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OPERATIVE OTOLARYNGOLOGY: HEAD AND NECK SURGERY
ISBN: 978-1-4160-2445-3
Second Edition
Copyright © 2008, 1997 by Saunders, an imprint of Elsevier Inc.
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by
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Notice
Knowledge and best practice in this fi eld are constantly changing. As new research and experience
broaden our knowledge, changes in practice, treatment and drug therapy may become necessary
or appropriate. Readers are advised to check the most current information provided (i) on
procedures featured or (ii) by the manufacturer of each product to be administered, to
verify the recommended dose or formula, the method and duration of administration, and
contraindications. It is the responsibility of the practitioner, relying on their own experience and
knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for
each individual patient, and to take all appropriate safety precautions. To the fullest extent of the
law, neither the Publisher nor the Editors and Authors assume any liability for any injury and/or
damage to persons or property arising out of or related to any use of the material contained in
this book.

The Publisher
Library of Congress Cataloging-in-Publication Data
Operative otolaryngology : head and neck surgery / editor, Eugene N. Myers ; associate editors,
Ricardo L. Carrau . . . [et al.].—2nd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4160-2445-3 (alk. paper)
1. Otolaryngology, Operative. I. Myers, Eugene N., 1933- II. Carrau, Ricardo L.
[DNLM: 1. Otorhinolaryngologic Surgical Procedures. 2. Otorhinolaryngologic Diseases—
surgery. WV 168 0612 2008]
RF51.O6145 2008
617.5′1059—dc22
2007040207
Inset cover image courtesy of Dr. Francis Marchal.
Acquisitions Editor: Scott Scheidt
Developmental Editor: Rachel Yard
Publishing Services Manager: Frank Polizzano
Senior Project Manager: Robin E. Hayward
Cover Designer: Ellen Zanolle
Design Direction: Ellen Zanolle
Printed in China.
Last digit is the print number: 9 8 7 6 5 4 3 2 1
Working together to grow
libraries in developing countries
| |

The Second Edition of Operative Otolaryngology: Head and Neck Surgery is dedicated
to the faculty of the Department of Otolaryngology at the University of Pittsburgh
School of Medicine and our wonderful colleagues in the Departments of
Dermatology, Neurological Surgery, Ophthalmology, Oral and Maxillofacial Surgery,
and Plastic Surgery. This book is also dedicated to our patients, who have taught us
well over the years.

CONTRIBUTORS
Frederic W.-B. Deleyiannis, MD, MPhil, MPH
Associate Professor of Plastic and Reconstructive
Surgery, Departments of Surgery and Otolaryngology,
University of Pittsburgh School of Medicine,
Pittsburgh, Pennsylvania

Chapters 81, 87
David E. Eibling, MD, FACS
Professor, Department of Otolaryngology, University
of Pittsburgh School of Medicine, Pittsburgh,
Pennsylvania

Chapters 8, 33, 35, 48, 49, 50, 57, 67, 78
Johnathan A. Engh, MD
Assistant Professor, Department of Neurological
Surgery, University of Pittsburgh School of Medicine,
Pittsburgh, Pennsylvania

Chapter 130
Berrylin J. Ferguson, MD, FACS
Associate Professor, Department of Otolaryngology,
University of Pittsburgh School of Medicine; Director,
Division of Sino-Nasal Disorders and Allergy,
University of Pittsburgh Medical Center, Pittsburgh,
Pennsylvania

Chapters 1, 3, 12, 19
Robert L. Ferris, MD, PhD, FACS
Associate Professor, Vice Chair for Clinical
Operations, and Chief, Division of Head and Neck
Surgery, Departments of Otolaryngology and
Immunology; Co-Leader, Cancer Immunology
Program, University of Pittsburgh Cancer Institute,
Pittsburgh, Pennsylvania

Chapters 24, 28, 46, 66, 73
Peter F. Ferson, MD
Professor, Department of Surgery, Heart, Lung, and
Esophageal Surgery Institute, University of Pittsburgh
School of Medicine; Chief, Thoracic Surgery,
Pittsburgh Health Care System

Chapter 67
Andrew S. Florea, MD
Assistant Professor, Department of Otolaryngology–
Head and Neck Surgery, Loma Linda University
School of Medicine; Chief, Division of Laryngology,
Loma Linda University Medical Center, Loma Linda,
California

Chapters 39, 40
Stephanie Moody Antonio, MD
Assistant Professor, Department of Otolaryngology,
Eastern Virginia Medical School, Norfolk, Virginia

Chapter 123
Jeffrey Balzer, PhD
Associate Professor, Department of Neurological
Surgery, University of Pittsburgh School of Medicine;
University of Pittsburgh Medical Center, Pittsburgh,
Pennsylvania

Chapter 130
Thomas W. Braun, DMD, PhD
Professor and Dean, Department of Oral and
Maxillofacial Surgery, University of Pittsburgh School
of Dental Medicine; Chair, Department of Dental
Medicine, UPMC Presbyterian-Shadyside, Pittsburgh,
Pennsylvania

Chapter 21
John F. Caccamese, Jr., DMD, MD, FACS
Assistant Professor and Residency Program Director,
Department of Oral and Maxillofacial Surgery,
University of Maryland Medical Center, R. Adams
Cowley Shock Trauma Center, Baltimore, Maryland

Chapter 91
Ricardo L. Carrau, MD, FACS
Professor, Department of Otolaryngology, University
of Pittsburgh School of Medicine; University of
Pittsburgh Medical Center, Pittsburgh, Pennsylvania
Chapters 2, 6, 15, 18, 20, 30, 42, 45, 52, 53, 54, 70,
96, 100, 101, 103, 104, 105, 106
C. Y. Joseph Chang, MD
Clinical Professor, Department of Otolaryngology–
Head and Neck Surgery, University of Texas-Houston
Medical School; University of Texas-Houston Medical
Center, Houston, Texas

Chapter 123
Bernard J. Costello, DMD, MD, FACS
Assistant Professor and Program Director, Department
of Oral and Maxillofacial Surgery, University of
Pittsburgh School of Dental Medicine; Chief, Pediatric
Oral and Maxillofacial Surgery, Children’s Hospital of
Pittsburgh, Pittsburgh, Pennsylvania

Chapters 83, 91
vii

viii
Contributors
Rebecca E. Fraioli, MD
Resident, Department of Otolaryngology, University
of Pittsburgh Medical Center, Pittsburgh,
Pennsylvania

Chapters 58, 61
Paul A. Gardner, MD
Assistant Professor, Department of Neurosurgery,
University of Pittsburgh School of Medicine;
University of Pittsburgh Medical Center, Pittsburgh,
Pennsylvania

Chapter 106
Brian R. Gastman, MD
Assistant Professor, Department of Otolaryngology
and Surgery, Divisions of Otolaryngology and Plastic
Surgery, University of Maryland School of Medicine,
Baltimore, Maryland

Chapter 81
Grant S. Gillman, MD, FRCS(C)
Assistant Professor, Department of Otolaryngology,
University of Pittsburgh School of Medicine; Director,
Division of Facial Plastic Surgery, UPMC Shadyside,
Pittsburgh, Pennsylvania

Chapters 24, 84, 86, 89, 90
Suman Golla, MD, FACS
Associate Professor, Department of Otolaryngology,
University of Pittsburgh School of Medicine,
Pittsburgh, Pennsylvania

Chapters 5, 23
Jennifer R. Grandis, MD, FACS
Professor, Department of Otolaryngology and
Pharmacology, University of Pittsburgh School of
Medicine; Vice Chair for Research, UPMC Endowed
Chair in Head and Neck Cancer Surgical Research,
Program Leader, Head and Neck Cancer Program,
University of Pittsburgh Cancer Institute, Pittsburgh,
Pennsylvania

Chapters 58, 61
Anil Gungor, MD
Director, Department of Otolaryngology–Head and
Neck Surgery, Anadolu Foundation Healthcare/Johns
Hopkins, Istanbul, Turkey

Chapter 83
Alyssa Hackett, MD
Visiting Research Instructor, Department of
Otolaryngology, University of Pittsburgh School of
Medicine; University of Pittsburgh Medical Center,
Pittsburgh, Pennsylvania

Chapter 107
Trevor Hackman, MD
Resident, Department of Otolaryngology, University
of Pittsburgh Medical Center, Pittsburgh,
Pennsylvania

Chapter 102
Bridget Hathaway, MD
Assistant Professor, Department of Otolaryngology,
University of Pittsburgh School of Medicine,
Pittsburgh, Pennsylvania

Chapter 54
Barry E. Hirsch, MD, FACS
Professor, Departments of Otolaryngology,
Neurological Surgery, and Communication Science
and Disorders, University of Pittsburgh School of
Medicine; Director, Division of Otology/Neurotology,
University of Pittsburgh Medical Center, Pittsburgh,
Pennsylvania

Chapters 108, 109, 111, 112, 113, 114, 117, 119,
121, 123, 124, 125, 126
Michael Horowitz, MD
Professor, Department of Neurological Surgery and
Radiology, University of Pittsburgh School of
Medicine; Chief, Department of Neurosurgery, UPMC
Presbyterian, Pittsburgh, Pennsylvania

Chapter 130
Jonas T. Johnson, MD
Professor and Eugene N. Myers, MD Chair,
Department of Otolaryngology, University of
Pittsburgh School of Medicine, Pittsburgh,
Pennsylvania
Chapters 9, 11, 13, 21, 26, 34, 44, 47, 55, 62, 63, 76,
77
Amin B. Kassam, MD
Professor and Chair, Department of Neurological
Surgery, University of Pittsburgh School of Medicine;
Director, Minimally Invasive endoNeurosurgery
Center, University of Pittsburgh Medical Center,
Pittsburgh, Pennsylvania
Chapters 6, 18, 79, 96, 100, 101, 103, 104, 105, 106,
124, 130
Karen M. Kost, MD, FRCSC
Associate Professor, Department of Otolaryngology,
and Director of the Voice Laboratory, McGill
University; Site Director, Department of
Otolaryngology, Montreal General Hospital, Montreal,
Quebec, Canada

Chapter 68

Contributors
ix
Priya Krishna, MD
Assistant Professor, Department of Otolaryngology,
University of Pittsburgh School of Medicine;
Laryngologist, University of Pittsburgh Voice Center,
University of Pittsburgh Medical Center, Pittsburgh,
Pennsylvania

Chapter 36
Stephen Y. Lai, MD, PhD, FACS
Assistant Professor, Department of Otolaryngology
and Pharmacology, University of Pittsburgh School of
Medicine, Pittsburgh, Pennsylvania

Chapter 55
John Y. K. Lee, MD
Assistant Professor, Department of Neurological
Surgery, University of Pennsylvania School of
Medicine; Pennsylvania Hospital, Philadelphia,
Pennsylvania

Chapter 130
Li-Xing Man, MD
Resident, Department of Otolaryngology, University
of Pittsburgh School of Medicine, Pittsburgh,
Pennsylvania

Chapter 1
Ernest K. Manders, MD
Professor, Department of Surgery, Division of Plastic
and Reconstructive Surgery, University of Pittsburgh
School of Medicine, Pittsburgh, Pennsylvania

Chapter 82
Arpita I. Mehta, MD
Resident, Department of Otolaryngology, University
of Pittsburgh Medical Center, Pittsburgh,
Pennsylvania

Chapter 116
Eugene N. Myers, MD, FACS,
FRCS Edin (Hon)
Distinguished Professor and Emeritus Chair,
Department of Otolaryngology, University of
Pittsburgh School of Medicine; University of
Pittsburgh Medical Center, Pittsburgh, Pennsylvania
Chapters 4, 8, 10, 22, 25, 27, 29, 31, 32, 35, 43, 51,
56, 60, 64, 65, 68, 69, 71, 72, 74, 75, 76
Jayakar V. Nayak, MD, PhD
Chief Resident, Department of Otolaryngology,
University of Pittsburgh Medical Center, Pittsburgh,
Pennsylvania

Chapter 87
Mark W. Ochs, DMD, MD
Professor and Chair, Department of Oral and
Maxillofacial Surgery, University of Pittsburgh School
of Dental Medicine; Head, Hospital Dentistry,
University of Pittsburgh Medical Center, Pittsburgh,
Pennsylvania

Chapters 92, 93
Yael Raz, MD
Assistant Professor, Department of Otolaryngology,
University of Pittsburgh School of Medicine;
University of Pittsburgh Medical Center, Pittsburgh,
Pennsylvania

Chapters 107, 110, 115, 116, 118, 120
Clark A. Rosen, MD, FACS
Associate Professor, Department of Otolaryngology,
University of Pittsburgh School of Medicine; Director,
University of Pittsburgh Voice Center, University of
Pittsburgh Medical Center, Pittsburgh, Pennsylvania

Chapters 36, 37, 38, 39, 40, 41, 59
Ramon Ruiz, DMD, MD
Clinical Assistant Professor, Department of Oral and
Maxillofacial Surgery, University of North Carolina at
Chapel Hill, Chapel Hill, North Carolina; Director,
Pediatric Craniomaxillofacial Surgery, Arnold Palmer
Hospital for Children and Winnie Palmer Hospital for
Women and Babies, Orlando, Florida

Chapter 83
James M. Russavage, MD, DMD
Assistant Professor, Department of Surgery, Division
of Plastic and Reconstructive Surgery, University of
Pittsburgh School of Medicine, Pittsburgh,
Pennsylvania

Chapter 81
Barry M. Schaitkin, MD, FACS
Professor, Department of Otolaryngology, University
of Pittsburgh School of Medicine; UPMC Shadyside,
Pittsburgh, Pennsylvania

Chapters 7, 14, 15, 16, 17, 88, 99
Jacob Sedgh, MD
Resident, Department of Otolaryngology, University
of Pittsburgh Medical Center, Pittsburgh,
Pennsylvania

Chapter 1

x
Contributors
Libby J. Smith, DO
Assistant Professor, Department of Otolaryngology,
University of Pittsburgh School of Medicine;
Laryngologist, University of Pittsburgh Voice Center,
University of Pittsburgh Medical Center, Pittsburgh,
Pennsylvania

Chapters 37, 38
Carl H. Snyderman, MD, FACS
Professor, Department of Otolaryngology, University
of Pittsburgh School of Medicine; Co-Director, Center
for Cranial Base Surgery, University of Pittsburgh
Medical Center, Pittsburgh, Pennsylvania
Chapters 2, 6, 18, 20, 79, 95, 96, 98, 100, 101, 103,
104, 105, 106
John C. Sok, MD, PhD
Resident, Department of Otolaryngology, University
of Pittsburgh Medical Center, Pittsburgh,
Pennsylvania

Chapter 59
Ryan J. Soose, MD
Assistant Professor, Department of Otolaryngology,
University of Pittsburgh School of Medicine;
University of Pittsburgh Medical Center, Pittsburgh,
Pennsylvania

Chapters 30, 42, 45, 52, 53, 70
S. Tonya Stefko, MD
Assistant Professor, Departments of Ophthalmology,
Otolaryngology, and Neurosurgery, University of
Pittsburgh School of Medicine; Director, Orbital,
Oculoplastics and Aesthetic Surgery, University of
Pittsburgh Medical Center, Pittsburgh, Pennsylvania

Chapters 94, 95, 97, 98
Michele St. Martin, MD, MBA
Assistant Professor, Department of Otolaryngology,
University of Florida College of Medicine, Gainesville,
Florida

Chapters 115, 121, 124
Elizabeth H. Toh, MD, FACS
Assistant Professor, Department of Otolaryngology,
University of Pittsburgh School of Medicine;
Attending/Faculty, University of Pittsburgh Medical
Center, Pittsburgh, Pennsylvania

Chapters 102, 111, 122, 127, 128, 129, 131
Alec Vaezi, MD, PhD
Resident, Department of Otolaryngology, University
of Pittsburgh Medical Center, Pittsburgh,
Pennsylvania

Chapter 126
Allan D. Vescan, MD, FRCS(C)
Lecturer in the Department of Otolaryngology–Head
and Neck Surgery, University of Toronto Faculty of
Medicine; Staff Surgeon, Otolaryngology–Head and
Neck Surgery, Mount Sinai Hospital/University
Health Network, Toronto, Ontario, Canada

Chapters 96, 100, 101, 104, 105
William A. Wood, MD
Resident, Department of Otolaryngology, University
of Pittsburgh Medical Center, Pittsburgh,
Pennsylvania

Chapters 120, 131
Robert F. Yellon, MD
Associate Professor, Department of Otolaryngology,
University of Pittsburgh School of Medicine; Director
of Clinical Services and Co-Director, Department of
Pediatric Otolaryngology, Children’s Hospital of
Pittsburgh, Pittsburgh, Pennsylvania

Chapter 85
Yu-Lan Mary Ying, MD
Resident, Department of Otolaryngology, University
of Pittsburgh Medical Center, Pittsburgh,
Pennsylvania

Chapters 122, 129
John A. Zitelli, MD
Clinical Associate Professor, Departments of
Dermatology and Otolaryngology, University of
Pittsburgh School of Medicine, Pittsburgh,
Pennsylvania

Chapter 80

PREFACE
area can be removed endoscopically. Transnasal endo-
scopic surgery also allows for decompression of the
optic nerve in patients with Graves’ disease, traumatic
injury, or orbital/skull base turmors. This technique
can be done quickly with no side effects and the imme-
diate return of vision is quite dramatic. Transnasal
dacryocystorhinostomy is a helpful technique in the
management of tearing. Cerebrospinal fl uid leaks of all
sizes are now managed successfully endoscopically.
The endoscope now plays an increasingly impor-
tant role in removal of tumors of the thyroid and para-
thyroid glands. These techniques, in select patients,
provide a bloodless surgical fi eld with the possibilities
for great exposure and complete removal of small- to
medium-size tumors. The scarring is minimal and this
technique has been well received.
The innovative use of the endoscope coupled with
the CO2 laser allows for the excision of both benign and
malignant tumors of the larynx. This technique was not
included in the previous edition but is well described
herein. The selective neck dissection, which wasn’t
widely used at the time of the First Edition, is also
described here.
In the last ten years, we have developed one of the
leading centers for the care of the voice. The University
of Pittsburgh Voice Center has three fellowship-trained
laryngologists in conjunction with a cadre of well-trained
speech-language pathologists who provide care for the
professional voice. They have contributed the entire
section on laryngology, which is all new to this edition.
Since many patients require Botox injection for various
spasmodic conditions in the larynx, our laryngologists
have also become quite expert in the technique of injec-
tion of Botox in the management of Frey’s syndrome,
another addition to the book.
The operative techniques described in this book
are augmented with detailed information regarding
preoperative evaluation and postoperative care since
the philosophy of our department is that preoperative
evaluation and postoperative care play important roles
in the outcome of the procedure.
We’ve dedicated this book to our department, our
colleagues, and our patients, who are the benefi ciaries
of these advances in surgery in our fi eld. We hope our
readers will benefi t from the innovative advances that
have taken place in this fi eld and are described in this
book.
Eugene N. Myers, MD
We are very pleased and proud to present the Second
Edition of Operative Otolaryngology: Head and Neck Surgery.
This book was written by members of our Department
of Otolaryngology together with our colleagues in the
Departments of Dermatology, Neurological Surgery,
Ophthalmology, Oral and Maxillofacial Surgery, and
Plastic Surgery, all from the University of Pittsburgh
Medical Center. We have a long record of excellent
relationships with our colleagues and without them we
would not have been able to become leaders in subspe-
cialty areas requiring intense multidisciplinary collabo-
ration such as head and neck surgery, surgery of the
cranial base, and neuro-otology.
In reviewing the table of contents from the First
Edition, I was astonished to see how many of the
procedures we described are now either completely
obsolete or rarely used. The specialty of otolaryngology
has evolved dramatically over the decade since the pub-
lication of the First Edition. We are now in an era in
which very exciting new developments in technology
have set the stage not only for new and improved surgi-
cal techniques but also for maintaining an excellent
quality of life for our patients.
The Second Edition has 131 chapters compared
with 125 in the First Edition. However, many of the
original chapters were eliminated or consolidated
under other headings so that we have been able to add
30 new chapters while only having to add an overall
total of 6 chapters. Forty-six new authors have played a
major role in producing this book. These new authors
are all on the faculty of the University of Pittsburgh
School of Medicine and bring great vigor and talent to
those chapters that refl ect their special areas of interest.
Exciting new work in the fi eld of otology includes the
new techniques for BAHA surgery and updates the fast-
moving fi eld of cochlear implantation. Functional
endoscopic sinus surgery was too new to be included
in the previous edition. Here, these techniques are
described in detail, as is the management of many of
the vexing complications encountered with this type of
surgery. The improvement in the quality of life of these
patients is remarkable.
Great emphasis has been placed on the endonasal
endoscopic management of tumors at the base of the
skull and the unique complications encountered. In
our institution, we have pioneered the two-team
approach, which includes an otolaryngologist/head
and neck surgeon and a neurosurgeon working simul-
taneously to allow two-hand dissection. Almost all
tumors, both benign and malignant, in this anatomical
xi

ACKNOWLEDGMENTS
We gratefully acknowledge the enormous contributions of our editorial
coordinator, Mary Jo Tutchko. Mary Jo was also the editorial coordinator
for the First Edition and brings the same wisdom, maturity, incredible
work ethic, and stamina to the Second Edition. Without her single-
handed efforts, producing this book would not have been possible.
We also acknowledge the effi cient and good natured help from Rebecca
S. Gaertner, Helen Sofi o, and Maria Lorusso from Elsevier, for all their
help in making this Second Edition possible.

VIDEOS
Access the following video clips online:
Chapter 1
Video 1-1. Nasal endoscopy of a patient with allergic
rhinitis.
Video 1-2. Nasal endoscopy of a patient with a common
cold, early and late.
Video 1-3. Rhinitis medicamentosa.
Video 1-4. Using a tuberculin syringe to obtain an
endoscopically guided aspirate culture.
Video 1-5. Demonstration of both endoscopically guided
aspiration and Calgiswab of middle meatus for culture in
acute sinusitis.
Video 1-6. Demonstration of maxillary sinus tap and
irrigation.
Video 1-7. Cicatricial pemphigoid with nasal stenosis.
Video 1-8. External nasal valve collapse with inspiration.
Video 1-9. Silver nitrate cauterization of bleeding from
anterior septum.
Video 1-10. Eosinophilic mucin rhinosinusitis.
Video 1-11. Bacterial atropic rhinitis with septal perforation.
Video 1-12. Biopsy of the nose in a patient with a new septal
perforation.
Video 1-13. Steroid injection of nasal polyp.
Video 1-14. Steroid injection of the inferior turbinates.
Video 1-15. Steroid injection of frontal sinus in a patient
with Wegener’s granulomatosis.
Video 1-16. Offi ce removal of nasal polyps with a
microdébrider.
Video 1-17. Offi ce removal of polyp with an alligator
forceps.
Video 1-18. Offi ce biopsy of areas suspicious for recurrent
inverting papilloma.
Video 1-19. Probable bacterial biofi lm in a patient with
prior endoscopic sinus surgery.
Video 1-20. Placement of a nasal septal button (Hood
Laboratories, Pembroke, MA).
Chapter 3
Video 3-1. Submucosal reduction of inferior turbinate with
microdébrider.
Chapter 7
Video 7-1. Endoscopic minimally invasive approach to the
maxillary sinus.
Chapter 14
Video 14-1. Endoscopic approach to the sphenoid sinus:
medial to the middle turbinate.
Video 14-2. Endoscopic approach to the sphenoid sinus:
lateral to the turbinate through the ethmoid.
Chapter 16
Video 16-1. Technique for endoscopic type IV frontal sinus
drill-out procedure.
Chapter 20
Video 20-1. The left anterior ethmoid artery is exposed
where it crosses the skull base by performing medial orbital
decompression and isolating the vessel at the point where it
leaves the orbit. This exposure was part of endonasal
craniofacial resection for neoplasm.
Video 20-2. The left internal carotid artery was lacerated
in this patient with a recurrent chordoma during endonasal
cranial base surgery. The video demonstrates control of
the hemorrhage with focal packing while additional
exposure is achieved by removal of bone around the
vidian artery (two surgeons). The laceration was welded
shut with bipolar electrocautery, and the patient was
transferred to the angiography suite for permanent sacrifi ce
of the vessel.
Chapter 95
Video 95-1. Endoscopic medial wall decompression.
Chapter 99
Video 99-1. Technique of gold weight insertion.
Chapter 103
Video 103-1. The right middle turbinate is transected and
removed. The stump of the middle turbinate remnant is
cauterized with monopolar electrocautery. The superior
turbinate is partially resected to expose the sphenoid sinus
ostium.
Video 103-2. The right inferior turbinate is lateralized with
a Cottle elevator to improve visualization of the septum and
vascular pedicle before harvesting a septal mucosal fl ap.
Video 103-3. A monopolar needle electrode is used to incise
a right septal mucosal fl ap. The initial incision starts at the
inferior edge of the right sphenoid mucosal surface and
follows the posterior nasal septum to the junction of the
septum and nasal fl oor. The incision extends anteriorly to
the anterior septum. A vertical septal incision is made just
posterior to the nasal vestibule. A superior septal incision
extends from the sphenoid os along the septum
approximately 5 mm below the skull base to the anterior
septum.
Video 103-4. The septal mucosal fl ap is elevated in a
subperichondrial/subperiosteal plane to the anterior face of
the sphenoid sinus. Fine scissors are used to complete the
incisions, and the fl ap is displaced into the oropharynx.
Video 103-5. A Cottle elevator is used to disarticulate the
posterior septal cartilage and bone from the sphenoid
rostrum and expose the contralateral anterior face of the
sphenoid sinus. The bone of the rostrum is removed with a
rongeur to open the sphenoid sinus. A Kerrison rongeur is
used to enlarge the sinusotomy and transect the intersinus
septum.
Video 103-6. The contralateral posterior nasal septal mucosa
is incised and the posterior edge of the transected septum is
xxi

xxii
Videos
resected with a back-biting rongeur. The sphenoidotomy is
enlarged.
Video 103-7. Sphenoid septations are carefully removed with
a drill or rongeurs while avoiding injury to the internal
carotid artery.
Video 103-8. The bone of the sella is thinned with a drill
and then removed with a 1-mm Kerrison rongeur while
being careful to direct the tip tangential to the carotid
artery.
Video 103-9. A left middle meatal antrostomy is performed
and the sphenopalatine artery is identifi ed at the foramen
at the posterosuperior corner of the sinus.
Video 103-10. The bone of the sphenopalatine foramen and
pterygopalatine space is removed with a 1-mm Kerrison
rongeur and the sphenopalatine artery is ligated.
Video 103-11. Bone surrounding the vidian artery and nerve
(pterygoid canal) is carefully drilled to determine the plane
of the petrous carotid artery.
Chapter 106
Video 106-1. Overview of the surgical fi eld after
sphenoidotomy and resection of the posterior nasal septum.
The surgical fi eld extends from the fl oor of the sphenoid
sinus superiorly to the level of the soft palate inferiorly and
to the eustachian tubes laterally.
Video 106-2. The mucosa, underlying paraspinal muscles,
and dense pharyngobasilar fascia of the nasopharynx are
resected to expose the underlying bone of the clivus and
C1.
Video 106-3. The outer cortical bone of the clivus is
removed from the fl oor of the sphenoid sinus to the
foramen magnum with a 3-mm hybrid bit. This facilitates
resection of the dense pharyngobasilar fascia.
Video 106-4. The central ring of C1 is removed with the
drill and the defect is widened laterally with a Kerrison
rongeur. Note the excessive mobility of C1 in this patient
with rheumatoid degeneration.
Video 106-5. The odontoid is hollowed out with a drill until
a thin shell of cortical bone remains.
Video 106-6. The base of the dens is detached from the
body of C2 and the shell of remaining bone is dissected free
from the surrounding ligamentous attachments.
Video 106-7. The rheumatoid pannus is thinned with an
ultrasonic aspirator until transmitted pulsations are evident.
Video 106-8. In the absence of a cerebrospinal fl uid leak,
the surgical defect is covered with fi brin glue.
Chapter 113
Video 113-1. Canal injection.
Video 113-2. Twelve- and 6-o’clock incisions.
Video 113-3. Back elevation of the posterior canal conchal
fl ap.
Video 113-4. Postauricular elevation of the posterior canal
fl ap.
Video 113-5. Connection of the canal incisions and
retraction with a tracheostomy tape.
Video 113-6. Anterior canal wall incision.
Video 113-7. Dissection of the medial canal skin.
Video 113-8. Canal skin elevated medially at the annulus.
Video 113-9. Removal of the superior and anterior canal/
tympanic membrane epithelium.
Video 113-10. Retrograde elevation of the anterior canal
wall skin.
Video 113-11. Anterior canalplasty.
Video 113-12. Access to the anterior annulus.
Video 113-13. Curettage of the annulus sulcus.
Video 113-14. Inspection of the middle ear and ossicular
chain.
Video 113-15. Removal of the incus.
Video 113-16. Preparation of the fascial graft.
Video 113-17. Placement of the fascial graft medial to and
around the malleus handle.
Video 113-18. Preparation of the canal wall skin.
Video 113-19. Trimming of the canal wall skin.
Video 113-20. Replacement of the canal wall skin.
Video 113-21. Placement of the medial rosebud packing.
Video 113-22. Placement of Merocel balls in the packing.
Video 113-23. Placement of Merocel balls in the lateral
rosebud packing.
Chapter 114
Video 114-1. Left ear. Reinforced Silastic sheeting is placed
under the handle of the malleus.
Video 114-2. Left ear. Reinforced Silastic sheeting has been
placed in the middle ear. A fascial graft is positioned lateral
to the Silastic sheeting and rests on the bony annulus.
Video 114-3. Left ear. The incus is removed from the attic
along with a focus of tympanosclerosis.
Video 114-4. The incus is held with toothed forceps. A
battery-powered drill is used to sculpt the incus for
placement between the stapes and malleus.
Video 114-5. Right ear. An Applebaum prosthesis is
positioned between the stapes and the eroded long process
of the incus.
Video 114-6. Partial ossicular replacement prosthesis with a
trimmable shaft. It is cut on a measuring block and then
placed on the stapes.
Video 114-7. Type IV tympanoplasty. The incus is sculpted
with a drill for placement of the long process on the
footplate and creation of a notch underneath the malleus.
Video 114-8. A 5-mm titanium sizing total ossicular
replacement prosthesis is placed between the stapes
footplate and tympanic membrane. A thin piece of cartilage
will be necessary.
Video 114-9. The prosthesis is positioned on the stapes
footplate and supported with pledgets of wet Gelfoam.
Video 114-10. The lateral chain is palpated and found to be
fi xed. The incudostapedial joint is separated.
Video 114-11. Fracture of the malleus handle at the
proximal handle is demonstrated.
Chapter 115
Video 115-1. Removal of squamous epithelium from the
scutum.
Chapter 117
Video 117-1. Stapes down-fracture. The stapes
superstructure is down-fractured with a curved pick and
removed.
Video 117-2. Right ear. The vein graft is positioned over the
stapedotomy.
Video 117-3. Right ear. A Robinson prosthesis is placed next
to and rested against the incus.

Videos
xxiii
Video 117-4. Right ear. The well of the Robinson prosthesis
is easily positioned under the lenticular process of the
incus.
Video 117-5. Right ear. A few attempts may be needed to
properly position the well of the prosthesis.
Video 117-6. A small piece of vein is placed over the incus
to further secure the bucket handle into position. This is
termed a “band-aid.”
Video 117-7. Right ear. The stapedial tendon and posteriori
crus are vaporized with a CO2 laser. The footplate is
fenestrated.
Video 117-8. Right ear. The footplate is being vaporized in a
rosette pattern with a CO2 laser.
Video 117-9. Right ear. The edges of the stapedotomy are
thinned with the laser and the opening enlarged with a
footplate pick.
Video 117-10. A wire-Tefl on prosthesis is positioned in the
fenestration and hooked onto the incus.
Video 117-11. A hand-held laser is used to heat the Nitinol
prosthesis to tighten it on the incus.
Video 117-12. Right ear with obliterative otosclerosis. The
stapes footplate is initially thinned with a small diamond
burr mounted on a micro ear drill.
Video 117-13. A graft of perichondrium is placed medial to
the tympanic membrane and lateral to the stapes prosthesis
to avoid extrusion.
Chapter 121
Video 121-1. Left ear treated via a transcanal approach for
separation of the incudostapedial joint and removal of the
incus. Note the facial nerve tumor located superior to the
stapes.
Video 121-2. A facial nerve neuroma of the horizontal and
vertical segments of the left ear is being dissected at the
second genu.
Video 121-3. The facial nerve tumor in the left ear is being
carefully dissected from the fallopian canal and arch of the
stapes.
Video 121-4. The areolar and adventitial layers are dissected
from the end of the nerve to be grafted. The epineurium is
left around the nerve fascicle.
Chapter 124
Video 124-1. Right translabyrinthine approach. The internal
auditory canal is outlined and the superior trough is being
developed.
Video 124-2. A high jugular bulb must be decompressed to
provide access to the internal auditory canal and inferior
trough.
Video 124-3. The dura of the posterior fossa is opened with
a Beaver blade. A microscissors completes this opening at
the porus of the internal auditory canal.
Video 124-4. The dural covering the internal auditory canal
is opened, providing access to the lateral aspect of the
tumor in the fundus.
Video 124-5. Following removal of most of the
cerebellopontine angle portion of the tumor, the proximal
eighth nerve is divided. The facial nerve is identifi ed more
medially.
Video 124-6. A suture of 4-0 silk is used to reapproximate
the dura of the posterior fossa.
Video 124-7. Strips of abdominal fat are placed through the
dura and fi ll the mastoid cavity. Fibrin glue is used to
further secure the dural closure.
Video 124-8. Right retrosigmoid approach. Opening the
cisterna magna and exposing the lower cranial nerves.
Video 124-9. The origin of the facial nerve can typically be
identifi ed before starting dissection of the tumor. The facial
nerve originates from the brain stem in close proximity to
the ninth cranial nerve. Using a Kartush facial nerve
stimulator, the location of the facial nerve can be verifi ed.
Once its position is confi rmed visually and with electrical
stimulation, a pledget of Tefl on felt is placed over the nerve
for protection and as a marker for subsequent tumor
dissection.
Video 124-10. After confi rming that the facial nerve is not
on the posterior surface of the tumor, surface vessels are
bipolared, the tumor is then biopsied, debulked with an
ultrasonic aspirator, and excised following the same
sequence of operative techniques.
Video 124-11. The petrosal vein (Dandy’s vein) is located
superiorly and laterally in the posterior fossa, just inferior to
the tentorium. The video clip demonstrates bipolar cautery
and division of the vessel before tumor removal.
Video 124-12. The inferior pole of the tumor is dissected
from the proximal eighth and seventh cranial nerves. Once
the dissection plane is defi ned, pledgets of Tefl on are
placed to maintain separation of tumor from the
surrounding normal structures.
Video 124-13. The dura over the posterior surface of the
porus is cauterized with a bipolar forceps. This region is
incised with a no. 15 blade. A fl ap of dura pedicled on the
posterior lip of the porus is developed.
Video 124-14. The posterior wall of the internal auditory
canal is being drilled. The fl ap of dura based on the lip of
the porus remains intact but will be subsequently excised.
Video 124-15. Using a diamond burr, troughs are created
above superior and inferior to the interior auditory canal as
the dissection is taken laterally toward the fundus.
Video 124-16. A narrow dissector is used to palpate the
limits of dissection in an extradural plane superior and
inferior to the tumor to determine whether adequate bone
removal has been achieved.
Video 124-17. The dura of the internal auditory canal is
opened. The tumor is dissected from the superior fold of
dura seeking the location of the facial nerve.
Video 124-18. Using a nerve stimulator, the tumor is
dissected and the facial nerve is identifi ed in the anterior
superior quadrant of the internal auditory canal.
Video 124-19. The tumor is dissected from the facial nerve
using an excavator.
Video 124-20. The inferior and lateral aspects of the tumor
are rolled from the fundus of the internal auditory canal.
The lateral fi bers of the vestibular nerve are sharply divided.
Video 124-21. The facial nerve often gets compressed at the
proximal internal auditory canal (IAC) near the porus. The
tumor is being dissected off the facial nerve at the mid and
proximal portions of the IAC.
Video 124-22. The tumor is removed from the proximal
internal auditory canal and cerebellopontine angle with
ultrasonic aspiration and dissection.

xxiv
Videos
Video 124-23. Excision of the remaining tumor is now
undertaken from a medial to lateral direction keeping the
facial nerve in view.
Video 124-24. If the tumor is adherent to the facial nerve,
meticulous dissection in a piecemeal fashion is necessary for
fi nal removal.
Chapter 125
Video 125-1. Using microbipolar forceps facilitates
hemostasis during removal of the tumor.
Video 125-2. Tumor resection is performed through the
facial recess approach with cup forceps.
Video 125-3. Cotton soaked with adrenalin is used to
control bleeding during tumor dissection.
Chapter 131
Video 131-1. The posterior semicircular canal is
skeletonized and blue-lined midway between its ampulla
and the common crus. A central bony island is left over the
membranous labyrinth. This remaining bone is removed
using a sharp pick, taking care to leave the membranous
labyrinth intact. The membranous canal is then plugged
with bone wax.

section 1
Nasal Cavity, Nasopharynx,
and Sinuses
Chapter 1
Offi ce-Based Diagnosis of
Sinonasal Disorders
Berrylin J. Ferguson, Li-Xing Man, and Jacob Sedgh
The nasal endoscopes have revolutionized our approach
to the diagnosis of disorders of the nose and sinuses.
The following discussions (and accompanying videos)
highlight some of the common disorders encountered
in rhinology.
ALLERGIC RHINITIS (see Video 1-1)
Allergic rhinitis affl icts between 15% and 30% of the
population depending on age. It is often characterized
as either seasonal allergic rhinitis or perennial allergic
rhinitis. Patients with longstanding congestion and
postnasal drainage may be unaware that they have aller-
gies because of the chronicity of the symptoms. On
physical examination, the physical fi ndings may mimic
that of a cold; however, the duration of several weeks
or months of persistent symptoms makes a viral etiology
unlikely.
In this example, a 20-year-old man with longstand-
ing nasal obstruction undergoes diagnostic endoscopy
after his nasal cavity has been decongested with a vaso-
constrictor (a few drops of 1 : 1000 adrenaline) and
anesthetized with 4% Xylocaine. The left side is exam-
ined fi rst; note the septal deviation and the thick white
secretions. There is no purulence in the middle meatus.
The fi ndings in the right side are similar. Note secre-
tions coming from both the inferior and middle turbi-
nate and being transported to the back of the nose.
Typically turbinates have a pale edematous appearance.
Red mucosa suggests other etiologies, such as exposure
to tobacco smoke, irritants, or food allergy.
VIEW OF THE COMMON COLD
(see Video 1-2)
The physical fi ndings associated with the common cold
often mimic those of allergic rhinitis. In this patient,
there is a septal excoriation on the right side. As we look
into the right middle meatus, white mucoid secretions
are present. A sample of these secretions is aspirated
for culture. It is also possible for the secretions during
a cold to be purulent in nature. Postinfl ammatory infec-
tious upregulation of mucus production is common,
and in this case we see the tenacious character of this
mucus several days after the primary symptoms of a cold
have resolved.
1

2
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
RHINITIS MEDICAMENTOSA
(see Video 1-3)
Rhinitis medicamentosa is a consequence of overuse of
a topical vasoconstrictor, most commonly oxymetazo-
line (Afrin). This patient had been using Afrin two or
three times a day for several months. Note the upregula-
tion of seromucinous glands characterized as “cobble-
stoning” along the septum and the inferior turbinate.
On the right side a similar appearance is noted, and
this patient is endoscoped after the nasal cavity has
been decongested to permit endoscopic visualization.
The treatment of rhinitis medicamentosa is to stop use
of the topical nasal decongestant. Treatment is often
optimized by use of a nasal steroid spray.
ENDOSCOPICALLY GUIDED ASPIRATE
CULTURE OF ACUTE BACTERIAL SINUSITIS
(see Video 1-4)
In performing an aspirate culture, an economical
method of obtaining the aspiration sample is to cut off
the end of a tuberculin syringe and attach that end
snugly to the suction tubing. A no. 7 Frazier suction is
attached to the nozzle of the syringe. Once the aspirate
is obtained, it is important to remove the contaminated
end of the syringe adjacent to the suction hose by
cutting it off before removing the aspirated sample to
a culture tube.
ACUTE BACTERIAL SINUSITIS
ILLUSTRATED THROUGH ENDOSCOPIC
MIDDLE MEATAL ASPIRATION
(see Video 1-5)
The suction tip is inserted into the nose with care to
avoid touching the nasal vestibule. Under endoscopic
visualization, purulent exudate from the middle meatus
is aspirated. The correlation of this aspirate with endo-
scopic maxillary sinus taps is between 50% and 80%.
Generally a Gram stain and aerobic culture is requested
in acute sinusitis.
In some situations it is impossible to aspirate with
a suction tip, because the secretions are too scant or the
suction catheter cannot access a narrowed area that is
lateral to the endoscope. In these situations, a Calgiswab
can be gently bent to access this area. The Calgiswab is
inserted carefully so as not to contaminate it with the
nasal vestibule.
MAXILLARY SINUS TAP IN ACUTE
BACTERIAL SINUSITIS (see Video 1-6)
In this case of acute bacterial sinusitis, the nasal cavity
is being anesthetized for a maxillary sinus tap. A cotton
pledget impregnated with 4% Xylocaine and a few
drops of adrenaline 1 : 1000 is placed into the nasal
cavity. After a few minutes, when the mucosa is partially
decongested and anesthetized, this pledget is removed
and a second pledget is placed under the inferior tur-
binate into the inferior meatus. An ear curette is useful
in positioning the pledget under the inferior turbinate.
Once this pledget has been in place for approximately
5 to 10 minutes, it is removed and 0.5 to 1 mL of 1%
Xylocaine 1 : 100,000 adrenaline is injected into the
mucosa of the inferior meatus using a 1.5-inch long
25-gauge needle. This is usually painless after the topical
anesthetic has been in place for 5 to 10 minutes. Anes-
thetizing the inferior turbinate allows one to painlessly
medialize the inferior turbinate, if needed, in the place-
ment of either a 16- to 18-gauge spinal needle or a
commercial antral tap trocar. The antral tap trocar or
needle is introduced through the thin bone in the
lateral inferior meatus into the maxillary sinus. The
bone is usually easiest to penetrate in the more superior
lateral aspects of the inferior meatus. Occasionally, very
thick bone or nasal anatomy precludes inferior meatal
antral tap. Once the needle or trocar is introduced
through the bone into the sinus, the introduced trocar
is removed and the purulent exudate is aspirated from
the maxillary sinus with a syringe. The aspirated speci-
men obtained is sent for aerobic and anaerobic cultures
and Gram stain. Depending on circumstances, such as
immunocompromised status or allergies, fungal cul-
tures should be obtained. After the culture specimen is
obtained, the sinus can be irrigated. If the sinus tap is
free of secretions, then a small amount of sterile saline
is introduced into the maxillary sinus and reaspirated.
To irrigate the sinus the patient is given a basin and
asked to lean forward while the sinus is gently irrigated
with 10 to 50 mL of sterile saline. If the procedure is
uncomfortable to the patient, it should be stopped,
because sometimes the outfl ow tract of the sinus is so
obstructed with edema that the introduced fl uid does
not have an egress. Maxillary sinus tap and irrigation
can be not only diagnostic but also therapeutic. At the
end of the irrigation, air is usually introduced into the
sinus cavity. Topical antibiotics can also be introduced,
if desired.
UNUSUAL DIAGNOSES IN SINUS DISEASE
Cicatricial Pemphigoid (see Video 1-7)
In this patient with cicatricial pemphigoid, we see com-
plete restenosis of the right side of her nose and well
over 50% restenosis of the left side despite several prior
surgical procedures. The left side of her nose is kept
patent only with the insertion of a stent, which is
removed only for cleaning and then is reinserted.
Complete Internal and External Nasal Valve
Collapse with Inspiration (see Video 1-8)
This patient demonstrates collapse of the nasal valve
with inspiration due to lack of support from the lower
lateral cartilages. Surgery of the septum and the infe-
rior turbinates would not successfully resolve this situa-
tion. The condition was treated with cartilage battens
added to the lower lateral cartilages to strengthen them
in order to prevent closure with inspiration. The more
rapidly a patient inspires, the more vigorous the closure

Chapter 1
Offi ce-Based Diagnosis of Sinonasal Disorders
3
of the nasal valve. This is due to the Bernoulli effect of
a vacuum produced by increased velocity of the inspired
air. Patients who complain of nasal obstruction and in
whom no site of obstruction is detected on physical
examination with the nasal speculum, should be evalu-
ated for nasal valve collapse. In this patient, the entire
upper airway was assessed with a fl exible scope.
OFFICE-BASED PROCEDURES IN PATIENTS
WITH SINONASAL DISORDERS
Control of Anterior Epistaxis (see Video 1-9)
Epistaxis occurs in up to 5% of the population per year
but only a minority of cases requires medical attention.
Ninety-fi ve percent of epistaxis that does come to
medical attention is due to bleeding from the plexus of
vessels at the anterior nasal septum. This is often called
Little’s area or Kiesselbach’s plexus. In such a patient,
the nose should be anesthetized with pledgets, and
impregnated with 4% Xylocaine and a vasoconstrictor.
If the nose is bleeding, the point of active bleeding can
be cauterized with silver nitrate. If no site of bleeding
is seen, then any 1- to 3-mm domelike lesions should be
gently touched with the silver nitrate stick. If this has
been the site of bleeding, then brisk bleeding will occur
with this gentle trauma to the telangiectasia or dilated
vessel. The silver nitrate can then be applied with light
pressure on the stick until bleeding stops. The patient
should also be apprised of methods of preventing epi-
staxis such as using gels or cocoa butter crème inserted
into the nasal vestibule and frequent use of humidifi ca-
tion and saline sprays. Patients can control most epi-
sodes of epistaxis by blowing the blood clot out of their
nose, leaning forward to prevent blood from going to
the back of their throat, and applying digital pressure
(squeezing) to the ala bilaterally. This should be held
for 5 to 10 minutes. Nasal Cease is an over-the-counter
product that the patient can use to stop bleeding by
placing it in the nose for 30 minutes and then removing
it. This temporary packing has a very high success rate
in uncomplicated epistaxis.
Septal perforations often bleed from the raw surface
at the posterior aspect of the perforation. The differen-
tial diagnosis of nasal bleeding, crusting, and perfora-
tion includes vasculitis, cocaine use, nasal steroid use
(rare), nose picking, prior septoplasty, and overly vigor-
ous cauterization for epistaxis leading to septal perfora-
tion. Occasionally, bacterial infection may cause crusting
and even atrophic rhinitis and perforation. Although
classically atrophic rhinitis is attributed to Klebsiella
ozaenae, other bacteria may be involved as well. Rarely,
invasive fungal infection leads to crusting and perfora-
tion. Patients with immunodefi ciency are at risk for
invasive fungal infection.
Eosinophilic Mucin Rhinosinusitis
(see Video 1-10)
The most refractory patients are those with nasal polyps
associated with eosinophilic mucin.
This patient is an adolescent with a 3-year history
of nasal polyps and sticky eosinophilic mucin, which was
not bacterial or fungal in etiology. Although she did
have allergies, her symptoms were not responsive to
allergy management. Note the tenacity of the mucous
secretions. These should be sent for histopathologic
evaluation with special note made to assess for the pres-
ence of fungi. Hyphae present in eosinophilic mucin in
conjunction with elevated IgE to the cultured fungus is
diagnostic of allergic fungal sinusitis.
Atrophic Rhinitis with Septal Perforation
(see Video 1-11)
Atrophic rhinitis can be caused by bacteria other than
Klebsiella ozaenae. Citrobacter koseri was cultured from this
80-year-old Cambodian woman with a 1-year history of
a foul smell from her nose. Following extensive débride-
ment of her nasal cavity, initiation of topical antibiotics
directed toward the pathogen (gentamicin 80 mg per
500 mL of saline with 20 mL irrigations twice a day),
and an oral fl uoroquinolone, the patient’s foul-smell-
ing crusting resolved. Note the sticky mucus in the
nasopharynx.
Biopsy of a Septal Perforation in a
20-Year-Old (see Video 1-12)
In a newly diagnosed septal perforation of unknown
etiology, a biopsy should be obtained to evaluate for
vasculitis and infectious etiologies such as tuberculosis
or syphilis. Laboratory evaluation includes sedimenta-
tion rate, complete blood count with differential, circu-
lating antineutrophil cytoplasmic antibody (C-ANCA),
and antinuclear antibody (ANA). A biopsy is obtained
at the margin of both the ulcerated and normal tissue
and sent for histopathology. The pathologist should be
apprised of the concerns leading to the biopsy and
specifi cally instructed to evaluate for Wegener’s granu-
lomatosis and vasculitis. Rarely infection can lead to
perforation and atrophic rhinitis with crusting. Classi-
cally this is secondary to Klebsiella ozaenae but may occur
with other bacteria as well. The patient whose diagnosis
eludes histopathologic abnormality but who continues
to have severe crusting may have cocaine abuse as an
etiology. Septal perforation and crusting can develop
and persist, and even lead to palatal perforation even
after cocaine use is stopped. The diagnosis in this 20-
year-old with a septal perforation was Staphylococcus
aureus infection in a patient with mild diabetes. The
crusting ultimately resolved with prolonged antibiotic-
directed therapy both orally and topically and frequent
débridement and nasal irrigation.
Steroid Injection for Nasal Polyps
(see Video 1-13)
Nasal polyps are usually responsive to the topical appli-
cation of nasal steroid sprays. In refractory nasal polyps
or in patients intolerant of nasal steroid sprays, the
polyp can be injected with steroids. Nasal polyps are
usually insensate, and steroid injection into the polyp

4
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
can be accomplished with or without prior topical anes-
thetics into the nose. The nasal polyp is rarely able to
contain more than 0.2 mL of steroid injected into the
polyp without the injected steroid leaking back out of
the puncture site when the needle is withdrawn. The
preferred steroid is triamcinolone acetonide, 40 mg/
mL, because of its small molecular size. The duration
of the steroid injection effect is usually 8 to 12 weeks.
Steroid Injection of the Inferior Turbinate
(see Video 1-14)
In the mid-1980s, there were several case reports of both
temporary and permanent blindness following the injec-
tion of steroid into the inferior turbinate. The mecha-
nism is one of retrograde embolization of the vessels of
the inferior turbinate into the retinal artery. If a steroid
injection into the inferior turbinate is undertaken, the
patient should be apprised of the risk, and the risk
should be minimized by adequately decongesting the
nose and then injecting steroid into multiple areas of the
inferior turbinate to minimize the deposition of a single
large bolus. Triamcinolone acetonide, 40 mg/mL, is
preferred because of its small molecular size. A total of
0.5 mL is injected into each turbinate. Several injections
are made beginning posteriorly and advancing anteri-
orly in order to minimize embolization into orbital
vessels. There is often bleeding following injection of the
inferior middle turbinate and pledgets are placed into
the nose following the steroid injection for approxi-
mately 5 to 10 minutes. The duration of effect is usually
8 to 12 weeks. Steroid injections of the turbinates are
helpful in nasal congestion responsive to steroids in the
patient who is intolerant of topical sprays.
Steroid Injection of the Frontal Sinus in a
Patient with Wegener’s Granulomatosis
Following Frontal Sinus Drill Out
(see Video 1-15)
Steroid injections, using a 26-gauge spinal needle, are
used to minimize frontal restenosis and scarring. In this
example, the frontal sinus recess is injected with a small
amount (0.15 mL) of triamcinolone acetonide. The
scope is placed through the superior septal perforation
up into both the right and left frontal sinus, and the
injec-tion is into the mucosa of the back wall of the
frontal sinus. This patient had a prior endoscopic
frontal sinus drill out (Lothrop IV).
In-Offi ce Microdébridement of Nasal Polyps
(see Video 1-16)
Up to 80% of nasal polyps recur following surgery unless
managed medically. Polyps can easily be removed with a
microdébrider. The nose is anesthetized for 10 minutes
topically with cotton pledgets impregnated with 4%
lidocaine and then a 3.5-mm microdébrider is used to
remove the nasal polyp. If there is enough room and the
polyps are large, a 4.0 mm microdébrider blade is rec-
ommended. Note that fi rmly applying the mouth of the
microdébrider to the maximum surface area of the
polyp facilitates removal. When the mouth of the micro-
débrider is not fully applied to the polyp, suboptimal
suction leads to a slower removal of the polyp. Polyps
may occur both medial and lateral to the middle turbi-
nate. Polyps are often sucked into the microdébrider so
that one does not have to “chase” the polyp into various
sinuses. If the patient begins to have discomfort during
the procedure, then further anesthetic pledgets are
placed in the nose for 5 to 10 minutes. Frequently one
can address the contralateral side of the nose while
waiting for the additional anesthesia to take effect. A
trap can be placed on the microdébrider so that the
material aspirated can be sent for histopathologic analy-
sis. Care should be taken not to touch the turbinates or
the septum because they will bleed and are far more
sensate than nasal polyps. Rarely does one need to inject
the nasal polyps to achieve anesthesia.
Removal of Nasal Polyp with Alligator
Forceps (see Video 1-17)
The cost of the microdébrider is somewhat less than
$150.00 per device. Polyps may also be removed with
Bellucci scissors or even alligator forceps. In some
patients, removal of this polyp will give immediate relief
of nasal obstruction. Unilateral polyps should always be
sent for histopathologic analysis because of the greater
chance that a unilateral polyp represents an inverting
papilloma or a malignancy. Antrochoanal polyps occur
unilaterally, whereas most infl ammatory polyps occur
bilaterally.
Endoscopic Biopsy of Patient with a History
of Inverting Papilloma (see Video 1-18)
Patients with a history of inverting papilloma are at risk
for recurrence and therefore frequent endoscopic
reevaluation postoperatively is important. In this case,
we see a patient who has a suspicious lesion in the left
anterior ethmoid area. This is at the skull base. Two
areas are being inspected both medially and laterally.
The irregularity in the lateral area is highlighted by
reducing the light of the endoscope. Then a topical
anesthetic is injected. Just above this injection is the
frontal sinus and at the base of the frontal sinus is some
polypoid tissue. This is the region of the anterior
ethmoid artery as well. In the injection to this area, the
anterior ethmoid is injected. This is confi rmed by the
brisk bleeding that occurs after the needle is withdrawn
as well as by the blanching of the patient’s left forehead
after the injection. Small biopsy forceps can be used to
collect biopsy specimens from the various areas. Speci-
mens should be labeled meticulously so that any posi-
tive biopsy can be localized for further removal. The
medial biopsy in this patient was benign and the lateral
biopsy showed inverting papilloma.
Chronic Bacterial Sinusitis with Biofi lm
(see Video 1-19)
Occasionally, patients’ sinus infections are refractory to
both surgical and medical intervention. The biofi lm is

Chapter 1
Offi ce-Based Diagnosis of Sinonasal Disorders
5
readily apparent in this patient by rigid endoscopy;
however, other postsurgical patients’ maxillary infec-
tion may only be visualized using a fl exible fi beroptic
endoscope and placing it into the maxillary sinus. Aspi-
rate cultures of the purulent exudate can be obtained
and the purulence can be irrigated from the maxillary
sinus. A curved suction facilitates both the aspirate
culture and the irrigation of the purulent exudate. In
addition, topical antibiotics or steroids can be placed
into the sinus.
Placement of Nasal Septal Button
(see Video 1-20)
Symptomatic perforations can be rendered asympto-
matic with the placement of a Silastic button. These are
commercially available through Hood Laboratories,
575 Washington Street, Pembroke, MA 02359 (Catalog
# NSB-10-S for 1 cm, NSB-20-S for 2 cm, and so on up
to 5 cm in diameter). The nasal cavity is fi rst anesthe-
tized and then using either the endoscope or a head-
light for visualization, the button is introduced into the
nose on the other side. The fl ange is extracted through
the contralateral side and then the button is positioned.
Usually the patient’s perforation is far smaller than the
button. Thus one must cut the button to modify its size
to fi t the patient’s perforation and nasal dimensions.
Placement of an antibiotic ointment to the button daily
may delay the formation of a bacterial biofi lm. Once
the button is too crusted, it should be removed. At this
point the perforation may be suffi ciently mucosalized
so there is no further bleeding or crusting.

Chapter 2
Epistaxis
Carl H. Snyderman and Ricardo L. Carrau
Epistaxis is one of the most common urgent problems
that otolaryngologists are asked to treat. Minor epistaxis
usually originates from the anterior nasal septum and
is often the result of minor trauma to the septal mucosa.
In children, it is often the result of nose picking, whereas
in adults, nosebleeds result from desiccation of the
mucosa associated with the dry air of the winter months.
Minor epistaxis is generally anterior in origin but may
also originate from the superior nasal cavity (anterior
ethmoid artery [AEA]) and posterior nasal cavity. Con-
servative measures such as direct pressure (pinching
the nose, nasal packing) and chemical cautery are
usually successful in controlling this type of hemor-
rhage, and surgical intervention is rarely necessary.
Major epistaxis lacks a precise defi nition but it is
characterized as being diffi cult for patients to control,
frequently results in a trip to the emergency depart-
ment, and can be life-threatening. The vast majority of
major epistaxis is idiopathic, but a careful history will
often yield some risk factors such as the use of antiplate-
let medications. Major epistaxis is generally posterior in
origin and originates from branches of the sphenopala-
tine artery, and it may pose a risk to the patient’s airway.
Patients with severe posterior epistaxis are typically
older and have medical comorbid conditions. Care of
these patients can be divided into acute management
and defi nitive management. Acutely, an attempt is
made to identify the source of the bleeding, and some
form of nasal packing is placed to provide temporary
control. Treatment options for defi nitive management
include placement of an anterior and posterior nasal
pack, hot-water irrigation of the nasal cavity,1-3 angio-
graphic embolization of the external carotid artery, and
surgery.4 Surgical options include electrocautery and
ligation of nasal vessels. Surgical ligation of the terminal
vessels (sphenopalatine artery [SPA] and ethmoidal
arteries) is superior to ligation of the external carotid
artery or internal maxillary artery (IMA) because of
decreased morbidity and increased effectiveness.5,6
Certain patients deserve special consideration,
including those with hereditary hemorrhagic telangiec-
tasia, sinonasal neoplasms, and postsurgical or post-
traumatic hemorrhage. An orderly plan of therapy or
a treatment algorithm will assist in the management
of patients with epistaxis, whatever the cause. This
chapter focuses on the surgical management of
severe epistaxis.
ANATOMY
The nasal mucosa has a rich arborizing network of sub-
mucosal vessels. The anterior septal plexus, termed
Little’s area or Kiesselbach’s plexus, is a confl uence of
small vessels from the AEA, SPA, and facial artery (Fig.
2-1). The mucosa of the superior aspect of the nasal
cavity is supplied by the ethmoidal arteries. Although
they are typically labeled the anterior and posterior
ethmoid arteries, there may be more than two vessels.
These vessels originate from the ophthalmic artery, a
branch of the internal carotid artery (Fig. 2-2). They
traverse the orbital tissues, enter the nasal cavity through
bony foramina along the frontoethmoidal suture line
to supply the mucosa of the superior nasal cavity, and
reenter the cranial cavity at the lateral margin of the
cribriform plate. The AEA is larger than the posterior
ethmoid artery (PEA) in most cases and is the most
clinically signifi cant. The AEA enters the nasal cavity a
little less than 2 cm (average, 14 to 18 mm) posterior to
the nasolacrimal suture line. It is situated at the poste-
rior margin of the nasofrontal recess and is generally
visible beneath the surface of the mucosa. In some cases
it is easily identifi able in a prominent ridge or septation
7

8
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
containing the vessel. With the aid of image guidance
technology, the vessel can be localized intraoperatively
in a coronal plane that is tangential to the posterior
surface of the globe. The PEA lies about 1 cm (average,
9 to 13 mm) posterior to the AEA and may lie as little
as 2 to 3 mm anterior to the optic canal (average, 4 to
7 mm). It crosses the skull base anterior to the sphenoid
sinus and helps demarcate the posterior margin of the
cribriform plate.
The predominant blood supply to the nasal cavity
comes from branches of the IMA, a major branch of the
external carotid artery (Fig. 2-3). The IMA enters the
pterygopalatine fossa or pterygomaxillary space later-
ally and branches into multiple vessels supplying the
nasal cavity, oral cavity, and surrounding soft tissues.
Within the pterygopalatine fossa, branches of the IMA
can have a simple or complex branching pattern, thus
making identifi cation of the individual vessels nearly
impossible. The SPA is the terminal branch of the IMA
and is the major blood supply to the mucosa of the
posterior nasal cavity.7 It enters the nasal cavity at the
sphenopalatine foramen. The sphenopalatine foramen
is located at the superior aspect of the vertical plate of
the palatine bone, which forms the medial boundary of
Posterior
ethmoidal artery
Ophthalmic artery
Spheno-
palatine artery
Internal
carotid artery
Maxillary
artery
External
carotid artery
Kiesselbach’s
area
Anterior
ethmoidal artery
Figure 2-1. Vascular supply of the nasal septum.
Posterior
ethmoidal artery
Ophthalmic
artery
Internal
carotid artery
Anterior
ethmoidal artery
Figure 2-2. Anterior and posterior ethmoid artery branches of
the ophthalmic artery.

Chapter 2
Epistaxis
9
the pterygopalatine fossa.8 The foramen can be found
at the posterior-superior-medial corner of the maxillary
sinus, just deep to the attachment of the middle turbi-
nate (Fig. 2-4). The SPA branches into lateral nasal
branches and posterior septal branches to supply the
mucosa of the lateral nasal wall and posterior nasal
septum, respectively. The posterior nasal branch is fre-
quently termed the posterior nasal artery, and this ter-
minology will be used throughout this chapter. This
branching of the SPA occurs proximal to the spheno-
palatine foramen in 42% of cadaver specimens and
results in separate bony foramina.7 The lateral nasal
branches travel along the turbinates in a posterior-to-
anterior direction. The posterior nasal artery courses
across the inferior aspect of the front wall of the
sphenoid sinus and is susceptible to injury when
a large sphenoidotomy is performed (Fig. 2-5).
PATIENT SELECTION
There is wide variation in the management of severe
epistaxis, including nasal packing, hot-water irrigation
of the nasal cavity, angiography with embolization, and
surgery. The choice of a treatment modality depends
on the cause of the epistaxis, its location, the experi-
ence of the otolaryngologist, the presence of medical
comorbid conditions, patient preference, the availabil-
ity of resources, and cost considerations. Most patients
are managed acutely with nasal packing. Historically,
this was accomplished with anterior and posterior nasal
gauze packs that were left in place for up to 5 days.
Currently, most physicians prefer to use a balloon cath-
eter because of ease of insertion and improved patient
comfort.
An alternative to nasal packing is hot-water irriga-
tion of the nasal cavity. The nasal cavity is irrigated with
hot water (50º C) through a double-lumen catheter
with a distal balloon to prevent aspiration. Clinical trials
have shown this technique to be as effective as nasal
packing with less pain and trauma to nasal tissues. Pos-
sible mechanisms of action include vasodilatation with
decreased blood fl ow, tissue edema with compression
of vessels, and activation of the clotting process. Hot-
water irrigation is more often used as an adjunct to
other methods of treating epistaxis.
Angiography with embolization is an effective treat-
ment of epistaxis but has several major limitations.
Embolization is limited to branches of the external
carotid circulation (IMA, facial artery) because the
ethmoid arteries cannot be embolized without causing
blindness. Despite the fact that angiography with embo-
lization is safe when performed by experienced inter-
ventional radiologists, the potential complications are
Posterior
ethmoidal artery
Ophthalmic
artery
Spheno-
palatine artery
Descending
palatine artery
Maxillary
artery
Internal
carotid artery
External
carotid artery
Lateral
posterior
nasal arteries
Greater
palatine artery
Anterior
ethmoidal artery
Figure 2-3. Vascular supply of the lateral nasal
wall.
Sphenopalatine foramen
Figure 2-4. Relationship of the sphenopalatine foramen to the
posterior attachment of the middle turbinate.

10
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
signifi cant and include visual loss, facial paralysis,
carotid dissection, and stroke. Surveys have demon-
strated that this type of angiography is not available
at most institutions, especially those in rural settings.
Indications
for
angiography
with
embolization
include patients who are poor surgical candidates,
epistaxis from tumors, patient preference, and
possibly children.
Surgical options include endoscopic electrocautery
and ligation of vessels supplying the mucosa of the nasal
cavity. The medical literature suggests that they are
equivalent therapies. The source of the bleeding is fre-
quently not apparent at surgery, however, and access to
the bleeding site may be limited. For these reasons, we
prefer surgical ligation in most patients. For many years
the “gold standard” of surgery was transantral ligation
of branches of the IMA and external ligation of the AEA
and sometimes the PEA. Transantral ligation may be
associated with signifi cant morbidity, such as pain,
dehiscence of the oral incision, and infraorbital nerve
hypoesthesia, and may fail because of diffi culty identify-
ing all branches of the IMA in the pterygopalatine
space. Ligation of the terminal vessels avoids the addi-
tional morbidity and is less likely to fail. The new stan-
dard of care is endoscopic (or microscopic) ligation of
the SPA at the point where it enters the nasal cavity.
Indications for surgical ligation include failure
of medical therapy, a history of recurrent epistaxis,
inability to place nasal packing because of an anatomic
deformity (severely deviated nasal septum), and a
contraindication to embolization. Contraindications to
embolization include carotid atherosclerosis, previous
ligation of the external carotid artery, and bleeding
from the AEA (internal carotid artery circulation).
Anterior and posterior nasal packing is extremely
uncomfortable for patients and may be associated with
signifi cant cardiopulmonary problems and death, espe-
cially in patients with medical comorbid conditions.
Given a choice, most patients will choose a surgical
procedure over multiple days with nasal packing. Thus,
surgical ligation may be indicated in all patients requir-
ing hospitalization for severe epistaxis.
Another consideration that may infl uence the
choice of therapy is the cost of care. At our institution,
prompt surgical ligation is approximately half the cost
of embolization. The most expensive therapy is poste-
rior nasal packing in an intensive care setting, especially
if the epistaxis recurs after removal of the packing.
Contraindications to surgical ligation include medical
comorbid disease that precludes general anesthesia and
underlying coagulopathy. Attempts should be made to
treat a coagulopathy fi rst, but surgical ligation may still
be benefi cial in these patients and can be performed
safely. Failure of previous surgical ligation may also be
a contraindication, depending on the vessels ligated
and the surgical technique.
Concurrent ligation of the SPA and AEA is per-
formed in the majority of cases. The PEA is rarely, if
ever, a source of epistaxis and is not ligated because of
its proximity to the optic nerve. Many patients are
referred after initial management of the epistaxis. The
patient’s history may be unreliable, and packing is
usually placed without identifi cation of the source of
bleeding. When the packing is removed in the operating
room, either there is no bleeding or minor mucosal
bleeding is noted from multiple sites. Even if the initial
epistaxis is from the territory of one vessel, there may be
secondary mucosal trauma from packing that affects the
distribution of another vessel. Other reasons for concur-
rent ligation of the SPA and AEA include the need for
defi nitive treatment of patients referred from rural com-
munities with limited resources and the low morbidity
associated with ligation of an additional vessel.
An algorithm can be developed to guide the man-
agement of patients with severe epistaxis (Fig. 2-6). In
patients who have a coagulopathy, epistaxis is fi rst con-
trolled with nasal packing and then treated medically.
Sometimes, a previously unrecognized coagulopathy is
discovered. If the patient is a candidate for surgery, the
AEA or SPA is individually ligated if the source is known.
If the source is unknown, both vessels are ligated. Surgi-
cal failures are treated by embolization or ligation of
the other vessel.
PREOPERATIVE EVALUATION
Preoperative evaluation of patients includes a careful
history to identify potential risk factors for epistaxis,
such as coagulopathy, nasal trauma, and other comor-
bid conditions for which they are taking anticoagulant
medications. In particular, patients should be ques-
tioned about the use of medications with antiplatelet
effects, such as nonsteroidal anti-infl ammatory drugs.
Patients may not be aware that ethanol, vitamin E, and
alternative medicines such as the “3 G’s” (garlic, ginseng,
and gingko) also have antiplatelet effects. Attempts to
determine the source of the bleeding from the history
(laterality, anterior versus posterior, amount) are prob-
ably of limited value. Associated symptoms such as nasal
obstruction, facial hypoesthesia, and diplopia may indi-
cate that the epistaxis is secondary to an undiagnosed
sinonasal neoplasm. The presence of medical comorbid
diseases may infl uence the choice of therapy.
Figure 2-5. Endoscopic view of the left posterior nasal artery at the
inferior margin of the sphenoidotomy.

Chapter 2
Epistaxis
11
Unless the severity of the bleeding precludes intra-
nasal examination, the nasal cavity should be decon-
gested and examined endoscopically in an attempt to
identify the source of the bleeding and rule out other
pathology. The vascular territories of the nasal vessels
should all be evaluated to identify active bleeding or
adherent clots. Gentle removal of a clot may be neces-
sary to reproduce the bleeding. Other abnormalities
such as a deviated nasal septum, nasal polyps, rhinosi-
nusitis, septal perforation, or neoplasm should be
recognized.
In the absence of associated symptoms, a sinus
radiograph is not necessary. If the history is unusual,
associated symptoms are present, or the physical exami-
nation is abnormal, a computed tomography (CT) scan
of the sinuses should be obtained. Hematologic tests of
coagulation are not necessary unless the patient has a
history of recurrent bleeding or bruising.
PREOPERATIVE PLANNING
Informed consent includes a discussion of alternative
treatments and their relative advantages and disadvan-
tages. Patients are counseled that surgery is probably
the most effective therapy because of its high success
rate and ability to deal with both the AEA and SPA.
Additional advantages include decreased morbidity and
shorter hospitalization. Potential risks of surgery are the
same as for endoscopic sinus surgery (hemorrhage,
orbital injury, cerebrospinal fl uid leak), with the addi-
tion of possible injury to the descending palatine nerve
(palatal hypoesthesia) and vidian nerve (decreased
tearing).
Although preoperative imaging is not essential, a
CT scan with image guidance may be helpful for local-
ization of anatomic structures intraoperatively. General
anesthesia is used for patient comfort and prevention
of aspiration.
Consultation with medical colleagues may be neces-
sary in patients who have major comorbid diseases.
Patients with a known coagulopathy or a history sugges-
tive of such should be seen in consultation by a
hematologist.
SURGICAL APPROACHES
The nasal packing is removed after induction of general
anesthesia and is replaced with cottonoids soaked in
oxymetazoline. Continued bleeding is rarely a problem.
If external ligation of the AEA is planned, temporary
tarsorrhaphy sutures are placed and the surgical site is
infi ltrated with local anesthetic. The AEA ligation is
performed fi rst in such cases because it is “cleaner” than
the nasal cavity, allows monitoring of the orbit during
surgery for the development of an orbital hematoma,
and may decrease intranasal bleeding during the endo-
scopic SPA ligation. If endonasal ligation of the AEA is
performed, it is carried out after ligation of the SPA.
External Ligation of the Anterior
Ethmoid Artery
A 1-cm curvilinear incision is made lateral to the nasal
dorsum, equidistant between the dorsum and the
medial canthus (Fig. 2-7). A smaller incision avoids cica-
trix contracture postoperatively and ensures a good
cosmetic result (Fig. 2-8). The inferior limit of the inci-
sion is the axial plane of the medial canthus because
the frontoethmoidal suture line lies above the medial
canthus. The incision extends through the soft tissues
and periosteum. Bleeding from a branch of the facial
vein may require ligation. The periosteum is elevated
from the bone and medial orbital wall with a Cottle
elevator along the frontoethmoidal suture line. The
inferior limit of the exposure is the lacrimal sac. The
frontoethmoidal suture line is identifi ed at the superior
aspect of the lacrimal bone and followed posteriorly
until the AEA is identifi ed. The orbital tissues are
retracted with a narrow malleable ribbon and the
AEA is identifi ed in the frontoethmoidal suture line
Severe Epistaxis
Coagulopathic
Nasal packing,
correct coagulopathy
Source known
AEA and/or SPA
Failure
Yes
AEA ligation
Embolization
AEA/SPA ligation
Failure
Source unknown
Nasal
packing,
embolization
Ligation
Surgical candidate?
Yes
Yes
No
Prior SPA ligation?
SPA ligation
No
Figure 2-6. Treatment algorithm for the management of
severe epistaxis. AEA, anterior ethmoid artery; SPA, sphe-
nopalatine artery.

12
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
(Fig. 2-9). The periosteum is elevated above and below
the AEA to create enough room to apply a hemoclip.
Herniation of orbital fat often occurs at the site of the
vessel. A 4-mm nasal endoscope is inserted into the
wound to verify the vessel, and two medium-sized hemo-
clips are placed securely on the artery (Fig. 2-10). The
AEA is not transected because of the risk of retraction
into orbital tissues. If ligation of the SPA is planned, the
wound is temporarily packed with moist cottonoids to
prevent the development of a hematoma. At the end of
surgery the wound is irrigated and closed with 4-0 poly-
glycolic acid sutures and a running 5-0 plain “fast-
absorbing” catgut suture. One-eighth-inch Steri-Strips
are placed longitudinally over the incision for a
dressing.
Endoscopic Ligation of the
Sphenopalatine Artery4,9
After the nasal cavity is decongested, endoscopic exami-
nation is performed. If the bleeding is brisk, the site is
temporarily controlled with monopolar electrocautery.
The uncinate process is removed with a backbiter to
create a large antrostomy. The antrostomy is enlarged
inferiorly to the level of attachment of the inferior
turbinate and posteriorly to the posterior wall of the
maxillary sinus (Fig. 2-11). A large antrostomy provides
additional room for instrumentation and facilitates sub-
periosteal dissection of the lateral nasal wall. A Cottle
elevator is then used to elevate the mucoperiosteum of
the lateral nasal wall, starting at the inferoposterior
aspect of the antrostomy (Fig. 2-12). By sweeping the
instrument in an inferior-to-superior direction, tenting
of the SPA at the sphenopalatine foramen can be
observed (Fig. 2-13). A small crest of bone (crista eth-
moidalis) is observed just inferior and anterior to the
foramen. The sphenopalatine foramen is located at the
posterosuperior corner of the maxillary sinus. Creation
of this large space has several advantages. It avoids
direct injury to the SPA during dissection, allows detec-
tion of multiple foramina because of proximal branch-
Figure 2-7. Surgical approach for external ligation of the anterior
ethmoid artery.
Figure 2-8. Healed scar without contracture after external ligation
of the anterior ethmoid artery.
Figure 2-9. Endoscopic view of the anterior ethmoid artery (exter-
nal approach).
Figure 2-10. Endoscopic view of the anterior ethmoid artery after
the placement of hemoclips (external approach).

Chapter 2
Epistaxis
13
ing, and provides room for placement of a suction
instrument (third hand).
Once the subperiosteal pocket is created, a 7F
Frazier tip suction is placed in the pocket to keep the
fi eld dry and stretch the SPA across the surgical fi eld.
The bone of the sphenopalatine foramen superfi cial to
the SPA is removed with a 1-mm Kerrison rongeur (Fig.
2-14). It is important to pass the tip of the rongeur
superfi cial to the vessel so that it is not transected.
Removal of bone overlying the pterygopalatine space
continues laterally for about 1 cm. This provides enough
room for clipping of the SPA proximal to its branching
point (Fig. 2-15). Ideally, individual hemoclips are
placed on the proximal main trunk, as well as the ter-
minal branches. The exposed vessels are covered with
a small piece of absorbable hemostatic material. A nasal
tampon is inserted only if there is continued bleeding
from surrounding mucosa. Silastic nasal splints are
placed on both sides of the septum to prevent postop-
erative synechiae, especially if there is diffuse mucosal
trauma from nasal packing or cautery.
Figure 2-11. After left middle meatal antrostomy, the mucoperios-
teum posterior to the antrostomy is elevated from the lateral nasal
wall. MT, middle turbinate; PWA, posterior wall antrum. (Reprinted
with permission from Waring M, Padgham N: Osteologic classifi cation of the
SP foramen. Laryngoscope 108:125-127, 1998.)
Figure 2-12. The sphenopalatine artery is exposed at the postero-
superior corner of the maxillary sinus. (Reprinted with permission
from Waring M, Padgham N: Osteologic classifi cation of the SP foramen.
Laryngoscope 108:125-127, 1998.)
Figure 2-13. Endoscopic view of the right sphenopalatine artery at
the point where it exits the foramen.
Figure 2-14. The foramen is enlarged with a rongeur to expose the
main trunk of the sphenopalatine artery. (Reprinted with permission from
Waring M, Padgham N: Osteologic classifi cation of the SP foramen. Laryn-
goscope 108:125-127, 1998.)

14
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
Endoscopic Ligation of the Anterior
Ethmoid Artery10
The intranasal approach is an alternative to external
AEA ligation. This approach has the advantages of
avoiding a facial scar and decreasing the risk of an
orbital complication. An anterior ethmoidectomy is
performed and the nasofrontal recess is exposed. The
AEA can often be visualized crossing the roof of the
ethmoid sinus at the posterior aspect of the nasofrontal
recess (Fig. 2-16). If the bone is dehiscent, bipolar cau-
terization of the vessel is performed. Otherwise, the
vessel is exposed at its lateral margin. The lamina papy-
racea is fractured with an elevator adjacent to the AEA,
and the fragments are elevated to the plane of the
cranial base. The periorbita is elevated from the bone
above the plane of the cranial base anterior and poste-
rior to the AEA. A hemoclip is placed on the orbital
side of the vessel, or it is cauterized with bipolar elec-
trocautery. The vessel is not transected because it may
retract into the orbit and cause an orbital hematoma.
POSTOPERATIVE CARE
The postoperative care of patients after surgical ligation
is not much different from that of any patient undergo-
ing endoscopic sinus surgery. Activities that increase
vascular pressure in the head should be avoided and
blood pressure controlled if necessary. A decongestant
nasal spray is used if minor bleeding persists. Nasal
splints are removed in 1 week, and nasal hygiene with
saline nasal sprays and rinses is performed until healing
is complete. Complete mucosalization over the hemo-
clips occurs within 1 to 2 months. Rarely, exposed
hemoclips can be a source of persistent crusting and
may need to be removed (Fig. 2-17).
COMPLICATIONS
In patients whose nasal mucosa has been traumatized
by nasal packing and cauterization of the mucosa before
referral, necrosis of the septum and septal perforation
may occur after ligation of the AEA or SPA. It is possible
that the decrease in blood fl ow from ligation of these
Figure 2-15. Hemoclips are placed on the main trunk of the sphe-
nopalatine artery proximal to its terminal branches. (Reprinted with
permission from Waring M, Padgham N: Osteologic classifi cation of the SP
foramen. Laryngoscope 108:125-127, 1998.)
Figure 2-16. Endoscopic view of the anterior ethmoid artery at the
point at which it crosses the cranial base.
A
B
Figure 2-17. Persistent crusting at the site of exposed hemoclips
on the sphenopalatine artery (A) months after surgery required
removal of the hemoclips (B).

Chapter 2
Epistaxis
15
vessels may increase the risk for necrosis, especially
when bilateral ligation is performed.
External Ligation of the Anterior
Ethmoid Artery
The skin incision that is used for external ethmoidec-
tomy or dacryocystorhinostomy is too low for external
AEA ligation. A longer incision is more curved, will be
associated with more scar contracture postoperatively,
and will result in an unsightly scar. Because of the cur-
vature of the bone, a short incision may limit the room
for instrumentation. Care should be taken to avoid
tearing the periorbita because herniation of orbital fat
will interfere with visualization. If herniation does
occur, the fat should be shrunk with bipolar cauteriza-
tion. The frontoethmoidal suture line demarcates the
level of the skull base. Although a small opening in the
ethmoid sinus may occur inferior to this line, fracturing
of the bone above the suture line should be avoided
because it may result in a cerebrospinal fl uid leak or
intracranial hemorrhage. Wide elevation of the perior-
bita is performed so that the tunnel of dissection does
not miss the AEA and risk going too deep. The dissec-
tion should not disrupt the trochlea superiorly, however,
because diplopia may result. The AEA is not transected
since the proximal stump of the vessel may retract into
the orbit and cause an orbital hematoma.
Endoscopic Ligation of the Anterior
Ethmoid Artery
The major risks associated with endoscopic ligation of
the AEA include injury to the orbital tissues, develop-
ment of an orbital hematoma, and creation of a cere-
brospinal fl uid leak. By dissecting on the orbital side of
the cranial base, the risk of a cerebrospinal fl uid leak is
minimized. Stripping of mucosa from the nasofrontal
recess should be avoided because it may result in post-
operative scarring and obstruction of the frontal
sinus.
Endoscopic Ligation of the
Sphenopalatine Artery
Wide exposure of the sphenopalatine foramen is per-
formed to ensure identifi cation of all branches of the
SPA and to provide room for instrumentation; other-
wise, bleeding from an unclipped branch may persist
(Fig. 2-18). Excessive bone removal posterior to the SPA
may injure the descending palatine or greater palatine
nerve and result in hypoesthesia of the palate. Excessive
dissection of the pterygopalatine space can injure other
branches of the IMA and give rise to troublesome bleed-
ing. Dissection deep to the arteries can injure branches
of the trigeminal nerve and the sphenopalatine gan-
glion. Loss of vidian nerve function results in decreased
tearing, especially emotional tearing. This may pose a
problem in patients who already have diminished
tearing or when the eye is challenged (windy condi-
tions). Reasons for failure after SPA ligation include an
unrecognized site of bleeding (AEA distribution),
failure to ligate all the terminal branches of the SPA,
A
B
Figure 2-18. Hemoclips were placed on the posterior nasal artery
(fi rst surgery), but additional branches of the sphenopalatine artery
(arrows) were missed (second surgery).
Figure 2-19. A, Hemoclips are visible at the site of ligation of the
left sphenopalatine artery. B, Recurrent epistaxis 6 months after
surgery was secondary to collateral circulation (arrows).

16
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
dislodged hemoclips, development of collateral circula-
tion (Fig. 2-19), and unrecognized coagulopathy.
SUMMARY
In our experience, surgical ligation offers the most cost-
effective and least morbid treatment of severe epistaxis.
Concurrent ligation of the AEA and SPA is usually per-
formed to maximize success. Currently, we prefer endo-
scopic AEA cautery or ligation because it avoids the
morbidity of an external approach and is easily per-
formed at the time of SPA ligation. Patients with severe
epistaxis can be managed with a stepwise algorithm that
reserves nasal packing and embolization for patients
who cannot be treated surgically or fail surgical
ligation.
References
1. Stangerup SE, Thomsen HK: Histological changes in the nasal
mucosa after hot-water irrigation. An animal experimental study.
Rhinology 34:14-17, 1995.
2. Stangerup SE, Dommerby H, Siim C, et al: New modifi cation of
hot-water irrigation in the treatment of posterior epistaxis. Arch
Otolaryngol Head Neck Surg 125:686-690, 1999.
3. Schlegel-Wagner C, Siekmann U, Linder T: Non-invasive treat-
ment of intractable posterior epistaxis with hot-water irrigation.
Rhinology 44:90-93, 2006.
4. Snyderman CH, Carrau RL: Advances in the treatment of
epistaxis. In Myers EN (ed): Advances in Otolaryngology–Head
and Neck Surgery, vol 14. St Louis, CV Mosby, 2000, pp
213-223.
5. Kumar S, Shetty A, Rockey J, Nilssen E: Contemporary surgical
treatment of epistaxis: What is the evidence for SPA ligation? Clin
Otolaryngol 28:360-363, 2003.
6. Snyderman CH, Goldman SA, Carrau RL, et al: Endoscopic sphe-
nopalatine artery ligation is an effective method of treatment for
posterior epistaxis. Am J Rhinol 13:137-140, 1999.
7. Schwartzbauer HR, Shete M, Tami TA: Endoscopic anatomy of
the sphenopalatine and posterior nasal arteries: Implications for
the endoscopic management of epistaxis. Am J Rhinol 17:63-66,
2003.
8. Waring M, Padgham N: Osteologic classifi cation of the SP
foramen. Laryngoscope 108:125-127, 1998.
9. Snyderman CH, Carrau RL: Endoscopic ligation of the spheno-
palatine artery for epistaxis. Op Tech Otolaryngol Head Neck
Surg 88:85-89, 1997.
10. Kassam A, Snyderman CH, Carrau RL, et al: Endoneurosurgical
hemostasis techniques: Lessons learned from 400 cases. Neuro-
surg Focus 19(1):E7, 2005. Available at
education/journal/neurosurgical/July05/19-1-7.pdf.
PEARLS
• Patients are often unaware that ethanol, vitamin E,
and herbal products (garlic, gingko, and ginseng)
may cause nasal bleeding.
• The sphenopalatine foramen is located at the
posterior attachment of the middle turbinate at the
posterosuperior corner of the maxillary sinus.
• The SPA branches proximal to the foramen 42% of
the time.
• Placement of a small suction device in the
subperiosteal pocket inferior to the sphenopalatine
foramen frees up a hand and maintains tension on
the SPA during clipping.
• The AEA is located in a coronal plane tangential to
the posterior surface of the globe.
PITFALLS
• Transection of the AEA may result in retraction of
the AEA into orbital tissues and subsequent orbital
hematoma.
• Limited dissection of the lateral nasal wall may miss
a branch of the SPA because of proximal branching.
• Placement of a nasal tampon after SPA ligation can
dislodge the hemoclips.
• Removal of bone posterior to the SPA can injure the
descending palatine nerve.
• Bilateral vessel ligation at the same time may
predispose to septal necrosis in patients whose nasal
mucosa has been traumatized.

Chapter 3
Surgical Correction of Nasal Obstruction
Berrylin J. Ferguson
The most common cause of persistent nasal obstruction
unresponsive to nasal decongestants or medical therapy
is a deformity of the nasal septum. Frequently an inter-
nal nasal deformity obstructing airfl ow coexists with
contralateral turbinate hypertrophy. Thus septal cor-
rection frequently requires concomitant reduction of
the hypertrophied inferior turbinate.
The differential diagnosis of nasal obstruction is
outlined in Table 3-1. In addition, nonfi xed or transient
causes of obstruction include secretions such as mucus,
purulent secretions, and blood or turbinate swelling
from a number of etiologies including rhinitis medica-
mentosum. Finally, the patient may have no objective
evidence of obstruction but may complain of inade-
quate airfl ow, presumably from inadequate sensation of
airfl ow in the nose.
PATIENT SELECTION
Objectively the physical fi nding of a septal defl ection is
more common than not, and defl ections that do not
signifi cantly impair the airway do not require correc-
tion, except in providing access for endoscopic sinus
surgery or to control epistaxis. A nasal septoplasty is of
benefi t to the patient who has nasal obstruction because
of the defl ection. The narrowest point of the nose is at
the internal nasal valve. A deviation of the septum of
only a few millimeters can cause signifi cant obstruction
in this location. Lateral traction on the cheek opens the
nasal valve. Relief with this maneuver pinpoints the
obstruction to the nasal valve area. This is called epony-
mously a Cottle maneuver after Dr. Maurice Cottle, who
promulgated the technique. In addition to septal defl ec-
tions at the nasal valve, sometimes the nose collapses at
the valve because of inadequate presence or strength of
the lateral cartilage (see Video 1-8). Correction requires
a lateral nasal batten.1 A prior rhinoplasty with over-
resection of the lower lateral cartilages is a risk factor
for nasal valve collapse. In the more posterior aspects
of the nose, beyond the narrow nasal valve, more sig-
nifi cant septal defl ections are required to cause
obstruction.
Occasionally, epistaxis requires a septoplasty for
control, particularly if the bleeding is coming from
beneath or posterior to a septal spur or the defl ection
precludes endoscopic visualization of the bleeding
vessel. Epistaxis is more common on the obstructed side
of the nose, in which the drying effects of unhumidifi ed
air impact more directly upon the septum. Many insur-
ance carriers will not pay for a septoplasty performed
only for exposure for endoscopic sinus surgery, but will
pay for concurrent septoplasty performed to correct
signifi cant nasal obstruction.
Septal spurs, with projections of up to a centimeter
or more, are common and frequently asymptomatic. In
some patients, they may be associated with facial pres-
sure or a trigger for referred pain in the ethmoid area
or temple. Relief of pain or pressure with the applica-
tion or injection of a local anesthetic to the contact
point may assist in predicting a successful result with
surgical removal of the spur. Long-term results with
sinus surgery and relief of headache and facial pain are
confl icting.2,3 If a septoplasty is performed for obstruc-
tion, the author generally removes incidental septal
spurs as well. This provides unobstructed nasal inspec-
tion and nasal intubation in the future if required.
During the offi ce examination, the patient’s nasal
passages are sprayed with a topical decongestant spray.
If this provides relief of nasal congestion, then a poten-
tially reversible cause of nasal obstruction related to
turbinate hypertrophy is present. This patient is more
likely to have relief of nasal obstruction with either a
steroid nasal spray or a topical antihistamine spray or
both. Before approving a septoplasty, some insurance
carriers require that a patient have persistent nasal
obstruction of at least 70% despite the use of a nasal
steroid spray. Overuse of topical nasal decongestants
leads to rebound nasal congestion and is termed rhinitis
17

18
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
medicamentosum. Treatment of this condition requires
elimination of the topical decongestant, which may be
facilitated by using a steroid nasal spray.4 The patient
complaining of persistent nasal obstruction, despite the
use of a steroid nasal spray, usually requires endoscopic
assessment for infection or polyps, which if present and
unresponsive to medical therapy should be addressed
with surgery.
In patients with nasal airway obstruction responsive
to medical therapy, the anatomic obstruction almost
always involves responsive nasal structures such as the
turbinates or nasal polyps. If the patient has other symp-
toms, such as thick mucus, or allergy symptoms, such as
sneezing or rhinorrhea, which are relieved by medical
therapy, such as steroid nasal sprays, then one might
recommend continued use of the steroid nasal spray or
allergy evaluation. Surgery does not relieve production
of mucus or sneezing. One should attempt to provide
comprehensive relief of the patient’s symptoms with the
safest and most cost effective intervention. In the patient
with symptoms in addition to nasal obstruction, indefi -
nite use of a steroid nasal spray or allergy evaluation
and allergy desensitization may provide the optimal
treatment. If nasal congestion persists despite treat-
ment, then surgical correction of septal deformities and
turbinate hypertrophy should be considered.
Subjective nasal obstruction may not correlate with
objective obstruction. The reverse is also true. Some
patients get so accustomed to nasal blockage that they
are unaware of the obstruction. Surgery will not benefi t
the patient with an objectively patent airway. The sub-
jective sensation of obstruction may be caused by
reduced sensation of airfl ow, which sometimes results
from prior overaggressive surgery on the turbinates. In
the patient who has undergone multiple nasal proce-
dures and objectively has a patent airway, one must also
be aware of somatization or psychological issues that
underlie the patient’s persistent complaints of inade-
quate airway. In these patients objective demonstration
of airway patency with acoustic rhinometry or video
endoscopy may be helpful in explaining why further
surgery will not be benefi cial.
Other causes of subjective/objective mismatch
include overlooking nasal valve collapse or nasal septal
body swelling.5 These latter causes may be amenable to
surgical correction.
ETIOLOGY OF NASAL SEPTAL DEFORMITY
AND TURBINATE HYPERTROPHY
Trauma, which is frequently associated with a fracture
of the nose, is an obvious cause, but not the most fre-
quent cause of septal defl ection. More commonly,
septal defl ection is congenital and not appreciated by
patients who have become accustomed to unilateral
nasal obstruction. When turbinate swelling or laxity of
cartilage, which is associated with aging, further aggra-
vates the congestion, the patient may then present for
evaluation of nasal blockage. As obstructive sleep apnea
(OSA) is more frequently appreciated, contributing
factors such as nasal obstruction are investigated and
appear to either contribute to the OSA or impair effec-
tive usage of continuous positive airway pressure
(CPAP). Some of the patients with OSA may have auto-
nomic nervous system dysfunction, probably mediated
by sympathetic tone impairment, which is greater than
parasympathetic tone impairment. This most likely
plays a role in recumbent nasal congestion caused by
turbinate swelling.6
The deviated nasal septum in some cases is associ-
ated with a twisted nose deformity. In such cases, a nasal
septoplasty must be carried out together with a rhino-
plasty, because such severe nasal deformities cannot be
satisfactorily managed by septoplasty alone. Conversely,
a twisted nose deformity can rarely be satisfactorily cor-
rected without performing a nasal septoplasty.
Turbinate hypertrophy may be congenital, but is
more often acquired and is initially reversible. The eti-
ologies of inferior turbinate hypertrophy include aller-
gies, vasomotor rhinitis, nonallergic rhinitis with
eosinophilia, and rebound congestion from overuse of
topical decongestants (rhinitis medicamentosum).
PREOPERATIVE PLANNING
If the decision is made that a septoplasty or turbinate
reduction will be benefi cial, then the patient is informed
of the anticipated course and risks involved. A summary
of the patient handout used to explain the postopera-
tive course and the possible risks is outlined in Tables
3-2 and 3-3. Elective surgery should be postponed if the
patient develops an infection or exacerbation of asthma.
Patients with active sinus infection should have nasal
cultures performed and be prescribed appropriate
culture-directed antibiotics to clear the infection before
septal surgery. We do not obtain a computed tomogra-
phy scan of the sinuses before septoplasty or turbinate
reduction, unless the patient has subjective or endo-
scopic evidence suggesting sinusitis. We always perform
assessment of the decongested nose before surgery and
almost always with endoscopy.
A thorough history should be taken to establish the
presence of coagulopathies, allergies to local anesthet-
Table 3-1
CAUSES OF NASAL OBSTRUCTION
Common
Uncommon or Rare
Deformity of the nasal
septum
Foreign body
Hypertrophy of the
inferior turbinate
Septal body swelling
Nasal polyps
Choanal atresia (unilateral
or bilateral)
Inverting papilloma
Tumors
Collapse of the internal or
external nasal valve
Acquired stenosis
(postsurgical or secondary
to systemic disease such as
pemphigoid)
Large concha bullosa
Septal hematoma

Chapter 3
Surgical Correction of Nasal Obstruction
19
SURGICAL TECHNIQUE
Until 3 or 4 decades ago, a septoplasty was usually per-
formed with a submucous resection of the nasal septum,
which removed a variable amount of the deviated por-
tions of the septal cartilage and bone. If aggressive
resection was required to correct a defl ection, then the
patient might develop a saddle nose deformity because
of inadequate support of the nasal dorsum. Today, a
nasal septoplasty corrects the deformity by reposition-
ing the twisted cartilage and bone and removing
minimal bone and cartilage.
Nasal surgery is usually performed as an outpatient
surgical procedure without overnight admission. The
procedure may be performed under local anesthesia
with intravenous sedation or more commonly, as in my
cases, under general anesthesia.
The facial skin is usually not prepped unless a con-
comitant rhinoplasty is being performed. Drapes are
arranged so that the nose is entirely exposed. The eyes
may be covered to avoid the glare of the lights. Strips
of Merocel (3 to 4 cm by 1 cm) cut from a Deaver
retractor cover are soaked in 4% lidocaine (Xylocaine)
solution and an equal amount of oxymetazoline (Afrin),
then inserted into the nose and ideally left for 10
minutes to adequately anesthetize the sedated patient
before injection of local anesthesia with a 30-gauge
needle and a solution of 1% lidocaine with 1 : 100,000
epinephrine. If the surgery is performed under general
anesthesia, one still injects in order to achieve vasocon-
striction. To provide adequate anesthesia for sedated
surgery, the anterior septum as well as the infraorbital
nerve is injected by aiming laterally submucosally
toward the infraorbital foramen, and fi nally the sphe-
nopalatine ganglion region is anesthetized intranasally
by injecting the area in the posterior 1-cm insertion of
the middle turbinate in the middle meatus. At least 10
minutes is required for the vasoconstrictive effect of
the epinephrine to become effective. The more poste-
rior aspects of the septum are injected to facilitate dis-
section as well as to increase vasoconstriction and
anesthesia. During this time the vibrissae, if present,
are trimmed from the nasal vestibule with small,
blunt-tipped scissors or a no. 15 blade dipped in petro-
latum (Vaseline) or an antibiotic ointment, so that
the cut hairs stick to the blades of the scissors rather
than falling into the nasal cavity. The inferior turbinates
on both sides are also anesthetized. In the case of
the severely deviated septum, anesthesia of the mucosa
posterior to the deviation may be obtained by inserting
a medium-length speculum, opening the blades, and
pushing the defl ection toward the concave side,
thus exposing the mucosa posterior to the deviation.
Infi ltration anesthesia can then be carried out. Occa-
sionally with bony defl ections, this is impossible, and if
working on a sedated patient, one must sequentially
correct the defl ection and then anesthetize more
posteriorly.
The surgery begins with an incision made at the
septocolumellar junction on one or both sides (hemi-
transfi xion vs. total transfi xion) (Fig. 3-1); with a total
Table 3-2
PATIENT HANDOUT: WHAT TO
EXPECT POSTOPERATIVELY
FOLLOWING NASAL SEPTOPLASTY OR
TURBINATE REDUCTION
• Bloody nasal discharge for several days is common in
the postoperative period.
• Use nasal slings to absorb nasal drainage (nurses in
postoperative area will provide).
• Swelling and bruising is minimal.
• Your nose will look the same or almost the same
externally postoperatively.
• Your nose will likely be more congested because of
blood and mucus until the splints are removed. Use
saline nasal washes twice a day to relieve congestion.
• Reduced energy for several days to weeks
postoperatively is common; take it easy.
• You should be able to return to work in 5 to 7 days
postoperatively, unless you work in a dirty or polluted
environment.
• Schedule an appointment 3 to 4 days after surgery for
splint removal.
• Your nose is “fragile” for at least 6 weeks; avoid trauma
to the nose in this period.
Table 3-3
INFORMED CONSENT FOR
SEPTOPLASTY AND TURBINATE
REDUCTION
Common Occurrences
• If bleeding occurs, you may require nasal packing.
• You should take an antibiotic postoperatively, but you
may still develop an infection. Notify our offi ce if you
have severe pain or fever greater than 100.5º F within
the fi rst 10 days after surgery.
• Up to 20% of septoplasties fail to resolve nasal
blockage and revision may be required.
• Turbinate rehypertrophy is common, and several years
after turbinate reduction regrowth of the turbinates
may lead to nasal blockage.
• Over-reduction of the turbinates in some patients may
lead to loss of sensation of nasal airfl ow. This is
termed empty nose syndrome. We will try to optimally
reduce your turbinates; however, we would rather
inadequately reduce rather than over-reduce. We can
correct inadequate reduction. We cannot correct
over-reduction.
• Septal perforation or a hole in the septum occurs
occasionally. This frequently causes no symptoms, but
if small may lead to a “whistling” sound with nasal
breathing and if large may crust and bleed.
• Loss of smell occurs in 1 in 10,000 septoplasties.
• Toxic shock syndrome, a life-threatening condition,
occurs in 1 in 100,000 cases. Notify your doctor
immediately if you have skin discoloration, fever, or
pass out in the fi rst week after surgery.
ics, or correctable medical conditions. Patients should
be cautioned not to take aspirin or aspirin-containing
compounds for 10 days before surgery or nonsteroidal
anti-infl ammatory drugs for at least 7 days before surgery
in order to minimize intraoperative bleeding.

20
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
transfi xion incision, the two incisions are joined by
sharp dissection with small, curved scissors.
Accurate identifi cation of the septal cartilage deep
to the mucoperichondrial layer is the single most impor-
tant maneuver in this surgical procedure and is abso-
lutely fundamental to successful septal surgery. If this
plane is found, the dissection is bloodless and fast in
most cases. With a no. 15 blade knife, the cartilage is
identifi ed by minimally undermining the mucoperi-
chondrium (Fig. 3-2). It may be helpful to have the
assistant hold the caudal end of the septum with a hook,
in order to gain exposure of the septal cartilage. Once
the cartilage, with its glistening white color, is identi-
fi ed, the sharp edge of a Cottle elevator is used to
completely undermine the mucoperichondrium (Fig.
3-3). When the mucoperichondrium has been elevated
approximately 2 cm posterior to the caudal margin, the
hook is removed and a nasal speculum with narrow
fl anges and medium-length blades is inserted into the
nose to observe the dissection from within the nasal
cavity or inserted between the perichondrial fl ap and
the septal cartilage in order to observe the dissection.
Adequate light and suction with amplifi ed magnifi ca-
tion with “loupes,” if necessary, are required to optimize
this dissection. Initiation of the dissection in the mid/
A
B
Figure 3-1. The septocolumellar incisions are made and the caudal
end of the septum is identifi ed.
Figure 3-2. Proper identifi cation of the septal cartilage is important
in order to fi nd the proper plane for undermining the
mucoperichondrium.
Figure 3-3. The sharp edge of a Cottle elevator is used to under-
mine the mucoperichondrium under direct vision. A Killian specu-
lum is inserted between the mucoperichondrial fl ap and the septal
cartilage in order to provide direct vision for further undermining.

Chapter 3
Surgical Correction of Nasal Obstruction
21
superior portion of the septum facilitates the dissection
in that the mucoperichondrium is less adherent there
than it is more inferiorly. After one has dissected far
posteriorly, it is easier to bring the Cottle elevator infe-
riorly in gentle, tight circular sweeping motions and
divide the more adherent mucoperichondrial fi bers
anteriorly and inferiorly from the septal cartilage. In
the very adherent connection of the mucoperichon-
drium to the inferior caudal septum, a no. 64 “beaver”
blade may be helpful. Caution is necessary when under-
mining the fl aps near the fl oor of the nose over a
“septal spur,” because the mucosa in this area is usually
adherent to the subluxed cartilage and is easily torn
(Fig. 3-4). A septal spur may be removed by elevating
the mucoperichondrium up to the point of most lateral
extension, then using a beaver blade or Cottle elevator
to perform a horizontal transection at the point where
the spur deviates laterally, to remove the spur. It is often
fairly easy to remove at that point.
The mucoperichondrium should be elevated bilat-
erally from the anterior 2 cm of septal cartilage if repo-
sitioning of the most caudal septum is required to
obtain a straight septum. The narrowest point of the
nose is at the nasal valve and small defl ections in this
area may “bottle-neck” the entire airway and cause
obstruction. Bilateral elevation is required to allow sat-
isfactory redraping of the mucosa, once the cartilagi-
nous structure has been satisfactorily repositioned. If
the septal obstruction begins posterior to the anterior
2 cm, then the elevation of the mucoperichondrium is
performed on only one side anteriorly, but bilaterally
at the site of defl ection. At the site of the defl ection, a
Cottle elevator is used to make a vertical incision and
then to begin the elevation of the contralateral side. A
suction, the Cottle elevator, or a suction elevator, may
be used in the dissection of the mucoperichondrium/
periosteum off the cartilaginous or bony septum. Pres-
ervation of at least a 1 cm superior cartilage strut and a
1.5 to 2 cm caudal strut of cartilage is critical to main-
tain nasal support and prevent saddling. To remove
defl ected cartilage, a vertical incision is made anterior
to the defl ection and a Cottle elevator, or a sharp
suction elevator or a Ballenger swivel knife is inserted,
and the cartilage is incised (Fig. 3-5). As more anterior
defl ected portions of cartilage are removed, one is able
to visualize more posterior defl ections. All superior cuts
should be made sharply to avoid the very rare complica-
tion of fracturing the cribriform plate and creating a
cerebrospinal fl uid fi stula. For this reason, a sharp supe-
rior transection is made initially over the defl ection,
with an instrument such as the slotted Jansen Middle-
tons. Once the superior cut is made, one can use tech-
niques that grasp or remove the inferior cartilage by
gently twisting to disrupt the attachment and then
removing. If removed cartilage is fairly straight, it may
be replaced between the mucoperichondrial fl aps at
the end of the case. A V-shaped osteotome and mallet
are useful in removing bony deviation of the maxillary
crest inferiorly.
Today, the more conservative cartilage-sparing
techniques are preferred to the more radical removal
of septal cartilage. However, if the cartilage is deformed,
repositioning is frequently impossible and the defl ected
septum must be removed.
The most diffi cult septal deformities involve the
most caudal portion of the septum, because this caudal
strut is required for support and its removal frequently
results in nasal tip collapse. Two methods are employed
in the severe caudal defl ection. The fi rst method
involves disarticulation of the caudal strip, if required,
and scoring incisions that alter the concavities and con-
vexities to render the septum straight. This method is
only moderately successful and an initially straight
septum may rebound a month or two postoperatively
into its preoperative shape and defection. Once it is
brought into the midline vertical position, the defl ected
caudal septum is longer than required, so an appropri-
ate reduction of 1 to 3 mm from the inferior aspect of
the caudal septum is performed to allow the septum to
swing to the midline position (Fig. 3-6).
In the second method, one may remove the
defl ected septum completely and replace it with an
adequate portion of straight septum harvested posteri-
orly. Securing the caudal repositioned or replaced
septum to the mucopericondrium of the anterior maxil-
lary spine with a nonabsorbable fi gure-of-eight suture
is helpful (Fig. 3-7). Occasionally, the anterior nasal
spine may be dislocated. This may be replaced into the
midline by grasping the bone with a Jansen-Middleton
rongeur and twisting the bone toward the concave
side.
The septal mucosa is carefully inspected, and any
opposing tears in the mucoperichondrial fl aps should
be closed with 4-0 chromic catgut suture on a curved
needle with a small circle in order to prevent a nasal
septal perforation. A piece of resected cartilage should
Figure 3-4. It is important to proceed cautiously in the area of the
septal spur, because the mucosa in this area is densely adherent to
the subluxed cartilage and may be easily torn.

22
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
A
B
Figure 3-5. A Ballenger swivel
knife is used to remove a portion of
the quadrilateral cartilage.
Figure 3-6 Caudal deviation of the nasal septum.
Figure 3-7. It is helpful to suture the mucoperichondrial fl aps of
the caudal strut when the caudal deviation has been repaired.
be placed between opposing tears if not already present.
An isolated laceration need not be sutured and in fact
may be useful in preventing hematoma. Some authors
suggest that if no laceration of the fl ap occurred during
the procedure, a “controlled drainage site” should be
produced by making several stab wounds in the fl ap.1
The blood is aspirated from the dead space between the
mucoperichondrial fl aps, and the septum is closed with
a small absorbable suture, such as 5-0 Biosym or 6-0
chromic.
Soft septal splints made commercially with nasal
ports or fashioned from sterilized plastic food container
lids, can be used to compress the mucoperichondrial
fl aps (Fig. 3-8). This eliminates the need for packing,
and helps prevent septal hematoma and synechiae for-
mation. If commercial septal splints with nasal ports are
used (e.g., Doyle splints), then the port provides pres-
sure against the turbinates and prevents the accumula-
tion of blood or swelling of the turbinate, particularly
if a submucous resection of the turbinate is performed.
The splints are secured anteriorly with a nonabsorbable
colored suture, usually 3-0 Ethilon. This facilitates visu-
alization of the suture for removal postoperatively.
Figure 3-8. Doyle splint secured anteriorly with 3-0 Ethilon
suture.

Chapter 3
Surgical Correction of Nasal Obstruction
23
These splints are removed in the offi ce in 3 to 8 days.
Other surgeons prefer using mattress sutures passed
through the mucoperichondrial fl aps, and others rely
on nasal packing. If packing is used, the gauze should
be impregnated with antibiotics. Antibiotics should be
administered systemically intraoperatively and postop-
eratively if packing is used. A small gauze dressing is
placed below the nasal tip to catch any bloody mucous
nasal drip.
The septoplasty usually precedes a rhinoplasty. If
endoscopic sinus surgery is performed at the same
sitting, then the endoscopic procedure is fi rst per-
formed on the more open side. The turbinate on this
side is then reduced, if it will cause obstruction once
the septum is in the midline. The septoplasty is per-
formed and the other side is addressed endoscopically
with the improved visualization.
Turbinate Reduction
Turbinate reduction of the turbinate contralateral to
the septal defl ection should always be considered
because frequently compensatory hypertrophy has
occurred. The turbinate can be reduced in a number
of ways. If there is a prominent bony obstruction, then
a submucous resection using either an endoscope or a
headlight is preferred. A vertical incision is made down
to the turbinate bone at the anterior aspect of the infe-
rior turbinate with a guarded Colorado-tipped electro-
cautery device. The inferior turbinate bone is dissected
free of the turbinate tissue with a Cottle elevator, which
is also helpful in fracturing the superior bony attach-
ment, so that the turbinate bone can be removed. If a
headlight is used, the medium-length speculum with
narrow fl anges is used to isolate the turbinate bone in
the center. This optimizes visualization for dissection
and removal of the bone. More posteriorly, bony hyper-
trophy can be fractured laterally (Fig. 3-9). If there is
abundant soft tissue hypertrophy, the 3.5 mm or smaller
microdébrider may be used to remove tissue submuco-
sally (see Video 3-1.) This is done under direct endo-
scopic vision more posteriorly. The most dangerous
part of this procedure is at the level of the middle tur-
binate, where the operator’s natural inclination is to
continue the angle of dissection upward, rather than
inferiorly, to follow the downward angling of the infe-
rior turbinate (Fig. 3-10). If the microdébrider perfo-
rates the inferior turbinate and then damages the
middle turbinate, brisk bleeding may result. Keeping
the blade of the microdébrider toward the turbinate
bone in diffi cult areas helps prevent turbinate perfora-
tion. Perforation is common, resulting in more bleed-
ing and the potential for scarring. In very hypertrophied
turbinates, a more aggressive turbinate reduction
involves resection of the lateral aspect of the inferior
turbinate, particularly anteriorly, and rolling the medial
turbinate up to cover the abraded area (Fig. 3-11).
Other methods of turbinate reduction include
radiofrequency reduction with devices such as the
Coblator. The tip of the Coblator is inserted into mul-
tiple areas of the inferior turbinate and activated for
Figure 3-9. Outfracture of a prominent inferior turbinate.
A
B
Figure 3-10. A, Microdébrider inserted into inferior turbinate
inappropriately angled so that it will potentially go through inferior
turbinate superiorly and engage middle turbinate. B, Microdébrider
inserted correctly into inferior turbinate, pocket minimizing risk of
middle turbinate injury.

24
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
about 10 seconds. This heats the tissue and results in
subsequent reduction of the tissue as it heals. Extensive
coblation of the turbinate prolongs the healing time, in
my experience from less than 3 weeks with a microdé-
brider to more than 6 weeks on average.
POSTOPERATIVE MANAGEMENT
Patients may be discharged the same day, unless they
are slow to recover from the general anesthesia, suffer
from persistent nausea or bleeding, or if a complication
is suspected or has been diagnosed. Patients with known
OSA should be monitored postoperatively with pulse
oximetry and not discharged to home if the pulse oxim-
etry falls below 85%. It is important to require all men
to void before discharge, because urinary retention
postoperatively may lead to prolonged catheterization.
During the week following surgery, strenuous exercise
or heavy lifting is avoided. The patient should be cau-
tioned to blow the nose gently, if necessary, and sneeze
with the mouth open. Saline nose drops or sprays or
nasal lavage may be used several times each day to help
keep blood from becoming hard crusts, particularly in
the ports of septal splints. Patients are usually seen
again within 3 to 8 days to remove septal splints and
decongest and clear the nasal cavity.
COMPLICATIONS
Complications following nasal septal surgery occur
infrequently. Bleeding is rarely more than enough to
change the nasal drip pad every 20 minutes and slowly
tapers off over the next few days. Nasal swelling or
ecchymosis is unusual if no rhinoplasty has been per-
formed. If the patient’s drip pad must be changed every
10 minutes because of bleeding, then this patient must
be reevaluated for a bleeding vessel that requires cau-
terization or packing. Occasionally these patients have
a coagulopathy. A septal hematoma may occur if the
focus of bleeding is within the septum and there are no
septal perforations to allow egress into the nasal cavity.
For this reason, small venting stab incisions should be
made in the septal mucosa if there are no inadvertent
mucosal tears. A septal hematoma is usually diagnosed
and must be evacuated when the patient complains of
severe pain in the nose. This can be carried out by
anesthetizing the mucosa topically with lidocaine fol-
lowed by injections of a small amount of lidocaine and
then aspirating with an 18-gauge needle. Additional
small stab incisions with a small blade helps prevent
reaccumulation. Packing may be inserted to prevent
recurrence of the hematoma. Septal hematoma, unrec-
ognized and untreated, may lead to pressure ischemia
and loss of the remaining septal cartilage with a possible
late saddle nose deformity.
Cerebrospinal fl uid rhinorrhea has been reported
infrequently and is probably attributable to avulsion
of the perpendicular plate of the ethmoid and its
attachment to the cribriform plate. This can be avoided
by not avulsing any bone or cartilage unless it has
already been fractured off the remaining bone or
cartilage.7
Toxic shock syndrome has been reported in patients
with and without nasal packing following nasal septo-
plasty and is thought to be due to colonization of the
nasal packing by Staphylococcus aureus, which produces
exotoxin. There does not appear to be an absolutely
certain way to prevent this complication.8,9 Avoidance
of nasal packing, packing with bacteria-resistant mate-
rial, and early removal of packing are appropriate, but
will not necessarily prevent this rare complication. If a
patient reports early fever, serious diarrhea, or ischemia
of the limbs, evaluation for toxic shock syndrome should
be done immediately. The packing should be removed
and cultured, antistaphylococcal antibiotics should be
administered, and careful observation and intervention
should be done as needed.
Nasal septal perforation should occur infrequently
following this procedure.10 This complication is proba-
bly the result of inadequately repaired or unrepaired
opposing lacerations of septal mucoperichondrium or
avulsion of a portion of the mucoperichondrium and
occasionally secondary to postoperative infection. Some
patients with nasal obstruction secondary to septal devi-
ation traumatize the nasal mucosa by picking their
nose. These traumatized areas become atrophic and
may be predisposed toward laceration or avulsion
during elevation of mucoperichondrial fl aps.
1
2
3
4
5
Figure 3-11. 1, Incision in the mucosa of the turbinate. 2, The
mucosa is elevated off the turbinate bone. 3, The bone is removed
with biting forceps. 4, Microdébrider to remove lateral wall. 5, Medial
mucosa rolled laterally.

Chapter 3
Surgical Correction of Nasal Obstruction
25
Saddle nose deformity or supratip depression may
result if there is failure to leave an adequate dorsal car-
tilaginous strut.
The caudal septal edge is usually left untouched
except in cases of protrusion of the septum caudally
when it can be resected. Over-resection results in colu-
mellar retraction.
For the carefully selected patient, a septoplasty or
turbinate reduction produces a signifi cant improve-
ment in quality of life.11
PEARLS
Septoplasty
• A septal hematoma can be prevented or the
likelihood reduced by placing small venting stabs in
the septal mucosa if there are no inadvertent
mucosal tears.
• A septal mucosal tear on one side will not cause a
perforation unless the opposing contralateral
mucosa is also torn.
• Palpating the nose at the caudal border allows one
to determine on which side the septum is most
prominent and to make a hemitransfi xion incision
on this side. This does not correlate with the side to
which the septum is most defl ected posteriorly.
• Developing the mucoperichondrial fl ap is usually
easiest in the superior plane.
• Posterior isolated spurs are most easily removed
endoscopically with an incision over the spur,
followed by removal, leaving the contralateral
mucoperichondrium intact.
Inferior Turbinate Reduction
• Doyle splints with a vent tube laterally not only hold
the septum in position but also provide pressure
against the turbinate, ensuring that the reduced
inferior turbinate does not swell with blood and can
be used even when no septoplasty is performed.
• The clogging of Doyle splints with hardened bloody
drainage and mucus can be minimized by vigorous
cleaning of the splints and nose with saline, up to 5
to 10 mL, three or more times a day combined with
gentle cleaning anteriorly with a cotton-tipped
applicator.
• The inferior turbinate mucosa should be spared as
much as possible in order to prevent the “empty
nose” sensation.
• The turbinate bone can be fractured laterally by
either placing a Cottle elevator in a submucosal
pocket or fracturing from the intranasal mucosal
side of the inferior turbinate.
• An obstructing polypoid posterior inferior turbinate
can be addressed with a microdébrider and suction
cautery under endoscopic guidance to minimize
hemorrhage.
PITFALLS
Septoplasty
• Cerebrospinal fl uid rhinorrhea resulting from
septoplasty is extremely rare and can be avoided by
sharply cutting (and not avulsing) the superior
attachment of cartilage or bone to be removed.
• Toxic shock syndrome is a rare complication more
commonly encountered when nasal packing is used.
This diagnosis should be considered when a patient
reports early fever, serious diarrhea, or ischemia of
the limbs.
• Saddle nose deformity or supratip depression may
result if there is failure to leave an adequate dorsal
cartilaginous strut.
• The caudal septal edge is usually left untouched,
except in cases of protrusion of the septum caudally;
when it can be resected, over-resection results in
columellar retraction.
• The most important element of septal cartilage for
support is the caudal 15-mm strip.
Inferior Turbinate Reduction
• Over-resection of the inferior turbinate can result in
loss of sensation of airfl ow, resulting in the “empty
nose syndrome” or nasal crusting secondary to
inadequate moisturization of the inspired air.
• The most common site of inadvertent injury in
performing a submucosal microdébridement of the
inferior turbinate is perforation of the inferior
turbinate superiorly with injury of the middle
turbinate above. Microdébridement of the middle
turbinate may result in brisk bleeding.
References
1. Becker DG, Becker SS: Treatment of nasal obstruction from nasal
valve collapse with alar batten grafts. J Long Term Eff Med
Implants 13:259-269, 2003.
2. Behin F, Behin B, Behin D, Baredes S: Surgical management of
contact point headaches. Headache 45:204-210, 2005.
3. Jones NS: Sinogenic facial pain: Diagnosis and management. Oto-
laryngol Clin North Am 38:1311-1325, x-xi, 2005.
4. Ferguson BJ, Paramaesvaran S, Rubinstein E: A study of the effect
of nasal steroid sprays in perennial allergic rhinitis patients with
rhinitis medicamentosa. Otolaryngol Head Neck Surg 125:253-
260, 2001.
5. Wexler D, Braverman I, Amar M: Histology of the nasal septal
swell body (septal turbinate). Otolaryngol Head Neck Surg
134:596-600, 2006.
6. Loehrl TA, Smith TL, Darling RJ, et al: Autonomic dysfunction,
vasomotor rhinitis, and extraesophageal manifestations of gastro-
esophageal refl ux. Otolaryngol Head Neck Surg 126:382-387,
2002.
7. Onerci TM, Ayhan K, Ogretmenoglu O: Two consecutive cases
of cerebrospinal fl uid rhinorrhea after septoplasty operation. Am
J Otolaryngol 25:354-356, 2004.
8. Keller JL, Evan KE, Wetmore RF: Toxic shock syndrome after
closed reduction of a nasal fracture. Otolaryngol Head Neck Surg
120:569-570, 1999.

26
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
9. Moser N, Hood C, Ervin D: Toxic shock syndrome in a patient
using bilateral silicone nasal splints. Otolaryngol Head Neck Surg
113:632-633, 1995.
10. Bateman ND, Woolford TJ: Informed consent for septal surgery:
The evidence-base. J Laryngol Otol 117:186-189, 2003.
11. Stewart MG, Smith TL, Weaver EM, et al: Outcomes after nasal
septoplasty: Results from the Nasal Obstruction Septoplasty Effec-
tiveness (NOSE) study. Otolaryngol Head Neck Surg 130:283-
290, 2004.

Chapter 4
Surgery for Choanal Atresia
Eugene N. Myers
Since the fi rst description of choanal atresia by Roede-
rer in 1755, more than 350 publications have described
multiple surgical techniques for correcting this con-
genital defect.1,2 Bilateral choanal atresia is a medical
emergency. The diagnosis of bilateral choanal atresia
requires a high index of suspicion and it should be
suspected by the pediatrician in the delivery room if the
child has the characteristic cyclic apnea, cyanosis, and
respiratory distress, which are temporarily relieved by
crying.
The embryologic basis for choanal atresia is not
entirely clear, but Hengerer and Strome suggest four
“theories” to explain it: (1) persistence of the bucco-
pharyngeal membrane from the foregut, (2) persis-
tence of the nasobuccal membrane of Hochstetter, (3)
abnormal persistence of mesoderm-forming adhesions
in the choanal region, and (4) misdirection of meso-
dermal fl ow secondary to local factors.3 An excess of this
displaced mesenchymal tissue in the midfacial region
creates a tangential atretic plate that blocks the nasal
airway from the posterior vomer across the lateral nasal
wall. Ninety percent of these plates are bone and can
be as thick as 12 mm.
In addition to the atretic plate, other anatomic
changes may include a diminished nasal airway second-
ary to septal defl ection toward the obstructed side, a
widened vomer, medial bowing of the lateral nasal wall,
and narrowing of the nasopharynx. This combination
of anatomic variations supports the concept of a gener-
alized defect in mesenchymal cell fl ow involving devel-
opment of the skull base. It is quite important to
understand not only the anatomy and embryology but
also these associated abnormal anatomic fi ndings to
safely correct choanal atresia.
Congenital atresia is uncommon and occurs once
in every 5000 to 10,000 live births.4 Approximately 50%
of patients with choanal atresia have additional con-
genital anomalies such as Treacher Collins syndrome,
Apert’s syndrome, trisomy D, and the cluster of defects
known as the CHARGE association (colobomas, congeni-
tal heart defects, choanal atresia, retarded develop-
ment, genital hypoplasia, and ear anomaly).5 Another
important single associated anomaly is cardiovascular
malformation, which is 20 times more frequent in
infants with choanal atresia than in the general popula-
tion. Mental retardation, micrognathia, deafness, cleft
palate, and facial palsy may also be encountered as
single associated anomalies.6 Unilateral choanal atresia
may not be detected until long after the newborn period
despite long-term unilateral rhinorrhea and nasal
obstruction.7
As part of the standard evaluation of newborn
infants, a catheter should be passed through each
nostril into the nasopharynx. Infants with choanal
atresia or severe stenosis may be identifi ed with this
maneuver. Infants are obligate nasal breathers, and
nasal obstruction produces respiratory distress and
marked feeding diffi culty. An oral airway, once placed
and secured, stabilizes the patient and allows complete
evaluation and surgical planning.8 A fi rm, curved dilator
can be used to gently palpate the atretic plate, or the
area can be inspected with a telescope once the mucus
has been aspirated from the nasal airway.9 Djupesland
and colleagues described the use of acoustic rhinome-
try.10 They compared acoustic measurements in fi ve
infants with congenital respiratory distress caused by
bilateral choanal atresia with their computed tomogra-
phy (CT) scans and concluded that acoustic rhinometry
represents a new and valuable tool in the diagnosis of
congenital choanal atresia. This technique may also be
helpful in the postoperative evaluation.
Cotton and Stith described the use of a standard
endotracheal tube placed transorally into the esopha-
gus as their choice of airway in the case of bilateral
choanal atresia.6 The tube acts as an airway by stenting
the patient’s oral airway open and may also be used for
gavage feeding.
Unilateral choanal atresia may go unrecognized
until later in life because the associated respiratory dis-
tress may not be present at birth. When this condition
27

28
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
goes unrecognized, patients are initially seen later in
childhood or as teenagers with unilateral nasal obstruc-
tion and chronic rhinorrhea. Unilateral atresia is more
common than bilateral atresia. This disorder affects
females more often than males and is found more com-
monly on the right side when it occurs unilaterally. A
bony atretic plate is found in 90% of patients, and a
membranous plate is found in the remaining 10%.11
The most widely accepted method of correcting the
problem of unilateral or bilateral choanal atresia has
been the transpalatal technique. However, with more
recent technologic advances, such as endoscopes for
functional endoscopic sinus surgery (FESS) and the
microdébrider, transnasal endoscopy has emerged as
an equally acceptable technique and is particularly
appealing because of widespread familiarity with endo-
scopic sinus surgery by present-day otolaryngologists. A
survey of pediatric otolaryngologists was completed in
1999 to determine their preferred techniques for cor-
rection of choanal atresia. Endoscopic techniques were
favored (85%) over transpalatal repair (Fig. 4-1).7
Pirsig pointed out that the ideal procedure for
choanal atresia should create a normal unobstructed
nasal passage, prevent damage to any growing struc-
tures important in facial development, be technically
safe, and require a brief operative time and a short
hospital stay and convalescence.12
A constant gradual evolution plus reevaluation of
the management of patients with choanal atresia is
apparent. Beinfi eld in 1956 performed transnasal curet-
tage with progressively larger curettes to perforate the
atretic plate. The choanae were stented open for several
months.13 Other transnasal approaches that have been
described for the treatment of choanal atresia include
the external rhinoplasty technique, the transseptal
technique, and the sublabial approach.9
Richardson and Osguthorpe8 performed a transna-
sal drill-out procedure with an operating microscope
and otologic instrumentation. Stankiewicz in 19901
described a similar procedure that incorporated
modern endoscopic telescopes for transnasal removal
of the atretic plate. Such instruments provide excellent
visualization of the entire atretic plate and make it pos-
sible to perform precise surgery on patients of all ages.
These techniques are generally applied to infants with
bilateral choanal atresia to obviate the necessity for pro-
longed use of an oropharyngeal airway.
More recently, Fong and coauthors reported using
the holmium:YAG laser to correct choanal atresia in
eight patients.14 The authors emphasized the safety of
the procedure and the advantage of a fl exible fi beroptic
system, good hemostasis, and better bone-cutting char-
acteristics than with the CO2 laser, which is in wide-
spread clinical use.
PATIENT SELECTION
An early surgical approach to bilateral choanal atresia
is currently advocated for several reasons. With medical
management, the risk for pneumonia as a result of
inadequate pulmonary ventilation and inhalation of
food is high in these patients. The medical approach
may also downgrade the chance for survival, particularly
if the patient has other congenital anomalies. Improve-
ment in techniques of neonatal anesthesia is another
factor that has enhanced the safety of infants under-
going early surgery for this condition. Arguments
against early surgical repair include claims of higher
rates of choanal stenosis. The procedure should be
delayed until associated medical problems have been
stabilized.
It is also important that the patient be thoroughly
evaluated for the more severe congenital anomalies,
such as cardiac abnormalities, that can be seen in asso-
ciation with choanal atresia. Other craniofacial anoma-
lies should be considered when planning the surgical
approach but should not delay defi nitive treatment.
A child with unilateral atresia who has signifi cant
symptoms should also be operated on soon after diag-
nosis. Surgery remains the defi nitive treatment once
other medical factors have been resolved or at least
stabilized.
April and Ward in 1996 introduced a technique
involving the use of powered instrumentation with pro-
tected blades and drills that allows more precise removal
of the atretic plate, thereby contributing to a more sat-
isfactory surgical procedure.15 Rombaux and associates
reported a series of seven children with both bony and
mixed soft tissue/bony unilateral choanal atresia who
were treated between 1999 and 2001 with powered
instrumentation.16 A dissector tip was used to open the
posterior choana in the inferior medial aspect of the
atretic plate. A microdébrider was then used to enlarge
the opening. The opening was coated with mitomycin
C and left unstented. There was no excessive operative
bleeding. One patient required a repeat endoscopic
procedure 9 months later because of stenosis, and
minor synechiae developed in another patient but did
not require treatment. No other complications were
reported. The mean number of surgical repairs per
patient in the powered instrumentation group was 1.14,
and the success rate after 12 months was 85.7%; in
contrast, in the standard treatment of unilateral choanal
atresia without powered instrumentation (n = 19), the
mean number of surgical procedures per patient was
1.89, and the success rate at 12 months was 47.3%.16
90
80
70
60
50
40
30
20
10
0
Transpalatal
Dilator
Physicians
Endoscopic
Microsonic
drill-out
Figure 4-1. Survey of the number of physicians who perform the
specifi c type of procedure for repair of choanal atresia. (Reprinted with
permission from Park AH, Brockenbrough J, Stankiewicz J: Endoscopic versus
traditional approaches to choanal atresia. Otolaryngol Clin North Am 33:77-
90, 2000.)

Chapter 4
Surgery for Choanal Atresia
29
Because of the small number of patients, however, the
results did not reach statistical signifi cance. In addition,
biases favoring a more recent technique such as the
microdébrider may be due to other improvement in
techniques, such as computer-assisted navigation. None-
theless, there is a trend toward superiority of results
with use of the microdébrider, as well as the appeal of
using this instrument because of improved visualization
and effi ciency of tissue removal. The authors suggest
that the reason for improved success in the treatment
of unilateral choanal atresia with powered instrumenta-
tion may be that it allows faster healing with less scar-
ring, thus reducing the risk for stenosis.16
PREOPERATIVE PLANNING
Before the availability of CT, propyliodone in peanut
oil (Dionosil Oily) was instilled in the nasal cavity after
the mucus was removed, and a cross-table lateral view
of the patient was taken. Failure of propyliodone to
enter the nasopharynx was taken as evidence of poste-
rior choanal atresia; however, this rather simple tech-
nique did not always provide the information necessary
for planning the management of these patients.
Radiographic evaluation of choanal atresia is now
carried out with CT to help differentiate bony from
membranous atresia. This is important for surgical
planning because management of membranous atresia
is less complex. CT also identifi es alterations frequently
present in the posterior aspect of the nasal septum and
reveals the confi guration of the lateral nasal wall and
nasopharynx (Fig. 4-2).17 Brown and coworkers reviewed
CT scans of 47 patients with choanal atresia from the
literature and 16 from their own clinical experience
and classifi ed the atresia as pure bony, mixed bony-
membranous, and pure membranous.18
A
B
C
D
Figure 4-2. A, Computed tomography scan demonstrating bony choanal atresia of the right side. B, Ninety-degree telescopic view of unilateral
choanal atresia. C, Puncturing choanal atresia. D, Stenting of the posterior choana.

30
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
SURGICAL TECHNIQUE
Transnasal Puncture Technique
Under general anesthesia, a small Lempert curette or
urethral sound is placed through the nose to puncture
the atretic plate. The surgeon’s index fi nger is inserted
into the nasopharynx to protect the skull base (Fig.
4-3). After puncturing the atresia, a stent is inserted to
prevent restenosis. Transnasal puncture usually requires
repeated revisions or dilatation. Complications include
leakage of cerebrospinal fl uid and meningitis. This is a
blind technique, and in the era of nasal endoscopy, it
is contraindicated.
Transpalatal Technique
The patient is placed in a modifi ed Trendelenburg
position with the shoulders extended over a folded
towel. A Dingman mouth retractor is used because the
retraction of the cheeks that it affords allows valuable
additional exposure. The area along the line of incision
is infi ltrated with lidocaine (Xylocaine 1%) with epi-
nephrine 1:100,000 to improve hemostasis. An incision
is made in the midline through the mucoperiosteum
down to palatal bone. The mucoperiosteum is then
undermined with a sharp elevator as far posterior as the
junction of the hard and soft palates. The greater pala-
tine vessels on one side may be clamped and cut if
necessary. Cutting both vessels deprives the soft palate
of its blood supply, which may cause necrosis or prevent
postoperative wound healing and is a severe technical
error. The muscular aponeurosis and nasopharyngeal
mucosa of the soft palate are incised transversely, and
the palate is retracted posteriorly and superiorly toward
the nasopharynx.
To remove the bony atresia and establish a patent
nasal airway, the bone of the posterior third of the hard
palate is removed with a rongeur until the nasal mucosa
is identifi ed (Fig. 4-4). The bony atresia plate and the
posterior third of the vomer are removed with a rongeur
or a curette (Fig. 4-5). The nasal mucosal fl ap should
be preserved whenever possible to prevent postopera-
tive stenosis. Failure to remove a portion of the vomer
and hard palate predisposes to eventual stenosis of the
choana.
This procedure must be done under direct vision,
although the use of a laryngeal mirror to adequately
visualize the atretic plate is helpful. After the atresia has
been corrected, soft Silastic stents should be inserted
(see Fig. 4-2D). We have used a nasopharyngeal airway
with the fl ange placed in the nasopharynx to good
advantage (Fig. 4-6). The airway is sutured to the
septum. This helps reconstitute nasal breathing and
provides a stent that is left in place for 2 months to
ensure healing and prevent stenosis.
At the end of the procedure, the palatal fl ap is
returned to the anatomic position and the wound is
closed with 3-0 silk suture on a cutting needle. The silk
seems to hold the knot in the oral cavity better than
absorbable or nylon suture does. The patient is allowed
to awaken from the anesthesia and is extubated.
Transnasal Endoscopic Technique
Under general anesthesia, a cottonoid or cotton pledget
soaked in oxymetazoline (Afrin) is placed in the nasal
cavity to decongest the mucosa. A 2.5- to 4.4-mm scope
is placed in the nasal cavity after the pledgets are
removed, which produces excellent visualization.
Powered instrumentation is then used to remove the
atretic plates and vomer. A backbiting rongeur can be
introduced through the nasal cavity to remove a portion
of the vomer. An endoscope placed in the contralateral
nasal cavity can provide excellent visualization during
this important step.
A
B
Figure 4-3. A and B, Removal of atretic bone inferiorly and medi-
ally. (Reprinted with permission from Kenna MA, Rahbar R: Congenital
nasal malformations. In Bluestone CD, Rosenfeld RM [eds]: Surgical Atlas
of Pediatric Otolaryngology. BC Decker, Ontario, Canada, 2002, p 303.)

Chapter 4
Surgery for Choanal Atresia
31
Figure 4-4. A rongeur is used to remove the posterior aspect of the
hard palate.
Figure 4-5. Removal of a portion of the hard palate and vomer.
Figure 4-6. Use of a nasopharyngeal airway as a stent.
POSTOPERATIVE MANAGEMENT
Antibiotics are administered to prevent infection. Suc-
tioning plus cleaning of the stents is important for per-
sonal hygiene and to ensure patency of the tube for
nasal breathing. Local care includes cleansing around
the stents with hydrogen peroxide to control any crust-
ing that may develop in the area of the nasal ala. After
the crusts are removed, antibiotic ointment is applied
to the vestibular skin. The use of nasal steroid spray for
6 weeks after stent removal to reduce granulation tissue
formation has been suggested.9 The stents are removed
after 2 months under general anesthesia in pediatric
patients, at which time the granulation tissue may be
removed with nasal endoscopes.
Sublabial Transseptal Repair
The technique is said to be helpful in neonates with
unfavorable nasal anatomy or craniofacial anomalies.
After a sublabial incision into the mucosa of the fl oor
of the nose, the septum is elevated and the atretic plate
is exposed and removed.
PEARLS
• The systematic use of CT scans to evaluate the
patient provides valuable information for planning.
• The use of nasal endoscopes and powered
instruments provides a precise technique for
removal of an atresia plate with a lower risk of
complications.
• Stenosis may be prevented by adequately removing
bone, preserving mucosal fl aps, and stenting.
• Complications may be avoided by meticulous
attention to surgical technique, the use of a
properly sized stent, and placement of an airway.
• The use of nasal steroid spray after removal of
stents may be helpful.

32
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
5. Hsu CY, Li YW, Hsu JC: Congenital choanal atresia: Computed
tomographic and clinical fi ndings. Acta Paediatr Taiwan 40:13-
17, 1999.
6. Cotton RT, Stith JA: Choanal atresia. In Gates GA (ed): Current
Therapy in Otolaryngology—Head and Neck Surgery, 3rd ed.
Toronto, BC Decker, 1987, pp 297-299.
7. Park AH, Brockenbrough J, Stankiewicz J: Endoscopic versus tra-
ditional approaches to choanal atresia. Otolaryngol Clin North
Am 33:77-90, 2000.
8. Richardson MA, Osguthorpe JD: Surgical management of choanal
atresia. Laryngoscope 98:915-918, 1988.
9. Wiatrak BJ: Unilateral choanal atresia: Initial presentation and
endoscopic repair. Int J Pediatr Otorhinolaryngol 46:27-35,
1998.
10. Djupesland P, Kaastad E, Franzen G: Acoustic rhinometry in the
evaluation of congenital choanal malformations. Int J Pediatr
Otorhinolaryngol 41:319-337, 1997.
11. Portela RR, Naclerio RM: Choanal atresia. In Johns ME, Price
JC, Mattox DE (eds): Atlas of Head and Neck Surgery, vol 1.
Philadelphia, BC Decker, 1990, pp 150-159.
12. Pirsig W: Surgery of choanal atresia in infants and children: His-
torical notes and undated review. Int J Pediatr Otorhinolaryngol
11:153-170, 1986.
13. Beinfi eld HH: Surgical management of the complete and incom-
plete bony atresia of the posterior nares. Trans Am Acad Oph-
thalmol Otolaryngol 60:778-786, 1956.
14. Fong M, Clarke K, Cron C: Clinical applications of the holmium:
YAG laser in disorders of the paediatric airway. J Otolaryngol
28:337-343, 1999.
15. April MM, Ward RF: Choanal atresia repair: The use of powered
instrumentation. Oper Tech Otolaryngol Head Neck Surg 7:248-
251, 1996.
16. Rombaux P, de Toeuf C, Hamoir M, et al: Transnasal repair of
unilateral choanal atresia. Rhinology 41:31-36, 2003.
17. Hengerer AS: Choanal atresia. In Gates GA (ed): Current Therapy
in Otolaryngology—Head and Neck Surgery. Philadelphia, BC
Decker, 1984, pp 342-346.
18. Brown OE, Pownell P, Manning SC: Choanal atresia: A new ana-
tomic classifi cation and clinical management applications. Laryn-
goscope 106:97-101, 1996.
19. Lore JM Jr: Posterior choanal atresia. In Lore JM Jr (ed): An Atlas
of Head and Neck Surgery, 3rd ed. Philadelphia, WB Saunders,
1988, p 210.
PITFALLS
• In the transpalatal approach there may be
intraoperative problems such as bleeding from the
greater palatine arteries, injury to the basiocciput
during removal of the atresia plate, and injury to the
contents of the incisive foramen.
• Early postoperative complications may include
airway obstruction secondary to edema of the soft
palate or tongue.
• Late complications include nasal infection, necrosis
of the palatal mucosa, velopharyngeal incompetence
from either muscular dysfunction or overly long
stents, oral antral fi stula, and stenosis of the
choana.
• Pressure necrosis of the columella or the alar rim
may be caused by improperly sized stents.
• Leakage of cerebrospinal fl uid as a result of injury to
the cribriform plate with or without meningitis has
been reported.19
References
1. Stankiewicz JA: The endoscopic repair of choanal atresia. Otolar-
yngol Head Neck Surg 103:931-937, 1990.
2. Deutsch E, Kaufman M, Eilon A: Transnasal endoscopic manage-
ment of choanal atresia. Int J Pediatr Otorhinolaryngol 40:19-26,
1997.
3. Hengerer AS, Strome M: Choanal atresia: A new embryologic
theory and its infl uence on surgical management. Laryngoscope
92:913-921, 1982.
4. Shivakumar AM, Naik AS, Prashanth KB, et al: Choanal atresia:
Transnasal endoscopic technique. Indian J Pediatr 70:875-876,
2003.

Chapter 5
Adenoidectomy
Suman Golla
Adenoid tissue, also known as the pharyngeal tonsils, is
lymphatic tissue situated in the nasopharynx. Adenoid
tissue rapidly increases in size during the fi rst 6 or 7
years of life and generally atrophies by adolescence.
This hypertrophy is physiologic but may also be related
to repeated infection. Numerous clinical conditions or
symptoms result from hypertrophy of the adenoids,
including nasal obstruction, mouth breathing, nasal
voice or hyponasality, snoring and restless sleep, mucoid
anterior nasal discharge, possible epistaxis, otitis media
with effusion, and sinusitis. Adenoid hypertrophy may
also be related to obstructive sleep apnea in children.
Abnormal facial development has been attributed
to adenoid hypertrophy. This occurs with chronic
mouth breathing during times when the facial bones
continue to change toward the adult confi guration.
The open-mouth position leads to certain anatomic
abnormalities, including a high arched palate and
shortening of the upper lip. The face therefore becomes
slightly elongated with the upper teeth often projecting
anteriorly. Along with mouth breathing, the previously
mentioned changes in facial expression lead to the con-
dition known as adenoid facies. Adenoid obstruction
can also cause lateral obstruction of the eustachian tube
orifi ce and contribute to the cause of chronic or recur-
rent effusions of the middle ear.
The adenoids are located inferior to the sphenoid
sinus and anterior to the occiput. Laterally, the ade-
noids end in a depression known as the fossa of Rosen-
müller. This region is medial to the opening of
the eustachian tube and torus tubarius. Adenoid
tissue forms the bulk of the lymphoid tissue known as
Waldeyer’s ring. The lingual tonsils form the posterior
aspect of this ring, whereas the palatine tonsils form the
lateral walls. Smaller aggregates of lymphoid tissue can
be found in the mucosa of the posterior wall of the
pharynx. These areas appear as submucosal nodules
and are often known as “cobblestones.” Inferiorly,
adenoid tissue extends to the superior margin of the
33
superior constrictor muscle and forms what is known as
Passavant’s ridge.
The blood supply to adenoid tissue is primarily
from the ascending pharyngeal artery. Additional supply
occurs through the ascending palatine branch of the
facial artery. Venous drainage occurs through the pha-
ryngeal plexus and occasionally the pterygoid plexus.
Ultimately, blood drains to the facial veins and internal
jugular. Innervation of the pharyngeal tonsils is derived
from the lesser palatine nerves, which eventually trans-
mit afferent fi bers to the sphenopalatine ganglion.
Additional innervation is provided by the lingual naso-
pharyngeal branch of the glossopharyngeal nerve; this
branch often provides the pathway for referred
otalgia.
PATIENT SELECTION
Absolute indications for adenoidectomy include
adenoid hyperplasia with obstructive sleep apnea. Other
indications for adenoidectomy include otitis media with
effusion, recurrent otitis media, and adenoid hypertro-
phy with accompanying symptoms and sinusitis.
In children with recurrent pharyngitis, adenoiditis
is a frequent concomitant disease process. Distinguish-
ing adenoiditis from tonsillitis may be diffi cult because
the symptoms are similar. Therefore, patients who
undergo tonsillectomy for episodes of recurrent acute
tonsillitis generally have adenoidectomy performed at
the same time. Patients with adenoiditis, however, often
have purulent rhinorrhea, postnasal drainage, fever,
otitis media, and nasal obstruction. The occurrence of
four or more episodes of acute nasopharyngitis in 1
year, particularly with associated sinus and otologic
symptoms, is an indication for adenoidectomy. These
symptoms are often diffi cult to differentiate from
chronic rhinosinusitis as well.
Adenoidectomy is characteristically performed in
children. Frequently, it is performed in conjunction

34
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
with tonsillectomy or myringotomy, or both, with the
insertion of pressure-equalizing (PE) tubes for chronic
serous otitis media. Nasopharyngeal adenoid tissue
serves not only as a mechanical obstruction to the eusta-
chian tube orifi ce, thereby leading to diffi culty in ven-
tilation of the middle ear mucosa and space, but also
as a reservoir of bacteria, which may contribute to epi-
sodes of otitis media.
Adenoidectomy as part of the routine treatment of
chronic otitis media with effusion (COME) is contro-
versial. In a 1987 study, Gates and colleagues demon-
strated a 50% reduction in the recurrence of COME in
patients who had undergone adenoidectomy in con-
junction with the insertion of ventilating tubes.1 Others
have suggested that the addition of adenoidectomy to
the insertion of PE tubes increases the risk associated
with the surgical procedure by requiring intubation and
creating the potential for blood loss. Currently, this
debate continues, although most authorities would
suggest that adenoidectomy is effi cacious in the treat-
ment of patients with otitis media with effusion and
should be considered in cases of recurrent COME or in
patients requiring a second insertion of a myringotomy
tube for recurrent otitis media. A recent study has indi-
cated that the location of the adenoid tissue may play
a role in determining the effi cacy of performing ade-
noidectomy for control of otitis media. Patients with
adenoid tissue abutting the torus tubarius seem to
benefi t more from an adjuvant adenoidectomy in addi-
tion to myringotomy and placement of ventilating
tubes.2
The effi cacy of adenoidectomy for the manage-
ment of chronic rhinosinusitis in children is controver-
sial. The adenoids are a probable source of obstruction
and infection for the paranasal sinuses. Functional
endoscopic sinus surgery (FESS) has been well known
to improve chronic sinusitis in adults and children. The
use of FESS in children, however, has been controver-
sial because of possible growth retardation.3 Studies
have nonetheless shown that adenoidectomy alone may
be benefi cial in controlling chronic sinusitis in chil-
dren.4-6 Other studies, though, have shown an improve-
ment in patients who underwent endoscopic sinus
surgery as opposed to adenoidectomy for the treatment
of chronic sinusitis in the pediatric age group. Further
studies have shown an improvement in outcome in
patients who have undergone both adenoidectomy and
endoscopic sinus surgery.7,8 Some surgeons favor ade-
noidectomy as the fi rst procedure, with endoscopic
sinus surgery being performed only if symptoms persist.
Other surgeons recommend proceeding with intrave-
nous antibiotics before surgical treatment. 9 In a survey
of pediatric otolaryngologists, the majority (80%) per-
formed adenoidectomy before proceeding with endo-
scopic sinus surgery.10
Chronic upper airway obstruction in children sec-
ondary to hypertrophy of the tonsils and adenoids has
long been recognized. Recently, however, increased
clinical signifi cance has been attributed to this condi-
tion, particularly with regard to sleep disorders result-
ing from chronic nasopharyngeal and oropharyngeal
Figure 5-1. Lateral soft tissue radiograph of the nasopharynx dem-
onstrating an enlarged adenoid pad (arrows).
obstruction. Selection of patients for adenoidectomy
and tonsillectomy in this population can be diffi cult.
Various aspects of the history may be useful in decision
making. Formal sleep studies can be performed but
require an overnight stay and are probably not cost-
effective. Audio or video recordings made of the child
during sleep may provide helpful clues; however, such
recordings require a signifi cant investment of time by
a trained observer to identify chronic obstructive sleep
patterns.
The patient’s parent or guardian will usually provide
accurate information that generally correlates with a
formal sleep study or video evaluation of sleep patterns.
A history of obstructive sleep patterns and loud snoring
may often provide an adequate indication for selection
of patients for tonsillectomy and adenoidectomy.11 As
opposed to adults, children merely require a history of
sleep-disordered breathing for the diagnosis of obstruc-
tive sleep apnea.11 Positive fi ndings on polysomnogra-
phy are not required.
Radiologic evaluation of the nasopharynx with soft
tissue lateral radiographs may provide additional
medical evidence of adenoid hypertrophy and make
case selection more objective (Fig. 5-1). Computed
tomography is not usually required or indicated in
these patients. Occasionally, patients older than 4 years
may be cooperative enough to undergo nasopharyngeal
examination in the offi ce, either with rigid endoscopy
or with fl exible fi beroptic laryngoscopy (or with both)
after adequate anesthesia of the nasal cavity. An enlarged
adenoid pad visualized in this manner would be a clear
indication for adenoidectomy in a patient who exhibits
symptoms of adenoid hypertrophy or adenoiditis.
PREOPERATIVE EVALUATION
Evaluation for potential bleeding disorders is contro-
versial, although most surgeons would not obtain blood
work. In the absence of a family or personal history
suggesting a coagulopathy, preoperative hematologic

Chapter 5
Adenoidectomy
35
evaluation is not cost-effective, thus obviating the need
for blood work.12 In patients with a history of a bleeding
disorder, evaluation with a prothrombin time and a
bleeding time may be necessary, especially to exclude
the common diagnosis of von Willebrand’s disease. If
this condition is diagnosed, patients may need desmo-
pressin (DDAVP) preoperatively and postoperatively.
Adenoidectomy may be performed on an outpa-
tient basis, although some authorities would suggest
that if tonsillectomy is included in a patient who is
younger than 2 years, the patient should be hospital-
ized. In this situation the patient may need to be
observed for fl uid administration or for the potential
for postoperative hemorrhage, or for both.
Although perioperative antibiotics are not required,
some studies suggest that the use of postoperative anti-
biotics after tonsillectomy results in decreased odor and
reduced pain.13 The majority of otolaryngologists pre-
scribe antibiotics for this reason in patients who undergo
adenoidectomy and tonsillectomy.14,15
Before performing an adenoidectomy with the
patient under general anesthesia, it is necessary to
palpate the palate to rule out the possibility of a sub-
mucous cleft. This defect can be identifi ed by the pres-
ence of a deep V that can be palpated on the posterior
edge of the hard palate (Fig. 5-2). The presence of a
submucous cleft is associated with a shorter than normal
soft palate. Frequently, these patients are able to
approximate their velum to the posterior pharyngeal
wall only when the adenoids are enlarged. If the
enlarged adenoids are removed, velopharyngeal insuf-
fi ciency may result in hypernasal speech and nasal
regurgitation of liquids. Adenoidectomy should not be
performed in patients who have a cleft palate or who
have previously undergone cleft palate repair because
velopharyngeal insuffi ciency will probably result or
become worse.
TECHNIQUE
Adenoidectomy is performed with the patient under
general anesthesia. The patient is usually placed in the
Rose position with a McIvor mouth gag in position to
provide oropharyngeal exposure, depress the tongue,
and secure the endotracheal tube (Fig. 5-3). Visualiza-
tion may be either indirect through the oral cavity or
direct through the nose with a nasal endoscope (Fig.
5-4).
Red rubber catheters are used for retraction of the
soft palate, after which a laryngeal mirror is used to
refl ect the beam of light from the surgeon’s headlight
for visualization of the nasopharynx. An adenotome or
an adenoid curette may be used to perform the ade-
noidectomy (Fig. 5-5). The mirror is used to ensure
adequate placement of the curette against the posterior
edge of the vomer. To prevent troublesome bleeding,
care must be taken to avoid contact between the curette
and the posterior end of the inferior turbinate. The
curette should also be distanced from the eustachian
tube orifi ce and torus tubarius. The curette is depressed
Figure 5-2. Palpation of the palate before adenoidectomy to rule
out a submucous cleft.
Figure 5-3. Patient positioning for adenoidectomy.
Figure 5-4. Mirrors for obtaining an indirect view of the
nasopharynx.

36
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
against the vomer edge, and with the thumb used as a
fulcrum, the blade is pushed over the posterior naso-
pharyngeal wall. More than one pass may be necessary
to completely remove the adenoid tissue. A slight
rocking motion may also be needed to complete the
adenoidectomy. Remnants of adenoid tissue that are
bleeding may be removed with small St. Clair Thomp-
son forceps or with electrocautery after the majority of
the choana is free of adenoid tissue (Fig. 5-6). An ade-
notome may also be used rather than a curette when
dissecting the adenoid. The basket of the adenotome
engages the central adenoid mass and is pressed against
the nasopharyngeal wall. Closure of the blade allows
removal of the nasopharyngeal adenoid mass. After
the adenotome removes most of the central adenoid
tissue, additional adenoid tissue may be removed
with a curette, St. Clair Thompson forceps, or
electrocautery.
The nasopharynx is packed with moist tonsil or
adenoid sponges. The use of electrocautery has come
into favor as a common means of controlling bleeding
(Fig. 5-7). Persistent bleeding is generally a result of
retained fragments of adenoid tissue. Removal of the
remaining tissue is usually all that is required to stop
such bleeding. If bleeding persists, additional tech-
niques may be necessary, including the use of nasopha-
ryngeal packing or the application of a hemostatic
agent. This is particularly common in older children
and adolescents because the adenoids in these patients
are less friable and more diffi cult to remove with
adenoid curettes. In this instance it is often preferable
to resort to cautery of the remnants of residual adenoid
tissue.
Recently, many otolaryngologists have been using
suction and electrocautery as the sole technique for
performing adenoidectomy. The initial setup is similar
to that for the adenoid curette technique. However,
rather than using the adenoid curette, suction electro-
cautery is used under direct visualization to cauterize
adenoid tissue, as well as to control bleeding. In addi-
tion to the adenoid curette and suction cautery, other
techniques are available for the performance of ade-
noidectomy. Use of the microdébrider has been
described for the performance of adenoidectomy, with
low complication rates being reported.16,17 Electrocau-
tery has been compared with curettage and power-
assisted methods. In this study the electrocautery
technique led to decreased blood loss and shorter oper-
ating times than achieved with the conventional curet-
tage technique. In this same study, power-assisted
adenoidectomy offered shorter operating times;
however, this technique was thought to require expen-
sive equipment, as well as more experience, and there-
fore was not as favored as the traditional electrocautery
technique.18
Surveys from otolaryngologists have indicated that
of the various techniques available for adenoidectomy,
the most popular is curettage followed by cautery. Elec-
trocautery alone, however, has been gaining favor as the
technique of choice, with decreased blood loss being
the reason cited.
Likewise, adenoidectomy should not be performed
in association with uvulopalatopharyngoplasty because
nasopharyngeal stenosis may ensue.
POSTOPERATIVE MANAGEMENT
Minimal postoperative care is required. Any residual
bleeding will generally stop once the patient awakens
and the pharyngeal muscles begin to contract. Patients
may be discharged once they are awake. No dietary
restrictions are necessary unless tonsillectomy has been
performed concurrently.
Figure 5-5. Various sizes of adenoid curettes are used to remove
the adenoids from the nasopharynx.
Figure 5-6. St. Clair Thompson forceps are helpful in removing
adenoid tissue, especially in the choanae.
Figure 5-7. Suction electrocautery is a popular way to remove
adenoid tissue and simultaneously control bleeding.

Chapter 5
Adenoidectomy
37
COMPLICATIONS
A serious problem is an inability to recognize a cleft
palate, submucous cleft, or a short soft palate before
performing this surgery. Removal of the adenoids may
result in an inability of the soft palate to contact the
posterior pharyngeal wall, thereby resulting in velopha-
ryngeal insuffi ciency with characteristic hypernasal
speech. This problem can be corrected by means of a
pharyngeal fl ap or palatal push-back. However, it is far
better to prevent the problem than to treat it.
Postoperative bleeding is unusual after adenoidec-
tomy; nevertheless, bleeding can result during the pro-
cedure and prolong the operation. Occasionally, it is
necessary to place a posterior pack to control bleeding
during performance of the operation. This pack can
generally be removed in the recovery room.
Injury to the posterior tips of the inferior turbinates
often results in troublesome bleeding and can be
avoided by direct visualization at the time of placement
of the adenoid curette. Injury to the eustachian tube
orifi ce by inadvertently placing the lateral aspect of the
curette anterior to the torus tubarius is a serious com-
plication. It can often be immediately recognized by the
appearance of cartilage in the adenoid specimen. Direct
visualization while the adenoid curette is placed is an
ideal means of preventing this complication as well.
References
1. Gates GA, Avery CA, Prihoda TJ, Cooper JC: Effectiveness of
adenoidectomy and tympanostomy tubes in the treatment of
chronic otitis media with effusion. N Engl J Med 317:1444-1451,
1987.
2. Nguyen LH, Manoukian JJ, Yoskovitch A, Al-Sebeih KH: Adenoid-
ectomy: Selection criteria for surgical cases of otitis media. Laryn-
goscope 114:863-866, 2004.
3. Mair EA, Bolger WE, Breisch EA: Sinus and facial growth after
pediatric endoscopic sinus surgery. Arch Otolaryngol Head Neck
Surg 121:547-552, 1995.
4. Vandenberg SJ, Heatley DG: Effi cacy of adenoidectomy in reliev-
ing symptoms of chronic sinusitis in children. Arch Otolaryngol
Head Neck Surg 123:675-678, 1997.
5. Rosenfeld RM: Pilot study of outcomes in pediatric rhinosinusitis.
Arch Otolaryngol Head Neck Surg 121:729-736, 1995.
6. Ungkanont K, Damrongsak S: Effect of adenoidectomy in chil-
dren with complex problems of rhinosinusitis and associated
diseases. Int J Pediatr Otorhinolaryngol 68:447-451, 2004.
7. Ramadan HH: Adenoidectomy vs endoscopic sinus surgery for
the treatment of pediatric sinusitis. Arch Otolaryngol Head Neck
Surg 125:1208-1211, 1999.
8. Ramadan HH: Surgical management of chronic sinusitis in chil-
dren. Laryngoscope 114:2103-2109, 2004.
9. Don DM, Yellon RF, Casselbrant ML, Bluestone CD: Effi cacy of
a stepwise protocol that includes intravenous antibiotic therapy
for the management of chronic sinusitis in children and adoles-
cents. Arch Otolaryngol Head Neck Surg 127:1093-1098, 2001.
10. Sobol SE, Samadi DS, Kazahaya K, Tom LW: Trends in the man-
agement of pediatric chronic sinusitis: Survey of the American
Society of Pediatric Otolaryngology. Laryngoscope 115:78-80,
2005.
11. Eibling DE: Tonsillectomy. In Myers EN (ed): Operative Otolar-
yngology—Head and Neck Surgery. Philadelphia, WB Saunders,
1997, pp 186-198.
12. Cressman WR, Myer CM: Management of tonsillectomy hemor-
rhage: Results of a survey of pediatric otolaryngology fellowship
programs. Am J Otolaryngol 16:29-32, 1995.
13. Grandis JR, Johnson JT, Vickers RM, et al: The effi cacy of peri-
operative antibiotic therapy on recovery following tonsillectomy
in adults: Randomized double-blind placebo-controlled trial.
Otolaryngol Head Neck Surg 106:137-148, 1992.
14. Krishna P, LaPage MJ, Hughes LF, Lin SY: Current practice pat-
terns in tonsillectomy and perioperative care. Int J Pediatr Oto-
rhinolaryngol 68:779-784, 2004.
15. Koltai PJ, Solares CA, Mascha EJ, et al: Intracapsular partial tonsil-
lectomy for tonsillar hypertrophy in children. Laryngoscope
112(Suppl 100):17-19, 2002.
16. Koltai PJ, Chan J, Younes A: Power-assisted adenoidectomy: Total
and partial resection. Laryngoscope 112(Suppl 100):29-31,
2002.
17. Sorin A, Bent JP, April MM, Ward RF: Complications of micro-
debrider-assisted powered intracapsular tonsillectomy and ade-
noidectomy. Laryngoscope 114:297-300, 2004.
18. Elluru RG, Johnson L, Myer CM 3rd: Electrocautery adenoidec-
tomy compared with curettage and power-assisted methods.
Laryngoscope 112(Suppl 100):23-25, 2002.
PEARLS
• Adenoid hypertrophy and sleep-disordered breathing
may be diagnosed by history in children without a
formal sleep study.
• Most surgeons recommend that adenoidectomy be
performed in association with insertion of a PE tube
if the otitis media is recurrent.
• Placement of the curette under direct visualization
will reduce the likelihood of injury to adjacent
structures such as the torus tubarius and inferior
turbinate.
PITFALLS
• Adenoidectomy should not be performed in patients
with a short palate, cleft palate, or submucous cleft.
• Adenoidectomy should not be performed in
association with an uvulopalatopharyngoplasty to
avoid nasopharyngeal stenosis.
• Persistent bleeding is usually due to retained
fragments of adenoid tissue.

Chapter 6
Juvenile Angiofi broma
Ricardo L. Carrau, Carl H. Snyderman, and Amin B. Kassam
Juvenile nasopharyngeal angiofi broma (JA) is a rare
benign tumor found exclusively in males, most often
during adolescence or young adulthood. The tumor
accounts for less than 0.5% of all tumors of the head
and neck and is found in 1 in 16,000 hospital admis-
sions to an ear, nose, and throat service.1 It is believed
that this tumor has been recognized since the time of
Hippocrates.2
The origin of JA remains undefi ned; however, its
exclusive occurrence in males suggests a hormonal
infl uence. The site of origin is most likely at the basi-
sphenoid, near the sphenopalatine foramen, at the
junction of the orbital and sphenoid processes of the
palatine bone and the body of the sphenoid bone. This
site of origin explains the frequent extension of the
tumor into the pterygopalatine fossa. JA also extends
into the nasal cavity, the nasopharynx, and the ethmoid
and sphenoid sinuses. JA may invade the orbit and
cranial cavity by direct extension following preformed
pathways or by destroying bone.
PATIENT SELECTION
History and Physical Examination
Nasal obstruction and epistaxis are the most common
complaints of patients with JA. Any adolescent male
presenting with these symptoms should be suspected of
having JA. As the tumor extends into other areas such
as the nasal cavity, orbit, and intracranial cavity, other
signs and symptoms may develop, such as proptosis or
displacement of the globe, diplopia, pain in the cheek,
headache, swelling of the cheek, sinusitis, headaches,
and hearing loss (e.g., middle ear effusion). The fi nd-
ings on physical examination depend on the extent of
the tumor. Endoscopic nasal examination and cranial
nerve testing provide clues regarding the extent of the
tumor. Typically, the JA is a gray-red, smooth, sessile,
polypoid mass, although it can be irregular and lobu-
lated (Fig. 6-1A-C). Physical examination may reveal
signs of orbital extension such as proptosis, displace-
ment of the globe, and limitations of extraocular muscle
movement (see Fig. 6-1D). Otoscopic evaluation may
demonstrate serous effusion or a retracted tympanic
membrane.
Imaging
JA may be identifi ed on plain fi lms as a soft tissue mass
occupying the posterior nasal cavity with or without
extension into the nasopharynx or paranasal sinuses.
The most suggestive fi nding is anterior bowing of the
posterior wall of the maxillary sinus observed on a sub-
mentovertex view. Computed tomography (CT) scan-
ning, however, is the preferred imaging technique for
the initial evaluation of a patient with a suspected JA.
CT scanning defi nes the bony architecture of the sino-
nasal tract and skull base, and the use of contrast dem-
onstrates the vascularity of the tumor (Fig. 6-2A).
Magnetic resonance imaging (MRI) complements the
CT scan in those cases that present with intracranial,
infratemporal, or intraorbital soft tissue extension (see
Fig. 6-2B). MRI better defi nes the soft tissue planes,
demonstrating the interface between the tumor and the
soft tissue of the infratemporal fossa (muscles or neu-
rovascular structures), or intracranial structures, and
helps differentiate tumor extension from retained
secretions in the sinuses.
Angiography demonstrates the blood supply of the
tumor, which is usually derived from branches of the
internal maxillary and ascending pharyngeal arteries.
Contributing branches from the internal carotid artery
are common in tumors that extend to the nasopharynx,
sphenoid sinus, orbital cavity, and infratemporal fossa
39