The Yin and Yang of Primary Unilateral Cleft Lip and Nose Repair: Balance through Opposing Cleft and Noncleft Side Changes.

BACKGROUND: Balance is achieved through opposing interactions. Objective three-dimensional assessment of changes during surgical treatment of the unilateral cleft lip and nasal deformity are limited, and false assumptions may prevent optimal management. METHODS: The authors performed anthropometric analysis on the immediate preoperative and postoperative images (captured under anesthetic) of patients undergoing primary repair ( n = 36). Changes in dimensions and measures of balance were assessed ( P < 0.05). RESULTS: Angles and ratios that reflect cleft to noncleft side balance normalized, although alterations occurred in opposing ways. Centralization of the columella narrowed the cleft nasal base and widened the noncleft nasal base. As the cleft columellar height elongated, the noncleft columellar height shortened. With these changes and correction of cleft alar base retrusion, the cleft alar dome was raised. The cleft and noncleft lateral lip heights and widths elongated. Meanwhile, the Cupid's bow broadened as the commissures were drawn closer together. Whereas the cleft philtral height lengthened, the noncleft philtral height shortened. Reduction in noncleft philtral height averaged 20% but varied with measures of preoperative severity including columellar angle ( R = 0.67), the difference in philtral heights ( R = 0.65), and lateral deviation of the subnasale ( R = 0.74). CONCLUSIONS: Tissue does not need to be added to "lengthen" the columella, the noncleft philtral height shortening can be estimated, and the contours of anatomic subunits change with surgery on both cleft and noncleft sides. It is inadequate to focus on correction of the cleft side alone without considering corresponding noncleft side changes. Achieving balance through opposing alterations should be the principal goal of treatment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Choice of Single-Staged Reconstruction of Nasal Defect.

INTRODUCTION: The nasal defect is still a challenge for plastic surgeon now. Many surgical options are reported in previous literatures. There are few studies reported about the 1-staged repair of large nasal defect. In this article, the authors describe the experience about the nasal reconstruction in the last 8 years. PATIENTS AND METHODS: Fifty-two patients diagnosed with nasal defect were retrospectively examined between 2011 and 2018. All of them performed under local anesthesia and received 1-staged surgical method. RESULTS: In the authors' patients, the mean size of the defect was 2.16 cm. Nine patients were treated by nasolabial flap, and 30 patients were treated by local flap. The modified auricular composite tissue flap was used in 5 patients. There were no major postoperative complications. All patients were satisfied with aesthetically nasal contours as well as inconspicuous scars when follow-up. CONCLUSION: Single-staged reconstruction is still considered the first choice for nasal defect. The design of flap depends on the surrounding condition and the size of defect. Locoregional flaps are still considered as an ideal choice for nasal reconstruction in most patients. O-Z flap and modified auricular free flap could be an option for large-sized defect of nasal alar and nasal tip.

Nonpharmacological Relaxation Technology for Office-Based Rhinologic Procedures.

BACKGROUND: Office-based rhinologic procedures are increasingly performed to control costs and enhance patient convenience. Adequate management of pain and anxiety is essential for the technical performance of these procedures, in addition to ensuring patient comfort. Pharmacologic agents are often used to manage anxiety and pain. Nonpharmacological adjuncts may be useful for achieving these effects without oral opioids and benzodiazepines. METHODS: Charts of patients who underwent office-based rhinologic procedures with the NuCalm system (Solace Lifesciences, Inc., Wilmonton, DE, USA) in combination with local anesthesia were reviewed. NuCalm is a proprietary system that combines cranial electrotherapy stimulation, neuroacoustic software, light-blocking lenses, and topical γ--aminobutyric acid. Patients rated their pain and anxiety before, during, and after the procedure. RESULTS: Twenty-five patients underwent office procedures using the NuCalm system. Preoperative anxiety (2.00) was significantly higher than postoperative anxiety (1.25) according to patient reporting on a 5-point scale (p = 0.005). Preoperative pain (1.83) was not significantly different from intraoperative (2.54) and postoperative pain (2.04, p = 0.054). CONCLUSIONS: A variety of office-based rhinologic procedures are technically feasible and can be performed with adequate patient comfort without the use of oral drugs. Adjuncts to pharmacologic agents may enhance pain control and anxiety management and improve patient tolerance of these procedures.

Hyperbaric oxygen therapy for wound breakdown after oronasal fistula and cleft palate repair: four cases.

We offer the first report of hyperbaric oxygen (HBO2) therapy to treat early surgical wound breakdown after oronasal fistula and cleft palate repair in the pediatric population. We present four patients' experiences after undergoing HBO2 therapy. HBO2 was initiated as soon as an oronasal fistula was identified. Three of the children underwent 10 HBO2 treatments with the fourth undergoing 11 treatments. There were no adverse effects during treatment; none of the patients required decompressive myringotomy. Follow-up shows portions of the repair have been salvaged by initiating HBO2 at the first sign of fistula formation. In our case series, the fistulas all decreased in size over the course of treatment and demonstrated granulation tissue at the wound edges. Given the positive outcomes from our preliminary results, our results suggest concurrent usage of HBO2 therapy for wound breakdown after cleft palate repair is an effective treatment option.

[Clinical observation on controlling antihypertension with the general anesthesia of TEAS and anesthetics in endoscopic endonasal surgery].

OBJECTIVE: To study whether the dose of controlling antihypertensive drug is reduced by transcutaneous electrical acupoint stimulation (TEAS) and the anesthetics, as well as the control of blood pressure (BP) and heart rate (HR) in endoscopic endonasal surgery with general anesthesia. METHODS: Sixty patients for selective endoscopic endonasal surgery with general anesthetics and controlling antihypertension involved were selected and randomized into a TEAS group, a sham-TEAS group, 30 cases in each one. The electric pads were attached to bilateral Hegu (LI 4), Zusanli (ST 36), Sanyinjiao (SP 6) and Quchi (LI 11), stimulated with Hans-200 apparatus, 3 to 5 mA, 2 Hz/100 Hz in the TEAS group based on the patients' response to comfort. No electric stimulation was applied to the sham-TEAS group. The general anesthesia started after 30 min intervention and lasted till the end of surgery. The BP and HR were observed and recorded at the end of monitoring in operation room, 10 min after tranquilization (T0), 30 min after intervention (Tj, after induction~of general anestiesa (T2), 30 min after surgery start (T3), 60 min after surgery start (T4) and 30 min after extubation (T5). The doses of vecuronium bromide, propofol and nitroglycerin were recorded statistically in surgery, as well as the operative bleeding volume, the operative time, the resuscitation time and the visual analogue scale (VAS) score after resuscitation. RESULTS: Compared with that at T0, the mean arterial pressure (MAP) at T2, T3, T4 and T5 in the TEAS group and at T3 and T4 in the sham-TEAS group was all reduced, indicating the significant difference (all P < 0.01). MAP at T2 and T5 in the TEAS group was lower than that in the sham-TEAS group (both P < 0.01). Compared, with that at T5, except at T2 in the TEAS group (P<0. 05), HR was not different significantly at the rest time points (all P > 0.05). HR was different at T2 to Ts in the sham-TEAS group statistically (all P < 0.01). The doses of vecuronium bromide, propofol and nitroglycerin, the operative bleeding volume, the operative time, the resuscitation time and VAS after resuscitation were not different significantly between the two groups (all P > 0.05). CONCLUSION: The general anesthesia with TEAS and anesthetics involved for controlling antihypertension contributes to the control of BP and HR in the patients in endoscopic endonasal surgery. The impacts are not obvious on the doses of antihypertensive drug, the general anesthetics, the operative bleeding volume, the time of resuscitation and the postoperative analgesia.

Effect of recombinant human bone morphogenetic protein-2 and Ling Zhi-8 on osteogenesis: a comparative study using a rabbit sinus model.

PURPOSE: This study evaluated the osteogenetic capability of Ling Zhi-8 (LZ-8; a protein purified from traditional Chinese medicine [lingzhi]) compared with recombinant human bone morphogenic protein-2 (rhBMP-2) in a standardized bony defect using a rabbit sinus model. MATERIALS AND METHODS: Twelve male New Zealand white rabbits (18 to 24 weeks old, 3.3 to 3.8 kg) were included in the study. Implants of normal saline 0.1 mg, rhBMP-2 0.1 mg, and LZ-8 0.1 mg were each mixed with a uniform biodegradable polyurethane-based material (Nasopore). The implants were inserted in a standardized bony defect of the nasal bone created by a 2.5-mm trephine bur. The rabbits were sacrificed at 1, 2, 4, and 8 weeks postoperatively. Volume computerized tomographic and histomorphometric examinations were used to evaluate the quantity and quality of regenerated bone. RESULTS: At postoperative week 4, radiography showed that the new bone volume was significantly larger in the rhBMP-2 group compared with the LZ-8 group (P = .041) and the control group (P = .015). Histomorphometrically, better wound healing of the rhBMP-2 group was found during the healing phase compared with the other 2 groups. CONCLUSION: The biomaterial implants using rhBMP-2 and LZ-8 had good biocompatibility and osteogenetic capabilities in the rabbit sinus model. Bone healing in rhBMP-2-treated defects was excellent and showed a significant difference compared with LZ-8. However, LZ-8-treated defects also exhibited bone regeneration, and this traditional Chinese medicine may possess osteogenic potential. Further investigations of the mechanism and application of this protein in osteogenesis are needed.

The role of alternative medicine in rhinology.

Complementary and alternative medicine (CAM) includes treatments from traditional Chinese medicine, homeopathy, naturopathy, herbal medicine, Ayurvedic medicine, mind-body medicine, chiropractic or osteopathic manipulations, and massage. More than 40% of patients in the United States use CAM, with 17% of CAM use related to otolaryngology diagnoses, but nearly half of CAM users do not communicate their use of these medications to their physicians. Perioperative risk of bleeding is a particular concern in surgical specialties, and knowledge of these therapies and their potential adverse effects is critical.

Long-term clinical results of radiofrequency tissue volume reduction for inferior turbinate hypertrophy.

OBJECTIVE: To investigate the long-term clinical results of radiofrequency tissue volume reduction for symptomatic inferior turbinate hypertrophy. STUDY DESIGN: Patients who were unresponsive to medical treatment (n = 197) received turbinate reduction using radiofrequency energy. Subjective symptoms were assessed using a 10 cm visual analogue scale, and all patients underwent acoustic rhinometry before the procedure and six, 24, 48 and 60 months afterwards. RESULTS: Of the 197 treated patients, 148 completed the protocol. No significant peri-operative complications were observed. Thirty-two patients required follow-up treatment. Significant improvements were seen in nasal obstruction and discharge scores and in acoustic rhinometry values, at six, 24, 48 and 60 months post-operatively, compared with pre-operative values (p < 0.001 and p < 0.05, respectively). CONCLUSION: Radiofrequency tissue volume reduction is an effective procedure for inferior turbinate hypertrophy. The clinical benefit of this procedure persisted 60 months after the procedure.

Regional nerve blockade prior to direct injection to achieve anaesthesia of the nasal ala.

BACKGROUND: Dermatological surgical procedures involving the nasal alae are commonplace in clinical practice. Direct infiltration of local anaesthetic into the nasal ala is extremely uncomfortable. OBJECTIVES: In this prospective clinical study, we investigate the effectiveness of alar anaesthesia provided by an infraorbital nerve block (IOB). METHODS: We recruited 100 consecutive patients requiring dermatological surgical procedures involving the nasal ala (or other sites necessitating an IOB). Following topical mucosal anaesthesia, an IOB was administered via the intraoral route. Effectiveness of anaesthesia was assessed after 10 min by testing the perception of a sharp stimulus at five standardized reference points on the nasal ala. If the ala was not completely anaesthetized, blockade of the external nasal branch of the anterior ethmoidal nerve (external nerve block, ENB) was performed. Sensation of the nasal ala was re-assessed after 10 min using the above method. RESULTS: Complete anaesthesia of the nasal ala was achieved with an IOB in 66 of 100 (66%) patients. Of the remaining 34 patients, the addition of an ENB achieved complete anaesthesia in 15 (44%). CONCLUSIONS: An IOB provides effective alar anaesthesia in the majority of patients. In those where it is ineffective for complete anaesthesia, an ENB is a useful adjunct. We recommend using an IOB (and ENB if required) prior to direct infiltration of local anaesthetic into the nasal ala to reduce patient discomfort.

Nitrous oxide for applying local anesthesia in nasal operations: a randomized placebo-controlled single-blinded study.

CONCLUSIONS: In our study setting nitrous oxide (N(2)O) did not show any clinical benefit in discomfort experienced when applying local anesthesia for nasal operations. Further studies with longer inhalation times are needed to elucidate the role of N(2)O in application of local anesthesia in nasal surgery. OBJECTIVES: N(2)O inhalation reduces the discomfort experienced in various medical procedures. The objective of this study was to assess the suitability of N(2)O inhalation before application of local anesthesia for nasal procedures in outpatient surgery. PATIENTS AND METHODS: This was a prospective, randomized, single-blinded, placebo-controlled study at the Helsinki University Central Hospital, Finland. Ninety patients were randomly divided into three groups. Group A inhaled 10 breaths of 50% N(2)O/50% O(2) through a nasal mask with a Porter 2000 MXR scavenging system before application of local nasal anesthesia, group B inhaled room air through the same mask and group C received only local anesthesia. A visual analog scale was used to assess pain, nausea, and discomfort related to the application of nasal anesthesia. RESULTS: The N(2)O inhalation was easy to perform and well tolerated. The N(2)O inhalation before applying local anesthesia for nasal operations did not show any significant additional benefit in reducing pain or discomfort.

Cocaine: what role does it have in current ENT practice? A review of the current literature.

Topical cocaine is used by many otorhinolaryngologists because of its good local anaesthetic and vasoconstrictive properties. A review of the available literature suggests a risk/benefit analysis would suggest that in the out-patient setting local anaesthetic agents which do not contain cocaine should be used. For rhinosurgical procedures, preparations containing cocaine and adrenaline in the appropriate concentrations and doseage are safe in the vast majority of patients without previous cardiac disease. The relative benefit of using cocaine in relation to other topical analgesics and vasoconstrictors in surgery remains unproven and alternative preparations should be used wherever there is concern over the cardiac status of the patient. It is important to be alert to the possibility that patients presenting with a septal perforation or destructive midfacial lesions may be suffering from an addiction to cocaine. It is important to arrive at the correct diagnosis in a destructive process and even in the presence of raised antineutrophilic cytoplasmic antibodies (ANCA) a diagnosis of cocaine abuse should actively be excluded.

The importance of rigid nasal endoscopy in the diagnosis and treatment of rhinolithiasis.

OBJECTIVES: Rhinolithiasis is the presence of mineralized and calcareous formations located in the nasal cavity. They have rare occurrence and can be easily confused with infection or obstruction of upper airways. If they are undetected for a long time, they may grow large enough to cause of nasal obstruction, mimicking sinusitis. Seven cases of rhinolithiasis were presented, and their diagnosis was made by rigid endoscopic nasal examination. Also computerized tomography scan was used to describe the size and site of the rhinoliths accurately. Our purpose was to determine the role of rigid nasal endoscopy in the diagnosis and the treatment of rhinolithiasis. METHODS: In this study, seven cases of rhinolithiasis, who were diagnosed and treated by rigid nasal endoscopy were presented. RESULTS: Between January 2000 and November 2004, seven cases (four males and three females; age ranged from 8 to 45 years) with rhinolithiasis were diagnosed. The most frequent symptoms were nasal obstruction with purulent rhinorhea, nasal and oral malodor. As complementary examinations, computerized tomography and simple X-ray of paranasal sinuses were used to locate and measure the dimension of calcareous mass, and to reveal possible invasion of the adjacent structures. The removal of rhinolithiasis was done with rigid nasal endoscopy under topical anesthesia in six cases and general anesthesia in one case. CONCLUSION: Rhinolithiasis is a rare condition but must always be suspected in patients with long standing nasal obstruction, nasal and oral malodor, purulent rhinorrhea and chronic headache.

Postrhinoplasty nasal cysts and the use of petroleum-based ointments and nasal packing.

Nasal cysts are rare complications of rhinoplasty, and numerous theories exist regarding their cause. The term "paraffinoma" has been used to describe cyst formation observed after topical antibiotic ointment application with nasal packing in the immediate postoperative period. Such complications are rare but may occur because of the inherent properties of the agent used or a lack of meticulous technique (in the placement of incisions and nasal packing). Three cases of postrhinoplasty cysts with a variety of presentations, including incidental intraoperative findings, bilateral medial canthal masses, and a draining dorsal cyst, are described. Although such cysts are uncommon, techniques to prevent these unwanted sequelae should routinely be used, with the judicious application of non-petroleum-based topical antibiotic preparations.

Does cocaine still have a role in nasal surgery?

Endonasal surgery is already very common and its importance is increasing. Successful anaesthesia in endonasal sinus surgery is of critical importance for the success of the procedure and many surgeons prefer to use cocaine for this purpose. However, there is a great body of evidence that suggests that use of cocaine, even in experienced hands, can cause rapid, unexpected and severe toxic reactions. Therefore, its use in endonasal surgery can no longer be recommended, especially since better tolerated alternatives are available for topical and infiltration anaesthesia. These alternatives include lidocaine (lignocaine) and tetracaine (pantocaine) in combination with epinephrine (adrenaline), naphazoline or oxymetazoline.

[Cocaine contact anesthesia for endonasal surgery. Kinetics and clinical tolerance of a concentrated solution]. / Anesthésie de contact à la cocaïne pour chirurgie endonasale. Cinétique et tolérance clinique d'une solution concentrée.

OBJECTIVE: To assess the pharmacokinetics and clinical tolerance of a 33% cocaine solution administered topically for intranasal surgery. STUDY DESIGN: Clinical prospective open trial. PATIENTS AND METHODS: Twelve ASA I patients scheduled for intranasal surgery were sedated with midazolam 2 mg and fentanyl 50 micrograms. Topical anaesthesia was obtained with aqueous 33% cocaine HCl 360 mg, lidocaine HCl 140 mg, adrenaline 0.04 mg and naphazoline 0.4 mg. Venous blood samples were taken before cocaine application and 15, 30, 45, 60, 90, 120, 150, 180, 240 min later. The plasma was immediately separated and the samples were frozen. The concentration of cocaine was measured by HPLC. Potential cardiotoxic and neurotoxic effects were clinically monitored. RESULTS: The mean dose of cocaine applied was 5.85 +/- 1.3 mg.kg-1 and the dose actually delivered was 4 +/- 1.5 mg.kg-1. The Cmax was 859 +/- 503 ng.mL-1 after a Tmax to 47 +/- 17 min. The mean elimination half-life was 87 +/- 19 min (mean +/- SD). The total clearance and the volume of distribution were respectively 4,521 +/- 1,858 mL.min-1 and 568 +/- 273 L. No clinical evidence of toxicity was found. CONCLUSIONS: This study shows that it is possible to perform major intranasal surgery under topical anaesthesia with a concentrated solution (33%) of cocaine at a high dose (6 mg.kg-1). These results differ completely with data obtained in addicts.

[Principles of rhinoplasty. THe "Indian" and "Italian" method]. / Grundlagen der Rhinoplastik. Die "indische" und die "italienische" Methode.

Enumeration of individual methods of rhinoplasty for total reconstruction of the nose does not lay claim to completeness. It is the sole purpose of this review to show that the development of rhinoplasty received its definitive origins about 600 BC ("Indian" method) and in the 15th century AD ("Italian" method). As a result of the need to reconstruct the external nose after its destruction from infectious diseases, injuries or tumors, various methods of rhinoplasty have evolved. As such, the history of reconstructive rhinoplasty is almost identical with that of plastic surgery. Since their introduction, adjacent flaps (Indian method) and distant flaps (Italian method) are still in use at the present time. Although India should be considered the cradle of rhinoplasty, further refinements must be credited to Italian surgeons who undoubtedly knew about the Indian method for rebuilding the nose.