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Visual Documentation of the Larynx

Key Points Laryngeal endoscopy, using flexible or rigid endoscopes, is used to examine vocal fold structure and gross function. Videostroboscopy is used to examine vocal fold vibration patterns and the relationship between the body and the cover. Laryngeal high-speed videoendoscopy complements endoscopy and stroboscopy by showing details of short and aperiodic vibration and quantifying vibration parameters. Narrow-band imaging uses the tissue's light-absorption characteristics to show vascular…

Laryngeal and Pharyngeal Function

Key Points The upper aerodigestive tract serves the competing functions of respiration and swallowing. The anterior ends of the vocal folds are fixed at the anterior commissure. All motion of the vocal folds is caused by muscles that move the arytenoid cartilage. The posterior cricoarytenoid muscle is the only muscle that actively opens the larynx. The recurrent laryngeal nerve supplies all intrinsic laryngeal muscles except for…

Facial Pain

Key Points Facial pain is a frustrating and debilitating condition for patients and can be a diagnostic challenge for the clinician. Management and diagnosis of facial pain requires a multidisciplinary team approach. Determining the pathology of facial pain is vital to the eventual diagnosis of the underlying condition. Introduction Facial pain is defined as pain that occurs between the hairline and the inferior border of the…

Systemic Disease of the Nose and Sinuses

Key Points Several inflammatory, infectious, and neoplastic disorders can present with nonspecific sinonasal symptoms requiring a high index of suspicion for timely diagnosis by the otorhinolaryngologist. Granulomatosis with polyangiitis (GPA) frequently presents with sinonasal involvement, including crusting, bloody discharge, septal perforation, saddle nose deformity, and epiphora. Sarcoidosis can manifest with various head and neck manifestations, including nasal subcutaneous nodules, lupus pernio, supraglottic nodules, and salivary gland…

Benign Tumors of the Sinonasal Tract

Key Points Unilateral nasal obstruction is the most common symptom in patients with either benign or malignant tumors of the sinonasal tract. Therefore, any patient with this complaint should be assessed with endoscopy, imaging studies, and, if required, histologic examination to establish an accurate diagnosis. Osteoma and inverted papillomas are the first and the second most frequent benign tumors of the sinonasal tract, respectively. However, because…

Sino-Orbital Interface

Key Points Endoscopic orbital surgery requires a multidisciplinary approach by an oculoplastic surgeon and an otolaryngologist with proficiency in both rhinologic and orbital surgery. Chronic epiphora should be investigated with a dacryocystogram, and possibly a scintillogram, prior to surgery, to localize the site of obstruction to ensure that it is amenable to dacryocystorhinostomy (DCR). If these studies are unavailable, expert clinical exam with Jones I and…

Cerebrospinal Fluid Rhinorrhea

Key Points Cerebrospinal fluid (CSF) rhinorrhea may be classified as traumatic (>90%) and nontraumatic (<10%). Approximately 80% of all traumatic leaks occur in the setting of accidental trauma, and the remaining traumatic CSF leaks occur after neurosurgical and rhinologic procedures. Nontraumatic etiologies include neoplasms and hydrocephalus. Idiopathic nontraumatic CSF rhinorrhea has been linked with elevated intracranial pressure. Numerous studies have confirmed an association of idiopathic nontraumatic…

Epistaxis

Key Points Epistaxis is a common otorhinolaryngologic complaint encountered by multiple medical disciplines and is the most common otorhinolaryngologic emergency. The vascular anatomy of the nose is extremely rich, with bilateral supply from both the external and internal carotid systems. Initial assessment should include evaluating the ABCs and identifying any underlying causes that predispose to bleeding. Identifying the site of bleeding allows for direct source control,…

Management of the Frontal Sinuses

Key Points Only instrument the frontal recess with good reason and sound intention. Functional drainage of the frontal sinus relies on preservation of the mucosa of the frontal recess. If the mucosa of the frontal recess cannot be preserved, a Draf III procedure is usually indicated. Maintain bony support around the frontal recess whenever possible. Do not use stents. Obliteration is avoided wherever possible, but if…

Causes of Failure, Revision Surgery for Rhinosinusitis, and Management of Complications in Endoscopic Sinus Surgery

Key Points Primary functional endoscopic sinus surgery (FESS) is an effective technique for relieving sinus ostial obstruction, removing osteitic bony partitions, decreasing inflammatory burden, and preparing the nasal cavity for topical medications. The initial surgery represents the greatest chance for long-term success. Patients who come to medical attention with headache and facial pain without concomitant inflammatory findings should have a workup for non-sinogenic etiologies prior to…

Primary Sinus Surgery

Key Points Primary surgery for chronic rhinosinusitis is almost exclusively performed endoscopically. Functional endoscopic sinus surgery (FESS) aims to restore mucociliary function by reestablishing physiologic sinus ventilation and drainage. Surgery should be personalized. The extent of surgery depends on symptoms and the pathology. “Large” hole surgery may be employed in certain disease states to optimize topical drug delivery. Identification of anatomic landmarks and variations helps limit…

Chronic Rhinosinusitis: Outcomes of Medical and Surgical Treatment

Key Points Outcomes research for chronic rhinosinusitis (CRS) has evolved significantly over the last decade. Although many types of outcome measures exist, patient-reported outcomes measures (PROMs) are currently the most commonly used metrics. The 22-question Sinonasal Outcomes Test (SNOT-22) has been thoroughly validated and is the most widely employed PROM at this time. When utilizing any outcome measure, it remains important to identify that improvements are…

Chronic Rhinosinusitis: Evidence-Based Medical Treatment

Key Points Strongly Recommended Therapies High volume saline irrigations and topical intranasal corticosteroids are supported by a strong recommendation for the treatment of chronic rhinosinusitis with and without nasal polyps (CRSwNP and CRSsNP). Recommended Therapies Nonstandard delivery of topical intranasal steroids in irrigations (budesonide irrigation) is supported for use in CRS (CRSwNP and CRSsNP) by moderate evidence as a recommendation. Aspirin desensitization is recommended in CRS…

Pathogenesis of Chronic Rhinosinusitis

Key Points Chronic rhinosinusitis (CRS) comprises a group of disorders that arise from complex inflammatory processes triggered by the interaction between an array of environmental agents and the host mucosal immune system. CRS is overwhelmingly idiopathic; however, few patients have an established association with systemic immunologic or genetic diseases. Comprehensive theories on the etiology and pathogenesis of idiopathic CRS have been proposed that place particular emphasis…

Acute Rhinosinusitis: Pathogenesis, Treatment, and Complications

Key Points Understanding the pathogenesis of rhinosinusitis depends on defining the specific types of rhinosinusitis. Acute bacterial rhinosinusitis (ABRS), chronic rhinosinusitis (CRS), and acute exacerbation of chronic rhinosinusitis (AECRS) are three distinct entities. A number of environmental and host factors predispose to the development of rhinosinusitis; these include allergy, infection, and environmental exposures. Acute rhinosinusitis is usually the result of a viral infection, whereas ABRS occurs…

Nonallergic Rhinitis

Key Points Nonallergic rhinitis (NAR) is a chronic, highly prevalent condition that presents with symptoms of nasal congestion, obstruction, and rhinorrhea in the setting of a negative allergen test. In contrast to allergic rhinitis (AR), NAR has a greater predilection for women and older adults, and is more likely to present with perennial symptoms. The pathophysiology of NAR is a non-IgE-mediated inflammatory process resulting from dysregulation…

Imaging of Nose and Sinuses

Key Points The diagnosis of acute rhinosinusitis is made on clinical grounds, and imaging is reserved for cases with suspected intracranial and orbital complications. Computed tomography (CT) is the modality of choice in imaging of chronic rhinosinusitis (CRS) and planning for functional endoscopic sinus surgery (FESS) because of the excellent bone detail provided. Acute secretions of the sinuses are of low attenuation on CT and resemble…

Objective Assessment of Nasal Function

Key Points Ciliary activity causes the transport of mucus in the airways, an essential defense mechanism of the respiratory tract. Mucociliary transport can be measured in vivo either by using the saccharine and/or color test or by radioisotope transport testing, and in vitro by measuring ciliary activity. Nasal nitric oxide was found to be 10-fold lower in patients with primary ciliary dyskinesia (PCD), but it cannot…

Olfactory Function and Dysfunction

Key Points Olfaction is important for hazard avoidance and quality of life. Olfactory dysfunction affects 20% of the general population and is most commonly caused by sinonasal disease, upper respiratory tract infections, head trauma, normal aging, and neurodegeneration. Olfactory dysfunction should be diagnosed through clinical history, examination, and psychophysical testing. Treatment of dysfunction should be in line with currently available guidelines. The sense of smell is…

Allergy and Immunology of the Upper Airway

Key Points The immune system protects the organism from infectious microbes and avoids responses that produce damage to host tissues. The immune system is divided into the innate and adaptive systems. The adaptive immune system recognizes different specific antigens, adapts to changing environments, and provides immunologic memory. The innate immune system includes all aspects of the host defense mechanisms, such as barrier mechanisms (epithelium, mucous layer,…