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DISEASES of the SINUSES

Diagnosis and Management

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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

WILLIAM E. BOLGER, MD, FACS


Associate Professor Chief of Rhinology and Sinus Surgery 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 B.C. Decker Inc. Hamilton London

B.C. Decker Inc. 20 Hughson Street South P.O. Box 620, L.C.D. 1 Hamilton, Ontario L8N 3K7 Tel: 905-522-7017; 1-800-568-7281 Fax: 905-522-7839 E-mail: info@bcdecker.com Website: www.bcdecker.com 2001 by David W. Kennedy, William E. Bolger, S. James Zinreich All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher. 00 01 / QP / 9 8 7 6 5 4 3 2 1 ISBN 1-55009-045-3 Printed in Canada

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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 eld 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 eld. 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 eld 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

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Anatomy of the Paranasal Sinuses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 William E. Bolger Radiographic Anatomy of the Sinuses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 S. James Zinreich and Thaddaeus Gotwald
A

Genetics of Rhinosinusitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Garry R. Cutting Physiology, Mucociliary Clearance, and Neural Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Pontus L.E. Stierna

4 5 6 7 8 9 10 11 12 13 14

Etiologic Factors in Inammatory Sinus Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Robert M. Naclerio and Anil Gungor Nasal Polyps: Origin, Etiology, Pathogenesis, and Structure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Mirko Tos and Per Leganger Larsen Nasal Polyps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Joel M. Bernstein Microbiology of Sinusitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Birgit Winther and Jack M. Gwaltney Jr Granulomatous Diseases and Tumors of the Nose and Paranasal Sinuses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Valerie J. Lund Environmental Inuence on Sinus Disease: the Role of Chemical Air Pollutants . . . . . . . . . . . . . . . . . . . . . . 107 Dean M. Clerico Nasal Endoscopy: Diagnosis and Staging of Inammatory Sinus Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Stephanie A. Joe, William E. Bolger, and David W. Kennedy Imaging in Sinus Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 David M. Yousem Management of Acute Rhinosinusitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 Erica R. Thaler Medical Treatment of Chronic Sinus Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Dean M. Clerico Complications in Sinus Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 Sukgi S. Choi and Kenneth M. Grundfast
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Fungal Rhinosinusitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 Hun-Jong Dhong and Donald C. Lanza


A

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 25 26 27 28 29 30 31 32 33

Ethmoidectomy with Head Light and Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 Werner Hosemann Endoscopic Modications of the Takahashi Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235 Hiroshi Moriyama Revision Endoscopic Sinus Surgery for Recurrent Rhinosinusitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245 Michelle Marie Cullen and William E. Bolger Pediatric Sinusitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255 Rodney P. Lusk Pediatric Sinus Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271 David S. Parsons and Gary Nishioka Surgery of the Frontal Sinus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281 Frederick A. Kuhn Surgical Complications and Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303 William E. Bolger and David W. Kennedy Dacryocystorhinostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317 Ralph Metson Endoscopic Applications in Orbital Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325 Raymond W. Lesser, Allan E. Wulc, and Jill A. Foster Endoscopic Management of Cerebrospinal Fluid Leaks and Cephaloceles . . . . . . . . . . . . . . . . . . . . . . . . . . . 335 Douglas E. Mattox and Mark Loury Role of Endoscopic Surgery in Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341 Werner Hosemann Role of Lasers in Intranasal and Sinus Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351 Elie E. Rebeiz and Stanley M. Shapshay Image-Guided Functional Endoscopic Sinus Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357 S. James Zinreich Intranasal and External Ethmoidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369 William Lawson and Anthony J. Reino Open Maxillary Sinus Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383 Richard L. Mabry and Bradley F. Marple External Approaches to the Frontal Sinuses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391 William H. Friedman Open Surgical Resection of Sinus Neoplasms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405 Gregory S. Weinstein and Robert Harvey

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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 rst 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 rened 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 scientic 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

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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 signicant 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 signicantly, 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 eld, 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 rst edition, there will undoubtably be some areas which would have benetted 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 inuence 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 signicant 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 rened. 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

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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 eld. 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 eld. 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 seless 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

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CONTRIBUTORS

JOEL M. BERNSTEIN, MD, PhD Professor of Clinical Otolaryngology and Pediatrics State University of New York at Buffalo Buffalo, New York Nasal Polyps WILLIAM E. BOLGER, MD, FACS Associate Professor Chief of Rhinology and Sinus Surgery Department of Otorhinolaryngology: Head and Neck Surgery University of Pennsylvania Health System Philadelphia, Pennsylvania Anatomy of the Paranasal Sinuses; Revision Endoscopic Sinus Surgery for Recurrent Rhinosinusitis; Surgical Complications and Postoperative Care SUKGI S. CHOI, MD Associate Professor in Otolaryngology and Pediatrics George Washington University Vice-Chairman Department Otolaryngology Childrens National Medical Center Washington, DC Complications in Sinus Disease DEAN M. CLERICO, MD Private Practice, Valley ENT Kingston, Pennsylvania Environmental Inuence on Sinus Disease: The Role of Chemical Air Pollutants; Medical Treatment of Chronic Sinus Disease MICHELLE MARIE CULLEN, MD Director, The Sinus Institute, LLC Duluth, Georgia Revision Endoscopic Sinus Surgery for Recurrent Rhinosinusitis GARRY R. CUTTING, MD Professor of Pediatrics Institute of Genetic Medicine Johns Hopkins University School of Medicine Baltimore, Maryland Genetics of Rhinosinusitis

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 Inammatory Sinus Disease

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JACK M. GWALTNEY JR, MD Head, Division of Epidemiology and Virology Department of Internal Medicine University of Virginia School of Medicine Charlottesville, Virginia Microbiology of Sinusitis ROBERT T. HARVEY, MD Instructor in Radiology Fellow in Interventional Radiology Department of Radiology University of Pennsylvania Health System Philadelphia, Pennsylvania Open Surgical Resection of Sinus Neoplasms WERNER HOSEMANN, MD Assistant Professor Department of Otorhinolaryngology University of Regensburg Regensburg, Germany Ethmoidectomy with Head Light and Endoscope; Role of Endoscopic Surgery in Tumors STEPHANIE A. JOE, MD Lecturer Department of Otorhinolaryngology: Head and Neck Surgery Fellow in Rhinology and Sinus Surgery University of Pennsylvania Health System Philadelphia, Pennsylvania Nasal Endoscopy: Diagnosis and Staging of Inammatory Sinus Disease DAVID W. KENNEDY, MD, FACS, FRCSI Professor and Chairman Department of Otorhinolaryngology: Head and Neck Surgery University of Pennsylvania Health System Philadelphia, Pennsylvania Surgical Complications and Postoperative Care FREDERICK A. KUHN, MD, FACS Georgia Nasal and Sinus Institute Memorial Health University Medical Center Savannah, Georgia Surgery of the Frontal Sinus DONALD C. LANZA, MD, FACS Head, Section of Nasal and Sinus Disorders Department of Otolaryngology and Communicative Disorders The Cleveland Clinic Foundation Cleveland, Ohio Fungal Rhinosinusitis PER LEGANGER LARSEN, MD ENT Department Hillerd Hospital Hillerd, Denmark Nasal Polyps: Origin, Etiology, Pathogensis, and Structure

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

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RALPH METSON, MD Associate Clinical Professor Department of Otology & Laryngology Harvard Medical School Massachusetts Eye and Ear Inrmary Boston, Massachusetts Dacryocystorhinostomy HIROSHI MORIYAMA, MD Department of Otorhinolaryngology Jikei University School of Medicine Jikei University Hospital Tokyo, Japan Endoscopic Modications 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 Inammatory Sinus Disease GARY NISHIOKA, DMD, MD Private Practice in Otolaryngology Salem, Oregon Environmental Inuence 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

New England Medical Center Boston, Massachusetts Role of Lasers in Intranasal and Sinus Surgery PONTUS L.E. STIERNA, MD, P D Department of Clinical Services Division of Otorhinolarygology, Karolinska Institute Huddinge, Sweden Physiology, Mucociliary Clearance, and Neural Control MIRKO TOS, MD Professor and Head, Department of Otorhinolaryngology, Head and Neck Surgery Gentofte University Hospital Copenhagen, Denmark Nasal Polyps: Origin, Etiology, Pathogenesis, and Structure ERICA R. THALER, MD Associate Professor Department of Otorhinolaryngology: Head and Neck Surgery University of Pennsylvania Health System Philadelphia, Pennsylvania Management of Acute Rhinosinusitis GREGORY S. WEINSTEIN, MD Associate Professor Department of Otorhinolaryngology: Head and Neck Surgery University of Pennsylvania Health System Philadelphia, Pennsylvania Open Surgical Resection of Sinus Neoplasms BIRGIT WINTHER, MD Assistant Professor, Department of Otolaryngology University of Virginia Health System Research Director, Virginia Sinus Center Charlottesville, Virginia Microbiology of Sinusitis ALLAN E. WULC, MD, FACS Clinical Associate Professor Scheie Eye Institute, University of Pennsylvania Abington Memorial Hospital Abington, Pennsylvania Endoscopic Surgery of the Orbit DAVID M. YOUSEM, MD Professor of Radiology, Department of Radiology Johns Hopkins Hospital Baltimore, Maryland Imaging in Sinus Disease S. JAMES ZINREICH, MD Associate Professor in Radiology / Otolaryngology: Head and Neck Surgery Chief Head and Neck Imaging Johns Hopkins Medical Institutions Baltimore, Maryland Radiographic Anatomy of the Sinuses; Image-Guided Functional Endoscopic Sinus Surgery

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