Endoscopic Approaches to the Paranasal Sinuses and Skull Base: A Step-by-Step Anatomic Dissection Guide

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Review by L Flood
Middlesborough, UK

An amusing Preface explains the Spanish influence in authorship of this book, and describes the challenges of performing live surgery, in order to convince the ‘Sauluses’ who doubted the closing statement ‘Nowadays almost nothing is impossible through the nose’. Well, by the end of this book, although neither blinded nor hearing voices (and mercifully not on the road to Damascus), I was a convinced reviewer.

Even the otologists amongst us can usually introduce an endoscope and punch a hole from the middle meatus into the antrum, usually without draining orbital fat. We will all open the occasional ethmoid cell and then rely on medication to do the rest. There is the very old gag of asking for the irrigation to be turned down, only to be told that there is no irrigation in use. Sure enough, three-dimensional (3D) coronal reconstructions of the facial skeleton, in the opening chapter, offer a somehow disturbing view, through the nasal aperture, of the entire brainstem. There have been moments, in the depths of a septoplasty, I do admit...

This is a lengthy manual, with the expected profusion of high-quality illustrations. Most are full colour images of cadaver dissections; imaging is sharply printed, and even the truly live surgical prints show how rhinology is somehow more photogenic than the practice of the aurist. Anatomy is demonstrated with the best contemporary 3D computed tomography reconstructions. Illustrations of surgery are accompanied by descriptions, for every procedure, of indications, technique, complications and ‘tips and tricks’ (which are really nicely done). To an ignoramus, the text very nicely complemented the images.

Now, frankly, by Chapter 4, this reviewer was already getting into unfamiliar territory. Draf’s endonasal frontal sinus drainage procedure types I–III mean little to one who sees the dire emergency route to the frontal sinus as below the eyebrow. Yet, somehow, the descriptions of endoscopic frontal and sphenoid approaches, and medial maxillectomy, made perfect sense. Then there was the hunt for those arteries, and certainly their sphenopalatine arterial pedicle looked much more convincing than the mucosal strand often shown to me by enthusiastic trainees.

By page 92, the content was getting serious, passing way beyond the nasal cavity. A ‘suprasellar approach to the third ventricle’ sounded like something I have spent my life trying to avoid doing. Transorbital neuroendoscopic surgery seems challenging considering the important contents, but proves entirely plausible. By ‘The Front Door to Meckel’s Cave’, ‘The Endoscopic Endonasal Approach to the Intrapetrous Carotid Artery’ or ‘The Anteromedial Corridors to the Cranial Nerves’, I knew I was now out of my depth as a reviewer, but could appreciate the quality of what I was reading. Descriptions of combined approaches, simultaneously transnasal and transcranial, reminded me of those tunnelling exercises, where, after months of drilling, the two teams meet under the Alps, just 2 cm out of alignment.

Read the title again and note that this is not just an endoscopic rhinology manual. This is for the small minority of surgeons who will progress way beyond the boundaries of the nasal cavity. Curiously, there was little mention of image guidance and navigation systems (the stress instead being on ‘profound knowledge of the complex anatomy’), and robots seem not to have yet replaced humans in this field. For once, videos of dissections would have been welcome, but would obviously have increased costs, for what is very good value indeed. Instead, spend the money on the instructional course. After all, it is in Barcelona.

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