Teaching nasal analysis to otolaryngology residents.

PURPOSE: This prospective cohort study was completed to evaluate a systematic approach for teaching nasal analysis to otolaryngology-head and neck surgery residents. METHODS: Residents from each post graduate year (PGY) were randomized to the control group or study group. Residents in the study group were given a 10-slide PowerPoint (Microsoft Corp) instruction on nasal analysis using the standard sequence of photographs and anatomic elements to describe in each view. All residents were given the standard sequence of photographs of 3 patients for assessment on nasal analysis. Then 12-14 weeks later all residents were re-evaluated using photographs of 3 new patients. The results were blinded and graded using an 18 point scale modified from a previous publication [1]. RESULTS: Twenty otolaryngology-head and neck surgery residents completed the study. Analysis was performed with and without multivariate regression modeling to adjust for PGY, sex, and number of rhinoplasties performed. The study group had overall higher scores in both the initial and follow up assessment, specifically with subsite-specific dorsal deviation, tip projection, and nostril symmetry. Neither group obtained high scores in facial symmetry, skin thickness, tip shape and contour, and radix position at initial or re-assessment. CONCLUSION: Nasal analysis is a complex task. A lecture on a systemic approach to facial analysis given to a group of residents, who performed significantly better on facial analysis cases than controls. Further research in providing feedback, periods of rehearsal or testing, or focused selected elements with serial exposure can be considered.

Total Nasal Reconstruction: Advances in Free Tissue Transfer for Internal Lining and Structural Support.

Total nasal reconstruction is a complex challenge due to the need to establish new internal lining, internal structural support, and external skin covering that is both functional and esthetic. The medial femoral condyle corticoperiosteal free flap represents an innovative option for restoration internal structure and internal nasal lining. When used in conjunction with a paramedian forehead flap, acceptable results in both function and esthetics can be achieved.

Age-Related Histologic and Biochemical Changes in Auricular and Nasal Cartilages.

OBJECTIVE: Analyze age-related changes in histologic features and biochemical properties of human auricular cartilage and two subsites of nasal cartilages (quadrangular cartilage and dorsal septal articulation with upper lateral cartilages). STUDY DESIGN: Prospective cross-sectional study of nasal and auricular cartilages from seventy-three (73) live donors. METHODS: Auricular cartilage (AC), quadrangular cartilage (QC), and dorsal septal cartilage articulation (DSA) with the upper lateral cartilage (ULCs) were collected intraoperatively. Histochemical staining was used: Safranin O for glycosaminoglycans (GAGs), Verhoeff's for elastin, and Masson's trichrome for collagen. ImageJ2 software was used to calculate cell count and percent stained for each cartilage type. R studio "ggplot" package was used to visualize age versus cell count or percent stained. RESULTS: Participant ages ranged from 20 to 77 years, average 46.5 years. There was a significant decline in GAGs with age for the DSA subsite, (n = 64, p < 0.001). Significant increase in collagen content with age was observed for DSA subsite (n = 66, p < 0.001) and the QC subsite (n = 64, p < 0.05). There was a statistically insignificant decline in elastin with age (n = 41, p = 0.309) for AC. Cell count declined with age at all cartilage subsites. CONCLUSION: Our findings confirm that there were age-related decreases in cartilage glycosaminoglycan content, and chondrocyte cell count in both auricular and nasal cartilages. We have also confirmed that collagen content increases with age for both auricular and nasal cartilage. The histologic findings while not statistically significant in all comparisons, provides additional evidence that there is some loss of structural integrity and flexibility in nasal and auricular cartilage with aging. LEVEL OF EVIDENCE: NA Laryngoscope, 134:1220-1226, 2024.

Biochemical Variability of Nasal Cartilages: Implications in Functional Rhinoplasty.

INTRODUCTION: Nasal valve compromise is a common issue for patients presenting to an otolaryngologist. Anatomically, the dorsal septal cartilage (DSA) articulates with the upper lateral nasal cartilage (ULC). When the ULC weakens, it is prone to collapse and may result in nasal obstruction. Our objectives were to analyze histological differences between quadrangular and DSA nasal cartilages and compare histological composition of these tissues among patients with diagnosis of nasal valve compromise (NVC) versus those without NVC (no NVC). METHODS: Prospective cross-sectional study of nasal cartilages from seventy-three (73) live donors. Quadrangular cartilage (QC), and DSA from patients undergoing septorhinoplasty were collected. Safranin O histochemical staining was used to observe glycosaminoglycans (GAGs) content and cell count. Masson's Trichrome staining was used to assess collagen content in these nasal cartilages. RESULTS: Mean GAG content was lower in DSA compared with QUAD cartilage (68.18% vs. 87.22%, p < 0.0001), and was lowest in DSA of patients with NVC (59.07%). Mean collagen content was higher in DSA compared with QUAD cartilage, (65.43% vs. 46.65%, p = 0.0002), and was highest in DSA of patients with NVC (74.86%). CONCLUSION: The DSA showed decreased GAG and increased collagen content compared with quadrangular cartilage. Within the DSA subsite, patients with presurgical NVC had the lowest GAG and highest collagen levels. This observation suggests that the biochemical composition of the DSA may contribute to its weakening, potentially resulting in its inability to withstand minor trauma and/or the effects of aging, ultimately leading to NVC. LEVEL OF EVIDENCE: N/A Laryngoscope, 2024.

Mucoepidermoid carcinoma of the parotid as a secondary malignancy after chemotherapy in a child with neuroblastoma.

Secondary neoplasms are not reported frequently after neuroblastoma, which until recently was a cancer with limited long-term survival. Although salivary gland tumors in children and adolescents may be idiopathic, they are seen more often after head and neck radiation. We report a child with stage 4 neuroblastoma treated with high-dose multiagent chemotherapy without radiation therapy to his neck who, within 1 year of treatment, developed a low-grade but large and locally aggressive mucoepidermoid carcinoma of his parotid gland further characterized by a t(11;19)(q21;p13.1). Our patient extends the spectrum of secondary neoplasms after neuroblastoma.

Casual Observers' Perception on the Aesthetics of the Butterfly Graft.

OBJECTIVE: The butterfly graft is an effective technique for improving the internal nasal valve, however, there is hesitancy among surgeons due to possible aesthetic changes. This study aims to determine if average observers rated the post-operative appearance of the butterfly graft negatively. METHODS: An online survey was distributed by social media to non-medical observers in which they rated either the pre-operative or post-operative appearance of 22 patients' noses (11 butterfly graft, 11 spreader graft). A heat map was used to determine if the supratip region was rated as the least aesthetically appealing. Post-operative ratings and heat maps of the butterfly graft patients were compared to pre-operative ratings as well as ratings of the spreader graft group. RESULTS: 226 observers responded. There was no difference in the pre-operative and post-operative rating of the butterfly graft group (58.27 vs. 58.00, p = 0.88) or the number of supratip regions selected as least attractive (165 vs. 169, p = 0.60). Similarly, there was no difference in post-operative ratings between the butterfly graft group and spreader graft group (58.00 vs. 58.21, p = 0.63) or in selection of the supratip as the least attractive region (169 vs. 172, p = 0.74). CONCLUSION: The butterfly graft did not negatively affect observers' opinion of patients' noses. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:2578-2583, 2023.

Body Dysmorphic Disorder in Adult Patients With an Orofacial Cleft: An Unseen Psychological Burden.

OBJECTIVES: Facial dysmorphic disorder (FDD), a variant of body dysmorphic disorder, occurs when individuals are preoccupied with perceived defects in their facial appearance. Cleft lip and/or palate (CL/P) requires many clinical interventions and has significant psychological impacts on a patient's perception of appearance. This study identified psychological burdens related to living as an adult with CL/P and characterizes the degree of FDD symptoms in an adult craniofacial population. METHODS: This was a prospective, single-center, cross-sectional case-control study using semi-structured interviews and symptom assessments at a university-based craniofacial center. Patients without CL/P undergoing non-cosmetic facial surgery were recruited as controls (n = 20). Patients with an orofacial cleft (n = 30) were recruited from medical and dental providers at the University of North Carolina. Body Dysmorphic Disorder-Yale Brown Obsessive Compulsive Scale (BBD-YBOCS) scores were collected from a control population and patients with CL/P to assess FDD severity. RESULTS: Demographic factors such age, biological sex, and ethnicity had no significant impact on FDD symptom scores. Patient with CL/P were more likely to have significant FDD symptoms (BDD-YBOCS greater than 16) than patients without CL/P (OR 10.5, CI95 2.7-41.1), and had a mean difference in FDD symptoms scores of 10.04 (p < 0.0001; CI95 5.5-14.6). Patients with CL/P seen by a mental health provider in the past 3 months had 3-fold lower overall FDD symptom scores (OR 0.081; CI95 0.0085-0.77). CONCLUSIONS: Adults with CL/P would benefit from treatment for cleft-specific needs and psychological support as they face unique stressors related to their appearance, including an increase in FDD-associated symptoms. This study emphasizes the importance of recognizing psychological symptoms and providing ongoing multidisciplinary care to adults with CL/P. LEVEL OF EVIDENCE: 3; Individual case-control study Laryngoscope, 133:818-821, 2023.

Molecular classification of head and neck squamous cell carcinomas using patterns of gene expression.

The prognostication of head and neck squamous cell carcinoma (HNSCC) is largely based upon the tumor size and location and the presence of lymph node metastases. Here we show that gene expression patterns from 60 HNSCC samples assayed on cDNA microarrays allowed categorization of these tumors into four distinct subtypes. These subtypes showed statistically significant differences in recurrence-free survival and included a subtype with a possible EGFR-pathway signature, a mesenchymal-enriched subtype, a normal epithelium-like subtype, and a subtype with high levels of antioxidant enzymes. Supervised analyses to predict lymph node metastasis status were approximately 80% accurate when tumor subsite and pathological node status were considered simultaneously. This work represents an important step toward the identification of clinically significant biomarkers for HNSCC.

Changing characteristics of facial fractures treated at a regional, level 1 trauma center, from 2005 to 2010: an assessment of patient demographics, referral patterns, etiology of injury, anatomic location, and clinical outcomes.

INTRODUCTION: Despite improvements in automotive safety, motor vehicle collision (MVC)-related facial fractures remain common and represent preventable injuries. This study examines the changing characteristics of facial fractures treated at a regional, level I trauma center, from 2005 to 2010. METHODS: We identified all patients with facial fractures admitted to our hospital, from 2005 to 2010, by querying the North Carolina Trauma Registry, using International Classification of Diseases, Ninth Revision codes. Prospectively collected data, sorted by year, were descriptively analyzed for demographics, referral patterns, etiology, anatomic location, and clinical outcomes. RESULTS: Number of patients with facial fractures increased from 201 per year to 263 per year (total n = 1508). Although transport distances remained constant at ∼85 miles, standard deviation increased from 37 to 68 miles. Transport time increased from 87 to 119 minutes. Referrals came from 28 surrounding counties in 2005 and 43 counties in 2010. Regarding etiology, MVCs decreased from 40% to 27%, all-terrain vehicle crashes decreased from 6% to 2%, falls increased from 8% to 19%, and bicycle accidents increased from 3% to 6%. Regarding anatomic location, frontal sinus fractures increased from 8% to 37%, zygomaticomaxillary fractures increased from 9% to 18%, nasoethmoid fractures decreased from 12% to 6%, orbital floor fractures decreased from 6% to 3%, and mandible fractures decreased from 28% to 18%. Single-site fractures increased from 75% to 90%. Length of intensive care unit and hospital stay remained stable at 3 and 7 days, respectively. CONCLUSIONS: Despite a decrease in MVC-related facial fractures, the overall increase in facial fractures referred to our trauma center is due to a growing number of patient transfers from rural hospitals, where a paucity of qualified surgeons may exist.

The impact of an independent transfer center on the evaluation and transport of patients with burn and maxillofacial injuries to definitive care at a level 1 trauma center.

OBJECTIVE: To assess the impact of an independent call center on facilitation of burn and maxillofacial trauma patient transfer to a level 1 trauma center. METHODS: All patients admitted to our level 1 trauma center for definitive management of either burn or maxillofacial injuries from September 1, 2004 to September 1, 2008, 2 years before and after transfer service initiation on September 1, 2006, were identified using the North Carolina Trauma Registry. Cohort demographics, referral patterns, transfer times/distances, and clinical outcomes were assessed. RESULTS: Burn patients increased from 1031 to 1208, from the 2 years before to after transfer center initiation. Average transport time increased from 113 to 165 minutes and average distance traveled increased from 84 to 86 miles. Out-of-state admissions increased from 24 to 46; number of referring counties increased from 58 to 60. Maxillofacial trauma patients increased from 390 to 576. Average transport time increased from 87 to 119 minutes, average distance increased from 84 to 89 miles, and number of referring counties jumped from 28 to 43. Length of stay did not change over the study period. CONCLUSIONS: The initiation of an independent call center, designed to facilitate the transfer of patients with burn and maxillofacial injuries to a level 1 trauma center, increased the number of referrals and expanded our geographic footprint, but did not decrease transport times.

Anatomic Optical Coherence Tomography (aOCT) for Evaluation of the Internal Nasal Valve.

OBJECTIVES/HYPOTHESIS: To establish the utility of anatomic optical coherence tomography (aOCT) in evaluating internal nasal valve (INV). STUDY DESIGN: Anatomic specimen imaging study. METHODS: Fresh-harvested human specimen heads were evaluated using both computed tomography (CT) imaging as well as using aOCT. Scans were performed at three time points: 1) After septoplasty for cartilage harvest, 2) after placement of butterfly graft (BFG), and 3) after placement of bilateral spreader grafts (SG). Imaging data were then converted into 3D models of the nasal airway. CT- and aOCT-generated models were compared by both static volumetric analysis and computational fluid dynamics (CFD) to predict nasal resistance and pressure. RESULTS: Scans using aOCT showed comparable results to CT in terms of volumetric parameters both before and after intervention. Analysis of aOCT data by CFD demonstrated decrease in pressure after SG or BFG intervention. No statistically significant difference was observed when comparing CT- and aOCT-generated calculations of pressure or resistance. CONCLUSION: The INV can be imaged in a static fashion using aOCT technology. Advantages over traditional CT imaging include lack of exposure to radiation and rapid scan time. In addition, in-office use is possible as aOCT technology develops. Further investigation will be necessary to define the role of aOCT in the dynamic evaluation of this vital component of the nasal airway. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:2148-2156, 2022.

Auricular avulsion injuries and reattachment techniques: A systematic review.

OBJECTIVES: Multiple surgical techniques exist in the acute management of auricular avulsion injuries, including reattachment of the tissue as a composite graft, reconstruction using local skin flaps, the pocket principle, the Baudet method, and microvascular repair. This review aimed to compare the success rates of reattachment methods in auricular avulsion injuries. METHODS: A PubMed search systematically identified cases in which (a) an auricular avulsion injury occurred and (b) reattachment was attempted. Search results were combined with an extensive review of references from published studies. In total, 148 cases were identified. Three reviewers independently graded the final aesthetic result of each case using a 5-point scale. The average grade of each repair was compared to the reattachment method to identify successful techniques. RESULTS: Microvascular repair was associated with a statistically significant higher success rate compared to all other reattachment methods. Composite graft reattachment also tended to generate better final aesthetic outcomes, but this difference was not statistically significant. CONCLUSION: Microvascular repair of the avulsed segment consistently demonstrated higher success rates. Composite graft reattachment should also be considered under the right circumstances. Overall, microvascular repair and composite graft reattachment should be considered the best options in cases of auricular avulsion repair. The authors share a major concern that other methods that rely on the use of periauricular skin will compromise any future attempts for secondary reconstruction, such as staged procedures using costal cartilage grafts. Manipulation of these tissues and in particular burying of the avulsed ear cartilage is discouraged. LEVEL OF EVIDENCE: 4.

Nasal Airflow Changes With Bioabsorbable Implant, Butterfly, and Spreader Grafts.

OBJECTIVES/HYPOTHESIS: Internal nasal valve compromise is a major cause of nasal obstruction, with a growing number of ways to treat this condition. In this study, we compared the effects of butterfly graft, spreader graft, and the bioabsorbable nasal implant on nasal airflow resistance. STUDY DESIGN: Cadaver study. METHODS: Computational fluid dynamics (CFD) simulations were completed from nine preoperative and postoperative cadaveric subjects. Each cadaveric head underwent placement of a bioabsorbable nasal implant (BNI) (Spirox Latera; Stryker ENT, Plymouth, MN), butterfly graft, or spreader graft. Pre- and postoperative computed tomography (CT) scans were used to generate three-dimensional models of the nasal airway used in steady-state CFD simulations of airflow and heat transfer during inspiration. RESULTS: Butterfly graft placement resulted in a mean improvement in nasal airway resistance of 24.9% (±7.3), whereas BNI placement resulted in a 6.7% (±1.2) improvement, and spreader graft placement also resulted in a consistent improvement of 2.6% (±13.5). Pressure within the main nasal cavity was consistently lower following butterfly graft placement versus a spreader graft or BNI. Butterfly and spreader graft placement also resulted in modest improvements in airflow allocation, whereas BNI demonstrated more variation (-1% to 12%). Heat flux was not significantly different; however, a small improvement in total heat flux was seen with all three interventions. CONCLUSIONS: The results of this study demonstrate reduction in nasal airway resistance in all three surgical interventions, with the butterfly graft demonstrating superiority to the other two techniques. However, these data only reflect a static environment and not dynamic changes in airflow seen during respiration. LEVEL OF EVIDENCE: NA Laryngoscope, 130:E817-E823, 2020.

Reconstruction of Defects Involving the Lip and Chin.

Successful perioral reconstruction is the result of consideration of both functional and esthetic goals. The lips are complex esthetic units with multiple tissue layers and distinct anatomic landmarks. Reconstruction can be difficult due to variables affecting the defect, such as size, depth, location, and involvement of adjacent subunits. There are many local flaps that can be used to match the complex tissue layers and anatomic landmarks. Use of the same reconstructive principles can be applied to secondary reconstruction to attain a successful outcome. This article focuses on local reconstructive options for defects of the lip and chin.

Comparison of Airflow Between Spreader Grafts and Butterfly Grafts Using Computational Flow Dynamics in a Cadaveric Model.

IMPORTANCE: Nasal valve compromise is a major cause of nasal obstruction, and multiple methods have been developed to address it. OBJECTIVE: To compare nasal airflow resistance, airflow partitioning, and mucosal cooling (heat flux) before and after 2 surgical interventions, butterfly and spreader graft placement, used to treat nasal valve compromise. DESIGN, SETTING, AND PARTICIPANTS: In this cadaveric tissue study, 4 fresh cadaveric heads underwent both spreader graft and butterfly graft surgical procedures in alternating sequence in March 2016. Preoperative and postoperative computed tomographic scans were used to generate 3-dimensional (3-D) models of the nasal airway. These models were then used in steady state computational fluid dynamics simulations of airflow and heat transfer during inspiration. INTERVENTION: Butterfly and spreader graft techniques. MAIN OUTCOMES AND MEASURES: Nasal airflow resistance, airflow partitioning, and heat flux. RESULTS: Donors 1, 2, and 3 were white males; donor 4, a white female. Computational fluid dynamics simulations during inspiration in 3-D models generated from preoperative and postoperative computed tomographic scans of the 4 cadaveric heads indicated reductions from preoperative values in nasal airflow resistance associated with both butterfly grafts (range, 20%-51%) and spreader grafts (range, 2%-29%). Butterfly grafts were associated with a greater reduction in nasal airflow resistance in models of all 4 cadaveric heads. Changes from preoperative values for heat flux, a biophysical variable that correlates with the subjective sensation of nasal patency, were more variable, ranging from -11% to 4% following butterfly grafts and -9% to 10% following spreader grafts. The preoperative airflow allocation in the left and right nostrils improved consistently with the butterfly graft. With the spreader graft, there were improvements for donors 1 and 4, but the allocations were worse for donors 2 and 3. CONCLUSIONS AND RELEVANCE: The results of this study suggest that the more recently developed butterfly graft technique may be associated with a similar level of improved nasal airflow as that observed with the use of a spreader graft in nasal valve compromise. Both interventions were associated with comparable changes in heat flux. Because this study addressed only static internal nasal valve stenosis, even greater differences in air flow and heat flux between the 2 techniques may be anticipated in a dynamic model. Further investigation in patients is warranted. LEVEL OF EVIDENCE: NA.

Correction: Molecular Subtypes in Head and Neck Cancer Exhibit Distinct Patterns of Chromosomal Gain and Loss of Canonical Cancer Genes.

[This corrects the article DOI: 10.1371/journal.pone.0056823.].

Reconstruction of nasal defects: contemporary approaches.

PURPOSE OF REVIEW: There are many well-established principles and surgical techniques for nasal reconstruction. The purpose of this study is to describe contemporary reconstruction of nasal defects. The unique anatomic features of the nose make this a challenging task. Although obtaining an optimal esthetic result is always the goal of reconstruction, maintenance and restoration of nasal function are of equal importance. RECENT FINDINGS: The first step of nasal reconstruction is a thoughtful analysis of the defect. The best surgical option will provide the patient with an excellent esthetic result and nasal function. Depending upon the extent of the defect as well as the anatomic site, a local flap, full-thickness skin graft, composite graft, or interpolated flap will provide the optimal result. The decision will depend on the surgeon's experience and expertise, as well as expectations and desires of the patient. Many cutaneous defects will require not only reconstruction of the defect, but also cartilage grafts to provide nasal contour and support. Most large or complex defects will require a paramedian forehead flap for reconstruction along with cartilaginous and/or bony support, as well as a lining flap. SUMMARY: This study highlights recent advances in nasal reconstruction and novel modifications of well-accepted traditional techniques.