Contents

Pillbury, MD vii Preface ix Acknowledgments xi Contributors xiii Abbreviations xv Chapter 1 Rhinology and Paranasal Sinus 1 Nasal and Paranasal Physiology and Anatomy 2 Evaluation of Nasal Obstruction 10 R. Pasha, Anthony J. Cornetta, and Robert T. Sataloff Salivary Gland Anatomy and Physiology 62 Parotid Gland Masses and Salivary Gland Salivary Gland Non-malignant Pathology 69 Chapter 3 Laryngology 83 R. Pasha, James P. Dworkin, and Robert J. Meleca Laryngeal Anatomy and...

Excisional Techniques

elliptical excision with bilateral advancement for a linear closure Advantages simplest technique Disadvantages must be able to be designed parallel to RSTL, ideal closure angle < 30 Common Uses most common excisional technique, ubiquitous M-plasty modification at the ends of a fusiform to close a larger lesion with an ellipse and limit extent of a normal skin excision Advantages shortens wound length, avoids extension of scars across an anatomical border Disadvantages slightly more complex,...

Revision Rhinoplasty and Complications

10 15 of rhinoplasties require revision work typically wait 1 year for revisions Immediate and Short-term Postoperative Complications epistaxis, infection, septal perforation, septal hematoma, skin necrosis, transient epiphora Late Postoperative Defects and Complications Pollybeak Deformity supratip prominence resulting in a convexity of the lower 2 3 of nasal dorsum Types soft tissue versus cartilaginous defects 1. excess resection of nasal dorsum resulting in increased dead space and...

Common Laser Types

CO2 Laser invisible beam (aiming beam must be used in conjunction with laser), primarily absorbed by water, excellent for cutting, coagulation, or ablating (depending on area of focus) Nd YAG Laser near-infrared beam, invisible (requires an aiming beam), primarily absorbed by pigmented tissues, deeper penetration, more scatter than CO2 lasers, may use a fiberoptic carrier, indicated for cutaneous lesions (port-wine stains, telangiectasias, hemangiomas, etc) KTP Laser visible laser, primarily...

Supraglottic Laryngectomy Horizontal Hemilaryngectomy

Rationale for Procedure embryological boundary between false and true vocal folds results in independent lymphatic drainage, supraglottic cancer tends to have pushing borders rather than infiltrating borders Indications T or T2 (limited T3) supraglottic tumors tumor does not involve vocal fold, ventricle, thyroid cartilage, arytenoid, interarytenoid region, pyriform, or base of tongue good pulmonary function tests (forced expiratory volume FEVJ > 50 60 ) patient must also give consent for...

Other Laryngeal Lesions

Acquired Angioedema histamine mediated inflammation (Urticaria) secondary to a variety of substances 2. Congenital (Hereditary) Angioedema deficiency in C1 esterase inhibitor (controls the complement pathway) Common Causes of Acquired Angioedema medications (ACE inhibitors, ASA, antibiotics, NSAIDs), food allergies (eggs, peanuts), insect bites, transfusions, infections (Hepatitis B, viral infections), emotional, other allergens SSx rapid onset of facial, oropharyngeal, or laryngeal edema, hot...

History and Physical Exam

Character of Dysphonia onset and duration, time course (acute versus chronic), periodicity (morning hoarseness associated with GERD, evening hoarseness associated with vocal abuse) Contributing Factors recent upper respiratory infection, fever, sore throat, cough, congestion history of voice, tobacco, or alcohol abuse past medical history of peripheral nerve diseases and other neurological disorders, gastroesophageal reflux, hypothyroidism, psychological stressors previous laryngeal trauma,...

Complications of Otitis Media Intracranial Complications

High Risk Pathogens Type III Pneumococcus (intracranial predilection), H. influenzae type B (higher risk of meningitis), and presence of coexisting anaerobes Routes of Spread into the Intracranium direct extension from bone erosion, lymphatic or hematogenous spread, invasion through normal anatomic structures (labyrinth), spread through iatrogenic or traumatic defects, extension through Hyrtle's Fissure (embryologic remnant that connects hypotympanum to the subarachnoid space) Dx CT of brain...

Odontogenic Cysts Periapical Cyst Radicular Cysts

most common odontogenic cyst Pathophysiology nonviable tooth (dental decay) results in osteitis of periapical bone from dental canal, epithelial cell rests of Malassez proliferate in the periodontal membrane causing cyst formation typically located on anterior maxilla and posterior mandible Lateral Periodontal Cyst less common variant of radicular cyst which is found on the lateral aspect of the tooth SSx typically asymptomatic, may illicit pain with percussion or heat Radiographic Findings...

Other Systemic Diseases Effects on the Esophagus

Presbyesophagus reduced peristalsis and decreased LES pressure seen in the elderly, probably neuropathic Chagas' Disease parasitic infection, destroys Auerbach's plexus, results in achalasia-like symptomatology Diffuse Idiopathic Skeletal Hyperostosis (DISH) (Forestier's Disease) paraspinous ligament calcification causes dysphagia from cervical osteophytes compression or periesophageal soft tissue inflammation Dx lateral neck film, esophagram Rx surgical reduction for severe symptoms

Microvascular Free Flaps

Advantage single-stage procedure, excellent perfusion, ability to preselect tissue characteristics of donor tissue for given recipient site defect, potential two-team approach, possible functional restoration (sensation motor), improved ability for spatial positioning of donor tissue Disadvantage requires microsurgical expertise and specialized instrumentation, may require longer operating time, possible color and texture mismatch 5 15 failure, most occur in first 24 72 hours salvage rate on...

Local Skin Flaps

almost all local flaps in the head and neck are random patterned flaps are elevated and undermined in the intermediate subdermal plane (depending on bulk required at recipient site) estimated length to width ratio of local flaps in the face is 4 1 and 2 1 in the neck (reduce by half for irradiated tissue) Types defined by direction of tissue movement Advancement Flaps linear movement (eg, monopedicle, bipedicle, Y V advancement flaps) Rotational Flaps radial movement Transposition Flaps...

Allergy And Rhinitis Allergic Rhinitis

The Allergic Response Primary Reaction Phase Type I immediate hypersensitivity (see Table 1 4) occurs within 5 minutes of allergen exposure with maximum effect at 15 minutes allergen recognition by IgE antibodies stimulates mast cells and basophils (via the IgE Fc receptor) immediate, self-limiting IgE mediated, stimulates mast cells and basophils which release histamine and other inflammatory mediators IgG, IgM multivalent binding to phagocyte or complement eg, Transfusion reactions,...

Cordectomy via Laryngofissure or Transoral Laser

Indications T glottic cancer limited to middle third of the vocal fold no extension of tumor to vocal process or anterior commissure no invasion into subglottis, ventricle, or false cord Technique external approach, divides laryngeal cartilage at midline, enter glottis at anterior commissure to remove involved vocal fold up to the vocal process of the arytenoid transoral approaches may utilize laser (CO2) Advantages external approach provides better access, transoral approach avoids external...

Physiology Of The Nose And Sinuses

Nasal Cycles and Respiratory Airflow nasal airflow is regulated through the volume of the venous sinusoids (capacitance vessels) in the nasal erectile tissue (located primarily in the inferior turbinate and to a lesser extent in the anterior septum) the hypothalamus continuously stimulates a sympathetic tone (via the superior cervical sympathetic ganglia) to maintain a level of nasal vasoconstriction inspired air is warmed to body temperature and is humidified to almost 100 humidity Sneeze...

Upper Airway Obstruction Evaluation of the Stridorous Patient

Evaluate Airway quickly determine severity and stability of airway (acute versus chronic, progression of stridor, dyspnea at rest versus with exercise) Establish Airway see pp. 443-447 for complete protocol in establishing an airway Administer Oxygen masked ventilation may adequately improve oxygenation until able to secure airway after establishing a secure airway, ease of ventilation and maintenance of oxygenation should be evaluated Heliox may be considered for short-term oxygenation for...

The Aging Face Blepharoplasty

Orbital Septum continuous with periosteum, houses orbital fat, barrier to both neoplastic and inflammatory invasion, upper eyelid septum fuses with levator aponeurosis, lower lid septum fuses with capsulopalpebral fascia Medial Canthal Tendon constructed from medial heads of the pretarsal and preseptal muscles, attaches to the lacrimal crest Lateral Canthal Tendon constructed from lateral heads of the pretarsal and preseptal muscles, attaches inside orbital tubercle of Whitnall Superior...

Electronystagmography ENG Battery

ENG battery of tests (oculomotor evaluation, positional positioning testing, and caloric testing) that record eye movements typically by utilizing corneoretinal potentials (see below) provides information regarding localization of lesion (peripheral versus central, side of lesion) dependent on anatomy of the ear canal and temporal bone, only induces a low frequency response to caloric stimuli difficult to perform in children Corneoretinal Potential an electrical voltage between the cornea and...

Regional Pedicled Flaps

Diagrams Types Skin Flaps

Delay Phenomenon surgically enhanced viability of flap by incising and partially undermining, but not transposing flap until 2 3 weeks, allows flap conditioning in preparation for transfer by increasing A-V shunting, increases vessel size and number, reorients vessels Vessel Insufficiency and Injury prevented with atraumatic technique (avoid vasospasm), avoid tension and compression at tunnel, careful postoperative monitoring, prophylactic antibiotics (especially for intraoral contamination)...

Parotidectomy

Indication diagnostic and therapeutic excision of benign or malignant tumors that involve the superficial lobe of the parotid only typically preserves facial nerve resects majority of parotid gland lateral to facial nerve (controversy on amount of parotid required for removal) 1. Tragal pointer the facial nerve may be located 1 cm medial, inferior, and deep from tragal cartilage 2. Tympanomastoid Suture Line the facial nerve is 6 8 mm deep to the inferior end of the tympanomastoid suture line...

Keratosis Obliterans Canal Cholesteatoma

Keratosis Obliterans external auditory canal cholesteatoma caused by blockage of the EAC permitting accumulation of epithelial debris, bone remodeling from pressure of the keratin plug may cause bony enlargement Invasive Keratitis local accumulation of epithelial debris that occurs on the floor of the EAC SSx keratin debris in EAC, bony expansion of canal wall, CHL, may become secondarily infected, may erode into middle ear or attic Dx clinical history and physical examination Rx frequent and...

Paranasal Sinuses Sinusitis

Anatomical (compromised patency of ostia causes hypooxygenation and impairment of sinus drainage) Dysfunction of Cilia Motility Change in Quality of Secretions Viral rhinovirus (most common) Bacterial S. pneumoniae (most common bacterial agent), H. influenzae, B. catarrhalis, S. aureus, S. pyogenes Fulminant Fungal Aspergillosis, Phaehyphomycosis, Mucor, Rhizopus Chronic anaerobes, S. aureus, H. influenzae, 1 2 fungal Complicated Sinusitis Cystic Fibrosis P. aeruginosa, S. aureus Nosocomial P....

Evaluation Of Nasal Obstruction History and Physical Exam

Character of Nasal Obstruction onset and duration, constant versus intermittent, unilateral tumors, normal nasal cycle versus bilateral obstruction, associated mouth breathing, snoring, anosmia hyposmia taste disturbances, tearing nasolacrimal duct obstruction or allergy Contributing Factors potential toxin and allergen exposure, known drug allergies, medications see Table 1 1 , history of immunodeficiency, asthma, sinusitis, otitis media, allergy, sleep disturbances, facial trauma or surgery...

Cicatricial Pemphigoid Ocular Pemphigus Benign Mucous Membrane Pemphigoid Mucosal Pemphigoid

Pathophysiology autoantibodies result in subepidermal blistering SSx subepithelial bullae or desquamative gingivitis primarily involving attached gingiva, Nikolsky's sign see Pemphigus Vulgaris , ocular lesions 50 70 incidence conjunctivitis, blindness, symblepharon, entropion , presents in 4th 5th decade Dx direct immunofluorescence in basement membrane subepithelial clefting , negative indirect immunofluorescence too localized Rx topical, intralesional, and oral corticosteroids, may consider...

Graves Disease

Pathophysiology thyroid receptor autoantibody IgG stimulates glandular hyperplasia via TSH receptor goiter and increased T3 and T4 secretion Risks radiation exposure, women adolescence or 30-40 , genetic disposition Histopathology hyperplasia, increased colloid material, papillary projections SSx diffuse goiter, hyperthyroid symptoms see above , infiltrate dermopathy, exophthalmos autoimmune extraocular muscle deposition , blindness from optic neuropathy, pre-tibial myxedema Dx...

Medical Management of Hypercalcemia

Saline Diuresis restores extracellular fluid volume and promotes calcium excretion, loop diuretics can also be given thiazides impair calcium excretion Biphosphonates inhibit bone resorption, calcium serum levels reduce over several days Plicamycin inhibits bone resorption toxic side effects include thrombocytopenia, hepatic dysfunction, and renal failure, therefore used only for malignant hypercalcemia Calcitonin rapid onset serum calcium falls within hours Glucocorticoids inhibit calcium...

Peritonsillar Abscess and Peritonsillar Space Infection

Pathophysiology spread of infection outside tonsillar capsule into the peritonsillar space typically begins at superior pole Boundaries of Peritonsillar Space palatal tonsil medial border , superior constrictor muscles lateral border , tonsilar pillars superior, inferior, and posterior border Risks recurrent infections, allergy, dental caries SSx unilateral otalgia, odynophagia, uvular deviation, pharyngotonsillar asymmetry, trismus, drooling Complications airway distress, parapharyngeal or...

Tracheoesophageal Fistulas

Congenital failure of recannulation of the esophagus or developmental failure of the tracheoesophageal septum 2. Acquired secondary to tracheostomies, long-term intubation, tumor, inflammation, trauma results in communication between lumen of the esophagus and the trachea 1. Esophageal Atresia with Distal Tracheoesophageal Fistula most common form 80-90 2. Isolated Esophageal Atresia second most common form, associated with polyhydramnios 3. Isolated Tracheoesophageal Fistula H-type may...

Progressive Systemic Sclerosis Scleroderma

Pathophysiology autoimmune disease causes small vessel vasculitis, widespread collagen deposition, and smooth muscle atrophy associated with other connective tissue diseases Dx barium swallow dilated, flaccid similar to achalasia, however, patent LES , manometry normal UES pressure, loss of tone of LES CREST Syndrome variant, milder form, Calcinosis cutaneous , Raynaud's phenomenon, Esophageal dysmobility, Sclerodactyly, Telangiectasis Rx reflux regimen, calcium channel blockers for Raynaud's...

Medullary Thyroid Carcinoma

Pathophysiology derived from parafollicular or C-cells produce calcitonin 1. Familial 20 , Multiple Endocrine Neoplasia IIA B see Table 4-3 , multicentric, bilateral 2. Sporadic 80 , unifocal, unilateral, worse prognosis 50-60 lymph node involvement late vascular involvement , approximately 8 distant metastasis TABLE 4-3. Multiple Endrocrine Neoplasms MEN I Werners Syndrome MEN II Sipple Syndrome Parathyroid hyperplasia Medullary thyroid carcinoma Pancreatic tumors insulinomas,...

Salivary Gland Enlargement

Pathogen S. aureus most common Pathophysiology salivary stasis or obstruction, retrograde migration of bacteria, postoperative parotiditis Risks dehydration, postsurgical GI procedures , radiation and chemotherapy, Sjogren's syndrome SSx sudden onset of erythema, tenderness, warmth, and purulence at ductal orifice, auricle may protrude, trismus Dx clinical history and exam, cultures Rx rehydration, warm compresses, antimicrobial therapy may require parenteral antibiotics for severe cases ,...

Nasal And Paranasal Physiology And Anatomy

Maxillary Crest Sphenopalatine Artery

Uncinate Process sickle-shaped thin bone part of the ethmoid bone, covered by mucoperiosteum, medial to the ethmoid infundibulum and lateral to the middle turbinate derived from the second ethmoidal turbinal Ethmoid Infundibulum pyramidal space that houses opening to the maxillary and anterior ethmoid sinuses superior attachment determines spatial relationship of frontal sinus drainage 80 attach to the lamina papyracea resulting in frontal sinus drainage medial to the uncinate, 20 attach to...

Adductor Spasmodic Dysphonia

more common than ABductor spasmodic dysphonia Pathophysiology focal laryngeal dystonia may be psychogenic origin , causes vocal fold hyper-ADduction phonation against a closed glottis , exacerbated by stress SSx strained or strangled voice, glottic stammering phonation breaks may be associated with other dystonias, tremors, or difficulty in breathing typically patients are able to whisper normally Dx clinical exam, history, and voice profile Rx voice therapy, botulinum toxin injections of...

Primary Hyperparathyroidism

Benign Adenoma most common, single adenomatous gland Rx see below Parathyroid Hyperplasia associated with MEN I amp IIA see Table 4-3 , familial hypocalciuric hypercalcemia autosomal dominant, increased renal calcium absorption , familial hyperparathyroidism Carcinoma of the Parathyroid Gland rare tumor, suspect with a palpable, gray mass, vocal fold paralysis, or severe hypercalcemia Rx en bloc resection including thyroid lobectomy, monitor for recurrence with serial serum calcium levels must...

Diffuse Colloid Goiter Adenomatous Goiter Multinodular Colloid Goiter

Pathophysiology iodine deficiency TSH hypersecretion stimulates chronic thyroid hyperplasia and involution multinodularity Toxic Nodular Goiter variation of diffuse colloid goiter in which one nodule is hyperfunctional resulting in hyperthyroidism 1. Endemic Goiter iodine deficiency, extrinsic goitrogens soybeans, lithium, iodides, etc. 2. Sporadic uncertain etiology SSx multiple nodules of varying size, may present with compressive symptoms stridor, dysphagia Dx FNA of a prominent nodule, TFT...

Benign Laryngeal Pathology Congenital Laryngeal Defects

most commonly anteriorly based Pathophysiology incomplete recanalization at 8th week of embryological development Types supraglottic 2 , glottic 75 , subglottic 7 SSx weak cry at birth, aphonia, variable degrees of respiratory obstruction inspiratory stridor Dx flexible nasopharyngoscopy, direct laryngoscopy Rx endoscopic lysis if gt 50 laser excision , consider keel or open procedure for extensive involvement, may require tracheotomy third most common laryngeal anomaly Pathophysiology...

Vocal Fold Paralysis

Unilateral Vocal Fold Paralysis SSx hoarse-breathy dysphonia, aspiration, stridor in children, dysphagia, limited phonation time, vocal fatigue, may be asymptomatic Bilateral Vocal Fold Paralysis SSx inspiratory or biphasic stridor, weak cry, aspiration, hoarseness voice may be normal Contributing Factors recent upper respiratory infection, fever, cough previous neck trauma, toxin exposure, surgery cardiothoracic, thyroid , or airway manipulation history of tobacco or alcohol abuse past...

Salivary Gland Cysts

most common mass in parotid Risks sialoadenitis, sialolithiasis, trauma 1. CT scan or U S to confirm cystic nature 2. FNA to evaluate for malignant cells 3. may observe or inject with sclerosing agents tetracycline 4. surgical excision for cosmesis, recurrent lesions, solid lesions, abnormal cytology increased incidence since HIV epidemic may progress to pseudolymphoma SSx multiple, bilateral parotid cysts Dx clinical history and exam, biopsy Histopathology lymphoreticular infiltrate, clusters...

Evaluation of the Parotid Gland Mass

Character of Parotid Mass onset and duration, rapid inflammatory versus slow growing neoplastic , diffuse versus discrete mass tumor , unilateral versus bilateral involvement sialadenosis, mumps , associated pain, association with food ingestion sialadenitis Contributing Factors history of smoking or alcohol abuse exposure to radiation or toxins lead or mercury history of sarcoidosis, Sjogren's disease, tuberculosis, gout, amyloidosis recent facial trauma or surgery Associated Symptoms...