Dean M. Clerico

Functional Endoscopic Sinus Surgery

Sinus surgery has undergone a dramatic change within the last 10 years owing in large part to the introduction of the nasal telescope. This device, along with the instrumentation developed to use with it, has permitted highly accurate diagnosis and effective treatment of chronic sinus disease. The key to diagnosing chronic or recurrent sinusitis is adequate visualization of the ostiomeatal complex (OMC). The importance of limited disease in the OMC as a cause of chronic and recurrent sinusitis has only recently gained widespread acceptance.

Sinus Headaches Reconsidered: Referred Cephalgia of Rhinologic Origin Masquerading as Refractory Primary Headaches

Headache associated with acute sinusitis is a well‐recognized entity; the diagnosis is easily made due to the associated nasal and sinus symptoms. However, the phenomenon of referred headache from chronic sinusitis or intranasal abnormalities or both without upper respiratory symptoms is not well understood. Only recently have the nasal and sinus cavities been adequately visualized by both the human eye and radiographic techniques; a fact that may account for the historic neglect in considering this region a factor in headache etiology. Modern techniques employed in the workup of sinusitis, namely the use of rigid nasal endoscopes and coronal‐plane CT scanning, have greatly enhanced the clinicians ability to evaluate and diagnose pathology in this area. This report describes a series of patients presenting with various primary headache syndromes without significant nasal or sinus symptoms who failed to respond to conventional antiheadache therapy. On nasal endoscopic and coronal CT examinations, various intranasal and sinus abnormalities were found (either anatomic variations or subclinical inflammation). Medical and/or surgical therapy addressing the sinonasal pathology resulted in improvement in every case, ranging from decreased severity of attacks to total resolution of headaches. A model explaining the possible mechanism of referred vascular‐type headache from sinus and nasal origin is proposed.

The forgotten turbinate: the role of the superior turbinate in endoscopic sinus surgery.

The fate of the middle turbinate in endoscopic sinus surgery has been a subject of debate for some time. The superior turbinates role, however, has been largely passed over. Past anatomic descriptions and illustrations have given surgeons the incorrect impression that this structure is well superior and out of the field of dissection. Injury to the superior turbinate may account for postoperative hyposmia. The superior turbinate also serves as a constant landmark for the sphenoethmoidal recess, and a limited resection allows the surgeon to identify and include the natural ostium of the sphenoid sinus in the sphenoidotomy. The embryology and anatomy of the superior turbinate are reviewed. An approach to the natural ostium of the sphenoid sinus from the lateral side of the middle turbinate, using the superior turbinate as a guide, is described.

Maxillary Sinus Aplasia

A 66-year-old man complaining of postnasal drip and recurrent sinus infections presented to one of us (D.M.C.). In 1991, the patient had a septoplasty performed that did not significantly alter his symptoms. He reported no difficulties with his dentition or vision. On initial office nasal endoscopie examination, no gross pus or polyps were seen, although each middle meatus was narrow. A computed tomography scan of the sinuses was performed after 3 weeks of oral antibiotics and steroid nasal sprays. Along with patchy ethmoid mucosal thickening and a large concha bullosa on the

Environmental factors in sinus disease

Educational objectives: To understand the role of environmental pollutants in sinus disease and to suggest practical methods to patients to limit their exposure to air pollutants.

Rhinopathic Headache: Diagnosis and Treatment

Educational objectives: To understand the pathophysiology ofrhinopathic headache, including mechanisms of referred pain, and to differentiate rhinopathic from nonrhinopathic headaches and treat patients with the disorder (both medically and surgically).

Book Review: Practical Endoscopic Sinus SurgeryPractical Endoscopic Sinus Surgery, edited by AnandVijay K. and PanjeWilliam R.. 186 pages with illustrations. McGraw-Hill, Inc., New York, 1993.

The stated goal of this textbook is to educate physicians at every level of training and experience in the endoscopic management of inflammatory disorders of the paranasal sinuses. The editors have authored about one third of the book, with other contributions from several prominent experts in their respective fields. In particular, the chapters on radiology, immunodeficiency, and videodocumentation are excellent. The book contains several excellent photographs, cadaver dissections, and illustrations describing paranasal sinus anatomy and endoscopic surgery. The surgical indications and techniques used by the editors are clearly and concisely stated. Several chapters diverge from the topic of practical endoscopic sinus surgery, but are certainly worthwhile (e.g., rhinomanometry and sublabial approach to the sphenoid). Unfortunately, there are multiple publishing errors that are distracting. Some endoscopic photographs lack labels, despite the fact that labels are indicated to be present by the legend. Also, some endoscopic photographs are repeated several times throughout the text, are inaccurate, and/or seem unrelated to the legend. Furthermore, some illustrations have misplaced labels. Despite these shortcomings, this text contains many quality clinical photographs, helpful illustrations, and is an informative text.