neuro-rhino-
phy called ozena. This was a striking misunderstanding of surgical interventions. I emphasize that my intention was
our concept of combining a minimally invasive approach not to describe anything that is feasible or has ever been
with a mucosa-preserving technique of resection. Within reported in the literature, but to describe specifically
a few years this adverse misinterpretation was resolved, what has proved valuable in the experience of the Erlan-
and endoscopic sinus surgery became popular. Today, it is gen ENT service. References to the literature are sparse
the worldwide method of choice for the surgical treat- and personal opinions, choices, and experiences are inte-
ment of chronic rhinosinusitis. During recent years other grated into the technical instructions to perhaps a higher
indications, as already mentioned in our first edition, degree than usual.
such as trauma, malformation, and neoplasia, were also I have to apologize for three features. First, the use of
brought within the range of endoscopic therapy. popular but not strictly correct terms has been retained
The desire of Thieme Publishers for an update of this in the interest of ease of communication. One speaks, for
textbook in the form of a revised edition was, therefore, example, of three turbinates, though there exists only one
logical, but completion of the task was delayed over sev- “os turbinale,” that is the inferior turbinate. Also the suf-
eral years by the authors’ absorption with writing a simi- fix “-ectomy” is slightly incorrect usage for a mere resec-
lar monograph on otosurgery. This enforced interlude tion. Secondly, for lack of the originals, many images had
proved fortunate, however, insofar as it meant that a to be copied from the book of the first edition, which has
number of recent advances in endoscopic sinus surgery reduced their brilliance to a some degree. And, finally,
could be included. some repetition is unavoidable to allow complete de-
Such fundamentals as the concepts of the pathophysi- scriptions in separate specialized sections.
ology of rhinosinusitis and its surgical therapy, the de- I was more than happy to gain Dr. Heinrich Iro—Pro-
scription of standard interventions and their modifica- fessor of Otorhinolaryngology and my successor in the
tions for the management of inflammatory complications, chair at the University of Erlangen-Nuremberg and also
trauma, malformation, and neoplasia have been revised head of the ENT Department in Erlangen—as a prestigious
and completed. The arrangement of related chapters was collaborator. His generous disposal of the modern facili-
accordingly altered, and new sections have been incorpo- ties of his service in Erlangen has substantially supported
rated like those on transcranial endoscopy and revisional the production of this new edition. Separate contribu-
surgery. This accumulation of new material necessitated tions from associated consultants with personal expertise
a marked change of the layout of the contents. In addi- have been included. I am grateful to Docent Dr. Holger
tion, the acquisition of many new images and schematic Greeß from the Department of Radiology for his addition
drawings has somewhat transformed the old textbook and explanation of new images, and to Drs. Torsten Birk-
into a kind of illustrated atlas. holz and Martin Marsch from the Department of Anes-
Along the same lines, particular sinusotomies are de- thesiology for renewing the sections on local and general
scribed in the order of the usual course of subsequent anesthesia. Also the excellent description, taken over
partial steps of complex operations, as during a pansinus from the first edition, of a sagittal dissection of the lateral
operation in our department. A supraturbinal nasoan- nasal wall in eight steps by Werner Hosemann, today Pro-
trostomy, for instance, always follows a preceding eth- fessor of Otorhinolaryngology at the University of Greifs-
moidectomy. wald, must be gratefully acknowledged. Professor Man-

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 Preface of the Second Edition VII

fred Weidenbecher’s sketch of endoscopic dacryocysto- I am deeply indebted to both Dr. Clifford Bergman,
rhinostomy has been slightly revised and updated. Executive Editor of Thieme Publishers Stuttgart, who in-
Younger collaborators have helped to provide new sisted on a new reformed edition of this monograph, and
data and new photographs for illustration. In this connec- to Stephan Konnry, Editor, who has continuously encour-
tion, thanks must be given to Drs. Alessandro Bozzato and aged the author and undertook the burden of realizing a
Klaus Bumm. The latter has, together with Dr. Jochen handsome monograph with the high quality typical of a
Wurm, also submitted some remarks on computer- Thieme product.
assisted surgery and navigation in the chapter on the in- Finally, respect and gratitude are proffered to the many
strumentarium of endoscopic sinus surgery. patients who have trusted themselves to the recommen-
Gratitude must be expressed to Mrs. Maria Ursprung, dation of the techniques described and have allowed
the librarian of the ENT Department in Erlangen, for the publication of their outcomes and photographs.
procurement of related literature, and also to Mrs. Mech-
thild Gerdemann, who, as a tireless companion, carefully Malte Erik Wigand
prepared the manuscript. Particular appreciation is owed
to Mrs. Gundula Bochmann’s assistance in identifying
and digitizing innumerable endophotographs.

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 VIII

Foreword to the First Edition

This is a book that has been eagerly awaited by many oto- soon as he began the first case, it was obvious that i was
laryngologists. It is a comprehensive and beautifully il- in the presence of a master. As I have gotten to know him
lustrated work by one of the recognized pioneers and better, my initial observation has been reinforced. He ap-
leading experts in this field. Professor Wigand carefully proached that first case with meticulous atraumatic tech-
documents the changes which have occurred in our con- nique and clear knowledge of the anatomy, and main-
cepts regarding the pathogenic mechanisms and treat- tained excellent hemostasis throughout. He has written
ment of chronic sinusitis. The difficult regional anatomy this book with the same attention to detail. However, per-
is presented in an organized fashion with sections on en- haps more importantly, he brings to his book a wealth of
doscopic, radiologic, and cadaver anatomy. Each section personal experience, the salient points of which are care-
is meticulously illustrated. fully elucidated in this writing. The advent of this book is
In addition to presenting both the anteroposterior and a significant milestone in the field of the sinus surgery.
posteroanterior surgical approaches, Professor Wigand
discusses endoscopic surgery for lesions of the anterior David W. Kennedy, MD, FRCS
skull base, tumors, and dacryocystorhinostomy. He high- Associated Professor
lights the importance of careful endoscopic follow-up Departments of Otolaryngology,
and postoperative care when surgery is performed for Head and Neck Surgery, and Neurosurgery
chronic inflammatory disease. He also details the results The Johns Hopkins Medical Institutions
obtained in over 10 years experience at the Erlangen Uni- Baltimore, Maryland
versity Clinic.
Some years ago I had the opportunity to visit Professor
Wigand and to scrub with him in the operating room. As

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 IX

Preface to the First Edition

“To be successful, intranasal operations must be so de- physiology and surgical anatomy, experience in diagnosis
signed as to restore the normal physiologic function of and surgical skill. Therefore the chapter on operative
the nose. It is impossible with impunity to operate upon technique is only a limited part of the book, and perhaps
the interior and on the sinuses as though they were not the most essential. Neither is this book intended as a
boxes.” compendium of all known operations on the nasal and
Eleven years ago we gave our first report of the advan- paranasal sinuses, but is restricted to those procedures
tages of endoscopy in intranasal surgery (Wigand and which have become established and taught at the Erlan-
Steiner 1977). Now we feel able to produce a comprehen- gen Clinic. Concentration on personally proven methods
sive account of this theme. This technique was originally imposes some limitations, but also guarantees wide ap-
thought to be merely a modification of the long-estab- plication and reliability. A good example of this is the per-
lished procedures for the treatment of inflammations of sonal modification of septal correction. This monograph
the paranasal sinuses, but this view had to be rapidly is not intended as a didactic operative atlas, but rather a
adapted to changing views of the pathological and regen- handbook based on the personal views and experiences
erative processes of the respiratory mucosa. The estab- of the author. For this reason the very extensive literature
lished surgical principle “where there is pus let it out” is on intranasal surgery of the paranasal sinuses is only re-
inadequate for this complex system of rigid epithelial ferred to sporadically, and many techniques are not men-
surfaces with a highly organized self-cleansing system. tioned.
Understanding of this system, of the importance of the Despite numerous publications from many centers, in-
mucociliary transport system discovered in the 1930s by tranasal endoscopy in the surgical management of chronic
Anderson C. Hilding and so beautifully illustrated in re- sinusitis remains widely unknown and neglected, proba-
cent years with endoscopic films by Messerklinger and bly because the nasal surgeon does not feel at ease work-
his colleagues, and adaption to the many new concepts ing in a delicate anatomical region through narrow ac-
demanded time and scientific proof. cess. Even until recent times intranasal ethmoidal surgery
Experience has justified our initial optimism that even has been regarded as being fraught with complications,
the most severely inflamed hyperplastic mucosa could including severe hemorrhage, blindness, and intracranial
recover after restoration of ventilation and drainage, and infection. It must be emphasized that these fears are
this has led to a general decline in radical surgery. Hose- much less with experienced endoscopic nasal surgeons. If
mann has shown that the concept of complete elimina- the jaws of the instrument can no longer be seen by the
tion of mucosa thought to be irreversibly damaged is no naked eye, and working distances and the direction of
longer tenable. Furthermore, the good results of tympa- dissection are difficult to estimate, then naturally the
noplasty for infections of the middle ear have supported procedure is unsafe. Safe dissection demands thorough
our confidence in a similar resolution of the chronically study of endoscopic anatomy, and practice of endoscopic
inflamed air cells of the anterior skull, and have shown manipulations with both hands. It is hoped that the re-
that the concept of a constitutionally determined biologi- sults given in Chapter 7 will be proof of this. The last sec-
cal mucosal inferiority (Wittmaack) is no longer valid. tion of the chapter on operative techniques shows that
Nonetheless many interactions between micro-anatomy the range of indications has been extended to include
and the local immune responses and healing processes of surgery of the anterior base of the skull, and of obstructed
the mucosa remain unexplained. It is difficult in the midst lacrimal ducts, as described by Professor Dr. M. Weiden-
of continuing research to declare a technique “ready” for becher.
a book. It is clear, however, that this new method must A wide range of illustrations is necessary to demon-
now be propagated and taught, and we as authors must strate all these procedures. Dr. Hosemann has been par-
accept the fact that criticisms, corrections, and further ticularly helpful with the organization of the material and
developments will be made by others. recording of the operative steps on practice models. I am
We have deliberately avoided writing a surgical atlas. also very grateful to my colleagues Dr. Burlein, Dr. Kachlik,
Good surgical results demand an understanding of patho- Dr. Riemann, and Herr Gerard for taking the endoscopic

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 X Preface to the First Edition

pictures, and for other photographs. I am very grateful to Our librarian Beate Broghammer has worked tirelessly
Herr M. Jauch of Richard Wolf (Kittlingen) for a series of and carefully an accumulating the references, and on the
diagrams to illustrate the use of the instruments. input of data for the index as outlined by Dr. Hosemann. I
Not all the operative steps could be illustrated on one wish to express my sincere gratitude to her, both for the
specimen, so the figures had to be taken from various dis- present work and for help with papers and courses over
sections. Since only one side of the nose is presented to many years.
give a better insight into endoscopic anatomy, many orig- I am very grateful to my wife Monika Christina whose
inal figures had to be transposed. careful reading has eliminated many unclear points from
I am particularly grateful to Professor Dr. Brandl, and the next, and who has compiled the index.
his many colleagues of the Institute of Anesthesiology Finally I wish to express my thanks to Dr. med. L.C.G.
(Director, Professor Dr. E. Ruegheimer) of the University Hauff of Georg Thieme for his untiring encouragement to
of Erlangen-Nuremberg for their contributions to general write this monograph, and to Herr W. Tannert for the high
anesthesia for this form of surgery, for their patience and quality which is characteristic of this publishing house.
understanding and for providing a bloodless field.
I wish to thank my former colleague Professor Dr. W. Erlangen, Spring 1988
Steiner, now Director of the Department of ORL at the
University in Goettingen, for his thoughtful and practical Malte Erik Wigand
support in the early phase of our joint venture into this
previously unknown field Lang, Director of the Anatomi-
cal Institute of the University of Wuerzburg, and to Dr. M.
P. Jaumann of Goeppingen for the loan of anatomical and
endoscopic illustrations.
I would like to record my thanks to my secretary Karin
Sippel for skilled assistance in the revision of the manu-
script under difficult circumstances; sadly she died in July
1988.

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 XI

Abbreviations

CAS Computer-assisted surgery

CRS Chronic rhinosinusitis
CT Computed tomography
DCR Dacryocystorhinostomy
EFR Eosinophilic fungal rhinosinusitis
ENT Ear, nose, and throat
ESS Endoscopic sinus surgery
FESS Functional endoscopic sinus surgery
HU Hounsfield unit
MRI Magnetic resonance imaging
STIR Short-tau-inversion-recovery
TE Echo time
TI Inversion time
TIVA Total intravenous anesthesia
TR Recovery time

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 XII

Abbreviations and Symbols used in the Figures

A. car. i. Internal carotid artery O. Orbit

A. eth. a. Anterior ethmoid artery O. m. Maxillary ostium
Ag. n. Agger nasi O. s. Secondary ostium
B. ol. Olfactory bulb P. Pons
Bu. Ethmoid bulla P. m. Soft palate
C. e. a. Anterior ethmoid cells Pre. Premaxilla
C. e. p. Posterior ethmoid cells Pr. un. Uncinate process
Cart. qu. Re. fr. Frontal recess
or Cart. 4 Quadrangular cartilage Re. zy. Zygomatic recess
Ch. Choana S. Nasal septum
Co. Concha S. interfr. Interfrontal septum
Co. i. Concha inferior, inferior turbinate Sin. cav. Cavernous sinus
Co. m. Concha media, middle turbinate Sin. f. Frontal sinus
Co. s. Concha superior, superior turbinate Sin. m. Maxillary sinus
Cr. g. Crista galli Sin. s. Sphenoid sinus
D. nf. Frontonasal duct V. Vomer
D. nl. Nasolacrimal duct
For. sp. Foramen spinosum Posterior wall
Hyp. Pituitary gland, hypophysis
i. c. a. Internal carotid artery Anterior wall
I. e. Ethmoid infundibulum
I. f. Frontal sinus infundibulum Superior wall/roof
Lam. p. Lamina papyracea
Lam. per. Lamina perpendicularis Inferior wall/bottom
N. io. Infraorbital nerve
N. max. Maxillary nerve Left lateral wall
N. o. Optic nerve
N. pet. m. Greater petrosal nerve Right lateral wall

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 XIII

Table of Contents

1 Concepts of Intranasal Surgery 3 Preoperative and Postoperative Diagnosis . . . . . . 68

of the Paranasal Sinuses . . . . . . . . . . . . . . . . . . . . . . . 1 History Taking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Surgical Pathology of the Sinus Mucosa . . . . . . . . 1 Rhinoscopy and Nasal Endoscopy. . . . . . . . . . . . . . 68
Mucositis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Surgical Principles. . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Ultrasound A Scan . . . . . . . . . . . . . . . . . . . . . . . . . 69
Healing Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Ultrasound B Scan . . . . . . . . . . . . . . . . . . . . . . . . . 70
Supplementary Procedures . . . . . . . . . . . . . . . . . . . 13 Radiography, Computed Tomography (CT),
Endoscopic Aftercare . . . . . . . . . . . . . . . . . . . . . . . . . 14 and Magnetic Resonance Imaging (MRI) . . . . . . . 71
Acute Postoperative Phase . . . . . . . . . . . . . . . . . . 15 Conventional Radiography. . . . . . . . . . . . . . . . . . 71
Late Postoperative Phase . . . . . . . . . . . . . . . . . . . 17 Computed Tomography (CT) . . . . . . . . . . . . . . . . 72
Maintenance of the Olfactory Cleft . . . . . . . . . . . . 19 Magnetic Resonance Imaging (MRI) . . . . . . . . . 75
Informed Consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Functional Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Basic Principles of Endoscopic Surgery of the Further Investigations . . . . . . . . . . . . . . . . . . . . . . . . 79
Paranasal Sinuses: Advantages, Disadvantages, Classification of Sinusitis . . . . . . . . . . . . . . . . . . . . . 79
and Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
4 Instrumentarium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
2 Endoscopic Anatomy of the Nose Surgical Endoscope . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
and Paranasal Sinuses . . . . . . . . . . . . . . . . . . . . . . . . . 22 The Microscope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
The Nasal Cavity and Its Endoscopic Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Landmarks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Auxiliary Equipment . . . . . . . . . . . . . . . . . . . . . . . . . 86
A CT Imaging Study of the Spatial Arrangement Computer-aided Surgery. . . . . . . . . . . . . . . . . . . . . . 86
of the Paranasal Sinuses . . . . . . . . . . . . . . . . . . . . . . 29
Vertical Coronal Sections . . . . . . . . . . . . . . . . . . . 29 5 Anesthesia and Patient Positioning. . . . . . . . . . . . . 89
Horizontal Axial Sections . . . . . . . . . . . . . . . . . . . 35 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Nasal and Paranasal Dissection of Specimens . . . 37 Topical, Infiltrative, and Regional Anesthesia . . . 89
The Laboratory Workplace. . . . . . . . . . . . . . . . . . 37 General Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Typical Operative Steps on a Cadaver . . . . . . . . 38 Positioning of the Patient . . . . . . . . . . . . . . . . . . . . . 93
Dissection of the Nasal Septum . . . . . . . . . . . . . 38
Stratigraphic Dissection of the Lateral 6 Standard Operations for Acute
Nasal Wall in Eight Steps . . . . . . . . . . . . . . . . . . . 41 and Chronic Sinusitis . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Endoscopic Dissection of the Turbinates Operations in the Nasal Cavity . . . . . . . . . . . . . . . . 94
and Lower Lateral Nasal Wall, Septoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Nasoantrostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Turbinectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Endoscopic Exposure of the Ethmoid Polypectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
and Anterior Skull Base . . . . . . . . . . . . . . . . . . . . 52 Removal of Foreign Bodies . . . . . . . . . . . . . . . . . . 101
Transfacial Exposure of the Ethmoid Biopsy and Tumor Removal . . . . . . . . . . . . . . . . . 101
and Frontal Sinus . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Endoscopic Use of the Laser . . . . . . . . . . . . . . . . 102
Endonasal Endoscopic Frontal Sinusotomy. . . 60 Operations on the Ethmoids . . . . . . . . . . . . . . . . . . 102
Endoscopic Sphenoidotomy . . . . . . . . . . . . . . . . 61 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Transcranial Exposure of the Nasal Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
and Paranasal Cavities. . . . . . . . . . . . . . . . . . . . . . 64 Operative Technique . . . . . . . . . . . . . . . . . . . . . . . 103
Operations on the Frontal Sinus . . . . . . . . . . . . . . . 114
Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Operative Technique . . . . . . . . . . . . . . . . . . . . . . . 114

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 XIV

Surgery on the Sphenoid Sinus . . . . . . . . . . . . . . . . 121 9 Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Operative Technique . . . . . . . . . . . . . . . . . . . . . . . 121 Operative Technique . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Surgery on the Maxillary Antrum . . . . . . . . . . . . . . 123 Foreign Bodies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Open Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Midfacial and Orbital Fractures . . . . . . . . . . . . . 172
Operative Technique . . . . . . . . . . . . . . . . . . . . . . . 123 Anterior Skull Base Fractures . . . . . . . . . . . . . . . 173
Total Ethmoidectomy with Exposure of Complications of Endoscopic Sinus Surgery . . . . 176
the Frontal, Maxillary, and Sphenoid Cavities:
Pansinus Operation. . . . . . . . . . . . . . . . . . . . . . . . . . . 131 10 Malformations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Endoscopic Operations on the Orbit . . . . . . . . . . . 133 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Operative Technique . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Operative Technique . . . . . . . . . . . . . . . . . . . . . . . 133 Thornwaldt and Other Cysts . . . . . . . . . . . . . . . . 179
Endoscopic and Microscopic Surgery Choanal Atresia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
on the Anterior Skull Base . . . . . . . . . . . . . . . . . . . . 134 Septal and Conchal Dysplasia . . . . . . . . . . . . . . . 182
Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Spontaneous Dural Fistula . . . . . . . . . . . . . . . . . . 182
Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Meningoencephalocele . . . . . . . . . . . . . . . . . . . . . 182
Operative Technique . . . . . . . . . . . . . . . . . . . . . . . 134
Neurorhinosurgical Combined Approach . . . . 138 11 Neoplasia and Tumorlike Lesions . . . . . . . . . . . . . . . 186
Endoscopic Sinus Surgery in Children . . . . . . . . . . 141 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 Operative Technique . . . . . . . . . . . . . . . . . . . . . . . . . . 186
Operative Technique . . . . . . . . . . . . . . . . . . . . . . . 141 Diagnostic Biopsy and Postoperative
Endoscopic Dacryocystorhinostomy (DCR) . . . . . 142 Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
Indications for Internal DCR . . . . . . . . . . . . . . . . 142 Mucopyoceles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
Etiology of Stenosis of the Expansive Polyposis. . . . . . . . . . . . . . . . . . . . . . . . 187
Nasolacrimal Duct . . . . . . . . . . . . . . . . . . . . . . . . . 142 Granuloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
Operative Technique . . . . . . . . . . . . . . . . . . . . . . . 142 Osteoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Results of DCR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Fibroma, Neuroma, Adenoma . . . . . . . . . . . . . . . 191
Juvenile Angiofibroma . . . . . . . . . . . . . . . . . . . . . 193
7 Complications of Sinusitis . . . . . . . . . . . . . . . . . . . . . 147 Inverted Papilloma . . . . . . . . . . . . . . . . . . . . . . . . . 194
Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Squamous-Cell Carcinoma and
Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Adenocarcinoma. . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Operative Technique . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Esthesioneuroblastoma . . . . . . . . . . . . . . . . . . . . 198
Orbital Complications . . . . . . . . . . . . . . . . . . . . . . 147
Mucopyoceles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 12 Results of Endoscopic Sinus Surgery:
Osteitis, Osteomyelitis . . . . . . . . . . . . . . . . . . . . . . . . 151 Personal Experience. . . . . . . . . . . . . . . . . . . . . . . . . . . 200
Meningitis, Brain Abscess . . . . . . . . . . . . . . . . . . . . . 153 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
Focal Spreading of Sinusitis . . . . . . . . . . . . . . . . . . . 154 Chronic Rhinosinusitis (CRS) . . . . . . . . . . . . . . . . . . 201
Partial Ethmoidectomy for Initial
8 Failures and Repeat Surgery . . . . . . . . . . . . . . . . . . . 156 and Limited Stages of CRS . . . . . . . . . . . . . . . . . . 201
Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 Total Ethmoidectomy/Pansinus Operation
Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 for Disseminated and Diffuse CRS . . . . . . . . . . . 202
Reasons for Failures and Their Repair . . . . . . . . . . 156 Endonasal Dacryocystorhinostomy (DCRS) . . . . . 207
Persistent or Recurrent Chronic Sinusitis . . . . 156 Neoplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
Inflammatory Complications after Surgery. . . 160 Endomicroscopy for Inverted Papilloma . . . . . 208
Surgical Mistakes . . . . . . . . . . . . . . . . . . . . . . . . . . 161 Malignancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Omitted Flanking Rhinosurgery . . . . . . . . . . . . . 165
Abnormal Anatomical Structure . . . . . . . . . . . . 165 13 Historical Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
Postoperative Hyposmia or Dysosmia . . . . . . . 166 Early Stages of Endoscopic Sinus Surgery. . . . . . . 213
Insufficient Postoperative Care . . . . . . . . . . . . . . 166
Noniatrogenic Causes of Recurrent CRS . . . . . . . . 167 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Staged Endoscopic Sinus Surgery . . . . . . . . . . . . . . 167

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 1

1 Concepts of Intranasal Surgery of the Paranasal Sinuses

Intranasal endoscopic surgery of the paranasal sinuses

has essentially been developed for the treatment of
Surgical Pathology of the
chronic sinusitis. Only a few decades ago, the therapy of Sinus Mucosa
chronic sinusitis had consisted of the radical removal of
the diseased mucosa, which was considered as of a bio- The respiratory mucosa of the nose and paranasal sinuses
logically inferior quality (Albrecht 1926). External—mean- is part of a large and coherent system of internal surfaces
ing transfacial and transoral—approaches were the rule. reaching from the nostrils to the bronchi and communi-
Intranasal endoscopic surgery has not only become mini- cating with the middle ear spaces (Fig. 1.1). It must, there-
mally invasive by changing the access but has also fore, be regarded as a unit and be thoroughly investigated
switched to the aim of preservation of the mucosa. Sev- whenever parts of it produce signs of pathological altera-
eral prerequisites must be met if this alternative to the tions. But it does not present a homogenous histological
classical operations is to succeed: structure throughout its extent. Its texture depends on
• Modification of long-standing concepts of mucosal
pathophysiology
• A more thorough knowledge of topographic anatomy
• Adaptation to endoscopic operative techniques using
special angled telescopes and instruments through a
narrow access port
• Abandonment of cherished principles of en-bloc clear-
ance via wide access
• A long-term treatment plan that includes supplemen-
tary procedures and time-consuming endoscopic af-
tercare, which the patient must accept as an important
part of the treatment

What was at first criticized as hazardous has subsequently

been accepted as routine throughout the world. Endo-
scopic sinus surgery (ESS) today includes the use of the
microscope and other technical improvements such as
the laser or computer-assisted navigation, and is widely
applied to other indications than sinusitis, e. g., for the
treatment of trauma, malformations, and neoplasias. Re-
gardless of this variety of indications, the local reactions
of the mucosal texture to any of these noxious factors
have much in common, and thus an intimate knowledge
of its endoscopic and pathohistological appearance is key
to its successful handling during surgery and during the
postoperative phase, when wound healing has to be sup-
ported.
Attention to the details of this complex strategy is
needed if one is to reap the full benefit of intranasal sur-
Fig. 1.1 The coherent system of respiratory mucosa extending
gery, to avoid complications and disappointing results,
from the nasal cavity into the paranasal sinuses, the tracheobron-
and to recognize the unsolved problems obstructing the
chial tree and, via the eustachian tube, into the middle ear. Its epi-
development of ideal treatment. thelial self-cleaning drainage system is susceptible to inflammatory
disturbances. Infection in one compartment can involve remote
areas.

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 2 1 Concepts of Intranasal Surgery of the Paranasal Sinuses

site, age, and physical/biological responses to metabolic, can change radically. The frequent macroscopic variants
endocrine, and other factors. Fig. 1.1 of the mucosa, even in the absence of inflammation, are
In the nasal cavity, secretory elements (goblet cells already familiar to the rhinologist: dry, thickened regions
and mucosal glands) are abundant where the mucosa at the nasal valve, atrophic areas over bony ridges, suc-
carries a dense ciliary layer. In the more remote niches of culent velvety ends of the turbinates with arterial or ve-
the large sinuses, these typical characteristics are sparser nous coloration, and finally the swollen, pale, mulberry-
and the histological picture more nearly resembles that like, bluish-red colored mucosa on the posterior end of
of a mucoperiosteum with, at times, a thin serosal layer the turbinates.
resembling the pattern of the middle ear and mastoid. The local appearances of the mucosa show even more
Tos et al. (1978) have accurately measured the normal marked variations in sinusitis. The endoscopist is familiar
variation in density of the mucosal glands in the sinuses: with the various swellings, edematous areas, papillary
under pathological conditions this pattern of distribution hyperplasia, and polyps that differ between the two sides

a c

b d

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 Surgical Pathology of the Sinus Mucosa 3

and even within one nasal cavity. Using standardized Nasal and paranasal polyps are a particular manifes-
mucosal biopsies, Hosemann and Wigand (1985) have tation of chronic sinusitis histologically featuring various
demonstrated the wide variation in histopathology of si- grades of intercellular edema (Fig. 1.3). Their macroscopic
nus mucosa in diffuse polypoid hyperplastic sinusitis appearance varies between small humps of 2–3 mm
(Fig. 1.2 a–e). A diagnosis of sinusitis by the histopatholo- diameter and large pedicled mucosal sacs pendulating
gist does not apply to the entire mucosa but only to that from the middle turbinate or out of the semilunar hiatus
part which is sampled. This conclusion is self-evident, but (see Chapter 3). Tos (2000) has given a review of the mul-
conflicts with the concept of radical surgery that demands tiple concepts of their pathogenesis. We are convinced
complete mucosal clearance. It is also in conflict with any that biomechanical obstruction of the submucous lymph
kind of classification of types of sinusitis based on single drainage plays a prominent role in the causation of polyp-
biopsies (Lund and McKay 1993, Cho et al. 2006). Fig. 1.2a-e ous swelling of the mucosa, which may easily occur in the
narrow spaces of the ostiomeatal complex in the anterior
ethmoids. Fig. 1.3

e
Fig. 1.2 a–e Histopathology of sinus mucosa in chronic rhinosinus- Fig. 1.3 Nasal polyp in a state of development, characterized by
itis. extremely wide intercellular spaces filled with edematous fluid (H&E,
a Normal respiratory mucosa of the ethmoid with ciliary epithelium × 63).
and few secretory glands (H&E, × 20).
b Edematous reaction of respiratory epithelium as first stage of
inflammation. Wide intercellular spaces filled with lymph and
hyalinic substance. Scarce cell infiltration (H&E, × 63).
c Ethmoid mucosa in chronic sinusitis showing loose stroma with
disseminated clumps of cells—microabscesses—but no glands
(Goldner, × 70).
d Chronic mucositis predominantly featuring glandular hyperplasia
(Goldner and Alcian blue, × 63).
e Chronic sinusitis with traits of scar formation, rich in collagen
fibers and poor in leukocytes (van Gieson, × 63).

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 4 1 Concepts of Intranasal Surgery of the Paranasal Sinuses

phatic drainage, edema, and finally organized connective

The local pathohistomorphological appearance of the mucosa
tissue and mucosal hyperplasia. The causes of local and
in one sinus does not reflect the actual stage of the disease in
other compartments. Transition from simple mucosal swelling temporal variations of pathology probably depend on
to hyperplasia and severe polyposis is gradual and varies at dif- anatomy, the local mucosal response, the influence of
ferent locations. other body systems, pathogens, and external noxious
agents. The etiology of chronic rhinosinusitis (CRS), so
In our experience, temporal factors are as important as far, remains unclear in the majority of cases. The assump-
local factors because histomorphological findings change tion seems justified that an initial acute phase, caused by
enormously over time. After a successful tympanoplasty viral or bacterial infection, precedes chronicity, which is
even the most severe mucosal lesions have often re- predominantly enhanced by the anatomical factors men-
gressed when the ear is later reopened after aeration and tioned. The manifold evidence of a postsurgical reforma-
internal drainage have been restored. A previously very tion of a thick, infiltrated mucosa into a thin, normal-
hyperplastic layer will be found to have been replaced by looking mucoperiosteum is the strongest argument for
noninflamed, soft mucosa. The same results have now the biomechanical hypothesis that an actual pathogenetic
been found many times after surgery for severe sinusitis anatomical constellation, influencing ventilation, drain-
with mucosal preservation: even previously thick, spongy, age, and subepithelial lymph flow, is the cardinal factor in
injected, and indurated mucosa presents a completely sustaining the chronicity of lasting mucositis.
healthy appearance after conservative sinus operations Systemic diseases, such as allergy, mucociliary insuf-
that restore drainage and aeration. Thus, neither the sur- ficiency syndrome, mucoviscidosis, Kartagener syndrome,
geon’s eye nor the results of a frozen tissue section can ASA-intolerance, etc., may act as important co-factors.
predict whether inflamed mucosa is capable of resolu- Nasal polyposis in patients with ASA-intolerance has a
tion. different pattern of leukotriene release and apoptosis of
eosinophils (Ziroli 2002), which does not explain its
At the time of a first operation, the surgeon can by no means higher recurrence rates.
predict whether the chronically diseased mucosa will recover Continuous infection from foreign bodies or from ad-
or not. jacent contaminated areas must also be taken into ac-
count. Examples are chronic sinusitis of dental origin due
to inflamed dental roots penetrating upward into the an-
trum or to perforating screws after implantation of dental
prostheses or after splinting of facial fractures (Fig.
Mucositis 1.4 a, b). Fig. 1.4a,b

Finally, environmental noxae have been postulated as

Little is known of the morphological and functional important. In recent years a particular eosinophilic reac-
changes in acute and chronic inflammation of the respira- tion on fungi in the nasal mucosa (eosinophilic fungal
tory mucosa or of the healing processes, either with or rhinosinusitis, EFR) was emphatically postulated as the
without surgery. Numerous histomorphological and origin of nasal polyposis (Ponikau et al. 1999; Lebowitz et
structural investigations have been done of the mucosal al. 2002; Taylor et al. 2002; Stammberger 2003; Lackner
response pattern, the lymphatic system, and the patho- et al. 2004). However, Kaschke et al. (2002) could detect
logical ciliary activity of the mucosa of humans and ani- only a low incidence (17 %) of EFR among their 124 ESS-
mals (e. g., Tos 1978; Hosemann 1985, 1991; Stammberger operated patients with chronic sinusitis.
1991; Thaler 2002; Benninger 2003), but an overall view Tos has presented a fine review of the different hy-
of nonspecific mucosal inflammation is not available. The potheses on the development of polyps (Tos et al. 2000).
temporal course of the phenomena associated with These cannot, at first glance, convince the endoscopic
spread of inflammation from the nasal cavity into the si- surgeon who perceives completely healed ethmoids and
nuses is not known. sphenoid sinuses after ESS with maximal preservation of
We suspect that an intermediate stage of hyperemia, the diseased mucosa, and who nevertheless detects a
lymphatic swelling, stasis in the blood and lymphatic typical polyp in the most anterior ethmoid close to the
pathways, and increased secretion of mucus succeeds an frontoethmoidal transition. If the simple removal of nar-
initial stage of hyperemia with reduced mucociliary row passages in the ethmoid for the restoration of venti-
transport. This is followed either by resolution or by pro- lation and drainage is able to normalize a polypous mu-
gression to a chronic stage with pathological increase in cosa and in the same patient a remaining isthmus in the
the elements of the lamina propria such as cells, fibers anterior ethmoid provides the basis for a recurrent poly-
and ground substance, and resultant permanent disrup- posis, it is hard to comprehend that a systemic mucosal
tion of the mucociliary transport and lymphatic drainage. pathology should be its main cause. It appears rather ob-
The resulting obstruction of the narrow ducts between vious that a major causative factor lies in the particular
the paranasal sinuses and the nasal cavity leads to a vi- local structure of the bone influencing the homeostasis of
cious cycle of retention of secretions, obstruction of lym- the mucosa: pathogenetic anatomy predisposing the nor-

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