"Should Pediatric Septal Surgery and Septorhinoplasty Be Performed for Nasal Obstruction?"-A Systematic Review of the Literature.

Corrective septal surgery for children with nasal obstruction has historically been avoided due to concern about the impact on the growing nose, with disruption of midfacial growth. However, there is a paucity of data evaluating complication and revision rates post-nasal septal surgery in the pediatric population. In addition, there is evidence to suggest that failure to treat nasal obstruction in children may itself result in facial deformity and/or developmental delay. The aim of this systematic review is to evaluate the efficacy and safety of septal surgery in pediatric patients with nasal obstruction. A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. MEDLINE, Embase, and the Cochrane Library were searched. Original studies in pediatric patients (<18 years of age) with nasal obstruction were eligible for inclusion. Patients with cleft lip or palate as their primary diagnosis were excluded. Our primary outcomes were patient-reported outcome measures (PROMs), postsurgical complications, and revision rates. Secondary outcomes included surgical technique, anatomical considerations, and anthropometric measurements. Eighteen studies were included (1,080 patients). Patients underwent septoplasty, septorhinoplasty, rhinoplasty, or a combination of procedures for nasal obstruction. Obstruction was commonly reported secondary to trauma, nasal septal deviation, or congenital deformity. The mean age of the patients was 13.04 years with an average follow-up of 41.8 months. In all, 5.6% patients required revision surgery and there was an overall complication rate of 7.8%. Septal surgery for nasal obstruction in children has low revision and complication rates. However, a pediatric-specific outcome measure is yet to be determined. Larger prospective studies with long-term follow-up periods are needed to determine the optimal timing of nasal surgery for nasal obstruction in the pediatric population.

Description of a Novel Technique to Address Both External Nasal Valve Collapse and the Aesthetic of the Nasal Tip.

Severe concavity of the lateral crura can lead to an unsightly aesthetic deformity of the nasal tip and narrowing of the external nasal valve. Concurrently, if the lateral crura are structurally weak, this can lead to a functional issue. We report a previously undescribed technique of combining a lateral crural reversal with a turn-in flap. This achieves dual goals of aesthetic improvement and structural reinforcement, without the need for grafting.

Litigation in Septorhinoplasty Surgery: A Pan-Specialty Review of National Health Service (the United Kingdom) Data.

Success in septorhinoplasty surgery can be difficult to assess due to a lack of objective and measurable outcomes. If patients' expectations are not met, it places surgeons performing septorhinoplasty at risk of litigation which can be stressful and costly. The National Institute of health (NHS) Resolution is a government-funded organization in the United Kingdom that provides expertise to the NHS on resolving patient concerns. Data were requested from NHS Resolution for claims involving septorhinoplasty surgery over a period of 5 years between April 2015 and April 2020. Rhinoplasty claims performed by all specialties were included. Data included the claim status, incident details, alleged injury, damages claimed, and damages paid. A total of 31 claims were identified by the study, equating to a total cost of £1,347,336.10. Of the 31 claims for rhinoplasty or septorhinoplasty, 9 cases were open (29%, £962,361.00) and 22 cases were closed (71%, £384,975.10). The common causes for claims were "intraoperative problems (32%)," "failure to warn-informed consent (19%)," and "foreign body left in situ (13%)." The most common injuries were "cosmetic disfigurement (39%)," "unnecessary pain (29%)," and "additional/ unnecessary operation (29%)." This study highlights the need for improved awareness of clinical negligence claims among surgeons who perform septorhinoplasty. Results are applicable to all specialties who perform the procedure. The study highlights the importance of assessing patients' motives and expectations prior to surgery and emphasizes the need for a well-documented rigorous consent process.

Safety of day-case endoscopic sinus surgery in England: An observational study using an administrative dataset.

INTRODUCTION: As elective surgical services recover from the COVID-19 pandemic a movement towards day-case surgery may reduce waiting lists. However, evidence is needed to show that day-case surgery is safe for endoscopic sinus surgery (ESS). The aim of this study was to investigate the safety of day-case ESS in England. DESIGN: Secondary analysis of administrative data. METHODS: We extracted data from the Hospital Episodes Statistics database for the 5 years from 1 April 2014 to 31 March 2019. Patients undergoing elective ESS procedures aged ≥17 years were included. Exclusion criteria included malignant neoplasm, complex systemic disease and trans-sphenoidal pituitary surgery. The primary outcome was readmission within 30 days post-discharge. Multilevel, multivariable logistic regression modelling was used to compare outcomes for those operated on as day-cases and those with an overnight stay after adjusting for demographic, frailty, comorbidity and procedural covariates. RESULTS: Data were available for 49 223 patients operated on across 129 NHS hospital trusts. In trusts operating on more than 50 patients in the study period, rates of day-case surgery varied from 20.6% to 100%. Nationally, rates of day-case surgery increased from 64.0% in the financial year 2014/2015 to 78.7% in 2018/2019. Day-case patients had lower rates of 30-day emergency readmission (odds ratio 0.71, 95% confidence interval 0.62 to 0.81). Outcomes for patients operated on in trusts with ≥80% day-case rates compared with patients operated on in trusts with <50% rates of day-case surgery were similar. CONCLUSIONS: Our data support the view that ESS can safely be performed as day-case surgery in most cases, although it will not be suitable for all patients. There appears to be scope to increase rates of day-case ESS in some hospital trusts in England.

Appropriateness for SARS-CoV-2 vaccination for otolaryngologist and head and neck surgeons in case of pregnancy, breastfeeding, or childbearing potential: Yo-IFOS and CEORL-HNS joint clinical consensus statement.

PURPOSE: SARS-CoV-2 vaccines are a key step in fighting the pandemic. Nevertheless, their rapid development did not allow for testing among specific population subgroups such as pregnant and breastfeeding women, or elaborating specific guidelines for healthcare personnel working in high infection risk specialties, such as otolaryngology (ORL). This clinical consensus statement (CCS) aims to offer guidance for SARS-CoV-2 vaccination to this high-risk population based on the best evidence available. METHODS: A multidisciplinary international panel of 33 specialists judged statements through a two-round modified Delphi method survey. Statements were designed to encompass the following topics: risk of SARS-Cov-2 infection and use of protective equipment in ORL; SARS-Cov-2 infection and vaccines and respective risks for the mother/child dyad; and counseling for SARS-CoV-2 vaccination in pregnant, breastfeeding, or fertile healthcare workers (PBFHW). All ORL PBFHW were considered as the target audience. RESULTS: Of the 13 statements, 7 reached consensus or strong consensus, 2 reached no consensus, and 2 reached near-consensus. According to the statements with strong consensus otorhinolaryngologists-head and neck surgeons who are pregnant, breastfeeding, or with childbearing potential should have the opportunity to receive SARS-Cov-2 vaccination. Moreover, personal protective equipment (PPE) should still be used even after the vaccination. CONCLUSION: Until prospective evaluations on these topics are available, ORL-HNS must be considered a high infection risk specialty. While the use of PPE remains pivotal, ORL PBFHW should be allowed access to SARS-CoV-2 vaccination provided they receive up-to-date information.

Early Outcomes of Emergency Surgery for Left-Sided Mechanical Valve Thrombosis.

BACKGROUND: Valve thrombosis is a potentially lethal complication of mechanical cardiac valves. We examined the clinical characteristics as well as the early outcomes of patients undergoing emergency surgery for left-sided mechanical valve thrombosis. METHODS: Between January 2012 and May 2020, 104 consecutive patients were offered an emergency redo surgery for acute mechanical valve thrombosis. Ninety-seven of these patients were included in the current study. RESULTS: The mean age was 34.2 ± 10.3 years. Most of the patients were females (61 patients), and 27 patients (27.8%) were pregnant. The mitral valve was the site of thrombosis in 81 patients. Inadequate anticoagulation was found in 60.8% of patients. The overall early mortality was 32.9% (32 patients) with an operative mortality of 25.7%. Outcomes in the pregnant subgroup tended to be worst with a maternal mortality in the range of 37%, and with fetal and neonatal survival as low as 33.3%. CONCLUSION: The overall mortality in cases of mechanical valve thrombosis warranting surgery remains high. Since inadequate anticoagulation seems to be one of the major precipitating factors, the current study highlights the need for improvements in anticoagulation practices. The use of tissue valves should also be contemplated more seriously in some younger patients, especially females expressing the desire for future pregnancies.

Restoring Balance and Symmetry to the Aging Nose.

Accurate assessment of facial symmetry is a key component of successful rhinoplasty surgery but is often overlooked by both surgeon and patient. Up to three-quarters of patients with a significantly crooked nose have been found to have concurrent marked facial asymmetry. Whilst not a contraindication to rhinoplasty, provided that facial asymmetry is identified in advance and expectations realistic, the correction of nasal deformities can improve perceived facial asymmetry. In the aging face, aside from soft tissue and bony resorption that can amplify facial asymmetry, there are specific surgical challenges to the aging nose; the normal tip support mechanisms deteriorate with age giving rise to distinctive changes to the aging nose-typically tip ptosis and a hanging columella; bone quality becomes more brittle and skin overlying this area becomes thinner. There is also weakening of the external nasal valve thus causing functional impairment too. As a result, rhinoplasty techniques used in younger patients may not be suitable in the aging nose. In this article, the authors describe their experience and outline the evidence on the management of the aging patient with facial and nasal asymmetry.

The Evidence Base for the Benefits of Functional Septorhinoplasty and its Future Post COVID-19.

Ever since the introduction of the concept of Procedures of Limited Clinical Value (PoLCV), procedures such as functional septorhinoplasty have been subject to additional funding restrictions within the British National Health Service. Recent publications have suggested that 10% of Clinical Commissioning Groups in the United Kingdom no longer fund septorhinoplasty surgery irrespective of the indications, including congenital malformations or post-trauma, and despite the strong evidence available in the literature in treating a range of health conditions. Thus, inequity exists across the country. At present functional septorhinoplasty surgery is frequently but incorrectly grouped together with aesthetic rhinoplasty, both of which are deemed to be cosmetic interventions. Moreover, as we exit the peak of the current coronavirus disease 2019 (COVID-19) pandemic, procedures deemed to be of lower clinical priority will potentially be at risk throughout Europe. The purpose of this review is twofold; the first is to put forward the evidence to commissioners in favor of functional septorhinoplasty surgery on patient well-being and mental health; the second is to demonstrate why functional septorhinoplasty surgery is a distinct procedure from aesthetic rhinoplasty and why it ought not to be classified as a procedure of limited clinical value.

A national survey of functional septorhinoplasty surgery performed in the United Kingdom: a clinician end-user questionnaire to assess current practice and help inform future practice.

PURPOSE: The aim of this national survey is to assess the current practice of functional septorhinoplasty (SRP) surgery in the UK and better inform future practice. METHODS: An ENT-UK approved questionnaire was sent out to all 135 consultant members of the British Society of Facial Plastic Surgery (BSFPS). Data was collected on numbers of functional SRPs performed on the NHS, use of outcome measures, psychology and photography support, antibiotic use, referral base and consenting practice. RESULTS: The response rate was 38.5%, with 52 out of 135 completed. The median number of annual SRP cases per surgeon was 40. Most surgeons (95%) used clinical photography as an outcome measure. However, 27% of the respondents use a subjective outcome measurement and 3% of them use an objective outcome measurement. Only 34% had access to psychology support and 60% receive their referrals from primary care. All surgeons counsel patients for aesthetic change, 15% mention CSF leak and 38% mention olfactory disturbance. The key comment from our respondents was to relabel the rhinoplasty procedure as a functional SRP procedure with the aim to remove it from the Procedures of Limited Clinical Value (PoLCV) list. CONCLUSION: The majority of our respondents perform a large proportion of the SRP surgeries in the UK with each of the respondents performing an average of 40 SRP surgeries per year. There is a need to recatergorise functional septorhinoplasty as a functional operation and recommend functional SRP surgery to be removed from the PoLCV list.

Outcomes in Rhinoplasty.

In recent years, there is an increasing trend to use health-related quality of life questionnaires after surgical procedures. The idea is to prove the success of an operation by objectively measurable parameters. Rhinoplasty is by far the most frequently performed surgery of facial plastic surgery. One of the most difficult parts of rhinoplasty is to measure the outcomes after surgery. Rhinoplasty is a unique operation because the surgeon affects three aspects: shape, function, and psychology of the patient. In an ideal world, the surgeon should have objective means of screening that cover these three aspects before and after surgery to measure outcomes. The goal of this article is to review these tools and compare them.

Postoperative Care in Aesthetic Rhinoplasty Patients.

After rhinoplasty, during the first 24 hours, the patients should be closely monitored for pain and discomfort, nausea and vomiting, and cool compresses must be applied regularly to decrease edema and ecchymosis. In the early postoperative period of the first month, the sutures, cast, and splints are usually removed during the first week. Then the patient is followed-up at 1, 3, 6, and 12-month intervals routinely to observe healing. In the meantime, any kind of intranasal and extranasal complications should be noted. The outcome measures such as ROE, NOSE, or SCHNOS should be used 3 to 6 months after surgery. If the patient is closely followed-up, then any unwanted complication or dissatisfaction can be solved after 6 to 12 months.

Deuterium-Labeled Precursor Feeding Reveals a New pABA-Containing Meroterpenoid from the Mango Pathogen Xanthomonas citri pv. mangiferaeindicae.

A new para-aminobenzoic-acid-containing natural product from the mango pathogenic organism Xanthomonas citri pv. mangiferaeindicae is described. By means of stable isotope precursor feeding combined with nontargeted LC-MS/MS, the generated spectra were clustered and visualized in a molecular network. This led to the identification of a new member of the meroterpenoids, termed xanthomonic acid, which is composed of an isoprenylated para-aminobenzoic acid. In vitro cytotoxicity assays demonstrated activity of xanthomonic acid against several human cancer cell lines by induction of autophagy.

Endoscopic management of antrochoanal polyps: a single UK centre's experience.

Antrochoanal polyps (ACPs) are benign lesions that originate from the mucosa of the maxillary sinus, and extend into the nasal cavity to reach the choana and nasopharynx. The treatment of ACPs is surgical, with a number of different surgical techniques having been described. We describe the first case series of ACPs from the UK and the endoscopic surgical technique that we have employed. A retrospective case note review of patients with ACPs managed under the care of the senior author was conducted. Demographic and clinical data for all patients were reviewed. The main outcome parameter measured was any sign of recurrence. A total of 29 consecutive patients were included for analysis from a 5-year study period, with 19 males and 10 females, and a mean age of 37.4 ± 13.6 years. Four patients within our group were referred to us with recurrent ACPs for revision surgery. All patients underwent surgery via the same endoscopic technique. The mean follow-up period was 14.7 ± 16.9 months, with an average follow-up of 22.5 months for the four revision cases. There were no recurrences in any of our patients. We describe the first reported series of endoscopic sinus surgery for antrochoanal polyps in the UK, and the largest worldwide series described for endoscopic management of ACPs in adults. We have had no recurrent cases, with a mean follow-up period of 14.7 months.

A 70-Year-Old Woman with a Sensation of Something Moving in Her Nose.

AbstractMorning Report is a time-honored tradition where physicians-in-training present cases to their colleagues and clinical experts to collaboratively examine an interesting patient presentation. The Morning Report section seeks to carry on this tradition by presenting a patient's chief concern and story, inviting the reader to develop a differential diagnosis and discover the diagnosis alongside the authors of the case.This report examines the case of a 70-year-old woman who sought evaluation for a sensation of something moving in her nose. The sensation began during a trip to South America and persisted after she returned home to Switzerland. Using questions, physical examination, and testing, an illness script for the presentation emerges. As the clinical course progresses, the differential is refined until a diagnosis is made.

Imaging of chronic rhinosinusitis with nasal polyps in the era of biological therapies.

PURPOSE OF REVIEW: Chronic rhinosinusitis (CRS) is a chronic inflammatory disorder of the sinonasal cavities classified into two major phenotypes: CRS with nasal polyps (CRSwNP) and without nasal polyps (CRSsNP). The diagnosis of CRS is based on clinical symptoms associated with imaging and/or nasal endoscopy findings of mucosal inflammation. RECENT FINDINGS: Recently, novel biological therapies have emerged as therapeutic options for CRSwNP. Imaging is helpful in deciding whether surgery is likely to be beneficial and in guiding surgery. It can also help demonstrate a clinical response to medical therapy. However, specific guidelines concerning the role of imaging in CRwNP are lacking. SUMMARY: This article provides a comprehensive and critical multidisciplinary review of the role of conventional radiology, computed tomography (CT), and magnetic resonance imaging (MRI) in the diagnosis and characterization of CRSwNP. Since the complete characterization of nasal polyps on CT or MR images is very challenging, we provide a critical review of the best imaging methods and essential reporting elements used to assess nasal polyps.

Early Weight-bearing Following Surgical Treatment of Ankle Fractures Without Trans-syndesmotic Fixation Is Safe and Improves Short-term Outcomes.

OBJECTIVES: The objective of this study was to ascertain outcome differences after fixation of unstable rotational ankle fractures allowed to weight-bear 2 weeks postoperatively compared with 6 weeks. DESIGN: Prospective case-control study. SETTING: Academic medical center; Level 1 trauma center. PATIENT SELECTION CRITERIA: Patients with unstable ankle fractures (OTA/AO:44A-C) undergoing open reduction internal fixation (ORIF) were enrolled. Patients requiring trans-syndesmotic fixation were excluded. Two surgeons allowed weight-bearing at 2 weeks postoperatively (early weight-bearing [EWB] cohort). Two other surgeons instructed standard non-weight-bearing until 6 weeks postoperatively (non-weight-bearing cohort). OUTCOME MEASURES AND COMPARISONS: The main outcome measures included the Olerud-Molander questionnaire, the SF-36 questionnaire, and visual analog scale at 6 weeks, 3 months, 6 months, and 12 months postoperatively and complications, return to work, range of ankle motion, and reoperations at 12 months were compared between the 2 cohorts. RESULTS: One hundred seven patients were included. The 2 cohorts did not differ in demographics or preinjury scores ( P > 0.05). Six weeks postoperatively, EWB patients had improved functional outcomes as measured by the Olerud-Molander and SF-36 questionnaires. Early weight-bearing patients also had better visual analog scale scores (standardized mean difference -0.98, 95% confidence interval [CI] -1.27 to -0.70, P < 0.05) and a greater proportion returning to full capacity work at 6 weeks (odds ratio = 3.42, 95% CI, 1.08-13.07, P < 0.05). One year postoperatively, EWB patients had improved pain measured by SF-36 (standardized mean difference 6.25, 95% CI, 5.59-6.92, P < 0.01) and visual analog scale scores (standardized mean difference -0.05, 95% CI, -0.32 to 0.23, P < 0.01). There were no differences in complications or reoperation at 12 months ( P > 0.05). CONCLUSIONS: EWB patients had improved early function, final pain scores, and earlier return to work, without an increased complication rate compared with those kept non-weight-bearing for 6 weeks. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Factors Influencing Maintenance of Alignment and Functional Improvement Following Adult Spinal Deformity Surgery: A 3-Year Outcome Analysis.

STUDY DESIGN: This was a retrospective review. OBJECTIVE: To assess the factors contributing to durability of surgical results following adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND: Factors contributing to the long-term sustainability of ASD correction are currently undefined. MATERIALS AND METHODS: Operative ASD patients with preoperatively (baseline) and 3-year postoperatively radiographic/health-related quality of life data were included. At 1 and 3 years postoperatively, a favorable outcome was defined as meeting at least three of four criteria: (1) no proximal junctional failure or mechanical failure with reoperation, (2) best clinical outcome (BCO) for Scoliosis Research Society (SRS) (≥4.5) or Oswestry Disability Index (ODI) (<15), (3) improving in at least one SRS-Schwab modifier, and (4) not worsening in any SRS-Schwab modifier. A robust surgical result was defined as having a favorable outcome at both 1 and 3 years. Predictors of robust outcomes were identified using multivariable regression analysis with conditional inference tree for continuous variables. RESULTS: We included 157 ASD patients in this analysis. At 1 year postoperatively, 62 patients (39.5%) met the BCO definition for ODI and 33 (21.0%) met the BCO for SRS. At 3 years, 58 patients (36.9%) had BCO for ODI and 29 (18.5%) for SRS. Ninety-five patients (60.5%) were identified as having a favorable outcome at 1 year postoperatively. At 3 years, 85 patients (54.1%) had a favorable outcome. Seventy-eight patients (49.7%) met criteria for a durable surgical result. Multivariable adjusted analysis identified the following independent predictors of surgical durability: surgical invasiveness >65, being fused to S1/pelvis, baseline to 6-week pelvic incidence and lumbar lordosis difference >13.9°, and having a proportional Global Alignment and Proportion score at 6 weeks. CONCLUSIONS: Nearly 50% of the ASD cohort demonstrated good surgical durability, with favorable radiographic alignment and functional status maintained up to 3 years. Surgical durability was more likely in patients whose reconstruction was fused to the pelvis and addressed lumbopelvic mismatch with adequate surgical invasiveness to achieve full alignment correction.