Packing in endonasal surgery.

Nasal packing is used to control bleeding in epistaxis and after endonasal surgery, for internal stabilization, and to prevent synechiae or restenosis, particularly after surgery. Generally accepted standards regarding the materials that should be used for packing, how long the packing should be left in place, or the indications for nasal packing are lacking. In view of the present lack of standardization and the many different packing materials used, we review the currently available materials and outline their respective properties, indications, and risks.

A graduated approach to the repair of nasal septal perforations.

Septal perforation is an avoidable complication of septal surgery, but it can also occur because of a variety of traumatic, iatrogenic, caustic, or inflammatory reasons. Symptoms usually are related to disruption of the normally laminar flow of air through the nasal passages. Crusting, bleeding, parosmia, and neuralgia can develop, leading the patient to seek medical care. When local hygiene and conservative care are unsuccessful in relieving symptoms, closure of the perforation is considered. Repair is often difficult because of the limited exposure and limited amounts of friable mucosa with impaired vascular supply. The failure of attempted closure of septal perforations can be as high as 80 percent. The authors have developed a graduated approach to the closure of septal perforations that tailors the surgical approach to the size and location of the defect. Perforations 0.5 to 2.0 cm in size were closed in 92.9 percent (13 of 14) of patients using an extended external rhinoplasty approach and bilateral posteriorly based mucosal flaps. Larger perforations (2.0 to 4.5 cm) were closed in 81.8 percent (18 of 22) of patients by a two-staged technique, using a midfacial degloving approach to medially advance posteriorly based, expanded mucosal flaps. With careful preoperative management and selection of the appropriate surgical technique, even moderate-to-large perforations can be repaired reliably with limited operative morbidity.

Secure endoscopic sinus surgery as an adjunct to functional nasal surgery.

The efficacy of functional endoscopic sinus surgery for the treatment of chronic sinusitis is well established. Two contrasting European techniques are currently in use: that espoused by Wigand, which includes endoscopic exenteration of all the sinus cavities with removal of the middle turbinates, and that developed by Messerklinger, who practices minimal opening of the narrow osteomeatal tract at the anterior ethmoidal sinus to achieve physiological reversal of sinus disease. After exposure to both techniques, one of us (P.H.T.) developed a middle-ground approach that lies between the extremes of the two European schools. The benefits of this middle-ground technique include a high success rate, maximal safety, relative ease of learning, and its ability to be performed as an adjunct to any other indicated functional nasal surgery.

Simplified protocol for management of malar fractures.

Our simplified protocol for the management of malar complex fractures of facial bones has shortened the operating time by one third to one fourth, produced consistent, satisfactory results, and reduced intraoperative and postoperative complications. In addition, with moderate training of residents, it has been installed as the primary method of treatment of this type of facial fracture in a residency training program that has a heavy load of these patients.

Simplified protocol for treatment of malar fractures. Based on a 1,220-case, eight-year experience.

A simplified protocol of approach has evolved from the treatment of approximately 1,200 malar fractures in an eight-year period in the private practice of one of us (R.S.M.) and at the Los Angeles County/University of Southern California Medical Center. The method begins with the Gillies incison for reduction and routinely uses internal wire pin fixation tailored to the mechanical requirements of the malar fracture. It advances only if necessary to brow and infraorbital incisions, direct wiring, orbital exploration, or Caldwell-Luc. Antrostomy with antral packing. Occasionally, a transcutaneous wire or small bone screw may be inserted for headcap or halo vector traction if indicated by the judgment of the surgeon. The internal wire pin protocol has produced hundreds of satisfactory reductions and fixations of malar fractures in our experience, with shortened operating time and reduced complications. It has been installed as the primary method of treatment for this type of facial fracture in a residency program that has many of these patients.