Innovative Surgical Techniques for Nasal Septal Perforations: Management and Treatment.

PURPOSE OF REVIEW: The aim of this study was to review and describe the main innovative surgical techniques for nasal septal perforation (NSP) repair that have been published in recent years. RECENT FINDINGS: Several techniques for NSP repair have been developed recently. The anterior ethmoidal artery (AEA) flap is a versatile technique for middle-size perforations in different locations. The greater palatine artery (GPA) flap is an excellent option for anterior-most NSPs. The lateral nasal wall flap and the pericranial flap are the most appropriate techniques for large perforations. The advent of these techniques has changed the management and has expanded the therapeutic arsenal to treat all types of NSPs according to the size, location, and osteo-cartilaginous support. However, no technique has been accepted as the gold standard. Extensive knowledge of different techniques is important to individualize the treatment, selecting the most appropriate in each case.

Greater palatine artery pedicled flap for nasal septal perforation repair: radiological study and case series.

PURPOSE: The greater palatine artery (GPA) is one of the main vessels supplying the nasal septum. We recently described a novel technique to reconstruct a nasal septal perforation (NSP) using a GPA flap. This radiological study explores the feasibility and limits of using a GPA flap for an anterior NSP repair. METHODS: We describe our technique for repairing anterior-most NSP. Radiological measurements of the GPA flap and their limits were analysed. Additionally, a cohort of four patients who underwent reconstruction of a NSP with a GPA flap was included. RESULTS: The radiological study of 150 nasal cavities showed a 31.5 ± 2.7 cm2 maximum flap area. Taking into account the retraction process (30%), the remaining area was 22.0 ± 1.9 cm2. The septal area anterior to the GPA was 6.1 ± 2.1 cm2. The septal portion of the flap was larger than the area anterior to the GPA pedicle in all cases. Complete NSP repair was achieved in four patients. All cases of NSP remained closed during the follow-up. CONCLUSION: The unilateral GPA pedicled flap is a useful technique suitable for the reconstruction of anterior-most perforations that are difficult to cover with other endonasal techniques.

Endoscopic maxillectomy: anatomo-radiological description of the "double" maxillary sinus window.

OBJECTIVES/HYPOTHESIS: To present a modified endoscopic medial maxillectomy (MEMM) approach to control maxillary sinus pathologies. METHODS: MEMM was completed in 13 fresh-frozen specimens. An MEMM includes cutting the nasolacrimal duct, inferior meatus flap, and repositioning the inferior turbinate (IT). The following measurements were obtained: length of IT, height from the nasal floor to valve of Hasner, height of the IT at the level of valve of Hasner, height of the IT at the insertion of the middle turbinate, and distance from the piriform aperture to the posterior wall of maxillary sinus and to the posterior border of palatine bone. Similar measurements were also performed on craniofacial computed tomography (CT) scans (n = 50). The surgical technique was performed in a case series (n = 8). RESULTS: The mean of the specimens was 82 (range 70-95) years old. The average area of the harvested inferior meatus flap area was 9.6 ± 1.0 cm2. In the radiologic study, the mean maximum antrostomy area was 8.8 ± 1.7 cm2 and the IT area overlapping the antral window was 5.8 ± 1.1 cm2, the area allowing a double window control was 3.1 ± 1.9 cm2, the posterior IT insertion length was 0.7 ± 0.4 cm, and the inferior meatus flap covering the inferior meatotomy had an area measuring 6.7 ± 1.7 cm2. Eight patients underwent MEMM for various benign conditions showing no recurrence after 26 month follow-up. CONCLUSION: The proposed modifications of MEMM provide a "double" window maxillary sinus control with access to all maxillary walls and preservation of the IT.

Ethyl alcohol threshold test: a fast, reliable and affordable olfactory Assessment tool for COVID-19 patients.

OBJECTIVE: COVID-19 patients may present mild symptoms. The identification of paucisymptomatic patients is paramount in order to interrupt the transmission chain of the virus. Olfactory loss could be one of those early symptoms which might help in the diagnosis of COVID-19 patients. In this study, we aim to develop and validate a fast, inexpensive, reliable and easy-to-perform olfactory test for the screening of suspected COVID-19 patients. STUDY DESIGN: Phase I was a case-control study and Phase II a transversal descriptive study. SUBJECTS AND METHODS: Olfaction was assessed with the ethyl alcohol threshold test and symptoms with visual analogue scales. The study was designed in two phases: In Phase I, we compared confirmed COVID-19 patients and healthy controls. In Phase II, patients with suspected COVID-19 infection referred for testing were studied. RESULTS: 275 participants were included in Phase I, 135 in Phase II. The ROC curve showed an AUC of 0.749 in Phase I, 0.737 in Phase II. The cutoff value which offered the highest amount of correctly classified patients was ≥ 2 (10% alcohol) for all age intervals. The odds ratio was 8.19 in Phase I, 6.56 in Phase II with a 75% sensitivity. When cases report normal sense of smell (VAS < 4), it misdiagnoses 57.89% of patients detected by the alcohol threshold test. CONCLUSION: The olfactory loss assessed with the alcohol threshold test has shown high sensitivity and odds ratio in both patients with confirmed COVID-19 illness and participants with suspected SARS-CoV-2 infection.

Intra and interobserver agreement of narrow band imaging for the detection of head and neck tumors.

BACKGROUND: Narrow band imaging (NBI) in combination with white light endoscopy (WLE) has improved the accuracy for the diagnosis and follow-up of head and neck carcinomas by identifying changes in the vascular patterns of the mucosa. However, NBI evaluation is explorer-dependent and may be influenced by the learning curve. The aim of this study is to assess the intra and interobserver agreement of NBI and WLE at the office, under local anaesthesia, by either experienced or non-experienced observers. METHODS: Eighty-seven images of head and neck lesions were routinely collected under WLE and NBI. A group of three experienced otolaryngologists and three medical students assessed the images after a brief training. No additional patient information was provided. The same protocol was repeated after three weeks. Intra and interobserver agreement were calculated with the kappa index. RESULTS: NBI intraobserver agreement was substantial (κ = 0.62) and better than with WLE alone, which was moderate (κ = 0.57) in both groups. Interobserver agreement was moderate with WLE (κ = 0.58) and substantial with NBI (κ = 0.63). Both groups improved intraobserver and interobserver agreement with the implementation of NBI. CONCLUSIONS: Intra and interobserver agreement with NBI for the evaluation of head and neck lesions are substantial, and improve the results of WLE alone in both, professionals and trainees.

Endoscopic "Racket-on-Donut" Technique for Large Anterior Nasoseptal Perforations.

Endoscopic Racket-on-Donut technique is a combination of a modified greater palatine artery and inverted edges flaps. Endoscopic Racket-on-Donut technique is very useful for anterior NSP repair. Laryngoscope, 134:143-147, 2024.

Nonsurgical Rhinoplasty after Rhinoplasty: A Systematic Review of the Technique, Results, and Complications.

Introduction: Surgical rhinoplasty is a complex procedure with a high revision rate. Nonsurgical rhinoplasty (NSR) could avoid secondary rhinoplasty allowing the correction of postsurgical defects. A systematic review has been performed among adult patients who had previously undergone surgical rhinoplasty and now presenting for NSR with filler, demonstrated most common indications, fillers, and complications in this technique. Materials and Methods: A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) system guidelines. Primary outcomes included indications for NSR in patients with prior rhinoplasty and complication rate. Secondary outcomes included filler material and degree of patient satisfaction. Results: Twenty articles met the inclusion criteria, obtaining 2,048 patients analyzed in the review. Hyaluronic acid was the most used filler, found in 67% of patients. Indications were highly variable, considering deformities of the middle third of the nose the most remarkable. A high degree of satisfaction was found in the analyzed studies and the rate of major complications was low. Discussion and Conclusions: NSR in patients with prior rhinoplasty is a useful option for correcting a range from subtle aesthetic defects to severe nasal deformities. However, this technique is not exempt from complications, since an increased risk of skin necrosis has been observed.

Septal Perforation Quality of Life questionnaire (SEPEQOL): validation of a new instrument to assess patients undergoing endoscopic repair of a nasal septal perforation.

PURPOSE: Nasoseptal perforations (NSP) are a clinically heterogeneous group of disorders with a wide range of available treatments. Patient-reported outcome measures (PROMs) can provide valuable insights for assessing clinical and surgical outcomes. This study aims to develop and validate a novel-specific questionnaire for patients with NSP. METHODS: A multi-centre prospective observational study was conducted at two tertiary referral hospitals. "Septal Perforation Quality of Life" (SEPEQOL) was developed by a committee of experts. The psychometric properties, including reproducibility, reliability, validity, and responsiveness, were assessed. RESULTS: The study included 96 symptomatic NSP patients and 30 healthy controls. SEPEQOL internal consistency was satisfactory [Cronbach´s α = 0.7843; 95% confidence interval (CI), 0.702-0.856]. Test-retest reliability was excellent, demonstrated by the absolute intraclass correlation (ICC = 0.974; 95% CI, 0.935-0.989, P-value < 0.001) and Bland-Altman plot (line bias = 1.6 ± 4.57; 95% CI -0.54-3.74, P-value < 0.001). The mean total SEPEQOL score was higher before surgery (25.16 ± 1.65) compared to 6-months after the procedure (13.72 ± 11.39), with a mean difference of 12.19 [standard deviation (SD) 10.76], P-value < 0.001. CONCLUSIONS: SEPEQOL is reliable, consistent, valid, and sensitive to change over time. SEPEQOL assesses the impact of health-related quality of life on NSP and its management in clinical practice. Moreover, it is easy to apply in clinical settings with minimal burden.

The current situation of tutoring in specialised training in otorhinolaryngology-head and neck surgery in Spain. Where are we? Where do we want to go?

BACKGROUND AND OBJECTIVE: There is great heterogeneity in the methodology and evaluation in specialized health training (SHT) in otorhinolaryngology in our country. The figure of the resident tutor is the cornerstone on which the ESF system is based and the regulation and recognition of this figure varies. This article aims to take a snapshot of the current situation of the ESF in Spain and to describe the activity of tutors. MATERIALS AND METHODS: During the month of September 2023, a survey was sent in a Google Forms® format through the Spanish Society of Otolaryngology and Head and Neck Surgery. The survey consisted of 8 multiple-choice questions and 4 questions in which they were asked to rank a series of 5 weaknesses, threats, opportunities and strengths selected by the authors, in order to perform a SWOT analysis. RESULTS: A total of 103 responses were obtained, of which 81 corresponded to accredited tutors. 63% of the tutors indicated that they did not have enough time to carry out their teaching work and 48% did not carry out a regular assessment of their residents. 64% of the tutors believe that the quality of otorhinolaryngology training in Spain is good and 61% are satisfied with their job as tutors. The main weakness was the short duration of the training programme, and the pressure of care was found to be the main threat. An experienced training system was considered the main strength and the creation of a national network of tutors was seen as an opportunity for improvement. CONCLUSIONS: The creation of a common and transversal otorhinolaryngology training pathway for all accredited centres and the creation of a network of mentors and residents are necessary to address the problems of SHT. The role of the tutor must be recognised and reinforced to improve specialist training.

State-of-the-art: septal perforation repair.

PURPOSE OF REVIEW: To provide a comprehensive overview of the evolution of the different techniques described for the surgical repair of nasal septal perforation, and a surgical decision-making algorithm for its surgical treatment. RECENT FINDINGS: Septal perforation surgery has evolved and improved in recent years. It has gone from being an avoided or discouraged surgical procedure to a procedure with success rates of >90%. Nowadays, there is no standard approach or single technique. The different techniques described include unilateral random pattern flaps, interposition grafts, unilateral pedicle septal local flaps, free mucosal grafts and bilateral random patter flaps. The incidence of success is higher in pediculated septal flaps such as the anterior ethmoidal artery flap or the greater palatine artery pedicled flap combined with additional techniques. SUMMARY: Nowadays, surgical closure of septal perforation is possible and should be an option to consider in symptomatic patients without response to medical treatment. The surgical approach that we recommend when planning the surgical closure of nasal septum (or nasoseptal) perforation is based on the osseocartilaginous support and the location of the defect.

Oroantral Fistula Closure Using Double-Layered Flap: Greater Palatine Artery Flap and Buccal Fat Pad.

A novel surgical technique based on a combined approach to oroantral fistula closure using a double-layered flap: greater palatine artery pedicled flap and buccal fat pad combination. Laryngoscope, 133:1824-1827, 2023.

Optimisation of the quality of care for patients with severe asthma: ASfarMA project.

Severe asthma has an important impact on patients and healthcare resources. Recently, the new specific treatments have defined a new scenario in which person-focused care and specialist multidisciplinary teams are necessary. Our Severe Asthma Unit (SAU) started the ASfarMA project along with an external human-centered design company to understand patients' vision of their illness, treatment, and healthcare experience, and to define the ideal SAU by performing a core group session, in-depth semistructured interviews and co-creation workshop. Herein, a series of tips classified as either 'transformative solutions' or 'quick wins', according to a value versus effort matrix are presented. Successful implementation of the proposed solutions will be valuable for patients and healthcare professionals, optimising patient care and resources. These findings can also be helpful to other SAUs or other humanisation projects involving complex, chronic and multidisciplinary pathologies.