Essentials of Rhinology 1st Edition

Hitesh Verma Alok Thakar

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Essentials of
Rhinology
Hitesh Verma
Alok Thakar
Editors

123
Essentials of Rhinology
Hitesh Verma • Alok Thakar
Editors

Essentials of Rhinology
Editors
Hitesh Verma Alok Thakar
Department of Otorhinolaryngology Department of Otorhinolaryngology
All India Institute of Medical Sciences All India Institute of Medical Science
New Delhi New Delhi
India India

ISBN 978-981-33-6283-3    ISBN 978-981-33-6284-0 (eBook)

https://doi.org/10.1007/978-981-33-6284-0
Jointly published with Byword Books

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Singapore Pte Ltd. 2021
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher,
whether the whole or part of the material is concerned, specifically the rights of translation,
reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any
other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publishers, the authors, and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publishers
nor the authors or the editors give a warranty, expressed or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publishers remain
neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd.
The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore
189721, Singapore
Foreword

Rhinology has been perhaps the most rapidly involving subspecialty in oto-
rhinolaryngology over the last few decades. Essentials of Rhinology is an
up-to-date and excellently illustrated text on the subject which captures the
essence of contemporary rhinology. As a multi-author book, led by the team
of Dr. Hitesh Verma and Dr. Alok Thakar at AIIMS New Delhi, it brings
together the experience of many recognized pioneers and experts from the
Indian subcontinent.
The book expands its scope beyond the conventional by including sections
on rhinological instruments, biofilms, packing materials, surgical cavity man-
agement, open transcranial skull base surgery, and a detailed description of
complications and their management. Authors from allied specialties have
contributed to sections on diagnostic microbiology, intervention radiology,
and nuclear medicine in sino-nasal diseases. Controversies are covered in a
comprehensive and balanced manner.
My congratulations to the editors in compiling this excellent textbook on
the subject. It serves both as a textbook on fundamental aspects of the subject
and as a reference guide for the recent advancements in the field.

Naresh Panda
Department of Otolaryngology
PGIMER
Chandigarh, India

v
Preface

The nose is an amazing organ. It undertakes humidification, filtration, and

heat exchange of inhaled air. It communicates with the four pairs of paranasal
sinuses to enable vocal resonance, allow spacing for the brain and eyes, and
enable protection of these structures from trauma. The exact dynamics relat-
ing to its contribution of inspiratory and expiratory resistance in respiration
and ventilatory physiology and sleep disordered breathing are yet not fully
apparent. Rhinology has benefited enormously from recent improved diag-
nostic tools and refinement of surgical techniques. The field of rhinology has
matured and evolved in the last two decades, but it does seem that there is yet
some way to go for its complete understanding.
This book is an attempt to capture the state of current knowledge in the
subject. It focuses on the basic principles of diagnosis and treatment, and
supplements on these with recent developments. Sections from allied special-
ties including microbiology, nuclear medicine, and interventional radiology
are designed to enable integrated care. Sinusitis, as the most common clinical
entity encountered by the practicing rhinologist, is discussed in detail, and
lessons from the past regarding the practice of non-endoscopic external sinus
procedures in current times are well covered.
We would hope and expect that the book shall provide rhinologists with a
template for contemporary care for their patients and also enable a basic
understanding of principles so as to be able to evaluate and adopt newer
developments as they become available.

New Delhi, India Hitesh Verma

 Alok Thakar

vii
Contents

1 Endoscopic Anatomy and Surgery ������������������������������������������������   1

Hitesh Verma, Smita Manchanda, Sunil Kumar, Vaibhav Saini,
Debesh Bhoi, Nagesh Tangirala, Abha Kumari,
and Anandita Gupta
2 Rhinoplasty Anatomy and Procedures������������������������������������������ 31
Arvind K. Kairo, Saurav Sarkar, Anindya Nayak,
Prateek Sharma, and Rakesh Kumar
3 Nasal Physiology and Sinusitis�������������������������������������������������������� 49
K. Davraj, Mayank Yadav, Preetam Chappity, Prity Sharma,
Mohnish Grover, Shitanshu Sharma, Tanmaya Kataria,
Kranti Bhawna, Anand Pendakur, Gurbax Singh,
David Victor Kumar Irugu, Anoop Singh, and Nitin Gupta
4 Granulomatous Disease and Faciomaxillary Trauma������������������ 103
Gaurav Gupta, Pooja D. Nayak, Manju Silu,
Shashank Nath Singh, and Harpreet Kocher
5 Diagnostic Method and Instrumentation in Rhinology���������������� 121
Gagandeep Singh, Immaculata Xess, Ankur Goyal,
Ashu Seith Bhalla, Shamim Ahmed Shamim,
Hitender Gautam, Zareen Lynrah, Pradip Kumar Tiwari,
Ripu Daman Arora, Nikhil Singh, and Nitin M. Nagarkar
6 Tumours of Nose and Paranasal Sinuses �������������������������������������� 157
Gyan Nayak, Hitesh Verma, Rakesh Kumar, Rupa Mehta,
Nikhil Singh, Kuldeep Thakur, Kapil Sikka, Anchal Kakkar,
and Deepali Jain
7 Extended Procedures ���������������������������������������������������������������������� 203
Pankuri Mittal, Hitesh Verma, Amit Kesari, R. S. Virk,
Kshitiz Charya, Smriti Panda, Alok Thakar,
Rajesh Kumar Meena, Ramesh S. Doddamani, Manish Gupta,
Rohit Verma, Vikas Gupta, Ganakalyan Behera, Amit Shanker,
Namrita Mahmi, M. Ravi Sankar, and Arulalan Mathialagan

ix
x Contents

8 Prevention and Management of Complications���������������������������� 277

Anupam Kanodia, Hitesh Verma, Avni Jain,
Gopica Kalsotra, Sheetal Kumari, Sonu Kumari Agrawal,
Hitender Gautam, Darwin Kaushal, Abhishek Gugliani,
and Jaini Lodha
9 Septum, Adenoid, and Epistaxis ���������������������������������������������������� 309
Ravneet Singh, Hitesh Verma, Shashikant Paul,
Sanjeev Bhagat, and Vishal Sharma
10 Radiotherapy, Chemotherapy, and Quality of Life���������������������� 329
Bharti Devnani, Suman Bhasker, Raja Pramanik,
Surya Prakash Vadlamani, and Suresh Mani
About the Editors

Hitesh Verma MBBS (SMS Medical College,

Jaipur), MS (PGIMER), DNB, MBA (IGNOU),
is working as Associate Professor of
Otorhinolaryngology, All India Institute of Medical
Sciences, New Delhi. The focus of his work has
been on rhinology and skull base surgery, sleep sur-
gery, and airway surgeries. Dr. Hitesh’s research
has included three funded research projects and
more than 70 research publications. He has also
received gold medal and Junior Consultant Award
by the Indian Rhinology and Delhi AOI society.

Alok Thakar MBBS (AIIMS), MS (AIIMS), DNB,

DLO (London), FRCS (Edinburgh), is the Professor
and Head of Otorhinolaryngology, All India Institute
of Medical Sciences, New Delhi. He worked as a
Specialist Registrar and a Skull Base Fellow-
Commonwealth Fellow in the UK. Dr. Thakar’s
research includes 11 funded research projects, more
than 250 research publications, with 2200 citations,
and 2 patent applications. He has also received
Shakuntala Amir Chand Award by the ICMR and a
Gold Medal by the NES Society of India.

xi
List of Contributors

Abha Kumari ENT, Command Hospital, Kolkata, West Bengal, India

e-mail: abhak12@gmail.com
Abhishek Gugliani ENT, AIIMS, Jodhpur, Rajasthan, India
e-mail: abhishekgugliani@gmail.com
Amit Kesari Neurootology, SGPGIMS, Lucknow, UP, India
e-mail: amitkeshri2000@yahoo.com
Amit Shanker ENT, Brighton and Sussex University Hospital NHS,
Brighton, UK
e-mail: shankarpgi22@yahoo.com
Anand Pendakur Allergy Asthma ENT Clinic, Bangalore, Karnataka, India
e-mail: pendakur.anand@gmail.com
Anandita Gupta ENT, Army College of Medical Sciences, New Delhi,
India
e-mail: anandita0508@gmail.com
Anchal Kakkar Pathology, AIIMS, New Delhi, India
e-mail: aanchalkakkar@gmail.com
Anindya Nayak ENT, AIIMS, Bhubaneswar, Odisha, India
e-mail: anindaa_nayak30690@yahoo.in
Ankur Goyal Radiology, AIIMS, New Delhi, India
e-mail: ankurgoyalaiims@gmail.com
Alok Thakar Department of ENT, AIIMS, New Delhi, India
e-mail: drathakar@gmail.com
Anoop Singh ENT, AIIMS, New Delhi, India
e-mail: anoop.aiims1@gmail.com
Anupam Kanodia ENT, AIIMS, New Delhi, India
e-mail: kanodiaanupam@gmail.com
Arulalan Mathialagan Neurootology, SGPGIMS, Lucknow, UP, India
e-mail: arulalan87@gmail.com
Arvind K. Kairo ENT, AIIMS, New Delhi, India
e-mail: arvindkairo@yahoo.com

xiii
xiv List of Contributors

Ashu Seith Bhalla Radiology, AIIMS, New Delhi, India

e-mail: ashubhalla1@yahoo.com
Avni Jain ENT, ESIC Medical College Faridabad, Faridabad, Haryana,
India
e-mail: avanijain87@hotmail.com
Bharti Devnani Radiotherapy, AIIMS, New Delhi, India
e-mail: bhartidevnani@gmail.com
Darwin Kaushal ENT, AIIMS, Jodhpur, Rajasthan, India
e-mail: drdarwin.aiims@gmail.com
David Victor Kumar Irugu ENT, AIIMS, New Delhi, India
e-mail: irugudavid72kumar@rediffmail.com
Debesh Bhoi Anaesthesiology, Pain Medicine and Critical Care, AIIMS,
New Delhi, India
e-mail: debeshbhoi@gmail.com
Deepali Jain Pathology, AIIMS, New Delhi, India
e-mail: deepalijain76@gmail.com
Gagandeep Singh Microbiology, AIIMS, New Delhi, India
e-mail: drgagandeep@gmail.com
Ganakalyan Behera ENT, AIIMS, Bhopal, MP, India
e-mail: drganakalyan@gmail.com
Gaurav Gupta ENT, SP Medical College, Bikaner, Rajasthan, India
e-mail: drgauravgupta24@gmail.com
Gopica Kalsotra ENT, GMC, Jammu, India
e-mail: drgopikapgimer@gmail.comm
Gurbax Singh ENT, GGS Medical College and Hospital, Faridkot, Punjab,
India
e-mail: drgurbax@gmail.com
Gyan Nayak ENT, PGIMER, Chandigarh, India
e-mail: gyani.nayak@gmail.com
Harpreet Kocher ENT, Yatharth Superspeciality Hospital, Greater Noida,
UP, India
e-mail: hpskochar@gmail.com
Hitender Gautam Microbiology, AIIMS, New Delhi, India
e-mail: drhitender@gmail.com
Hitesh Verma ENT, AIIMS, New Delhi, India
Department of ENT, AIIMS, New Delhi, India
e-mail: drhitesh10@gmail.com
Immaculata Xess Microbiology, AIIMS, New Delhi, India
e-mail: immaxess@gmail.com
List of Contributors xv

Jaini Lodha ENT, Seven Hills Hospital, Andheri East Mumbai,

Maharashtra, India
e-mail: jainilodha@gmail.com
K. Davraj ENT, KMC, Manipal, Karnataka, India
e-mail: deardrdr@gmail.com
Kapil Sikka ENT, AIIMS, New Delhi, India
e-mail: kapil_sikka@yahoo.com
Kranti Bhawna ENT, AIIMS, Patna, Bihar, India
e-mail: bhavana.kranti@gmail.com
Kshitiz Charya Indus Hospital, Mohali, Punjab, India
e-mail: charaya.k@gmail.com
Kuldeep Thakur ENT, AIIMS, New Delhi, India
e-mail: drkuldeep70@gmail.com
M. Ravi Sankar Neurootology, SGPGIMS, Lucknow, UP, India
e-mail: drravisankarpgi@gmail.com
Manish Gupta ENT, MMIMSR, MMU, Ambala, Haryana, India
e-mail: manishgupta1217@gmail.com
Manju Silu ENT, SP Medical College, Bikaner, Rajasthan, India
e-mail: manjusilu35@gmail.com
Mohnish Grover ENT, SMS Medical College, Jaipur, Rajasthan, India
e-mail: drmohnish.aiims@gmail.com
Mayank Yadav ENT, SHKM GMC, Nalhar, Nuh, Haryana, India
e-mail: drmayankyadav@yahoo.co.in
Nagesh Tangirala Anaesthesiology, Pain Medicine and Critical Care,
AIIMS, New Delhi, India
e-mail: nag947@gmail.com
Namrita Mahmi Department of ENT, AIIMS, New Delhi, India
e-mail: namritamehmi@gmail.com
Nikhil Singh ENT, AIIMS, Raipur, Chhattisgarh, India
e-mail: doc.niks03@gmail.com
Nitin Gupta ENT, GMCH, Chandigarh, India
e-mail: nitinent123@gmail.com
Nitin M. Nagarkar ENT, AIIMS, Raipur, Chhattisgarh, India
e-mail: nmnent63@gmail.com
Pankuri Mittal Department of ENT, AIIMS, New Delhi, India
e-mail: mamc.pankhuri@gmail.com
Pooja D. Nayak ENT, SP Medical College, Bikaner, Rajasthan, India
e-mail: poomahe2007@gmail.com
Pradip Kumar Tiwari ENT, NIGRIMS, Shillong, Meghalaya, India
e-mail: dr.pradiptiwari@gmail.com
xvi List of Contributors

Prateek Sharma ENT, AIIMS, New Delhi, India

e-mail: drprateeksharma.mamc@gmail.com
Preetam Chappity ENT, AIIMS, Bhubaneswar, Odisha, India
e-mail: drcpreetam@aiimsbhubaneswar.edu.in
Prity Sharma ENT, AIIMS, Bhubaneswar, Odisha, India
e-mail: sharmaprity21@gmail.com
R. S. Virk ENT, PGIMER, Chandigarh, India
e-mail: virkdoc@hotmail.com
Raja Pramanik Medical Oncology, Dr.B.R.A-IRCH, AIIMS, New Delhi,
India
e-mail: drrajapramanik@gmail.com
Rajesh Kumar Meena Neurosurgery, AIIMS, New Delhi, India
e-mail: drrajeshmeena165@gmail.com
Rakesh Kumar ENT, AIIMS, New Delhi, India
e-mail: winirk@hotmail.com
Ramesh S. Doddamani Neurosurgery, AIIMS, New Delhi, India
e-mail: drsdramesh@gmail.com
Ravneet Singh ENT, GMCH, Chandigarh, India
e-mail: ravneetrverma@gmail.com
Ripu Daman Arora ENT, AIIMS, Raipur, Chhattisgarh, India
e-mail: neelripu@gmail.com
Rohit Verma ENT, DMC, Ludhiana, Punjab, India
e-mail: rohitaiims@yahoo.co.in
Rupa Mehta ENT, AIIMS, Raipur, Chhattisgarh, India
e-mail: rmehta0409@yahoo.com
Sanjeev Bhagat ENT, Rajindra Hospital Patiala, Patiala, Punjab, India
e-mail: sbent224@gmail.com
Saurav Sarkar ENT, AIIMS, Bhubaneswar, Odisha, India
doc.sauravsarkar@gmail.com
Shamim Ahmed Shamim Nuclear Medicine, AIIMS, New Delhi, India
e-mail: sashamim2002@gmail.com
Shashank Nath Singh ENT, SMS Medical College, Jaipur, Rajasthan, India
e-mail: drshashanknathsingh@gmail.com
Shashikant Paul ENT, JIPMER, Pondicherry, India
e-mail: drshashikantpol@gmail.com
Sheetal Kumari ENT, GMC, Jammu, India
e-mail: gphonshashetal@gmail.com
Shitanshu Sharma ENT, SMS Medical College, Jaipur, Rajasthan, India
e-mail: shsharma811@gmail.com
List of Contributors xvii

Smita Manchanda Radiology, AIIMS, New Delhi, India

e-mail: smitamanchanda@gmail.com
Smriti Panda Department of ENT, AIIMS, New Delhi, India
e-mail: smriti.panda.87@gmail.com
Sonu Kumari Agrawal Microbiology, AIIMS, New Delhi, India
e-mail: drhitender@gmail.com
Suman Bhasker Radiotherapy, AIIMS, New Delhi, India
e-mail: drsumanbhasker@gmail.com
Sunil Kumar ENT, LHMC, New Delhi, India
e-mail: suku321@rediffmail.com
Suresh Mani ENT, CMC, Vellore, Tamil Nadu, India
e-mail: msuresh.doc@gmail.com
Surya Prakash Vadlamani Medical Oncology, Dr.B.R.A-IRCH, AIIMS,
New Delhi, India
e-mail: vadlamanisuryaprakash@gmail.com
Tanmaya Kataria ENT, SMS Medical College, Jaipur, Rajasthan, India
e-mail: tanmayakataria@gmail.com
Vaibhav Saini ENT, AIIMS, Bhatinda, Punjab, India
e-mail: drvaibhavsaini@gmail.com
Vikas Gupta ENT, AIIMS, Bhopal, MP, India
e-mail: vikasmsent@gmail.com
Vishal Sharma ENT, Rajindra Hospital Patiala, Patiala, Punjab, India
e-mail: drvishalsharma2@gmail.com
Zareen Lynrah ENT, NIGRIMS, Shillong, Meghalaya, India
e-mail: zareenalynrah@gmail.com
 Endoscopic Anatomy and Surgery
1
Hitesh Verma, Smita Manchanda, Sunil Kumar,
Vaibhav Saini, Debesh Bhoi, Nagesh Tangirala,
Abha Kumari, and Anandita Gupta

Contents
1.1 Part A: Anatomy of Nasal Cavity and Paranasal Sinuses 2
1.1.1 Ethmoid Cells 4
1.1.2 Frontal Sinus 6
1.1.3 Maxillary Sinus 6
1.1.4 Anterior Ethmoid Artery 6
1.1.5 Sphenopalatine Artery 7
1.1.6 Cribriform Plate 7
1.1.7 Sphenoid Sinus 7
1.1.8 Optic Nerve Relationship with Paranasal Sinuses 8
1.2 Part B: Local Anesthesia and Regional Blocks in Nasal Surgery 8
1.3 Part C: General Anesthesia 13
1.3.1 Preoperative Concerns 13
1.3.2 Anesthesia Technique 14
1.3.3 Hypotensive Anesthesia 14
1.3.4 Acute Normovolemic Hemodilution 15
1.3.5 Juvenile Nasopharyngeal Angiofibroma with Intracranial Extension 15
1.3.6 Emergence from Anesthesia 15
1.3.7 Postoperative Concerns 15
1.3.8 Emergency Surgical Intervention 16

D. Bhoi · N. Tangirala
H. Verma (*) Anaesthesiology, Pain Medicine and Critical Care,
ENT, AIIMS, New Delhi, India AIIMS, New Delhi, India
e-mail: drhitesh10@gmail.com
A. Kumari
S. Manchanda ENT, Command Hospital, Kolkata,
Radiology, AIIMS, New Delhi, India West Bengal, India
S. Kumar A. Gupta
ENT, LHMC, New Delhi, India ENT, Army College of Medical Sciences,
V. Saini New Delhi, India
ENT, AIIMS, Bhatinda, Punjab, India

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 1
H. Verma, A. Thakar (eds.), Essentials of Rhinology, https://doi.org/10.1007/978-981-33-6284-0_1
2 H. Verma et al.

1.4 Part D: FESS 16

1.4.1 Diagnostic Endoscopy 16
1.4.2 FESS Techniques and Steps 17
1.4.3 NASAL POLYP and FESS 23
1.4.4 AFRS and FESS 23
1.4.5 ESS in Pediatric Age Group 23
1.4.6 Balloon Sinuplasty 24
1.4.7 Conclusion 24
1.5 Part E: Packing Materials for Nose and Paranasal Sinuses 24
1.5.1 U
 ses of Nasal Packing 24
1.5.2 Types of Nasal Packing Material 25
1.5.3 Non-Absorbable Nasal Packs 25
1.5.4 Absorbable Nasal Packs 27
References 29

1.1  art A: Anatomy of Nasal

P or split of these processes will present as con-
Cavity and Paranasal Sinuses
The nasal cavity is the initial entry point in the
airway. It extends from anterior nares to poste-
rior choana. Pneumatized air spaces within facial
bones are known as paranasal sinuses. They con-
verse with the nasal cavity at various levels. The
frontal sinus is the supraorbital airspace within
the frontal bone which comes in the superior
relationship of the nasal cavity and it drains into
the middle meatus via frontal recess. The maxil-
lary sinus is the airspace inside the maxilla bone
which communicates with the middle meatus via
ethmoid infundibulum. Ethmoid air cells are
located within the nasal cavity just below the
skull base from agger nasi cells till anterior wall
of the sphenoid sinus. The sphenoid sinus is the
airspace of the body of the sphenoid and it lies in
the superior relationship of the nasopharynx.
The nasal placode and mesenchymal processes
around the primitive mouth develop nose. A
primitive nasal cavity develops by fusion of
maxillary process of the first brachial arch with
the medial nasal process and frontonasal pro-
cess. Choana is derived by a split of bucconasal
membrane which separates the primitive oral
cavity from the nasal cavity. The nasal cavity is
divided into two half by fusion of septum with
palatine process of both sides. Failure of fusion
genital anomalies like cleft lip, cleft palate, cho-
anal atresia, etc. The vestibule is the initial part
of the nasal cavity which extends from the exter-
nal opening till the nasal valve. The vestibule is
a line by the skin with vibrissae, sweat, and seba-
ceous gland. The nasal cavity proper is the
remaining part of the nasal cavity which is a line
by pseudo-stratified columnar epithelium. The
anatomy of the nose and paranasal sinuses is
very complex. The detailed knowledge of ana-
tomical variation is the foremost thing to over-
come complications of surgery. The lateral nasal
wall contains three to four projections which are
known as turbinates [1].
A. Inferior Turbinate: Inferior turbinate is a
separate bone with an irregular surface. It is
the largest turbinate of the nasal cavity
(Fig. 1.1).
B. Middle Turbinate
1. In the sagittal plane, it attaches with crib-
riform plate at the junction of the vertical
and horizontal lamina (Fig. 1.1).
Inadvertent pooling of middle turbinate
can lead to cribriform plate injury and iat-
rogenic CSF leak. The collection of air
within the lower free part of the middle
turbinate is known as concha bullosa
(Fig. 1.1).
1 Endoscopic Anatomy and Surgery
CP
MM
MT
IM
IT
Fig. 1.1 NCCT PNS orbit (Coronal cuts) is showing infe-
rior turbinate (IT), inferior meatus (IM) middle turbinate
(MT), middle meatus (MM), and cribriform plate (CP).
2. In frontal and horizontal plane it attached
with lamina papyracea. It is known as
ground lamella. Ground lamella divides
ethmoid air cells into anterior and poste-
rior ethmoid cells. Lamina papyracea is
thin at the site of attachment so that unin-
tentional pooling of turbinate can leads to
orbital fat prolapse.
3. Normally middle turbinate is concave on
the middle meatus side. Paradoxical turbi-
nate is the convex presentation of middle
turbinate which reduces the volume of
middle meatus (Fig. 1.1). Minimum
inflammation in the middle meatus can
affect the drainage of anterior sinuses
significantly.
Meatus is the part of the nasal cavity
which is present deep and lateral to the tur-
binate. Sphenoethmoidal recess and
supreme meatus are present medial to
superior turbinate (Fig. 1.7). Inferior
meatus is the largest and it is present along
the entire length of the inferior turbinate.
Nasolacrimal duct opening locates at ante-
rior third and posterior two-third junction
of the inferior turbinate. Genu is the part of
inferior meatus which locates just below
and posterior to the nasolacrimal duct
3
UP
The central picture is depicting bullosa of MT (white
arrow) and the right side picture is showing paradoxical
MT with uncinate process attachment on middle turbinate
opening. Surgical window to reach the
floor of the maxillary sinus in endoscopic
surgery, in ancient surgery like Proof
puncture and for inferior meatal antros-
tomy (2 × 1 cm) is performed at genu
because lateral wall bone is thinnest in this
area. The middle meatus is the space pres-
ent lateral to the middle turbinate. It con-
tains the uncinate process, hiatus
semilunaris, bulla ethmoidalis, and eth-
moid infundibulum (Fig. 1.2). Anterior
ethmoid air cells, maxillary, and frontal
sinuses drains into middle meatus. Middle
turbinate along with its contents is known
as osteomeatal complex (Fig. 1.2).
Superior meatus is the smallest meatus.
It is located between the middle and supe-
rior turbinate and posterior ethmoid cells
lies within it. Sphenoethmoid recess is the
space above and behind the superior
meatus. Posterior ethmoid cells and sphe-
noid sinus drains into it.
C. Uncinate Process
It is a boomerang shape of two-dimensional
structure. It attaches laterally with the lacrimal
bone and inferiorly with the inferior turbinate.
Superiorly, the uncinate process has three dif-
ferent kinds of attachments. In 70–80% cases,
1 Endoscopic Anatomy and Surgery
outflow, thereby helps to induce controlled hypo-
tension. It also decreases the requirement of
anesthetic agent. Nitroglycerine and sodium
nitroprusside infusion, by vasodilatation reduce
the peripheral vascular resistance. Beta-blockers
like esmolol, labetalol, or metoprolol, and cal-
cium channel blockers also help to maintain
hypotension. Magnesium sulfate infusion also
helps to induce hypotension and helps to reduce
blood loss, however, it might prolong the anes-
thesia emergence time [14].
1.3.4 Acute Normovolemic
Hemodilution
It can be used as a technique for blood conserva-
tion strategies. After induction of anesthesia,
blood is withdrawn upto a limit of 7 g% hemo-
globin, and subsequently, crystalloids and col-
loids are infused to maintain the blood volume.
Intraoperative red blood cell salvage is not done
as there is chance of contamination by nasal flora.
Blood loss is carefully estimated by counting the
number of gauze pieces used and from the suc-
tion bottle. End tidal CO2 is maintained to pre-
vent any hypercarbia or hypocapnia.
Normothermia is maintained for the proper func-
tioning of platelets and coagulation factors.
1.3.5 Juvenile Nasopharyngeal
Angiofibroma
with Intracranial Extension
Patients with Radkowski Grade III tumors are
usually require combined approach with the neu-
rosurgery team. Intraoperative blood loss is an
predicting factor for better Glasgow Outcome
scale, so these cases should be planned with mul-
tidisciplinary approach involving the neurosur-
geon, intervention radiologist, and
anesthesiologist, so that there will be minimal
blood loss and stable hemodynamics periopera-
tively [12, 15]. Such cases are kept intubated and
put on mechanical ventilatory support to main-
tain the end tidal carbon dioxide (EtCO2), as
hypercarbia can cause cerebral vasodilatation
and subsequent rise in intracranial pressure
15
(ICP). The extensiveness of the surgery with
massive blood loss, postoperative mechanical
ventilation with intensive care unit (ICU) stay
should be explained in informed consent.
1.3.6 Emergence from Anesthesia
Smooth recovery of anesthesia is warranted to
prevent any straining and bleeding. The throat
pack is removed after suctioning of the oral cavity
and it is better to do under either direct laryngo-
scope or video laryngoscope. Postnasal space
should be carefully evaluated to remove any blood
clots. Administration of esmolol or lignocaine
prevents extubation response. Decompression of
the stomach with an orogastric tube should be
performed prior to extubation to remove the blood
clots, which is a predisposing factor for postop-
erative nausea and vomiting. In cases with mas-
sive blood loss or high-grade JNA with intracranial
extension, patients are kept intubated and mechan-
ically ventilated to avoid any rise of ICP by hyper-
carbia. Dexamethasone is administered 0.1 mg/kg
to decrease airway edema by surgical trauma.
Extubation should be done in controlled environ-
ment with adequate hemostasis, stable coagula-
tion status, and hemodynamics [16].
1.3.7 Postoperative Concerns
Patients should be kept in closed observation
with monitoring of vitals. Postoperative hemo-
gram should be done to ensure adequate replace-
ment of blood loss.
For Nausea and Vomiting:
• The presence of blood in the stomach, inflam-
mation of the uvula and throat and the
­occasional use of opioids for pain control is
contributing factors. Intraoperatively ondan-
setron and dexamethasone are administrated
as a prophylactic measure.
Postoperative Pain:
• The expected postoperative pain from FESS
may range from mild to moderate and is due to
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