Use of Mastoid Periosteum Graft in Primary and Revision Rhinoplasty.

BACKGROUND: The authors initiated the use of a mastoid periosteum graft to augment or camouflage the dorsum and radix. This report describes the techniques and treatment outcomes of mastoid periosteum grafts in primary and revision rhinoplasty. MATERIALS AND METHODS: Medical records of 62 patients who underwent rhinoplasty with mastoid periosteum were reviewed retrospectively. Of these, 21 patients who participated in follow-up for more than 6 months were analyzed through a comparison of pre- and postoperative photographs. Aesthetic results were scored on a scale of 0 to 4 (0 = poor, 1 = fair, 2 = moderate, 3 = good, 4 = excellent) with photographic evaluation by two independent surgeons. RESULTS: A mastoid periosteum graft was used in 32 primary and 30 revision cases. The graft was used to augment the radix (28 cases), dorsum (15 cases), and both radix and dorsum (19 cases). Cartilage underlay was combined with mastoid periosteum grafts in 38 patients (61.3%, 17 in radix graft, 8 in dorsal graft, and 13 in both). The aesthetic outcome score assessed in 21 patients was 2.8 on average (3.2 in primary and 2.4 in revision cases). Cartilage combined cases showed better aesthetic outcome than free graft cases (3.1 vs. 2.5, respectively). Three cases of partial graft resorption were found, but there were no major complications. CONCLUSIONS: Mastoid periosteum grafting is a safe and effective method to augment the radix or dorsum in primary and revision rhinoplasty. Long-term partial resorption cannot be completely excluded, which necessitates further study. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Treatment outcomes of sinonasal malignant melanoma: a Korean multicenter study.

BACKGROUND: The aim of this work was to evaluate factors that influence local recurrence and survival after surgical resection of sinonasal malignant melanoma, using a large population-based multicenter study in Korea. METHODS: Retrospective analysis was performed for 155 newly diagnosed sinonasal malignant melanoma patients gathered from 15 university hospitals throughout Korea. Demographic data, tumor characteristics, surgical approach, adjuvant treatment, recurrence, and outcomes were analyzed. RESULTS: Three-year and 5-year overall survival rates were 48.8% and 40.1%, respectively. Local recurrence rate was 46.6%, with a mean recurrence time of 15.5 months. On multivariate analysis, patients who underwent surgery that included an endoscopic approach showed decreased local recurrence rate (p = 0.042) and increased survival rate (hazard ratio [HR], 1.702; 95% confidence interval [CI], 1.007 to 2.875; p = 0.047) compared to those who underwent an external approach. Patients with postoperative radiotherapy showed a decreased local recurrence rate (p = 0.001), but without impact on survival rate. Male gender, tumor beyond the nasal cavity, and presence of distant metastasis were associated with poor survival. CONCLUSION: An endoscopic-including surgical approach was associated with improved local control and survival in sinonasal malignant melanoma patients. Postoperative radiotherapy helped increase the local control rate.

Frequency and Characteristics of Facial Asymmetry in Patients With Deviated Noses.

IMPORTANCE: Facial asymmetry is frequently detected in patients who are seeking rhinoplasty for a deviated nose, and its presence often leads to failure to create a straight-looking nose. OBJECTIVE: To analyze the frequency and characteristics of facial asymmetry in patients with a deviated nose and to identify representative parameters to describe types and severity of facial asymmetry. DESIGN, SETTING, AND PARTICIPANTS: Retrospective review of at a tertiary referral center of preoperative photographs of 152 patients who underwent rhinoplasty for a deviated nose between January 2008 and December 2012. The incidence of facial asymmetry in these patients was compared with the incidence in 60 control patients undergoing septoplasty without external nose deviation. INTERVENTIONS: Using frontal photographs, the presence of facial asymmetry and the types of deviated nose were noted and measured by 2 observers. MAIN OUTCOMES AND MEASURES: Facial asymmetry was categorized into 4 types depending on which subunit of the face was affected, and deviated nose shapes were classified into 5 types. Anthropometric measurements were also performed. RESULTS: Facial asymmetry was more common in patients with a deviated nose (84 of 152 [55%]) than in controls (19 of 60 [32%]) (P = .04). Mixed-type facial asymmetry was the most common type in the patient group. Among the anthropometric measurement parameters, the distance between the midpoint of the interpupil line to the most prominent malar point, lateral canthal angle, lateral alar angle, lip margin angle, and tilted chin angle were significantly different between the patient group and the control group (P < .05 for all comparisons). There was no difference in the incidence of asymmetry with respect to deviation type. CONCLUSIONS AND RELEVANCE: Facial asymmetry was more common in patients with a deviated nose than in control patients, and mixed-type facial asymmetry was the asymmetry most often associated with deviated nose. This study suggests that deviated nose may be a developmental defect caused by a discrepancy in the growth of facial bony skeleton between the 2 sides of the face. The objective anthropometric measurements developed in this study could be useful for making appropriate preoperative facial assessments. LEVEL OF EVIDENCE: NA.

Human rhinovirus serotypes in the nasal washes and mucosa of patients with chronic rhinosinusitis.

BACKGROUND: Chronic rhinosinusitis (CRS) can be aggravated by viral upper respiratory infections. We aimed to investigate whether any specific human rhinovirus (HRV) serotype is more common in the mucosa of CRS patients, and to find any defining clinical characteristics, according to the various HRV serotypes. METHODS: A prospective case-control study was conducted to determine HRV serotypes in 111 CRS patients and 51 non-CRS controls. No participant had a history of upper respiratory infection over a 4-week period. Nasal lavage fluids and turbinate epithelial cells were collected prospectively. When HRV was detected with multiplex polymerase chain reaction (PCR), strains were further characterized by sequencing the VP4/VP2 region of the HRV genome. RESULTS: HRV was detected in 40 CRS subjects (36%) and 11 non-CRS controls (21%). The overall detection rates of HRV in CRS patients were higher than in non-CRS controls (p < 0.05). Of the 8 serotypes detected in CRS patients, 5 belonged to HRV-A and 3 belonged to HRV-B; HRV-C was not detected. In non-CRS controls, only HRV-A was identified, with only 2 serotypes detected (HRV-A13 and HRV-A16). HRV-B and C were not detected. CONCLUSION: The high prevalence of HRV in CRS patients was confirmed in our study. However, we were unable to determine whether certain HRV serotypes are more predominant in CRS patients than non-CRS controls. HRV-A13 was the most common serotype in both CRS patients and non-CRS controls. We could not find any differences in the clinical characteristics according to the HRV serotypes in CRS patients.

Effect of septoplasty with a caudal septal batten graft on changes in nasal shape.

OBJECTIVE: This study aimed to determine frequency of external nasal deformities in patients with deviated septa and the effect of endonasalseptoplasty with batten grafting on the external nasal appearance. METHODS: The 52 patients who underwent endonasalseptoplasty with a batten graft for the correction of caudal septal deviations were included in the study. The preoperative and postoperative photographs of 52 patients were reviewed retrospectively. Gross changes (nasal deviation, dorsal middle vault height, tip height change, and nostril asymmetry) were assessed. Anthropometric measurements (dorsal height, nasal tip projection, nasolabial angle, nasofrontal angle, and deviation angle) were performed. RESULTS: Preoperative assessment showed that 71% of the 52 patients had deformities, including nasal deviation (n=28), hump nose (n=19), saddle nose (n=3), and nostril asymmetry (n=15). On postoperative analysis, favorable changes in dorsal deviations were seen in 61% of patients. There were no aesthetic changes for hump or saddle nose deformities, whereas nostril asymmetry was corrected in 20% of patients. Anthropometric measurements also showed that dorsal deviation angles were corrected after surgery (P<.05), whereas other parameters showed no significant changes. CONCLUSION: In selected cases, deviated noses can be corrected to some extent by septoplasty with caudal septal batten grafting.

Development of Aspergillus protease with ovalbumin-induced allergic chronic rhinosinusitis model in the mouse.

BACKGROUND: Chronic rhinosinusitis (CRS) is a multifactorial inflammatory disease. Particularly, eosinophilic CRS is often recalcitrant to treatment, so an appropriate animal model is required to evaluate the pathogenesis of, and to develop therapies for, recalcitrant eosinophilic CRS. This study aimed to improve the ovalbumin (OVA)-induced mouse model of eosinophilic/allergic CRS by combining OVA with Aspergillus protease, which is known to trigger allergic reactions in mouse lungs. METHODS: In a model of allergic CRS, mice were challenged intranasally with Aspergillus protease combined with OVA. Local and systemic responses were measured. Protease (0.54 U) from Aspergillus oryzae, prepared with or without OVA (75 micrograms), OVA alone, or saline, was administered intranasally to wild-type mice for 5 weeks. Sinonasal complex samples were evaluated histologically, and interleukin (IL)-4, IL-5, IL-6, macrophage inflammatory protein (MIP) 2, and tumor necrosis factor (TNF) alpha were measured in nasal lavage fluid. A differential white blood cell count was also performed. RESULTS: OVA alone induced minimal eosinophilic inflammation in sinonasal mucosa, while protease + OVA and protease alone induced moderate eosinophilic inflammation. Protease + OVA elevated eosinophil counts in blood comparable with controls, but not compared with OVA alone. Although IL-4, IL-5, IL-6, MIP-2, and TNF-alpha were increased in all study mice, the levels of IL-4 and IL-6 were higher in mice treated with protease + OVA than in mice treated with OVA alone. Protease alone excessively elevated the levels of IL-6, MIP-2, and TNF-alpha, not Th2 cytokines, compared with OVA alone and protease + OVA. CONCLUSION: Aspergillus protease combined with OVA induced more severe allergic inflammation in sinonasal mucosa compared with OVA alone and similar eosinophilia. This model could be more relevant to recalcitrant eosinophilic CRS in humans than OVA-induced allergic CRS.

Relationship between positive bacterial culture in maxillary sinus and surgical outcomes in chronic rhinosinusitis with nasal polyps.

OBJECTIVES: There are many studies on clinical prognosis following endoscopic sinus surgery (ESS) for the treatment of chronic rhinosinusitis with nasal polyp (CRSwNP). However, there are no independent reports on bacterial infection as a factor that influences surgical outcomes. We investigated the association between bacterial infection and surgical outcomes following ESS. METHODS: This retrospective review of medical records was performed on 71 patients with CRSwNP that was refractory to medical treatment and who were diagnosed between July 2007 and June 2012. The extent of the polyps and the Lund-Mackay CT score (L-M score) were preoperatively evaluated in all the patients. For this analysis, patients were classified into three groups (normal flora, culture-positive, and culture-negative) according to their intraoperative bacterial culture results. We compared the objective endoscopic findings between these groups at 6-months postsurgery. RESULTS: Bacteria were cultured in 55 of the 71 patients (77%). Of these, 43 patients (61%) demonstrated endoscopic improvement at the 6-month follow-up examination. The preoperative L-M score and polyp grade demonstrated no significant statistical differences in terms of surgical outcome, but the cure rate was statistically higher in culture-negative patients in comparison with normal flora and culture-positive patients (87.5% vs. 46.2% vs. 54.8, respectively). CONCLUSION: Intraoperative culture results can be a prognostic factor for the clinical outcomes of ESS in CRSwNP patients. Hence, the intraoperative culturing of pathologic secretions and the postoperative administration of susceptible antibiotics could improve surgical results.

Perspectives in asian rhinoplasty.

Asian patients present with relatively poorly developed dorsal and tip height and thicker skin, so augmentation rhinoplasty is the most commonly performed rhinoplasty procedure. Tip surgery using autologous cartilage followed by dorsal augmentation using an alloplastic implant material is the most widely performed surgical procedure for augmentation rhinoplasty on Asian patients. Cartilage tip grafting procedures, including shield grafting, multilayer tip grafting, onlay grafting, and modified vertical dome division, are key maneuvers for building up and providing better definition on a relatively poorly developed Asian tip. When performing primary cosmetic dorsal augmentation using alloplastic implants, the implant material should be selected according to the surgeon's experience, the pros and cons of available dorsal implant materials, and host factors such as skin thickness, associated deformities, and aesthetic goals. The costal cartilage is best reserved for difficult revisions, except in a limited number of primary cases who present with a very poorly developed nasal skeleton and thick skin.

Results of anterior facial nerve rerouting procedures for removing skull base tumors.

OBJECTIVES: The purpose of this study was to estimate the rates of functional recovery of the facial nerve and of total tumor resection in patients who undergo short anterior rerouting and long anterior rerouting of the facial nerve in removal of skull base tumors. METHODS: We retrospectively collected data on 37 patients with skull base tumors who underwent facial nerve rerouting during the procedure for tumor removal. Information on the rerouting technique, the completeness of tumor resection, and changes in facial nerve function were obtained from the medical records. Rerouting techniques were classified as short anterior rerouting or long anterior rerouting. RESULTS: Ten of 16 patients (62.5%) in the group with short anterior rerouting showed postoperative facial palsy, and all completely recovered within 1 year. In the group with long anterior rerouting, 18 of 21 patients (85.7%) showed postoperative facial palsy, and recovery to a preoperative level of facial function was found in 10 patients at 1 year of follow-up. Total tumor resection was possible in 94% and 81% of patients with short rerouting and long rerouting, respectively. The mean operation time was not significantly related to the postoperative recovery of facial function. CONCLUSIONS: Short rerouting techniques, when appropriately chosen on the basis of tumor and patient characteristics, offer excellent preservation of facial function and tumor resection, comparable to those of long rerouting techniques.

Proportion of bony cochlear nerve canal anomalies in unilateral sensorineural hearing loss in children.

OBJECTIVE: The aim of this study was to characterize the various bony anomalies of the inner ear in patients with unilateral sensorineural hearing loss using high-resolution temporal bone computed tomography and establish the relationship between hearing and the diameter of the bony cochlear nerve canal. METHODS: We performed a retrospective review of 51 patients (mean age 11 years, range 0-20 years, 27 boys, 24 girls) who were diagnosed with unilateral sensorineural hearing loss with an audiogram. Coronal and axial diameter of the inner ear structures, including the internal auditory canal, bony cochlear nerve canal, and each turn of the cochlea and semicircular canals, were measured with high-resolution temporal bone computed tomography. The mean values (± 2 standard deviations) were calculated and compared between sensorineural hearing loss and normal ears, and between narrow bony cochlear nerve canal and normal bony cochlear nerve canal ears. Bony cochlear nerve canal atresia/stenosis was defined as a value less than 1.4mm in axial images. RESULTS: The diameter of the bony cochlear nerve canal was significantly smaller in sensorineural hearing loss ears than in normal ears (p<.05). Associated inner ear anomalies, such as IAC stenosis (24%), cochlear hypoplasia (7-17%), and narrow semicircular canal bony island (8%) were only observed in the narrow bony cochlear nerve canal group. This group also showed statistically significant, severe to profound hearing loss compared to the normal bony cochlear nerve canal group (p<.05, R(2)=12.8%). CONCLUSIONS: Most (57%) of the unilateral sensorineural hearing loss ears had bony cochlear nerve canal stenosis/atresia and this group showed associated inner ear anomalies. When the diameter of the bony cochlear nerve canal was less than 1.4mm, pure tone audio averages were more than 70 dB HL in most ears.

18F-FDG PET/CT for detecting distant metastases in patients with recurrent head and neck squamous cell carcinoma.

BACKGROUND: Distant metastases (DMs) increase in patients with recurrent head and neck squamous cell carcinoma (HNSCC). We evaluated the ability of fluorine 18-fluorodeoxyglucose ((18) F-FDG) positron emission tomography/computed tomography (PET/CT) to detect DMs in these patients. METHOD: We evaluated 82 consecutive patients with histologically confirmed recurrent HNSCC. Patients with previous DMs were excluded. All patients received whole-body (18) F-FDG PET/CT scanning for restaging of recurrent HNSCC and follow-up after salvage surgery. Any suspected DMs were confirmed by histology and further imaging workups. The diagnostic ability of (18) F-FDG PET/CT to detect DMs was assessed. RESULTS: Of the 82 patients, 14 (17%) had DMs. The lung (93%) and bone (43%) were the most frequent metastatic sites. (18) F-FDG PET/CT correctly diagnosed the presence of DMs in 12 of 14 patients and their absence in 57 of 68 patients. The sensitivity, specificity, accuracy, and positive (PPV) and negative predictive values (NPV) of (18) F-FDG PET/CT for detecting DMs were 86% (95% confidence interval, 57-98%), 84% (72-91%), 84% (74-91%), 52% (30-73%), and 97% (88-99%), respectively. CONCLUSIONS: (18) F-FDG PET/CT may be useful in the detection of DMs prior to and after salvage surgery in the high-risk patients with recurrent HNSCC.

Malignant tumors of the sinonasal tract in the pediatric population.

CONCLUSION: Sarcoma and lymphoma comprised 75% of 20 cases of pediatric sinonasal malignancies. As regards treatment, all 20 patients received chemotherapy and 6 patients (30%) underwent surgery. The overall 5-year survival rate was 52%, with favorable outcome for solid tumors compared with lymphoma. OBJECTIVE: We aimed to investigate the clinical features and treatment outcomes of sinonasal malignancies in 20 pediatric patients. METHODS: Clinical features were evaluated and tumors were staged according to the staging system for each histologic type. RESULTS: The 20 patients consisted of 12 males and 8 females, ranging in age from 1 to 16 years, with a median age of 9.6 years at diagnosis. More than half of the patients presented with nasal obstruction as the primary symptom, and mean symptom duration to diagnosis was 5.4 months. Primary tumor sites included the paranasal sinuses alone in four patients, the nasal cavity alone in eight, and both in eight. Eight tumors were sarcomas and seven were lymphomas. The remaining tumors included three olfactory neuroblastomas and two primitive neuroectodermal tumors. The main treatment modality was chemotherapy rather than surgery. The overall survival rate was 52%, and patients with solid tumors survived significantly longer than those with lymphoma (p = 0.02).

Effect of upper airway surgery on heart rate variability in patients with obstructive sleep apnoea syndrome.

To determine whether surgery influences cardiovascular autonomic modulation in obstructive sleep apnoea syndrome (OSAS), the present study was performed to evaluate the effect of upper airway (UA) surgery on heart rate variability (HRV) using frequency domain analysis for patient groups who have had either successful or unsuccessful surgery. We compared body mass index (BMI), polysomnographic [apnoea index (AI), apnoea-hypopnoea index (AHI), minimum SaO(2)] and HRV [very low frequency (VLF) power, low frequency (LF) power, high frequency (HF) power, HF/LF ratio, LFnu = LF/(LF + HF), HFnu = HF/(LF + HF)] parameters between the unsuccessful (n = 14) and successful (n = 22) surgical groups before and after UA surgery. Significant changes were observed for the successful patient group with respect to mean AI (from 29.1 ± 21.3 to 2.0 ± 3.2 events h(-1), P < 0.001), AHI (from 38.6 ± 20.0 to 5.6 ± 5.1 events h(-1), P < 0.001), minimum SaO(2) (from 73.3 ± 12.7 to 86.3 ± 6.5%, P < 0.001), VLF power (from 25599 ± 12906 to 20014 ± 9839 ms(2), P = 0.013), LF power (from 17293 ± 7278 to 14155 ± 4980 ms(2), P = 0.016), LFnu (from 0.700 ± 0.104 to 0.646 ± 0.128, P = 0.031) and HFnu (from 0.300 ± 0.104 to 0.354 ± 0.128, P = 0.031); however, mean BMI, HF power and LF/HF ratio did not change significantly after UA surgery. No significant changes were observed in the unsuccessful surgical group. Successful UA surgery may improve cardiac sympathetic and parasympathetic modulation in patients with OSAS.

Evaluation of 18F-FDG PET/CT and CT/MRI with histopathologic correlation in patients undergoing salvage surgery for head and neck squamous cell carcinoma.

BACKGROUND: (18)F-fludeoxyglucose (FDG) positron emission tomography (PET) is a sensitive and specific method for detecting active residual disease after chemoradiotherapy or radiotherapy, but few studies have accurately evaluated its diagnostic accuracy with histopathologic correlation. We therefore investigated the clinical utility of (18)F-FDG PET/computed tomography (CT) in patients undergoing salvage surgery for residual head and neck squamous cell carcinoma (HNSCC) after primary nonsurgical treatments. METHODS: Thirty-nine patients who initially received chemotherapy (n = 23), radiotherapy (n = 3), or chemoradiotherapy (n = 13) were evaluated 8-28 weeks later by (18)F-FDG PET/CT and CT/magnetic resonance imaging (MRI) prior to salvage surgery to clear residual disease. These results were compared with those of histopathologic analysis of the primary tumor and neck dissection tissue samples. RESULTS: Of these 39 patients, 22 (56%) had residual primary tumor. The sensitivity, specificity and accuracy of (18)F-FDG PET/CT for detecting primary tumors were 91, 65, and 79%, respectively. Of 56 dissected heminecks, 37 (66%) had residual metastatic lymph nodes. (18)F-FDG PET/CT and CT/MRI had accuracies for positive heminecks of 91 and 75%, respectively (P = 0.004). On a cervical level-by-level-based analysis, (18)F-FDG PET/CT and CT/MRI had accuracies of 89 and 78%, respectively (P < 0.001); (18)F-FDG PET/CT had a specificity of 93% and a negative-predictive value of 92% for detection of positive levels. CONCLUSIONS: (18)F-FDG PET/CT is superior to CT/MRI in detecting residual nodal disease in head and neck squamous cell carcinoma patients undergoing salvage surgery. Accurate preoperative diagnosis using (18)F-FDG PET/CT may help to determine the extent of salvage surgery.

Palatine tonsil size in obese, overweight, and normal-weight children with sleep-disordered breathing.

OBJECTIVE: To assess palatine tonsil size relative to degree of obesity in children with sleep-disordered breathing (SDB). STUDY DESIGN: Case-control study. SETTING: Tertiary care rhinology clinic. SUBJECTS AND METHODS: We compared the subjective and objective tonsil size, including tonsil height (TH), tonsil width (TW), tonsil thickness (TT), tonsil weight (TWt), and tonsil volume (TV), in 26 obese children and 26 age- and gender-matched control children with SDB, and in 29 overweight children and 29 matched controls with SDB. RESULTS: Despite similar subjective tonsil size in obese and control children, the objective tonsil size, including TH, TW, TT, and TWt, was larger in obese than in control children, and the mean TV was significantly greater in obese than in control children with SDB (8.53 +/- 3.30 mL vs 6.90 +/- 2.05 mL; 95% confidence interval [CI] of the difference 0.03-3.25; P = 0.019). In contrast, mean TV (7.38 +/- 3.43 mL vs 7.65 +/- 1.97 mL; 95% CI -1.92 to 1.37; P = 0.320) as well as the other parameters of objective palatine tonsil size, including TH, TW, TT, and TWt, did not differ significantly between overweight children and controls. CONCLUSION: Obese children with SDB had larger palatine tonsils than did normal-weight children with SDB. This finding suggests that larger palatine tonsils may have a greater effect on upper airway obstruction in obese than in normal-weight children with SDB.

Diagnostic accuracy of CT and ultrasonography for evaluating metastatic cervical lymph nodes in patients with thyroid cancer.

BACKGROUND: The present study was designed to investigate the diagnostic ability of computed tomography (CT) and ultrasonography (USG) in the preoperative evaluation of the cervical nodal status of patients with thyroid cancer. METHODS: The study population consisted of 37 consecutive patients (female:male = 30:7, age range: 20-68 years) who subsequently underwent total thyroidectomy and neck dissection for thyroid cancer. The results of the review of the preoperative CT and those of the original USG reports were compared with the histopathologic results. The accuracy was evaluated by "per level" and "per patient" analyses of whether the CT or USG results had or had not altered the choice of surgical method. RESULTS: By "per level" analysis, the sensitivities, specificities, and diagnostic accuracies were 77%, 70%, 74% for CT and 62%, 79%, 68% for USG, respectively, with a significant difference in the sensitivities (p = 0.002). When the lymph node levels were grouped into central and lateral compartments, all of the values for the lateral compartment tended to be higher than those for the central compartment for both CT (78%, 78%, 78% versus 74%, 44%, 64%) and USG (65%, 82%, 71 versus 55%, 69%, 60%). By per patient analysis, the sensitivities, specificities, and diagnostic accuracies of CT and USG were 100%, 90%, 97% and 100%, 80%, 95%, respectively. CONCLUSION: Despite of very high accuracy of USG by per patient analysis, the superior sensitivity of CT on the per level analysis may enable CT to play a complementary role for determining the surgical extent in selected patients with thyroid cancer.