Facial disfigurement due to olfactory neuroblastoma: beauty regained with chemotherapy.

BACKGROUND: Olfactory neuroblastoma (ONB) is a sinonasal malignancy seldom seen in clinical practice. It is also known by various other names like esthesioneuroblastoma, esthesioneuroepithelioma, esthesioneurocytoma, and esthesioneuroma. Surgery and radiation therapy are considered as standard treatment modalities for ONB; however, the role of chemotherapy is not well established. AIMS: We aim to define the role of chemotherapy in the neoadjuvant setting in a case of ONB. METHODS AND RESULTS: We report a young female patient presenting with a naso-facial swelling causing facial disfigurement, proptosis, decreased visual acuity, and poor performance status. She was diagnosed with advanced-stage ONB. Prompt administration of chemotherapy led to the improvement in the symptoms and rapid regression of the tumor mass. Later on, the tumor mass was excised completely without any neurological deficit. CONCLUSION: This report justifies the role of neoadjuvant chemotherapy in the management of ONB.

Nasal Airway Obstruction Study (NAIROS): a phase III, open-label, mixed-methods, multicentre randomised controlled trial of septoplasty versus medical management of a septal deviation with nasal obstruction.

BACKGROUND: Septoplasty (surgery to straighten a deviation in the nasal septum) is a frequently performed operation worldwide, with approximately 250,000 performed annually in the US and 22,000 in the UK. Most septoplasties aim to improve diurnal and nocturnal nasal obstruction. The evidence base for septoplasty clinical effectiveness is hitherto very limited. AIMS: To establish, and inform guidance for, the best management strategy for individuals with nasal obstruction associated with a deviated septum. METHODS/DESIGN: A multicentre, mixed-methods, open label, randomised controlled trial of septoplasty versus medical management for adults with a deviated septum and a reduced nasal airway. Eligible patients will have septal deflection visible at nasendoscopy and a nasal symptom score ≥ 30 on the NOSE questionnaire. Surgical treatment comprises septoplasty with or without reduction of the inferior nasal turbinate on the anatomically wider side of the nose. Medical management comprises a nasal saline spray followed by a fluorinated steroid spray daily for six months. The recruitment target is 378 patients, recruited from up to 17 sites across Scotland, England and Wales. Randomisation will be on a 1:1 basis, stratified by gender and severity (NOSE score). Participants will be followed up for 12 months post randomisation. The primary outcome measure is the total SNOT-22 score at 6 months. Clinical and economic outcomes will be modelled against baseline severity (NOSE scale) to inform clinical decision-making. The study includes a recruitment enhancement process, and an economic evaluation. DISCUSSION: The NAIROS trial will evaluate the clinical effectiveness and cost-effectiveness of septoplasty versus medical management for adults with a deviated septum and symptoms of nasal blockage. Identifying those individuals most likely to benefit from surgery should enable more efficient and effective clinical decision-making, and avoid unnecessary operations where there is low likelihood of patient benefit. TRIAL REGISTRATION: EudraCT: 2017-000893-12, ISRCTN: 16168569. Registered on 24 March 2017.

Management of Postsurgical Empty Nose Syndrome.

Empty nose syndrome (ENS) is a controversial condition associated with disruption of nasal airflow caused by excessive loss of turbinate tissue. ENS arises after total or near-total inferior turbinate resection. Patients present with intense fixation on the perception of nasal obstruction. Diagnostic tools to assess for empty nose syndrome include a validated patient questionnaire and the office cotton test. Treatment involves topical moisturization, behavioral/psychiatric assessment/treatment, and surgical reconstruction. Current data show promising long-term efficacy after surgical intervention. Postprocedural ENS is best prevented by minimizing inferior and middle turbinate tissue loss.

Septoplasty with or without concurrent turbinate surgery versus non-surgical management for nasal obstruction in adults with a deviated septum: a pragmatic, randomised controlled trial.

BACKGROUND: Septoplasty (surgical correction of the deviated nasal septum) is the most frequently performed ear, nose, and throat operation in adults, but no randomised controlled trials or non-randomised comparative studies on the effectiveness of septoplasty have been published. Consequently, health-care providers, health insurance companies, and policy makers are concerned about the effectiveness of the procedure. We aimed to assess the effectiveness of septoplasty for nasal obstruction in adults with a deviated septum. METHODS: We did this open, multicentre, pragmatic, randomised controlled trial in 16 secondary and two tertiary referral hospitals in the Netherlands. Adults (aged ≥18 years) with nasal obstruction, a deviated septum, and an indication to have septoplasty done were randomly allocated (1:1) to receive either septoplasty with or without concurrent turbinate surgery or non-surgical management. Patients were stratified by sex, age (<35 years or ≥35 years), and deviation severity (mild, moderate, or severe). The primary outcome was health-related quality of life, measured with the validated Glasgow Health Status Inventory at 12 months. Analyses were done on an intention-to-treat basis. The trial is registered with the Netherlands Trial Register, number NTR3868. FINDINGS: Between Sept 2, 2013, and Dec 12, 2016, we randomly assigned 203 participants to receive either septoplasty with or without concurrent turbinate surgery (n=102) or non-surgical management (n=101). 189 participants were analysed at 12 months. At 12 months, mean score on the Glasgow Health Status Inventory of patients assigned to septoplasty was 72·2 (SD 12·2) and for those assigned to non-surgical management was 63·9 (SD 14·5, mean difference 8·3 [95% CI 4·5-12·1], favouring septoplasty). Septal abscess occurred in one surgical patient and septal perforation in two surgical patients. No side-effects of nasal medication were reported. INTERPRETATION: Septoplasty is more effective than non-surgical management for nasal obstruction in adults with a deviated septum. This effect was sustained up to 24 months of follow-up. FUNDING: The Netherlands Organisation for Health Research and Development (ZonMw).

Septoplasty versus non-surgical management for nasal obstruction due to a deviated nasal septum in adults: A modelling study of cost-effectiveness.

OBJECTIVE: The objective of this study was to demonstrate how decision-analytic modelling can help to determine circumstances under which surgery may become cost-effective, using septoplasty as an example. DESIGN: We developed a decision-analytic model comparing septoplasty to non-surgical management for nasal obstruction in adults with a deviated septum. Based on the estimated cost difference between both treatments, we calculated the minimal (a) gain in quality-adjusted life-years, or (b) reduction in productivity losses needed for septoplasty to be cost-effective. Input was derived from literature and publicly available data sources. The time horizon of our model was one year, and the willingness-to-pay per quality-adjusted life-year was €20 000, in accordance with current guidelines. RESULTS: The cost difference between septoplasty and non-surgical management for nasal obstruction due to a deviated nasal septum was €2227 per patient from a healthcare perspective (including direct healthcare costs) and €3288 per patient from an extended perspective (additionally including travel expenses and productivity losses due to poor health). In comparison with non-surgical management, septoplasty needed to gain 0.11 to 0.16 QALYs or save 13 sick days for nasal obstruction. The longer septoplasty's effect lasts, the more time it will have to compensate its extra costs. CONCLUSION: This study shows that the known cost difference between treatments can be used as the starting point to determine beneficial effects needed for cost-effectiveness of surgical interventions. The effect required by septoplasty from a healthcare perspective seems potentially achievable, meaning that it would be useful to perform an RCT assessing the actual benefits of septoplasty.

Nonsurgical Rhinoplasty: Nasal Grid Analysis and Nasal Injecting Protocol.

BACKGROUND: Nonsurgical rhinoplasty using injectable fillers improved skin quality and texture, cost-effectiveness, and quick recovery. The aim of this study was to provide a valid and customized protocol for injecting the nose with the aid of a nasal grid. METHODS: From January of 2016 to October of 2017, 150 consecutive patients entered the trial. The mean patient age was 36 years (range, 16 to 60 years). The patients were divided into two arms: primary nasal defects (no previous surgery, n = 109) and secondary nasal defects (previous surgery, n = 41). The primary defect group included 43 male patients and 66 female patients, and the secondary nasal defect group included 14 male patients and 27 female patients. Within each arm, patients were stratified into three age group tiers: younger than 30 years, 30 to 45 years, and older than 45 years. RESULTS: The grid became the reference for quantity and sequence of injection records. The overall complication rate was 1.82 percent, and a visual analogue scale ranging from 1 to 10 was implemented (with 10 being the most accurate correction). Of the patients evaluated, 98.350 percent scored 8 to 10, 0.825 percent scored 6 to 8, and 0.825 percent scored below 6. CONCLUSIONS: Fillers can be either alternatives or complementary to plastic surgery. Nonsurgical rhinoplasty, with its avoidance of general anesthesia, splints, swelling, and bruising, represents a distinct advantage, allowing the patient to return to work as quickly as the same or the next day. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

An esthetic modification of a nasal conformer.

Facial contractures caused by burns can collapse the nasal aperture and lead to airway obstruction. Management in such situations requires surgical and prosthetic intervention. Prosthetically, although a nasal conformer is the treatment of choice, even a well-fabricated nasal conformer may be esthetically unappealing and require an aid for enhanced retention. Expensive implant-aided conformers are not always a viable option. This article introduces a technique for fabricating a nasal conformer that is both esthetically appealing and cost-effective. The technique is illustrated by the treatment of a 12-year-old girl who presented with a history of burn injuries leading to nasal contracture that was effectively managed with this concept.

Effectiveness of septoplasty versus non-surgical management for nasal obstruction due to a deviated nasal septum in adults: study protocol for a randomized controlled trial.

BACKGROUND: Septoplasty, i.e., surgical correction of the deviated nasal septum, is the most common ear, nose and throat (ENT) operation in adults. Currently the main indication to perform septoplasty is nasal obstruction. However, the effectiveness of septoplasty for nasal obstruction in adults with a deviated nasal septum remains uncertain. Scientific evidence is scarce and inconclusive, and internationally accepted guidelines are lacking. Moreover, there is no consensus on whether or not septoplasty should be combined with concurrent turbinate surgery. The objective of the current ongoing trial is to study the effectiveness of septoplasty (with or without concurrent turbinate surgery) as compared to non-surgical management for nasal obstruction in adults with a deviated nasal septum, both in terms of subjective (health-related quality of life) as well as objective (nasal patency) outcome measures. METHODS/DESIGN: The study is designed as a pragmatic, multicenter, parallel-group, randomized controlled trial. A total of 200 adults will be enrolled with nasal obstruction based on a deviated nasal septum and an indication for septoplasty according to current medical practice in the Netherlands. Participants will be randomized to either septoplasty (with or without concurrent turbinate surgery as originally indicated by the otorhinolaryngologist) or a non-surgical watchful waiting strategy. Follow-up visits will be scheduled at 0, 3, 6, 12, and 24 months. During each follow-up visit, health-related quality of life questionnaires will be administered and measurements of four-phase rhinomanometry and peak nasal inspiratory flow will be performed. Costs will be studied using a patient-based diary. Effects of septoplasty on health-related quality of life (primary outcome) and nasal patency will be calculated as mean differences with 95 % confidence intervals. Subgroup analyses according to gender, age, and severity of the septal deviation will be performed. All analyses will be performed on an intention-to-treat basis. DISCUSSION: With the results of this study we aim to contribute to the development of evidence-based guidelines regarding indications for septoplasty. TRIAL REGISTRATION: Nederlands Trial Register/Dutch Trial Registry ( www.trialregister.nl ), trial identifying number: NTR3868 . Registered on 21 February 2013.

Multiplane hyaluronic acid (EME) in female Chinese rhinoplasty using blunt and sharp needle technique.

BACKGROUND: Hyaluronic acid has been widely used for nonsurgical rhinoplasty. Little literature focuses on Chinese women of the Han nationality, who have a characteristic flattened facial contour. Projection of the nose, including the nasal dorsum, nasal tip, and columella, plays an important role in achieving an attractive face. AIM: The aim of this study was to investigate the application of multiplane hyaluronic acid in rhinoplasty using blunt and sharp needle technique. METHOD: From June 2011 to February 2014, 280 cases of nonsurgical rhinoplasty by hyaluronic acid were applied; 1-9 months follow-up showed satisfactory appearance. RESULT: Postoperative results showed no complications, such as infection or flap necrosis. CONCLUSION: For esthetic and safety considerations, we suggest multiple plane injections using blunt combined with sharp needle-filling techniques.

Common postburn deformities and their management.

This article describes a practical, clinically based approach to classification of postburn deformities. Burn scar contractures are of either the broad diffuse type or linear band-like type. The former generally respond well to release and insertion of a skin graft or substitute, whereas the latter are generally repaired using a simple or modified Z-plasty or a transpositional flap technique. The pulsed dye laser is a promising technique used to reduce scar thickness and redness. Postburn deformities of the face, upper and lower extremities, and trunk are discussed, in addition to novel techniques for vascularized composite allotransplantation of the face.

[The original splint-electrode for endonasal electrophoresis].

The objective of the present study was to improve the effectiveness of the treatment of the patients presenting with deflection of the nasal septum and vasomotor rhinitis by developing a method for endonasal electrophoresis in the postoperative period. The study involved 102 patients allocated to three groups. All of them underwent septoplasty including splinting of the nasal septum and submucous laser vaporization of the inferior turbinate bones. The patients of group 3 were treated with the use of an original septal stent with the integrated electrode that allowed to reduce the injurious effect of the procedure of nasal electrophoresis and thereby to decrease the duration of the rehabilitation period following the intranasal surgical intervention; moreover, this approach enhanced the effectiveness of surgery.

Tratamiento de secuelas nasales con PMMA / Treatment of sequelae nasal with PMMA

El relleno de los tejidos blandos, en particular en la cara, es un procedimiento cada vez mas utilizado. En épocas recientes el número de agentes de relleno ha venido incrementándose, mejorando el rango de opciones para médicos y pacientes. En el presente manuscrito comunicamos nuestra experiencia con el uso del polimetilmetacrilato o PMMA en el relleno de las secuelas de la nariz. Este simple procedimiento de consultorio permite solucionar distintas fallas en la estructura nasal, habitualmente después de una o más rinoplastias. Presentamos un pequeño grupo de pacientes y los resultados logrados con el mencionado material en forma ambulatoria y en consultorio

Soft-tissue augmentation of the face is an increasingly popular cosmetic procedure. In recent years, the number of available fi lling agents has also increased dramatically, improving the range of options available to physicians and patients. In the present manuscript we communicate our experience using poly methyl meta acrylate known as PMMA for the fi lling of the sequelae in the nose, after one or more rhinoplasties. We show a small group of patients and their results and achievements, all of them through an ambulatory basis and carried out at the offi ce.

Fat grafting to the nose: personal experience with 36 patients.

BACKGROUND: Clinicians are facing an increasing trend toward nonsurgical nose reshaping using synthetic injectables, mainly for patients who refuse standard rhinoplasties. Autologous fat grafting is a safer and convenient alternative to permanent or semipermanent injectables due to better results as well as fewer and milder side effects. The author reports his experience with fat grafting to the nose using his personal technique for 36 consecutive patients. The experience covers primary treatments of noses not treated by surgery, treatment of post rhinoplasty deformities, and combination fat grafting and rhinoplasties. METHODS: The technique used by the author for fat grafting to the nose does not differ significantly from that used for other body or face areas. It is based in the atraumatic extraction of fat fragments using a multi-orifice cannula and injection of these fragments using 1.4- to 1.6-mm cannulas or needles. In combining rhinoplasties with fat grafting, fat grafts are used in the same location instead of a prosthesis or cartilage grafts. RESULTS: The initial analysis of postoperative results showed a good to high level of patient satisfaction, particularly in primary cases, with virtually no complications or severe side effects. Some easily corrected side effects probably were learning curve dependent. CONCLUSIONS: Autologous fat grafting is an effective and reliable technique for aesthetic and reconstructive nose reshaping for patients who refuse surgical treatments. Although optimal results can be achieved with this technique, they are not comparable with those obtained by surgical rhinoplasties, and this is an important issue to discuss with the prospective patient.

Manipulation of fractured nose using mallet and champagne cork.

We describe an alternative method of manipulating fractured nasal bones using a surgical mallet and a champagne cork. This method enables accurate fracture reduction with minimal skin trauma, by affording the surgeon a high level of control. This method may be applied successfully to late-presenting fractures.

Rhinoplasty to correct nasal deformities in postseptoplasty patients.

BACKGROUND: Although not so common, septoplasty carries the risk of inducing nasal deformity such as saddle nose and deviated nose. Surgical correction for those deformities is a formidable task to deal with, because the septal cartilage framework was already weakened due to previous procedure. This study was designed to examine various causes and effective techniques of rhinoplasty for correction of nasal deformities after septoplasty. METHODS: Subjects comprised 19 patients who developed nasal deformities after septoplasty. Pre- and postoperative photographs were analyzed by two rhinoplastic surgeons. Anthropometric measurements of the external nose before and after surgery were made using frontal and lateral photographs to objectively evaluate outcomes. RESULTS: Intraoperative analysis showed that 5 patients had weak L-struts and 13 patients had displaced caudal septa. Septum was reconstructed using costal cartilage in 13 cases. Spreader grafting was performed in 13 patients and caudal septal extension grafts were performed in 10 patients. All but 1 patient had successful functional and esthetic outcomes. In the saddle nose group, all parameters except nasolabial angle were significantly improved. In the deviated nose group, curved deviated angles were completely corrected, whereas the linear deviated angle was not. CONCLUSION: Loss of caudal septal support appears to be a major reason for nasal deformity after septoplasty. The best surgical approach for septal cartilage framework reconstruction appears to involve the use of bilateral spreader or septal extension grafts using costal cartilage.

Mastoid bone as a new graft material in rhinoplasty.

BACKGROUND: The management of certain nasal deformities, especially after prior rhinoplasty, may require grafting material. In this study we describe the use of mastoid bone as a viable and low morbidity autologous graft. METHODS: Mastoid bone was used for nasal augmentation, smoothing dorsal nasal irregularities, or augmentation of radix. Candidates for mastoid bone graft were patients undergoing primary rhinoplasty suffering from low radix or saddle nose deformity and candidates for secondary rhinoplasty suffering from prior overresection of the osteocartilaginous structures. RESULTS: Fifty-six patients met the study criteria. Eighteen patients underwent secondary rhinoplasty and suffered from prior overresection of osteocartilaginous structures and 38 patients underwent primary rhinoplasty. Of these, 18 patients had a low radix and 20 patients had a saddle nose deformity. Follow-up was 6-49 months (mean, 23 months). All cases resulted in an augmented straightened nasal dorsum, increased tip projection, and adjusted radix. There were no cases of graft infection. In two cases the graft was displaced requiring revision. The amount of graft absorption even after 2 years follow-up was acceptable. There were no donor site complications. CONCLUSIONS: The mastoid bone graft provides adequate autologous bone in most cases of primary or revision rhinoplasty. The donor site carries low morbidity and a well camouflaged scar. It is easily accessible especially for the otolaryngologist who is accustomed to operating on the mastoid bone.

The use of Dermicol-P35 dermal filler for nonsurgical rhinoplasty.

A growing number of patients with congenital or acquired nasal defects is seeking nonsurgical procedures to correct the appearance of their nose. The use of fillers for the correction of nasal deformities is expanding because of their low risk and reversibility compared with surgery. Dermicol-P35 (Evolence; Ortho Dermatologics, Skillman, NJ) is a novel crosslinked, fibrillar type I collagen isolated from porcine tendons that has not been associated with the same degree of immunogenicity as bovine collagen. The use of Dermicol-P35 in this study of 12 subjects was associated with high tolerance, as well as a high degree of satisfaction.

Long-term results after using dynamic presurgical nasoalveolar remodeling technique in patients with unilateral and bilateral cleft lips and palates.

OBJECTIVE: To evaluate the effects and durability of results after using dynamic presurgical nasoalveolar remodeling in patients with unilateral and bilateral cleft lips and palates. METHOD: Dynamic presurgical nasoalveolar remodeling technique does not rely on the relatively static force exerted by the orthopedic plate held in place by means of tape or adhesives. The principle behind this procedure is the use of the force generated during suction and swallowing to produce the remodeling effects on the nasal structures. The nasal component acts not only on the nasal structures but also in the lip function by stimulating labial muscle contraction. Direct anthropometry performed before primary reconstruction of the lip and nose and 1 year later posterior to surgery suggests that results are permanent. CONCLUSIONS: When the dynamic presurgical nasoalveolar remodeling protocol is instituted early, it can avoid memory cartilage fixation. Changes incorporated to the nasal extension allowed us to obtain better results, elevating the nasal tip, remodeling the depressed cleft side alar cartilages in unilateral cases, and repositioning and correcting the positional alteration of the nasal cartilages building a new columella in bilateral cases. In addition, comfort and tolerance of patients has been improved, and adjustments needed during follow-up have been simplified, significantly reducing the consultation time and increasing the interval between appointments. The obtained outcome facilitates primary surgical cleft lip and nose reconstruction and improves surgical results.