Endonasal septal perforation repair using posterior and inferiorly based mucosal rotation flaps.

IMPORTANCE: Repair of nasal septal perforations is challenging regardless of surgical technique due to their location and the health of surrounding tissue. There is currently no surgical procedure which is completely effective in the treatment of anteriorly located perforations. OBJECTIVE: To report a novel method of closing anterior septal perforations using an inferiorly based mucosal rotation flap and an acellular dermal interposition graft, as well as expand upon a previous series. DESIGN: The study includes patients who underwent surgical repair for septal perforations by the senior author between 2003 and 2015. SETTING: The study took place at MetroHealth Medical Center in Cleveland, Ohio. PARTICIPANTS: Thirty-nine patients (15 male) with septal perforations of various size and etiology underwent endonasal repair using rotation flaps. The average age of patients was 42-years old (range 10-67years). INTERVENTION FOR CLINICAL TRIALS OR EXPOSURE FOR OBSERVATIONAL STUDIES: Five patients had perforations such that we used inferiorly based flaps, while 35 cases utilized posteriorly based flaps. Acellular dermis was used in addition to a unilateral rotation flap. MAIN OUTCOMES AND MEASURES: The primary outcome desired was a complete closure of the septal perforation. The success, or lack thereof, was monitored after healing from surgery. RESULTS: Thirty-seven of the forty surgical procedures demonstrated complete closure of the perforation, a 92.5% success rate. Perforations were separated based upon size. Small perforations (<1cm) had a 93.3% success rate, medium (1-2cm) 88.9%, and all seven large perforations (>2cm) were closed successfully. In addition, all five of the inferiorly based procedures resulted in complete closure of the perforation. Of the failed repairs, one required revision surgery to repair a recurring perforation, while the other two were asymptomatic following the procedure. CONCLUSIONS AND RELEVANCE: Endonasal repair using inferiorly based mucosal rotation flaps coupled with an acellular dermal interposition graft is a valid technique for the repair of septal perforations. Posterior rotation flaps are preferred due to major septal blood supply from branches of the sphenopalatine artery, but inferiorly based flaps are also viable options for repair for perforations located in the anterior septum.

Novel treatment of a septal ulceration using an extracellular matrix scaffold (septal ulceration treatment using ECM).

BACKGROUND: Septal ulceration is a mucositis involving the mucous membranes of the nasal septum. Patients often complain of nasal irritation, crusting, and epistaxis. Presently, there is no gold standard for the treatment of septal ulcerations. Currently described therapies include local debridement, septal dermoplasty, septal flap reconstruction, and cadaveric dermal graft repair; however, no therapy has demonstrated a consistent improvement of symptoms. We present a novel approach for the treatment of chronic septal ulceration, using an extracellular matrix scaffold (MatriStem® Wound Care Matrix, ACell, Inc.) to repair unilateral partial septal mucosal defects. METHODS: This is a retrospective chart review of three patients with age range from 42 to 74years. All three patients underwent several years of unsuccessful conservative medical management and two patients had prior unsuccessful septoplasty and septal ulcer debridement procedure. There are no complications noted in the post-operative period. RESULT: All three patients had complete symptom relief on post-operative visit after chronic septal ulceration repair using an extracellular matrix scaffold mechanism. Patients were able to manage with conservative nasal regiment after surgery with significant improvement on quality of life. CONCLUSION: The use of extracellular matrix scaffolding provides the nasal septum with a framework for the in-growth of healthy mucosa over ulcerated areas. We propose this as a new treatment approach for patients who failed conservative medical management. Chronic septal ulcerations can be healed to provide improved quality of life to patients.

A nasal mucocele originating from complex facial fractures.

Mucoceles are benign, epithelial-lined mucous cysts. Commonly mucoceles form secondary to obstruction of a sinus outflow tract or from mucosal gland entrapment from chronic infection, inflammation, iatrogenic trauma, external trauma, or neoplasm. We present a rare case of a nasal mucocele in a 37-year old male arising from a remote history of maxillofacial trauma. To our knowledge, mucoceles associated with nasal bone fractures have not been reported in the literature.

Lateral arm microvascular free tissue reconstruction of a large neck keloid.

Keloid scars pose a surgical challenge in the region of the head and neck. We present a rare case of a large infected and recurrent neck keloid that failed multiple prior reconstructive attempts. Ultimately, the tissue was resected and the surgical bed was repaired with a lateral arm microvascular free flap. This repair emphasizes the need for adequate coverage of the defect while maintaining neck mobility, ease of swallowing, and cosmesis. This is the second report in the literature of free tissue transfer as treatment for a large keloid scar, and the first to show the feasibility of early post operative low dose irradiation of the surgical bed.

Extracranial ligation of ethmoidal arteries before resection of giant olfactory groove or planum sphenoidale meningiomas: 3 illustrative cases with a review of the literature on surgical techniques.

OBJECT: There are several surgical techniques for reducing blood loss-open surgical and endoscopic-prior to resection of giant anterior skull base meningiomas, especially when preoperative embolization is risky or not technically feasible. The authors present examples of an institutional experience using surgical ligation of the anterior and posterior ethmoidal arteries producing persistent tumor blush in partially embolized tumors. METHODS: The authors identified 12 patients who underwent extracranial surgical ligation of ethmoidal arteries through either a transcaruncular or a Lynch approach. Of these, 3 patients had giant olfactory groove or planum sphenoidale meningiomas. After approval from the institution privacy officer, the authors studied the medical records and imaging data of these 3 patients, with special attention to surgical technique and outcome. The variations of ethmoidal artery foramina pertaining to this surgical approach were studied using preserved human skulls from the Hamann-Todd Osteological Collection at the Museum of Natural History, Cleveland, Ohio. RESULTS: The extracranial ligation was performed successfully for control of the ethmoidal arteries prior to resection of hypervascular giant anterior skull base meningiomas. The surgical anatomy and landmarks for ethmoidal arteries were reviewed in anthropology specimens and available literature with reference to described surgical techniques. CONCLUSIONS: Extracranial surgical ligation of anterior, and often posterior, ethmoidal arteries prior to resection of large olfactory groove or planum sphenoidale meningiomas provides a safe and feasible option for control of these vessels prior to either open or endoscopic resection of nonembolized or partially embolized tumors.

Foreign body impaction of the vertebral canal.

Foreign body impactions in the aerodigestive tract are common, but have the potential for serious complications. A foreign body may disrupt the mucosal lining and migrate regionally thereby risking impingement or injury to critical neurovascular structures in the cervical region. It is important to recognize potential complications that may arise from luminal compromise. In such cases, expeditious surgical treatment is warranted.

Development of a Pictorial Patient Education Handout on Tracheostomy Care: A Mixed-Method Study.

This article describes a qualitative and quantitative approach to the development and iterative revision process of producing valid, user-friendly pictorial patient education handouts (infographics) on tracheostomy care. An iterative user-centered design with health professional, patient, and family caregiver panels was used. The authors first developed a new evaluation tool for pictorial education handouts, the Perceived Infographics Usability Measurement (PIUM). The patient education handout, consisting of three A3-size posters with illustrations on key steps of daily tracheostomy care, reached a high consensus among health professional experts (88.3%) and patients and family caregivers (89.1%) on PIUM usability indexes. Patients and family caregivers expressed that the patient education handout would be an understandable teaching tool and procedure reminder, which would help alleviate fears about tracheostomy care. The PIUM demonstrated satisfactory content validity and reliability properties and was a quality tool to guide the transformation of text-based content to a pictorial patient education handout.

Effectiveness of Pictorial Education Handout on Tracheostomy Care Self-efficacy in Patients With Head and Neck Cancer and Family Caregivers: A Pilot Quasi-Experimental Study.

BACKGROUND: Learning and performing tracheostomy care are challenging for laypersons. Effective pictorial patient education handouts are needed for nonprofessional individuals to learn health management skills. OBJECTIVES: The study aims to (1) evaluate the preliminary efficacy of the pictorial education handout on patients' and family members' self-efficacy in tracheostomy care and (2) identify demographic, psychological, and education-related factors associated with lower self-efficacy on tracheostomy care. INTERVENTIONS/METHODS: This was a preliminary pilot study with a pretest-posttest design. We recruited a total of 39 participants, including 22 patients with head and neck cancer-related tracheostomy and 17 family caregivers in 2021. All participants received A3-size (297 × 420 mm) pictorial patient education handouts on how to suction and how to clean their tracheostomy at home. RESULTS: Pictorial education handouts showed a medium to large effect size on self-efficacy in the patient (Cohen D = 0.46) and caregiver participants (Cohen D = 0.78). Participants with higher anxiety were associated with a greater gain in self-efficacy with the pictorial patient education handouts (r = 0.35, P = .027). CONCLUSIONS: Pictorial patient education handouts were effective tools for improving patients' and family caregivers' confidence in tracheostomy care, and it is particularly helpful for individuals with high anxiety with tracheostomy. IMPLICATION FOR PRACTICE: Clinical nurses should use the pictorial education handouts not only to assist patients and family members on learning and practicing tracheostomy care but also to relieve anxiety associated with tracheostomy care at home.

Anosmia: Brighton Collaboration case definition and guidelines for data collection, analysis, and presentation of immunization safety data.

This is a Brighton Collaboration case definition of anosmia to be used in the evaluation of adverse events following immunization, and for epidemiologic studies for the assessment of background incidence or hypothesis testing. The case definition was developed by a group of experts convened by the Coalition for Epidemic Preparedness Innovations (CEPI) in the context of active development of SARS-CoV-2 vaccines. The case definition format of the Brighton Collaboration was followed to develop a consensus definition and defined levels of certainty, after an exhaustive review of the literature and expert consultation. The document underwent peer review by the Brighton Collaboration Network and by two expert reviewers prior to submission.

Subcutaneous emphysema after otologic surgery: a case report.

Subcutaneous emphysema of the head and neck after otologic surgery is exceedingly rare. The mechanism relates to the intimate relationship of the temporomandibular joint to the external auditory canal. We present a rare case of subcutaneous emphysema after otologic surgery for ear disease. An astute clinical index of suspicion coupled with prompt treatment can help minimize morbidity and improve patient outcomes.

Metastasis of untreated head and neck cancer to percutaneous gastrostomy tube exit sites.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) has become a mainstay in providing enteral access for patients with obstructive head and neck tumors. PEG tube placement is considered safe and complications are infrequent. METHODS: A comprehensive review of the literature in MEDLINE (1962-2011) was performed. We report herein 3 new cases. RESULTS: The literature search revealed 43 previous cases. The interval between PEG placement and diagnosis of metastasis ranged from 1 to 24 months. CONCLUSIONS: Metastatic cancer should be considered in patients with head and neck cancer that have persistent, unexplained skin changes at PEG site, anemia, or guaiac positive stools without a clear etiology. The direct implantation of tumor cells through instrumentation is the most likely explanation, although hematogenous and/or lymphatic seeding is also a possibility. Our review of the literature and clinical experience indicate that the "pull" technique of PEG placement may directly implant tumor cells at the gastrostomy site.

Post-Traumatic Distress and Symptom Experience in Patients With Head and Neck Cancer-Related Tracheostomy and Family Caregivers.

OBJECTIVES: To describe post-traumatic distress and identify associated factors in patients with head and neck cancer-related tracheostomy and their family caregivers. SAMPLE & SETTING: This observational study assessed 22 patients with surgically managed head and neck cancer-related tracheostomy and 17 family caregivers at a comprehensive cancer center. METHODS & VARIABLES: Instruments included the Impact of Event Scale-Revised, the Memorial Symptom Assessment Scale, and the Patient-Reported Outcomes Measurement Information System Depression 6a Short Form scale. RESULTS: Post-traumatic distress related to tracheostomy and general depression in patients and family caregivers was highly prevalent. An increased level of physical symptoms was moderately correlated with higher levels of post-traumatic distress. IMPLICATIONS FOR NURSING: Patients who experienced higher symptom burden may also suffer from post-traumatic distress related to tracheostomy. Oncology nurses can implement post-traumatic distress screening in patients and their family caregivers.

Rhinotillexomania Manifesting as Empty Nose Syndrome.

OBJECTIVES: To highlight a severe case of rhinotillexomania (compulsive nasal picking) and its potential to manifest as empty nose syndrome (ENS). METHODS: A single case report with the presentation and management of a patient with severe rhinotillexomania who presented with chronic obstructive symptoms. We review the current literature on rhinotillexomania and ENS. RESULTS: This patient's manifestations mimic the obstructive symptoms of ENS, despite widely patent nasal passages. CONCLUSION: This is the first report of rhinotillexomania manifesting with features of ENS.

Surgical risk factors for recurrence of inverted papilloma.

OBJECTIVES/HYPOTHESIS: To identify variations in surgical technique that impact the recurrence of inverted papilloma following endoscopic excision. STUDY DESIGN: Retrospective cohort. METHODS: Data from 127 consecutive patients who underwent endoscopic excision of inverted papilloma and oncocytic papilloma at a tertiary care medical center from 1998 to 2011 were reviewed. Patient demographics, comorbidities, tumor stage, and intraoperative details, including tumor location and management of the base, were evaluated to identify factors associated with tumor recurrence. RESULTS: Recurrence of papilloma occurred in 16 patients (12.6%). Mean time to recurrence was 31.0 months (range, 5.2-110.0 months). Mucosal stripping alone was associated with a recurrence rate of 52.2% (12/23 patients), compared to 4.9% (3/61 patients) when the tumor base was drilled, 4.7% (1/21 patients) when it was cauterized, and 0.0% (0/22 patients) when it was completely excised (P = .001). Increased recurrence rate was associated with tumors located in the maxillary sinus (P = .03), as well as the performance of endoscopic medial maxillectomy (P = .001) and external frontal approaches (P = .02). CONCLUSIONS: Drilling, cauterizing, or completely excising the bone underlying the tumor base during endoscopic resection reduces the recurrence rate of inverted and oncocytic papilloma, when compared to mucosal stripping alone. Surgeons who perform endoscopic resection of these tumors should consider utilization of these techniques when possible. LEVEL OF EVIDENCE: 4.

Invasive fungal disease of the sinus and orbit: a comparison between mucormycosis and Aspergillus.

BACKGROUND/AIMS: Invasive fungal infections of the head and neck are rare life-threatening infections where prompt diagnosis and intervention is critical for survival. The aim of this study is to determine the clinical characteristics and outcomes of invasive fungal disease of the sinus and orbit, and to compare mucormycosis and Aspergillus infection. METHODS: A retrospective review was conducted from a single tertiary care eye and ear hospital over 20 years (1994-2014). Twenty-four patients with a confirmed pathological diagnosis of invasive fungal disease of the sinus and/or orbit were identified and their medical records were reviewed. The main outcome measures were type of fungus, location of disease, mortality and visual outcome. RESULTS: Patients with orbital involvement had a higher mortality and higher likelihood of mucormycosis infection compared with those with sinus-only disease (78.6% vs 20%, p=0.01; 86% vs 30%, p=0.01, respectively). Patients with mucormycosis had a higher mortality (71%) than patients with Aspergillus (29%); however, this was not statistically significant (p=0.16). All patients with orbital involvement and/or mucormycosis infections were immunosuppressed or had inadequately controlled diabetes, and had a cranial neuropathy or ocular motility dysfunction. All five post-transplant patients with orbital infections died, while the two transplant patients with sinus infections survived. CONCLUSIONS: Patients with orbital fungal infections are more likely to be infected with mucormycosis compared with Aspergillus and have a higher mortality compared with infections sparing the orbit. History of transplant portends a dismal prognosis in orbital infections. Invasive fungal disease should be considered in any immunocompromised patient presenting with a new cranial neuropathy or ocular motility abnormality.

Surgery for allergic rhinitis.

BACKGROUND: Allergic rhinitis (AR) is a highly prevalent disorder that significantly impacts quality of life and affects millions of people annually. The most bothersome complaint is nasal obstruction, which is most commonly due to inferior turbinate hypertrophy. METHODS: This work presents a review of the literature and an overview of operative techniques. RESULTS: A variety of methods are available for addressing inferior turbinate hypertrophy in patients afflicted with AR. Although no single modality has been defined as the gold standard for treatment, the otolaryngologist should be familiar with an armamentarium of surgical techniques. CONCLUSION: The inferior turbinate is the initial deposit point for allergens and undergoes dynamic changes through the allergic cascade, which results in nasal obstruction. Targeting the inferior turbinate to augment the nasal airway is the mainstay of surgical treatment in AR. Judicious technique and a mucosal sparing philosophy are necessary to maximize outcomes and improve quality of life.

Endoscopic resection of orbital hemangiomas.

BACKGROUND: Cavernous hemangiomas are the most common orbital tumors in adults. Traditional orbitotomy approaches to resect these intraconal lesions are associated with patient morbidity due to difficulties with visualization and access in the region of the orbital apex. METHODS: In this retrospective chart review and case series, the records of 5 patients who underwent endoscopic resection of orbital hemangiomas by the senior authors (A.F. and R.M.) between 2007 and 2011 were reviewed. Patient demographics, preoperative, and postoperative variables were assessed. RESULTS: All tumors were located in the medial orbital apex. Mean tumor size was 1.7 cm in maximum dimension (range, 1.0-2.7 cm). Proptosis and/or optic neuropathy were present in all cases. Surgeries were performed through an entirely endoscopic transnasal approach. One patient underwent subtotal tumor resection. Proptosis improved by a mean ± standard deviation of 1.75 ± 0.87 mm. The average improvement in visual acuity was 1.8 lines on a Snellen chart (range, 1-4 lines). There were no long-term adverse sequelae. CONCLUSION: Endoscopic techniques for the treatment of patients with hemangiomas in the posterior medial orbit appear to offer the advantage of enhanced surgical access with reduced patient morbidity compared to conventional orbitotomy approaches.

The nasoseptal flap for reconstruction of the medial and inferior orbit.

BACKGROUND: Endoscopic endonasal orbital surgery may result in large orbital defects that mandate reconstruction to minimize the risk of diplopia and enophthalmos. The purpose of this study is to determine whether the nasoseptal flap can provide adequate coverage of maximal orbital defects. METHODS: This was an anatomic cadaveric study. Morphometric measurements were completed in 5 cadaveric orbits to determine the dimensions of an orbital defect comprising the entire lamina papyracea and the orbital floor. The dimensions of a planned nasoseptal flap were then calculated and an appropriately sized flap was harvested to verify complete coverage of the defect. RESULTS: The mean ± standard deviation (SD) medial orbital defect was a depth of 47.3 mm ± 2.52, height of 13.67 mm ± 2.73, and width of 13.33 mm ± 1.03 for the orbital floor. The mean flap dimensions were a width of 55 ± 6.16 mm, height of 48 ± 4.47 mm, and depth of 70 ± 3.54 mm. In all cases, the harvested flap adequately covered the orbital defect. These dimensions correlated with flap incisions subtending the mucocutaneous junction anteriorly, the inferior meatus laterally, the attachment of the middle turbinate superiorly, and the choanal arch posteriorly. CONCLUSION: Endoscopic orbital approaches may result in large orbital defects with significant orbital fat herniation and extraocular muscle exposure. Immediate vascularized flap reconstruction of the orbit may help to limit the attendant morbidity including diplopia and enophthalmos. This study is the first to demonstrate the feasibility of the nasoseptal flap for the reconstruction of maximal orbital defects.