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The evolution of perioperative pain management in otolaryngology—head and neck surgery

Overview and historical pain management Perioperative pain management is an essential component of surgical care. In the United States, an estimated 360,000–420,000 head and neck surgeries are performed annually. Pain severity tends to differ depending upon the type of otolaryngological procedure performed as well as with the anatomic location of the procedure. Opioid pain medications have been a mainstay in the treatment of acute perioperative pain…

Antral Lavage; Endoscopic Middle Meatal Antrostomy/Antrochoanal Polyp

Introduction Since the 1980s, the surgical approach to the maxillary sinuses has been revolutionized by the endoscopic endonasal approach. The goals of treatment of maxillary sinus disease are aeration and resumption of normal mucociliary flow. Additionally, there is an increasing number of surgeons who now operate with a goal of access for topical medications. Although often believed to be the one of the most straightforward steps…

Balloon Sinus Dilation

Introduction Sinus surgery continues to evolve, greatly enhanced by technological innovations. Thirty years ago, largely due to advances in endoscopic visualization, functional endoscopic sinus surgery (FESS) became less extirpative than traditional operative sinus surgery. Now another stage in this evolution is occurring toward minimally invasive sinus procedures such as office-based balloon sinuplasty. This technique, performed under local/topical anesthesia, affords several distinct benefits over sinus surgery under…

Rhinectomy

Introduction The nose is the most prominent part of the face defining an individual’s unique identity. It plays an important role functionally and aesthetically. However, the prominent position of the nose also accounts for its constant exposure to sunlight and thus for its predisposition to the development of cancer of the overlying skin. Thus surgical resection of the nose, rhinectomy, presents a difficult problem for both…

Surgical Management of Hereditary Hemorrhagic Telangiectasia

Introduction Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant genetic disorder with incomplete penetrance that is characterized by arteriovenous malformations (AVMs) in various organs and mucocutaneous telangiectasias in the nose, oral cavity, gastric mucosa, and fingers. Diagnosis is based on the Curaçao criteria, established in 2000 ( Table 100.1 ). Recurrent epistaxis is the most common symptom, present in almost all patients who have HHT by…

Operative Otolaryngology: Anterior and Posterior Ethmoid Artery Ligation for Epistaxis

Introduction Epistaxis is a common medical problem; however, the exact prevalence of this condition is unknown because patients themselves manage many cases conservatively. It is believed the prevalence may be as high as 30% in children younger than 5 years old and up to 50% in children aged between 6 and 15 years. In adults, the prevalence of epistaxis has not been as well documented but…

Sphenopalatine Artery Ligation for Epistaxis

Introduction Most episodes of epistaxis are minor and self-limited and originate in the anterior nasal cavity. Posterior epistaxis, however, can be life threatening and is usually associated with bleeding from branches of the sphenopalatine artery (SPA). Rarely, the ethmoidal arteries or internal carotid artery (ICA) may be a source of severe epistaxis. Proper evaluation of the patient can usually reveal the source of the bleeding and…

Surgery of the Turbinate

Introduction Surgical therapy for the inferior or middle turbinates is most commonly indicated in the setting of turbinate hypertrophy and chronic nasal obstruction that has failed to improve with medical therapy. Surgery of the turbinate may be an isolated stand-alone procedure or carried out in conjunction with a nasal septoplasty in which compensatory inferior turbinate hypertrophy may be present on the concave side of a significantly…

Nasal Septal Perforation

Introduction The nasal septum plays an important role in the structural and physiologic functions of the nose, contributing to nasal shape, appearance, and laminar airflow. The septum is made up of three distinct layers. Superficially, the mucosa is made up of ciliated respiratory epithelium. High in the nasal vault, in the region of the olfactory cleft, the mucosa is incorporated with specialized olfactory epithelium. Deep to…

Septoplasty—Classic and Endoscopic

Introduction The most common structural cause of persistent nasal obstruction unresponsive to nasal decongestants or medical therapy is a deformity of the nasal septum. Septal deformities may be cartilaginous, bony, or both, with tilts to the septum, curves, spurs, twists, angulations, telescoping segments, or any combination thereof. A septal deviation can be observed within a nasal framework that is straight externally, crooked, twisted, or collapsed and…

Office-Based Diagnosis of Sinonasal Disorders

Introduction Nasal endoscopy is integral to the physical examination of patients with sinonasal symptoms seeking management from the otolaryngologist. With proper local decongestion and anesthesia, it is possible to obtain excellent visualization of the nasal mucosal lining, middle meatus, inferior meatus, sphenoethmoid recess, olfactory cleft, turbinates, septum, and nasopharynx with minimal discomfort to the patient. Anesthesia is accomplished with a variety of techniques, including atomizers using…

Deep Lobe Parotidectomy

Introduction The most common indication for surgery of the parotid gland is the presence of a mass or tumor. The majority of distinct parotid masses are neoplasms with benign tumors predominating. Pleomorphic adenoma (mixed tumor) and Warthin tumor (papillary cystadenoma lymphomatosum) account for the majority of benign lesions with adenomas and oncocytomas being encountered regularly. Malignant tumors of the parotid gland represent a heterogeneous group of…

Superficial Parotidectomy

Introduction Tumor resection is the most common indication for superficial parotidectomy. Approximately 85% of parotid neoplasms are benign. Malignant tumors vary greatly in behavior, from the indolent (acinic cell carcinoma) to the highly lethal (carcinosarcoma). A recent surveillance epidemiology and end results (SEER) data base review of more than 22,000 cases showed that mucoepidermoid carcinoma continues to be the most common salivary gland malignancy (31%). Some…

Excision of the Submandibular Gland

Introduction The submandibular gland is one of three paired major salivary glands that drains into the oral cavity. It is midway in size and location between the largest, the parotid gland, and the smallest, the sublingual gland. Histologically, it consists of both serous and mucinous acini, which collectively drain into an excretory duct that carries the secreted saliva into the oral cavity. The gland is located…

Mass in the Buccal Space

Introduction A mass appearing within the substance of the cheek is unusual and suggests a tumor of the buccal space or the accessory lobe of the parotid gland. The buccal space, first described by Kostrubala in 1945, is a potential space between the buccinator muscle and the more superficial muscles of facial expression ( Fig. 90.1 ). There are a number of reports of buccal space…

Surgical Management of Ranula

Introduction A ranula is an extravasation mucocele that arises in the floor of mouth secondary to trauma to the sublingual gland or obstruction of the salivary ducts. The term ranula is derived from the Latin word rana , meaning frog, which describes the bluish floor of mouth swelling that resembles a frog’s underbelly. These lesions are classified into two types: oral or simple ranulas and cervical…

Salivary Endoscopy

Introduction Salivary endoscopy is a minimally invasive technique for the treatment of a variety of inflammatory salivary gland pathologies. The procedure has been in practice globally since the early 1990s. The small high-resolution telescopes are in their fifth generation of development and now incorporate rinsing and instrumentation capabilities. The technique is useful for removing calculi and treating stenosis, as well as for inflammatory conditions such as…

Office-Based Procedures

Introduction The breadth of office-based procedures continues to expand within the field of otolaryngology. Office-based procedures allow for prompt, low-cost diagnosis and management of many otolaryngological conditions. Fine needle aspiration (FNA) is a well-established procedure, which provides prompt and accurate diagnosis of neck pathology, including saliva gland and thyroid masses. The application of ultrasound guidance improves accuracy as well as diagnostic yield. In addition, the application…

Reoperative Parathyroidectomy

Introduction Parathyroidectomy for primary hyperparathyroidism has a success rate of 90% to 95% among experienced surgeons. However, management of persistent hyperparathyroidism following surgery can be challenging. Careful preoperative analysis of factors that lead to the failure of the initial surgery must be performed prior to reoperative parathyroidectomy. After confirmation of the diagnosis of persistent hyperparathyroidism, all prior operative reports, pathology reports, and imaging studies should be…

Parathyroidectomy for Secondary Hyperparathyroidism

Introduction Secondary hyperparathyroidism (SHPT) is a consequence of the decreased concentration of ionized calcium in the blood, which may have many causes. SHPT is characterized by increased compensatory parathyroid hormone (PTH) secretion due to the malabsorption of intestinal calcium mainly caused by chronic renal disease. For this reason, SHPT is often referred to as renal SHPT, but it may be due to other chronic conditions that…