Head neck - Plural Publishing, Inc. · of Head and Neck Surgery Kaiser Permanente-Southern California, Anaheim, CA Clinical Asst. Professor Department of Otolaryngology/ Head and

otolaryngologyHead & neck

S u r g e r y

clinical reference guide

f i f t h e d i t i o n

otolaryngologyHead & neck

S u r g e r y

clinical reference guide

f i f t h e d i t i o n

Raza Pasha, MDJustin S. Golub, MD, MS

5521 Ruffin RoadSan Diego, CA 92123

e-mail: [email protected]: www.pluralpublishing.com

Copyright © 2018 by Plural Publishing, Inc.

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NOTICE TO THE READERCare has been taken to confirm the accuracy of the indications, procedures, drug dosages, and diagnosis and remediation protocols presented in this book and to ensure that they conform to the practices of the general medical and health services communities. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. The diagnostic and remediation protocols and the medications described do not necessarily have specific approval by the Food and Drug administration for use in the disorders and/or diseases and dosages for which they are recommended. Application of this information in a particu-lar situation remains the professional responsibility of the practitioner. Because standards of practice and usage change, it is the responsibility of the practitioner to keep abreast of revised recommendations, dosages, and procedures.

Library of Congress Cataloging-in-Publication Data:

Names: Pasha, R., author. | Golub, Justin S., author.Title: Otolaryngology : head and neck surgery : clinical reference guide / Raza Pasha, Justin S. Golub.Description: Fifth edition. | San Diego, CA : Plural, [2018] | Includes bibliographical references and index.Identifiers: LCCN 2017028235| ISBN 9781944883393 (alk. paper) | ISBN 1944883398 (alk. paper)Subjects: | MESH: Otorhinolaryngologic Diseases--surgery | Face--surgery | Head--surgery | Neck--surgery | Otorhinolaryngologic Surgical ProceduresClassification: LCC RF46 | NLM WV 168 | DDC 617.5/1059--dc23LC record available at https://lccn.loc.gov/2017028235

vv

contentS

Preface to the Fifth Edition ixPreface to the Fourth Edition xContributors xiCommon Abbreviations in Otolaryngology–Head and Neck Surgery xvii

Chapter 1 Rhinology and Paranasal Sinuses 1Matthew Kim, Qasim Husain, Justin S. Golub, Steven C. Marks, and Raza PashaAnatomy of the Nose and Paranasal Sinuses 2Physiology of the Nose and Paranasal Sinuses 11Evaluation for Nasal Obstruction 13Nasal Diseases 16Allergy and Rhinitis 34Paranasal Sinus Disease 47Sinus Surgery 57Immunology 63

Chapter 2 Salivary Glands 73Oscar Trujillo, Justin S. Golub, and Raza PashaSalivary Gland Anatomy and Physiology 74General Salivary Gland Pathology 78Benign Salivary Gland Tumors 84Salivary Gland Malignancy 88Parotidectomy 91

Chapter 3 Laryngology 93Ashley P. O’Connell Ferster, Amanda Hu, James P. Dworkin, Robert J. Meleca, Robert J. Stachler, Justin S. Golub, and Raza PashaLaryngeal Anatomy and Physiology 94The Hoarse (Dysphonic) Patient 98Upper Airway Obstruction 102Benign Laryngeal Pathology 109Neurogenic and Other Vocal Pathologies 120

Chapter 4 Otolaryngologic Endocrinology 129Jiahui Lin, Kenny F. Lin, Richard Chan Woo Park, Justin S. Golub, and Raza PashaThyroid 130Parathyroids 147

vi Otolaryngology-Head and Neck Surgery

Chapter 5 Sleep Medicine 153Raza Pasha, Sarah E. Keesecker, and Justin S. GolubSleep Physiology 154Polysomnography (PSG) 156Sleep-Disordered Breathing (SDB) 166Other Sleep-Related Disorders 177

Chapter 6 General Otolaryngology 187Mahmoud I. Awad, Valeria Silva Merea, Robert J. Stachler, Terry Y. Shibuya, Justin S. Golub, and Raza PashaEsophageal and Swallowing Disorders 188Oral and Oropharyngeal Benign Disorders 206Odontogenic, Jaw, and Bone Pathology 220Neck Masses 232Neck Planes, Spaces, and Infection 239Head and Neck Manifestations of Systemic Diseases 245

Chapter 7 Head and Neck Cancer 255Richard Chan Woo Park, Vishad Nabili, George H. Yoo, Justin S. Golub, and Raza PashaCancer Staging Index 256Introduction to Head and Neck Cancer 257Chemotherapy and Radiation Therapy 264Cancer of the Neck 277Oral Cancer 284Oropharyngeal Cancer 289Hypopharyngeal Cancer 294Laryngeal Cancer 297Nasopharyngeal Cancer 310Nasal and Paranasal Cancer 312Cutaneous Malignancies 318Other Head and Neck Neoplasms 326Robotic Surgery 335

Chapter 8 Otology and Neurotology 339Theodore R. McRackan, Jonathan L. Hatch, Matthew L. Carlson, Syed F. Ahsan, Dennis I. Bojrab, Raza Pasha, and Justin S. GolubAnatomy, Embryology, and Physiology of Hearing 340

and BalanceAudiology and Hearing Devices 353Approach to Hearing Loss and Tinnitus 366

CONTENTS vii

Infections of the Ear and Temporal Bone 373Noninfectious Disorders of the Ear and 389

Temporal BoneVestibular Pathology 411The Facial Nerve 426

Chapter 9 Reconstructive and Facial Plastic Surgery 441Rohan R. Joshi, Qasim Husain, Richard Chan Woo Park, Richard Zoumalan, Joseph F. Goodman, Neil Tanna, Richard L. Arden, Justin S. Golub, and Raza PashaFundamentals of Wound Healing 443Head and Neck Reconstructive Flaps 449Grafts, Implants, and Expanders 465Facial Reconstruction Techniques 471Facial Aesthetic Surgery 483Rhinoplasty 485Otoplasty 495Blepharoplasty 496Rhytidoplasty (Rhytidectomy, Facelift) 503Forehead Lift and Brow Lift 507Liposurgery 508Complications of Rhytidectomy, Brow Lift, 509

LiposurgeryChin and Malar Augmentation 510Facial Resurfacing 511Fillers, Skin Substitutes, and Injections 516Surgery for Alopecia 520Incision/Excision Planning and Scar Revisions 521

Chapter 10 Pediatric Otolaryngology 529Valerie Cote, Amy Li Dimachkieh, Jeremy David Prager, Peggy E. Kelley, Christopher R. Grindle, Tulio A. Valdez, and Justin S. GolubThe Pediatric Encounter 531General Pediatric Otolaryngology and Pediatric Sleep 532Pediatric Rhinology 550Pediatric Laryngoesophagology 557Pediatric Salivary Glands 577Pediatric Otology 580Pediatric Syndromes and Congenital Disorders 595Pediatric Head and Neck Surgery 603Pediatric Reconstructive and Facial Plastic Surgery 616Pediatric Head and Neck Trauma 625

viii Otolaryngology-Head and Neck Surgery

Chapter 11 Head and Neck Trauma 629Rohan R. Joshi, Oscar Trujillo, Cody A. Koch, Timothy D. Doerr, Robert H. Mathog, and Raza PashaEvaluation of the Head and Neck Trauma Patient 630Mandibular Fractures 636Maxillary Fractures 644Zygomaticomaxillary and Orbital Fractures 648Frontal Sinus and Naso-Orbitoethmoid Fractures 653Nasal Fractures 658Temporal Bone and Otologic Trauma 659Penetrating Head and Neck Trauma 663Laryngeal Trauma 666Soft Tissue Trauma 669

Appendix A Cancer Staging Index 675Appendix B Cranial Nerves 677Appendix C Radiology 681

Stephanie Y. Chen, Anju Dubey, and Gul MoonisAppendix D Anesthesia 693

Raza Pasha and Justin S. Golub

Index 695

ixix

Preface to tHe fiftH edition

The fourth begets a fifth and, like a cauldron of cooling magma, these editions are becoming more and more challenging to churn. This initial pet project when I was jet-black-haired has now become that insatiable Waponian volcano god that demands and demands episodic updates. So here you go, the public, for your consumption. I’ve asked for a reprieve for at least a few years or so until the beast requires another sacrifice of an epoch of time and effort.

But I kid!! True, it’s not always the best of times revisiting Alport versus Apert on my holiday, yet I’m happy to serve. This edition bookmarks the era of Trump . . . a divided nation of ballooners and anti-ballooners. I only ask one thing . . . stop taking out uvulas. That little punching bag has God’s/Darwinian purposes beyond all of us. Oh, and also never ever use the term uvulopharyngopalatoplasty. That term belongs in a song from Mary Poppins. Quite frankly it sounds dumb, no one knows what it means anymore, and I’m tired of hearing they were told that “it” doesn’t work. “Palatal reconstruction” please; it’s sexier.

OK, off the sermon, enjoy the book, study hard, and all the best. See you at conference.

— Raza Pasha

P.S. Need to give a shout out to Abdullah Al-Bader who humbled the authors and editors by providing 5 pages of errata from the fourth edition. Dr. Al-Bader would later provide 23 alternative pathways to our academy’s position paper on cerumen impaction (total joke . . . we appreciate Abdullah).

x

Preface to tHe fourtH edition

This fourth edition evens out my staggered, shadow-boxed display in my office waiting room. It also satisfies an essential update and provides an introduction to our more-than-welcome Little People chapter for those of you entrenched in transmittable conjunctivitis and the everlasting cold/influenza rotation.

As for me, I’ve spent the last few years as a target for academics and skeptics alike lecturing cross-country on “hot button” topics such as indications of in-office balloon sinuplasty and the surgical management of sleep apnea. Should you ever find yourself with a desire to nettle to the brink of combat, walk into a rhinology conference and brag about how balloon sinuplasty is the greatest thing since electrocautery. Better yet, whisper to your pulmonologist colleague that you operated on his 23-year-old bachelor referral last week by jerking his 4+ tonsils without offering him a CPAP machine. “What?!!! You didn’t even have the decency to offer him a dental appliance so he can experience referred otalgia and teeth shifting first?!?”

No worries though. You’d be pressed to find any controversial points in this handbook. No need for naked disclosures. We’re once again, no nonsense. We’ve kept to the highlights so you can pass your boards and possibly prevent an occasional cauliflower ear now and then.

No specific acknowledgments section this year, since a well-deserved Justin Golub is now blazed in the front of the book and authors are cred-ited within.

Deeply entrenched in midlife, with three sprouting legacies, my time is apportioned between soccer matches, Super Mario marathons, and piano recitals. I dream about Mary’s Little Lamb as an adjuvant remedy for psycho-physiological insomnia. The fourth edition is a product of my free time. I was tempted to include illustrations of the cochlear labyrinth crafted by my 5-year-old. Wanting to minimize distractions and leaving something for inclusion in the fifth edition, I opted to leave those out.

Thanks for your support.

— Raza Pasha

xixi

contributorS

Italic lines indicate areas of author’s contributions.

Syed F. Ahsan, MD, FACSOtology/Neurotology Department

of Head and Neck SurgeryKaiser Permanente-Southern

California,Anaheim, CAClinical Asst. ProfessorDepartment of Otolaryngology/

Head and Neck SurgeryUC IrvineOrange, CaliforniaChapter 8

Richard L. ArdenWilliam Beaumont HospitalTroy, MichiganChapter 9

Mahmoud I. Awad, MDResident PhysicianOtolaryngology–Head and Neck

SurgeryNewYork-Presbyterian HospitalUniversity Hospital of Columbia

and CornellNew York, New YorkChapter 6

Dennis I. Bojrab, MDCEO and Director of ResearchMichigan Ear InstituteProfessor of OtolaryngologyOakland University William

Beaumont School of MedicineRochester Hills, MichiganClinical Professor of Otolaryngology

and NeurosurgeryWayne State University

Detroit, MichiganFounding PresidentAmerican CISEPO (Canada

International Scientific Exchange Program)

Toronto, CanadaChapter 8

Matthew L. Carlson, MDAssociate Professor of

Otolaryngology–Head & Neck Surgery

Associate Professor of Neurosurgery

Director, Neurotology Fellowship Program

Medical Director, Cochlear Implant Program

Mayo ClinicRochester, MinnesotaChapter 8

Stephanie Y. Chen, BMMedical StudentCollege of Physicians and

SurgeonsColumbia UniversityNew York, New YorkRadiology Appendix

Valerie Cote, MD, CM, FAAP, FRCSCPediatric OtolaryngologistDivision of Otolaryngology–Head

and Neck SurgeryAdvocate Children’s HospitalOak Lawn, IllinoisChapter 10

xii Otolaryngology-Head and Neck Surgery

Amy Dimachkieh, MDFellowDepartment of Pediatric

OtolaryngologyChildren’s Hospital ColoradoUniversity of ColoradoAurora, ColoradoChapter 10

Timothy D. Doerr, MD, FACSAssociate ProfessorResidency Program DirectorHead of Facial Plastic SurgeryDepartment of Otolaryngology–

Head and Neck SurgeryUniversity of Rochester Medical

CenterRochester, New YorkChapter 11

Anju Dubey, MD, MSClinical Assistant ProfessorDepartment of RadiologySUNY Downstate Medical CenterBrooklyn, New YorkRadiology Appendix

James P. DworkinProfessorDepartment of OtolaryngologyDetroit Medical CenterDetroit, MichiganCollege of Osteopathic MedicineMichigan State UniversityEast Lansing, MichiganChapter 3

Ashley P. O’Connell Ferster, MDResident PhysicianDivision of Otolaryngology–Head

and Neck SurgeryPenn State HealthMilton S. Hershey Medical

CenterHershey, PennsylvaniaChapter 3

Justin S. Golub, MD, MSAssistant ProfessorOtology, Neurotology, and Skull

Base SurgeryDepartment of Otolaryngology–

Head and Neck SurgeryCollege of Physicians and

SurgeonsColumbia UniversityNewYork-Presbyterian/Columbia

University Medical CenterNew York, New York

Joseph F. Goodman, MDDivision of Otolaryngology–Head

and Neck SurgeryGeorge Washington UniversityWashington, District of ColumbiaChapter 9

Christopher R. Grindle, MDPediatric OtolaryngologistConnecticut Children’s Medical

CenterAssistant ProfessorUniversity of Connecticut School

of MedicineHartford, ConnecticutChapter 10

Jonathan L. Hatch, MDClinical InstructorMedical University of South

CarolinaCharleston, South CarolinaChapter 8

Amanda Hu, MD, FRCSCAssistant ProfessorLaryngologistDepartment of Otolaryngology–

Head and Neck SurgeryDrexel University College of

MedicinePhiladelphia, PennsylvaniaChapter 3

CONTRIBUTORS xiii

Qasim Husain, MDResident PhysicianOtolaryngology–Head and Neck


and CornellNew York, New YorkChapters 1 and 9

Rohan R. Joshi, MDResident PhysicianOtolaryngology–Head and Neck



Sarah E. Keesecker, MDResident PhysicianOtolaryngology–Head and Neck



Peggy E. Kelley, MD, FACS, FAAPAssociate Professor of

OtolaryngologyUniversity of ColoradoPediatric OtolaryngologyAurora, ColoradoChapter 10

Matthew Kim, MDResident PhysicianOtolaryngology–Head and Neck


and Cornell

New York, New YorkChapter 1

Cody A. Koch, MD, PhDClinical InstructorDepartment of Otolaryngology–

Head and Neck SurgeryUniversity of WashingtonSeattle, WashingtonKoch Facial Plastic SurgeryDes Moines, IowaChapter 11

Jiahui Lin, MDResident PhysicianOtolaryngology–Head and Neck



Kenny F. Lin, MDResident PhysicianOtolaryngology–Head and Neck



Steven C. Marks, MDPrivate PracticeHavre de Grace, MarylandChapter 1

Robert H. Mathog, PhD, MD (deceased)Professor and ChairmanDepartment of Otolaryngology–

Head and Neck SurgeryWayne State UniversityKarmanos HospitalHarper HospitalDetroit, Michigan

xiv Otolaryngology-Head and Neck Surgery

Oakwood HospitalDearborn, MichiganCrittenton HospitalRochester Hills, MichiganChapter 11

Theodore R. McRackan, MDDirector, Lateral Skull Base

ProgramAssistant ProfessorMedical University of South

CarolinaCharleston, South CarolinaChapter 8

Robert J. Meleca, MD, FACSGrand Rapids ENT, PCGrand Rapids, MichiganChapter 3

Gul Moonis, MDAssociate Professor of RadiologyCollege of Physicians and

SurgeonsColumbia UniversityNewYork-Presbyterian/Columbia

University Medical CenterNew York, New YorkRadiology Appendix

Vishad Nabili, MD, FACSDiplomate, ABFPRSAssociate ProfessorClinical Head and Neck SurgeryResidency Program DirectorDepartment of Head and Neck

SurgeryUniversity of California, Los

AngelesLos Angeles, CaliforniaChapter 7

Richard Chan Woo Park, MD, FACSAssistant Professor

Department of Otolaryngology–Head and Neck Surgery

Rutgers New Jersey Medical School

Newark, New JerseyChapters 4, 7, and 9

Raza Pasha, MDPasha Snoring and Sinus CenterChief Medical OfficerAltus Healthcare Management

ServicesHouston, TexasAssistant Clinical ProfessorUTMB School of MedicineGalveston, Texas

Jeremy David Prager, MDAssociate ProfessorPediatric OtolaryngologyChildren’s Hospital ColoradoUniversity of Colorado School of

MedicineAurora, ColoradoChapter 10

Terry Y. Shibuya, MD, FACSCo-Director SCPMG Head and

Neck Tumor BoardCo-Director SCPMG Skull Base

Surgery Center of ExcellenceFull-Time PartnerDepartment of Head and Neck

SurgerySouthern California Permanente

Medical GroupOrange County, CaliforniaAssistant Clinical ProfessorDepartment of Otolaryngology–

Head and Neck SurgeryUniversity of California, Irvine

School of MedicineIrvine, CaliforniaChapter 6

CONTRIBUTORS xv

Valeria Silva Merea, MDResident PhysicianOtolaryngology–Head and Neck



Robert J. StachlerSenior StaffOtolaryngology–Head and Neck

SurgeryHenry Ford Medical GroupDivision ChiefLakeside Medical CenterClinical Associate ProfessorWayne State UniversityDepartment of Otolaryngology–

Head and Neck SurgeryDetroit, MichiganChapters 3 and 6

Neil Tanna, MD, MBAAssociate ProfessorPlastic Surgery and

OtolaryngologyHofstra North Shore–LIJ School

of MedicineHuntington, New YorkDivision of Plastic and

Reconstructive SurgeryNew York Head and Neck

InstituteNew York, New YorkChapter 9

Oscar Trujillo, MD, MSResident Physician

Otolaryngology–Head and Neck Surgery

NewYork-Presbyterian HospitalUniversity Hospital of Columbia


Tulio A. Valdez, MD, MScAssociate Professor of Pediatric

OtolaryngologyConnecticut Children’s Medical

CenterUniversity of Connecticut Health

CenterHartford, ConnecticutChapter 10

George H. Yoo, MD, FACSChief Medical OfficerKarmanos Cancer CenterProfessorDepartments of Otolaryngology–

Head and Neck Surgery and Oncology

Wayne State University School of Medicine

Detroit, MichiganChapter 7

Richard Zoumalan, MDPrivate PracticeBeverly Hills, CaliforniaCedars-Sinai Medical CenterWest Hollywood, CaliforniaClinical InstructorUCLA and USC Schools of

MedicineLos Angeles, CaliforniaChapter 9

xviixvii

common abbreviationS in otolaryngology–Head and neck Surgery

3D 3 dimensional5-FU 5-fluorouracilA-E aryepiglotticAA arytenoid abductionABG arterial blood gas, air

bone gapABI auditory brainstem

implantABR auditory brainstem

responseAC air conductionACE angiotensin

converting enzymeAHI apnea-hypopnea

indexAI apnea indexAIDS acquired

immunodeficiency syndrome

AJCC American Joint Commission on Cancer

ALD assisted listening device

ALS amyotrophic lateral sclerosis

ANA antinuclear antibodyAOM acute otitis mediaAPAP autotitrating positive

airway pressureASA aspirinASSR auditory steady-state

responseAVM arteriovenous

malformation

BAEP brainstem auditory evoked potential

BAER brainstem auditory evoked response

BAHA bone-anchored hearing aid

BC bone conductionBCC basal cell carcinomaBID twice a dayBiPAP bilevel positive airway

pressureBMT bilateral

myringotomy and tubes

BOA behavioral observation audiometry

BPD bronchopulmonary dysplasia

BPPV benign paroxysmal positional vertigo

BTE behind the earBUN blood urea nitrogenCAPE-V Consensus Auditory-

Perceptual Evaluation of Voice

CBC complete blood count

cGy centigrayCHL conductive hearing

lossCI cochlear implantCIC completely in canalCMV cytomegalovirusCN cranial nerve

xviii Otolaryngology-Head and Neck Surgery

CNS central nervous system

COM chronic otitis mediaCOMMANDO combined

mandibulectomy and neck dissection operation

CPA cerebellopontine angle, conditioned play audiometry

CPAP continuous positive airway pressure

CROS contralateral routing of sound

CRP C-reactive proteinCRS chronic rhinosinusitisCSA central sleep apneaCSF cerebrospinal fluidCT computed tomographyCTA computed

tomographic angiography

CVA cerebrovascular accident

cVEMP cervical vestibular evoked myogenic potential

CXR chest x-raydB decibeldB HL decibel hearing leveldB SL decibel sensation leveldB SPL decibel sound

pressure levelDCR dacryocystorhinostomyDDx differential diagnosisDL direct laryngoscopyDLB direct laryngoscopy

and bronchoscopyDLBE direct laryngoscopy,

bronchoscopy, and esophagoscopy (panendoscopy)

DPOAE distortion product otoacoustic emissions

Dx diagnosisEAC external auditory

canalEBV Epstein-Barr virusECA external carotid arteryECG electrocardiogramECMO extracorporeal

membrane oxygenation

ECoG electrocochleographyECS extracapsular spreadEEG electroencepha-

lographyEGFR epidermal growth

factor receptorEJV external jugular veinEMG electromyogramEND elective neck

dissectionENE extranodal extensionENG electronystagmographyENoG electroneuronographyEOG electrooculographyESR erythrocyte

sedimentation rateESS endoscopic sinus

surgeryET eustachian tube,

endotrachealETD eustachian tube

dysfunctionETT endotracheal tubeEUA examination under

anesthesiaEXIT ex-utero intrapartumFB foreign bodyFEES functional endoscopic

evaluation of swallowing

COMMON ABBREVIATIONS IN OTOLARYNGOLOGY xix

FEESST functional endoscopic evaluation of swallowing with sensory testing

FESS functional endoscopic sinus surgery

FEV forced expiratory volume

FNA fine-needle aspirationFOM floor of mouthFTA-ABS fluorescent

treponemal antibody-absorption test

FTSG full-thickness skin graft

FVPTC follicular variant of papillary thyroid carcinoma

GABHS group A ß-hemolytic streptococci

GCS Glasgow Coma ScaleGERD gastroesophageal

reflux diseaseGI gastrointestinalGPA granulomatosis

with polyangiitis (Wegner’s)

GRBAS grade, roughness, breathiness, asthenia, strain

GSPN greater superficial petrosal nerve

Gy grayH&N head and neckHA hearing aid, headacheHB House-BrackmannHBO hyperbaric oxygenHFSNHL high frequency

sensorineural hearing loss

HHT hereditary hemorrhagic telangiectasia

HINT hearing-in-noise testHIV human

immunodeficiency virus

HL hearing level, hearing loss

HNSCC head and neck squamous cell carcinoma

HPV human papilloma virus

HSV herpes simplex virusI&D incision and drainageIAC internal auditory

canalICA internal carotid arteryICP intracranial pressureIFN interferonIg immunoglobulinIHC inner hair cell,

immunohisto-chemistry

IJV internal jugular veinIL interleukinIM intramuscularlyIMF intermaxillary

fixation (see MMF)IMRT intensity-modulated

radiation therapyIS incudostapedial

(joint)ISSNHL idiopathic sudden

sensorineural hearing loss

ITC in the canalITE in the earITM in the mouthIVIG intravenous

immunoglobulinJNA juvenile

nasopharyngeal angiofibroma

xx Otolaryngology-Head and Neck Surgery

KCOT keratocystic odontogenic tumor

KTP potassium titanyl phosphate

LAD lymphadenopathyLARP left anterior, right

posterior semicircular canal pair

LCA lateral cricoarytenoid muscle

LDH lactate dehydrogenaseLDL loudness discomfort

levelLEMG laryngeal

electromyographyLES lower esophageal

sphincterLFT liver function testLMA laryngeal mask airwayLP lumbar punctureLPR laryngopharyngeal

refluxLSPN lesser superficial

petrosal nerveLTB laryngotracheobron-

chitisMBS modified barium

swallowMBSS modified barium

swallow studyMCL medial canthal

ligamentMDL microdirect

laryngoscopyMDLB microdirect

laryngoscopy and bronchoscopy

ME middle earMEE middle ear effusionMEN multiple endocrine

neoplasia

MHL mixed hearing lossMMA maxillomandibular

advancementMMF maxillomandibular

fixationMND modified neck

dissectionMRA magnetic resonance

angiographyMRI magnetic resonance

imagingMRND modified radical neck

dissectionMRSA methicillin resistant

Staphylococcus aureusMSLT multiple sleep latency

testMWT maintenance of

wakefulness testMϕ macrophageNCCN National

Comprehensive Cancer Network

ND neck dissectionNET nerve excitability testNF neurofibromatosisNHL non-Hodgkin’s

lymphomaNIHL noise-induced

hearing lossNOE naso-orbitoethmoidNP nasopharynxNPC nasopharyngeal

carcinomaNPO nothing by mouthNREM nonrapid eye

movementNSAID nonsteroidal anti-

inflammatory drugNSTI necrotizing soft tissue

infection

COMMON ABBREVIATIONS IN OTOLARYNGOLOGY xxi

OAE otoacoustic emissionsOC oral cavityOCR ossicular chain

reconstructionOE otitis externaOHC outer hair cellOM otitis mediaOMC ostiomeatal complexOME otitis media with

effusionOP oropharynxORIF open reduction

internal fixationORL otorhinolaryngologyOSA obstructive sleep

apneaOSAS obstructive sleep

apnea syndromeOTC over-the-counterOTE over-the-earoVEMP ocular vestibular

evoked myogenic potential

OW oval windowPB max phonetically balanced

maximumPCA posterior

cricoarytenoid musclePCR polymerase chain

reactionPDT percutaneous

dilational tracheotomy

PE physical examination, pressure equalization, pulmonary embolus

PEEP positive end-expiratory pressure

PEG percutaneous endoscopic gastrostomy

PET pressure equalization tube, positron emission tomography

PLM periodic leg movement

PLMD periodic limb movement disorder

PORP partial ossicular replacement prosthesis

PPI proton-pump inhibitor

PSG polysomnographyPT prothrombin timePTA pure-tone average,

peritonsillar abscessPTH parathyroid hormonePTT partial

thromboplastin timePVFD paradoxical vocal fold

motion disorderPVFM paradoxical vocal fold

motionQOL quality of lifeRALP right anterior, left

posterior semicircular canal pair

RAST radioallergosorbent test

RDI respiratory disturbance index

REM rapid eye movementRERA respiratory effort-

related arousalRF rheumatoid factor,

radiofrequencyRFFF radial forearm free flapRLN recurrent laryngeal

nerveRPA retropharyngeal

abscess

xxii Otolaryngology-Head and Neck Surgery

RRP recurrent respiratory papillomatosis

RSTL relaxed skin tension line

RTOG Radiation Therapy Oncology Group

RW round windowRx treatmentSC subcutaneousSCC squamous cell

carcinoma, semicircular canal

SCM sternocleidomastoidSDB sleep-disordered

breathingSIADH syndrome of

inappropriate antidiuretic hormone

SL sensation levelSLE systemic lupus

erythematosusSLN superior laryngeal

nerveSLP superficial lamina

propria, speech-language pathologist

SMAS superficial musculoaponeurotic system

SMG submandibular glandSML suspension

microlaryngoscopySNHL sensorineural hearing

lossSPL sound pressure levelSQ subcutaneousSML suspension

microlaryngoscopySRT speech (spondee)

reception thresholdSSD single-sided deafness

SSNHL sudden sensorineural hearing loss

SSx signs and symptomsSTSG split-thickness skin

graftT&A tonsillectomy and

adenoidectomyTA thyroarytenoid

muscleTB tuberculosisTCA tricyclic

antidepressant, trichloroacetic acid

TEOAE transiently evoked otoacoustic emissions

TEP tracheoesophageal puncture

TFT thyroid function testTg thyroglobulinTGDC thyroglossal duct cystTID three times a dayTL total laryngectomyTLM transoral laser

microsurgeryTM tympanic membraneTMJ temporomandibular

jointTNF tumor necrosis factorTNM tumor, node,

metastasisTORCH toxoplasmosis,

other, rubella, cytomegalovirus, herpes simplex virus

TORP total ossicular replacement prosthesis

Trach tracheostomy, tracheotomy, tracheostomy tube, tracheotomy tube

COMMON ABBREVIATIONS IN OTOLARYNGOLOGY xxiii

TSH thyroid-stimulating hormone

TVC true vocal cordTVF true vocal foldU/S ultrasoundUARS upper airway

resistance syndromeUES upper esophageal

sphincterUP3 uvulopalato-

pharyngoplastyUPPP uvulopalato-

pharyngoplastyURI upper respiratory

infectionVBI vertebrobasilar

insufficiencyVC vocal cordVCD vocal cord dysfunction

(see PVFD)VDRL venereal disease

research laboratoryVEMP vestibular evoked

myogenic potential

VF vocal foldVFSS videofluoroscopic

swallow studyvHIT video head impulse

testingVNG videonystagmographyVOR vestibulo-ocular

reflexVPI velopharyngeal

insufficiencyVRA visual response

audiometryVZV varicella zoster virusW/U workupWDTC well-differentiated

thyroid carcinoma (papillary and follicular)

XRT radiation therapyYAG yttrium aluminum

garnetZMC zygomaticomaxillary

complex

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Dedicated to my family:Dad, Mom, Mamta, Aramay Ocean, Zaedyn Bear, Ayla Sofia,

Little Brother (Nasir), Anita, Jamie, Tasnim, Imran, Jazair, Rahul Uncle, Swati Auntie, Dave, Rumi, and Zephyr

— Raza

To my wife, Katrina, for her infinite support and patience; my daughters, Lily and Mia, for keeping me young; and my mother, Carol, father, Larry, and sister, Danielle, for

their unwavering kindness and encouragement.— Justin

1

Anatomy of the Nose and Paranasal Sinuses . . . . . . . . 2Paranasal Sinus Anatomy . . . . . . . . . . . . . . . . . . . . . . . 2Nose Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Physiology of the Nose and Paranasal Sinuses . . . . . . 11Physiology of the Nasal Airway . . . . . . . . . . . . . . . . . . . 11Olfactory Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Evaluation for Nasal Obstruction . . . . . . . . . . . . . . . . 13History and Physical Exam . . . . . . . . . . . . . . . . . . . . . . 13Ancillary Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Nasal Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Congenital Nasal Disorders . . . . . . . . . . . . . . . . . . . . . 16Inflammatory Nasal Masses . . . . . . . . . . . . . . . . . . . . . 16Benign Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Systemic Diseases Affecting the Nose . . . . . . . . . . . . . . . 21Nasal Anatomic Abnormalities . . . . . . . . . . . . . . . . . . . 22Olfactory Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . 25Epistaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Allergy and Rhinitis . . . . . . . . . . . . . . . . . . . . . . . . . . 34Allergic Rhinitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34Nonallergic Rhinitis . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Paranasal Sinus Disease . . . . . . . . . . . . . . . . . . . . . . . . 47Rhinosinusitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Complicated Rhinosinusitis . . . . . . . . . . . . . . . . . . . . . 50Complications of Rhinosinusitis . . . . . . . . . . . . . . . . . . 54

Sinus Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Complications of Sinus Surgery . . . . . . . . . . . . . . . . . . . 61

Immunology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63Immunodeficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Chapter

1rhinology and Paranasal Sinuses

matthew kim, Qasim Husain, Justin S. golub, Steven c. marks, and raza Pasha

2 Otolaryngology-Head and Neck Surgery

ANATOMY OF THE NOSE AND PARANASAL SINuSES

Paranasal Sinus Anatomy

Lateral Nasal Wall (see Figure 1–1)

• Turbinates (Conchae): three to four bony shelves (inferior, middle, superior, and supreme [normal variant]) covered by erectile mucosa, serve to increase the interior surface area; function to warm, moisture, and filter airflow

• Meatuses: spaces located beneath each turbinate 1. Superior Meatus: drainage pathway of the sphenoid and

posterior ethmoid sinuses 2. Middle Meatus: drainage pathway of the frontal, anterior

ethmoid, and maxillary sinuses 3. Inferior Meatus: contains orifice of the nasolacrimal duct

• uncinate Process: sickle-shaped thin bony part of the ethmoid bone covered by mucoperiosteum; anteriorly attaches to lacrimal bones; inferiorly attaches to the inferior turbinate; superiorly attaches to lamina papyracea (80%), roof of the ethmoid (base of skull), or middle turbinate

• Ethmoid Infundibulum: pyramidal space that houses the drainage of the maxillary, anterior ethmoid, and frontal sinuses

• Recess Terminalis: blind pouch in the infundibulum created when the uncinate inserts superiorly into the lamina papyracea

• Semilunar Hiatus: gap that empties the ethmoid infundibulum, located between the uncinate process and the ethmoid bulla

• Sphenopalatine Foramen: posterior to inferior attachment of the middle turbinate; contains sphenopalatine artery, sensory nerve fibers, and secretomotor fibers (parasympathetic fibers from vidian nerve to pterygopalatine ganglion)

• Concha Bullosa: a pneumatized turbinate (middle turbinate most common), may result in nasal obstruction or obstruction of the osteomeatal complex

• Paradoxical Middle Turbinate: a middle turbinate that is “turned” medially instead of laterally

• Ostiomeatal Complex (OMC): region referring to the anterior ethmoids containing the ostia of the maxillary, frontal, and ethmoid sinuses; lateral to the middle turbinate

• Nasal Fontanelles: areas of the lateral nasal wall where no bone exists, located above the insertion of the inferior turbinate, may be the site of accessory maxillary ostia

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• Nasolacrimal Duct and Sac: duct is located lateral to the anterior uncinate process, sac is lateral to the agger nasi cell and opens into the inferior meatus via Hasner’s valve, located 3–6 mm anterior to level of maxillary sinus ostium

Frontal Sinus• Embryology: last to develop, does not pneumatize until 5–6 years old• Volume at Adult: 4–7 mL by 12–20 years old (5–10% aplastic/

hypoplastic)• Drainage: frontal recess into the anterior middle meatus most

commonly medial to the uncinate (when uncinate attaches superiorly to the lamina papyracea) or lateral to the uncinate (when uncinate attaches superiorly to skull base or middle turbinate)

• Vasculature: supraorbital and anterior ethmoidal arteries, ophthalmic (cavernous sinus) and supraorbital (anterior facial) veins

• Innervation: supraorbital nerve (CN V1)• Frontal Recess: drainage space between the frontal sinus and

semilunar hiatus/middle meatus; bounded by the posterior wall of the agger nasi cell, lamina papyracea, and middle turbinate

• Frontal Sinus Infundibulum: space that drains into frontal recess, superior to the agger nasi cells

• Foramina of Breschet: small venules that drain the sinus mucosa into the dural veins

• Frontal Cells: anterior ethmoid cells that pneumatize the frontal recess, may cause obstruction or persistent disease, posterior to the agger nasi cell, 4 types (as defined by Bent and Kuhn)

Type I: single cell above agger nasi cell but below the floor of the frontal sinus (infundibulum)Type II: multiple cells above agger nasi cell, may extend into the frontal sinus properType III: single large cell that extends supraorbitally through the floor of the frontal sinus, attaches to the anterior tableType IV: single isolated cell that is within the frontal sinus

Maxillary Sinus• Embryology: first to develop in utero, biphasic growth at 3 and 7–18

years old• Volume at Adult: typically 15 mL (largest paranasal sinus)• Drainage: ethmoid infundibulum (middle meatus, 10–30% have

accessory ostium)• Vasculature: branches of maxillary artery and corresponding veins to

facial vein/pterygoid plexus

CHAPTER 1 Rhinology and Paranasal Sinuses 5

• Innervation: branches of maxillary nerve (CN V2)• Adjacent Structures: lateral nasal wall, alveolar process of maxilla

(contains second bicuspid and first and second molars), orbital floor, posterior maxillary wall (contains pterygopalatine fossa housing the maxillary artery, pterygopalatine ganglion, and branches of CN V2 )

Ethmoid Sinus• Embryology: three to four cells at birth (most developed paranasal

sinus at birth), formed from 5 ethmoturbinals (1 = agger nasi, uncinate; 2 = middle turbinate; 3 = superior turbinate; 4–5 = supreme turbinate; may vary by source)

• Volume at Adult: 10–15 aerated cells, total volume of 2–3 mL (adult size at 12–15 years old)

• Drainage: anterior cells drain into the ethmoid infundibulum (middle meatus), posterior cells drain into the superior meatus

• Vasculature: anterior and posterior ethmoid arteries (from ophthalmic artery), branches of sphenopalatine artery; see Figure 1–2 for distance relationships of anterior and posterior ethmoid arteries and optic foramen to the anterior lacrimal crest (“24/12/6 rule”); maxillary and ethmoid veins (cavernous sinus)

• Innervation: anterior and posterior ethmoidal nerves (from nasociliary nerve, CN V1 )

• Adjacent Structures: skull base, anterior ethmoid artery (roof of anterior ethmoid cells), nasal cavity, orbit

• Agger Nasi Cells: most anterior of anterior ethmoid cells found anterior and superior to the middle turbinate attachment to the lateral wall, the posterior wall of the agger nasi cells forms the anterior wall of the frontal recess

• Ethmoid Bulla: the largest of the anterior ethmoid cells that lies above the infundibulum, the anterior ethmoid artery courses superior and posterior to this cell

• Basal (Ground) Lamella of the Middle Turbinate: bony attachment of the middle turbinate to lateral nasal wall that separates anterior and posterior ethmoid cells; anterior part inserts vertically into the crista ethmoidalis, middle part inserts obliquely into the lamina papyracea, posterior third attaches to the lamina horizontally

• Onodi Cells: ethmoid cells that pneumatize lateral or posterior to anterior wall of the sphenoid, commonly mistaken as sphenoid cells; optic nerve or carotid artery may indent into the lateral wall

• Haller Cells: ethmoid cells that extend into maxillary sinus above the ostium, pneumatize the medial and inferior orbital walls

• Lamina Papyracea: lateral thin bony wall of the ethmoid sinus, separates orbit from ethmoid cells as a part of the medial orbital wall

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• Fovea Ethmoidalis: roof of ethmoid sinus• Supraorbital Cell: pneumatization of the posterior orbital plate of

the frontal bone often forms septations in the frontal recess• Olfactory Fossa: depression in anterior cranial cavity with floor

formed by cribiform plate, below which lies the olfactory cleft; Keros classification describes distance relationship between fossa and ethmoid roof (Type 1: 1–3 mm, Type 2: 4–7 mm, Type 3: 8–16 mm); Type 3 has higher risk of violating skull base

• Lamellae of Ethmoid Bone (anterior to posterior): 1 = uncinate process, 2 = bulla ethmoidalis, 3 = basal lamella of middle turbinate, 4 = lamella of superior turbinate

Sphenoid Sinus• Embryology: evagination of nasal mucosa into sphenoid bone• Volume at Adult: 0.5–8 mL (adult size at 12–18 years old)• Drainage: sphenoethmoidal recess• Vasculature: posterior ethmoidal and sphenopalatine arteries,

maxillary vein (pterygoid plexus)• Innervation: posterior ethmoidal nerves (CN V1)• Adjacent Structures: pons, pituitary (sella turcica), carotid artery

(lateral wall, 25% dehiscent), optic nerve (lateral wall, 5% dehiscent), cavernous sinus (laterally), CN V2 and VI, clivus, septal branch of the sphenopalatine artery (inferior aspect of the sphenoid os)

Nose Anatomy

External Nose• Piriform Aperture: bounded inferolaterally by maxilla and superiorly

by nasal bones• upper Lateral Cartilage: inferior to nasal bone (paired)• Lower Lateral (Greater) Alar Cartilage: cartilage inferior to the

upper lateral cartilage, composed of lateral and medial crura (paired)• Lesser Alar Cartilage: small cartilaginous plates that are lateral to the

lower lateral alar cartilage (paired)• Septum: see below• Muscles: procerus, nasalis, dilator naris anterior, depressor septi and

levator labii superioris alaeque nasi; all innervated by CN VII• Nasal (Aesthetic) Subunits: see pp. 485–487

Nasal Septum (see Figure 1–3)

• Quadrangular Cartilage: septal cartilage

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• Perpendicular Plate of the Ethmoid: projects from cribriform plate to septal cartilage

• Vomer: posterior and inferior to perpendicular plate• Nasal Crest (Maxillary and Palatine Bone): trough of bone that

supports the septal cartilage• Anterior Nasal Spine: bony projection anterior to piriform aperture

Nasal Cavity• Vestibule: lies just inside the naris anterior to the limen nasi (ridge

that marks beginning of nasal cavity), lined by keratinized stratified squamous epithelium with coarse hair-bearing skin inferiorly

• Roof: bounded by nasal/frontal bone anteriorly, cribiform plate and sphenoid face posteriorly

• Floor: formed by palatine process of maxilla and horizontal plate of palatine bone, communicates with piriform aperture anteriorly and choana posteriorly

• Septum and Lateral Wall

Sensory Innervation

External Innervation• supratrochlearandinfratrochlearnerves(CNV1): nasal dorsum• externalnasalbranchofanteriorethmoid(CNV1): nasal tip• infraorbitalnerve(CNV2): malar, lateral nose, and subnasal regions

Internal Innervation• internalnasalbranchofanteriorethmoid(CNV1): anterosuperior

nasal cavity• posteriorethmoidnerve(CNV1): posterosuperior nasal cavity• naspopalatinenerve(CNV2): posterior and inferior septum• greaterpalatinenerve(CNV2): posterior lateral wall, floor, and roof• superioralveolarnerve(CNV2): anterior septum, floor, and lateral

wall

Vascular Anatomy (see Figures 1–1 and 1–3)

External Carotid Artery Branches

Maxillary Artery (Internal Maxillary Artery)

• descendingpalatineartery→ greater palatine and lesser palatine arteries


• sphenopalatineartery→ sphenopalatine foramen (posterior to the middle turbinate) → medial (nasoseptal) and lateral nasal artery (middle and inferior turbinates)

Facial Artery

• superiorlabialartery→ collumella, nasal septum, and alar branches

• lateralnasalartery• angularartery→ nasal sidewall, tip, and dorsum

Internal Carotid Artery → Ophthalmic Artery• anteriorethmoidartery(largerthantheposteriorethmoidartery)→

lateral nasal wall and septum• posteriorethmoidalartery→ superior turbinate and septum• dorsalnasalartery→ external nose

Venous System• greaterpalatinevein→ posterior facial vein (external jugular vein)

and cavernous sinus• septalvein→ anterior facial vein (internal jugular vein)• sphenopalatinevein→ cavernous sinus and maxillary vein (internal

jugular vein)• anteriorandposteriorethmoidalveins→ ophthalmic veins

(cavernous sinus)• angularvein→ anterior facial vein (internal jugular vein) or

ophthalmic veins (cavernous sinus)• “Danger Triangle”: bounded by oral commissures and nasal bridge,

retrograde drainage from superficial veins may lead to intracranial extension of infection

Lymphatics• External: primarily to level Ib, root of nose to superficial parotid

nodes• Internal: anterior nasal cavity drains superficially and then to level IB,

rest drains to retropharyngeal and upper cervical nodes

Documents

Head neck - Plural Publishing, Inc. · of Head and Neck Surgery Kaiser Permanente-Southern California, Anaheim, CA Clinical Asst. Professor Department of Otolaryngology/ Head and