A systematic review of the surgical techniques for the treatment of internal nasal valve collapse: where do we stand?

BACKGROUND: A myriad of interventions have been described to address the restoration or preservation of the internal nasal valve, the narrowest portion of nasal airway. OBJECTIVE OF REVIEW: To review systematically available knowledge and evidence about management options of the collapse of the internal nasal valve area. TYPE OF REVIEW: Systematic review. SEARCH STRATEGY: A MEDLINE, EMBASE, Cochrane Library and CENTRAL database search, followed by extensive hand searching for the identification of relevant studies. EVALUATION METHOD: Review of all English-language studies addressing the treatment of the internal nasal valve collapse. RESULTS: Fifty-three studies were eventually identified and systematically reviewed. The majority (50 of 53) of the included articles are graded as level IV evidence and only one randomised trial was identified. The included randomised study reported no significant difference in improvement between the intervention group (autospreader flap) and placebo arms. The majority of the included studies presented in this systematic review provide level IV evidence concerning the optimal approach for cases of nasal valve collapse. Current research is driven more by reports of techniques than patient outcomes. CONCLUSIONS: Proper evaluation and identification of the cause of the internal nasal valve collapse is paramount prior to selection of the preferred surgical solution. The three-dimensional construction of the nasal valve implies that many pathologies cannot be restored by a single solution. Treatment approaches should be directed at specific involved sites. Present systematic review of the literature revealed that the available evidence is based on low-level studies and focuses more on the description of various surgical techniques rather than on patient-reported outcome measures. Future studies are needed, including homogenous patient groups, comparing different surgical techniques and incorporating patient-reported outcome measures.

Rhinological interventions for obstructive sleep apnoea - a systematic review and descriptive meta-analysis.

OBJECTIVES: Obstructive sleep apnoea is a common chronic sleep disorder characterised by collapse of the upper airway during sleep. The nasal airway forms a significant part of the upper airway and any obstruction is thought to have an impact on obstructive sleep apnoea. A systematic review was performed to determine the role of rhinological surgical interventions in the management of obstructive sleep apnoea. METHODS: A systematic review of current literature was undertaken; studies were included if they involved comparison of a non-surgical and/or non-rhinological surgical intervention with a rhinological surgical intervention for treatment of obstructive sleep apnoea. RESULTS: Sixteen studies met the selection criteria. The pooled data suggest that there are reductions in the apnoea/hypopnea index and respiratory disturbance index following nasal surgery. However, the current body of studies is too heterogeneous for statistically significant meta-analysis to be conducted. CONCLUSION: Nasal surgery may have limited benefit for a subset of patients based on current evidence.

How advances in light technology have shaped ENT.

The development of light technologies, allowing anatomical visualisation of otherwise hidden structures, led to significant advances in ENT in the nineteenth and twentieth centuries. Natural light from the sun, and from candles, was initially harnessed using mirrors. Later, the invention of limelight and electricity preceded the emergence of the modern-day endoscope, which, in tandem with the discovery of coherent fibre-optics in the 1950s, significantly expanded the surgical repertoire available to otolaryngologists. This study aimed to trace the rich history of ENT through the specialty's use of light.

A case of oropharyngeal bullous pemphigoid presenting with haemoptysis.

Objective. Bullous pemphigoid is well known for its cutaneous features; however in rare cases it may present with mucosal involvement. We report a case of bullous pemphigoid presenting with haemoptysis, initially presenting to the Ear, Nose and Throat Department for investigation. Methods. An 87-year-old lady was admitted with haemoptysis. She also complained of a spreading, pruritic, bullous rash, which first began three weeks previously. Initial investigations, which included nasendoscopy, revealed a normal nasal mucosa and a normal postnasal space. A large deroofed blister was observed on the soft palate. The presenting symptoms and signs raised the suspicion of an immunobullous disease including bullous pemphigoid. Conclusion. Bullous pemphigoid (BP) is a subepidermal immunobullous disease that typically manifests in elderly patient populations. Although rare, BP can present in a mucocutaneous fashion akin to its more aggressive variant, mucous membrane pemphigoid (MMP). Differentiation of the two is based on clinical grounds, with the prevailing feature for the latter being the predominance of mucosal involvement, which may be extensive. The mainstay of treatment for bullous pemphigoid is steroid therapy, which may be administered both topically and systemically. A deeper understanding into the pathophysiology of the various immunobullous diseases may assist in our understanding of how the various disease entities manifest themselves.

Regenerative medicine in otorhinolaryngology.

BACKGROUND: Tissue engineering using biocompatible scaffolds, with or without cells, can permit surgeons to restore structure and function following tissue resection or in cases of congenital abnormality. Tracheal regeneration has emerged as a spearhead application of these technologies, whilst regenerative therapies are now being developed to treat most other diseases within otolaryngology. METHODS AND RESULTS: A systematic review of the literature was performed using Ovid Medline and Ovid Embase, from database inception to 15 November 2014. A total of 561 papers matched the search criteria, with 76 fulfilling inclusion criteria. Articles were predominantly pre-clinical animal studies, reflecting the current status of research in this field. Several key human research articles were identified and discussed. CONCLUSION: The main issues facing research in regenerative surgery are translation of animal model work into human models, increasing stem cell availability so it can be used to further research, and development of better facilities to enable implementation of these advances.

Gay men, sexual risk and therapy.

AIDS: Risk reduction must go beyond safe sex guidelines and encompass the ongoing process of sexual negotiation. Therapists can play a role in assisting clients to safely navigate sexual activity. Several case scenarios of therapy related to sexual risk, particularly among gay and bisexual men, are discussed. For the sexually compulsive client, sex often camouflages depression, hopelessness, anxiety, or rage. Alan, a 41-year old seronegative lawyer, presents with complaints about compulsive, high-risk sex. His therapist might negotiate a contract around sexual acting out, interpret and explore the specific meanings of acting out, and suggest the possibility of couples' counseling. The second case scenario involves an uninfected couple, Phil and Tom, who are exploring non-monogamy. The therapist can assist the couple in negotiating a relationship contract that requires the trust that partners will keep their agreements and disclose breaches in sexual behavior. Sam and Peter, a second couple, are having a problem with sexual negotiation. Sam wants to have unprotected sex with Peter. Peter is angry that unsafe sex is so important to Sam. Their therapist needs to explore individual and relationship issues, educate them about the meanings of sexual behaviors, and address the level and history of trust in the relationship. Overall, to help clients navigate sexual activity, therapists must blend together their clients' psychodynamic histories, the social meaning of sex for gay men, and the medical and ethical context in which particular behaviors take place.^ieng

Achieving flying colours in surgical safety: audit of World Health Organization 'Surgical Safety Checklist' compliance.

OBJECTIVE: The World Health Organization 'Surgical Safety Checklist' has been adopted by UK surgical units following National Patient Safety Agency guidance. Our aim was to assess compliance with our local version of this Checklist. METHODS: Otolaryngology trainee doctors prospectively assessed compliance with the local Checklist over a six-week period. A staff educational intervention was implemented and the audit was repeated 12 months later. RESULTS: A total of 72 cases were assessed. The initial audit found that: 44 per cent of procedures were undocumented at 'Sign in'; 'Time out' was inappropriately interrupted in 39 per cent of cases; the procedure started before Checklist completion in 33 per cent of cases; and the 'Sign out' was not read out in 94 per cent of cases and was not fully documented in 42 per cent of cases. Following education, re-audit indicated that overall compliance had improved from 63.7 per cent (± 8.9 per cent standard error of the mean) to 90.4 per cent (± 2.7 per cent standard error of the mean). CONCLUSION: Our completed audit cycle demonstrated a significant improvement in Checklist compliance following educational intervention. We discuss barriers to compliance, as well as strategies for quality improvement, and we call for other surgeons to similarly publish their Checklist experience and assess its impact on surgical outcomes.

Prospective, randomised controlled trial comparing intense endoscopic cleaning versus minimal intervention in the early post-operative period following functional endoscopic sinus surgery.

OBJECTIVE: There is currently no standardised management protocol following functional endoscopic sinus surgery. This study assessed frequent endoscopic cleaning versus minimal intervention in the early post-operative period following such surgery. STUDY DESIGN: Prospective, randomised controlled, single-blinded, within-subject trial involving 24 patients with bilateral chronic rhinosinusitis undergoing bilateral functional endoscopic sinus surgery. MAIN OUTCOME MEASURE: The primary outcome measure was ethmoid cavity healing, based on endoscopic appearance, graded using a modified Lund-MacKay endoscopic score. SECONDARY OUTCOME MEASURE: Lund-MacKay symptom score before and after surgery. RESULTS: There was no overall statistically significant difference between the two groups (p = 0.37). Subgroup analysis revealed a significant effect of regular suction clearance on adhesions at three months (p = 0.048), but not on oedema, polyps, granulation, discharge or crusting. CONCLUSION: There is no evidence from this study to support frequent endoscopic cleaning in the early post-operative period after functional endoscopic sinus surgery. Less intensive post-operative management is recommended, resulting in decreased patient morbidity and fewer post-operative follow-up appointments.

A retropharyngeal multinodular goitre.

Thyroid goitre usually presents as a mid-line lump in the neck with or without compressive symptoms. More commonly, the goitre can extend inferiorly into the mediastinum resulting in a retrosternal goitre. We present an unusual case of goiterous enlargement of the thyroid gland into the retropharyngeal space presenting as a retropharyngeal mass.

Titanium mini-plate for securing septal cartilage--a case of high-impact nasal trauma.

A technique is presented of securing the cartilaginous nasal septum using titanium mini-plates in the repair of a complex open comminuted type I nasoethmoid fracture, with internal impaction of the external cartilaginous nose. This technique allows primary skin closure and obviates the need for external metal-work and the attendant potential complications.

Wegener's granulomatosis of the orbit: two cases requiring endoscopic surgical decompression.

OBJECTIVES: We report two unusual and contrasting cases of Wegener's granulomatosis involving the orbit, requiring urgent endoscopic orbital decompression surgery. CASE SERIES: Both patients presented with an acute deterioration in visual function which failed to improve with medical management. Case one presented with systemic features of the condition, in contrast with case two, who presented with a more localised form of the disease. Whereas case one exhibited primary orbital disease with maxillary sinus extension (i.e. focal disease), case two illustrates orbital involvement secondary to sinus disease extension (i.e. contiguous disease). Prompt diagnosis, assisted by the presence of systemic features, led to a good visual outcome in case one. In case two, in which diagnosis was difficult and surgery delayed, the outcome was poor. CONCLUSIONS: These cases of orbital Wegener's granulomatosis illustrate the diagnostic challenge, the requirement for early intervention following acute visual deterioration and the importance of heightened awareness of the rarer ENT manifestations of this disease.