Arterial Blood Supply of the Nose: An Angiographic Study.

OBJECTIVE: To define anatomical variations associated with arterial blood supply of the nose which has clinical implications on the management of different disorders, especially intractable posterior epistaxis. STUDY DESIGN: Case series. METHODS: Selective angiography of external and internal carotid arteries of 100 patients scheduled for routine angiography was done. RESULTS: Different anatomical variations were documented. The ophthalmic artery can arise from the middle meningeal artery in 1% while ethmoidal arteries can be absent in 5%. The maxillary artery courses as 2 loops in the pterygopalatine fossa in 64% of cases where the descending palatine artery originates before the first loop or on its top so that caution is needed in controlling epistaxis. The sphenopalatine artery has different patterns of branching and may have more than 2 branches in 18% of cases. In 19% of cases, there is cross-circulation between both sides through the nasal blood supply. CONCLUSION: Angiographic study of the nose is a very helpful tool for accurate knowledge of anatomical variations of the arteries with a tremendous effect on our surgical approaches and techniques for the management of different diseases in the nasal region, especially intractable posterior epistaxis.

Timing of tracheostomy in patients with prolonged endotracheal intubation: a systematic review.

The objective of this article is to evaluate the appropriate timing of tracheostomy in patients with prolonged intubationregarding the incidence of hospital-acquired pneumonia, mortality, length of stay in intensive care unit (ICU) and duration of artificial ventilation. The study included published articles yielded by a search concerning timing of tracheostomy in adult and pediatric patients with prolonged intubation. The search was limited to articles published in English language in the last 30 years (between 1987 and 2017). For the 690 relevant articles, we applied our inclusion and exclusion criteria and only 43 articles were included. 41 studies in the adult age group including 222,501 patients and 2 studies in pediatric age group including 140 patients met our criteria. Studies in adult age group were divided into three groups according to the methodology of determining the cut off timing for early tracheostomy, they were divided into studies that considered early tracheostomy within the first 7, 14 or 21 days of endotracheal intubation, while in pediatric age group the cut off timing for early tracheostomy was within the first 7 days of endotracheal intubation. There was a significant difference in favor of early tracheostomy in adults' three groups and pediatric age group as early tracheostomy was superior regarding reduced duration of mechanical ventilation, with less mortality rates and less duration of stay in ICU. Regarding hospital-acquired pneumonia, it was significantly less in adult groups but with no significant difference in pediatric age group (3 patients out of 72 pediatric patient with early tracheostomy had pneumonia compared to 11 patients out of 68 with late tracheostomy). Studies defining early tracheostomy as that done within 7 days of intubation had better results than those defining early tracheostomy as that done within 14 or 21 days of intubation. In conclusion, early tracheostomy within 7 days of intubation should be done for both adults and pediatric patients with prolonged intubation.

The necessity of post-maneuver postural restriction in treating benign paroxysmal positional vertigo: a meta-analytic study.

The objective of this article is to verify the role of postural restrictions after repositioning maneuvers in treating patients with benign paroxysmal positional vertigo (BPPV). The study included published articles yielded by a Pubmed search concerning post-maneuver postural restriction in treating BPPV. The search was limited to articles published in English language in the last three decades. The search was done on 1/11/2011. For the 18 relevant articles, we applied our inclusion and exclusion criteria and only 9 articles were included. The data collected from each article were statistically analyzed utilizing meta-analytic Review Manager (RevMan 5.1) software. (Version: 5.1.0.0). There were no significant differences between patients instructed with postural restriction after undergoing repositioning maneuver and patients left free to move after undergoing repositioning maneuver with regard to the presence or absence of post-maneuver symptoms. In conclusion, post-maneuver restrictions do not add to the success of the treatment of BPPV and there is no reason to submit patients to these impractical instructions.

Role of steroids in reducing postoperative edema in rhinoplasty: a meta-analytic study.

The study aimed at verifying the use of steroids to decrease postoperative edema after rhinoplasty. The study included published articles yielded by the Medline database search concerning role of steroids in rhinoplasty. The search was limited to articles published in English in the last three decades. The search was done on 1/2/2012. For the 15 relevant articles, we applied our inclusion and exclusion criteria and only four articles were included. The data collected from each article were statistically analyzed utilizing meta-analytic Review manager (RevMan 5.1) software (Version: 5.1.0.0). Perioperative steroid use significantly reduces postoperative edema of the upper and lower eyelids on the first and third days postoperative, with no significant effect after third day. The results indicated that steroids should be given for patients undergoing rhinoplasty for decreasing periorbital edema postoperatively especially in the first 3 days, however, it has little effect after the third day.

Management of iatrogenic tegmen plate defects: our clinical experience and surgical technique.

The objective of our study is to present our recommended approach for surgical management of iatrogenic tegmen plate defects. Patients diagnosed to have symptomatic iatrogenic tegmen plate defects were treated by one of the authors using a one-stage trans-mastoid standardized surgical procedure at Ain Shams University Hospitals. Patients' information records included history, complete examination, computed tomography (CT) and magnetic resonance imaging (MRI) of the temporal bone, and the followup data after the procedure to assess the final outcome in each case. Twelve patients with symptomatic iatrogenic tegmen plate defects were included in our study. The tegment plate defect size in the 12 patients varied from 2.2 to 15 mm (mean 5.6 ± 1.3). Postoperative followup of the patients ranged from 6 months up to 2 years (mean 1.6 ± 0.8). One patient only developed wound infection and was treated with antibiotics and regular dressings, with no other immediate postoperative complications (intracranial hematoma or meningitis). In the entire patient group, no local recurrence of middle fossa encephalocele was recorded. Our surgical trans-mastoid approach using multilayered autologous grafts is successful in closing iatrogenic tegmen plate defects more than 2.2 mm and less than 15 mm.