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Frontal Sinusotomy—Draf I and IIa

Introduction ▪ Dissection of the frontal recess is the most difficult of the basic endoscopic dissections. ▪ Care must be taken to preserve the mucosa surrounding the frontal recess. Stripping of mucosa can result in postoperative stenosis and neo-osteogenesis. ▪ The frontal recess is difficult for another reason: the variable anatomy that can present an obstruction within the frontal recess. Frontal recess cells, posteriorly located frontal…

Sphenoidotomy

Introduction ▪ There are two ways to approach and perform a sphenoidotomy: transnasal and transethmoid. ▪ In the transnasal approach, the sphenoidotomy is performed while sparing the ethmoid cavity. Dissection proceeds medial to the middle turbinate. Common indications for this approach are isolated pathologic processes within the sphenoid sinus (e.g., fungal ball, isolated sphenoid sinusitis). This approach may also be combined with a posterior septectomy for…

Partial and Complete Ethmoidectomy

Introduction ▪ The terms partial and complete ethmoidectomy refer to the removal of the anterior and posterior ethmoids ( Figs. 7.1 and 7.2 , respectively). ▪ A partial ethmoidectomy is the removal of the ethmoid bulla and any cells against the medial orbital wall anterior to the basal lamellae. ▪ A partial ethmoidectomy is often combined with a maxillary antrostomy and termed mini–FESS. The most common…

Maxillary Antrostomy

Introduction ▪ The maxillary antrostomy is the first step in performing functional endoscopic sinus surgery. ▪ Based on a good working knowledge of the anatomy and using proper visualization and mucosa-sparing techniques, a well-performed maxillary antrostomy will not only address maxillary sinus disease but properly set up the remaining portions of the sinus surgery. Anatomy ( Figs. 6.1, 6.2, and 6.3 ) ▪ The uncinate process…

Endoscopic Repair of Choanal Atresia

Introduction The opening of choanal atretic plates can be obtained by various techniques. Despite the substantial available published literature on the treatment modalities of choanal atresia, the optimum technique is not fully established. The choice many times depends on the surgeon’s preference. This chapter describes the cross-over flap technique, which can be employed in unilateral or bilateral choanal atresia. Surgical endoscopic techniques incorporating mucosal flaps have…

Endoscopic and Open Anterior/Posterior Ethmoid Artery Ligation

Introduction ▪ The anterior ethmoid artery (AEA) and the posterior ethmoid artery (PEA) are major vessels supplying the ethmoid sinus, septum, and anterior skull base. ▪ Control of these vessels is a key step in performing extended sinus and skull base procedures. ▪ The critical location of these vessels, which traverse the orbit and roof of the ethmoid sinus, makes iatrogenic damage to these vessels potentially…

Sphenopalatine/Internal Maxillary Artery Ligation

Introduction ▪ Epistaxis is one of the most common otolaryngologic emergencies. ▪ Minor epistaxis usually originates from the anterior nasal septum and is often satisfactorily treated with direct pressure or anterior nasal packing. ▪ Epistaxis that is not controlled by adequate anterior nasal packing can be pragmatically defined as posterior epistaxis. Refractory posterior epistaxis is continued hemorrhage that occurs despite placement of anteroposterior nasal packing or…

Middle and Inferior Turbinates

Introduction ▪ Turbinate surgery is performed most commonly to treat obstruction. Examples are nasal airway obstruction caused by oversized inferior turbinates and obstruction of sinus drainage by a lateralized middle turbinate or concha bullosa. ▪ The middle and inferior turbinates are dynamic functional structures within the nasal cavity and sinuses. Anatomic variations and/or dysfunction commonly lead to the need for turbinate reduction or resection. ▪ Total…

Septoplasty

Introduction ▪ The nasal septum plays a key role in the form and function of the nose, nasal cavity, and paranasal sinuses. ▪ Septal deformities are common and occur in nearly 77% to 90% of the general population worldwide. ▪ Even small deviations in key areas have been shown to adversely affect nasal airflow, delivery of nasal medications, mucociliary clearance, and the external appearance of the…

Sample Uveitis Questionnaire

Family History These questions refer to your parents, grandparents, children, grandchildren, brothers, sisters, aunts, and uncles. Has anyone in your family had: Cancer Yes No Diabetes Yes No Allergies Yes No Arthritis or rheumatism Yes No Syphilis Yes No Tuberculosis Yes No Sickle cell disease or trait Yes No Lyme disease Yes No Has anyone in your family had medical problems of the: Eyes Yes No…

Masquerade Syndromes

Key Concepts The masquerade syndromes comprise a group of disorders that mimic an ocular inflammatory disease but require specific treatment other than, or in addition to, anti-inflammatory therapy. Because many of the masquerade syndromes are malignancies or infectious processes, early diagnosis and prompt treatment are critical. Intraocular lymphomas, sometimes called vitreoretinal lymphomas, are frequently primary central nervous system (CNS) lymphomas (non-Hodgkin lymphoma [NHL] involving the CNS).…

White-Dot Syndromes

Key Concepts White-dot syndromes include a group of posterior uveitides characterized by discrete, well-circumscribed white or yellow-colored lesions at the level of the outer retina, retinal pigment epithelium, or choroid. These lesions may have some degree of atrophy as well. The white-dot syndromes are inflammatory in mechanism and predominantly noninfectious, although the possibility of an underlying infectious cause should always be considered because the exact cause…

Serpiginous Choroiditis

Key Concepts Serpiginous choroiditis is a rare, clinically defined disorder characterized by a geographic pattern of choroiditis that typically extends from the juxtapapillary area and spreads centrifugally over time. The disease often involves both eyes and can cause irreversible retinal damage and permanent vision loss. No specific etiology can be identified in most cases, and the disease is thought to be autoimmune. As a result, the…

Behçet Disease

Key Concepts Behçet disease is a multisystem disease, with imminently vision-threatening posterior ocular complications. The posterior pole disease should not be treated with corticosteroids alone. Tumor necrosis factor (TNF) inhibitors have been suggested as first-line immunosuppressives for ocular Behçet disease. Retinal vascular involvement is a common finding in many patients with posterior and intermediate uveitis. Behçet disease may be the best example of a disorder characterized…

Birdshot Chorioretinopathy

Key Concepts Human leukocyte antigen (HLA)-A29 is very strongly associated with birdshot chorioretinopathy. Birdshot chorioretinopathy can lead to severe visual handicap. Long-term therapy is often needed to control the disease. The spectrum of posterior uveitic entities is quite broad, with similar or identical entities referred to by various names in the literature. Better definition of these entities is a constant goal. Birdshot chorioretinopathy (BCR) fits the…

Vogt-Koyanagi-Harada Syndrome

Key Concepts Vogt-Koyanagi-Harada (VKH) syndrome is a systemic autoimmune disease, which targets melanin containing cells. Typical manifestations include uveitis with exudative retinal detachments, headache, tinnitus, poliosis, and vitiligo. Posterior pole disease should be treated very aggressively. Vogt-Koyanagi-Harada (VKH) syndrome is a systemic disorder involving many organ systems with melanin containing cells, including the eyes, ears, skin, and meninges. It includes a constellation of clinical signs and…

Sympathetic Ophthalmia

Key Concepts Sympathetic ophthalmia (SO) is a bilateral condition. SO is now more commonly seen after vitrectomy than after accidental injury. Dalen-Fuchs nodules are commonly seen in the retinal periphery of eyes with SO, but they are not pathognomonic for the disease. Sympathetic ophthalmia (SO) probably is the intraocular inflammatory condition best known to health care practitioners outside of ophthalmology. It has been suggested that although…

Sarcoidosis

Key Concepts Sarcoidosis is a multisystem granulomatous disease that can affect almost every organ in the body in people of all racial and ethnic groups. The cause of sarcoidosis remains unknown, but a number of studies have elucidated the immunologic basis for the disease pathogenesis, with the macrophage playing a central role. Most patients with sarcoidosis present with respiratory symptoms, although some present with generalized symptoms,…

Intermediate Uveitis

Key Concepts Diagnosis is based on the anatomic location of ocular inflammation: vitreous and peripheral retina with macular edema. Intermediate uveitis is frequently associated with a systemic or infectious disease. Pars planitis is a subtype of intermediate uveitis. Complications include macular edema, epiretinal membrane, vitreous hemorrhage, retinal detachment, and glaucoma. Uveitis in patients with multiple sclerosis may be associated with a shorter time to first disease…