A contemporary review of "realistic" success rates after surgical closure of nasal septal perforations.

OBJECTIVE: The surgical closure of septal perforations is a challenging procedure. Various techniques exist. Each perforation proves that there is not the one precise procedure for all perforations. Nevertheless, success rates of about 90% are reported, although the procedure for closing the defect is challenging. Our goal was to evaluate the existing data. METHODS: We performed a contemporary review of published closure rates of septal perforations on order to compare the present results in the literature. The limitations of the respective studies were analyzed. RESULTS: We found closure rates from 30 to 100%. Numerous procedures were described and combined. Prospective studies comparing different techniques are missing. The follow-up time in studies was quite short or not even specified. Studies on long-term success rates are rare. CONCLUSION: The closure of septal defects is one of the most challenging rhinosurgical interventions. Closure rates ≥90% as described in literature seem relatively high. One reason might be short follow-ups and retrospective study designs. Frequently, precise information on the follow-up and the method of follow up is missing. Thoroughly designed prospective studies are absent. Longer follow-up times are associated with lower complete closure rates. A long-term success rate between 70 and 80% seems realistic.

Symptom Control of Patients With Chronic Rhinosinusitis With Nasal Polyps Under Maintenance Therapy With Daily Acetylsalicylic Acid.

INTRODUCTION: Nonsteroidal anti-inflammatory drugs (NSAID)-exacerbated respiratory disease (NERD) is defined by intolerance to cyclooxygenase 1 inhibitors, chronic rhinosinusitis with recurrent nasal polyps, and/or intrinsic bronchial asthma. Long-term administration of acetylsalicylic acid (ASA) after desensitization has been used to mitigate these sequelae, but the optimal dose and balancing symptom relief and side effects remain unsettled. METHODS: Retrospective data analysis of 85 patients with NERD receiving maintenance therapy of 300 mg ASA was followed by questionnaires (our own, not validated and the Sino-Nasal Outcome Test-20). We received responses from 55 patients and examined 30 of them clinically. RESULTS: Patients with no ASA-associated side effects were 56.4% (56 of 85 patients) of the cohort. In this study, 60% (33 of 55 patients) continued prophylaxis of 300 mg ASA daily for an average of 34.7 months. Elective surgery was the most frequent cause of discontinuation of ASA (21.8%; 12 of 55 patients). Rhinomanometry values were significantly improved with ASA (P < .05; Wilcoxon), but there was no significant reduction in nasal polyposis or improvement in olfaction at the time of follow-up examination. CONCLUSIONS: Minor clinical improvements were identified. Side effects were well tolerated by most patients, and no serious sequelae occurred. The indications for long-term ASA therapy in NERD patients remain unsettled.

Adenoid cystic carcinoma of the head and neck area: Oncologic treatment and plastic-reconstructive options.

Adenoid cystic carcinoma of the head and neck area is a rare malignant tumor with acceptable short-term but mediocre long-term prognosis. Radical tumor excision with clear resection margins, and sometimes resection of the facial nerve due to perineural growth, remains the fundamental therapy. We present 3 distinct clinical cases and discuss the current therapeutic options with special focus on plastic-reconstructive techniques. For reconstruction, the full armament of local and free flaps, as well as prosthetics, may be necessary. Adjuvant radiotherapy increases local control in advanced stages or close resection margins. However, systemic treatment options are limited. Further multicenter clinical trials are necessary due to the rare occurrence of the tumor.

Recent advances in robot-assisted head and neck surgery.

OBJECTIVE: This article reviews current clinical applications and experimental developments for robotic surgery in the head and neck with special focus on financial challenges, current clinical trials, and the controversial aspect of haptic and tactile feedback. DATA SOURCES: Literature was screened using the pubmed library. Information on clinical trials was excerpted from the National Institute of Health database. Additional data on experimental developments were gathered by personal communication. RESULTS: A steep increase in clinical applications for robotic surgery in the head and neck is determined as possible indications extend. Clinical trials are mostly non-randomized. A wide range of new robotic systems are expected to come into clinical use in the near future. CONCLUSION: As head and neck surgeons become more familiar with robotic surgery some patients evidently benefit from new technologies. Increased competition between the systems will certainly drive technological improvement and decrease the financial burden. Copyright © 2016 John Wiley & Sons, Ltd.

Three different turbinoplasty techniques combined with septoplasty: Prospective randomized trial.

OBJECTIVES/HYPOTHESIS: Septal deviation and hypertrophic inferior turbinates are a frequent cause of nasal breathing disorders. The goal of this study was to prove the effectiveness and safety of three current turbinoplasty techniques. STUDY DESIGN: This is a prospective, three-arm, single-blinded, single-center, randomized controlled trial. METHODS: Sixty patients were randomly assigned to either anterior turbinoplasty (ATP) (n = 20), radiofrequency ablation (RFA) (n = 19; Celon Pro Breath), or novel submucous radial diode laser ablation (DLA) (n = 21; ELVeS Radial PainLess, wavelength = 1,470 nm), each in combination with standard septoplasty. Acoustic rhinometry, rhinomanometry, subjective nose questionnaire, and saccharin test served as outcome parameters for preoperative and 3-month, 1-year, and 2-year postoperative examinations. RESULTS: After 3 months 47/60 patients were evaluated, 28/60 patients were evaluated after 1 year, and 26/60 patients were evaluated in the 2-year follow-up visit. An improvement of nasal breathing was observed in all three groups in all follow-up visits. The increase of endonasal volume 2 (volume between the nasal valve and body of the inferior turbinate) was statistically significant in the ATP and RFA group after 3 months and 2 years, and in the RFA group also after 1 year. The DLA group failed to reach significance level in all follow-up visits. Subjective evaluation of nasal breathing improved in all three groups. CONCLUSIONS: In this trial, three different current techniques of turbinate surgery in combination with standard septoplasty were effective for the improvement of nasal breathing. The ATP and RFA techniques were more effective in the long term than DLA. LEVEL OF EVIDENCE: 1b. Laryngoscope, 2016 127:303-308, 2017.

Hybrid procedure for total laryngectomy with a flexible robot-assisted surgical system.

INTRODUCTION: Total laryngectomy is a standard procedure in head-and-neck surgery for the treatment of cancer patients. Recent clinical experiences have indicated a clinical benefit for patients undergoing transoral robot-assisted total laryngectomy (TORS-TL) with commercially available systems. Here, a new hybrid procedure for total laryngectomy is presented. METHODS: TORS-TL was performed in human cadavers (n = 3) using a transoral-transcervical hybrid procedure. The transoral approach was performed with a robotic flexible robot-assisted surgical system (Flex®) and compatible flexible instruments. Transoral access and visualization of anatomical landmarks were studied in detail. RESULTS: Total laryngectomy is feasible with a combined transoral-transcervical approach using the flexible robot-assisted surgical system. Transoral visualization of all anatomical structures is sufficient. The flexible design of the robot is advantageous for transoral surgery of the laryngeal structures. CONCLUSION: Transoral robot assisted surgery has the potential to reduce morbidity, hospital time and fistula rates in a selected group of patients. Initial clinical studies and further development of supplemental tools are in progress. Copyright © 2016 John Wiley & Sons, Ltd.

Demonstration of nasopharyngeal surgery with a single port operator-controlled flexible endoscope system.

BACKGROUND: Nasopharyngeal surgery is commonly performed with a rigid endoscope using a transnasal or transoral approach. Here, we demonstrate a flexible single port computer-assisted endoscopic system enabling easy transoral access to the nasopharynx. METHODS: Transoral nasopharyngeal surgery was performed in human cadavers (n = 8) using the Flex System (Medrobotics, Raynham, MA). Learning curves were evaluated based on the time necessary for reaching the Eustachian tube. Mock surgical procedures were performed with compatible flexible instruments. RESULTS: Nasopharyngeal surgery is feasible with the Flex System with a nontraumatic approach. The inbuilt HD digital camera enables high-quality visualization of the nasopharynx. The design of the flexible compatible tools adequately meets the requirements for surgical procedures in the nasopharynx. CONCLUSION: The single port operator-controlled flexible endoscope system is a feasible way to approach the nasopharynx for surgical manipulation. Further clinical studies as well as development of supplemental tools are in progress.

Potential Advantages of a Single-Port, Operator-Controlled Flexible Endoscope System for Transoral Surgery of the Larynx.

INTRODUCTION: Transoral surgery of the larynx is commonly performed with a rigid laryngoscope, a microscope, and a laser. We investigated the potential utility of a flexible, single-port, robot-assisted and physician-controlled endoscopic system to enable easy, transoral surgical access to the larynx. METHODS: Transoral laryngeal surgery was performed in human cadavers (n = 4) using the Flex System and compatible flexible instruments. Anatomical landmarks were identified, and mock surgical procedures were performed. RESULTS: Standard laryngeal surgical procedures were completed successfully in a human cadaver model. The built-in HD digital camera enabled high-quality visualization of the larynx. Epiglottectomy, as well as posterior cordectomy, were performed by laser and radio-frequency resection. The flexible design of the compatible tools enabled a nontraumatic approach. CONCLUSION: The Flex System has the potential to improve surgical access to the larynx, especially in patients with challenging anatomy. The associated flexible instruments enabled completion of surgical procedures in the larynx in a human cadaveric model. Further clinical studies, as well as the development of supplemental technology and tools, are recommended for future clinical applications.

First use of a computer-assisted operator-controlled flexible endoscope for transoral surgery.

Transoral robotic surgery (TORS) has become an accepted treatment option for head and neck cancer. However, anatomical limitations and a relevant financial burden require alternative developments in this field. To this end, a patient presenting with a T2 squamous cell carcinoma of the lower lateral oropharyngeal wall was effectively treated with a new Conformité Européene-certified, computer-assisted, operator-controlled flexible endoscope (Flex). Intraoperative visualization and tissue handling were acceptable and safe. Transoral surgery with the flexible endoscope was safely conducted in a clinical setting. The introduction of alternative TORS systems will increase competition, drive scientific improvement, and reduce financial expenses.

The auricle's cavum conchae composite graft in nasal reconstruction.

BACKGROUND: Autologous transplants consisting of skin and cartilage, so-called composite grafts (CGs), are useful in nasal reconstruction of multilayered defects. A CG from the auricle's cavum conchae serves both functional and esthetic demands. This article outlines the indications and the requirements of the CG, making special considerations to improve wound healing, and discusses our results in consideration with recent publications. METHODS: A retrospective case-control study assessing the functional and esthetic long-term results in the donor and recipient site is presented. RESULTS: Between 2005 and 2011, 91 patients received differently sized CGs of the auricle for nasal reconstruction. In 85/91 cases the donor site defect was closed using a retroauricular pedicled island flap. Six of 91 defects were closed primarily. Indications were multilayered defects of the nasal vestibule, the nasal floor, the inner nasal valve, and the lateral sidewall. The main indication for surgery was skin malignancies. One of 91 major and 14/91 minor complications were observed. Seventy-seven of 91 patients received a custom-made prosthesis to prevent stenotic scarring. The 2.5-year follow-up showed excellent results of stability and shape at the donor and recipient site. CONCLUSION: The auricular inner lining CG is a versatile and reliable autologous transplant, which is ideal for multilayered nasal reconstruction because of easy harvesting, little donor site morbidity, and its convex shape. Septal splints and custom-made prosthesis secure healing and prevent stenotic scarring.

Empty nose syndrome: limbic system activation observed by functional magnetic resonance imaging.

OBJECTIVES/HYPOTHESIS: Empty nose syndrome (ENS) patients have a persistent sense of impaired nasal patency despite radical resection of nasal turbinates. The aim of this study was to elucidate differences in cerebral activation during free breathing and after inhalation of a fragrance (lemonene) and a pseudodecongestant (menthol) over a nasofacial mask. Our hypothesis was that menthol would be perceived as beneficial and that cerebral activation would show differences in areas corresponding to emotional suffering and air hunger in ENS patients. STUDY DESIGN: Prospective, controlled intervention with lemonene and menthol during functional magnetic resonance imaging (f-MRI) experiment. METHODS: Ten right-handed ENS patients were compared to 15 controls using f-MRI and fully automated data analysis with SPM software. Nasal patency was measured with rhinomanometry and rated on a four-point scale. RESULTS: Despite similar objective nasal flow, ENS patients rated nasal patency significantly worse than did controls. Menthol was perceived to increase nasal patency. In patients, f-MRI data showed different activation of temporal cortex areas after inhalation of menthol. The comparison of patients and controls showed ENS-specific activation of temporal and cerebellar areas and amygdala during the rating task itself. CONCLUSIONS: Our experiments showed different cerebral processing of the feeling of nasal patency in ENS patients with prominent activation of areas belonging to the limbic system. The beneficial effect of menthol seems to correspond to activation differences in the temporal pole. These results demonstrate a neuronal substrate for both symptoms and their relief in ENS patients.

Impact of menthol inhalation on nasal mucosal temperature and nasal patency.

BACKGROUND: Menthol is a natural herbal compound. Its isomer l-menthol presents the characteristic peppermint scent and is also responsible for the cooling sensation when applied to nasal mucosal surfaces because of stimulation of trigeminal cold receptors. The aim of this study was to assess the effect of menthol inhalation on end-inspiratory nasal mucosa temperature and nasal patency. METHODS: Eighteen healthy volunteers with a mean age of 30 years were enrolled in this study. Objective measurements included the septal mucosal temperature within the nasal valve area by using a miniaturized thermocouple as well as active anterior rhinomanometry before and after inhalation of l-menthol vapor. All subjects completed a visual analog scale (VAS; range, 1-10) evaluating nasal patency before and after menthol. RESULTS: The mean end-inspiratory mucosal temperature ranged from 27.7 degrees C (+/-4.0) before menthol inhalation to 28.5 degrees C (+/-3.5) after menthol inhalation. There were no statistically significant differences between the temperature values before and after menthol inhalation (p > 0.05). In addition, no statistically significant differences between the rhinomanometric values before and after menthol inhalation were observed. Sixteen of the 18 subjects reported an improvement of nasal breathing after menthol inhalation by means of the VAS. CONCLUSION: Menthol inhalation does not have an effect on nasal mucosal temperature and nasal airflow. The subjective impression of an improved nasal airflow supports the fact that menthol leads to a direct stimulation of cold receptors modulating the cool sensation, entailing the subjective feeling of a clear and wide nose.

The influence of a multifunctional, polymeric biomaterial on the concentration of acute phase proteins in an animal model.

The concentrations of the acute phase proteins alpha1-Acid Glycoprotein (AAG) and haptoglobin were determined in Sprague-Dawley-rats after implantation of a novel biodegradable multifunctional polymeric biomaterial for the reconstruction of a gastric wall defect (polymer group; n=42). For comparison, the concentrations of AAG and haptoglobin were measured as well after primary wound closure of the gastric wall defect without biomaterial implantation (control group; n=21) and in rats without any surgical procedure (baseline group; n=21). The implantation periods were 1 week, 4 weeks and 6 months. The concentrations of AAG and haptoglobin were measured by an ELISA assay. Gastrointestinal complications like fistula, perforation or peritonitis did not occur in any of the animals. No statistically significant differences in the concentrations of AAG and haptoglobin were detected between the polymer and the control group. An adequate mechanical stability of the polymeric biomaterial was detectable under the extreme pathophysiological conditions of the stomach milieu. In further examinations the correlation between the intraperitoneal cytokine levels of the animals and the following systemic inflammatory markers should be analysed. Further investigations are needed to analyse the mechanisms of the tissue integration of a biomaterial as well as the process of the tissue remodeling and the influence of the immune system on these mechanisms. The knowledge of these processes is necessary to adapt the multifunctional biomaterial and prepare it thus for the use and implantation in different body locations and to develop novel therapeutical options in medicine.

[First results of the investigation of the stability and tissue integration of a degradable, elastomeric copolymer in an animal model]. / Erste Ergebnisse zur Untersuchung der Stabilität und Gewebeintegration eines abbaubaren, elastischen Copolymers im Tiermodell.

The stability and tight integration into adjacent tissue of a novel, degradable, elastic copolymer were examined in an animal model. The biomaterial was used for the reconstruction of a gastric wall defect in Sprague-Dawley rats (n=42) to test the polymeric material under the extreme chemical, enzymatical and mechanical conditions of the stomach. In the control group (n=21) the same defect of the gastric wall was primarily closed without biomaterial implantation. In the baseline group (n=21) the animals were kept under standard conditions without any surgical procedure. The implantation periods were 1 week, 4 weeks and 6 months. The animals' weight was determined preoperatively and before explantation. After explantation, air was pumped into the stomach and the pressure was measured by using a pressure-gauge in order to test whether the surgically produced union of the stomach wall and the polymer patch was gas-tight. After 1 week of implantation time a statistically significant increase of the body weight of the animals was found only in the baseline group. Four weeks and 6 months after the abdominal surgical procedure, a statistically significant increase of the animals' weight was found in the implantation group, the control and the baseline group. Gastrointestinal complications like fistula, perforation or peritonitis did not occur in any of the animals. The measurement of the stomach pressure after maximal gas insufflation did not show significant differences between the implantation group, the control and the baseline group in any of the time periods investigated. Despite very high strains of the gastric wall, no gas leakage was detected. There was a tight connection between the polymer and the adjacent stomach wall in all animals investigated. An adequate mechanical stability of the biomaterial was detectable under the extreme pathophysiological conditions of the stomach milieu. A fast and unfavourable degradation of the degradable polymer was not found in any of the animals. Further investigations are needed to analyse the mechanisms of the tissue integration of the biomaterial as well as the degradation kinetic of the polymer and the process of the tissue remodeling. The knowledge of these processes is necessary to adapt the novel biomaterial and thus prepare it for the use and implantation in different body locations and to develop novel therapeutical options in medicine.