Effect of culture hydrodynamics on Arthrospira platensis production using a single-use photobioreactor system through a CFD supported approach.

Laboratory scale conventional single-use bioreactor was used to investigate the effect of different stirrer speeds on the Arthrospira platensis (Spirulina platensis) culture. Experiments were handled in two steps. First step was the selection of the stirring speeds, which was simulated via using CFD, and the second was the long term cultivation with the selected speed. During 10 days of batches as the first step, under identical culture conditions, stirrer speed of 230 rpm gave higher results, compared to 130 and 70 rpm, with respect to dry biomass weight, absorbance value (AB) and chlorophyll-a concentration. Volumetric productivity during the growth phase of the cultures were calculated as 0.39 ± 0.03, 0.28 ± 0.01, and 0.19 ± 0.02 g L-1 d-1, from the fast to the slower speeds. According to the results a 17 day batch was handled with 230 rpm in order to monitor the effects on the culture. The culture reached a volumetric productivity of 0.33 ± 0.04 g L-1 d-1. Statistical analysis showed the significance of the parameters related with the stirring speed.

Contextualising adverse events of special interest to characterise the baseline incidence rates in 24 million patients with COVID-19 across 26 databases: a multinational retrospective cohort study.

Background: Adverse events of special interest (AESIs) were pre-specified to be monitored for the COVID-19 vaccines. Some AESIs are not only associated with the vaccines, but with COVID-19. Our aim was to characterise the incidence rates of AESIs following SARS-CoV-2 infection in patients and compare these to historical rates in the general population. Methods: A multi-national cohort study with data from primary care, electronic health records, and insurance claims mapped to a common data model. This study's evidence was collected between Jan 1, 2017 and the conclusion of each database (which ranged from Jul 2020 to May 2022). The 16 pre-specified prevalent AESIs were: acute myocardial infarction, anaphylaxis, appendicitis, Bell's palsy, deep vein thrombosis, disseminated intravascular coagulation, encephalomyelitis, Guillain- Barré syndrome, haemorrhagic stroke, non-haemorrhagic stroke, immune thrombocytopenia, myocarditis/pericarditis, narcolepsy, pulmonary embolism, transverse myelitis, and thrombosis with thrombocytopenia. Age-sex standardised incidence rate ratios (SIR) were estimated to compare post-COVID-19 to pre-pandemic rates in each of the databases. Findings: Substantial heterogeneity by age was seen for AESI rates, with some clearly increasing with age but others following the opposite trend. Similarly, differences were also observed across databases for same health outcome and age-sex strata. All studied AESIs appeared consistently more common in the post-COVID-19 compared to the historical cohorts, with related meta-analytic SIRs ranging from 1.32 (1.05 to 1.66) for narcolepsy to 11.70 (10.10 to 13.70) for pulmonary embolism. Interpretation: Our findings suggest all AESIs are more common after COVID-19 than in the general population. Thromboembolic events were particularly common, and over 10-fold more so. More research is needed to contextualise post-COVID-19 complications in the longer term. Funding: None.

Investigation of Vitamin D Levels and the Effects of Being an Agricultural Worker on Etiology and Night Pain in Children and Adolescents With Chronic Low Back Pain.

OBJECTIVE: Chronic low back pain in children is a condition that should be investigated. In this study, we examined the effects of agricultural work on imaging results, risk factors, night pain, and vitamin D levels in children and adolescents with chronic low back pain. MATERIAL AND METHODS: The study included 133 patients who presented to the Physical Medicine and Rehabilitation and Neurosurgery outpatient clinics with low back pain that had lasted more than three months. The patients were evaluated based on the duration of their low back pain, the presence of night pain, a family history of low back pain, their employment status, local or radicular pain, and their body mass index (BMI). A physical examination was carried out to look into the etiologies of low back pain. Appropriate imaging, such as x-ray radiography, magnetic resonance imaging (MRI), and computed tomography (CT), was performed for the patients. Blood samples were collected from patients to assess inflammatory pathologies and vitamin D levels. RESULTS: The 133 patients in the study ranged in age from seven to 16 years, with a mean age of 14.3 + 1.9 years. Further, 60.2% (n = 80) of the cases were male, while 39.8% (n = 53) were female. Imaging revealed findings in 59.4% of the patients. In 97.7% of the participants, D hypovitaminosis was detected. There was no significant relationship between the patients' imaging findings and vitamin D deficiency, family history, BMI, and employment status (p = 0.441, 0.147, 0.082, 0.605). The relationship between family history, employment status, and night pain was statistically significant (p < 0.001). There was no statistically significant relationship between night pain and vitamin D deficiency (p = 0.667). CONCLUSION: Mechanical strain due to agricultural work and family history was found to be associated with night pain in patients with chronic low back pain in our study. The most important finding of this study is that night pain, which is considered a red flag, can occur in both inflammatory pathologies and situations causing mechanical low back pain, and risk factors should be thoroughly investigated. Studies with patients who have sufficient vitamin D will help to clarify the relationship between chronic low back pain and vitamin D.

Pain and neurogenic claudication control in lumbar stenosis, which is the most common cause of spinal surgery in the geriatric population.

OBJECTIVES: The authors aim to present when to do physical therapy or surgery in geriatric patients with degenerative lumbar stenosis. METHODS: The authors retrospectively analyzed 250 patients who underwent physical therapy due to lumbar degenerative stenosis between December 2014 and April 2017. The patients were divided into two groups: Central canal stenosis and lateral recess/foraminal stenosis groups. Visual analogue scale and neurological claudication values of both patient groups were evaluated before and after physical therapy. The association between comorbid diseases and the frequency of surgery was also evaluated. RESULTS: 142 of the patients were female and 108 were male, and the mean age of these patients was 69 years. The mean onset of symptoms was 55 months. In the visual analog scale value of patients after physical therapy, the authors observed decreases of 4-6° in patients with central canal stenosis and 2-3° in patients with lateral recess/foraminal stenosis. In addition, the authors observed that patients with lateral recess/foraminal stenosis together with diabetes mellitus benefit less from physical therapy. CONCLUSION: Physical therapy and rehabilitation play an important role in the treatment of lumbar stenosis. Physical therapy is the primary treatment option for patients who do not have motor muscle strength losses and incontinence and who have pain control through medications. The authors can consider surgical interventions in patients with lateral recess/foraminal stenosis who do not benefit from physical therapy at a satisfactory level.

Evidence for etiologic field changes in tongue distant from tumor in patients with squamous cell carcinoma of the oral tongue.

Oral cancer is a paradigm of Slaughter's concept of field cancerization, where tumors are thought to originate within an area of cells containing genetic alterations that predispose to cancer development. The field size is unclear but may represent a large area of tissue, and the origin of mutations is also unclear. Here, we analyzed whole exome and transcriptome features in contralateral tumor-distal tongue (i.e. distant from the tumor, not tumor-adjacent) and corresponding tumor tissues of 15 patients with squamous cell carcinoma of the oral tongue. The number of point mutations ranged from 41 to 237 in tumors and from one to 78 in tumor-distal samples. Tumor-distal samples showed mainly clock-like (associated with aging) or tobacco smoking mutational signatures. Tumors additionally showed mutations that associate with cytidine deaminase AID/APOBEC enzyme activities or a UV-like signature. Importantly, no point mutations were shared between a tumor and the matched tumor-distal sample in any patient. TP53 was the most frequently mutated gene in tumors (67%), whereas a TP53 mutation was detected in only one tumor-distal sample, and this mutation was not shared with the matched tumor. Arm-level copy number variation (CNV) was found in 12 tumors, with loss of chromosome (Chr) 8p or gain of 8q being the most frequent events. Two tumor-distal samples showed a gain of Chr8, which was associated with increased expression of Chr8-located genes in these samples, although gene ontology did not show a role for these genes in oncogenic processes. In situ hybridization revealed a mixed pattern of Chr8 gain and neutral copy number in both tumor cells and adjacent nontumor epithelium in one patient. We conclude that distant field cancerization exists but does not present as tumor-related mutational events. The data are compatible with etiologic field effects, rather than classical monoclonal field cancerization theory. © 2022 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.

Antigen peptide transporters are upregulated in squamous cell carcinoma of the oral tongue and show sex-specific associations with survival.

Transporter associated with antigen processing 1 (TAP1) and TAP2 serve pivotal roles in adaptive immunity. Tumor cells often show reduced antigen presentation on their surface as one mechanism to escape immune recognition. Whether downregulation of TAPs is a common mechanism of tumor immune evasion in squamous cell carcinoma of the oral tongue (SCCOT) is unclear. In the present study, samples from 78 patients with SCCOT and 17 patients with benign hyperplastic tongue lesions were analyzed for TAP1 and TAP2 expression by immunohistochemistry. The percentage of positive cells and staining intensity were scored. Associations with clinicopathological variables and survival outcome were also investigated. The results demonstrated that TAP1 and TAP2 levels were highly associated with each other in individual samples and were upregulated in SCCOT compared with benign lesions (P<0.001). The proportion of TAP1- or TAP2-positive tumor cells was >80% in all but two of the tumors, whereas 25.6 and 23.0% of the tumors showed weak intensity of TAP1 and TAP2, respectively. There were no significant associations with clinicopathological variables or survival outcomes between TAP-intermediate/strong and TAP-weak tumors. However, in patients <70 years old and with early stage SCCOT, male patients had better outcomes than female patients (log-rank P<0.05), and the best outcome was observed in male patients with intermediate/strong TAP expression. In conclusion, loss of TAP was not a frequent event in SCCOT and stronger TAP expression in male patients was associated with improved survival, providing further evidence for sex-specific immune modulation in cancer.

Variation in Plasma Levels of TRAF2 Protein During Development of Squamous Cell Carcinoma of the Oral Tongue.

As early detection is crucial for improvement of cancer prognosis, we searched for biomarkers in plasma from individuals who later developed squamous cell carcinoma of the oral tongue (SCCOT) as well as in patients with an already established SCCOT. Levels of 261 proteins related to inflammation and/or tumor processes were measured using the proximity extension assay (PEA) in 179 plasma samples (42 collected before diagnosis of SCCOT with 81 matched controls; 28 collected at diagnosis of SCCOT with 28 matched controls). Statistical modeling tools principal component analysis (PCA) and orthogonal partial least square - discriminant analysis (OPLS-DA) were applied to provide insights into separations between groups. PCA models failed to achieve group separation of SCCOT patients from controls based on protein levels in samples taken prior to diagnosis or at the time of diagnosis. For pre-diagnostic samples and their controls, no significant OPLS-DA model was identified. Potentials for separating pre-diagnostic samples collected up to five years before diagnosis (n = 15) from matched controls (n = 28) were seen in four proteins. For diagnostic samples and controls, the OPLS-DA model indicated that 21 proteins were important for group separation. TNF receptor associated factor 2 (TRAF2), decreased in pre-diagnostic plasma (< 5 years) but increased at diagnosis, was the only protein showing altered levels before and at diagnosis of SCCOT (p-value < 0.05). Taken together, changes in plasma protein profiles at diagnosis were evident, but not reliably detectable in pre-diagnostic samples taken before clinical signs of tumor development. Variation in protein levels during cancer development poses a challenge for the identification of biomarkers that could predict SCCOT development.

Retrospective analysis of 195 surgically treated cases of chronic subdural hematoma.

INTRODUCTION: The incidence of chronic subdural hematoma (CSDH) is increasing. This study evaluates the etiologic causes and findings of CSDH and compared unilateral CSDH with bilateral CSDH. This study aims to draw attention to this increasingly prevalent condition. METHODS: We retrospectively analysed 195 surgically treated cases of CSDH in our clinic between 2008 and 2018. RESULTS: The average age of the patients was 65.7 ± 19.6 years. The most common symptom was headache (53.3%). The case background was the use of anticoagulant (37.9%), head trauma (34.3%). The hematomas were 28.7% right side, 44.6% left side, and 26.7% bilateral. The mean Glasgow Coma Score (GCS) was 13.4 ± 2.9, early postop 13.8 ± 2.5, and late postop was 14.6 ± 1.1. Postoperative complications included acute subdural hematoma (5.1%), cerebral infarction (1.5%), wound infection (0.5%) and others (13.3%). Re-expansion of the brain were statistically significantly less frequent and impaired consciousness, anticoagulant use, early and late postop thickness were statistically significantly more frequent in patients with bilateral CSDH. CONCLUSIONS: CSDH is seen more patients of advanced age, those who use anticoagulants, patients with hypertension and diabetes and in patients with a history of head trauma. Prognosis is worse in bilateral CSDH. We estimate that the incidence of CSDH will go up in the future.

Large Schwannoma of the Deep Peroneal Nerve: A Case Report.

This article presents the case of a 32-year-old female patient with schwannoma. The patient had swelling on the anterior aspect of her right foot for 1 year with increasing pain over the past 2 months. Moreover, a positive Tinel sign was present over the swelling. Magnetic resonance imaging revealed a large schwannoma mass in the deep peroneal nerve. Consequently, the patient?s large schwannoma was completely excised along with its capsule. Schwannomas are benign tumors of the peripheral nerves that rarely exhibit malignant transformation. Treatment is considered to be curative if complete resection is achieved.

Effects of tamoxifen therapy on sciatic nerve crush injury: An experimental study in rats.

OBJECTIVE: This study aimed to determine the effects of tamoxifen on sciatic nerve crush injury in a rat model using histopathological, histomorphometric, and immunohistochemical approaches. METHODS: In this study, 24 male Sprague-Dawley rats aged of 5 to 7 weeks and weighing between 300 g and 400 g were used. The rats were randomly divided into 3 groups: control (group C), sciatic nerve injury (group SNI), and sciatic nerve injury with tamoxifen (group SNT). The sciatic nerve crush injury model was performed using the De Koning's crush force method. In group C, only a skin incision was made and then the skin was sutured. In group SNI, the injury model was performed but no treatment was applied. In group SNT, the injury model was executed, and then 40 mg/kg/day tamoxifen was given for 4 weeks by intraperitoneal methods. At the end of 4 weeks, all animals were killed using high doses of an anesthetic. Approximately, 2-cm sciatic nerve samples were obtained for histopathological, histomorphometric, and immunohistochemical analyses using the old skin incision. RESULTS: In the histopathological examination, vascular congestion and density of vacuolization were significantly lower in group SNT than in group SNI (p<0.05). In the histomorphometric examination, the mean sciatic nerve diameter was 306±62 µm in group C, 510±42 µm in group SNI, and 204±23 µm in group SNT. A significant difference was observed in the sciatic nerve diameter measurements among the 3 groups (p<0.05). In pairwise comparisons, the mean sciatic nerve diameter was significantly lower in group SNT than in group SNI (p=0.00002). Sciatic nerve diameter measurements of both groups were found to be significantly higher than group C (p<0.05). The mean epineurium thickness was 17±0.8 µm in group C, 32±2.5 µm in group SNI, and 17±0.8 µm in group SNT. A significant difference was observed in the epineurium thickness measurements among the 3 groups (p<0.05). In pairwise comparisons, the epineurium thickness was significantly higher in group SNI than in groups SNT and C (p<0.05). In the immunohistochemical analysis, S100 immunoreactivity was found significantly higher in group SNI than in the other 2 groups (p<0.05). CONCLUSION: The histomorphometric, histopathological, and immunohistochemical data obtained from this study have shown that tamoxifen has a beneficial effect on sciatic nerve crush injury in the experimental rat model.

Effect of Antithrombotic Therapy on Development of Acute Subdural Hematoma After Burr Hole Drainage of Chronic Subdural Hematoma.

AIM: To evaluate the relationship between the time from cessation of anticoagulant/antiplatelet medication to surgery and risk of postoperative acute subdural hematoma (ASDH) after burr hole drainage of chronic subdural hematoma (CSDH). MATERIAL AND METHODS: A retrospective study of patients who underwent burr hole drainage of CSDH between December 2014 and December 2019 was performed. Demographic and clinical data regarding age, gender, medication (antithrombotic therapy), smoking, daily alcohol consumption, history of head trauma, presenting symptoms, and neurological examination were collected from the medical records. Patients were divided into 3 groups based on time from referral to surgery: < 24 hours, 24?72 hours, and > 72 hours. RESULTS: One hundred seventeen patients underwent burr hole drainage of CSDH during the 5-year study period. Seventy-two patients were male (61.5%) and 45 were female (38.5%). Mean age was 70.5 ± 7.2 years. Postoperative ASDH occurred in 2 of the 32 patients (6.3%) who were not taking antithrombotic medication and 6 of the 85 patients (7.1%) who were taking antithrombotic medication. The difference was not significant (p=0.797). CONCLUSION: The risk of ASDH after burr hole drainage of CSDH was not affected by antithrombotic medication. Although the literature suggests that antiplatelet and anticoagulant drugs to be discontinued between 5 and 7 days before surgery, our results showed that acute hemorrhage was not detected in any patient who underwent surgery more than 72 hours after referral.

An unusual complication of posterior packing in epistaxis.

Endonasal or transnasal procedures are sometimes necessary in patients with head trauma. Before these procedures, the integrity of the skull base must be considered to avoid penetration of the cranial vault. A 54-year-old man was taken to a district hospital following a car accident. After the initial assessment and emergency treatment, he was transferred to our emergency clinic for further examination. The patient had massive nasal bleeding, though a Foley catheter had been inserted to control posterior bleeding. Computed tomography (CT) revealed that the catheter was not positioned correctly and was in the cranial vault. Several fractures of the maxillofacial and cranial bones and cervical vertebrae were detected on CT. He also had right hemothorax and bilateral brain contusions. Endonasal insertion of catheters or tubes in trauma patients without a complete assessment of the skull base can cause serious complications.

Associations of Trauma Severity with Mean Platelet Volume and Levels of Systemic Inflammatory Markers (IL1ß, IL6, TNFα, and CRP).

We investigated the associations of injury severity scores (ISSs) with the mean platelet volume, the serum levels of two interleukins (IL1ß and IL6), and the serum levels of tumour necrosis factor-α (TNFα) and C-reactive protein (CRP). We sought to identify biochemical parameters that could be used as components of a new biochemical parameter-based ISS system. The levels of CRP, TNFα, IL1ß, and IL6 differed significantly (all p values < 0.05) between severely injured patients and controls. The mean platelet volume (MPV) did not correlate with the ISSs (p > 0.05). The TNFα and IL6 levels were useful for determining the severity of injury, and the CRP level was elevated in all trauma patients but did not correlate with the ISS. The IL1ß level was higher in the study group but did not increase as the ISS increased. IL6 and TNFα levels were higher in the study group and increased as the ISS increased. We found no significant difference between the trauma group and healthy individuals in terms of MPV values. IL6 and TNFα levels can be used to assess trauma severity. However, neither the MPV nor the CRP or IL1ß level is useful for this purpose.

An isolated hyoid bone fracture caused by blunt trauma to the neck.

Hyoid bone fractures due to blunt trauma are exceedingly rare. Here, we present an isolated hyoid bone fracture caused by blunt trauma as well as a detailed discussion of the injury and treatment options. A 32-year-old male was admitted to emergency department with odynophagia and severe neck pain. He had been hit in the neck with a metal rod during a fight. Computed tomography scan revealed a fracture on hyoid bone and local swelling of adjacent soft tissues. The patient\'s head was elevated, and ice packs were used to reduce the swelling. Diclofenac sodium and prednisolone were administered. Patient was discharged with a recommendation of out-patient control. Odynophagia, dysphagia and dyspnoea should alert the physician to possible hyoid or laryngeal damage. Fibre optic laryngoscopy and neck CT are important diagnostic steps to reveal a possible life-threatening injury. Conservative treatment is usually adequate, and patients rarely require surgical intervention.

Fourth Ventriculostomy in Occlusion of the Foramen of Magendie Associated with Chiari Malformation and Syringomyelia.

We present four cases of hydrocephalus caused by occlusion of foramen of Magendie associated with Chiari Type I malformation and syringomyelia. The aim of this study is to evaluate the results of surgical treatment via fourth ventriculostomy with catheter from the fourth ventricle to the upper cervical subarachnoid space. Obstructive tetraventricular hydrocephalus due to occlusion of the foramina of Luschka and Magendie can be treated with cerebrospinal fluid shunting, opening the membranes with suboccipital craniotomy, placement of a catheter, endoscopic third ventriculostomy, and endoscopic fourth ventriculostomy. Our aim was to solve all the pathologies such as Chiari malformation, hydrocephalus, and syringomyelia in one approach. Thus, the treatment consisted of posterior fossa decompression and exploration. All the patients were treated with suboccipital craniectomy and C1 laminectomy with excision of the membrane obstructing the foramen of Magendie. Fourth ventriculostomy with cathetering from fourth ventricle to upper cervical subarachnoid space was performed. The postoperative period was uneventful in all the patients. Neurological status of all the patients improved. Tetraventricular hydrocephalus and syrinx were reduced in the control cranial magnetic resonance imaging. Complications such as infection and catheter migration were not observed during the follow-up period. Treatment with fourth ventriculostomy using a catheter from fourth ventricle to upper cervical subarachnoid space could be a treatment of choice in cases with hydrocephalus caused by occlusion of the foramina of Magendie, with associated Chiari Type I malformation and syringomyelia.

The role of septated concha bullosa on sinonasal pathologies.

The purpose of this study was to retrospectively determine the possible role of septated concha bullosa on sinonasal pathologies. Paranasal sinus computerized tomography scans of patients with symptoms of headache, postnasal drip, nasal obstruction and smell disorders were retrospectively evaluated. Twenty-eight subjects with unilateral septated concha bullosa and 13 subjects with unilateral concha bullosa without septation were selected as the study and control groups, respectively. Both groups were compared according to the presence of septal deviation and sinus pathology. There were no statistically significant differences in baseline characteristics (age and gender) between the groups. Sinus involvement was found in 20 patients (71.4 %) in the study group and in 10 patients (76.9 %) in the control group. The most common pathology accompanying septated concha bullosa was maxillary sinusitis (65 %), and ethmoid sinus was the second most involved sinus (25 %). Similar results in terms of sinus involvement were also seen in the control group. Septal deviation was seen in 18 patients in the study group (64.2 %) and in 12 patients in the control group (92.3 %). Eventually, there was no statistically significant difference between septated and non-septated concha bullosa groups according to the accompanying sinonasal pathologies.

The relationship between AHI, Epworth scores and sleep endoscopy in patients with OSAS.

This prospective study aimed to evaluate the relationship between sleep endoscopy findings, the apnea-hypopnea index (AHI) or the Epworth sleepiness scale in patients and obstructive sleep apnea syndrome (OSAS). Patients with symptoms of OSAS were searched, and their polysomnography findings, Epworth sleepiness scales and sleep endoscopy findings were recorded. Those who were diagnosed with mild, moderate or heavy OSAS were included in the study. Patients included in the study were observed under sedative-induced sleep in the operation room using flexible nasopharyngoscopy. The obstruction levels and degrees were recorded and compared with other variables. Of the 88 patients included in the study, 67 (76.1 %) were male, and 21 (23.9 %) were female. The mean age (±standard deviation) of all 88 patients was 43.77 ± 10.07 years (range 21-65 years). Sleep endoscopy findings were classified as uvulopalatal, lateral pharyngeal, tongue base and laryngeal collapses. The Epworth sleepiness scale showed no significant correlation with the sleep endoscopy findings. No significant relationship was found between the AHI and collapses in the uvulopalatal, lateral and laryngeal zones (p > 0.05). However, tongue base collapse was correlated with AHI (p < 0.05). AHI increased with the degree of collapse in the tongue base. No meaningful relationship was noted among the Epworth sleepiness scale, AHI, and number of involved zones (p > 0.05). The degree of collapse in the related zones was not meaningfully associated with AHI, which is accepted as the indicator of disease severity.

Bilateral superior concha bullosa: a rare case overlooked.

Concha bullosa is generally defined as the pneumatization of the middle turbinate and, rarely, of the superior or the inferior turbinates. A symptomatic pneumatization of the superior turbinate is extremely rare. When symptomatic, concha bullosa may cause various problems. Concha bullosa can be easily recognized in paranasal sinus computed tomography. In this article we present a very rare case with bilateral pneumatization of the superior turbinates in a patient with relevant symptomatology.

Bilateral triple concha bullosa: a very rare anatomical variation of intranasal turbinates.

Pneumatization of the intranasal turbinates or concha bullosa is an anatomic variation of the lateral nasal wall. Concha bullosa is defined as the presence of air cells in turbinates. It can be best diagnosed with paranasal sinus computed tomography. Concha bullosa is a possible etiologic factor for recurrent sinusitis due to its negative effect on paranasal sinus ventilation and mucociliary clearance. Concha bullosa is most commonly seen in the middle turbinate and less frequently in the inferior or superior turbinate. Pneumatization of all turbinates is very rare. To our knowledge, there are only two publications about a case with concha bullosa in all turbinates in the current literature. Here, we present a woman with bilateral pneumatization in all three intranasal turbinates.

The strengthened stair-step technique for correction of lateral crural malpositioning.

BACKGROUND: Currently, clinicians better understand the functional and aesthetic consequences of a cephalic malpositioned lateral crus of the lower lateral cartilage, which was identified 30 years ago. Functionally, cephalic malpositioning causes alar support deficiency, which results in external valve insufficiency. Cosmetically, it causes alae nasi retraction, alar bracket deformity, boxiness, and underprojection of the nasal tip. The stair-step technique, defined by Boccieri and Raimondi, is an effective repositioning technique for the repair of this deformity. The strengthened stair-step technique, a combination of the lateral crural-rim graft and the stair-step technique, is described in this article. METHODS: In this study, designed as a prospective case series, the strengthened stair-step technique was performed for 62 patients (43 women and 19 men; mean age, 27.3 years) between November 2009 and December 2012. Because 12 patients did not attend follow-up visits regularly, their outcomes could not be evaluated. These patients were excluded from the study. Pre- and postoperative photos of all the patients were taken. RESULTS: Aesthetic evaluations showed that six patients were not satisfied with their results, four patients had complaints about the nasal tip (1 had asymmetry and 3 had alar stiffness and/or thickness), and two patients had nasal dorsum complaints. Functional evaluation showed that four patients had slight dissatisfaction with their breathing. They reported continuing collapse in the valve area with inspiration. The remaining patients were satisfied with their results. CONCLUSION: The strengthened stair-step technique is a safe and effective technique for correcting not only lateral crus cephalic malpositioning but also alar rim retraction and external valve collapse.