Correlation of maximal nasal septal deviation with deviation at the maxillary insertion.

PURPOSE: It is unclear if septal deviation at the insertion points to the nasal cavity is associated with the overall septal deviation. This study aimed to assess septal deviation at the cribriform plate (CP) and maxillary crest (MC) using CT scans and to see if there was any correlation with overall septal deviation. METHODS: All consecutive CT sinus scans between January 2020 and December 2021 were retrospectively reviewed. Patients were excluded if they had a history of head, nasal or facial trauma, or any previous nasal surgical procedure. Angles between the septum and MC and the septum and CP as well as maximal angle of septal deviation (MSD) were measured. RESULTS: A total of 70 scans were included in the final analysis. The mean MSD was 8.14°. The mean septal deviation was 0.89° at the CP and 2.02° at the MC. The correlation coefficient between the deviation at the CP and MSD was 0.025 and between the deviation at the MC and MSD was 0.321. CONCLUSION: Our data reveal a positive correlation between septal deviation at the floor of the nose and overall septal deviation; this was not observed at the septal deviation at the roof. This could be explained due to the inherent tilt in the cribriform plate or by earlier ossification and fixation of the septum during its development at its insertion to the roof, thereby allowing further growth and potential for deviation of the lower part of the septum and its insertion to the floor.

A-T Flap for Reconstruction of Nasal Dorsum Skin Defects.

BACKGROUND: Reconstruction of nasal defects can be challenging, especially when encountering larger defects. We describe the use of a single-stage conversion of an 'A' shaped defect to a 'T' shaped scar of large nasal skin defects in the cosmetically sensitive supra-tip and supra-alar regions. OBJECTIVE: This study aimed to determine whether an A-T flap is a suitable option for nasal reconstruction and if so where and what size defects it can be used for. METHODS: Retrospective case series review over an 8-year period (2011-2019) in a tertiary referral center in the United Kingdom. Case analysis was undertaken in 2020 including all patients who underwent A-T reconstruction of nasal defects. A review of histology, case notes, and clinical photography was undertaken. RESULTS: A total of 27 patients were identified-13 (48%) female and 14 (52%) male. The median age was 73 years (range 31-90 years). Defect locations were supra-tip (48%) and supra-alar (52%). The largest defect closed was 895 mm2 (30 × 38 mm). Range 35 to 895 mm2 (median 264 mm2). No patient required revision or corrective procedures. No functional impairment was identified. Patient and clinician reported aesthetic outcomes as good in all cases. No reports of this technique could be identified in the literature. CONCLUSION: The A-T flap is a viable option for supra-tip and supra-alar skin defects (up to 895 mm2 in our series). It aligns well with the basic principles of nasal reconstruction. The flap can be performed under local anesthesia in one stage, resulting in good functional and aesthetic outcomes and so can be considered a valuable tool for the nasal reconstructive surgeon.

Our experience and modification of the Antia-Buch flap for pinna reconstruction.

OBJECTIVE: The Antia-Buch flap technique is used for the reconstruction of pinna helical defects. We present our modification of this flap to reconstruct large defects (greater than 20 mm) with good outcomes. METHODS: A retrospective review was conducted on all modified Antia-Buch flaps performed in a single unit from January 2011 to April 2019. All adult patients (greater than 16 years of age) who underwent this method of reconstruction after surgical excision of a pinna lesion were included. Measurements of the excision specimens from the final histological reports were used to determine the defect size. The helical lengths of the defect were used for analysis. Medical records were reviewed to identify postoperative complications from the reconstruction. RESULTS: A total of 103 patients underwent the modified Antia-Buch flap reconstruction. All cases were performed by a single surgeon (senior author SA). Patients were 51-96 years of age (mean 76 years, SD±8.6), including 92 males and 11 females. The helical length of defects closed was between 12 and 42 mm (mean 26.7 mm, SD±6.46), and defect widths were 6-37 mm (average 14.5 mm, SD±5.28). There were 5 complications in our series (4.8% complication rate), with a revision rate of 2.9% (n = 3). CONCLUSIONS: Our case series is the largest in the literature. Our modification demonstrates that large pinna defects can be reliably repaired with modification of the Antia-Buch flap that gives patients the option of a single-stage reconstruction without added morbidity and a good cosmetic outcomes.

Medical management of rhinitis in pregnancy.

Medical treatment options for patients with rhinitis during pregnancy need careful considerations. It is important to distinguish between the causes of rhinitis, as this can influence treatment. Conservative options are important for patients with pregnancy-induced rhinitis (PIR) and pre-existing allergic or non-allergic rhinitis. Education and knowledge that PIR symptoms will resolve after pregnancy can offer some relief. Other strategies such as exercise, positioning, saline nasal douching/lavage, and nasal valve dilators are safe in pregnancy and can have a benefit in these patients with rhinitis of any aetiology. The main medical therapies usually used in rhinitis cannot always be directly translated to pregnant patients due to potential teratogenic effects. Topical corticosteroids have generally shown to be safe with budesonide having the strongest recommendations. Oral corticosteroids are mostly used in moderate-severe disease and should be avoided in the first trimester. Oral decongestants have associations with cardiac, ear, gut and limb abnormalities and are not recommended in the first trimester. Loratadine and cetirizine have been the most well-studied second-generation antihistamines and are generally considered safe. There has been no reported increased risk of teratogenicity with anticholinergics or cromones, with the latter being one of the first line options in pregnant women with allergic rhinitis. The role of allergen immunotherapy needs further research, but current guidance states it can be continued if already initiated prior to pregnancy. The management of rhinitis in pregnancy can therefore be complex. This review aims to evaluate the current medical management options for rhinitis in pregnancy.

British Rhinological Society Consensus Guidance on the use of biological therapies for chronic rhinosinusitis with nasal polyps.

OBJECTIVES: We set out to create Consensus Guidelines, based on current evidence and relative risks of adverse effects and the costs of different treatments, which reflect the views of the British Rhinological Society (BRS) Council on where the use of biologics should be positioned within treatment pathways for CRSwNP, specifically in the setting of the National Health Service (NHS). DESIGN: An expert panel of 16 members was assembled. A review of the literature and evidence synthesis was undertaken and circulated to the panel. We used the RAND/UCLA methodology with a multi-step process to make recommendations on the use of biologics. SETTING: N/A. PARTICIPANTS: N/A. RESULTS: Recommendations were made, based on underlying disease severity, prior treatments and co-morbidities. A group of patients for whom biologics were considered an appropriate treatment option for CRSwNP was defined. CONCLUSIONS: Although biologics are not currently available for the treatment of CRSwNP, the BRS Council have defined a group of patients who have higher rates of "failure" with current treatment pathways, higher resource use and are more likely to suffer with uncontrolled symptoms. We would urge NICE to consider approval of biologics for such indications without applying further restrictions on use.

Socioeconomic, comorbidity, lifestyle, and quality of life comparisons between chronic rhinosinusitis phenotypes.

BACKGROUND: Chronic rhinosinusitis (CRS) is a heterogeneous group of inflammatory sinonasal disorders with key defining symptoms, but traditionally separated into phenotypes by clinical/endoscopic findings. It is not known whether the two phenotypes have differing socioeconomic, comorbidity, and lifestyle differences. This analysis of the Chronic Rhinosinusitis Epidemiology Study (CRES) database sought to analyze any key differences in the socioeconomic variables between those with CRS with nasal polyps (CRSwNPs) and those without nasal polyps (CRSsNPs). We also sought to analyze differences in comorbidities, lifestyle, and quality of life. METHODS: Patients with a confirmed diagnosis of CRS in secondary and tertiary care outpatient settings in the UK were invited to participate in a questionnaire-based case-control study. Variables included demographics, socioeconomic factors, comorbidities, lifestyle factors, and health-related quality of life (HRQoL) (level 3 evidence). RESULTS: A total of 1204 patients' data were analyzed: 553 CRSsNP and 651 CRSwNP participants. The key socioeconomic variables did not demonstrate any notable differences, nor did lifestyle variables other than alcohol consumption being higher in those with CRSwNP (P = .032), but the latter was not significant after adjusting for age and sex. Aside from confirmation of asthma being more common in CRSwNP, it was notable that this group complained less of upper respiratory tract infections (URTIs), and CRSsNP participants showed evidence of worse HRQoL scores in respect of body pain (P = .001). CONCLUSIONS: Patients with CRSwNP experience higher rates of asthma and lower rates of URTIs; patients with CRSsNP have worse body pain scores. Otherwise, there are no demonstrable significant socioeconomic, comorbidity, lifestyle, or quality of life differences between the two phenotypes. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:2179-2186, 2021.

Management of new onset loss of sense of smell during the COVID-19 pandemic - BRS Consensus Guidelines.

OBJECTIVES: The primary aim of the study is to provide recommendations for the investigation and management of patients with new onset loss of sense of smell during the COVID-19 pandemic. DESIGN: After undertaking a literature review, we used the RAND/UCLA methodology with a multi-step process to reach consensus about treatment options, onward referral, and imaging. SETTING AND PARTICIPANTS: An expert panel consisting of 15 members was assembled. A literature review was undertaken prior to the study and evidence was summarised for the panellists. MAIN OUTCOME MEASURES: The panel undertook a process of ranking and classifying appropriateness of different investigations and treatment options for new onset loss of sense of smell during the COVID-19 pandemic. Using a 9-point Likert scale, panellists scored whether a treatment was: Not recommended, optional, or recommended. Consensus was achieved when more than 70% of responses fell into the category defined by the mean. RESULTS: Consensus was reached on the majority of statements after 2 rounds of ranking. Disagreement meant no recommendation was made regarding one treatment, using Vitamin A drops. Alpha-lipoic acid was not recommended, olfactory training was recommended for all patients with persistent loss of sense of smell of more than 2 weeks duration, and oral steroids, steroid rinses, and omega 3 supplements may be considered on an individual basis. Recommendations regarding the need for referral and investigation have been made. CONCLUSION: This study identified the appropriateness of olfactory training, different medical treatment options, referral guidelines and imaging for patients with COVID-19-related loss of sense of smell. The guideline may evolve as our experience of COVID-19 develops.

Defining appropriateness criteria for endoscopic sinus surgery in the management of adult dental implant patients with incidental maxillary sinus findings on conebeam computed tomography.

OBJECTIVES: Conebeam computed tomography (CBCT) imaging is commonly requested by dental implant surgeons, preoperatively, for patients being considered for dental implants. Incidental maxillary sinus findings often result in otolaryngology (ENT) referral for further assessment. CBCT findings include transient and benign mucosal changes that may not require any intervention and therefore unnecessarily delay implant surgery. We aim to define appropriateness criteria for ESS in the management of adult dental implant patients with incidental maxillary sinus findings on CBCT and provide guidance to both dental implant and ENT surgeons. DESIGN: The RAND/UCLA appropriateness methodology was used to develop and define the appropriateness criteria. SETTING: A virtual panel of 13 international experts in ESS. PARTICIPANTS: The expert panel completed two rounds of a modified Delphi ranking process for nine clinical scenarios, considering various factors affecting decision-making processes. MAIN OUTCOME MEASURES: To define appropriateness criteria for ESS in adult dental implant patients who have incidental maxillary sinus findings on CBCT. RESULTS: Patients with clinical symptoms and endoscopic findings of chronic rhinosinusitis together with an obstructed ostiomeatal complex (OMC) and concentric mucosal thickening of the ipsilateral maxillary sinus or pansinusitis were deemed appropriate candidates for ESS prior to their dental implant. ESS was not appropriate in asymptomatic patients with a patent OMC and mucosal thickening isolated to floor of the ipsilateral maxillary sinus. For uncertain scenarios, further discussion between dental implant and ENT surgeon should be considered. CONCLUSIONS: This study has developed and reported a list of appropriateness criteria to offer ESS in adult dental implant patients with incidental maxillary sinus findings on CBCT.

Nasal columella reconstruction - A comprehensive review of the current techniques.

The nasal columella is often described as being one of the most difficult nasal subunits to reconstruct. There are a wide range of indications for columella reconstruction, with defects resulting from ischaemic injuries, trauma, tumour resection, vascular malformations and congenital agenesis/dysgenesis of nasal anatomy. There is a variety of columella reconstruction techniques reported in the literature, giving reconstructive surgeons options when approaching different columella defects. Each technique has surgical pearls and pitfalls as well as advantages and disadvantages. This review aims to give reconstructive surgeons a comprehensive review of currently used columella reconstruction techniques.

Prevalence of asthma, aspirin sensitivity and allergy in chronic rhinosinusitis: data from the UK National Chronic Rhinosinusitis Epidemiology Study.

BACKGROUND: Chronic rhinosinusitis (CRS) is a common disorder associated with other respiratory tract diseases such as asthma and inhalant allergy. However, the prevalence of these co-morbidities varies considerably in the existing medical literature and by phenotype of CRS studied. The study objective was to identify the prevalence of asthma, inhalant allergy and aspirin sensitivity in CRS patients referred to secondary care and establish any differences between CRS phenotypes. METHODS: All participants were diagnosed in secondary care according to international guidelines and invited to complete a questionnaire including details of co-morbidities and allergies. Data were analysed for differences between controls and CRS participants and between phenotypes using chi-squared tests. RESULTS: The final analysis included 1470 study participants: 221 controls, 553 CRS without nasal polyps (CRSsNPs), 651 CRS with nasal polyps (CRSwNPs) and 45 allergic fungal rhinosinusitis (AFRS). The prevalence of asthma was 9.95, 21.16, 46.9 and 73.3% respectively. The prevalence of self-reported confirmed inhalant allergy was 13.1, 20.3, 31.0 and 33.3% respectively; house dust mite allergy was significantly higher in CRSwNPs (16%) compared to CRSsNPs (9%, p < 0.001). The prevalence of self- reported aspirin sensitivity was 2.26, 3.25, 9.61 and 40% respectively. The odds ratio for aspirin sensitivity amongst those with AFRS was 28.8 (CIs 9.9, 83.8) p < 0.001. CONCLUSIONS: The prevalence of asthma and allergy in CRS varies by phenoytype, with CRSwNPs and AFRS having a stronger association with both. Aspirin sensitivity has a highly significant association with AFRS. All of these comorbidities are significantly more prevalent than in non-CRS controls and strengthen the need for a more individualised approach to the combined airway.

The Caucasian Nasal Septum: An In Vivo Computed Tomography Study.

BACKGROUND: The nasal septum is composed of cartilaginous and bony components and an understanding of each component volume is essential in both functional and cosmetic surgery. OBJECTIVES: We sought to radiographically measure septal dimensions on cross sectional computer tomography (CT) images, establishing average parameters for normal anatomy among a single, Caucasian population group. METHODS: One hundred and fifty consecutive sinus CT scan images were examined and 100 cases with appropriate sagittal views were included in the study. On each septum, the sagittal CT images were assessed and 14 points were identified and 23 lengths measured and tabulated. Trigonometric formulae were used to accurately calculate surface areas of 11 resulting triangles which constituted the components of the nasal septum. RESULTS: Measurements from 100 patients were included, with a mean age of 50.2 years, constituting 47 males and 53 females. Our surface area mapping established the following areas for both males and females respectively (mm2): quadrangular cartilage 1148 and 981; vomer 894 and 741; perpendicular plate of ethmoid bone 1244 and 1006; and total surface area 3287 and 2728. Our only statistically significant comparison in the series was found in the female series when age and reducing quadrilateral cartilage size were compared, highlighting reducing size with age (P = 0.04). CONCLUSIONS: The study presents the largest published data series representing nasal septal measurements on CT images in a living Caucasian population. Our data demonstrates that septal size remains constant after adolescence, throughout our age-varied series (18-79 years), except in the female population where the quadrilateral cartilage reduces in size with age.

Peripheral histological clearance of cutaneous BCC and SCC excised using the wet blotting technique.

INTRODUCTION: Accurate identification of the peripheral margin of cutaneous basal cell and squamous cell carcinomas plays a crucial role in ensuring complete excision of the skin cancer. The recommended margin of excision for cutaneous malignancies varies in the current guidelines. The aim of this study was to assess the success rate of peripheral margin clearance with a 4 mm peripheral margin of excision when the clinical margin of the lesion has been identified using the wet blotting technique. METHODS: The peripheral margin of each skin cancer was marked using the wet blotting technique and a 4-mm margin of excision rule was applied to all skin cancers regardless of their type and other clinical features. Data collection was performed from patients who were operated on over a period of 34 months (2011 to 2014). Information gathered included patient demographics, clinical details of the lesion and histopathological data. RESULTS: The total number of patients identified were 456. The case notes were reviewed and eventually 276 patients were included and 180 patients were excluded. The histology report showed 95-97% clearance of the peripheral margin in all BCCs and SCCs regardless of their clinical features and their location. CONCLUSIONS: Our study has shown that a standard rule of maintaining a 4 mm margin around all head and neck skin BCCs and SCCs, measured after the visible margin of the lesion had been accurately identified by the wet-blotting technique, can successfully achieve 95-97% peripheral clearance of all lesions, irrespective of the subtype, size and location.

Infections and foreign bodies in ENT.

Infections of the ear, nose and throat are common. The majority of these infections are managed by the primary care physicians and they settle with conservative and medical management. However, a small group can progress to become troublesome and develop complications to the extent that they may require surgical intervention. Some of the infections can lead to life-threatening complications therefore awareness and correct diagnosis along with appropriate management is paramount. Foreign bodies in the ear, nose and throat are commonly encountered. The location and type of foreign body can have an implication on the urgency of action and the possible complications. In this article the common ENT infections and foreign bodies and their management are discussed.

A case-control study of medical, psychological and socio-economic factors influencing the severity of chronic rhinosinusitis.

BACKGROUND: Chronic rhinosinusitis (CRS) is a common and debilitating disorder. Little is known about the epidemiology of this disease. The aims of the study were to identify differences in socio-economic variables and quality of life between patients with chronic rhinosinusitis and healthy controls, to identify any significant associations between CRS and other medical co-morbidities, psychiatric disease or environmental exposure and to explore the experience of CRS from the perspective of CRS sufferers. METHODS: Participants were recruited from ENT clinics from 30 centres across the UK. They completed a study-specific questionnaire considering environmental, medical and socio-economic factors, and SF-36 and SNOT-22 scores. All participants with CRS were diagnosed by a clinician and categorised as having CRS (with polyposis, without polyposis or allergic fungal rhinosinusitis (AFRS)). Controls included family and friends of those attending ENT outpatient clinics and hospital staff who had no diagnosis of nose or sinus problems and had not been admitted to hospital in the previous 12 months. RESULTS: A total of 1470 study participants (1249 patients and 221 controls) were included in the final analysis. Highly significant differences were seen in generic and disease-specific quality of life scores between CRS sufferers and controls; mean SNOT-22 score 45.0 for CRS compared with 12.1 amongst controls. There were no clear differences in socioeconomic variables including social class, index of multiple deprivation and educational attainment between cases and controls. Common comorbidities with a clear association included respiratory and psychiatric disorders, with a higher frequency of reported upper respiratory tract infections. CONCLUSIONS: CRS is associated with significant impairment in quality of life and with certain medical co-morbidities. In contrast to other common ENT disorders, no socioeconomic differences were found between patients and controls in this study.

The burden of revision sinonasal surgery in the UK-data from the Chronic Rhinosinusitis Epidemiology Study (CRES): a cross-sectional study.

OBJECTIVES: The aim of this study was to investigate the surgical revision rate in patients with chronic rhinosinusitis (CRS) in the UK CRS Epidemiology Study (CRES). Previous evidence from National Sinonasal Audit showed that 1459 patients with CRS demonstrated a surgical revision rate 19.1% at 5 years, with highest rates seen in those with polyps (20.6%). SETTING: Thirty secondary care centres around the UK. PARTICIPANTS: A total of 221 controls and 1249 patients with CRS were recruited to the study including those with polyps (CRSwNPs), without polyps (CRSsNPs) and with allergic fungal rhinosinusitis (AFRS). INTERVENTIONS: Self-administered questionnaire. PRIMARY OUTCOME MEASURE: The need for previous sinonasal surgery. RESULTS: A total of 651 patients with CRSwNPs, 553 with CRSsNPs and 45 with AFRS were included. A total of 396 (57%) patients with CRSwNPs/AFRS reported having undergone previous endoscopic nasal polypectomy (ENP), of which 182 of the 396 (46%) reported having received more than one operation. The mean number of previous surgeries per patient in the revision group was 3.3 (range 2-30) and a mean duration of time of 10 years since the last procedure. The average length of time since their first operation up to inclusion in the study was 15.5 years (range 0-74). Only 27.9% of all patients reporting a prior ENP had received concurrent endoscopic sinus surgery (ESS; n=102). For comparison, surgical rates in patients with CRSsNPs were significantly lower; 13% of cases specifically reported ESS, and of those only 30% reported multiple procedures (χ(2) p<0.001). CONCLUSIONS: This study demonstrated that there is a high burden of both primary and revision surgery in patients with CRS, worst in those with AFRS and least in those with CRSsNPs. The burden of revision surgery appears unchanged in the decade since the Sinonasal Audit.

Tonsillectomy for recurrent sore throats in children: indications, outcomes, and efficacy.

OBJECTIVE: To perform a comprehensive narrative review of the literature to provide a better understanding of the indications, outcomes, and efficacy of tonsillectomy for recurrent sore throats in children. This article explores the reasons why there is a lack of robust clinical evidence for its efficacy despite good evidence of positive reported outcomes from parents of children who undergo the procedure. DATA SOURCES: Articles published between 1960 and July 2013 were searched in PubMed and Cochrane databases. REVIEW METHODS: A narrative review method was adopted to provide a comprehensive overview of articles. Only individual, interventional studies on children (0-16 years old) undergoing tonsillectomy or adenotonsillectomy for recurrent sore throats with greater than 1 month of follow-up were included. CONCLUSIONS: The inclusion criteria and outcome measures in the studies were varied, but most investigated changes in symptoms related to sore throats or illness episodes. Quality-of-life tools validated for measuring pediatric outcomes were used in a number of more recent studies. None of the outcome measures were specific for recurrent sore throats in children. No qualitative method designed studies were identified. IMPLICATIONS FOR PRACTICE: The disparity between parental satisfaction rates and published clinical efficacy can be explained by a lack of parent/child outcome measures specific to tonsillectomy for recurrent sore throats. A more parent/child-centered approach may establish what tonsillectomy could offer this group of children.

Sandwich technique in nasal dorsal augmentation.

Tutoplast fascia lata (TFL) has been used as an onlay graft for nasal dorsal augmentation in open approach rhinoplasty; however, insertion of layers of moist TFL in the closed approach is technically challenging. We have presented a "sandwich" technique which facilitates graft insertion in a closed approach rhinoplasty. The available autologous graft (cartilage or perpendicular plate of ethmoid) is sandwiched and secured between layers of TFL (sandwich technique) prior to insertion of the graft for nasal dorsal augmentation in a closed rhinoplasty approach. All our cases of nasal dorsal augmentation were reviewed in a 2 year period. Eight cases of nasal dorsal augmentation in secondary rhinoplasty through a closed approach were reviewed. The ease of insertion and the subsequent manipulation of the graft were noted in all the cases. Good aesthetic results have been noticed in all the cases after an average of 14 months follow-up. The sandwich technique ensures ease of the graft insertion and the subsequent manipulation in a closed approach secondary rhinoplasty for dorsal augmentation.

Accuracy of predissection assessment of the lower lateral cartilage configuration: a cadaveric study.

BACKGROUND: Preoperative planning of nasal tip surgery requires an accurate assessment of the nasal tip cartilages configuration. The current literature lacks any evidence on the accuracy of preoperative assessment of the lower lateral cartilages (LLC) shape. OBJECTIVE: This study was designed to determine the accuracy of the LLC shape and configuration assessment prior to dissection. METHODS: The configuration of the lateral, middle, and medial crura was assessed on 42 LLC (21 cadavers) prior to dissection by way of observation and palpation. The findings were then compared with those observed after LLC exposure through an open-approach dissection. RESULTS: The accuracy of predissection LLC shape assessment was 42 of 42 (100%), 32 of 42 (76%), and 12 of 42 (29%) for medial, middle, and lateral crus, respectively. CONCLUSIONS: The configuration of the lateral crus of LLC cannot be accurately assessed prior to exposure of the cartilage. A rhinoplastic surgeon who embarks on nasal tip surgery should be familiar with a number of techniques to address any tip deformity encountered after exposure, as the preoperative clinical and photographic assessments cannot reliably demonstrate the type of LLC deformity.