The Role of Nasal Endoscopy in the Preoperative Evaluation of Nasal Airway Obstruction.

OBJECTIVE: To examine the prevalence and nature of nasal endoscopic findings in patients referred for structural nasal obstruction, and analyze how such findings influence the preoperative evaluation or operative plan. STUDY DESIGN: Cross-sectional study. SETTING: University-based academic otolaryngology practice. METHODS: Nasal endoscopy was performed by a single surgeon and the exam findings were documented. Patient demographics, variables in the patient history, Nasal Obstruction Symptom Evaluation scores, and an Ease-of-Breathing Likert Scale were tested for associations with findings on endoscopy. RESULTS: A total of 82 of 346 patients (23.7%) had findings on rigid nasal endoscopy not appreciable on anterior rhinoscopy. Prior nasal surgery (p = .001) and positive allergy testing (p = .013) were significantly associated with findings on nasal endoscopy. Endoscopic findings prompted additional preoperative studies in 50 (14.5%) patients, and a change in the operative plan in 26 (7.5%) patients. CONCLUSION: In patients referred for surgical management of nasal obstruction, findings on nasal endoscopy otherwise undetected with anterior rhinoscopy are most common in but certainly not limited to those with prior nasal surgery or allergic rhinitis. Routine nasal endoscopy should be considered for all patients being evaluated for nasal airway surgery. These results may benefit future updates of the clinical consensus statements regarding the role of nasal endoscopy in the evaluation of nasal valve compromise and septoplasty.

Will nasal airway surgery improve my sense of smell? A prospective observational study.

BACKGROUND: The effect of nasal airway surgery on olfaction has not been well established. The goal of this study is to assess changes in olfaction after septoplasty with inferior turbinate reduction through both objective and patient-reported measures. METHODS: Prospective, observational study was conducted of patients with nasal airway obstruction presenting between July 2017 and October 2019 who underwent septoplasty with inferior turbinate reduction. Nasal airflow was characterized with the Nasal Obstruction Symptom Evaluation (NOSE) scale and an 11-point ease-of-breathing (EOB) Likert scale, and olfaction with an 11-point olfactory Likert scale and the 40-item University of Pennsylvania Smell Identification Test (UPSIT), pre- and postoperatively. Pearson correlations were used to assess the relationship between measures of nasal obstruction and olfaction. RESULTS: Among 80 patients, mean NOSE scores improved from 67.4 preoperatively to 19.6 postoperatively (p < 0.001). EOB Likert scores improved from a mean of 3.9/10 to 8.1/10 after surgery (p < 0.001). Olfactory Likert scores improved from a baseline of 6.1/10 preoperatively to 7.9/10 after surgery (p < 0.001). No statistically significant difference was noted in UPSIT testing pre- versus postoperatively. A moderate correlation was noted between the degree of change in NOSE scores and improved olfactory Likert scores (r = 0.51, p < 0.001), and similarly between the degree of change in EOB Likert scores and improved olfactory Likert scores (r = 0.55, p < 0.0001). CONCLUSIONS: Based on our data, subjective tests of olfaction may improve with nasal airway surgery in some patients. Changes in olfaction best correlate with the extent to which surgery can improve subjective nasal obstructive symptoms.

An uncommon case of lip swelling: Granulomatous cheilitis associated with Crohn's disease.

Unbeknownst to most otolaryngologists, there is quite a range of oral manifestations which commonly manifest in the context of inflammatory bowel disease. As providers who will encounter such patients in consultation it is beneficial to be aware of that association. Lip swelling (granulomatous cheilitis) is just one such presentation, which is often otherwise mistaken for angioneurotic edema and can lead to unwarranted testing and misdirected treatment. We present such a case to highlight the educational value of this patient encounter.

A Prospective Study of Outcomes of Septoplasty with Turbinate Reductions in Patients with Allergic Rhinitis.

OBJECTIVE: Examine outcomes of septoplasty with turbinate reductions in patients with allergic rhinitis as compared to patients without allergic rhinitis using validated outcome and quality-of-life (QOL) instruments. STUDY DESIGN: Prospective observational cohort study. SETTING: Single surgeon, university hospital. SUBJECTS AND METHODS: Consecutive study-eligible patients with a symptomatic nasal septal deviation, with (n = 30) or without (n = 30) documented allergic rhinitis, were enrolled from March 2014 to February 2017. All patients subsequently underwent nasal septoplasty and inferior turbinate reductions. Outcomes were studied using the Nasal Obstruction Symptom Evaluation (NOSE) scale, mini-Rhinoconjunctivitis Quality of Life Questionnaire (mini-RQLQ), and Ease-of-Breathing (EOB) Likert scores completed preoperatively and, together with a patient satisfaction Likert, at 3 and 6 months postoperatively. RESULTS: NOSE scores, EOB scores, and mini-RQLQ scores improved significantly in both groups at 3 and 6 months postoperatively. Results were sustained from 3 to 6 months. Although mini-RQLQ scores in allergic patients were higher at all intervals, the magnitude of change in scores in both groups was comparable. CONCLUSION: Although patients with allergic rhinitis report greater allergy-related QOL impairment (mini-RQLQ) on a day-to-day basis than nonallergic patients, this does not appear to attenuate the benefit they might experience from septoplasty and turbinate reductions when indicated for nasal obstruction. Furthermore, the symptomatic relief of their structural nasal obstruction appears to significantly improve their overall allergy-related quality of life. If appropriate expectations are set pre-operatively, allergic rhinitis is neither a contraindication nor a deterrent to septoplasty and turbinate reductions and these patients can reasonably expect a high degree of satisfaction post-operatively.

The impact of nasal surgery on sleep quality: a prospective outcomes study.

OBJECTIVE: (1) Evaluate the impact of nasal airway surgery on sleep quality using validated outcome measurements, (2) compare the utility of Epworth Sleepiness Scale (ESS) versus Pittsburgh Sleep Quality Index (PSQI) as a reflection of sleep quality, and (3) identify perioperative variables that might correlate with a beneficial effect of nasal surgery on sleep quality. STUDY DESIGN: Prospective outcome study of patients with symptomatic nasal obstruction undergoing nasal airway surgery. SETTING: Academic medical center. METHODS: Patients completed the Nasal Obstruction Symptom Evaluation (NOSE) scale, ESS, PSQI, and Ease-of-Breathing and Sleep Quality Likert scales preoperatively and 3 months postoperatively. A nonparametric analysis compared pre- and postoperative values, and associations were examined using Spearman correlations. RESULTS: Sixty-one patients completed the study. Mean NOSE scores decreased significantly from 68.2 preoperatively to 17.5 three months after surgery. Mean ESS scores and PSQI scores improved (P < .0001) over that same interval (7.5 to 5.3 and 7.8 to 4.6, respectively). There was a correlation seen between the degree of change in both NOSE scores and Ease-of-Breathing scores and the change in sleep quality measured using the PSQI or Sleep Quality Likert scores. The PSQI correlated better with Sleep Quality Likert scores than the ESS. Overall, 86.9% of subjects reported subjective improvement in sleep quality postoperatively. CONCLUSION: In patients undergoing nasal airway surgery there may be a secondary improvement in subjective sleep quality. The degree of change in sleep quality correlates with the severity of nasal obstruction preoperatively and the degree of improvement in obstruction with surgery.

Revision septoplasty: a prospective disease-specific outcome study.

OBJECTIVES/HYPOTHESIS: 1) Study outcomes of revision septoplasty using a validated disease-specific questionnaire and a patient satisfaction survey; 2) assess the effect of surgery on the use of medication to treat nasal congestion; and 3) report on sites of persistent septal deviation identified at revision septoplasty. STUDY DESIGN: Prospective, single-center outcome study of patients with symptomatic nasal obstruction and persisting septal deviation despite prior septal surgery. METHODS: The Nasal Obstruction Symptom Evaluation (NOSE) scale was administered preoperatively and at 3 and 6 months following revision surgery. Patients were also questioned regarding ease of breathing and medication use preoperatively and postoperatively, as well as satisfaction with the surgical outcome. Anatomic site(s) of residual septal deviation were recorded intraoperatively. RESULTS: Thirty-nine patients completed the study. Mean NOSE scores decreased significantly from 75.9 preoperatively to 14.9 3 months after revision surgery. Mean Ease-of-Breathing scores over this interval improved from 3/10 preoperatively to 8.5/10. Both results were sustained at 6 months (P <0.0001). Patient satisfaction was very high, and many patients required less medication to treat symptoms of nasal congestion postoperatively. Deviations persisting from prior surgery most commonly involved the dorsal or caudal septum. CONCLUSION: In patients who experience ongoing nasal obstruction with a persistent septal deviation despite prior septoplasty, revision surgery significantly improves disease-specific quality of life, results in high patient satisfaction, and may diminish the need for nasal medications postoperatively. Caudal or dorsal deflections may be more difficult to correct, leading to the need for revision surgery. LEVEL OF EVIDENCE: 2C.

Clinical consensus statement: appropriate use of computed tomography for paranasal sinus disease.

OBJECTIVE: To develop a consensus statement on the appropriate use of computed tomography (CT) for paranasal sinus disease. SUBJECTS AND METHODS: A modified Delphi method was used to refine expert opinion and reach consensus by the panel. RESULTS: After 3 full Delphi rounds, 33 items reached consensus and 16 statements were dropped because of not reaching consensus or redundancy. The statements that reached consensus were grouped into 4 categories: pediatric sinusitis, medical management, surgical planning, and complication of sinusitis or sinonasal tumor. The panel unanimously agreed with 13 of the 33 statements. In addition, at least 75% of the panel strongly agreed with 14 of 33 statements across all of the categories. CONCLUSIONS: For children, careful consideration should be taken when performing CT imaging but is needed in the setting of treatment failures and complications, either of the pathological process itself or as a result of iatrogenic (surgical) complications. For adults, imaging is necessary in surgical planning, for treatment of medical and surgical complications, and in all aspects of the complete management of patients with sinonasal and skull base pathology.

Applications of Gore-Tex implants in rhinoplasty reexamined after 17 years.

OBJECTIVE: To determine the efficacy of GORE-TEX (W. L. Gore & Associates Inc, Flagstaff, Arizona) alloplast in rhinoplasty. DESIGN: A 17-year retrospective medical chart review at a teaching hospital, community hospital, and private facial cosmetic surgery center. A total of 521 patients (122 male and 399 female; age range, 13-70 years) were followed for 12 months to 17 years. All patients had undergone GORE-TEX implantation rhinoplasty (685 implants in 158 primary procedures and 508 secondary procedures) performed by 1 surgeon. Patient satisfaction, expressed with respect to desired cosmetic benefit and functional outcome, and physician assessment, based on aesthetic improvement, technical considerations, and complications, were evaluated. Results were assessed according to the follow-up notes in the medical chart reflecting patients' and surgeon's comments and full preoperative and postoperative photographic documentation. RESULTS: GORE-TEX alloplasts, 1 to 10 mm thick, implanted in the nasal dorsum (n = 264), lateral nasal wall (n = 252), supratip dorsum (n = 85), and premaxilla (n = 84) showed excellent stability and tissue tolerance. Biological complications that required implant removal occurred in 1.9% of patients and included infection, soft tissue swelling, migration, and extrusion. CONCLUSIONS: With the exception of the nasal tip, columella, or problems in which corrections would require rigidity of the grafted or implanted material, the GORE-TEX alloplast is a safe, inexpensive, and predictable alternative to autografts. In the present series, more than 95% of implants used were 1 to 4 mm thick. In the remaining 5%, 6 implants ranged from 8 to 10 mm thick, and we found them acceptable. It is our opinion that for both primary and secondary rhinoplasty with adequate endonasal and external soft tissue coverage, GORE-TEX should be strongly considered for major and minor corrections of the nasal wall and bridge in properly selected patients.

Questioning the need to use Botox within 4 hours of reconstitution: a study of fresh vs 2-week-old Botox.

OBJECTIVE: To determine whether injection with botulinum toxin type A (Botox; Allergan Inc, Irvine, California) reconstituted with preservative-free saline (0.9% isotonic sodium chloride) after 2-week cold storage in a refrigerator (4 degrees C) or freezer (-20 degrees C) is less efficacious than injection with freshly reconstituted Botox. METHODS: We conducted a prospective, double-blind, randomized controlled trial at an academic facial plastic surgery practice with 40 volunteers for treatment of horizontal forehead rhytids, each acting as his or her own control. In a blinded fashion each subject received freshly reconstituted Botox (control) on one side of the forehead (frontalis muscle) and 2-week-old reconstituted Botox (experimental) stored at 4 degrees C (refrigerated) or stored at -20 degrees C (frozen) on the other side. The right and left forehead movement was measured and photographed at rest and during maximum contraction of the frontalis muscle prior to Botox administration and on follow-up days 14, 30, 60, 90, and 120 after injection. Each participant also completed a questionnaire regarding right and left forehead movement prior to injection and at each follow-up visit. RESULTS: No significant difference was noted for any subject in the timing of onset or duration of action or the measurable reduction of forehead movement between the fresh and 2-week-old refrigerated Botox or between the fresh and 2-week-old frozen Botox. The subjects had a gradual return of muscle function over the 4-month follow-up period. CONCLUSIONS: No measurable difference was found in the potency or duration of efficacy of Botox in the treatment of forehead rhytids after 2 weeks of refrigeration or freezing compared with fresh reconstituted Botox. When Botox, fresh or stored, is given at an adequate dose to cause full paralysis of the desired muscle, the duration of the muscle paralysis is dependent on the physiologic rate for the motor nerve to reestablish neural transmission.

Bell's palsy in pregnancy: a study of recovery outcomes.

OBJECTIVE: To study facial nerve recovery in patients with Bell's palsy of pregnancy compared with that of the nonpregnant population. METHODS: A retrospective chart analysis was conducted of all patients seen within 6 weeks of the onset of Bell's palsy of pregnancy, with a minimum of 1-year follow-up. Recovery outcomes were compared with similarly chosen randomly selected groups of nonpregnant females 15 to 40 years old (group 1), nonpregnant females of all ages (group 2), males 15 to 40 years old (group 3), and males of all ages (group 4), all of whom were also seen within 6 weeks of onset. Recovery was categorized as satisfactory (House-Brackmann grade I to II) or unsatisfactory (House-Brackmann grade III or IV). The 2-tailed Fisher exact test was used to statistically analyze differences between groups. RESULTS: Fifty-two percent of women with Bell's palsy of pregnancy whose facial palsy progressed to complete paralysis within 10 days of onset recovered to a satisfactory level compared with 77% to 88% of comparison patients. These differences were statistically significant in all cases. Recovery for those with an incomplete palsy was satisfactory in virtually 100% of all patients studied. CONCLUSION: The prognosis for a satisfactory recovery for women who develop a complete facial paralysis with Bell's palsy while pregnant is significantly worse than for that for the general population. This information should be taken into consideration by all physicians involved in the counseling of these patients.