Postoperative Ecchymosis and Edema After Creation of Subperiosteal Tunnels in Rhinoplasty: A Randomized Clinical Trial.

IMPORTANCE: Periorbital ecchymosis and edema are commonly associated with rhinoplasty and are the principal limiting factors for return to daily activities after rhinoplasty. Several methods have been evaluated to minimize these sequelae including creation of subperiosteal tunnels, which involves elevating the vascular periosteal layer, preserving it from trauma when creating osteotomies. OBJECTIVE: To assess the efficacy of the creation of subperiosteal tunnels prior to lateral osteotomies during rhinoplasty for reducing postoperative ecchymosis and edema. DESIGN, SETTING, AND PARTICIPANTS: A randomized, blinded, matched-paired, prospective, clinical trial took place between April 1 and August 30, 2015, in a private practice in a stand-alone clinic and surgical center. All patients who were undergoing aesthetic rhinoplasty requiring bilateral lateral osteotomies were offered inclusion in the trial. All 34 enrolled patients completed the follow-up requirements. INTERVENTION: Creation of subperiosteal tunnels prior to lateral osteotomies on 1 randomly selected side. MAIN OUTCOMES AND MEASURES: Three blinded evaluators independently graded the degree of ecchymosis and edema on a visual analog scale of 0 to 10 on each side of the nose on postoperative days 2 and 7. Each patient had 1 side that was randomly selected to undergo creation of subperiosteal tunnels. A difference in mean score between sides of the nose was calculated for each patient using a paired t test. RESULTS: Of the 34 patients (28 females and 6 males; mean [SD] age, 27.3 [9.2]), the mean (SD) difference in ecchymosis scores between sides on day 2 was -0.05 (1.94) (95% CI, -0.43 to 0.33) and on day 7 was -0.22 (1.23) (95% CI, -0.47 to 0.02), favoring the side without tunnels. The mean (SD) difference in edema scores on day 2 was -0.21 (1.66) (95% CI, 0.53-0.12) and on day 7 was -0.29 (1.11) (95% CI, -0.51 to -0.07). There were no clinically significant differences between sides in terms of postoperative ecchymosis and edema. CONCLUSIONS AND RELEVANCE: Ecchymosis and edema can have significant postoperative practical, emotional, and financial effects on patients. Creation of subperiosteal tunnels prior to lateral osteotomies showed no clinically significant differences in edema and ecchymosis after the procedure. LEVEL OF EVIDENCE: 1. TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN42741475.

Topical cocaine vs adrenaline in endoscopic sinus surgery: a blinded randomized controlled study.

BACKGROUND: Adequate surgical field visualization is among the most important factors in preventing complications in functional endoscopic sinus surgery (FESS). The aim of this study was to assess the effect of topical cocaine vs adrenaline on surgical field visualization and intraoperative bleeding during FESS. METHODS: A randomized controlled trial was conducted. A total of 37 patients that underwent FESS for chronic rhinosinusitis were randomized to the side of the nose that received adrenaline or cocaine-soaked patties, and the side that was operated first. The surgeon evaluating the bleeding was blinded to the vasoconstrictor allocation. At the commencement of surgery and at regular 15-minute intervals, the operating surgeon evaluated the extent of bleeding in the operative field according to a validated scale. At each assessment, mean arterial pressure (MAP), heart rate, and end tidal CO2 were also recorded. At the end of each side, total blood loss was measured. RESULTS: There was no difference in the mean surgical field scores between the adrenaline and cocaine sides (2.04 ± 0.75 vs 2.17 ± 0.7, p = 0.24), nor the total blood loss (p = 0.43). On the cocaine side, there was a correlation between surgical field grade and duration of surgery (p < 0.05) as well as blood loss (p < 0.05) and MAP (p < 0.05). CONCLUSION: There is no difference in the quality of the surgical field achieved through the use of topical cocaine or adrenaline during FESS. Either of these agents can be effectively used for topical decongestion at the onset of surgery.

Causes of failure in endoscopic frontal sinus surgery in chronic rhinosinusitis patients.

BACKGROUND: The frontal sinus is the most challenging area to address in endoscopic sinus surgery (ESS). Incomplete surgery or iatrogenic injury in the narrow space of the frontal recess with synechia formation can lead to recurrence or persistence of disease. The goal of this study was to identify causes of failure of endoscopic frontal sinus surgery and to determine complication rates. METHODS: A cross-sectional retrospective study was conducted. Charts and preoperative sinus computed tomography (CT) scans of patients who underwent revision frontal ESS for chronic frontal rhinosinusitis, between 2006 and 2012 were reviewed. RESULTS: Of 829 patients who underwent ESS during the study period, 740 had the frontal recess dissected and frontal sinus opened. Of these, 66 patients had revision surgery of the frontal sinus, with a total of 109 frontal sinuses. The mean ± standard deviation (SD) age was 52 ± 12.9 years. Forty patients were male (59.1%). The most common findings were the following: edematous or hypertrophic mucosa (92.7%); retained agger nasi cell (73.4%); neo-osteogenesis within the frontal recess (45.9%); lateral scarring of the middle turbinate (47.7%); residual anterior ethmoid air cell (32.1.%); and residual frontal cells (24.8%). CONCLUSION: With the exception of mucosal disease and neo-osteogenesis, all identified causes of failure of frontal sinus surgery are a result of surgical technique. Careful preoperative planning and meticulous and complete surgical execution are therefore critical for a successful surgical outcome in primary frontal sinus surgery.

Radiological localization of Schneiderian papilloma.

BACKGROUND: It has been recently reported that the site of attachment of Schneiderian papillomas can be predicted with high accuracy on preoperative computed tomography (CT) scans using bony osteitic changes as an indicator. The objective of this study is to evaluate, in a blinded fashion, the reliability of the osteitis sign at predicting the site of attachment of Schneiderian papillomas. METHODS: A retrospective cohort study of patients who underwent endoscopic surgical resection for inverted papilloma (IP) or cylindrical papilloma between September 2002 and September 2009 in a tertiary care rhinology center was carried out. The preoperative sinus CT scans were collected and reviewed by a fellowship-trained and experienced head and neck radiologist who was blinded to the intraoperative findings. The radiologist attempted to identify and grade bony osteitic changes in the sinuses. The radiological findings were then correlated with the actual site of attachment reported by the surgeon in the operative report. RESULTS: A total of 34 patients were evaluated. Six (18%) patients had a single site of osteitis and 28 (82%) were found to have multiple sites of osteitis. The sensitivity and specificity of the radiological prediction based on the degree of osteitis was found to be 74% (46.5-90.3%) and 0% (0-17%), respectively. The predictive value of the radiological localization was 41%. CONCLUSION: Osteitic changes are very common nonspecific findings on CT scans of patients with Schneiderian papillomas. Their presence as well as the degree of osteitis did not allow preoperative localization of tumor attachment.

Quantitative proteomics of nasal mucus in chronic sinusitis with nasal polyposis.

BACKGROUND: Proteomics has been used as a tool for identification of the protein content of nasal mucus in diseased and healthy subjects. Thirty-five proteins in both chronic rhinosinusitis (CRS) and control groups were identified in a previous study by our group using conventional mass spectrometry analysis. Ten of these proteins were related to innate and acquired immunity and showed differences in expression between the two groups. OBJECTIVE: To investigate the quantitative differential expression of specific nasal mucus proteins previously identified by our group using multiple reaction monitoring (MRM) mass spectrometry in patients with CRS with nasal polyposis compared with normal subjects. METHODS: In a prospective case control study, nasal mucus from patients and control subjects was collected, desalted, resolubilized, and digested using proteolytic enzymes. Previously identified nasal mucus proteins with differential expression in CRS patients were targeted and quantitatively measured using MRM mass spectrometry. RESULTS: Analysis of 12 samples (6 patients and 6 controls) identified 7 of the 10 targeted proteins, many of which were related to innate and acquired immunity. Quantitative analysis showed differential expression in CRS patients compared with control subjects. A detailed analysis and characterization of the protein isolates is outlined. CONCLUSION: This is the first proteomics study of nasal mucus in CRS with polyposis using the MRM technique. The findings suggest that innate and acquired immunity may play a role in the pathophysiology of CRS. Future steps in evaluating the protein characteristics of the mucus of CRS patients are aimed at developing biomarkers and potentially targeted therapies.

Proteomics of nasal mucus in chronic rhinosinusitis.

BACKGROUND: Chronic rhinosinusitis (CRS) is among the three most common chronic diseases in North America. The area of proteomics research is providing tremendous insight into the mechanisms of a variety of physiological processes and disease states. The purpose of this study was to evaluate qualitative and quantitative differences in protein content of nasal mucus in patients with chronic hypertrophic sinusitis with nasal polyposis when compared with control subjects. METHODS: A case-control study was performed in a tertiary academic center. Nasal mucus was collected from four patients with CRS and nasal polyposis as well as four control subjects. The protein content was digested using proteolytic enzymes, labeled with iTRAQ reagents, and subjected to mass spectrometry (MS) analysis. RESULTS: A total of 35 proteins were identified, many of which were related to innate and acquired immunity. Lysozyme C precursor was found to be down-regulated by a ratio (R) of 0.65 (p = 0.016) in CRS patients, as was Clara cell phospholipid-binding protein (R = 0.23; p = 0.0018), and antileukoproteinase 1 (R = 0.47; p < 0.0001). A detailed analysis and characterization of the protein isolates is outlined. CONCLUSION: The field of proteomics has great potential in leading to a better understanding of the mechanism of the disease process in CRS. Differences in the expression of proteins related to regulation of immune cells and mediators merit additional investigation.

Factors affecting unanticipated hospital admission following otolaryngologic day surgery.

BACKGROUND: Day surgery constitutes an important part of modern otolaryngology practice. However, high rates of unplanned admissions remain an issue. OBJECTIVE: To determine the incidence, reasons, and predictive factors for unanticipated admission after ambulatory otolaryngologic surgery. METHODS: A retrospective review of all cases of unplanned admission following otolaryngology day surgery at a tertiary care centre over a 4-year period from 2000 to 2004. Data relating to patient demographics, physical status, surgical procedure, perioperative complications, and reasons for hospital admission were recorded. A case-control analysis of these parameters with nonadmitted day surgery patients was used for comparison. RESULTS: During the above period, 1106 patients underwent otolaryngologic day surgery, of whom 74 (6.7%) required admission. Fifty-seven percent of the patients were male, and the average age was 48.9 years. The three most common procedures with unplanned admission were open neck biopsy (27%), functional endoscopic sinus surgery (20.3%), and panendoscopy (16.2%). The reasons for admission could be divided into airway monitoring (37.7%), postoperative bleeding (28.6%), the need for supportive or pain management (19.5%), anesthetic complication (5.2%), cardiovascular complication (3.9%), clerical error (3.9%), and suspicion of a cerebrospinal fluid leak (1.3%). Risk factors for admission were determined to be an American Society of Anesthesiologists' class of 3 or greater, open neck surgical procedures, and a length of surgery of 60 minutes or greater. Minor factors included the use of general anesthesia, male gender, advanced age, and living far from a hospital. CONCLUSIONS: This study suggests strategies to reduce the rate of unplanned admission by means of careful preoperative assessment and planning, patient selection, careful scheduling of higher-risk patients, and appropriate postoperative observation and management.

Endoscopic frontal sinus drillout in 100 patients.

OBJECTIVE: To determine the efficacy of frontal sinus drillout surgery for the treatment of chronic frontal sinusitis. DESIGN: Retrospective case-control study. Mean +/- SD follow-up was 4.1 +/- 1.53 years (range, 1.4-6.9 years). SETTING: Academic medical center. PATIENTS: One hundred consecutive patients with chronic sinusitis who underwent frontal sinus drillout surgery. Indications were failed previous frontal sinusotomy (n = 88) and frontal sinus mucocele (n = 12). INTERVENTIONS: Endoscopic removal of the floor of the frontal sinus (unilateral, n = 34; bilateral, n = 66) with a surgical drill. An intraoperative image-guidance system was used in 65 patients. MAIN OUTCOME MEASURES: Frontal sinus patency and improvement of symptoms associated with frontal sinusitis. RESULTS: Frontal sinus patency with control of symptoms was achieved in 80% of patients. There were no intraoperative complications. Postoperative epistaxis occurred in 4% of patients. Of the 20 patients who developed restenosis of the frontal sinus ostium, 11 underwent revision frontal sinus drillout and 9 proceeded to frontal sinus obliteration. The success rate was comparable for the image-guidance and non-image-guidance groups (83.1% vs 74.3%, respectively; P =.56). CONCLUSIONS: Frontal sinus drillout performed with or without an image-guidance system appears to be a safe and effective surgery for the treatment of patients with advanced disease of the frontal sinus. This procedure provides a reasonable alternative to frontal sinus obliteration, which remains a treatment option for patients who fail frontal drillout.

Image-guided resection of fibro-osseous lesions of the skull base.

BACKGROUND: Endoscopic resection of sinonasal fibro-osseous lesions remains a technical challenge because of the loss of anatomic landmarks and the frequent need to resect bone along the skull base. The purpose of this study was to evaluate the usefulness of image-guidance systems for the resection of these lesions. METHODS: Endoscopic surgery was performed in 10 patients with fibro-osseous lesions of the sinuses and skull base (six fibrous dysplasias and four osteomas). Indications for surgical intervention were recurrent infection (7), facial pain (3), mucocele (1), and compressive optic neuropathy (1). All surgeries were performed with an image-guidance system, which included an integrated high-speed drill system. RESULTS: Anatomic localization was accurate to within 1 mm when monitoring the depth of bone removal along the skull base. Complete resection of the fibro-osseous lesion was possible in six patients (60%) and partial removal was possible in four patients (40%). In the latter group, a margin of dysplastic bone was preserved along the ethmoid roof to prevent dural exposure. There were no intraoperative complications. Surgery resulted in resolution of infection and facial pain in nine patients (90%). Additional surgery was required in one patient (10%) who developed recurrent optic neuropathy because of continued dysplastic bone growth. Mean follow-up was 34 months (range, 13-67 months). CONCLUSION: Image-guidance technology appears to be ideally suited for the treatment of patients with fibro-osseous lesions of the sinonasal cavity. Real-time monitoring of the depth of bone removal relative to the skull base may enhance the safety and efficacy of such surgery.

Reduction of diplopia following endoscopic orbital decompression: the orbital sling technique.

OBJECTIVE: Although endoscopic orbital decompression has become the surgical treatment of choice for patients with proptosis from Graves disease, postoperative diplopia requiring corrective eye muscle surgery can occur in up to 63% of patients. The purpose of the study was to evaluate a new technique intended to reduce the incidence of diplopia following endoscopic orbital decompression. STUDY DESIGN: Case-control. METHODS: Endoscopic orbital decompression was performed on 58 orbits in 37 patients with proptosis from Graves disease. The orbital sling technique, which makes use of a horizontal strip of periorbital fascia to prevent prolapse of the medial rectus muscle, was used on 20 orbits in 13 patients. Conventional endoscopic decompression was performed in 24 control subjects. The mean duration of follow-up was 3.3 +/- 1.3 years (range, 1.7-5.1 y). RESULTS: The incidence of new-onset or worsened diplopia following endoscopic decompression was significantly lower for the orbital sling group compared with control subjects (0% vs. 29.2%, respectively [ =.038]). No patients in the orbital sling group developed new-onset diplopia following surgery. Of the eight patients with pre-existing diplopia from the orbitopathy, double vision improved in four patients (50%) and was unchanged in the remaining four patients (50%). The mean reduction in proptosis was comparable for the orbital sling and control groups (5.1 +/- 1.1 mm vs. 5.0 +/- 1.9 mm, respectively [ P=.98]). CONCLUSIONS The preservation of a fascial sling overlying the medial rectus muscle during endoscopic orbital decompression appears to reduce the incidence of postoperative diplopia, while still allowing for a satisfactory reduction in proptosis. This modification of the standard decompression technique should be considered for the treatment of patients with proptosis.

Dacron implants in rhinoplasty: a review of 136 cases of tip and dorsum implants.

The achievement of successful results in rhinoplasty may require the use of autografts, homografts, or alloplastic materials. Among the alloplasts, Dacron is an easily handled and manipulated synthetic material, readily applicable to nasal augmentation. The following represents the indications, surgical technique, outcome results, and analysis of our experience with Dacron mesh implants to the nasal tip, dorsum, and lateral walls in 136 patients.