Radiographic evaluation of nasal septal deviation from computed tomography correlates poorly with physical exam findings.

BACKGROUND: Performance of septoplasty is dependent on objective evidence of nasal septal deviation. Although physical examination including anterior rhinoscopy and endoscopic examination is the gold standard for evaluation of septal deviation, third-party payors' reviews of septoplasty claims are often made on computed tomography (CT) findings. However, the correlation between radiographic evaluation of septal deviation with physical examination findings is unknown. METHODS: Retrospective, blinded, independent evaluation of septal deviation in 39 consecutive patients from physical examination, including anterior rhinoscopy and endoscopic examination, by an otolaryngologist and radiographic evaluation of sinus CT scan by a neuroradiologist. Four distinct septal locations (nasal valve, cartilaginous, inferior/maxillary crest and osseous septum) were evaluated on a 4-point scale representing (1) 0% to 25%, (2) >25% to 50%, (3) >50% to 75%, and (4) >75% obstruction. Correlation between physical examination and radiographic evaluations was made by Pearson's correlation and quantitative agreement assessed by Krippendorf's alpha. RESULTS: Statistically significant correlation was detected between physical examination including nasal endoscopy and radiographic assessment of septal deviation only at the osseous septum (p = 0.007, r = 0.425) with low quantitative agreement (α = 0.290). No significant correlation was detected at the cartilaginous septum (p = 0.286, r = 0.175), inferior septum (p = 0.117, r = 0.255), or nasal valve (p = 0.174, r = 0.222). Quantitative agreement at the nasal valve suggested a bias in CT to underestimate physical exam findings (α = -0.490). CONCLUSION: CT is a poor substitute for physical examination, the gold standard, in assessment of septal deviation. Clinical decisions about pursuit of septoplasty or third-party payors' decisions to approve septoplasty should not be made on radiographic evidence.

Preapproval of sinus computed tomography for otolaryngologic evaluation of chronic rhinosinusitis does not save health care costs.

OBJECTIVES/HYPOTHESIS: To evaluate the cost-effectiveness of preapproval requirements for computed tomography (CT) of the sinuses in the evaluation and management of chronic rhinosinusitis (CRS). STUDY DESIGN: Retrospective analysis of prospectively collected data. METHODS: Over a 6-month period, all sinus CT scans ordered by an otolaryngology practice and requiring preapproval by a third-party payor were tabulated. Characteristics of the preapproval process that were recorded and analyzed included time spent by office administrative staff, need for peer-to-peer review, and time spent by the ordering physician. RESULTS: All 111 sinus CT scans ordered during the 6-month time period required preapproval based on insurer requirements-38 performed by computer, 71 by telephone, and two required both-costing an average of 8.1 minutes per scan by administrative staff (range, 2.0-20.0 minutes). Thirteen preapprovals required peer-to-peer telephone interaction by the ordering physician, utilizing an average of 7.7 minutes (range, 5-12 minutes). In no case was the insurance company peer an otolaryngologist. Ultimately, no sinus CT scan request was rejected by a third-party payor. CONCLUSIONS: Preapprovals for sinus CTs ordered by otolaryngologists are unlikely to save costs for third-party payors, as sinus CT for the evaluation of CRS is well established and therefore unlikely to be rejected. Preapproval in this context comes at the expense of practice administrative and physicians' time. Based on our results, preapproval for sinus CT scans ordered by an otolaryngologist for evaluation of CRS appears to be an unnecessary and costly requirement. LEVEL OF EVIDENCE: N/A.

Clinical assessment is an accurate predictor of which patients will need septoplasty.

OBJECTIVES/HYPOTHESIS: Septoplasty is a frequently performed surgical procedure with the most common indication being nasal airway obstruction. Almost universally, health insurance companies mandate a trial of medical therapy consisting of intranasal corticosteroids prior to performance of septoplasty regardless of clinical assessment. Evidence for this requirement is lacking. We sought to evaluate the initial clinical assessment as a predictor of response to this mandated trial of medical treatment. STUDY DESIGN: Retrospective review of prospectively collected data on 137 consecutive patients who presented with symptoms of nasal obstruction and a deviated nasal septum on physical examination. METHODS: Patients were placed into one of three cohorts based on prediction of 1) failure of medical therapy with subsequent septoplasty, 2) success of medical therapy without subsequent septoplasty, or 3) unable to make a prediction. Patients from each cohort were assessed for subsequent response to medical therapy and ultimate need for septoplasty. RESULTS: Overall clinical assessment had a sensitivity of 86.9%, specificity of 91.8%, positive predictive value of 93.6%, and negative predictive value of 96.4% for detecting/predicting need for septoplasty. The accuracy of the overall clinical assessment is considerably better than severe deviation at any one septal anatomical site. Of patients whose response to medical therapy could not be predicted, 61.3% failed medical therapy and needed surgery; this is statistically equivalent to a 50/50 distribution between either needing septoplasty or not. CONCLUSIONS: Clinical assessment at initial presentation of patients with nasal obstruction and deviated septum is highly accurate in predicting which patients will need septoplasty.

Bolsterless management for recurrent auricular hematomata.

OBJECTIVES/HYPOTHESIS: The objectives were to describe our experience with a bolsterless technique for the management of auricular hematomata and discuss the management options for auricular hematomata and the comparative benefits of the bolsterless technique. STUDY DESIGN: Retrospective case series. METHODS: Patients presented with recurrent auricular hematomata following traditional treatment with incision and drainage and bolster placement. Revision incision and drainage were performed, and then auricular skin was stabilized using through-and-through absorbable horizontal mattress sutures. Patients were seen in follow-up to evaluate for recurrence and assess cosmetic results. RESULTS: Twenty-eight patients were treated for recurrent auricular hematomata using the bolsterless technique. There were no recurrences in follow-up, and cosmetic results were judged to be excellent by both patient and surgeon. CONCLUSIONS: Bolsterless management for auricular hematomata using absorbable mattress sutures has been described intermittently in the otolaryngology literature since 1991 but is not widely utilized. In this series, patients presenting with recurrent auricular hematomata following failure of traditional bolster management were effectively managed with the bolsterless technique. This technique is well tolerated by patients and allows for early return to athletic activity.

Lateral dermoid cyst of the floor of mouth: unusual radiologic and pathologic findings.

A lateral dermoid cyst is a rare lesion of the floor of mouth, with only 12 cases reported in the literature. We describe the case of a 60-year-old man with a slowly enlarging mass in the submandibular region. Magnetic resonance imaging demonstrated a lesion containing multiple uniformly rounded foci, creating a "sack-of-marbles" appearance. Needle aspirations showed atypical findings, and the mass was excised. Histopathology revealed a cyst containing a keratinizing stratified squamous epithelial lining with apocrine and eccrine glands. These findings were diagnostic of a dermoid cyst, which should be considered in the differential diagnosis of any midline or lateral cervical lesion.

Reformation of concha bullosa following treatment by crushing surgical technique: implication for balloon sinuplasty.

OBJECTIVES/HYPOTHESIS: There are various surgical techniques designed to treat conchae bullosae (CB). These include partial or total resection and crushing. Frontal sinus balloon sinuplasty is thought to work by the crushing/remodeling of the agger nasi and frontal recess air cells. The long-term outcome of sinuplasty in the frontal/ethmoid air cell region is unknown. To date, no study has been done on the reformation of CB after crushing. We report on the long-term outcome of a series of patients who underwent crushing of their CB and suggest implications for frontal sinus balloon sinuplasty. STUDY DESIGN: Retrospective case series. METHODS: Retrospective review of 10 patients who re-presented with CB as a component of their nasal obstructive symptoms despite previously undergoing crushing of their CB. Data analyzed included paranasal sinus computed tomography (CT) scans and operative reports. RESULTS: These 10 patients re-presented with recurrent rhinosinusitis and nasal obstructive symptoms. The patients had previously undergone septoplasty surgery with crushing of the CB and were noted to have reformed the CB on their most recent sinus CT. The previous surgeries were preformed from 2 to 15 years prior to their representation. CONCLUSIONS: CB can reform following crushing technique. One may extrapolate that agger nasi and frontal recess air cells may reform following balloon sinuplasty leading to recurrent obstruction of the frontal sinus outflow tract.

Efficacy of montelukast in the treatment of nasal polyposis.

OBJECTIVES: Twenty-four consecutive patients with symptomatic nasal polyposis and nonallergic or perennial rhinitis who were undergoing chronic nasal steroid therapy were prospectively evaluated for response to adjunctive oral montelukast sodium therapy. METHODS: The patients were undergoing daily intranasal steroid sprays for a minimum of 6 months before being started on montelukast sodium 10 mg by mouth per day for 3 months while intranasal steroids were continued. The patients were given a validated symptom score survey at the start and end of therapy, with a lower score indicating fewer symptoms. The nasal polyps were submitted to biopsy before and after treatment to determine their degree of eosinophilia. Eosinophilia was graded in a blinded fashion by an independent pathologist on a scale of 0 to 3, with 3 being severe. Patients with seasonal allergies were excluded, and the studied patients were treated during the winter season to avoid confounding by potential seasonal allergic responses. RESULTS: The patients tended to improve on montelukast therapy in terms of their symptom scores and polyp eosinophil counts. The symptoms improved in 17 patients (71%) and remained the same or worsened in 7 patients (29%). The symptom score for the group improved from a pretreatment value of 33.4 (SD, 7.73) to a posttreatment value of 23.3 (SD, 13.73; p < .001). In addition, the eosinophilia score improved from 2.3 (SD, 0.68) to 1.5 (SD, 0.82; p < .01). The improvement was most noticeable in the patients with perennial allergies. CONCLUSIONS: These results suggest that montelukast appears to be beneficial for some patients with nasal polyposis. Patients with perennial allergies and nasal polyposis seem more likely to respond to the treatment than those with nonallergic nasal polyposis.

Isolated chronic maxillary sinusitis of non-dental origin does not correlate per se with ipsilateral intranasal structural abnormalities.

A case series of 35 patients with isolated chronic maxillary sinusitis of inflammatory non-dental origin was retrospectively reviewed to determine the correlation of ipsilateral intranasal structural abnormalities. The records were examined for computed tomographic, nasal endoscopic, and intraoperative findings. The incidence of ipsilateral and contralateral intranasal structural abnormalities at the ostiomeatal complex region, including conchae bullosae, Haller cells, paradoxical middle turbinates, and septal deviations, was determined. Nineteen of 35 patients (54%) had ipsilateral abnormalities and 16 (46%) did not. Of the 19 patients with ipsilateral abnormalities, 4 had Haller cells, 4 had conchae bullosae, 2 had paradoxical middle turbinates, and 12 had septal deviations. (Two patients had multiple ipsilateral factors.) Of the 16 patients with contralateral abnormalities, 4 had Haller cells, 3 had conchae bullosae, 2 had paradoxical middle turbinates, and 9 had septal deviations. Ten patients had only contralateral abnormalities, and 6 had no identifiable anatomic abnormality. The difference between the incidences of ipsilateral and contralateral abnormalities in this series of 35 patients with isolated chronic maxillary sinusitis was not statistically significant when the factors were analyzed as a group or by individual factor (range in odds ratios for the various factors, 1 to 1.54; range in p values for the various factors, .25 to 1). Thus, the data show that ipsilateral structural abnormalities at the ostiomeatal complex region, including conchae bullosae, Haller cells, paradoxical middle turbinates, and septal deviations, did not correlate per se with isolated chronic maxillary sinusitis that was not attributable to dental disease.

Same-day discharge for selected patients undergoing combined nasal and palatal surgery for obstructive sleep apnea.

To determine the safety of same-day discharge for patients who undergo combined nasal and palatal surgery for obstructive sleep apnea syndrome, we undertook a retrospective review and analysis of 2 groups of patients (total, 86 patients) who underwent such surgery. The patients with obstructive sleep apnea syndrome who underwent combined nasal and palatal surgery were considered for same-day discharge if they fulfilled the following postoperative criteria: sustained O2 saturation of 94% or greater on room air while asleep, no history of cardiopulmonary disease or diabetes mellitus, adequate oral analgesia and oral intake, hemostasis, and normal vital signs. Twenty-three patients met these criteria and were assigned to group 1. The remaining 63 patients were admitted overnight for monitoring and were assigned to group 2. The data collected included patient demographics, respiratory disturbance index, lowest O2 saturation, body mass index, and postoperative complications. The mean age, respiratory disturbance index, lowest O2 saturation, and body mass index for group 1 were 45.9 years, 36 events per hour, 84.9%, and 28.7 kg/m2, respectively. For group 2, the results were 48 years, 36.5 events per hour, 82%, and 32.5 kg/m2. There were no postoperative complications in group 1, and 3 in group 2. There were no incidents of airway compromise or cardiopulmonary events in the immediate postoperative period in either group. There were no readmissions for either group. We conclude that same-day discharge for patients who have undergone combined nasal and palatal surgery for obstructive sleep apnea syndrome is relatively safe in selected cases in which significant comorbid diseases are not present. These selected cases would have constituted a minority of the patients studied.

Treatment of isolated sphenoid sinus inflammatory disease by endoscopic sphenoidotomy without ethmoidectomy.

OBJECTIVES/HYPOTHESIS: Isolated chronic sphenoid sinusitis is a rare entity. The study was conducted to determine the efficacy of endoscopic sinus surgery with partial middle turbinectomy and without ethmoidectomy in treating isolated sphenoid opacification from inflammatory and infectious disease. STUDY DESIGN: Case series of 20 patients generated by retrospective review of 307 consecutive patients who underwent surgical treatment for chronic rhinosinusitis. METHODS: The medical records were reviewed for pertinent demographic, symptom, radiographic, and endoscopic data preoperatively, interoperatively, and postoperatively. All patients in the series underwent computed tomographic image-guided endoscopic sphenoid sinus surgery with partial middle turbinectomy. RESULTS: The study population consisted of 12 male and 8 female patients between 28 and 75 years of age. Headache (15 patients) and/or postnasal drip (14 patients) were the presenting symptoms in 17 of the patients. Three patients were asymptomatic. Surgical findings included inspissated secretions (15 patients), fungal debris (2 patients), and mucopyoceles (3 patients). The 17 patients with preoperative symptoms were symptom free by 12 weeks postoperatively and have remained so with follow-up ranging from 12 months to 3.25 years (mean follow-up, 23.1 mo). There were no operative complications in the series. CONCLUSIONS: Endoscopic sphenoid sinus surgery without ethmoidectomy is effective for treating isolated sphenoid sinus opacification associated with inflammatory or infectious sinus disease. Partial middle turbinectomy at the time of surgery facilitates the approach, as well as postoperative cleaning and surveillance.