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.
Typeset in 9/11 Adobe Garamond Pro by Flanagan’s Publishing Services, Inc.Printed in the United States of America by McNaughton & Gunn
All rights, including that of translation, reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording, or otherwise, including photocopying, recording, taping, Web distribution, or information storage and retrieval systems without the prior written consent of the publisher.
For permission to use material from this text, contact us byTelephone: (866) 758-7251Fax: (888) 758-7255e-mail: [email protected]
Every attempt has been made to contact the copyright holders for material originally printed in another source. If any have been inadvertently overlooked, the publishers will gladly make the necessary arrangements at the first opportunity.
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
SurgeryNewYork-Presbyterian HospitalUniversity Hospital of Columbia
and CornellNew York, New YorkChapters 1 and 9
Rohan R. Joshi, MDResident PhysicianOtolaryngology–Head and Neck
SurgeryNewYork-Presbyterian HospitalUniversity Hospital of Columbia
and CornellNew York, New YorkChapters 9 and 11
Sarah E. Keesecker, MDResident PhysicianOtolaryngology–Head and Neck
SurgeryNewYork-Presbyterian HospitalUniversity Hospital of Columbia
and CornellNew York, New YorkChapter 5
Peggy E. Kelley, MD, FACS, FAAPAssociate Professor of
OtolaryngologyUniversity of ColoradoPediatric OtolaryngologyAurora, ColoradoChapter 10
Matthew Kim, MDResident PhysicianOtolaryngology–Head and Neck
SurgeryNewYork-Presbyterian HospitalUniversity Hospital of Columbia
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
SurgeryNewYork-Presbyterian HospitalUniversity Hospital of Columbia
and CornellNew York, New YorkChapter 4
Kenny F. Lin, MDResident PhysicianOtolaryngology–Head and Neck
SurgeryNewYork-Presbyterian HospitalUniversity Hospital of Columbia
and CornellNew York, New YorkChapter 4
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
SurgeryNewYork-Presbyterian HospitalUniversity Hospital of Columbia
and CornellNew York, New YorkChapter 6
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
and CornellNew York, New YorkChapters 2 and 11
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
Found an error?
Untruth?
Alternative fact?
Typo?
Dot out of place?
We welcome any tips, suggestions, criticisms, or corrections for this dynamic reference guide. Please e-mail [email protected]
Please keep to this simple format:• YourName• YourE-mail• YourPhoneNumber• YourComment/Illustration• ReferenceSupporttoYourComment/Illustration
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
3
Orif
ice
of
sphe
noid
al s
inus
Sphe
nopa
latin
efo
ram
en
Fron
tal s
inus
Agge
r nas
i
Cut
edg
e of
infe
rior t
urbi
nate
Cut
edg
e of
the
supe
rior t
urbi
nate
Ost
ium
of
naso
lacr
imal
duct
Sem
iluna
ris
hiat
us
Ethm
oida
lbu
lla
Sphe
noid
sin
us
Unc
inat
epr
oces
s
Fron
tal r
eces
s
Ante
rior e
thm
oid
arte
ry
Post
erio
r eth
moi
d ar
tery
Gre
ater
pala
tine
arte
ry
Sphe
nopa
latin
ear
tery
Gre
ater
pala
tine
fora
men
Inci
sive
cana
l
Sella
turc
ica
FIG
uR
E 1–
1. A
nato
my
of
the
late
ral n
asal
wal
l inc
ludi
ng
vasc
ular
supp
ly.
4 Otolaryngology-Head and Neck Surgery
• 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
6
6 m
m12
mm
24 m
m
Pos
terio
ret
hmoi
dal
arte
ry
Ant
erio
ret
hmoi
dal
arte
ryA
nter
ior
lacr
imal
cre
st
Opt
ic fo
ram
en
FIG
uR
E 1–
2. A
nato
mic
rela
tions
hip
betw
een
ethm
oida
l art
erie
s and
bon
y la
ndm
arks
(“24
/12/
6 ru
le”).
CHAPTER 1 Rhinology and Paranasal Sinuses 7
• 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
8
Pter
ygoi
d ha
mul
us
Perp
endi
cula
r pla
te
of th
e pa
latin
e bo
ne
Fron
tal s
inus
Kies
selb
ach'
s pl
exus
Max
illar
ycr
est (
nasa
l cr
est o
f the
m
axill
ary
bone
)
Vom
erPerp
endi
cula
r pla
teof
eth
moi
d bo
ne
Sphe
noid
si
nus
Qua
dran
gula
r(s
epta
l) ca
rtila
ge
Sept
al b
ranc
hof
sup
erio
rla
bial
arte
ry
Sept
al b
ranc
h of
ante
rior e
thm
oid
arte
ry
Post
erio
r eth
moi
d ar
tery
Nas
al c
rest
of t
he
pala
tine
bone
Nas
al b
one
Inci
sive
cana
l
Ante
rior
nasa
l spi
ne
Med
ial p
late
of t
he
pter
ygoi
d pr
oces
s (s
phen
oid
bone
)
Gre
ater
pa
latin
e ar
tery
Sella
tu
rcic
a
Sphe
nopa
latin
e ar
tery
FIG
uR
E 1–
3. A
nato
my
of th
e se
ptum
incl
udin
g va
scul
ar su
pply.
CHAPTER 1 Rhinology and Paranasal Sinuses 9
• 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
10 Otolaryngology-Head and Neck Surgery
• 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