E-Book, Englisch, 237 Seiten, ePub
Wigand Endoscopic Surgery of the Paranasal Sinuses and Anterior Skull Base
2. Auflage 2008
ISBN: 978-3-13-257962-0
Verlag: Thieme
Format: EPUB
Kopierschutz: 6 - ePub Watermark
E-Book, Englisch, 237 Seiten, ePub
ISBN: 978-3-13-257962-0
Verlag: Thieme
Format: EPUB
Kopierschutz: 6 - ePub Watermark
Returning in an up-to-date second edition, this book offers expanded coverage of the most important concepts in endoscopic sinus surgery with new insights into the anatomy of the paranasal sinuses. This text covers the basic concepts of intranasal surgery of the paranasal sinuses, endoscopic anatomy, preoperative and postoperative diagnosis, instrumentation, anesthesia and patient positioning. It describes standard and advanced surgical techniques for the nasal cavity, the maxillary antrum, the ethmoid, frontal and sphenoid sinuses, and the anterior base of the skull.
Highlights of the second edition:
New chapters on managing complications of rhinosinusitis, trauma, malformation, and neoplasms
New section on transcranial exposure of the anterior skull and paranasal cavities
Detailed presentation of endoscopic and microscopic approaches
Extensive discussion of reasons for failed surgery and the principles of revision surgery
More than 580 illustrations and new schematic drawings, including images that place special emphasis on anatomical landmarks to help orient the surgeon
This book is a must-have reference for ENT surgeons and otolaryngologists seeking to enhance the versatility.
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Weitere Infos & Material
1 Concepts of Intranasal Surgery of the Paranasal Sinuses
2 Endoscopic Anatomy of the Nose and Paranasal Sinuses
3 Preoperative and Postoperative Diagnosis
4 Instrumentarium
5 Anesthesia and Patient Positioning
6 Standard Operations for Acute and Chronic Sinusitis
7 Complications of Sinusitis
8 Failures and Repeat Surgery
9 Trauma
10 Malformations
11 Neoplasia and Tumorlike Lesions
12 Results of Endoscopic Sinus Surgery: Personal Experience
13 Historical Overview
1 Concepts of Intranasal Surgery of the Paranasal Sinuses
Intranasal endoscopic surgery of the paranasal sinuses has essentially been developed for the treatment of chronic sinusitis. Only a few decades ago, the therapy of chronic sinusitis had consisted of the radical removal of the diseased mucosa, which was considered as of a biologically inferior quality (Albrecht 1926). External–meaning transfacial and transoral–approaches were the rule. Intranasal endoscopic surgery has not only become minimally invasive by changing the access but has also switched to the aim of preservation of the mucosa. Several prerequisites must be met if this alternative to the classical operations is to succeed:
• Modification of long-standing concepts of mucosal pathophysiology
• A more thorough knowledge of topographic anatomy
• Adaptation to endoscopic operative techniques using special angled telescopes and instruments through a narrow access port
• Abandonment of cherished principles of en-bloc clearance via wide access
• A long-term treatment plan that includes supplementary procedures and time-consuming endoscopic aftercare, which the patient must accept as an important part of the treatment
What was at first criticized as hazardous has subsequently been accepted as routine throughout the world. Endoscopic sinus surgery (ESS) today includes the use of the microscope and other technical improvements such as the laser or computer-assisted navigation, and is widely applied to other indications than sinusitis, e. g., for the treatment of trauma, malformations, and neoplasias. Regardless of this variety of indications, the local reactions of the mucosal texture to any of these noxious factors have much in common, and thus an intimate knowledge of its endoscopic and pathohistological appearance is key to its successful handling during surgery and during the postoperative phase, when wound healing has to be supported.
Attention to the details of this complex strategy is needed if one is to reap the full benefit of intranasal surgery, to avoid complications and disappointing results, and to recognize the unsolved problems obstructing the development of ideal treatment.
Surgical Pathology of the Sinus Mucosa
The respiratory mucosa of the nose and paranasal sinuses is part of a large and coherent system of internal surfaces reaching from the nostrils to the bronchi and communicating with the middle ear spaces (Fig. 1.1). It must, therefore, be regarded as a unit and be thoroughly investigated whenever parts of it produce signs of pathological alterations. But it does not present a homogenous histological structure throughout its extent. Its texture depends on site, age, and physical/biological responses to metabolic, endocrine, and other factors.
Fig. 1.1 The coherent system of respiratory mucosa extending from the nasal cavity into the paranasal sinuses, the tracheobronchial tree and, via the eustachian tube, into the middle ear. Its epithelial self-cleaning drainage system is susceptible to inflammatory disturbances. Infection in one compartment can involve remote areas.
In the nasal cavity, secretory elements (goblet cells and mucosal glands) are abundant where the mucosa carries a dense ciliary layer. In the more remote niches of the large sinuses, these typical characteristics are sparser and the histological picture more nearly resembles that of a mucoperiosteum with, at times, a thin serosal layer resembling the pattern of the middle ear and mastoid. Tos et al. (1978) have accurately measured the normal variation in density of the mucosal glands in the sinuses: under pathological conditions this pattern of distribution can change radically. The frequent macroscopic variants of the mucosa, even in the absence of inflammation, are already familiar to the rhinologist: dry, thickened regions at the nasal valve, atrophic areas over bony ridges, succulent velvety ends of the turbinates with arterial or venous coloration, and finally the swollen, pale, mulberrylike, bluish-red colored mucosa on the posterior end of the turbinates.
Fig. 1.2 a–e Histopathology of sinus mucosa in chronic rhinosinusitis.
a Normal respiratory mucosa of the ethmoid with ciliary epithelium and few secretory glands (H&E,×20).
b Edematous reaction of respiratory epithelium as first stage of inflammation. Wide intercellular spaces filled with lymph and hyalinic substance. Scarce cell infiltration (H&E,×63).
c Ethmoid mucosa in chronic sinusitis showing loose stroma with disseminated clumps of cells–microabscesses–but no glands (Goldner,×70).
d Chronic mucositis predominantly featuring glandular hyperplasia (Goldner and Alcian blue,×63).
e Chronic sinusitis with traits of scar formation, rich in collagen fibers and poor in leukocytes (van Gieson,×63).
The local appearances of the mucosa show even more marked variations in sinusitis. The endoscopist is familiar with the various swellings, edematous areas, papillary hyperplasia, and polyps that differ between the two sides and even within one nasal cavity. Using standardized mucosal biopsies, Hosemann and Wigand (1985) have demonstrated the wide variation in histopathology of sinus mucosa in diffuse polypoid hyperplastic sinusitis (Fig. 1.2a–e) . A diagnosis of sinusitis by the histopathologist does not apply to the entire mucosa but only to that part which is sampled. This conclusion is self-evident, but conflicts with the concept of radical surgery that demands complete mucosal clearance. It is also in conflict with any kind of classification of types of sinusitis based on single biopsies (Lund and McKay 1993, Cho et al. 2006).
Nasal and paranasal polyps are a particular manifestation of chronic sinusitis histologically featuring various grades of intercellular edema (Fig. 1.3). Their macroscopic appearance varies between small humps of 2–3 mm diameter and large pedicled mucosal sacs pendulating from the middle turbinate or out of the semilunar hiatus (see Chapter 3). Tos (2000) has given a review of the multiple concepts of their pathogenesis. We are convinced that biomechanical obstruction of the submucous lymph drainage plays a prominent role in the causation of polypous swelling of the mucosa, which may easily occur in the narrow spaces of the ostiomeatal complex in the anterior ethmoids.
Fig. 1.3 Nasal polyp in a state of development, characterized by extremely wide intercellular spaces filled with edematous fluid (H&E,×63).
| The local pathohistomorphological appearance of the mucosa in one sinus does not reflect the actual stage of the disease in other compartments. Transition from simple mucosal swelling to hyperplasia and severe polyposis is gradual and varies at different locations. |
In our experience, temporal factors are as important as local factors because histomorphological findings change enormously over time. After a successful tympanoplasty even the most severe mucosal lesions have often regressed when the ear is later reopened after aeration and internal drainage have been restored. A previously very hyperplastic layer will be found to have been replaced by noninflamed, soft mucosa. The same results have now been found many times after surgery for severe sinusitis with mucosal preservation: even previously thick, spongy, injected, and indurated mucosa presents a completely healthy appearance after conservative sinus operations that restore drainage and aeration. Thus, neither the surgeon's eye nor the results of a frozen tissue section can predict whether inflamed mucosa is capable of resolution.
| At the time of a first operation, the surgeon can by no means predict whether the chronically diseased mucosa will recover or not. |
Mucositis
Little is known of the morphological and functional changes in acute and chronic inflammation of the respiratory mucosa or of the healing processes, either with or without surgery. Numerous histomorphological and structural investigations have been done of the mucosal response pattern, the lymphatic system, and the pathological ciliary activity of the mucosa of humans and animals (e. g., Tos 1978; Hosemann 1985, 1991; Stammberger 1991; Thaler 2002; Benninger 2003), but an overall view of nonspecific mucosal inflammation is not available. The temporal course of the phenomena associated with spread of inflammation from the nasal cavity into the sinuses is not known.
We suspect that an intermediate stage of hyperemia, lymphatic swelling, stasis in the blood and lymphatic pathways, and increased secretion of mucus succeeds an initial stage of hyperemia with reduced mucociliary transport. This is followed either by resolution or by progression to a chronic stage with pathological increase in the elements of the lamina propria such as cells, fibers and ground substance, and resultant permanent disruption of the mucociliary transport and lymphatic drainage. The resulting obstruction of the narrow ducts between the paranasal sinuses and the nasal cavity leads to a vicious cycle of retention of secretions, obstruction of lymphatic drainage, edema, and finally organized connective tissue and mucosal hyperplasia. The causes of local and temporal variations of pathology probably depend on anatomy, the local mucosal response, the infl uence of other body systems, pathogens, and external noxious agents. The...
