**Therapeutic and Diagnostic Approaches in Rhinology and Allergy**

Pongsakorn Tantilipikorn

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/50355

### **1. Introduction**

### **1.1. Diagnostic rhinoscopy**

#### *1.1.1. Applied anatomy of nose & paranasal sinuses*

Nasal cavity is the complex structure. It is divided by the nasal septum into the left and right side. Lateral nasal wall composed of three turbinates and their meati.(figure 1).

**Figure 1.** Normal anatomy of left nasal cavity, shows nasal septum, inferior turbinate & meatus, and middle turbinate & meatus.

© 2013 Tantilipikorn; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The anterior group of paranasal sinuses consists of the frontal, maxillary and anterior eth‐ moid sinus. The posterior group of paranasal sinuses consists of the sphenoid and posterior ethmoid sinus.

By histology, nasal and paranasal sinus mucosa is the psuedostratified ciliated columnar ep‐ ithelium. The mucous blanket is moved from sinuses through their ostium. The drainage of anterior group of paranasal sinuses is through their ostium and middle meati.The posterior group is drained through the superior meati & sphenoethmoidal recess.

With the concept of 'mucous drainage drain through meatus", the most important structure inside the nose is called "ostiomeatal complex", especially the middle meatus area.[1]

### *1.1.2. Clinical presentation of common rhinologic condition*

The most common disease of nose is the inflammatory conditions – rhinitis. It can be caused by the infectious vs non-infectious causes.The non-infectious rhinitis can be further divided into allergic rhinitis (AR) and non-allergic rhinitis (NAR). When the inflammatory process extended beyond the nasal cavities, the inflammation spread into the paranasal sinuses, leads to be 'rhinosinusitis'.

**Figure 3.** Squamous cell carcinoma of left nasal cavity.

Nasal endoscopy can reveal the detail of color of nasal mucosa, the swelling, and the dis‐ charge. These detail help rhinologist to differential the various causes of rhinitis.For instan‐ ces, the turbinate of AR will be in pale color with watery discharge. (figure 4). On the

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Because of the tumor of nose&paranasal sinuses usually presents with the subtle symptoms. The early stage may present with minimal nasal congestion or minor nasal bleeding. Nasal endoscopy will be a good armamentarium to exam the detail of deep structure inside the

contrary, NAR will be injected and swelling turbinate or atrophic in some conditions.

*1.1.3. Diagnostic application of endoscopy*

**Figure 4.** Congest inferior turbinate with pale color.

nasal cavities.

Besides the mucosal inflammation, some anatomic variations may caused the symptoms re‐ semble to rhinitis. Those anatomic variations are pneumatization of middle turbinate (Con‐ cha Bullosa), paradoximal middle turbinate, or deviated nasal septum (DNS), etc. (figure 2).

**Figure 2.** Deviation of nasal septum to the left, with its contact point to the inferior turbinate.

The tumor of nose & paranasal sinuses commonly arises from the maxillary sinuses and lat‐ eral nasal wall. Squamous cell carcinoma is the most common malignant type, and Inverted papilloma is the most common benign type. The other tumors are adenocarcinoma, ade‐ noidcysticcarcinom, olfactory neuroblastoma, lymphoma, vascular tumor, etc. (figure 3).

**Figure 3.** Squamous cell carcinoma of left nasal cavity.

### *1.1.3. Diagnostic application of endoscopy*

The anterior group of paranasal sinuses consists of the frontal, maxillary and anterior eth‐ moid sinus. The posterior group of paranasal sinuses consists of the sphenoid and posterior

By histology, nasal and paranasal sinus mucosa is the psuedostratified ciliated columnar ep‐ ithelium. The mucous blanket is moved from sinuses through their ostium. The drainage of anterior group of paranasal sinuses is through their ostium and middle meati.The posterior

With the concept of 'mucous drainage drain through meatus", the most important structure

The most common disease of nose is the inflammatory conditions – rhinitis. It can be caused by the infectious vs non-infectious causes.The non-infectious rhinitis can be further divided into allergic rhinitis (AR) and non-allergic rhinitis (NAR). When the inflammatory process extended beyond the nasal cavities, the inflammation spread into the paranasal sinuses,

Besides the mucosal inflammation, some anatomic variations may caused the symptoms re‐ semble to rhinitis. Those anatomic variations are pneumatization of middle turbinate (Con‐ cha Bullosa), paradoximal middle turbinate, or deviated nasal septum (DNS), etc. (figure 2).

inside the nose is called "ostiomeatal complex", especially the middle meatus area.[1]

group is drained through the superior meati & sphenoethmoidal recess.

**Figure 2.** Deviation of nasal septum to the left, with its contact point to the inferior turbinate.

The tumor of nose & paranasal sinuses commonly arises from the maxillary sinuses and lat‐ eral nasal wall. Squamous cell carcinoma is the most common malignant type, and Inverted papilloma is the most common benign type. The other tumors are adenocarcinoma, ade‐ noidcysticcarcinom, olfactory neuroblastoma, lymphoma, vascular tumor, etc. (figure 3).

*1.1.2. Clinical presentation of common rhinologic condition*

ethmoid sinus.

90 Endoscopy

leads to be 'rhinosinusitis'.

Nasal endoscopy can reveal the detail of color of nasal mucosa, the swelling, and the dis‐ charge. These detail help rhinologist to differential the various causes of rhinitis.For instan‐ ces, the turbinate of AR will be in pale color with watery discharge. (figure 4). On the contrary, NAR will be injected and swelling turbinate or atrophic in some conditions.

**Figure 4.** Congest inferior turbinate with pale color.

Because of the tumor of nose&paranasal sinuses usually presents with the subtle symptoms. The early stage may present with minimal nasal congestion or minor nasal bleeding. Nasal endoscopy will be a good armamentarium to exam the detail of deep structure inside the nasal cavities.

According to the most recent guideline – European Position Paper of Sinusitis (EPOS) 2012, the rhinosinusitis is a disease of 'clinical diagnosis'.[2] By using the two symptoms of nasal obstruction and rhinorrhea with the duration longer than 10 days, the diagnosis of acute rhi‐ nosinusitis (ARS) is made.[3] But if the initial treatment cannot alleviate the symptoms, na‐ sal endoscopy should be done. Moreover, the chronic rhinosinusitis (CRS) need nasal endoscopy along with the history for diagnosis. The CRS can be subclassified into CRS with nasal polyp (CRS c NP) and CRS without nasal polyp (CRS s NP).

The selection of antibiotic for treatment of infectious RS usually follows the guideline that depends on the prevalence of responsible organism in each community. Three most com‐ mon organisms of RS are *Streptococcus pneumoniae, Haemophilusinfluenzae and Moraxella catar‐ rhalis*.[6,7]Most of the guidelines suggest the high dose-amoxycillin with/without clavulanic acid as the first –line drug.When there is little (minimal) response of RS patient, the physi‐ cian may switch to the second-line drug or consider taking the microbiologic culture/sensi‐

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The gold standard of obtaining RS specimen for culture is the sinus puncture, usually from the maxillary sinus through the inferior meatus. But the so-called maxillary Antral punc‐ ture&Irrigation (AI) is considered as an invasive procedure, which can cause the significant pain for RS patient. To avoid this limitation and minimal contamination of non-pathogenic organism in the nasal cavity, endoscopic-guided culture at the ostiomeatal complex (OMC)

If the RS patient fails to the medical treatment, the surgical procedure is needed. Conven‐ tionally, the open-approach sinus surgeries are the Caldwell-Luc (CWL) and the external frontoethmoidectomy (eg. Lynch). Prof Messerklinger proposed the breakthrough principle of mucociliary drainage through OMC in 1975.With this principle and the advancement of surgical instrument (especially the rigid endoscope), Prof Kennedy and Prof Stammberger lead the concept of "Functional Endoscopic Sinus Surgery-FESS" into the acceptable sinus

FESS consists of the utilization of rigid nasal endoscope and the cutting forceps to clear the pathology at OMC area. Then, obstructed secretion inside the sinus cavities can be drained

Over the 30 years, there are tremendous improvement of surgical instrument and the ad‐ junctive procedure.For instance, the cutting&suction instrument such as the microdebrider

is the alternation procedure with comparable accuracy to AI.[8] (figure 6)

**Figure 6.** Endoscopic-guide culture from the left middle meatus.

out through OMC by the function of respiratory cilia.

procedure as a standard treatment.[9]

tivity test.

NP can be seen as the pale, semi-translucent mass protruding from the middle meatus. (figure 5).

Its etiology remains obscure but related to mucosal inflammation by eosinophilic cell.[4,5] The principle of treatment of CRS, especially CRS c NP, is topical nasal steroid. Oral predni‐ solone may be used for the short course of large NP 's treatment.Nasal endoscopy is the es‐ sential instrument to differentiate CRS c NP from CRS s NP.Due to their different natural course, these conditions should be made since the initial treatment process.

### **2. Therapeutic options of nasal endoscope**

### **2.1. Rhinologic condition**

#### *2.1.1. Rhinosinusitis*

Three principle treatments of rhinosinusitis (RS) are the eradication of infectious process, promotion of secretion in sinus cavity and treatment of underlying disease (eg. Allergic in‐ flammation).Endoscopy has its role in the treatment of RS by 1) utilization of endoscope for obtaining responsible organism, and 2) utilization of endoscope as a principle instrument of surgical procedure.

The selection of antibiotic for treatment of infectious RS usually follows the guideline that depends on the prevalence of responsible organism in each community. Three most com‐ mon organisms of RS are *Streptococcus pneumoniae, Haemophilusinfluenzae and Moraxella catar‐ rhalis*.[6,7]Most of the guidelines suggest the high dose-amoxycillin with/without clavulanic acid as the first –line drug.When there is little (minimal) response of RS patient, the physi‐ cian may switch to the second-line drug or consider taking the microbiologic culture/sensi‐ tivity test.

The gold standard of obtaining RS specimen for culture is the sinus puncture, usually from the maxillary sinus through the inferior meatus. But the so-called maxillary Antral punc‐ ture&Irrigation (AI) is considered as an invasive procedure, which can cause the significant pain for RS patient. To avoid this limitation and minimal contamination of non-pathogenic organism in the nasal cavity, endoscopic-guided culture at the ostiomeatal complex (OMC) is the alternation procedure with comparable accuracy to AI.[8] (figure 6)

According to the most recent guideline – European Position Paper of Sinusitis (EPOS) 2012, the rhinosinusitis is a disease of 'clinical diagnosis'.[2] By using the two symptoms of nasal obstruction and rhinorrhea with the duration longer than 10 days, the diagnosis of acute rhi‐ nosinusitis (ARS) is made.[3] But if the initial treatment cannot alleviate the symptoms, na‐ sal endoscopy should be done. Moreover, the chronic rhinosinusitis (CRS) need nasal endoscopy along with the history for diagnosis. The CRS can be subclassified into CRS with

NP can be seen as the pale, semi-translucent mass protruding from the middle meatus.

Its etiology remains obscure but related to mucosal inflammation by eosinophilic cell.[4,5] The principle of treatment of CRS, especially CRS c NP, is topical nasal steroid. Oral predni‐ solone may be used for the short course of large NP 's treatment.Nasal endoscopy is the es‐ sential instrument to differentiate CRS c NP from CRS s NP.Due to their different natural

Three principle treatments of rhinosinusitis (RS) are the eradication of infectious process, promotion of secretion in sinus cavity and treatment of underlying disease (eg. Allergic in‐ flammation).Endoscopy has its role in the treatment of RS by 1) utilization of endoscope for obtaining responsible organism, and 2) utilization of endoscope as a principle instrument of

course, these conditions should be made since the initial treatment process.

**2. Therapeutic options of nasal endoscope**

nasal polyp (CRS c NP) and CRS without nasal polyp (CRS s NP).

(figure 5).

92 Endoscopy

**Figure 5.** Nasal polyp of the right nasal cavity.

**2.1. Rhinologic condition**

*2.1.1. Rhinosinusitis*

surgical procedure.

If the RS patient fails to the medical treatment, the surgical procedure is needed. Conven‐ tionally, the open-approach sinus surgeries are the Caldwell-Luc (CWL) and the external frontoethmoidectomy (eg. Lynch). Prof Messerklinger proposed the breakthrough principle of mucociliary drainage through OMC in 1975.With this principle and the advancement of surgical instrument (especially the rigid endoscope), Prof Kennedy and Prof Stammberger lead the concept of "Functional Endoscopic Sinus Surgery-FESS" into the acceptable sinus procedure as a standard treatment.[9]

FESS consists of the utilization of rigid nasal endoscope and the cutting forceps to clear the pathology at OMC area. Then, obstructed secretion inside the sinus cavities can be drained out through OMC by the function of respiratory cilia.

Over the 30 years, there are tremendous improvement of surgical instrument and the ad‐ junctive procedure.For instance, the cutting&suction instrument such as the microdebrider helps the surgeon to minimize tissue trauma, which leads to less intraoperative bleeding and better postoperative result.[10] (figure 7). The image-guidance system also helps the rhi‐ nologist to operate in the high-risk area, such as the orbit or skull base, or the uncertain anatomy with more accuracy.[11]

**Figure 8.** Endoscopic submucous resection of the left inferior turbinate.

Tumor of nose&PNS can be benign or malignant in-origin.The most common benign tu‐ mor is inverted papilloma.Inverted papilloma has its natural course of frequent recurrence due to its histologic character of 'inverted tumor cell into the attachment bony origin. So the principle of surgical treatment is the medial maxillectomy through open-approach such as the lateral rhinotomy or CWL.Nowadays, the medial maxillectomy procedure can be done under endoscope with the help of suction&cutting device (eg. Microdebrider). The endoscopic medial maxillectomy procedure reaches it comparable result as the open

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Another benign lesion that can be benefit from endoscopic procedure is the transnasal pitui‐ tary procedure. The hypophysectomy procedure has been done as the microscopic transept‐ al approach. Rhinologic surgeon can work along with neurosurgeon as a 'four-handed technique' through the nostrils by using endoscope.[15] The sphenoid sinus can be approach and further procedure of hypophysectomy can be done with the same principle of transeptal

Malignant tumors of nose & PNS can be squamous cell carcinoma that commonly originates from the maxillary sinus or lateral nasal wall. Its symptom is subtle and the patient usually comes to visit the otorhinolaryngologist as the advance stage. To obtain the free-margin, the open procedure should be done to provide the good 5-years survival. But for some malig‐ nant lesions near skull base, such as olfactory neuroblastoma, the endoscope can help rhino‐ logic surgeon to delineate the surgical margin and precise surgical resection with minimized

*2.1.3. Tumor of nose & paranasal sinuses (PNS)*

procedure.[14]

approach.

injury to the vital structure.[16]

**Figure 7.** Endoscopic resection of left nasal polyp by microdebrider.

### *2.1.2. Allergic rhinitis with turbinate hypertrophy*

Allergic Rhinitis (AR) is the disease mediated by 'antigen-antibody' reaction. The responsi‐ ble antigen is the immunoglobulin E (Ig E). This pathomechanism leads to mast cell degra‐ nulation and subsequently releasing of various mediators, especially histamine and leukotrienes (LTs). The principle treatments of AR are the avoiding of responsile allergens, anti-allergic medication (eg. Antihistamine, corticosteroid nose spray), and modulation of immune response (eg. Allergen Immunotherapy – AIT).[12]

The most troublesome symptom of AR is nasal blockage/obstruction. Antihistamine (AH) and Intranasal corticosteroid (INCS) have their excellent result in alleviating of nasal ob‐ struction. In some unresponsive AR patients, their inferior turbinates are hypertrophic from the submucous gland/vascular structures.

The original turbinate-reduction procedures are the total/subtotal turbinate resection or the cauterization by chemical agents, electrical instruments. These procedure leads into the los‐ ing of mucosal surface and subsequently crusting and dryness of nasal cavities.

More conservative procedures, with the utilization of nasal endoscopy, are done with more physiologic state. The endoscopic submucous resection (either by cutting-forceps or micro‐ debrider) and radiofrequency volumetric tissue reduction (RFVTR) can be done with the ex‐ cellent accuracy and surgical result.[13] (figure 8).

**Figure 8.** Endoscopic submucous resection of the left inferior turbinate.

### *2.1.3. Tumor of nose & paranasal sinuses (PNS)*

helps the surgeon to minimize tissue trauma, which leads to less intraoperative bleeding and better postoperative result.[10] (figure 7). The image-guidance system also helps the rhi‐ nologist to operate in the high-risk area, such as the orbit or skull base, or the uncertain

Allergic Rhinitis (AR) is the disease mediated by 'antigen-antibody' reaction. The responsi‐ ble antigen is the immunoglobulin E (Ig E). This pathomechanism leads to mast cell degra‐ nulation and subsequently releasing of various mediators, especially histamine and leukotrienes (LTs). The principle treatments of AR are the avoiding of responsile allergens, anti-allergic medication (eg. Antihistamine, corticosteroid nose spray), and modulation of

The most troublesome symptom of AR is nasal blockage/obstruction. Antihistamine (AH) and Intranasal corticosteroid (INCS) have their excellent result in alleviating of nasal ob‐ struction. In some unresponsive AR patients, their inferior turbinates are hypertrophic from

The original turbinate-reduction procedures are the total/subtotal turbinate resection or the cauterization by chemical agents, electrical instruments. These procedure leads into the los‐

More conservative procedures, with the utilization of nasal endoscopy, are done with more physiologic state. The endoscopic submucous resection (either by cutting-forceps or micro‐ debrider) and radiofrequency volumetric tissue reduction (RFVTR) can be done with the ex‐

ing of mucosal surface and subsequently crusting and dryness of nasal cavities.

anatomy with more accuracy.[11]

94 Endoscopy

**Figure 7.** Endoscopic resection of left nasal polyp by microdebrider.

immune response (eg. Allergen Immunotherapy – AIT).[12]

*2.1.2. Allergic rhinitis with turbinate hypertrophy*

the submucous gland/vascular structures.

cellent accuracy and surgical result.[13] (figure 8).

Tumor of nose&PNS can be benign or malignant in-origin.The most common benign tu‐ mor is inverted papilloma.Inverted papilloma has its natural course of frequent recurrence due to its histologic character of 'inverted tumor cell into the attachment bony origin. So the principle of surgical treatment is the medial maxillectomy through open-approach such as the lateral rhinotomy or CWL.Nowadays, the medial maxillectomy procedure can be done under endoscope with the help of suction&cutting device (eg. Microdebrider). The endoscopic medial maxillectomy procedure reaches it comparable result as the open procedure.[14]

Another benign lesion that can be benefit from endoscopic procedure is the transnasal pitui‐ tary procedure. The hypophysectomy procedure has been done as the microscopic transept‐ al approach. Rhinologic surgeon can work along with neurosurgeon as a 'four-handed technique' through the nostrils by using endoscope.[15] The sphenoid sinus can be approach and further procedure of hypophysectomy can be done with the same principle of transeptal approach.

Malignant tumors of nose & PNS can be squamous cell carcinoma that commonly originates from the maxillary sinus or lateral nasal wall. Its symptom is subtle and the patient usually comes to visit the otorhinolaryngologist as the advance stage. To obtain the free-margin, the open procedure should be done to provide the good 5-years survival. But for some malig‐ nant lesions near skull base, such as olfactory neuroblastoma, the endoscope can help rhino‐ logic surgeon to delineate the surgical margin and precise surgical resection with minimized injury to the vital structure.[16]

### *2.1.4. Nasal bleeding (epistaxis)*

Nasal bleeding (Epistaxis) can be categorized into two groups, anterior or posterior epistax‐ is. Anterior epistaxis is usually bled from Little's area, which located at anteroinferior part of nasal septum. The mild degree anterior bleeding can be stopped by cold compression or cauterization. The more severe one can be stopped by standard anterior nasal packing.

gerNasi bone work is done by drill or ronguer.(figure 10). The next step is to marsupialise the lac and make the sac stay widely open into the nasal cavity. Endoscopic DCR provides many advantages such as: ability to correct intranasal anatomy, less bony drilling, and no

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The etiologies of cerebrospinal fluid (CSF) leakage are either traumatic or non-traumatic cause. Most of the traumatic from accidental cause heal spontaneously after a few weeks of

For the indicated cases of CSF leak, the external approach via bi-coronal incisions with uti‐ lization of various materials, such as fascia, can be done with excellent result.[21,22] Endo‐ scopic approach to the anterior skull base is an alternative method, especially for the singlelesion leakage or the same-stage repair with the intranasal resection of tumor.[23] Many choices of repairing material is used, for instance:autologous fat graft, nasal mucosa, carti‐ lage from septum or auricle, and allografts. (figure 11). Metaanalysis study reveals the com‐

Proptosis from thyroid hyperfunction is treated initially by prednisolone and immunosup‐ pressive drugs. Surgical approach reserves for the refractory case, which can be done by re‐ moval of the bony wall of orbital. Theoretically, the selective on particular wall can be

chosen, depending on the surgeon's preference and the degree of proptosis.

**Figure 10.** Endoscopic DCR. The transilluminated area is the AggerNasi area.

*2.2.2. Cerebrospinal fluid repair*

conservative treatments.

parable result with the external approach.[24]

*2.2.3. Orbital/optic nerve decompression*

scarring.[19,20]

The location of posterior epistaxis is around the posterior end of middle turbinate, which is supplied by the sphenopalatine artery. The sphenopalatine is the terminal branch of internal maxillary artery. Before the era of nasal endoscopy, the severe posterior epistaxis, which is failed from the posterior nasal packing, can be treated by internal maxillary artery ligation through the CWL approach. Nowadays, the sphenopalatine artery can be directly ligated or clipped by endoscopic approach.[17,18] (figure 9). This procedure requires less operative time and provides less tissue trauma comparing to the CWL approach.

#### **2.2. Non-rhinologic condition**

#### *2.2.1. Obstruction of nasolacrimal system*

Lacrimal system consists of the lacrimal punctum, cannaliculus, lacrimal sac and lacrimal duct. The duct drains tear into the inferior meatus. Location of lacrimal drainage obstruction commonly occurs below the level of sac. Dacryocystorhinostomy (DCR) is the procedure for the treatment of obstructive of lacrimal system at that level. DCR can be bone via the inci‐ sion around the medial canthus region. Then, the cavity of sac is entered. The medial (nasal surface) of sac is drained into the nasal cavity.

By using the endoscope approach, intranasal cavity can be examined and corrected if that particular structure may contribute to the obstruction.The intranasal specific area of lacrimal sac is called "AggerNasi" area is approached. The medial side of sac is entered after the Ag‐ gerNasi bone work is done by drill or ronguer.(figure 10). The next step is to marsupialise the lac and make the sac stay widely open into the nasal cavity. Endoscopic DCR provides many advantages such as: ability to correct intranasal anatomy, less bony drilling, and no scarring.[19,20]

### *2.2.2. Cerebrospinal fluid repair*

*2.1.4. Nasal bleeding (epistaxis)*

96 Endoscopy

Nasal bleeding (Epistaxis) can be categorized into two groups, anterior or posterior epistax‐ is. Anterior epistaxis is usually bled from Little's area, which located at anteroinferior part of nasal septum. The mild degree anterior bleeding can be stopped by cold compression or cauterization. The more severe one can be stopped by standard anterior nasal packing.

The location of posterior epistaxis is around the posterior end of middle turbinate, which is supplied by the sphenopalatine artery. The sphenopalatine is the terminal branch of internal maxillary artery. Before the era of nasal endoscopy, the severe posterior epistaxis, which is failed from the posterior nasal packing, can be treated by internal maxillary artery ligation through the CWL approach. Nowadays, the sphenopalatine artery can be directly ligated or clipped by endoscopic approach.[17,18] (figure 9). This procedure requires less operative

Lacrimal system consists of the lacrimal punctum, cannaliculus, lacrimal sac and lacrimal duct. The duct drains tear into the inferior meatus. Location of lacrimal drainage obstruction commonly occurs below the level of sac. Dacryocystorhinostomy (DCR) is the procedure for the treatment of obstructive of lacrimal system at that level. DCR can be bone via the inci‐ sion around the medial canthus region. Then, the cavity of sac is entered. The medial (nasal

By using the endoscope approach, intranasal cavity can be examined and corrected if that particular structure may contribute to the obstruction.The intranasal specific area of lacrimal sac is called "AggerNasi" area is approached. The medial side of sac is entered after the Ag‐

time and provides less tissue trauma comparing to the CWL approach.

**Figure 9.** Clipping the right sphenopalatine artery in the posterior epistaxis case.

**2.2. Non-rhinologic condition**

*2.2.1. Obstruction of nasolacrimal system*

surface) of sac is drained into the nasal cavity.

The etiologies of cerebrospinal fluid (CSF) leakage are either traumatic or non-traumatic cause. Most of the traumatic from accidental cause heal spontaneously after a few weeks of conservative treatments.

For the indicated cases of CSF leak, the external approach via bi-coronal incisions with uti‐ lization of various materials, such as fascia, can be done with excellent result.[21,22] Endo‐ scopic approach to the anterior skull base is an alternative method, especially for the singlelesion leakage or the same-stage repair with the intranasal resection of tumor.[23] Many choices of repairing material is used, for instance:autologous fat graft, nasal mucosa, carti‐ lage from septum or auricle, and allografts. (figure 11). Metaanalysis study reveals the com‐ parable result with the external approach.[24]

#### *2.2.3. Orbital/optic nerve decompression*

Proptosis from thyroid hyperfunction is treated initially by prednisolone and immunosup‐ pressive drugs. Surgical approach reserves for the refractory case, which can be done by re‐ moval of the bony wall of orbital. Theoretically, the selective on particular wall can be chosen, depending on the surgeon's preference and the degree of proptosis.

proptosis. Then, the bony decompression is done with minimally disturbance of orbital con‐ tent. The hyperplastic orbital content protrudes into the ethmoid cavity (figure 12), which will make the proptosis improves. When more space is needed, the additional inferior orbi‐ tal wall is performed in the same setting. In this 'infero-medial wall decompression', the or‐

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For the blunt traumatic injury of optic nerve, rhinologic surgeon can use the endoscope to decompress the medial&interior wall of orbital apex. This procedure provides more space

Endoscope can be utilized in various conditions in rhinology&allergy. It provides both diag‐ nostic and therapeutic value.The surgical treatment with endoscopic approach can be done in the inflammatory condition and the others conditions such as tumor resection, CSF leak‐

Division of Rhinology & Allergy, Faculty of Medicine Siriraj Hospital, Mahidol University,

[1] Kennedy DW ,Zinreich SJ. Endoscopic middle meatalantrostomy: theory, technique,

[2] Fokkens WJ, Lund VJ, Mullol J, et al. The European Position Paper on Rhinosinusitis

[3] Benninger MS. Adult chronic rhinosinusitis: Definition, diagnosis, epidemiology, and pathophysiology. Otolaryngol Head Neck Surg. 2003; 129(3 Suppl): S1-S32. [4] Tan BK, SchleimerRP , Kern RC. Perspectives on the etiology of chronic rhinosinusi‐

[5] Shin SH, Lee SH, JeongHS , Kita H. The effect of nasal polyp epithelial cells on eosi‐

[6] Tantilipikorn P, Bunnag C, Srifuengfung S, et al. A Surveilance Study of Bacteriologic

bital content gains more space into the maxillary & ethmoid cavities.

age repair, DCR, orbital decompression, vascular ligation in epistaxis.

and patency. Laryngoscope. 1987; 97(8 pt 3 Suppl 43): 1-9.

tis. CurrOpinOtolaryngol Head Neck Surg. 2010; 18(1): 21-6.

and Nasal Polyps. Rhinology. 2012; Suppl(23): 1-299.

nophil activation. Laryngoscope. 2003; 113(8): 1374-7.

Profile in Rhinosinusitis. Siriraj Med J. 2007; 59: 117-80.

for the compressed optic nerve.

**3. Conclusion**

**Author details**

Bangkok, Thailand

**References**

Pongsakorn Tantilipikorn

**Figure 11.** Endoscopic CSF leak repair. The cartilaginous free-graft is inserted to repair the skull base defect.

**Figure 12.** Endoscopic orbital decompression. The lamina papyracea is dissected from the periorbital by curettage.

Endoscopic medial wall decompression is commonly done, allowing the orbital content ex‐ pands into the ethmoid cavity.[25,26] The first step of medial wall decompression is to do the ethmoidectomy with/without middle meatal antrostomy. Lamina papyracea is exposed and the surgeon can estimate the area of bony area to match with the degree of patient's proptosis. Then, the bony decompression is done with minimally disturbance of orbital con‐ tent. The hyperplastic orbital content protrudes into the ethmoid cavity (figure 12), which will make the proptosis improves. When more space is needed, the additional inferior orbi‐ tal wall is performed in the same setting. In this 'infero-medial wall decompression', the or‐ bital content gains more space into the maxillary & ethmoid cavities.

For the blunt traumatic injury of optic nerve, rhinologic surgeon can use the endoscope to decompress the medial&interior wall of orbital apex. This procedure provides more space for the compressed optic nerve.

### **3. Conclusion**

Endoscope can be utilized in various conditions in rhinology&allergy. It provides both diag‐ nostic and therapeutic value.The surgical treatment with endoscopic approach can be done in the inflammatory condition and the others conditions such as tumor resection, CSF leak‐ age repair, DCR, orbital decompression, vascular ligation in epistaxis.

### **Author details**

**Figure 11.** Endoscopic CSF leak repair. The cartilaginous free-graft is inserted to repair the skull base defect.

98 Endoscopy

**Figure 12.** Endoscopic orbital decompression. The lamina papyracea is dissected from the periorbital by curettage.

Endoscopic medial wall decompression is commonly done, allowing the orbital content ex‐ pands into the ethmoid cavity.[25,26] The first step of medial wall decompression is to do the ethmoidectomy with/without middle meatal antrostomy. Lamina papyracea is exposed and the surgeon can estimate the area of bony area to match with the degree of patient's

Pongsakorn Tantilipikorn

Division of Rhinology & Allergy, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

### **References**


[7] Brook I. Microbiology and management of sinusitis. J Otolaryngol. 1996; 25(4): 249-56.

[23] Lanza D, O'Brien D , Kennedy D. Endoscopic repair of cerebrospinal fluid fistulae

Therapeutic and Diagnostic Approaches in Rhinology & Allergy

http://dx.doi.org/10.5772/50355

101

[24] Hegazy H, Carrau R ,Snyderman C. Transnasal endoscopic repair of cerebrospinal

[25] Sheng H, Cai C, Cheng Y, et al. Endoscopic orbital decompression for thyroid-associ‐ ated ophthalmopathy. Lin Chung Er Bi Yan HouTou Jing WaiKeZaZhi. 26(1): 27-9.

[26] Boboridis KG, Bunce C. Surgical orbital decompression for thyroid eye disease. Co‐

fluid rhinorrhea: a meta-analysis. Laryngoscope. 2000; 110: 1166-72.

and encephaloceles. Laryngoscope. 1996; 106: 1119-25.

chrane Database Syst Rev. 2011; (12): CD007630.


[23] Lanza D, O'Brien D , Kennedy D. Endoscopic repair of cerebrospinal fluid fistulae and encephaloceles. Laryngoscope. 1996; 106: 1119-25.

[7] Brook I. Microbiology and management of sinusitis. J Otolaryngol. 1996; 25(4):

[8] Ozcan M, Unal A, Aksaray S, Yalcin F, Akdeniz T. Correlation of middle meatus and ethmoid sinus microbiology in patients with chronic sinusitis. Rhinology. 2002; 40(1):

[9] Stammberger H. Functional endoscopic sinus surgery: concept, indications and re‐ sults of the Messerklinger technique. Eur Arch Otorhinolaryngol. 1990; 247: 63-76.

[10] SetliffRC , Parsons DS. The "hummer": new instrumentation for functional endoscop‐

[11] Tantilipikorn P, Metheetrairut C, Lumyongsatien J, Bedavanija A, Assanasen P. Im‐

[12] Bousquet J, Khaltaev N, Cruz AA, et al. Allergic Rhinitis and its Impact on Asthma

[13] Banhiran W, Tantilipikorn P, Metheetrairut C, Assanasen P, Bunnag C. Quality of Life in Patients with Chronic Rhinitis after Radiofrequency Inferior Turbinate Reduc‐

[14] Sham CL, Woo JK , van Hasselt CA. Endoscopic resection of inverted papilloma of

[15] Briner HR, Simmen D, Jones N. Endoscopic sinus surgery: advantages of the bimanu‐

[16] Harvey RJ, Winder M, Parmar P, Lund V. Endoscopic skull base surgery for sinonas‐

[17] Agreda B, Urpegui A, Ignacio Alfonso J, Valles H. Ligation of the sphenopalatine ar‐ tery in posterior epistaxis. Retrospective study of 50 patients]. ActaOtorrinolaringol

[18] Howe DJ , Skinner DW. Outcomes of endoscopic sphenopalatine artery ligation for epistaxis: a five-year series from a single institution. Ear Nose Throat J. 91(2): 70-2.

[19] Al-Qahtani AS. Primary endoscopic dacryocystorhinostomy with or without silicone tubing: A prospective randomized study. Am J Rhinol Allergy. 26(4): 332-4.

[20] Feng YF, Cai JQ, Zhang JY , Han XH. A meta-analysis of primary dacryocystorhinos‐ tomy with and without silicone intubation. Can J Ophthalmol. 46(6): 521-7.

[21] McCormack B, Cooper PR ,Persky M. Extrncranial repair of cerebrospinal fluid fistu‐

[22] Persky MS, Rothstein SG , Breda SD. Extracranial repair of cerebrospinal fluid otorhi‐

las: technique and results in 37 patients. Neurosurgery. 1990; 27: 412-7.

the nose and paranasal sinuses. J Laryngol Otol. 1998; 112(8): 758-64.

al malignancy. OtolaryngolClin North Am. 44(5): 1081-140.

age-guided Surgery in Rhinology. Siriraj Med J. 2010; 62(203-6).

ic sinus surgery. Am J Rhinol. 1994; 8: 275-8.

(ARIA) 2008. Allergy. 2008; 63(Suppl 86): 8-160.

tion. J Med Assoc Thai. 2010; 93(8): 950-60.

al technique. Am J Rhinol. 2005; 19: 269-73.

norrhea. Laryngoscope. 1991; 101: 7-15.

Esp. 62(3): 194-8.

249-56.

100 Endoscopy

24-7.


**Chapter 7**

**Role of Endoscopic Sinus Surgery**

Timothy P. McEvoy, Charles A. Elmaraghy and

Additional information is available at the end of the chapter

Kris R. Jatana

**1. Introduction**

**2. Equipment**

**2.1. Camera and monitors**

http://dx.doi.org/10.5772/52551

and preservation of normal mucosa [1, 2].

cations of acute sinusitis as well as approaches to the skull base.

**in Pediatric Acute Complicated Sinusitis**

Sinus surgery was initially done transnasally or by a transmaxillary approach with the use of external lighting (often a headlight) and the surgeon's direct vision. Endoscopic techni‐ ques for intranasal surgery were first pioneered for adult applications and were gradually applied to pediatric sinus surgery as endoscope technology improved and smaller diameter endoscopes became available. Techniques that were developed in Europe were championed by Kennedy in the United States, with an emphasis on targeted removal of diseased tissue

In 1989, Gross *et al.* published one of the first case series documenting functional endoscopic sinus surgery in the pediatric population. They noted that all 57 children in the series toler‐ ated the procedure well and that there were no major complications [3]. Since that time, en‐ doscopic intranasal surgical techniques in children have become commonplace for applications ranging from chronic sinusitis and nasal polyposis to the treatment of compli‐

Initially, endoscopic sinus surgery was performed with the surgeon looking directly through the optical telescope. As digital cameras improved, the images could be magnified and viewed on a monitor allowing the surgeon better visualization as well as improving

and reproduction in any medium, provided the original work is properly cited.

© 2013 McEvoy et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

**Chapter 7**
