Nasal Airflow Changes With Bioabsorbable Implant, Butterfly, and Spreader Grafts.

OBJECTIVES/HYPOTHESIS: Internal nasal valve compromise is a major cause of nasal obstruction, with a growing number of ways to treat this condition. In this study, we compared the effects of butterfly graft, spreader graft, and the bioabsorbable nasal implant on nasal airflow resistance. STUDY DESIGN: Cadaver study. METHODS: Computational fluid dynamics (CFD) simulations were completed from nine preoperative and postoperative cadaveric subjects. Each cadaveric head underwent placement of a bioabsorbable nasal implant (BNI) (Spirox Latera; Stryker ENT, Plymouth, MN), butterfly graft, or spreader graft. Pre- and postoperative computed tomography (CT) scans were used to generate three-dimensional models of the nasal airway used in steady-state CFD simulations of airflow and heat transfer during inspiration. RESULTS: Butterfly graft placement resulted in a mean improvement in nasal airway resistance of 24.9% (±7.3), whereas BNI placement resulted in a 6.7% (±1.2) improvement, and spreader graft placement also resulted in a consistent improvement of 2.6% (±13.5). Pressure within the main nasal cavity was consistently lower following butterfly graft placement versus a spreader graft or BNI. Butterfly and spreader graft placement also resulted in modest improvements in airflow allocation, whereas BNI demonstrated more variation (-1% to 12%). Heat flux was not significantly different; however, a small improvement in total heat flux was seen with all three interventions. CONCLUSIONS: The results of this study demonstrate reduction in nasal airway resistance in all three surgical interventions, with the butterfly graft demonstrating superiority to the other two techniques. However, these data only reflect a static environment and not dynamic changes in airflow seen during respiration. LEVEL OF EVIDENCE: NA Laryngoscope, 130:E817-E823, 2020.

Utility of endoscopic anatomical optical coherence tomography in functional rhinoplasty.

Objective measurement of the nasal valve region is valuable for the assessment of functional rhinoplasty surgical outcomes. Anatomical optical coherence tomography (aOCT) is an imaging modality that may be used to obtain real-time, quantitative, and volumetric scans of the nasal airway. We aim to evaluate if volumetric aOCT imaging is useful for the examination of the nasal valve region before and after functional rhinoplasty procedures. aOCT scans of the nasal valves were performed on four cadaveric heads before and after spreader graft and butterfly graft procedures. The resulting aOCT images were compared against video endoscopy images, and the segmented volumes of the nasal airway obtained from aOCT scans were compared with computed tomography (CT) derived volumes acquired under the same conditions. The aOCT-derived volumes match the CT volumes closely, with a mean Dice similarity coefficient of 0.88 and a mean Hausdorff distance of 2.3 mm. Furthermore, the aOCT images were found to represent the shape of the nasal cavity accurately. Due to its ability to perform real-time, quantitative, and accurate evaluation of the nasal airway, aOCT imaging is a promising modality for the objective assessment of the nasal valves before and after functional rhinoplasty procedures.

Scapular Tip Free Flap in Composite Head and Neck Reconstruction.

OBJECTIVES: To describe the use of the scapular tip free flap (STFF) in the reconstruction of head and neck defects. STUDY DESIGN: Case series with chart review. SETTING: Academic medical center. SUBJECTS AND METHODS: A review of the electronic medical record was performed of all patients who underwent head and neck reconstructive surgery with STFFs from January 1, 2014, through January 1, 2016. Details regarding the disease, defect reconstructed, and surgical outcomes were quantified. RESULTS: Thirty-one consecutive cases were performed at our institution within the period reviewed. The procedures included reconstruction of 5 maxillectomy and 26 mandibulectomy defects. The mean length of mandible reconstructed was 6.8 cm (95% CI, 6.01-7.59; range, 4.0-10.2). Osteotomies were made to contour the scapular bone in 11 cases, including double osteotomies performed in 2 cases. The most common surgical complications were orocutaneous fistula and postoperative hematoma, which occurred in 3 (10%) and 2 (6.5%) of 31 patients, respectively. CONCLUSION: This series describes a large number of STFFs performed in head and neck reconstruction. The average length of bony defect repair can be significantly larger than what was previously described. Performing osteotomies to the STFF allows for application to anterior mandibular defects. The STFF offers a large soft tissue component, a relatively long pedicle, and acceptable donor site morbidity. The STFF is a versatile reconstructive option that should be considered to address composite defects of the head and neck.

Comparison of Airflow Between Spreader Grafts and Butterfly Grafts Using Computational Flow Dynamics in a Cadaveric Model.

IMPORTANCE: Nasal valve compromise is a major cause of nasal obstruction, and multiple methods have been developed to address it. OBJECTIVE: To compare nasal airflow resistance, airflow partitioning, and mucosal cooling (heat flux) before and after 2 surgical interventions, butterfly and spreader graft placement, used to treat nasal valve compromise. DESIGN, SETTING, AND PARTICIPANTS: In this cadaveric tissue study, 4 fresh cadaveric heads underwent both spreader graft and butterfly graft surgical procedures in alternating sequence in March 2016. Preoperative and postoperative computed tomographic scans were used to generate 3-dimensional (3-D) models of the nasal airway. These models were then used in steady state computational fluid dynamics simulations of airflow and heat transfer during inspiration. INTERVENTION: Butterfly and spreader graft techniques. MAIN OUTCOMES AND MEASURES: Nasal airflow resistance, airflow partitioning, and heat flux. RESULTS: Donors 1, 2, and 3 were white males; donor 4, a white female. Computational fluid dynamics simulations during inspiration in 3-D models generated from preoperative and postoperative computed tomographic scans of the 4 cadaveric heads indicated reductions from preoperative values in nasal airflow resistance associated with both butterfly grafts (range, 20%-51%) and spreader grafts (range, 2%-29%). Butterfly grafts were associated with a greater reduction in nasal airflow resistance in models of all 4 cadaveric heads. Changes from preoperative values for heat flux, a biophysical variable that correlates with the subjective sensation of nasal patency, were more variable, ranging from -11% to 4% following butterfly grafts and -9% to 10% following spreader grafts. The preoperative airflow allocation in the left and right nostrils improved consistently with the butterfly graft. With the spreader graft, there were improvements for donors 1 and 4, but the allocations were worse for donors 2 and 3. CONCLUSIONS AND RELEVANCE: The results of this study suggest that the more recently developed butterfly graft technique may be associated with a similar level of improved nasal airflow as that observed with the use of a spreader graft in nasal valve compromise. Both interventions were associated with comparable changes in heat flux. Because this study addressed only static internal nasal valve stenosis, even greater differences in air flow and heat flux between the 2 techniques may be anticipated in a dynamic model. Further investigation in patients is warranted. LEVEL OF EVIDENCE: NA.

Staging of Sinonasal and Ventral Skull Base Malignancies.

Tremendous pathologic diversity among sinonasal and ventral skull base malignancies complicates development of a uniform and prognostically relevant staging system. Because of the comparatively low incidence of these tumors, comprehensive evaluation and comparison of specific staging systems is difficult. The current American Joint Committee on Cancer TNM staging system for sinonasal malignancies is the most common and widely used system in current clinical practice. Alternative systems have been proposed for use with individual histopathologic subtypes. Many of these staging systems are of great utility and accurately predict patient survival. Further research and adjustment of these current staging systems remains an important area of research.

Transfacial and Craniofacial Approaches for Resection of Sinonasal and Ventral Skull Base Malignancies.

Malignancies of the paranasal sinuses and ventral skull base present unique challenges to physicians. A transfacial or craniofacial approach allows for wide, possibly en bloc, resection and is ideal for tumors that involve surrounding soft tissue, the palate, the orbit, anterolateral frontal sinus, and lateral dura. Transfacial approaches include a lateral rhinotomy often combined with a medial, subtotal, or total maxillectomy. Reconstruction is most commonly performed with a pericranial flap to separate the intranasal and intracranial compartments. These approaches have evolved and been refined but now are usually reserved for advanced tumors not amenable to endoscopic resection.

Vestibular Schwannoma Excision in Sporadic versus Neurofibromatosis Type 2 Populations.

OBJECTIVE: To understand the differences in characteristics of neurofibromatosis type 2 (NF2) and sporadic patients with surgically excised vestibular schwannomas in the state of California. STUDY DESIGN: Cross-sectional. SETTING, SUBJECTS, AND METHODS: The records of all patients who underwent vestibular schwannoma excision between 1997 and 2011 were extracted from the California Hospital Inpatient Discharge Databases (CHIDD). NF2 cases were identified using ICD-9-CM diagnosis code 237.72, neurofibromatosis, type 2. All other cases were recoded as sporadic. Trends in total number and population-adjusted rates (per 1 million California residents) of surgery, demographics, hospital case volume, state of residency, complications, length of stay, total charges, expected source of payment, and disposition were examined. RESULTS: Vestibular schwannoma (VS) excision was performed on 7017 patients, of which 464 patients (6.6%) had NF2. The population-adjusted surgery rate declined from 11.8 to 6.2 (P < .001) for sporadic cases and from 0.3 to 0.2 (P = .01) for NF2 cases over the study period. NF2 was associated with younger age (mean, 32.9 vs 51.3), higher rate of other complications (8.8% vs 4.4%) and facial nerve complications (32.3% vs 16.8%), higher total charges (median $70,106 vs $46,395), longer stay (median 5 vs 4), and high volume hospitals (80.4% vs 48.8%) (all P < .001). CONCLUSION: The surgery rates for vestibular schwannoma excision for both sporadic and NF2 patients have declined, but the decline is more prominent for sporadic cases. NF2 patients tend to be younger and have a longer hospitalization and possibly higher corresponding hospital charges compared to patients with sporadic VS.

Nasopharyngeal acid reflux and Eustachian tube dysfunction in adults.

OBJECTIVE: This study aimed to evaluate the relationship between nasopharyngeal pH and Eustachian tube dysfunction (ETD) in adults. STUDY DESIGN: Unmatched case-control study. METHODS: Forty-one subjects, 20 adults with a diagnosis of ETD and 21 healthy adults as controls, were enrolled from an outpatient clinic. All subjects had a Dx-pH probe placed near the torus tubarius in the posterior nasopharynx for 24 hours. The pH values were recorded every 0.5 second. Decreases in pH were considered as reflux events if the pH dropped below 5.5. RESULTS: The average nasopharyngeal pH value was 6.90 (range, 5.33-7.73) in the subjects with ETD and 7.07 (range, 5.99-7.94) in the controls. The difference between the 2 groups was not statistically significant (P = .30). The ETD group, on average, had a higher number of nasopharyngeal reflux events (2.3 +/- 1.6 vs 0.8 +/- 1.2, respectively; P = .002) and higher reflux finding score (3.6 +/- 2.7 vs 0.4 +/- 1.4, respectively; P < .00 I) than the control group. CONCLUSION: By using a novel pH probe that allows detection of acidity in a nonliquid environment, a comparison of nasopharyngeal pH between control patients and those with ETD was performed. Eustachian tube dysfunction was more likely to be associated with a higher number of nasopharyngeal reflux events and higher reflux finding score. Nasopharyngeal reflux may have a role in the pathogenesis of ETD.