Prognostic Impact of Adverse Pathologic Features in Sinonasal Squamous Cell Carcinoma.

Objective This study aimed to describe the impact of adverse clinical and pathologic features in sinonasal squamous cell carcinoma (SCC). Design This study is designed with retrospective chart review. Setting The present study is conducted at a tertiary care institution. Participants All patients treated surgically for sinonasal SCC at our tertiary care institution between January 2006 and December 2013. Main Outcome Measures Overall survival (OS) and disease free survival (DFS) are the final measurement of this study. Results Forty-eight patients were identified. Mean age at surgery was 65.8 years, and mean follow-up time was 40.7 months. Eighteen patients (38%) had T1-T3 disease, while 30 patients (63%) had T4 disease. Seven patients (8.3%) had nodal disease at presentation. At 2, 5, and 10 years, OS was 71, 54, and 48%, respectively, while DFS was 64, 51, and 45%, respectively. Twelve patients (25%) experienced local recurrences with mean time to recurrence of 15.3 months. Twenty-five patients (52%) had positive margins, 24 (50%) had high-grade tumors, 18 (38%) had perineural invasion (PNI), and 15 (31%) had lymphovascular invasion (LVI). In the univariate analysis, T4 disease (risk ratio [RR] = 2.7) and high grade (RR = 2.4) had a significant association with DFS. In the multivariate analysis, high grade (RR = 4.0 and 4.5) and LVI (RR = 4.1 and 4.7) had a significant association with OS and DFS. Conclusion Our single-institution experience of 48 patients suggests that high grade and LVI are independently associated with survival outcomes in sinonasal SCC, while PNI and microscopically positive margins do not have a significant impact.

Facial paralysis: timing of repair and management of the nonflaccidly paralyzed face.

PURPOSE OF REVIEW: To explore recent advances in therapeutic interventions for nonflaccid facial paralysis (NFFP), including new evidence for surgical and nonsurgical treatments. Timing of treatment is also discussed, along with possible future treatments. RECENT FINDINGS: NFFP remains a difficult disease to treat. Chemodenervation with botulinum toxin remains a first-line treatment to suppress aberrant and antagonistic movements during voluntary use of muscles. More permanent treatments such as selective neurectomy, myectomy, and nerve and muscle transfers have been shown to offer promising results for the nonflaccidly paralyzed face. SUMMARY: NFFP is commonly seen in patients who have incomplete recovery from facial paralysis, and carries high psychosocial morbidity. A large array of treatments have been described in the literature, both procedural and nonprocedural. Both treatment type and timing are important in optimal patient recovery.

Modified Skoog Method for Hump Reduction.

Dorsal hump reduction is a key component of rhinoplasty. Spreader grafts are the most frequently used technique; however, dorsal irregularities may result. The modified Skoog method involves removal of the osseocartilaginous dorsal hump, its modification, further reduction of the nasal dorsum, replacement of the modified dorsal segment, and suspension of the upper lateral cartilages. The dorsal segment acts as an onlay spreader graft, preserves the middle vault, closes the open roof deformity, and creates a smooth dorsal contour from radix to anterior septal angle. The modified Skoog method produces optimal functional and aesthetic outcomes in appropriately selected patients.

Review of literature of saddle nose deformity reconstruction and presentation of vomer onlay graft.

OBJECTIVE: Saddle nose deformity is a well-described condition that most commonly results from trauma or prior surgery. For larger saddle nose deformity defects, bone grafts are a reconstructive option that provide adequate structure for repair. One new technique for repair of these deformities is a vomerian bone onlay graft. We aim to provide a review of literature on autogenous repair of saddle nose deformities, as well as introduce a new technique in which the vomer bone is used as an onlay bone graft. METHODS: Literature review and case series. Five cases in which vomer onlay grafts were used for repair of saddle nose deformity were reviewed between January 2013 and December 2015. Aesthetic outcomes and postoperative complications were evaluated at subsequent follow-up visits in clinic. RESULTS: In all cases where vomer bone was harvested, the vomer onlay graft provided adequate structure to traverse the saddle nose deformity. No postoperative complications were observed in an 18 month follow-up period. CONCLUSION: Vomerian bone onlay grafts are a reconstructive option for saddle nose deformity and nasal dorsum defects. While septal cartilage is commonly used, and ethmoidal bone has been previously described as an option for composite graft reconstruction, vomer bone onlay grafting has not been well described in the literature. This method may be of use when previous nasal surgery has been performed and standard septal cartilage is not possible to harvest. The aesthetic outcomes following nasal dorsum reconstruction using onlay grafts are favorable, but long-term outcomes of these grafts require further study. LEVEL OF EVIDENCE: IV.

Preoperative characteristics of over 1,300 functional septorhinoplasty patients.

OBJECTIVE: To identify characteristics of patients presenting preoperatively for functional septorhinoplasty associated with increased Nasal Obstruction Symptom Evaluation (NOSE) scores. STUDY DESIGN: Retrospective analysis of a prospective cohort at a tertiary medical center. Only baseline assessments were analyzed in this cross-sectional study. METHODS: 1,338 patients completed baseline nasal evaluation, resulting in 1,034 NOSE scores. Demographics, medical history, surgical history, and physical exam findings were recorded. RESULTS: The average preoperative NOSE score was 59.8 out of 100 (standard deviation: 24.9). Fifty-four percent (578 per 1,074) of respondents were female, although sex did not affect baseline NOSE score (P = 0.7). Forty-five percent (404 per 896) reported prior nasal surgery. History of rhinoplasty was not associated with a difference in baseline NOSE score (P = 0.1924); however, history of septoplasty (P = 0.0390) was associated with an increased baseline NOSE score. Snoring was also both associated with higher baseline NOSE score (P = 0.0003). All 12 septal/nasal valve measurements were associated with higher preoperative NOSE score, whereas the internal nasal valve narrowing variables retained significance in multivariate analysis (left: P = .0490; right: P = .0077). CONCLUSION: Patients presenting for nasal airway obstruction were evaluated. Sex was not associated with difference in NOSE score. History of septoplasty was associated with higher baseline NOSE score, as were snoring and internal nasal valve narrowing at rest. LEVEL OF EVIDENCE: 2C Laryngoscope, 130:25-31, 2020.

Role of mobile health on patient enrollment for cleft lip-palate surgery: A comparative study using SMS blast text messaging in zimbabwe.

BACKGROUND: Patients' lack of awareness of available services is a significant barrier to delivering surgical care in resource-limited settings. Short message service (SMS) text messaging is a potential means to disseminate this information in resource-limited settings, where rates of mobile phone usage are high. METHODS: A blast SMS text informing local populations of upcoming cleft lip-palate (CLP) surgical services was distributed to 25% of the subscriber base 1 week prior to arrival of a (CLP) surgical team in Zimbabwe. A retrospective cohort analysis comparing characteristics of patients presenting to the CLP clinic in the year prior to (2016) and 2 years following (2017-2018) the implementation of the blast SMS text messaging system is performed to assess its impact. RESULTS: Patients presenting to a single Zimbabwean CLP surgical program in the years with SMS messaging notifications were significantly more likely (52 [64%] vs. 5 [17%], P < .001) to have been informed of surgical services through their mobile phones. The average distance traveled per patient was not significantly different prior to implementation of mass text messaging (180.4 km [SD114.8] vs. 167.4 km [SD105.9], P = .580). The average patient age was significantly higher following the implementation of mass text messaging (7.4 [SD8.7] vs. 3.0 [SD2.8] years, P = .010). CONCLUSIONS: SMS messaging is an effective method of informing patients of CLP surgical services in resource-limited settings. After implementation of SMS text notifications, surgical patients were of increased age, but showed no difference in distance traveled. LEVEL OF EVIDENCE: IV.

A Comparative Health Utility Value Analysis of Outcomes for Patients Following Septorhinoplasty With Previous Nasal Surgery.

IMPORTANCE: Using health utility values (HUVs) as an outcome measure for surgical procedures, including rhinoplasty, allows for a standardized measurement of the qualitative and financial benefit of that procedure on overall health. OBJECTIVE: To use Euroqol 5-Dimension (EQ-5D)-derived HUVs to evaluate nasal obstruction outcomes following surgery between primary rhinoplasty (PSRP) and rhinoplasty with previous nasal surgery (RNS) in a prospective cohort study. DESIGN, SETTING, AND PARTICIPANTS: A single-institution prospective cohort study between 2013 and 2017 was carried out including 185 patients who underwent RNS before functional rhinoplasty and 278 patients who underwent PSRP for nasal obstruction. The analysis was carried out between December 2018 and February 2019. MAIN OUTCOMES AND MEASURES: Patients in the RNS cohort and PSRP cohort who completed the EQ-5D questionnaire immediately prior to surgery and postoperatively at 2, 4, 6, and 12 months were included in the study. The EQ-5D scores were converted to HUV scores and compared to evaluate for improvement in health status following surgery. RESULTS: Of the 185 patients in the RNS cohort, 97 (52%) were women and the mean (SD) age was 42.6 (13.4) years. Of the 278 in the PSRP cohort, 156 (55%) were women and the mean (SD) age was 36.0 (15.8) years. Both cohorts experienced significant improvement in HUV postoperatively. The mean (SD) HUV values were decreased in the RNS cohort versus the PSRP cohort both preoperatively (0.85 [0.16] versus 0.89 [0.14]) and postoperatively at 1 year (0.92 [0.14] versus 0.94 [0.11]); however, the difference in HUV was not statistically significant after 6 months postoperatively. Patients in the RNS cohort were typically older (76 [41%] older than 40 years vs 84 [31%], P = .02) and more likely to have sleep apnea (31 [19%] vs 24 [10%], P = .01) than in the PSRP cohort. On multivariable analysis, the use of spreader grafts and alar rim grafts in the PSRP cohort was significantly associated with improved HUV at 12 months. (r = -0.06; 95% CI, -0.11 to -0.01, P = .03). CONCLUSIONS AND RELEVANCE: Patients with a history of prior nasal surgery may represent a unique cohort when assessing health utility outcomes. Euroqol 5-dimension questionnaire-derived HUVs are a valid predictor of outcomes in all patients who undergo septorhinoplasty. Although outcomes were significantly improved for both cohorts, previous surgical history should be considered when performing cost utility analysis on the benefits of functional rhinoplasty. LEVEL OF EVIDENCE: 3.

Health Utility Values as an Outcome Measure in Patients Undergoing Functional Septorhinoplasty.

IMPORTANCE: By measuring health utility values (HUVs) for patients with nasal obstruction after septorhinoplasty, the association of nasal congestion with overall health can be measured and the functional outcomes of septorhinoplasty can be determined. OBJECTIVE: To use the EuroQol 5-Dimension (EQ-5D) questionnaire to evaluate nasal obstruction outcomes after septorhinoplasty and to determine HUVs. DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study included patients who underwent septorhinoplasty for nasal obstruction at a single institution by a single surgeon from January 1, 2013, through December 31, 2017. Participants completed the EQ-5D questionnaire immediately before surgery and postoperatively at 2, 4, 6, and 12 months. The EQ-5D scores were converted to HUVs using population-based data for individuals with chronic diseases. Data were analyzed from May 1 through December 31, 2018. EXPOSURE: Functional septorhinoplasty. MAIN OUTCOMES AND MEASURES: Preoperative and postoperative EQ-5D scores were compared to evaluate improvement in overall health after septorhinoplasty. RESULTS: A total of 463 patients (53.8% women; mean [SD] age, 36.8 [15.7] years) who underwent septorhinoplasty and completed EQ-5D surveys at baseline and postoperatively were included in the study population. Overall mean (SD) preoperative HUV was 0.872 (0.01), compared with 1.00 for those with a perfect state of health. On univariate analysis, female sex (mean [SD] HUV, 0.853 [0.01]; P = .004), previous nasal surgery (mean [SD] HUV, 0.85 [0.16]; P = .02), previous septoplasty (mean [SD] HUV, 0.88 [0.15]; P = .02), and previous sinus surgery (mean [SD] HUV, 0.79 [0.20]; P = .009) were associated with significantly lower baseline HUVs. On multivariate regression including these variables, only previous septoplasty was significantly associated with a positive change in mean (SD) HUV (0.88 [0.15] vs 0.85 [0.16]; P = .02). Mean (SD) HUV was significantly improved at 2 months postoperatively to 0.91 (0.14; P = .001) and remained significantly improved from baseline at 12 months, at 0.93 (0.13; P < .001). CONCLUSIONS AND RELEVANCE: Nasal obstruction is associated with significant detriment to overall health, in line with other chronic conditions affecting the US population. Functional septorhinoplasty appears to substantially improve overall health, as measured by HUV, in an immediate and sustained fashion. LEVEL OF EVIDENCE: 3.

Necrotizing Sialometaplasia of the Hypopharynx.

Necrotizing sialometaplasia (NSM) is a benign, reactive metaplastic condition of the minor salivary gland tissue typically seen in the setting of injury, chemical or traumatic, and is nonneoplastic and self-limited. The diagnosis may be challenging as it may clinically mimic malignancy. We present the case of a 74-year-old male with a 1 pack per day smoking history for 60 years who presented with a reported 20-pound weight loss, dysphagia, and dysphonia progressing over the course of 6 months and found to have a 3.5-cm hypopharyngeal mass on computed tomography imaging and fiberoptic laryngoscopy. Initial frozen section of the mass was concerning for squamous cell carcinoma in situ, but permanent specimens returned as nondiagnostic. Repeat biopsy established a diagnosis of NSM. Two-month follow-up showed complete resolution of the mass. Clinicians should be aware that NSM may present in unusual locations when considering differential diagnoses for laryngeal masses and evaluating for malignancy.

Analysis of Patient-Perceived Nasal Appearance Evaluations Following Functional Septorhinoplasty With Spreader Graft Placement.

IMPORTANCE: Spreader grafts have been shown to improve nasal airway obstruction in patients with nasal valve dysfunction; however, their use has been limited by concerns over their aesthetic penalty of widening the nasal dorsum. OBJECTIVE: To evaluate the association of functional septorhinoplasty (FSRP) using spreader graft placement with patient satisfaction with nasal appearance postoperatively. DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study was conducted in a university-based tertiary care medical center. All participants were patients undergoing FSRP for the treatment of nasal obstruction who had spreader grafts placed between June 2016 and May 2018. EXPOSURES: The Nasal Obstruction Symptom Evaluation (NOSE) scale and the FACE-Q Satisfaction With Nose, FACE-Q Satisfaction With Nostrils, and FACE-Q Social Functioning scales were administered to patients preoperatively and at 2, 4, 6, and 12 months postoperatively. Patient demographics, nasal history, and outcomes were analyzed. MAIN OUTCOMES AND MEASURES: Comparison of preoperative and postoperative NOSE and FACE-Q scores. RESULTS: A total of 154 patients (72 male [46.8%]) with mean (SD) age of 36.8 (15.4) years underwent FSRP with spreader graft placement. Mean (SD) last follow-up was 5.8 (4.1) months postoperatively (range, 2-12 months). Fifty-seven patients had 6 months follow-up, and 42 patients had at least 12 months of follow-up. At time of last follow-up, mean (SD) NOSE and FACE-Q Satisfaction With Nose, Satisfaction With Nostrils, and Social Functioning scores significantly improved from 62.7 (20.7) to 22.8 (21.0) (P < .001), 54.7 (22.2) to 76.2 (25.1) (P < .001), 59.4 (27.9) to 83.6 (24.8) (P < .001), and 73.6 (21.8) to 81.7 (21.9) (P < .001), respectively. When separated into those with only spreader grafts (n = 89) and those with spreader grafts plus other graft types (n = 65), there was no significant difference between score improvements in the 2 groups. There were no significant differences in final nasal appearance scores between patients undergoing functional vs dual functional and cosmetic FSRP. CONCLUSIONS AND RELEVANCE: Despite concerns that placement of spreader grafts for the treatment of nasal obstruction due to nasal valve dysfunction during FSRP may have a negative impact on nasal aesthetics, this study shows that both nasal obstruction and patient satisfaction with their nasal appearance were significantly improved following surgery. LEVEL OF EVIDENCE: 3.

Comparison of NOSE Scores Following Functional Septorhinoplasty Using Autologous versus Cadaveric Rib.

In functional septorhinoplasty (FSRP), alternative grafting material is used if septal cartilage is insufficient for reconstructive needs. Autologous costal cartilage (ACC) and irradiated homologous costal cartilage (IHCC) are compared via the Nasal Obstruction Symptom Evaluation (NOSE) scale. One-hundred forty-one patients who underwent FSRP with ACC or IHCC between January 2013 and March 2018 were administered the NOSE scale pre- and postoperatively at 2, 4, 6, and 12 months. There was no significant difference in mean NOSE scores between the ACC and IHCC cohorts at the preoperative visit (68.5 [standard deviation, SD 24.1] and 71.7 [20.1], respectively; p < 0.6) or first postoperative visit (30.4 [26.6] and 33.9 [30.4], respectively; p < 0.6) or subsequent visits. NOSE scores demonstrated a clinically and statistically significant improvement at all follow-up time points for both the ACC and IHCC groups. Patients who underwent grafting with IHCC were significantly older than those with ACC; average age of 55.6 [SD: 17.3] versus 40.1 [SD:12.1]; (p < 0.001). Two IHCC (0.05%) patients had postoperative infections; both resolved with antibiotics, but one required revision surgery. Both ACC and IHCC provide reliable grafting material when septal cartilage is insufficient. In FSRP for nasal airway obstruction, ACC and IHCC both provide a clinically and statistically significant reduction in NOSE scores postoperatively that remain stable between follow-up time points. The authors find no difference in NOSE scores between the ACC and IHCC groups; however, IHCC did have a higher rate of postoperative infection. Both materials should be discussed with patients and are an important part of the informed consent process.

A Facial Plastic and Reconstructive Surgery Training Module Using Surgical Simulation for Capacity Building.

OBJECTIVE: To introduce 3 novel intensive facial plastic and reconstructive surgery teaching modules for surgical capacity building using simulation in a low-middle income country. DESIGN: Prospective cohort study. SETTING: University-based medical center in Quito, Ecuador. PARTICIPANTS: First- and second-year otolaryngology residents in Quito, Ecuador. RESULTS: Residents participated in an intensive 3-day teaching program focused on microtia, nasoseptal abnormalities, and facial paralysis that included didactic lectures, simulation workshops, and live surgery. Residents underwent rigorous pre- and postmodule testing including written, oral, and practical examinations in each subject area. All participants completed anonymous feedback surveys with ratings on a Likert scale from 0 (very poor) to 10 (excellent). Nineteen residents completed both pre- and postmodule testing. The training module was successfully implemented and testing performance across all 3 subject areas significantly improved. Resident feedback was exceedingly positive, with average scores for each component ranging from 8.9 to 9.8, with highest scores given to the simulation workshops. The postmodule survey indicated that all residents found the course helpful and they desired additional courses covering more subject areas. CONCLUSIONS: Implementation of an intensive surgical training module combining didactics, surgical simulation, and live surgery resulted in the successful transfer of both skills and knowledge. While the long-term benefit of this program is yet to be determined, this model of training may prove to be a useful tool to help address surgical capacity building in the developing world.

Using Mobile Text and Media to Complement Teaching in a Facial Reconstruction Training Module in Haiti.

OBJECTIVES: (1) To describe electronic communication between global surgeons and trainees in a low-middle income country (LMIC) and to gauge appeal of the WhatsApp platform (2) To introduce a novel intensive ear reconstruction teaching module for surgical capacity building using simulation in a LMIC. DESIGN: Prospective cohort study. SETTING: University-based medical center in Haiti. PARTICIPANTS: Eleven otolaryngology trainees and faculty in Haiti. RESULTS: Three months prior to on-site arrival, a WhatsApp Messenger group was created for information-sharing and distribution of teaching materials. A surgical curriculum was created to incorporate didactics, cartilage framework simulation, and live surgery. During the intensive on-site week, WhatsApp was used to distribute materials and to recap learning points from each case, with pre- and postoperative surgical photographs circulated. Postmodule written, oral, and practical testing was conducted on the final day, and a postmodule survey was administered a month later. Post-tests scores were significantly improved from pretests scores. Initial scores on the written, oral, and practical tests averaged 24.6%. Postmodule scores averaged 86.9% (p < 0.001). Participants rated the use of WhatsApp to be highly important to their learning and requested further use of mobile health technology. CONCLUSIONS: WhatsApp Messenger technology complemented a reconstructive surgery education module in a LMIC. WhatsApp provides opportunities for premodule patient screening, real-time discussion, and postmodule review. Its usage was well-received by Haitian otolaryngology trainees and faculty. Our results suggest that the combination of didactic teaching, simulated surgery, and live surgery resulted in successful transfer of both skills and knowledge.

Peak nasal inspiratory flow is a useful measure of nasal airflow in functional septorhinoplasty.

OBJECTIVE: To evaluate the utility of peak nasal inspiratory flow (PNIF) as a measure of nasal airflow and functional septorhinoplasty (FSRP) outcomes. METHODS: Patients with nasal obstruction were administered Nasal Obstruction Symptom Evaluation (NOSE) questionnaire and PNIF testing between January 2015 and 2018. Surgical patients repeated these tests at 2, 4, 6, 12, and 24 months postoperatively. Patient demographics and operative techniques were recorded. RESULTS: A total of 610 patients were evaluated for nasal obstruction with mean (standard deviation [SD]) NOSE score of 61.5 (23.2) and PNIF of 74.1 (35.4) liters per minute (L/min); correlation -0.16 (P < 0.001). Predictors of lower PNIF were female gender (ß = -13.3, 95% confidence interval [CI] 7.7 to 18.2, P < .001) and higher NOSE scores (ß = -0.43, 95% CI 0.19 to 0.68, P < 0.001). A total of 281 patients underwent FSRP with statistically and clinically significant improvements in both mean NOSE and PNIF scores that were stable out to 2 years. NOSE scores changed -41.0 (25.5) points, and PNIF improved 20.7 (35.5) L/min at last follow-up. Grafting material did not affect outcomes, whereas spreader grafts improved PNIF values (ß = 25.46, 95% CI 5.5 to 45.4, P = 0.013). Clinically significant changes between NOSE and PNIF were concordant, although the correlation was weak (r = -0.26, P = 0.02). CONCLUSION: Peak nasal inspiratory flow is a rapid, cheap, and easily performed test that detects nasal obstruction and clinically significant improvements in airflow following FSRP. Although PNIF does not correlate well enough with the patient experience of nasal obstruction to be used as a diagnostic tool, it does provide unique and complementary information useful for evaluating, understanding, and improving the effects of surgical techniques. LEVEL OF EVIDENCE: 2C Laryngoscope, 129:594-601, 2019.

Functional septorhinoplasty in the pediatric and adolescent patient.

OBJECTIVES: To describe pediatric and adolescent patients undergoing functional septorhinoplasty and to analyze both subjective and objective outcomes. METHODS: Retrospective review of prospective cohort study of patients ≤18 years old undergoing functional septorhinoplasty between 2013 and 2016 at a tertiary care center. Patient demographics, nasal exam, procedure, and pre- and postoperative nasal obstruction symptom evaluation (NOSE) score, EuroQOL 5-dimension (EQ5D), and peak nasal inspiratory flow (PNIF) scores were analyzed. RESULTS: 39 patients, 48.7% male, mean age 15.9 years (range 7-18), with nasal obstruction underwent functional septorhinoplasty with mean follow up of 8.5 months. Patients reported a history of allergies (46.5%), nasal fracture (59.0%), and previous nasal surgery (25.6%). Most common exam findings included internal nasal valve narrowing (92.3%), superior/dorsal septal deviation (74.4%), external nasal valve narrowing (43.6%), caudal septal deviation (35.9%), and a narrow middle vault (33.3%). Septal cartilage grafts were placed in 79.5% of patients and PDS plate was used in 28.2%. Most common procedures included spreader grafts (84.6%), columellar strut graft (30.8%), and swinging door (23.1%). Of patients with both baseline and postoperative scores, at last follow up NOSE scores (SD) decreased from 59.0 (23.7) to 21.2 (8.8) (n = 26, p < 0.001), EQ5D VAS scores increased from 76.2 (17.7) to 85.8 (13.5), (n = 19, p = 0.056), and PNIF scores increased from 66.2 (25.3) to 90.8 (46) L/min, (n = 13, p < 0.01); all mean differences met the minimal clinically important difference for each score. 2 patients underwent revision surgery and there was one complication of a nasal abscess. CONCLUSIONS: Functional septorhinoplasty is safe and effective in select pediatric and adolescent patients with significant nasal obstruction and results in significant improvements in both subjective and objective outcomes measures.

Diagnostic and Therapeutic Management of Nasal Airway Obstruction: Advances in Diagnosis and Treatment.

IMPORTANCE: Nasal airway obstruction (NAO) is a common complaint in the otolaryngologist's office and can have a negative influence on quality of life (QOL). Existing diagnostic methods have improved, but little consensus exists on optimal tools. Furthermore, although surgical techniques for nasal obstruction continue to be developed, effective outcome measurement is lacking. An update of recent advances in diagnostic and therapeutic management of NAO is warranted. OBJECTIVE: To review advances in diagnosis and treatment of NAO from the last 5 years. EVIDENCE REVIEW: PubMed, Embase, CINAHL, the Cochrane Library, LILACS, Web of Science, and Guideline.gov were searched with the terms nasal obstruction and nasal blockage and their permutations from July 26, 2012, through October 23, 2017. Studies were included if they evaluated NAO using a subjective and an objective technique, and in the case of intervention-based studies, the Nasal Obstruction Symptom Evaluation (NOSE) scale and an objective technique. Exclusion criteria consisted of animal studies; patients younger than 14 years; nasal foreign bodies; nasal masses including polyps; choanal atresia; sinus disease; obstructive sleep apnea or sleep-disordered breathing; allergic rhinitis; and studies not specific to nasal obstruction. FINDINGS: The initial search resulted in 942 articles. After independent screening by 2 investigators, 46 unique articles remained, including 2 randomized clinical trials, 3 systematic reviews, 3 meta-analyses, and 39 nonrandomized cohort studies (including a combined systematic review and meta-analysis). An aggregate of approximately 32 000 patients were reviewed (including meta-analyses). Of the subjective measures available for NAO, the NOSE scale is outstanding with regard to disease-specific validation and correlation with symptoms. No currently available objective measure can be considered a criterion standard. Structural measures of flow, pressure, and volume appear to be necessary but insufficient to assess NAO. Therefore, novel variables and techniques must continue to be explored in search of an ideal instrument to aid in assessment of surgical outcomes. CONCLUSIONS AND RELEVANCE: Nasal airway obstruction is a clinical diagnosis with considerable effects on QOL. An adequate diagnosis begins with a focused history and physical examination and requires a patient QOL measure such as the NOSE scale. Objective measures should be adjunctive and require further validation for widespread adoption. These results are limited by minimal high-quality evidence among studies and the risk of bias in observational studies. LEVEL OF EVIDENCE: NA.

Global surgery: current evidence for improving surgical care.

PURPOSE OF REVIEW: The field of global surgery is undergoing rapid transformation, owing to several recent prominent reports positioning it as a cost-effective means of relieving global disease burden. The purpose of this article is to review the recent advances in the field of global surgery. RECENT FINDINGS: Efforts to grow the global surgical workforce and procedural capacity have focused on innovative methods to increase surgeon training, enhance international collaboration, leverage technology, optimize existing health systems, and safely implement task-sharing. Computer modeling offers a novel means of informing policy to optimize timely access to care, equitably promote health and financial protection, and efficiently grow infrastructure. Tools and checklists have recently been developed to enhance data collection and ensure methodologically rigorous publications to inform planning, benchmark surgical systems, promote accurate modeling, track key health indicators, and promote safety. Creation of institutional partnerships and trainee exchanges can enrich training, stimulate commitment to humanitarian work, and promote the equal exchange of ideas and expertise. SUMMARY: The recent body of work creates a strong foundation upon which work toward the goal of universal access to safe, affordable surgical care can be built; however, further collection and analysis of country-specific data is necessary for accurate modeling and outcomes research into the efficacy of policies such as task-sharing is greatly needed.

Polydioxanone plates are safe and effective for L-strut support in functional septorhinoplasty.

OBJECTIVES/HYPOTHESIS: To evaluate the safety, efficacy, and result stability of polydioxanone (PDS) plate use for L-strut stabilization. STUDY DESIGN: Retrospective analysis of a prospective cohort. METHODS: Patients who underwent functional septorhinoplasty with the use of PDS plates between January 2013 and January 2017 were administered the Nasal Obstruction Symptom Evaluation (NOSE) scale pre- and postoperatively at 2, 4, 6, and 12 months. Patient demographics, reason for PDS use, graft type, complications, and outcomes were analyzed. RESULTS: Eighty-eight patients aged 34.3 years (standard deviation [SD] = 15.7 years; range, 7.5-71.5 years) were included. All patients were found to have a fracture and/or severe deviation of the L-strut for which the PDS plate was used for rigid support. Mean preoperative NOSE score 65.2 (SD = 22.1) significantly decreased to 19.6 (SD = 21.6) at 7.2 months (SD = 5.5 months) postoperatively. There were no significant differences in NOSE scores between follow-up time points. There was one complication, a septal abscess, and one revision. CONCLUSIONS: A PDS plate is a safe and effective material to be utilized in functional septorhinoplasty for patients with a fracture or iatrogenic injury to the septal L-strut or poor quality septal cartilage that requires stability without additional width. Outcomes are stable at 6 and 12 months, after the plate has dissolved. The use of a PDS plate may decrease the need for rib grafting in patients with a history of previous septoplasty and persistent nasal obstruction with a dorsal or caudal C-shaped septal deformity or fracture of the L-strut. LEVEL OF EVIDENCE: 2c. Laryngoscope, 127:2725-2730, 2017.