Correction of Symptomatic Chronic Nasal Airway Obstruction in Conjunction With Bimaxillary Orthognathic Surgery: Does It Complicate Recovery and Is It Effective?

PURPOSE: The purpose of this study was to assess the safety and efficacy of intranasal procedures carried out simultaneously with bimaxillary orthognathic surgery. MATERIALS AND METHODS: The authors executed a retrospective cohort study derived from patients treated by a single surgeon at 1 institution from 2004 through 2013 with a minimum follow-up of 1 year (range, 1 to 10 yr). An index study group consisting of a consecutive series of patients with symptomatic chronic obstructive nasal breathing (CONB) and a bimaxillary developmental dentofacial deformity (DFD) also involving the chin were identified. They underwent a minimum of: Le Fort I osteotomy, bilateral sagittal ramus osteotomies, septoplasty, inferior turbinate reduction (ITR), and osseous genioplasty. Study variables included age at operation, gender, pattern of presenting DFD, presence of obstructive sleep apnea, segmentation of the maxilla, and airway management. The primary outcome variable studied was residual CONB. RESULTS: During the study period, 262 patients met the inclusion criteria. Their age at operation averaged 25 years (range, 13 to 63 yr) and 134 were female (51%). The major patterns of presenting DFD included long face (29%) and maxillary deficiency (25%). No patients required nasal packing, reintubation, tracheostomy, or blood transfusion. In 6 of the 262 patients (2%), the intranasal procedures did not resolve nasal breathing difficulties. In these patients, procedures recommended included synechiae release (n = 3), revision septoplasty (n = 3), and further ITR (n = 4). An association between age at time of surgery and non-segmental Le Fort I osteotomy with the occurrence of residual nasal obstruction was confirmed. CONCLUSIONS: When completing septoplasty and ITR through a Le Fort I, airway management need not be altered from standard protocol. The management of CONB in conjunction with orthognathic surgery is highly effective, with few complications. Non-segmental Le Fort I in patients at least 40 years of age is more likely to be associated with residual CONB, but the incidence remains low.

Persistent local demucosalization after endoscopic sinus surgery: A report of 3 cases.

Mucosal preservation is paramount to achieving successful outcomes after endoscopic sinus surgery (ESS). Despite best surgical practices and implementation of evidenced-based postoperative care, patients in rare cases might exhibit persistent demucosalization that is recalcitrant to conservative therapies. We retrospectively reviewed the records of 3 patients-a 63-year-old woman, a 67-year-old woman, and a 43-year-old man-who experienced clinically significant local demucosalization after uncomplicated ESS despite routine surgical and postoperative management. We collected data on the characteristics of presentation, wound management strategies, and postoperative care practices. Two patients achieved remucosalization with mechanical debridement, gelatin sponge placement, and intensive moisturization therapy. Our experience suggests that surgical debridement of these chronic, persistent demucosalized wounds may be an effective management strategy for patients who develop this unusual and rare postoperative complication. Biopsy and culture of the persistently demucosalized wound bed may be useful in recognizing the presence of worrisome disease processes and identifying any tenacious infectious agents so that more appropriate therapy can be initiated if necessary.

The value of otolaryngologists' services in America: a national survey.

OBJECTIVE: To evaluate the perceived monetary value of physician services within the general population and to foster academic discussion about the finances of clinical practice in the setting of recent health care reform. STUDY DESIGN, SUBJECTS, AND METHODS: National survey of 409 members of the general population and review of Centers for Medicare and Medicaid Services data. RESULTS: The perceived monetary values of office visits were comparable to the actual physician reimbursements. However, the average perceived value associated with surgical treatments was significantly higher than the true Medicare reimbursement amount. For example, survey participants said that a reasonable price for a doctor to be paid for performing a tonsillectomy is $955.58, whereas the national average Medicare reimbursement is $257.74. Furthermore, 59% of respondents also believe that insurers, Medicare, and Medicaid pay doctors more than the respondent's perceived value for each service. CONCLUSION: The current patterns of Centers for Medicare and Medicaid Services reimbursement reveal a trend of declining payments for physician services. A survey of a sample of the general population indicated that most people believe that their doctors are paid far more than they actually are. It is important for otolaryngologists and head and neck surgeons to understand and discuss the economic forces that continue to shape our practices, and it is vital that we all play an active role in the discussions surrounding the evolution of the American health care system.

Simultaneous intranasal procedures to improve chronic obstructive nasal breathing in patients undergoing maxillary (le fort I) osteotomy.

PURPOSE: The aim of this study was to evaluate the safety and efficacy of septoplasty and inferior turbinate reduction, carried out through a Le Fort I osteotomy as part of the correction of a dentofacial deformity, designed to improve nasal breathing in patients who reported pre-existing nasal airway obstruction and had documented septal deviation and inferior turbinate hypertrophy. PATIENTS AND METHODS: A validated outcomes instrument, the Nasal Obstruction Symptom Evaluation (NOSE) questionnaire, was used to objectively assess the extent of clinical nasal obstruction both before and after septoplasty and inferior turbinate reduction performed at the time of Le Fort I down-fracture. The study group comprised 43 consecutive patients scheduled for orthognathic surgery (including Le Fort I osteotomy) over a 12-month period who complained of chronic nasal obstruction and were found (by an independent otolaryngology evaluation) to have septal deviation and inferior turbinate hypertrophy unresponsive to medical therapy, who met the inclusion criteria, and who agreed to the procedures (septoplasty and turbinate reduction). The data collected included age, gender, health and social history, type of dentofacial deformity, concomitant surgical procedures, and any associated postoperative complications. RESULTS: For the 43 study patients, significant improvement in nasal breathing was documented (by NOSE scores) at 3 months (P < .001) after the procedures (Le Fort I osteotomy, septoplasty, and inferior turbinate reduction). Comparison of the 3-month and 6-month NOSE scores showed maintenance of improved nasal breathing with further improvement that did not demonstrate statistical significance. CONCLUSIONS: The findings of this study indicate that simultaneous management of the maxillary jaw deformity (Le Fort I osteotomy) and intranasal pathology (septoplasty and reduction of inferior turbinates) were effective for the symptomatic relief of nasal airway obstruction. The complication rate for the intranasal procedures completed simultaneously with a Le Fort I osteotomy was minimal and not dissimilar to the rates reported for each procedure performed as an isolated event.

Acinic cell carcinoma of the glottis: case report.

Acinic cell carcinoma is a rare tumor of the head and neck that mainly affects the parotid gland but occasionally involves the minor salivary glands of the upper aerodigestive tract. The authors present a case report of an occurrence of a low-grade acinic cell carcinoma of the true vocal fold, which they believe to be the first reported case of this type of carcinoma in this location. Laryngoscopy and laser excision was completed for what was initially thought to be a granuloma, and pathology confirmed low-grade acinic cell carcinoma of the right true vocal fold. The mass was well circumscribed and did not invade adjacent structures. After complete excision, postoperative radiation therapy was used to reduce local recurrence.