Assessment of opioid use following septorhinoplasty and its association with pain catastrophizing.

PURPOSE: Anxiety towards pain is correlated with increased post-surgical pain and assessed with the "Pain Catastrophizing Scale" (PCS). We assess patient reported pain and opioid usage following septorhinoplasty and their association with the PCS. METHODS: This prospective cohort study enrolled patients over 18 years of age undergoing open septorhinoplasty on an outpatient basis at a single academic institution. Participants completed the PCS preoperatively and recorded post-operative pain and analgesic use with a daily online based survey through post-operative day 5. Total opioid use and highest pain rating are assessed. RESULTS: Postoperative pain was assessed in 34 patients with a median age of 37 years (Range: 22-62y). The average highest pain rating was 6.2/10 (σ = 2.03) and occurred on post-operative day 2. A median of 20 5-mg narcotic tablets (Range: 10-25) was prescribed to study participants though only an average of 7.25 (Range: 0-15) were reported as used. Medical comorbidities and surgical characteristics, including history of anxiety, cosmetic indication, surgical revision, use of osteotomies, Doyle splints, costal or conchal cartilage grafts, or inferior turbinate reduction, were not associated with increased pain or narcotic use. Those using >10 tablets scored higher on the PCS ([10.6] v. [4.8], p = 0.025). CONCLUSION: Most patients require <10, 5 mg opioid tablets following septorhinoplasty. Surgeons should attempt to decrease opioid prescriptions while considering that patients with significant anxiety towards pain may report higher narcotic needs.

Comparison of Decellularized and Gamma-Irradiated Septal and Costal Cartilage Allografts in a Rabbit Model.

Background: Traditional gamma-irradiated allograft costal cartilage used for cartilage-depleted rhinoplasty patients contains cellular remnants that are potentially responsible for immunological stimulation and graft resorption. Objective: To determine whether decelullarized and/or chemically crosslinked rabbit costal and nasal septal cartilage allografts reduce the risk of allograft resorption. Materials and Methods: In vitro and in vivo analyses of septal and costal cartilage grafts in New Zealand white rabbits were carried out. Irradiated, decellularized, and/or carbodiimide crosslinked cartilage grafts were compared with nontreated autografts and allografts controls. Gross analysis, biomechanical testing, DNA quantification, and histological analyses were performed. Results: All treated grafts had a similar "feel" to native cartilage except for crosslinked grafts, which were significantly stiffer with decreased maximum load and tensile strain. Decellularization effectively reduced DNA content. Biomechanics of explants were unchanged except in untreated allografts, which exhibited increased stiffness, decreased strain, and significant scarring/fibrosis. There was increased glycosaminoglycans retention and less resorption in crosslinked septal cartilage grafts. Conclusion: This study demonstrates the potential benefits of decellularization and crosslinking allograft cartilage and further refinements in crosslinking may improve resorption characteristics while maintaining suitable physical characteristics.

Early Adverse Events Following Pediatric Mandibular Advancement: Analysis of the ACS NSQIP-Pediatric Database.

OBJECTIVE: This study aims to assess early adverse events and patient factors associated with complications following mandible distraction osteogenesis (MDO). MATERIALS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-Pediatric) database, years 2012 to 2019, was queried for patients undergoing mandible advancement via relevant Current Procedural Terminology and postoperative diagnosis codes. Thirty-day adverse events and co-morbidities are assessed. RESULTS: A total of 208 patients were identified with 17.3% (n = 36) experiencing an adverse event, reoperation (n = 14), and readmission (n = 11) being most common. Patients < 365 days old at the time of operation were more likely to experience an adverse event (26.1% vs 10.8%; P = .005). However, among patients less than 1 year of age, differences in the complication rates between patients ≤ 28 days and >28 days (30.2% vs 22.2%; P = .47) and those weighing ≤ 4 kg and >4 kg (31.7% vs 11.5%; P = .063) did not reach statistical significance. CONCLUSIONS: Adverse events following mandible advancement are relatively common, though often minor. In our analysis of the NSQIP-Pediatric database, neonatal age ( ≤ 28 days) or weight ≤ 4 kg did not result in a statistically significant increase in complications among patients less than 1 year of age. Providers should consider early intervention in patients who may benefit from MDO.

Outcomes of Two-Stage Interpolated Flaps Versus Single-Stage Techniques for Reconstruction of Intermediate Nasal Defects.

Objective: This study compares the results of patients undergoing reconstruction of intermediate nasal defects, measuring 1.5-2.5 cm, with single-staged techniques as opposed to the traditionally recommended staged interpolated flap reconstruction. Design: This is a retrospective review of patients who underwent reconstruction of a nasal defect by a single surgeon between 2010 and 2016. Methods: Postoperative results including revision surgery, treating persistent edema with Kenalog (triamcinolone acetonide), and perioperative complications were analyzed. Aesthetic outcomes were analyzed by a panel of experts and nonexperts, and compared using a 5-point Likert scale. Results: In total, 51 single-stage and 26 two-stage patients underwent evaluation, and of these, 40 single-stage and 15 two-stage patients underwent panel analysis of aesthetic outcomes. The odds of requiring a revision procedure were 6.69 times higher and odds of using Kenalog postoperatively were 29.67 times higher in the two-stage group than in the single-stage group. Aesthetic scores were consistently better for the single-stage group for both panels. Conclusion: Patients undergoing single-stage techniques for reconstruction of intermediate nasal defects showed improved appearance and reduced number of additional procedures relative to patients undergoing two-stage techniques with short-term follow-up.

Facial Artery Musculomucosal Flap for Nasopharyngeal and Oropharyngeal Reconstruction.

Importance: The facial artery musculomucosal (FAMM) flap is a well vascularized axial flap which has been described for mucosal reconstructions throughout the oral cavity. There are limited data regarding its efficacy in secondary repair of nasopharyngeal stenosis and velopharyngeal insufficiency due previous surgery and scar tissue formation. Objective: This study seeks to demonstrate the efficacy of FAMM flap procedure in patients with nasopharyngeal stenosis and velopharyngeal insufficiency. Design, Setting, and Participants: A retrospective case series included patients treated for nasopharyngeal stenosis or velopharyngeal insufficiency with a FAMM flap at an academic medical center from January 1, 2012 to November 1, 2017. Patients included in the study were those who underwent a FAMM flap procedure by the senior author during the specified time period. Main Outcomes and Measures: Functional outcomes included nasopharyngeal airway patency, nasal regurgitation, and speech quality. Any postoperative complications were recorded, including flap necrosis, infection, flap failure, dehiscence, trismus and need for revision surgery. Results: A total of 6 FAMM flap procedures were performed by the senior author over the study period for the indications of this case series. Three patients had nasopharyngeal stenosis and three had velopharyngeal insufficiency. All had successful, sustained nasopharyngeal airway patency or restored velopharyngeal function. The only postoperative complication noted was trismus at the cheek donor site. There were no patients who suffered flap failure or need for revision surgery of the FAMM flap. Conclusions: The FAMM flap is useful for secondary reconstruction of nasopharyngeal stenosis and velopharyngeal insufficiency due to previous surgery and scarring. This study demonstrates the efficacy and reliability of FAMM flaps for repair of complete/near complete nasopharyngeal stenosis and cases of velopharyngeal insufficiency due to scarring of the pharynx.

Cultivating and Recruiting Future Otolaryngology Residents: Shaping the Tributary.

The future vibrancy, relevancy, and strength of our specialty depend on cultivating a pipeline of resident otolaryngologists who embody what our society wishes to become. In attracting, seeking, and nourishing physicians of all stripes, we offer several considerations regarding medical student education and the residency selection process.

Normal and variant anatomy of the nasal tip.

A thorough understanding of nasal tip anatomy is a prerequisite to understanding the nuances of restructuring the nasal tip. The three-dimensional structural anatomy of the nasal tip is complex. Additionally, the interrelationship between these structures determines the ultimate form and function of the nasal tip. As a result, alteration of one structure in the tip will often lead to change in other portions of the nasal tip. This dynamic concept of anatomy in the nasal tip makes proper alteration of the nasal tip one of the most challenging tasks faced by a rhinoplasty surgeon. This article provides a fundamental knowledge of the normal anatomy of the tip structures and how their interaction with each other determines the shape and support of the lower portion of the nose. It also provides a description of some common variants of tip anatomy that cause patients to seek consultation for rhinoplasty. A proper understanding of the concepts presented provides a foundation to build on as the reader continues to explore the "nuances of the nasal tip."

Assessing fundamental 2-dimensional understanding of basic soft tissue techniques.

OBJECTIVE: To develop a written practical examination and scoring system for assessing trainee skills in basic soft-tissue techniques. DESIGN: A brief written practical examination was developed to assess the ability of trainees to sketch preoperative plans and postoperative results for common soft-tissue techniques: simple-excision, M-plasty, geometric broken line closure, Z-plasty, V-to-Y flap, and rhombic flap. A scoring system was developed to assign 0 to 5 points to each of 10 items on the examination for a total score of 0-50. The 15-minute examination was administered as a pretest, posttest, and 3-month posttest assessment as part of a soft-tissue course at our institution. SETTING: University of Minnesota, Otolaryngology Department. RESULTS: Three raters reviewed all examination answer sheets independently. The pretest scores of examinees correlated strongly with their level of training; the average pretest for junior residents (PGY 1-2) compared with senior residents (PGY 4-5) was 17.3 (of 50) versus 26.0 (p < 0.01). The scoring system showed a high intrarater reliability and high interrater reliability with correlation coefficients of r = 0.99 and r = 0.95, respectively and agreement coefficients of κ = 0.82 and κ = 0.77, respectively. CONCLUSION: This written practical examination and scoring system may be used to assess the skills of trainees accurately in basic soft tissue techniques and to expose areas of deficiency that can be addressed in future training sessions.

Reconstruction of the dorsal and sidewall defects.

Defects of the nasal dorsum or sidewall can result from trauma, congenital lesions, extirpation of neoplasms, or iatrogenic injuries. Simple techniques are often used to reconstruct defects in this area with excellent outcomes. Complex defects require more sophisticated techniques including multilayer closures using pedicled flaps or free tissue transfer. This review discusses key anatomic and functional principles and techniques to assist in planning for reconstruction of nasal dorsum and sidewall defects from any cause.

Comparison of techniques used to support the nasal tip and their long-term effects on tip position.

OBJECTIVES: To examine the indications for the use of septal extension grafts, columellar struts, and tongue-and-groove techniques to provide support and set the tip position during rhinoplasty, and to compare the strength of their support and analyze their long-term effects on tip position. METHODS: The medical records and photographs of patients who underwent external septorhinoplasty during a 2-year period were analyzed. Forty patients had photographs from short-term follow-up (<12 weeks) and were included in the study. The short-term and long-term (>52 weeks) tip positions were compared to determine the maintenance of tip position with each technique. Each stabilization technique was performed on 5 fresh cadavers, and the resistance to displacement of the tip was measured and compared. RESULTS: Objective measurements in the cadaver analysis show increased resistance to tip displacement with the use of caudal septal extension grafts and tongue-and-groove techniques. There was no difference in the maintenance of tip position between the techniques in analysis of the patients who have undergone rhinoplasty. CONCLUSIONS: Many factors influence the maintenance of tip position in patients who have undergone rhinoplasty. One should consider using a stabilization technique to help resist displacement of the nasal tip. Clinical and operative findings, as well as secondary effects, are used to help determine which technique should be used.

Osteotomies.

The most challenging and instrumental step in achieving harmonious form and function during rhinoplasty is the successful completion of osteotomies. Osteotomies are performed to correct deformities of the bony nasal vault. Successful treatment of deformity of the bony vault is achieved through organized thinking, comprehensive knowledge of nasal anatomy, and thorough preoperative and intraoperative planning. In this review the authors discuss the pertinent anatomy, technical considerations, and complications that rhinoplasty surgeons should be aware of to optimize the correction of deformities of the nasal bony vault.

Cheek defects.

The challenge surgeons face when reconstructing cheek defects varies significantly depending on the location and depth of the defect and the distensibility of the surrounding tissues. The cheek is a large aesthetic unit characterized in most areas with a convex surface and inherent transitions in color and texture. These characteristics demand the surgeon's attention to achieve superior results during reconstruction. Surgeons must also recognize the free margins of the adjacent structures, including the lower eyelid, nasal ala, and lip, to minimize distortion of these areas during healing. With these challenges in mind, this article discusses several approaches to reconstruction of various types of cheek defects.

Septoplasty pearls.

Techniques used for the diagnoses and treatment of septal deformity vary according to indications for the procedure and surgeon preference. Septoplasty is commonly performed to treat septal deformity causing nasal airway obstruction. Various preoperative and intraoperative "pearls" that the authors have found to be helpful in treating septal deformity and nasal airway obstruction are discussed.

Subcutaneous implants coated with tissue-engineered cartilage.

OBJECTIVE: To investigate the ability to coat two alloplastic implants, porous high-density polyethylene (PHDPE) and expanded polytetrafluoroethylene (e-PTFE), with tissue-engineered cartilage (TEC) from human septal chondrocytes in a mouse model. STUDY DESIGN: Prospective study. METHODS: PHDPE and e-PTFE disks were coated with alginate impregnated with human septal chondrocytes and implanted into athymic nude mice. A control group consisting of PHDPE and e-PTFE disks coated with alginate only were implanted. Gross, histological, and biochemical characteristics of the TEC constructs were examined at 10 and 20 weeks following implantation. RESULTS: One animal in the experimental group and one animal in the control group died. Implants coated with TEC were successfully generated in 18 (94.7%) mice in the experimental group (n = 19) and in zero (0%) of the control group (n = 17). The final weight of each harvested specimen decreased in the control group and increased in the experimental group, when compared with preimplant weight. Mean decrease in weight in the control group was greater at 20 weeks than at 10 weeks (P = .017). Mean increase in weight in the experimental group was greater at 20 weeks than at 10 weeks (P = .009). The diameter of the control group decreased, while the diameter of the experimental group was maintained. The reduction in diameter was less in the experimental group than in the control group at 10 (P = .018) and 20 weeks (P = .01). Gross and histological examination confirmed the formation of neocartilage, with characteristics similar to native cartilage, in the experimental group at 10 and 20 weeks. Glycosaminoglycan content in the experimental group at 20 weeks was approximately 80% of that measured in implanted human septal cartilage. Cartilaginous and fibrovascular ingrowth into implant pores was more extensive in the PHDPE than the e-PTFE experimental group. CONCLUSIONS: Implants coated with TEC from human septal cartilage can be reliably produced in the athymic nude mouse model. Maintenance of shape, as measured by the conservation of construct diameter, is possible. Fibrovascular ingrowth and cartilage formation into the pores of the alloplastic implants was observed. This integration of a construct composed of a synthetic implant coated with TEC may improve the performance of alloplastic implants through better long-term fixation and increased resistance to infection.

Injectable cartilage: using alginate and human chondrocytes.

OBJECTIVE: To create engineered cartilage through an injectable medium that could be used as a minimally invasive implant material. METHODS: Human nasal septal chondrocytes, carried in an alginate polymer, were injected and molded percutaneously into nude mice and developed in vivo. The cartilage was harvested from 14 to 38 weeks and analyzed through gross, histological, immunohistochemical, and biochemical analysis. RESULTS: Of the 15 explants, 14 (93%) resembled native cartilage on gross analysis. The injections maintained their overall appearance with some loss of definition. On histological analysis, 6 of the explants (40%) appeared similar to native cartilage throughout the sample. Eight of the explants (53%) resembled native cartilage; however, there were some areas of fibrous tissue differentiation. The neocartilage stained positive for type II collagen. Explants harvested at week 26 or later and the samples that histologically resembled native cartilage had similar hydroxyproline content to native septal cartilage. CONCLUSIONS: Injectable, autologous cartilage may be the answer to the long search for the ideal implant in facial plastic surgery. Alginate and human chondrocytes can be used to create an injection that may be molded and maintains its overall size and shape, with some loss of definition, for at least 38 weeks after injection.

Revision septoplasty: review of sources of persistent nasal obstruction.

BACKGROUND: Patients with nasal obstruction from septal deviation commonly undergo septoplasty to improve nasal airflow. Some patients suffer from persistent obstruction after their primary septoplasty and may undergo a revision septoplasty to improve their nasal passageway. Our objective was to identify patients who underwent revision septoplasty and to identify their sources of persistent nasal obstruction. METHODS: Patients who underwent septoplasty at our institution between 1995 and 2005 were reviewed. Data is collected on demographics, comorbidities, age at septoplasty, associated and concomitant procedures, surgical approach, and anatomic site of obstruction. RESULTS: Five hundred forty-seven patients met inclusion criteria including 477 who underwent primary septoplasty and 70 who underwent revision surgery. Nineteen percent of nonrevision patients underwent nasal valve surgery along with their primary septoplasty versus 4% of patients in the revision group. Fifty-one percent of revision patients had nasal valve surgery at revision surgery. Patients who underwent sinus surgery along with primary septoplasty were less likely to undergo revision septoplasty. History of facial trauma, obstructive sleep apnea, site of deviation, and performance of inferior turbinate surgery did not affect the likelihood of revision septoplasty. CONCLUSION: A significant number of patients who undergo revision septoplasty also have nasal valve collapse. We recommend that in addition to septal deviation and inferior turbinate hypertrophy, nasal valve function be fully evaluated before performing septoplasty. This will help to ensure a complete understanding of a patient's nasal airway obstruction and, consequently, appropriate and effective surgical intervention.

To POP or not: ossiculoplasty in congenital aural atresia surgery.

OBJECTIVES/HYPOTHESIS: To examine indications for ossiculoplasty (OP) in aural atresia surgery and to compare audiometric results and surgical revision rates between patients undergoing OP and those undergoing intact native chain reconstruction (INCR). STUDY DESIGN: Retrospective chart review. METHODS: Charts of patients undergoing surgery for congenital aural atresia were reviewed for demographic data, preoperative Jahrsdoerfer score, ossicular chain status, and audiometric data. Patients undergoing OP were compared with an equal number of age and Jahrsdoerfer grade-matched patients who had an INCR. The preoperative and postoperative average air-bone gap (ABG), speech reception thresholds (SRT), and rates of revision surgery were compared between the two groups. RESULTS: Nineteen patients (20 ears) underwent OP during aural atresia repair and were compared with 20 matched patients who had INCR. Mean age, Jahrsdoerfer score, preoperative ABG, and SRT were similar for both groups. Mean postoperative audiometric follow-up was 33.1 months for the OP group and 20.4 months for the INC group (P = .24). Mean postoperative ABG was 33.8 dB HL for OP and 23.8 dB HL for INCR (P < .05). Mean improvement in ABG was 16.8 dB HL for OP and 29.9 dB HL for INCR (P < .001). Mean improvement in SRT was 24.6 dB HL for OP and 34.8 dB HL for INCR (P < .05). Nine ears (45%) in the OP group and four ears (20%) in the INCR group underwent revision surgery (P = .09). CONCLUSIONS: Patients reconstructed with their own intact native chain during aural atresia surgery have better audiometric outcomes than those undergoing OP and are less likely to undergo revision surgery.

Effects of nasal saline spray on human neutrophils.

BACKGROUND: Nasal saline spray (NSS) used in the treatment of rhinitis and sinusitis often contains the preservative benzalkonium chloride (BKC). Previous studies have shown that corticosteroid nasal sprays and topical decongestants containing BKC damage respiratory mucosa, decrease mucociliary activity, and inhibit neutrophil functions in vitro. OBJECTIVE: To evaluate the effects of NSS with BKC on human neutrophils. DESIGN: Prospective, basic science observations. METHODS: Human neutrophils were exposed to NSS with BKC or to phosphate-buffered saline (PBS) at varying times and concentrations. The cells were examined for morphologic changes by light microscopy and for viability as determined by trypan blue exclusion. Lactate dehydrogenase levels were measured to quantify neutrophil cell lysis. In vivo morphologic changes were studied in neutrophils obtained from the oral mucosa in human volunteers who rinsed their mouths with NSS or PBS. RESULTS: Neutrophils exposed to NSS concentrations as low as 15% showed near-total cell lysis, and neutrophils exposed to 20% NSS demonstrated no cell viability by trypan blue staining. Phosphate-buffered saline-exposed cells were unaffected. The release of lactate dehydrogenase from lysed neutrophils increased sharply at NSS concentrations higher than 10% but remained stable in PBS-exposed cells. All neutrophils isolated from NSS oral rinses were lysed, while a mean of 78% of neutrophils from PBS rinses showed normal morphologic structure. CONCLUSIONS: Nasal saline spray with BKC is toxic to human neutrophils even at concentrations far lower than those found in commercially available preparations. Saline solutions without BKC appear to be safer alternatives, and additional studies are needed to determine the clinical significance of these findings.