Professional Documents
Culture Documents
Diseases of The Sinuses
Diseases of The Sinuses
of the
SINUSES
Diagnosis and
Management
Exit
DISEASES
of the
SINUSES
Diagnosis and
Management
DAVID W. KENNEDY, MD, FACS, FRCSI
Professor and Chairman
Department of Otorhinolaryngology: Head and Neck Surgery
University of Pennsylvania Health System
Philadelphia, Pennsylvania
S. JAMES ZINREICH, MD
Associate Professor
Department of Radiology/Otolaryngology: Head and Neck Surgery
Chief, Head and Neck Imaging
Johns Hopkins Medical Institutions
Baltimore, Maryland
2001
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Notice: The authors and publisher have made every effort to ensure that the patient care recommended herein, including choice of drugs
and drug dosages, is in accord with the accepted standard and practice at the time of publication. However, since research and regulation
constantly change clinical standards, the reader is urged to check the product information sheet included in the package of each drug, which
includes recommended doses, warnings, and contraindications. This is particularly important with new or infrequently used drugs.
DEDICATIONS
I would like to dedicate this book to my family, to those who have taught me, and to those who will continue to advance the field of rhinologic knowledge in future years. My wife Eddie has been most supportive
while I have been busy trying to gain a better understanding and to teach what I have learned of this exciting field. My son Garrett and my daughter Kirin have each lost a portion of their childhood because of
the times that I have either been away teaching at courses or working in my study. I thank each of you for
your love and understanding and dedicate this book to you.
David W. Kennedy, MD, FACS, FRCSI
In working on this text I dedicate my efforts to those wanting to learn more of the field of rhinology and
sinus surgery and hope the text will be helpful.
William E. Bolger, MD, FACS
I dedicate this work to my wife, whose love, support, and dedication have created the necessary foundation for my career and accomplishments.
S. James Zinreich, MD
CONTENTS
Genetics of Rhinosinusitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Garry R. Cutting
Nasal Polyps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Joel M. Bernstein
Microbiology of Sinusitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Birgit Winther and Jack M. Gwaltney Jr
Environmental Influence on Sinus Disease: the Role of Chemical Air Pollutants . . . . . . . . . . . . . . . . . . . . . . 107
Dean M. Clerico
10
11
12
13
14
15
16
Functional Endoscopic Sinus Surgery: Concepts, Surgical Indications, and Instrumentation . . . . . . . . . . 197
David W. Kennedy
Functional Endoscopic Sinus Surgery: Anesthesia, Technique, and Postoperative Management . . . . . . . . 211
David W. Kennedy
17
18
19
20
21
22
23
24
Dacryocystorhinostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
Ralph Metson
25
26
27
28
29
30
31
32
33
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FOREWORD
n mid 1984, David Kennedy spoke to me about a new approach to surgery of the paranasal sinuses. As
a new department chairman at Johns Hopkins and trained in the then standard approaches to sinus
surgery, I have to admit that I was skeptical. Davids enthusiasm and passion to pursue this was fueled by
his knowledge and understanding of the physiology of the sinuses as taught to him by then emeritus Hopkins faculty member Don Proctor. He was not to be denied. We agreed we would obtain the necessary
endoscopic equipment and David would first develop his skills in the anatomy laboratory.
David did just that. He took a careful and systematic approach and developed his new skills in the
laboratory before taking them to his patients. His reading and work raised many questions in his mind and
he pursued their answers relentlessly. Today, 16 years later, David is a master endoscopic sinus surgeon, clinician, researcher and academic leader. He has instructed thousands of physicians in the clinical care of sinus
disease and he has contributed to our understanding of the pathophysiology of sinusitis.
David also quickly recognized the importance of high quality imaging to the proper diagnosis and
treatment of sinus disease. He partnered with Jim Zinreich, a talented neuroradiologist who developed
and refined techniques to image the paranasal sinuses, adding value to the diagnostic and therapeutic
approach to diseases of the sinuses. In this book, Kennedy, Zinreich, and Bolger provide an authoritative
text that comprehensively covers all medical and surgical aspects of the paranasal sinus and the diseases that
affect them. They have recruited an international group of contributors known for their clinical expertise
and contributions to the scientific literature. Disease of the paranasal sinuses and particularly chronic sinusitis is one of the most common clinical illnesses to present to the physician. This book will serve as a penetrating and guiding beacon both to those who are entering otolaryngologyhead and neck training and
to experienced clinicians.
Michael M.E. Johns, MD
Chairman and CEO, Emory Healthcare
Executive Vice President for Health Affairs, Emory University
Director of the Robert W. Woodruff Health Sciences Center of Emory University
ix
PREFACE
hose who work with patients suffering from chronic rhinosinusitis recognize that it has a much greater
effect on the quality of life of affected individuals than was previously recognized. Chronic rhinosinusitis is also one of the most common healthcare complaints and frequently has an insidious onset. The
significant international prevalence of this disease has been brought home to me as I travel to meetings
and to give courses. Whether in a developed nation or a developing nation, one of the most common
greetings is You have come to the right place; this must be the sinusitis capital of the world.
In recent years, our understanding of rhinosinusitis has increased significantly, along with our diagnostic potential and our ability to treat the disorder effectively. At the same time, there has been a resurgence of clinical and basic research in an area which was, for a long time, relatively ignored.
The goal of this book is to provide a comprehensive volume, produced by the international leaders in the field, which details our current level of knowledge regarding diagnosis, medical care, and surgical therapy of rhinosinusitis. We hope that we have succeeded, but as in any first edition, there will
undoubtably be some areas which would have benefitted from expansion, some which could have been
condensed, and others that could have been included. I would particularly like to thank all of the chapter authors for their hard work and patience during the process of development of this book.
As a resident, I was frequently concerned about the seemingly poor results of our treatment of
sinonasal disease. However, I was fortunate to have the opportunity to work with Donald Proctor, MD,
on a sinus mucociliary clearance research project. Clinically, he also taught us the importance of endoscopic diagnosis and the key role of the ethmoid sinuses in the pathogenic process. In my early academic
career as an otologist, the influence of sino-nasal disease on eustachian tube function was evident. Therefore we would frequently perform medical management and intranasal ethmoidectomy under the microscope in patients where the sinus disease appeared to be a significant factor in the patients otologic process.
In the late 70s, I had reviewed Professor Messerklingers classical work, Endoscopy of the Nose
for one of the journals and was intrigued with the level of diagnostic precision that he described. However, at that time it was not evident why such detailed diagnosis was required, since a wide extirpative
surgical procedure with mucosal stripping was typically performed. In the early 1980s I had the opportunity to interact with Professor Messerklinger at a meeting, and to see him present the superb work that
he had performed on mucociliary clearance. This, combined with his concepts of more focused surgical
procedures under endoscopic visualization, rekindled my interest in sinus disease.
Since we originally introduced the concept of functional endoscopic sinus surgery, I have had the
opportunity to visit and to learn from many great rhinologists and my thinking, as well as that of the specialty, has become more refined. This book provides all the specialists who have an interest in this exciting area with a synopsis of our current state of knowledge of the pathogenesis and treatment of sinus disease. It is our hope that it will improve clinical care and spur some individuals onto additional research.
David W. Kennedy, MD, FACS, FRCSI
xi
ACKNOWLEDGMENTS
o my many teachers I would also like to extend my sincere thanks for the time that you have spent
with me. Space does not permit me to mention each of you who has contributed to this work and,
directly or indirectly, to this field. William McGowan and Harold Brown taught me how to be a surgeon, my uncle John McAuliffe Curtin taught me that otolaryngology could be fun, George Nager taught
me how to really care for patients, Donald Proctor taught me the excitement of research in sinus disease, Walter Messerklinger shared his knowledge and techniques with me and Michael Johns encouraged me to proceed with developing this exciting field. To each of you, and to others too numerous to
mention, I dedicate this book. Finally, I would also like to dedicate this book to those of you who will
pick up the torch and, by continued research, close clinical observation and the highest quality of clinical care, publications, and selfless teaching will further advance our knowledge in rhinology and sinus
disease from this point forward.
David W. Kennedy, MD, FACS, FRCSI
wish to acknowledge those who have helped in my pursuit to learn about rhinology and to grow as a
sinus surgeon. For introducing me to rhinology, inspiring me to learn more, and patiently teaching
me I acknowledge and thank David S. Parsons, MD, Frederick A. Kuhn, MD, and David W. Kennedy,
MD. For their leadership and direction that helped guide and nurture my growth as a surgeon I
acknowledge and thank David H. Thompson, MD, and Norman M. Rich, MD.
For endless support over many years and for teaching me the most valuable lessons in colleagueship I acknowledge and thank Eric A. Mair, MD, and John D. Casler, MD.
William E. Bolger, MD, FACS
xiii
CONTRIBUTORS
HUN-JONG DHONG, MD
Associate Professor of Otorhinolaryngology
Samsung Medical Center
Sungkyunkwan University School of Medicine
Seoul, Korea
Fungal Rhinosinusitis
JILL A. FOSTER, MD, FACS
Director of Ophthalmic Plastic and Orbital Surgery
Division of Ophthalmology
The Cleveland Clinic Foundation
Cleveland, Ohio
Endoscopic Applications in Orbital Surgery
WILLIAM H. FRIEDMAN, MD, FACS
Director, Park Central Institute
Chief of Otolaryngology
Deaconess/Incarnate World Health Care System
St. Louis, Missouri
External Approaches to the Frontal Sinuses
THADDAEUS GOTWALD, MD
Assistant Professor, Radiology
University Clinic of Innsbruck
Innsbruck, Austria
Radiographic Anatomy of the Sinuses
KENNETH M. GRUNDFAST, MD
Professor and Chairman
Department of Otolaryngology
Boston University Medical School
Boston Medical Center
Boston, Massachusetts
Complications in Sinus Disease
ANIL GUNGOR, MD
Assistant Professor
Department of Pediatric Otolaryngology
University of Pittsburgh School of Medicine
Childrens Hospital of Pittsburgh
Pittsburgh, Pennsylvania
Etiologic Factors in Inflammatory Sinus Disease
xv
xvi
WILLIAM LAWSON, MD
Professor of Otolaryngology
Mount Sinai School of Medicine, New York
Chief of Otolaryngology
Veterans Hospital, Bronx, New York
Attending Otolaryngologist, Mount Sinai Hospital
New York, New York
The Intranasal and External Ethmoidectomy
RAYMOND LESSER, MD, FACS
Assistant Clinical Professor
MLP/Hahnemann University
Philadelphia, Pennsylvania
Endoscopic Applications in Orbital Surgery
MARK LOURY, MD, FACS
Private Practice, Intermountain Otolaryngology
Ft. Collins, Colorado
Endoscopic Management of Cerebrospinal Fluid Leaks and
Cephaloceles
VALERIE J. LUND, MS, FRCS, FRCSEd
Professor of Rhinology, Institute of Laryngology and Otology
Honorary Consultant Otorhinolaryngologist
Royal National Throat, Nose and Ear Hospital
Granulomatous Diseases and Tumors of the Nose
and Paranasal Sinuses
RODNEY P. LUSK, MD
Professor and Director, Pediatric Otolaryngology
St.Louis Childrens Hospital
at Washington University Medical Center
St. Louis, Missouri
Pediatric Sinusitis
RICHARD L. MABRY, MD
Professor and Director
Resident Education
Department of Otolaryngology: Head and Neck Surgery
University of Texas Southwestern Medical Center
Dallas, Texas
Open Maxillary Sinus Procedures
BRADLEY F. MARPLE, MD
Associate Professor of Otolaryngology
Department of Otolaryngology
University of Texas, Southwestern Medical Center
Chief of Otolaryngology, Parkland Memorial Hospital
Chief of Otolaryngology, Dallas Veterans Administration Hospital
Dallas, Texas
Open Maxillary Sinus Procedures
DOUGLAS E. MATTOX, MD
Professor and Chair
Department of Otolaryngology: Head and Neck Surgery
Emory University School of Medicine
The Emory Clinic
Atlanta, Georgia
Management of Cerebrospinal Fluid Rhinorrhea
RALPH METSON, MD
Associate Clinical Professor
Department of Otology & Laryngology
Harvard Medical School
Massachusetts Eye and Ear Infirmary
Boston, Massachusetts
Dacryocystorhinostomy
HIROSHI MORIYAMA, MD
Department of Otorhinolaryngology
Jikei University School of Medicine
Jikei University Hospital
Tokyo, Japan
Endoscopic Modifications of the Takahashi Technique
ROBERT NACLERIO, MD
Professor and Chief of Otolaryngology
Head and Neck Surgery
University of Chicago Hospital
Chicago, Illinois
Etiologic Factors in Inflammatory Sinus Disease
GARY NISHIOKA, DMD, MD
Private Practice in Otolaryngology
Salem, Oregon
Environmental Influence on Sinus Disease;
Medical Treatment of Chronic Sinus Disease
DAVID S. PARSONS, MD, FAAP, FACS
Clinical Professor
Pediatric Otolaryngology and Sinus Surgery
University of South Carolina
Greenville Hospital System, St. Francis Hospital System
Greenville, South Carolina
Pediatric Sinus Surgery
ELIE E. REBEIZ, MD
Associate Professor
Director, Head and Neck Surgery
Department of Otolaryngology: Head and Neck Surgery
New England Medical Center
Boston, Massachusetts
Role of Lasers in Intranasal and Sinus Surgery
ANTHONY J. REINO, MD, MSc
Assistant Clinical Professor
Mount Sinai School of Medicine
Associate Director Otolaryngology
Bronx VA Medical Hospital
Assistant Attending Mt. Sinai Medical Center
New York, New York
Assistant Attending St. Lukes-Roosevelt Medical Center
New York, New York
The Intranasal and External Ethmoidectomy
STANLEY M. SHAPSHAY, MD
Professor and Chairman
Department of Otolaryngology: Head and Neck Surgery
Tufts University School of Medicine
xvii