Long-term effects of the titanium butterfly implant on quality of life: a prospective cohort study.

PURPOSE: Nasal valve insufficiency is known to have a negative impact on both nasal patency and quality of life. The titanium butterfly implant is a surgical treatment proven to have a positive effect on these aspects up to 6 months postoperative. This study aimed to determine the long-term effects of the titanium butterfly implant on nasal obstruction symptoms and quality of life in adult patients with nasal valve insufficiency up to 5 years after procedure. METHODS: A prospective single cohort study was performed including 29 patients that underwent the titanium butterfly implant in one tertiary medical center. Data was obtained before and at least 5 years after surgery using three questionnaires: the Nasal Obstruction and Septoplasty Effectiveness questionnaire, the Sino-Nasal Outcome Test 22 and the Glasgow Benefit Inventory questionnaire. RESULTS: A significant decrease in total NOSE score was seen compared to baseline measurements. The SNOT-22 scores also showed a significant decrease, whereas the GBI scores showed no significant changes at the late follow-up. CONCLUSION: Seven years after placement the titanium butterfly implant still has a statistically significant improvement on otorhinologic-related quality of life compared to preoperative measurements.

Optimization of the automated Sunnybrook Facial Grading System - Improving the reliability of a deep learning network with facial landmarks.

OBJECTIVE: The Sunnybrook Facial Grading System (SFGS) is a well-established grading system to assess the severity and progression of a unilateral facial palsy. The automation of the SFGS makes the SFGS more accessible for researchers, students, clinicians in training, or other untrained co-workers and could be implemented in an eHealth environment. This study investigated the impact on the reliability of the automated SFGS by adding a facial landmark layer in a previously developed convolutional neural network (CNN). METHODS: An existing dataset of 116 patients with a unilateral peripheral facial palsy and 9 healthy subjects performing the SFGS poses was used to train a CNN with a newly added facial landmark layer. A separate model was trained for each of the 13 elements of the SFGS and then used to calculate the SFGS subscores and composite score. The intra-class coefficient of the automated grading system was calculated based on three clinicians experienced in the grading of facial palsy. RESULTS: The inter-rater reliability of the CNN with the additional facial landmarks increased in performance for all composite scores compared to the previous model. The intra-class coefficient for the composite SFGS score increased from 0.87 to 0.91, the resting symmetry subscore increased from 0.45 to 0.62, the symmetry of voluntary movement subscore increased from 0.89 to 0.92, and the synkinesis subscore increased from 0.75 to 0.78. CONCLUSION: The integration of a facial landmark layer into the CNN significantly improved the reliability of the automated SFGS, reaching a performance level comparable to human observers. These results were attained without increasing the dataset underscoring the impact of incorporating facial landmarks into a CNN. These findings indicate that the automated SFGS with facial landmarks is a reliable tool for assessing patients with a unilateral peripheral facial palsy and is applicable in an eHealth environment.

Which techniques are relevant in the surgical management of the nasal tip?

In this article, we give an overview of safe and consistent techniques for nasal tip surgery. A change in the morphology of the tip has an impact on the profile of the face. A knowledge of facial proportions is therefore important when performing rhinoplastic surgery. We prefer an external approach because it provides the best overview and because the possibility of bimanual working makes manipulation of the lower lateral cartilages easier. The techniques described here can be used to alter the nasal tip in a controllable way.

Autologous versus prosthetic nasal and auricular reconstruction - patient, professional and layperson perceptions.

The aim of this study was to retrospectively evaluate the perceptions of aesthetic outcome following the autologous and prosthetic reconstruction of nasal and auricular defects among patients, professionals (oral and maxillofacial surgeons and ear, nose and throat surgeons) and people unfamiliar with reconstructive surgery. The influence of anatomical subunits on the overall perception of nasal and auricular reconstructions was also determined. A total of 119 patients treated for nasal and auricular defects between 1997 and 2016, with a minimum follow-up period of 6 months, were selected, and photographs of 77 of these patients (65%) were presented in a digital survey and reviewed using a standardized questionnaire. No clinically relevant correlations were found between the age or gender of patients (as well as those of the respondents) and their scores. Prosthetic reconstructions of nasal and auricular defects were considered advantageous over autologous reconstructions in terms of the subjective aesthetic outcome in the view of the professionals, in particular oral and maxillofacial surgeons; however, the patients judged both techniques to be equally effective in terms of aesthetics. No anatomical subunits were found to have a significant impact on the overall match of a nasal or auricular reconstruction with the patient's face.

Evidence-based recommendations regarding the differential diagnosis and assessment of nasal congestion: using the new GRADE system.

Nasal congestion is an important symptom in nasal pathology and can be defined as an objective restriction of nasal cavity airflow because of mucosal pathology and/or increased mucus secretion (excluding anatomical variants). Using the new Grading Recommendations Assessment, Development and Evaluation system, evidence-based recommendations are made that will encompass different clinical questions regarding diagnostic modalities of nasal congestion: (i) their usefulness in assessment of presence and severity of congestion; (ii) their usefulness in assessment of etiological pathology responsible for congestion; and (iii) their usefulness in follow up and treatment effectiveness evaluation of nasal congestion.

[Regional metastases of head and neck cutaneous squamous cell carcinoma]. / Regionale metastasen van plaveiselcelcarcinoom van de huid in het hoofd-halsgebied.

Two patients, a woman aged 54 years and a man aged 76 years, developed regional metastases of head and neck cutaneous squamous cell carcinoma (HNCSCC). In general, cutaneous SCC has a low metastatic potential. However these patients illustrate that this tumour may behave aggressively, metastasising to the regional lymph nodes in the neck or parotid gland. Certain clinical and histological features of the primary tumour are associated with a higher risk for nodal metastases. In patients at risk, a more rigorous investigation for nodal metastasis is warranted at diagnosis of SCC as well as during follow-up. The extent of treatment of lymph nodes in the neck region should be directed by the location of the primary tumour, which is an indicator of the most probable lymph drainage pattern. In the case of metastatic parotid involvement, elective treatment of the neck should be considered, even when there are no clinical signs of metastasis. Treatment consists of surgery and/or ipsilateral radiotherapy.

Does self-consciousness of appearance influence postoperative satisfaction in rhinoplasty?

BACKGROUND: Facial plastic surgeons and patients benefit from knowledge about how psychological aspects can influence the outcome of cosmetic surgery. The influence of preoperative self-consciousness of appearance and its effect on benefit after surgery in rhinoplasty patients has not been explored before in other studies. METHOD: A prospective study was conducted on patients undergoing (septo)rhinoplasty for a combination of cosmetic and functional problems. Before the operation subjects were asked to complete two questionnaires, the Derriford Appearance Scale (DAS59) to measure distress associated with self-consciousness of appearance and the Rhinoplasty Outcome Evaluation (ROE) to measure satisfaction with their nose. Three months after surgery, they were asked to complete the ROE again and the Glasgow Benefit Inventory to measure benefit of the surgery in daily life. Scores of the pre- and postoperative questionnaires were analyzed and compared. Statistical analysis was performed to determine change after surgery and correlations between the scores. SUBJECTS: Fifty-five consecutive patients undergoing (septo)rhinoplasty received a letter in which they were asked to participate in the study. Thirty-three patients completed both pre- and postoperative questionnaires. Their mean age was 28 years. MAIN FINDINGS: Patient satisfaction improved significantly after the surgery. Lower self-consciousness of appearance before surgery was positively correlated with more benefit after the surgery and a greater change in patient satisfaction with their nose. Males have a lower benefit scores than females. CONCLUSIONS: Patients seeking rhinoplasty have more distress associated with self-consciousness of appearance than a general unconcerned population. They can benefit a lot from a well-executed procedure. A significant improvement in quality of life can be achieved by rhinoplasty. Although males are equally satisfied as females, they benefit less from the surgery in daily life.

Measuring nasal tip and lobule width; effect of transdomal and lateral crura suturing.

STATEMENT OF PROBLEM: There is no golden standard in measuring the width of the nasal tip and lobule. In this study we tried to validate the parameters Tip Index (TI) and Lobular Index (LI) as parameters for Nasal Tip Width (NTW) and Nasal Lobule Width (NLW) respectively. Trandomal suturing and lateral crura suturing were used to alter NTW and NLW respectively. METHODS: Standardized digital photographs (basal view) of open approach rhinoplasty patients were analysed. Transdomal sutures and lateral crura sutures were used in 29 and 28 patients, respectively. TI and LI were determined with digital imaging software (Adobe Photoshop) pre- and postoperatively. RESULTS: Average (SD) preoperative LI changed from 0.74 (0.07) to 0.71 (0.06) postoperatively with the lateral crura suturing technique (p = 0.045). We were not able to measure an effect in TI with the transdomal suturing technique. CONCLUSIONS: Detailed postoperative analysis with digital imaging software contributes to greater understanding of nasal tip mechanics. LI proved to be a valuable technique to describe NLW refinement.

[3D-navigation in nasal sinus surgery]. / 3D-navigatie in de neusbijholtechirurgie.

Mechanical, infra-red and electrofrequency 3D-navigation equipment enables the visualisation of a probe in a patient in the three dimensions ofa CT-scan. Such a system guarantees better orientation in difficult anatomical areas. 3D navigation is particularly suitable for nasal-sinus surgery as the bony structures are reproduced in precise detail on a CT-scan and bone parameters do not change during operation. These technical developments mean that not only the indications for operation but also the surgical approach have greatly altered. In functional nasal-sinus surgery the aim is to open up the sinus by removing all those structures which may hinder drainage. The mucous membrane with its mucociliary transport is spared and goes on to heal. - Prior to operation the patient's anatomical landmarks are tracked and spatially linked to the corresponding points on the CT-scan. The coordinates of these points are registered on a computer. A probe is moved around within the spaces, its coordinates are calculated and their position shown on a CT-scan. The patient's head is fixed in a frame that is able to move with the head. The advantage of the 3D-navigation system is its surgical and anatomical orientation. Disadvantages are its cost and, to a lesser extent, time requirements and the size of the equipment.

Ventilation tubes in infants increase the risk of otorrhoea and antibiotic usage.

1) PROBLEM/OBJECTIVE: The effect of ventilation tubes on acute otitis related symptoms (otorrhoea, earache, and fever) and on antibiotic usage was investigated in children with persistent otitis media with effusion, as part of a multicenter, randomised, controlled clinical trial. 2) METHODOLOGY: One hundred-eighty-seven children were randomly placed into either a watchful waiting group (WW group) (n = 94) or a group treated with ventilation tubes (VT group) (n = 93). Both groups were followed for 12 months. Data were collected from parental reports and from medical files kept by the attending ENT-surgeons. 3) RESULTS: There were significant differences in the reported frequency of otorrhoea (but not of earache or fever) between both groups during follow-up, i.e. children in the VT group had more episodes of otorrhoea than the children in the WW group (p < 0.003). As a consequence, children in the VT group had been prescribed antibiotics more often. 4) CONCLUSIONS: Young children treated with ventilation tubes due to persistent otitis media with effusion have a higher risk of developing otorrhoea because of the tubes, and they have a higher risk of needing treatment with antibiotics.

Three-dimensional changes in nose and upper lip volume after orthognathic surgery.

Orthognathic surgery aims to improve both the function and facial appearance of the patient. Translation of the maxillomandibular complex for correction of malocclusion is always followed by changes to the covering soft tissues, especially the nose and lips. The purpose of this study was to evaluate the changes in the nasal region and upper lip due to orthognathic surgery using combined cone beam computed tomography (CBCT) and three-dimensional (3D) stereophotogrammetry datasets. Patients who underwent a Le Fort I osteotomy, with or without a bilateral sagittal split osteotomy, were included in this study. Pre- and postoperative documentation consisted of 3D stereophotogrammetry and CBCT scans. 3D measurements were performed on the combined datasets and analyzed. Anterior translation and clockwise pitching of the maxilla led to a significant volume increase in the lip. Cranial translation of the maxilla led to an increase in the alar width. The combination of CBCT DICOM data and 3D stereophotogrammetry proved to be useful in the 3D analysis of the maxillary hard tissue changes, as well as changes in the soft tissues. Measurements could be acquired and compared to investigate the influence of maxillary movement on the soft tissues of the nose and the upper lip.

Generalizability of trial results based on randomized versus nonrandomized allocation of OME infants to ventilation tubes or watchful waiting.

The objective was to study the generalizability of trial results by comparing randomized patients to eligible but nonrandomized patients who received the same management. Implementation of trial results is only justifiable when the results can be generalized to the total domain population. The design was a multicentre randomized controlled trial on the effect of early screening and treatment with ventilation tubes on infants with otitis media with effusion. Randomized (n = 187) and nonrandomized eligible patients (n = 133) were followed up. The study population comprised children who were detected by auditory screening at the age of 9-12 months and who were subsequently diagnosed with persistent bilateral otitis media with effusion for 4-6 months. A significant difference was found in the distribution of some prognostic factors: more randomized children had older siblings, did not attend day care and had mothers with a lower educational level than the nonrandomized children. These factors, however, did not modify the outcome. No differences were found in mean hearing levels between the randomized and nonrandomized children: in both the randomized and nonrandomized children ventilation tubes improved the hearing level, especially after 6 months. However, in the long term (12 months), the hearing levels were equal again. The results of the randomized and nonrandomized patients were comparable. The results of this trial appear to be generalizable to the total domain population. The procedure of following up both randomized and nonrandomized patients is recommended when there is concern about selective participation and reduced generalizability.

Comparison of the CAPAS and Ewing tests for screening of hearing in infants.

OBJECTIVE: To study the similarities and differences between the non-automated labour intensive Ewing hearing test and the less labour intensive automated CAPAS (Compact Amsterdam Paedo-Audiometrical Screening) hearing test. SETTING: A multicentre study in which all the children born in the eastern part of the Netherlands between 1 January 1996 and 1 April 1997 were routinely screened for hearing impairment at 9 months of age. METHODS: Differences and similarities between the two methods were described for the proportion of children who failed every test, the percentage of referred children, the yield of bilateral and unilateral otitis media with effusion (OME), the positive predictive value of the third test result, and the yield of persistent OME after 4-6 months' follow up at an ENT department. RESULTS: 12,603 infants were screened with the CAPAS test and 17,496 with the Ewing test. There were differences between the CAPAS and Ewing tests respectively in the proportions of children lost to follow up (10.1% v 15.2%), the proportions of children referred diagnosed with OME (59% v 81%), the yield of bilateral otitis media with effusion (2.4% v 3.0%), and the yield of persistent OME after 4-6 months' follow up (1.1% v 1.6%). CONCLUSIONS: The CAPAS test is more practical than the Ewing test, but the non-automated Ewing test seems to be more reliable and valid for detecting conductive hearing loss.

Influence of cocaine and lidocaine on human nasal cilia. Beat frequency and harmony in vitro.

The effects of cocaine and lidocaine on ciliary beat frequency and ciliary beat harmony were studied in biopsy specimens of normal human nasal mucosa. Cocaine was investigated in increasing concentrations (0.875%, 1.75%, 3.5%, and 7%) in five samples; lidocaine (0.125%, 0.25%, 0.5%, 1%, and 2%), in four samples. Ciliary beat was recorded photoelectrically and the signal was analyzed. Cocaine was found to decrease ciliary beat frequency and ciliary beat harmony at concentrations of 1.75% and higher. Partially reversible ciliostasis was seen at 7%. Lidocaine was found to decrease ciliary beat frequency and ciliary beat harmony at concentrations of 0.25% and higher. Irreversible ciliostasis was seen at 2%. Cocaine and lidocaine affected ciliary beat frequency and ciliary beat harmony in the same way.

Economic evaluation of ventilation tubes in otitis media with effusion.

OBJECTIVE: To determine the costs and effectiveness of treatment with ventilation tubes as compared with watchful waiting in children with persistent otitis media with effusion. DESIGN: Randomized controlled trial. SETTING: Institutional practice. PATIENTS: A total of 187 young children (19 months old) with persistent bilateral otitis media with effusion. INTERVENTIONS: Treatment with ventilation tubes or watchful waiting. MAIN OUTCOME MEASURES: The time without effusion, language development, and the costs from a societal perspective during 1-year follow-up. RESULTS: The mean duration of effusion was 9.2 months in the watchful waiting group and 4.7 months in the ventilation tube group. The language development was comparable in both groups (0.7 month of improvement difference [95% confidence interval, -0.3 to 1.7 months] after correction for confounding variables). Because no statistically significant differences were found in the language development between the treatment groups, we performed a cost minimization analysis. The mean costs per child during 1 year of follow-up were 454 US dollars in the ventilation tube group and 120 US dollars in the watchful waiting group. On average, an additional investment of 334 US dollars per patient was needed for ventilation tube treatment. CONCLUSION: In the absence of differences in language development and in view of higher costs, treatment with ventilation tubes is not recommended as standard treatment in all young children with persistent otitis media with effusion traced by a population-based screening program.

Prognostic factors for persistent otitis media with effusion in infants.

OBJECTIVE: To study prognostic factors for persistent otitis media with effusion (OME) in a birth cohort of 30,099 children born in the eastern part of The Netherlands between January 1, 1996, and April 1, 1997. DESIGN: Case-referent study. SUBJECTS: Children who failed a triple hearing test before their first birthday and were subsequently diagnosed with bilateral OME during 3 of the 4 bimonthly visits to an ear, nose, and throat (ENT) department (n = 372). The persistent cases were compared with 3 referent groups: (1) all the children who attended the first of 3 hearing tests; (2) all the children of the birth cohort who were referred to an ENT department after the third hearing test; and (3) all the children who were diagnosed with bilateral OME during the first visit to an ENT department. RESULTS: When all the children who participated in the first hearing test were taken as referents, persistent OME was associated with upper respiratory tract infections, attending a day-care center, having older siblings, and a family history of otitis media. When all the children who were referred to an ENT department were taken as referents, only attending a day-care center was associated with persistent OME. When the children diagnosed with bilateral OME during the first visit to an ENT department were taken as referents, no prognostic factors were found for OME persistence. CONCLUSION: When a child is referred early, an otolaryngologist can ask the parent about the presence of prognostic factors to decide which policy to follow.

Reliability of manometric eustachian tube function tests in children.

OBJECTIVE: To assess the reliability of manometric eustachian tube function tests in children with ventilation tubes in situ. STUDY DESIGN: Repeated manometric eustachian tube function tests during one session. SETTING: The study took place at a secondary referral hospital and a tertiary referral hospital. PATIENTS: Ninety-nine children with ventilation tubes in situ because of persistent otitis media with effusion. MAIN OUTCOME MEASURES: Opening pressure (Po), closing pressure (Pc), and tubal function group. RESULTS: Analysis of Po and Pc showed a decrease with repeated measurement (p = 0.0001 and p = 0.001, respectively). The effect of repeated measurement on Po was more pronounced than the effect on Pc. The results of the first and second pressure equilibration tests showed 99% agreement. CONCLUSIONS: This study showed good reproducibility of the categorized results of the pressure equilibration test, whereas the results of the forced-response test seemed to be less reproducible and showed a downward shift with repeated measurement. A single measurement using wet swallowing and starting pressures of 100 and -100 daPa and the mean of the first three measurements of the Po and Pc are sufficient to determine tubal function. Further studies are needed to determine the discriminative power of these tests in children with different degrees of middle ear disease.

A comprehensive model for the aetiology of otitis media with effusion.

Otitis media with effusion is highly prevalent among young children. Adverse effects of this disorder are mainly restricted to the group of children with a history of recurrent or persistent otitis media with effusion. Early identification, assessment and intervention might prevent these adverse effects. Up to now it is not possible to distinguish these children from those with transient otitis media with effusion. This article presents a comprehensive model for the aetiology of otitis media with effusion. Eustachian tube functioning and the immunological response to environmental pathogens are the two core elements. This model can be used to formulate specific hypotheses about the interaction of several factors that may lead to the early identification of children who are likely to develop persistent or recurrent otitis media with effusion.

Eustachian tube function in children after insertion of ventilation tubes.

This study was performed to assess the effect of the insertion of ventilation tubes and the subsequent aeration of the middle ear on eustachian tube (ET) function in children. Manometric ET function tests were performed repeatedly for 3 months after the placement of ventilation tubes in 83 children with otitis media with effusion (OME). Opening and closing pressures (passive tubal function) and active tubal function were measured. Analysis of the results showed a significant increase in opening pressure over time, whereas the closing pressure did not change. The active tubal function did not change and remained at the same poor level. Therefore, the opening pressure and closing pressure and, especially, the poor active tubal function, were more likely to be a causal factor of OME than a result. Certain children may have poor intrinsic ET function that makes them more susceptible to OME.

Hearing deficits at school age; the predictive value of otitis media in infants.

AIM: To evaluate the long-term predictive value of persistent/recurrent otitis media with effusion (OME) in infants in relation with hearing levels at (early) school age. DESIGN: A case-cohort study among a population-based sample of school-age children screened for hearing deficits. POPULATION AND METHODS: Schoolchildren (second grade, 5-6 years of age) in the city of Utrecht, the Netherlands, who failed the hearing screening test and a sample of children invited for this screening. History of otitis media (serosa and acute) was assessed using three sources of information: a self-completion questionnaire mailed to the parents; medical records of otolaryngology visits; data from the (Ewing) hearing screening test at 9 months of age. RESULTS: Children who failed the primary Ewing test and children with recurrent and or persistent OME in the first 2 years of life showed an increased risk of failing school audiometry compared to children without such an OME history (OR=1.6 and 2.3, respectively). In a logistic model, the results of the primary Ewing test and the frequency of acute otitis media, proved to be moderately predictive for the screening test result at school age. CONCLUSION: OME in infants is a prognostic factor for hearing performance in the early school years.