ABSTRACT

Figure 20.1 A large left concha bullosa. Note that it is not touching the septum nor blocking the middle meatus in spite of its large size

Figure 20.2 The CT scan of an asymptomatic subject similar to that in Figure 20.1. The short arrow points to the large left concha bullosa and the long arrow to a smaller right one

a Hartmann forceps. This procedure has been abandoned by the author who; at present, considers the concha bullosa a normal and non-significant finding

Figure 20.4 Another left concha bullosa 1 year after crushing. Note that it had not re-expanded

Figure 20.5 While performing endoscopic ethmoid and maxillary surgeries, the plane between the posterior mucoperiosteum of the maxillary sinus and the underlying bone (short arrow) is very easily entered inadvertently. Should this happen, the antrostomy becomes more difficult to perform because of the resultant laxity of the fontanelle. This figure shows the left side. The long arrow points to the posterior maxillary wall as seen through the middle meatal antrostomy, and the arrowhead to the bony angle between the medial and the inferior walls of the orbit

Figure 20.6 The same incorrect plane mentioned in Figure 20.5 but on the right side (short arrow). The long arrow points to the ostium of the maxillary sinus and the arrowhead to a curved suction introduced into the sinus

obliterating the middle meatus and touching the middle turbinate. This finding is almost pathognomonic of maxillary mucupyoceles. The long arrow points to the middle turbinate

Figure 20.8 The CT scan of the patient shown in Figure 20.7. Note the almost total opacity of the right maxillary sinus and the bony density in its center

Figure 20.10 Another patient with a bulging right lateral nasal wall (short arrow) characteristic of a maxillary mucopyocele. The long arrow points to the middle turbinate and the arrowhead to the septum

Figure 20.11 The CT scan of the patient shown in Figure 20.10 revealed a total opacity of the right maxillary sinus which bulges into the nasal cavity

purulence and a fungus ball (short arrow) with whitish soft debris was suctioned. The long arrow points to the middle turbinate

Figure 20.13 A multicolored fungus ball (short arrow) seen through a previously performed right middle meatal antrostomy. The long arrow points to the tail of the middle turbinate

Figure 20.15 Allergic fungal mucin (short arrow) in a case of recurrent polyposis (long arrow). The arrowhead points to the septum

Figure 20.16 Allergic fungal mucin is not friable. It looks and feels like rubber glue

Figure 20.17 Thick rubber glue (short arrows) in the left ethmoid cavity of a patient with mastocytosis and recurrent nasal polyposis. The long arrow points to the middle turbinate

Figure 20.18 The allergic mucin shown in Figure 20.17 was very

Figure 20.19 A fleshy mass (short arrow) seen in the left nasal cavity. The patient was an adult with a 6-month history of left nasal blockage and bloody mucus on noseblowing. Six years before, he had had sinus surgery. He was on no medications and gave no history of a bleeding tendency. The long arrow points to the middle turbinate

Figure 20.20 The CT scan of the patient shown in Figure 20.19. Note the mass seen on endoscopy (short arrow). The left maxillary sinus is almost totally opaque (long arrow)

Figure 20.22 The medical grade radio-opaque silicone stent (‘FES stent’, Boston Medical Products, Westborough, MA, USA) is used routinely to prevent postoperative adhesions lateral to the middle turbinate, which the author likes to preserve. This stent is easily cut to proper size and shape before being placed. Its two fingers, introduced through the middle meatal antrostomy, help to anchor it safely and prevent dislodgement on sniffing, nose-blowing, and sneezing

Figure 20.23 A FES stent (short arrow) placed in the left ethmoid cavity after surgery. The long arrow points to a gelfilm roll introduced into the ethmoid labyrinth as an extra precaution to prevent postoperative adhesions. The arrowhead points to the middle turbinate

and gelfilm roll (long arrow) kept on the right side, as seen on the 13th postoperative day. Both are easily and painlessly pulled out in the office after a local anesthetic spray. The arrowhead points to the middle turbinate

Figure 20.25 right ethmoid

Figure 20.26 The appearance of the osteoma in Figure 20.25 (short arrow) at endoscopic surgery. The long arrow points to the right middle turbinate

Figure 20.27 The osteoma in Figures 20.25 and 20.26 after its endoscopic excision

Figure 20.28 An adult with a recent onset of a right nasal blockage and a feeling of right nasal pressure. The CT scan was suggestive of a middle turbinate mucocele. (Courtesy of Dr Nicolas Busaba)

Figure 20.29 At surgery, the mass in Figure 20.28 proved to be a mucocele of the anterior half of a right concha bullosa

Figure 20.30 An adult with chronic headache. Nasal endoscopy was negative but the CT scan showed a total opacity of the sphenoid sinus

Figure 20.31 Intraoperative view of the patient in Figure 20.30 showing pus in the sphenoid sinus after it was opened

extensive sinus surgeries. A left posterior ethmoid mucocele is seen. His complaint was a dull and deep right nasal pain

Figure 20.33 After revising the right ethmoidectomy in the patient in Figure 20.32, the mucocele was identified and marsupialized endoscopically. The nasal pain was relieved

Figure 20.34 A patient with Alzheimer’s disease in a nursing home. She had complained of chronic headaches that were managed conservatively. One day she lost the vision in her right eye. An MRI revealed a large mucocele

Figure 20.35 The mucocele in Figure 20.34 was marsupialized endoscopically, exposing a large bone defect in the roofs of both ethmoids and sphenoid sinuses bilaterally. The dura was thick and intact. It pulsated a little

sinusitis after the middle meatal antrostomy stenosed totally. It had to be revised (short arrow). The long arrow points to purulence found inside the maxillary sinus

Figure 20.37 Orbital fat (short arrow) in the right nasal cavity following an endoscopic orbital decompression for Graves’ disease. Note that the middle turbinate had been totally resected. The long arrow points to the septum. (Courtesy of Dr Ralph Metson)

Figure 20.38 The CT scan of a patient with a left inverted papilloma showing a defect in the right fovea ethmoidalis

Figure 20.39 At endoscopic excision of the inverted papilloma in Figure 20.38, the defect was identified. The dura was not pulsating. No leak of cerebrospinal fluid could be noted, spontaneously or when the anesthesiologist increased the intracranial pressure by a sustained inspiration

Figure 20.39 was chosen. The arrow points to the graft in place. It was taken from the ipsilateral inferior turbinate

Figure 20.41 A recurrent inverted papilloma (short arrow) in the roof of the right posterior ethmoid. The long arrow points to the septum

completion of surgery. The long arrow points to the tip of the middle turbinate and the arrowhead to a frontal sinus suction tip

Figure 20.43 A closer look at the left frontal sinusotomy (short arrow) in the patient in Figure 20.42. The long arrow points to the fovea ethmoidalis with its slight yellowish discoloration

Figure 20.44 Severe scarring in the left anterior ethmoid area (short arrow), 2 months after an ethmoidectomy and a frontal sinusotomy, blocking the latter totally. The long arrow points to the middle turbinate

Figure 20.45 The scar in Figure 20.44 was excised at revision surgery, and a well-epithelialized nasofrontal duct was identified underneath the scar which had blocked it

noted 3 months after a right ethmoidectomy and frontal sinusotomy. At surgery, the nasofrontal duct was found to be blocked with cancellous bone formation which required the use of a drill. It blocked again within a few weeks.The long arrow points to the middle turbinate

Figure 20.47 A steroid cream (short arrow) instilled in a left nasofrontal duct after it was opened surgically, hoping to reduce the risk of restenosis. The long arrow points to the middle turbinate

Figure 20.48 A catheter used as a stent, kept in place for 2 months in a reconstructed left nasofrontal duct. It was well tolerated but did not prevent restenosis

Figure 20.49 A small Penrose drain (short arrow) in a reconstructed right nasofrontal duct was kept for 2 months. The nasofrontal duct did not restenose in this case. The long arrow points to the middle turbinate

tunnel created in the left inferior turbinate, in preparation for a partial submucous inferior turbinectomy, the author’s preferred method for turbinate reduction. The long arrow points to the incision in thr turbinate

Figure 20.51 The 1.5 cm piece of the turbinate bone that was removed from the patient in Figure 20.50

after the bone was removed and before the incision was sutured. Note the stump of the inferior turbinate bone