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.

Loss of smell in patients with traumatic brain injury is associated with neuropsychiatric behavioral alterations.

OBJECTIVE: We sought to identify and correlate the severity of traumatic brain injuries (TBIs) associated with olfactory dysfunction with cognitive and behavioral profiles. PARTICIPANTS AND SETTING: Patients with TBI undergoing treatment in a specialized neuro-rehabilitation hospital. DESIGN: Prospective study. MAIN MEASURES: Glasgow Coma Scale (GCS) at the time of injury and during posttraumatic amnesia. Motor functions were assessed with the Functional Instrument Measure and Disability Rating Scales. The Wechsler Adult Intelligence test was used for neuropsychologic assessment and the Neuropsychiatric Inventory was used to assess behavioral changes. The Barcelona Smell Test-24 was used to study subjective smell loss. RESULTS: A total of 111 patients with TBI were enrolled (33 females; mean age 32.86 years); 38.73% exhibited smell loss. Patients with no olfactory impairment (OI) had worse TBIs than those with OI (GCS scores 5.65 and 7.74, respectively); no significant differences in cognitive behaviors, such as attention memory, visuoperception, and visuoconstruction, were observed. However, patients with TBI and olfactory dysfunction showed statistically significant alterations in neuropsychiatric behavioral performances such as feeding when compared with patients with TBI without smell loss. CONCLUSION: Olfactory dysfunction in patients with a TBI correlates with altered neuropsychiatric behavioral performances such as feeding, sleeping, and motor behavior.

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.

Relationship between odor intensity estimates and COVID-19 prevalence prediction in a Swedish population.

In response to the COVID-19 pandemic, countries have implemented various strategies to reduce and slow the spread of the disease in the general population. For countries that have implemented restrictions on its population in a step-wise manner, monitoring of COVID-19 prevalence is of importance to guide decision on when to impose new, or when to abolish old, restrictions. We are here determining whether measures of odor intensity in a large sample can serve as one such measure. Online measures of how intense common household odors are perceived and symptoms of COVID-19 were collected from 2440 Swedes. Average odor intensity ratings were then compared to predicted COVID-19 population prevalence over time in the Swedish population and were found to closely track each other (r=-0.83). Moreover, we found that there was a large difference in rated intensity between individuals with and without COVID-19 symptoms and number of symptoms was related to odor intensity ratings. Finally, we found that individuals progressing from reporting no symptoms to subsequently reporting COVID-19 symptoms demonstrated a large drop in olfactory performance. These data suggest that measures of odor intensity, if obtained in a large and representative sample, can be used as an indicator of COVID-19 disease in the general population. Importantly, this simple measure could easily be implemented in countries without widespread access to COVID-19 testing or implemented as a fast early response before wide-spread testing can be facilitated.

The Loss of Smell and Taste in the COVID-19 Outbreak: a Tale of Many Countries.

PURPOSE OF REVIEW: Olfactory dysfunction in upper airway viral infections (common cold, acute rhinosinusitis) is common (> 60%). During the COVID-19 outbreak, frequency of sensory disorders (smell and/or taste) in affected patients has shown a high variability from 5 to 98%, depending on the methodology, country, and study. RECENT FINDINGS: A sudden, severe, isolated loss of smell and/or taste, in the absence of other upper airway inflammatory diseases (allergic rhinitis, chronic rhinosinusitis, nasal polyposis), should alert individuals and physicians on being potentially affected by COVID-19. The evaluation of smell/taste disorders with a visual analogue scale or an individual olfactory or gustatory test, at the hospital or by telemedicine, to prevent contamination might facilitate an early detection of infected patients and reduce the transmission of SARS-CoV-2. During the COVID-19 outbreak, patients with sudden loss of smell should initiate social distancing and home isolation measures and be tested for SARS-CoV-2 diagnostic test when available. Olfactory training is recommended when smell does not come back after 1 month but can be started earlier.

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.

Multimorbidities of Pediatric Allergic Rhinitis.

PURPOSE OF REVIEW: Most children and adolescents with allergic rhinitis (AR) present extra-nasal multimorbid conditions, including conjunctivitis, asthma, atopic dermatitis, rhinosinusitis, or seromucous otitis. Additionally, they may present nasal obstructive disorders, such as septal deformity, turbinate enlargement, and adenoidal hyperplasia, which worsen nasal symptoms, especially nasal obstruction. This is a narrative review on the current state of the concomitant presence of AR and one or more multimorbidities. RECENT FINDINGS: The presence of AR and one or more accompanying multimorbidities is associated to a higher severity and duration of the disease, a negative impact on quality of life, with worse control and lack of improvement with medical treatment. Therefore, AR needs to be managed with a multidisciplinary collaborative approach. Pediatric AR needs to be considered in the context of a systemic disease, which requires a coordinated therapeutic strategy.

Development of an International Odor Identification Test for Children: The Universal Sniff Test.

OBJECTIVE: To assess olfactory function in children and to create and validate an odor identification test to diagnose olfactory dysfunction in children, which we called the Universal Sniff (U-Sniff) test. STUDY DESIGN: This is a multicenter study involving 19 countries. The U-Sniff test was developed in 3 phases including 1760 children age 5-7 years. Phase 1: identification of potentially recognizable odors; phase 2: selection of odorants for the odor identification test; and phase 3: evaluation of the test and acquisition of normative data. Test-retest reliability was evaluated in a subgroup of children (n = 27), and the test was validated using children with congenital anosmia (n = 14). RESULTS: Twelve odors were familiar to children and, therefore, included in the U-Sniff test. Children scored a mean ± SD of 9.88 ± 1.80 points out of 12. Normative data was obtained and reported for each country. The U-Sniff test demonstrated a high test-retest reliability (r27 = 0.83, P < .001) and enabled discrimination between normosmia and children with congenital anosmia with a sensitivity of 100% and specificity of 86%. CONCLUSIONS: The U-Sniff is a valid and reliable method of testing olfaction in children and can be used internationally.

Narrow band imaging endoscopy improves visualization of vessels of the perforated tympanic membrane.

PURPOSE: Because successful healing of a tympanic membrane perforation (TMP) depends upon the maintenance of blood supply to the injured area, we assessed the usefulness of narrow band imaging (NBI) video endoscopy to evaluate its vascularization. To our knowledge, the use of NBI to assess tympanic membrane (TM) vascular patterns has never been attempted. METHODS: Prospective observational study. NBI and cold white light (CWL) flexible videoendoscopy was used to explore perforated TMs of 100 patients. Main outcome measures were visualization of vessels among abnormal TM findings: monomeric areas (MA) (n = 6), myringosclerosis plaques (MP) (n = 65) and perforation edges (n = 100). They were graded by a vascular otoendoscopic score (VOS) comparing both types of lights (Wilcoxon test). Location and vascularization patterns were analyzed (Fisher's test). RESULTS: NBI was better to observe vascularization of 32% of perforation edges and 75.4% of MP (p < 0.001). NBI displayed higher (better) VOS when evaluating TMP edges (1.05 vs. 0.73) and MP (1.56 vs. 0.81, p < 0.001). The majority of TMP edges showed a ring pattern (66%), followed by irregular (19%), avascular (12%) and radial patterns (3%). The avascular pattern was more frequent in posterior perforations (p = 0.003). The radial pattern was most frequently found in MP, especially at posterior quadrants (p = 0.048). MA presented an irregular pattern in 83.3% of TMs. CONCLUSIONS: NBI videoendoscopy is a promising non-invasive technique, superior to CWL for visualizing vessels among TMP edges and MP, based on further study, could become a supplementary diagnostic tool in the workup of TMP and the decision-making surgical field.

Nasal obstructive disorders induce medical treatment failure in paediatric persistent allergic rhinitis (The NODPAR Study).

BACKGROUND: Allergic rhinitis (AR) is the most common chronic disease among children. To characterize the disease, a modified classification of severity (m-ARIA) has recently been validated in AR children. When medical treatment fails, surgery for nasal obstructive disorders (NOD) may be a therapeutic option. Our objective was to assess the prevalence of NOD and their influence in medical treatment response among children with persistent AR (PER). METHODS: In a prospective, real-life study, 130 paediatric PER patients (13.1 ± 2.8 years, females 31.5%, severe rhinitis 49%) referred from Allergy to ENT department were assessed for their response (R, responders; NR, non-responders) to medical treatment (intranasal steroids and antihistamines or antileukotrienes) by direct questioning and nasal symptom visual analogue scale, the presence of NOD (septal deformity, turbinate enlargement and adenoidal hyperplasia), comorbidities, nasal symptoms, rhinitis severity (modified ARIA criterion) and asthma control (International Consensus On Pediatric Asthma criterion). RESULTS: After 2 months of treatment, the NR group presented a higher prevalence of obstructive septal deformity and severe inferior turbinate enlargement when compared with the R group. Higher septal deformity and turbinate enlargement scores were strongly associated with treatment refractoriness. The prevalence of severe PER was also higher for the NR group. Higher asthma control scores were associated with the probability of treatment-induced improvement. CONCLUSIONS: In paediatric PER patients, medical therapy refractoriness was associated with NOD, mainly septal deformity and turbinate enlargement. In those patients, ENT examination will facilitate an early NOD diagnosis in order to indicate potential corrective surgery.

Nasal obstructive disorders impair health-related quality of life in adolescents with persistent allergic rhinitis: A real-life study.

BACKGROUND: We previously reported a higher prevalence of nasal obstructive disorders (NOD) in pediatric patients with persistent allergic rhinitis (PER) not responding to medical treatment. The aim of this study was to determine the impact of NOD on quality of life (QoL) in this population. METHODS: Real-life prospective study including 142 patients (41 children, 6-11 years old and 101 adolescents, 12-17 years old) with moderate and severe PER. After 2 months of medical treatment (intranasal steroids and antihistamines), patients were asked whether their symptoms had improved (yes/no) and classified accordingly in R, responders and NR, non-responders. Nasal symptoms (visual analog scale, VAS), NOD (nasal endoscopy), and QoL (PRQLQ, AdolQRLQ) were also assessed. RESULTS: Sixty-nine adolescents and 24 children were included in the NR group. NR presented worse QoL overall scores in adolescents (3.16±1.1 vs 1.63±0.99; P=.00001) and children (2.19±0.82 vs 1.51±0.77, P=.02). Medical treatment failure was associated with worse outcomes in QoL (adolescents OR: 1.6, P<.0001; children OR: 1.04, P=.036). Female adolescents presented worse QoL scores than males (3.19 vs 2.36, P=.001). The presence of obstructive septal deviation (OR: 1.02, P=.005), obstructive turbinate hyperplasia (OR: 1.03, P=.0006), and coexistence of both (OR=2.06, P=.001) was associated with worse QoL in adolescents. A strong and highly significant correlation was found between nasal symptoms VAS and QoL. CONCLUSION: The presence of NOD, particularly in adolescents, is associated with poor QoL outcomes. Assessment of NOD in pediatric PER should be considered an essential approach to determine the response to treatment and its impact on patient's QoL.

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.

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.

Turbinate surgery in pediatric patients: A worldwide survey.

OBJECTIVE: Impaired nasal breathing is a common condition among pediatric patients, being rhinitis the most common cause. In recent years, turbinate surgery, mainly turbinate radiofrequency ablation (TRA), has increased in popularity amongst pediatric otolaryngologists and rhinologists as a safe and useful technique to address turbinate hypertrophy in pediatric patients. The present paper is designed with the aim of assessing the current worldwide clinical practice regarding turbinate surgery in pediatric patients. METHODS: The questionnaire was developed based on previous researches, by a group of 12 experts from the rhinology and pediatric otolaryngology research group belonging to the Young Otolaryngologists of the International Federation of Otorhinolaryngological societies (YO-IFOS). The survey was then translated to 7 languages and sent to 25 scientific otolaryngologic societies around the globe. RESULTS: 15 scientific societies agreed to distribute the survey to their members. There were 678 responses from 51 countries. From them, 65% reported to usually perform turbinate surgery in pediatric patients. There was a statistically significant increased likelihood of performing turbinate surgery for those practicing rhinology, sleep medicine, and/or pediatric otolaryngology compared to other subspecialties. The main indication to perform turbinate surgery was nasal obstruction (93.20%); followed by sleep disordered breathing (53.28%), chronic rhinosinusitis (28.70%) and facial growth alterations (22.30%). CONCLUSIONS: There is no general consensus on the indications and ideal technique for turbinate reduction in children. This dissension arises mainly from the lack of scientific evidence. The points with highest agreement (>75%) between respondents is the use of nasal steroids prior to surgery; reintroducing nasal steroids in allergic patients; and performing turbinate surgery as day-case surgery.

Endoscopic endonasal approach to pituitary adenomas: Impact on adenohypophyseal function. Study of 231 cases.

PURPOSE: To identify presurgical and surgical factors associated with the development of hypopituitarism and its recovery after endoscopic endonasal transsphenoidal (EET) resection of pituitary adenomas (PAs). METHODS: Retrospective study of patients with PAs operated by the same neurosurgeon through an EET approach in two Spanish tertiary hospitals in ten years. RESULTS: 242 pituitary surgeries performed in 231 patients were analyzed. In the 154 surgeries performed in 146 patients with non-functioning PAs (NFPAs), 46.8% (n=72) presented presurgical hypopituitarism. After PAs resection, 41 of these (56.9%) normalized pituitary function and 11 of 82 patients with preoperative normal function (13.4%) developed new pituitary deficits. Patients with preoperative visual impairment (OR=3.9, p=0.046) and operated in the first four years of the neurosurgeon's learning curve (OR=5.7, p=0.016) presented a higher risk of developing postoperative hypopituitarism. Of the 88 surgeries in 85 patients with functioning PAs (FPAs), 23.9% presented presurgical hypopituitarism, and 47.6% of those recovered after surgery. 9% of the cases with preoperative normal function developed new pituitary deficit/s. Diabetic patients presented a higher risk of persistence of hypopituitarism (OR=10.5, p=0.024). Patients with presurgical visual impairment (OR=30.0, p=0.010) and PAs>3cm (OR=14.0, p=0.027) had higher risk of developing new pituitary deficits. CONCLUSION: Approximately 50% of patients with PAs and preoperative hypopituitarism recover pituitary function after EET surgery. 10% of patients with normal function develop new deficits. Patients with NFPAs with visual involvement and operated in the first four years of neurosurgeon's learning curve, and FPAs patients with presurgical visual impairment and tumor size>3cm have a higher risk of postoperative hypopituitarism.

An olfactory self-test effectively screens for COVID-19.

Background: Key to curtailing the COVID-19 pandemic are wide-scale screening strategies. An ideal screen is one that would not rely on transporting, distributing, and collecting physical specimens. Given the olfactory impairment associated with COVID-19, we developed a perceptual measure of olfaction that relies on smelling household odorants and rating them online. Methods: Each participant was instructed to select 5 household items, and rate their perceived odor pleasantness and intensity using an online visual analogue scale. We used this data to assign an olfactory perceptual fingerprint, a value that reflects the perceived difference between odorants. We tested the performance of this real-time tool in a total of 13,484 participants (462 COVID-19 positive) from 134 countries who provided 178,820 perceptual ratings of 60 different household odorants. Results: We observe that olfactory ratings are indicative of COVID-19 status in a country, significantly correlating with national infection rates over time. More importantly, we observe indicative power at the individual level (79% sensitivity and 87% specificity). Critically, this olfactory screen remains effective in participants with COVID-19 but without symptoms, and in participants with symptoms but without COVID-19. Conclusions: The current odorant-based olfactory screen adds a component to online symptom-checkers, to potentially provide an added first line of defense that can help fight disease progression at the population level. The data derived from this tool may allow better understanding of the link between COVID-19 and olfaction.

Usefulness of endonasal flaps and grafts in skull base surgery. Consensus document.

INTRODUCTION: Skull base reconstruction is one of the greatest challenges extended endonasal endoscopic surgery. Many grafts and flaps from the endonasal fossa have been demonstrated to be useful in the control of complications such a cerebrospinal fluid leaks. Review and analysis of these resources are necessary in skull base recontruction to improve outcomes. OBJECTIVES: The target is to create a consensus document on the use of different endonasal flaps and grafts in the skull base surgery. MATERIAL AND METHODS: Literature review of the most relevant free grafts and vascularized flaps from the endonasal fossa. Analysis using the Delphi method on the use of the different endonasal resources for endoscopic repair of skull base defects. RESULTS: We obtained two results: 1) A selection of the most representative flaps and grafts from the endonasal fossa, describing origin, surface and indications, based on a literature review. 2) A consensus document, using Delphi methodology, with general considerations (2), recommendations (10) and limitations (6) of the different endonasal flaps and grafts. CONCLUSIONS: We present the first consensus document in the field of extended endonasal endoscopic surgery using the Delphi method as a working tool. We highlight the usefulness of the nasoseptal flap together with other endonasal flaps and grafts for skull base reconstruction.

Radiofrequency ablation turbinoplasty improves the sense of smell in pediatric patients: A prospective study.

INTRODUCTION: The olfactory sense is of paramount importance for the adequate development of a child. Olfactory loss in children might have different origins. One of the most common is conductive, when nasal obstruction prevents odorants from reaching the olfactory epithelium. Rhinitis and turbinate enlargement have been proven to diminish the sense of smell in pediatric patients. A common treatment for resistant rhinitis in these patients is turbinate radiofrequency ablation (TRA). However, despite an increasing research effort in this field, there are no studies instrumentally assessing olfaction in children undergoing turbinate surgery to date. This study was designed with the aim of assessing changes in olfaction through validated instrumental tools in pediatric patients undergoing TRA for the first time. METHODS: A prospective uncontrolled intervention clinical trial design was conducted. Two cohorts of children ranging 4-15 years old were consecutively selected from a third level referral Hospital and subjected to the universal sniff test (U-Sniff), alcohol sniff test (AST), and sniffin sticks threshold test (SST) before and 1, 3 and 6 months after surgery. Cohort A consisted of children solely undergoing TRA. Cohort B consisted of children on whom adenoidectomy and TRA had been performed. Additionally, a cohort of Spanish healthy controls, paired by sex and age, were asked to perform the U-Sniff. RESULTS: A total of 81 participants with a mean age of 10.31 ± 2.56 years were included. Fifty-three patients underwent TRA exclusively and 28 were subjected to associated adenoidectomy. Despite a tendency toward improvement in the U-sniff scores, there were no statistically significant differences after surgery. However, statistically significant differences were obtained for threshold tasks measured with SST and AST, revealing differences at 1, 3 and 6 months after surgery compared to preoperative scores. CONCLUSIONS: In summary, this research demonstrated adequate levels in the sense of smell regarding identification tasks, but decreased olfactory threshold scores in pediatric patients suffering from TE. TRA, alone or with adenoidectomy, improved smell threshold scores, but had no significant effect on identification tasks.

Usefulness of endonasal flaps and grafts in skull base surgery. Consensus document. / Utilidad de los colgajos e injertos endonasales en cirugía endoscópica nasosinusal y de base de cráneo. Documento de consenso.

INTRODUCTION: Skull base reconstruction is one of the greatest challenges extended endonasal endoscopic surgery. Many grafts and flaps from the endonasal fossa have been demonstrated to be useful in the control of complications such a cerebrospinal fluid leaks. Review and analysis of these resources are necessary in skull base recontruction to improve outcomes. OBJECTIVES: The target is to create a consensus document on the use of different endonasal flaps and grafts in the skull base surgery. MATERIAL AND METHODS: Literature review of the most relevant free grafts and vascularized flaps from the endonasal fossa. Analysis using the Delphi method on the use of the different endonasal resources for endoscopic repair of skull base defects. RESULTS: We obtained two results: 1) A selection of the most representative flaps and grafts from the endonasal fossa, describing origin, surface and indications, based on a literature review. 2) A consensus document, using Delphi methodology, with general considerations (2), recommendations (10) and limitations (6) of the different endonasal flaps and grafts. CONCLUSIONS: We present the first consensus document in the field of extended endonasal endoscopic surgery using the Delphi method as a working tool. We highlight the usefulness of the nasoseptal flap together with other endonasal flaps and grafts for skull base reconstruction.