The role of ANCA in the management of cocaine-induced midline destructive lesions or ENT pseudo-granulomatosis with polyangiitis: a London multicentre case series.

OBJECTIVE: In this multicentric study involving three London hospitals, we compared ANCA-positive and ANCA-negative cocaine-induced midline destructive lesions (CIMDL) patients to assess how presence of antineutrophil cytoplasmic antibodies (ANCA) may correlate with disease severity. Our secondary aims are to better classify etiology centered around ANCA positivity and, consequently, better disease management. METHODS: A retrospective review was performed to identify patients with CIMDL seen between January 2019 and December 2022. Population data including age, sex, presentation, endoscopic findings, duration of cocaine use and active use of cocaine, type of treatment, laboratory (including ANCA serology), radiological, and histological findings were collected. RESULTS: Forty CIMDL patients (25 male, median age of 42 years) were identified. The majority of them (72.5%) presented with either a septal perforation, a saddle nose deformity (22.5%), and/or a palatal fistula (20.0%). ANCA was positive in 71.1% of cases (66.7% p-ANCA). No statistically significant differences in the general characteristics, type of treatment, laboratory results, radiological or histological findings were observed when comparing ANCA-positive and ANCA-negative CIMDL patients or when comparing p-ANCA and c-ANCA patients. Similarly, no statistically significant difference was obtained when comparing the pattern of distribution of lesions between the two groups. CONCLUSIONS: A large percentage of CIMDL patients showed positive ANCA test (71.1%) and in the majority of the cases a p-ANCA pattern specifically targeting PR3 (p-ANCA, PR3 + MPO-). However, ANCA positivity or presence of a specific ANCA pattern was not associated with more severe presentation or more aggressive disease. Given its similarities to granulomatosis with polyangiitis (GPA), we recommend the use of the term "cocaine-induced ENT pseudo-GPA" instead of CIMDL. LEVEL OF EVIDENCE: IV Laryngoscope, 2023.

Nasal reconstructive surgery for vasculitis affecting the nose: our two-centre international experience.

PURPOSE: To recommend an international multidisciplinary medical and surgical algorithm of treatment in nasal vasculitis, which will create a more streamlined approach. METHODS: A two-centre, international retrospective analysis of granulomatosis with polyangiitis (GPA) and levamisole-associated vasculitis (LAV) cases presenting between 2005 and 2019 was carried out. Demographic data, and surgical and medical treatment were recorded. Patients' signs and symptoms were analysed, and recommended treatment strategies outlined with key surgical procedures described. RESULTS: Forty-one GPA patients and 11 LAV patients were included in the study with a mean age of 38.6 and 38.8 years, respectively. A stepwise surgical management approach with reconstructive options is described and includes: (1) examination under general anaesthesia, biopsy, and insertion of silastic nasal splints; (2) septal perforation repair (with caution); (3) mild-to-moderate saddle nose reconstruction with costal cartilage; (4) severe saddle nose reconstruction with osseocartilaginous rib grafts; (5) soft-tissue reconstruction techniques. CONCLUSIONS: The management of nasal vasculitis is a particular challenge in facial plastic surgery. It requires a close collaborative approach with a physician skilled in the medical management of vasculitis. Surgery must be planned judiciously, with realistic patient expectations and only after a sustained period of remission. For more severe saddle deformities, the modified osseocartilaginous Andrews technique gives excellent long-term results.

A pilot study to determine the effects of nasal co-phenylcaine on drug-induced sleep endoscopy.

PURPOSE: The use of nasal decongestant and nasal anaesthesia is currently not recommended during drug-induced sleep endoscopy (DISE) according to the European position paper. The evaluation of the effects of nasal decongestant/anaesthesia on DISE has not been performed before and our aim is to perform a pilot study to determine whether nasal decongestants/anaesthesia affects DISE outcomes. METHODS: 27 patients undergoing DISE for OSA or for simple snoring were included. On each patient, DISE was performed twice, before and approximately 10 min after the administration of two puffs of co-phenylcaine nasal spray (lidocaine hydrochloride 5%, phenylephrine 0.5%, and benzalkonium chloride 0.01%) into each nostril. A nasal peak inspiratory flow was used for the objective assessment of nasal airway obstruction. During the first and the second DISE the loudness of the snoring was also recorded. RESULTS: Change in DISE total grading after nasal spray administration was not statistically significant. For the same grading, changes in percentage of contribution to collapse were not statistically significant. Sex, AHI, BMI, tonsils grade, presence of rhinitis, turbinate hypertrophy, nasal septal deviation, or nasal peak inspiratory flow limitation had no influence on the effect of nasal spray. Co-phenylcaine did not significantly influence the loudness of snoring. CONCLUSIONS: Our pilot study supports the use of co-phenylcaine nasal spray during DISE and the positive effects of the nasal spray do not influence the grading outcome. Importantly, the decongestant enhances the nasal assessment during DISE and potentially aids in the diagnosis of nasal obstruction while the nasal anaesthetic component may be beneficial by reducing nasal discomfort during DISE and thereby helping to reduce the total dose of intravenous anaesthetic administered. However, further studies on a larger population are needed to confirm our results.

Revision Rhinoplasty: What Can We Learn from Error Patterns? An Analysis of Revision Surgery.

Of the many challenges in rhinoplasty, achieving a satisfactory outcome at the first operation is important. There are multiple reasons for secondary surgery, and generally revisions can be broadly classified into minor (often one area of deficit) or a total redo. Understanding the common technical reasons for failure in primary surgery by analyzing the deformities has resulted in various error patterns emerging. Understanding these patterns means we can modify techniques in primary surgery to reduce the incidence of revision. This article describes our prospective revision rhinoplasty experience over 5 and then 2 years, highlighting the main error patterns encountered. We also describe a stepwise analysis of four frequently encountered key problem areas alongside techniques to address them and offer pearls to help prevent further revision. Comparison of two cohorts of patients from a teaching hospital setting and private practice with the same operating surgeon indicates an increasing tendency to the open approach for revisions. The re-revision rates for these groups are 15.7 and 9%, respectively. Revision rhinoplasty is a difficult operation to perform to the satisfaction of both the surgeon and the patient. Understanding the common technical reasons for failure in primary surgery by fully analyzing the deformities means we can modify techniques in primary surgery to reduce the incidence of revision.

Patient aesthetic satisfaction with timing of nasal fracture manipulation.

Introduction. To determine patient cosmetic satisfaction following nasal fracture manipulation under general anaesthetic when offered at different time intervals after injury. Materials and Methods. Prospective chart review of adult patients with nasal fractures treated by closed reduction at a busy district general hospital in Greater London over a 10-month period. Patients were asked by a standardised telephone interview about satisfaction with nasal cosmesis pre- and postoperatively using a Likert scale. Results. Seventy-six of 106 patients presented for nasal manipulation at up to 9 weeks after injury and were successfully contacted (72%) postoperatively. Forty-nine patients (64%) reported that they still would have had the surgery in retrospect. Those done within 1-2 weeks after injury resulted in the highest mean satisfaction score (4.56 ± 0.25). There was a negative correlation between patient satisfaction and timing of surgery (ρ = -0.37, P = 0.001). Of the patients satisfied or very satisfied with their procedure, 96% had it done within 4 weeks. Conclusion. The majority of patients treated with closed reduction of nasal fractures under general anaesthetic are satisfied with the cosmetic outcome and would still have undergone surgery in retrospect. Increasing time of surgery after 2 weeks resulted in lower patient satisfaction.

A comparison of the voice handicap index-10 scores between medical and musical theater students.

OBJECTIVE: Elite professional voice users experience a high vocal load and if voice quality deteriorates, their livelihoods are affected. Our aim was to assess how an elite professional voice user group, musical theater students (n=49), perceive their voices in comparison with medical students (n=43). STUDY DESIGN: Cross-sectional study. METHODS: Participants completed a confidential questionnaire including demographics and the Voice Handicap Index-10 (VHI-10) in September 2010. RESULTS: Response rate was 100% (92/92). The mean age of the medical students was 25 years and of musical theater students was 20 years. The mean overall VHI-10 score was higher in musical theater students compared with that of medical students (mean score, 5.56 and standard deviation [SD], 4.13 vs mean score, 3.79 and SD, 3.02, P=0.02), particularly in three VHI-10 items: voice strain, lack of clarity, and being upset from voice problem (mean score, 0.82 and SD, 0.86 vs mean score, 0.44 and SD, 0.67, P=0.02; mean score, 0.92 and SD, 0.89 vs mean score, 0.53 and SD, 0.70, P=0.02; and mean score, 0.49 and SD, 0.79 vs mean score, 0.07 and SD, 0.26, P=0.001, respectively). Furthermore, musical theater students report higher possible voice problems in the past (6/43 [14%], 21/49 [43%], P=0.002). CONCLUSIONS: In this small group, musical theater students report more handicap compared with medical students. It is possible that this difference may be because of the musical theater students experiencing greater voice use over time or better recognition of potential voice problems. This may mean that we need to do more to protect student's voices by optimizing vocal care during their training, without neglecting the vocal needs of other students.