A Non-inferiority Trial: Safety and Efficacy of Topical 1:1000 versus 1:10 000 Epinephrine in Sino-nasal Surgeries.

OBJECTIVE: This study aimed to test the non-inferiority of topical 1:1000 epinephrine compared to topical 1:10 000 with regard to intraoperative hemodynamic stability, and to determine whether it produced superior visibility conditions. METHODS: A single-blinded, prospective, cross-over non-inferiority trial was performed. Topical 1:1000 or topical 1:10 000 was placed in 1 nasal passage. Hemodynamic parameters (heart rate, systolic and diastolic blood pressures, and mean arterial pressure) were measured prior to insertion then every minute for 10 minutes. This was repeated in the contralateral nasal passage of the same patient with the alternate concentration. The surgeon graded the visualization of each passage using the Boezaart Scale. The medians of the greatest absolute change in parameters were compared using a Wilcoxon Rank-Signed test and confidence intervals were calculated using a Hodges-Lehman test. The non-inferiority margin was pre-determined at 10 bpm for heart rate and 10 mmHg for blood pressures. A Wilcoxon Rank-Signed test was used to assess superiority in visualization. RESULTS: Thirty-two patients were enrolled and after exclusions, nineteen were assessed (mean age = 35.63 ± 12.49). Differences in means of greatest absolute change between the 2 concentrations were calculated (heart rate = 2.49 ± 1.20; systolic = -1.51 ± 2.16; diastolic = 2.47 ± 1.47; mean arterial pressure = 0.07 ± 1.83). In analyses of medians, 1:1000 was non-inferior to the 1:10 000. There was a significant difference (-0.58 ± 0.84; P = .012) in visualization in favor of topical 1:1000. CONCLUSION: Topical 1:1000 epinephrine provides no worse intraoperative hemodynamic stability compared to topical 1:10 000 but affords superior visualization and should be used to optimize surgical conditions.

Experience harvesting costal cartilage under IV sedation.

IMPORTANCE: While numerous techniques for costal cartilage harvesting have been described, one consistency in the published literature is that the procedure is performed under general anesthesia. This is the first report to offer IV sedation as a safe alternative to general inhalational anesthesia in cases involving costal cartilage harvesting. OBJECTIVE: To determine the feasibility and safety of costal cartilage harvest with IV sedation. DESIGN: A retrospective chart review was performed of 116 rhinoplasty patients who underwent harvest of costal cartilage grafts under IV sedation from 2005 to 2019. SETTING: Private practice of senior author (AF) at Lasky Clinical Surgical Center. PARTICIPANTS: Consecutive patients who underwent cosmetic and/or functional rhinoplasty. MAIN OUTCOME & MEASURES: The number of cases involving a pneumothorax, size of the pleural injury, radiographic findings, repair technique and treatment for pneumothorax were all recorded. RESULTS: There were 7 cases involving a pleural tear (size range 3-8 mm) during costal cartilage harvest and each of these was repaired intra-operatively. All 7 patients remained clinically stable in recovery room on 2 L of oxygen. Although clinically stable, one patient had radiologic evidence of a pneumothorax of 50%, and thus she was transferred to a hospital for placement of a Heimlich tube with overnight observation. CONCLUSIONS AND RELEVANCE: Although plenural tears can be attributed to surgical technique rather than the type of anesthesia, these cases do provide valuable insight to the fact that successful management of such complications can be accomplished without the need for general anesthesia.

An Analysis of Lateral Crural Repositioning and Its Effect on Alar Rim Position.

IMPORTANCE: Cephalically malpositioned lateral crura are a frequent cause of alar rim retraction during both primary and revision rhinoplasty. OBJECTIVE: To demonstrate the efficacy of lateral crural repositioning as an isolated maneuver as and combined with adjunctive grafts for lowering the alar rim. DESIGN, SETTING, AND PARTICIPANTS: From August through December 2014, we retrospectively reviewed the cases of 54 patients (102 hemi-noses) who had lateral crural repositioning performed by the same surgeon between 2007 and 2013. Only patients with standardized photographs taken preoperatively and at least 6 months postoperatively were included in the study. INTERVENTIONS: All primary and revision cases were completed via an open rhinoplasty approach and had lateral crural repositioning performed. MAIN OUTCOMES AND MEASURES: Preoperative and postoperative photographs were compared using Adobe Photoshop CS via a modified Gunter technique to measure the degree of alar rim retraction on lateral views. The change in angle was then calculated, and statistical analysis conducted using a paired t test. RESULTS: A total of 54 patients (102 hemi-noses) met inclusion criteria; 42 (79%) were women, and the average patient age was 41.3 years. Forty-five (83%) of the cases were revision rhinoplasties, and the average time to obtaining postoperative photographs was 11.3 months. The mean (SD) anterior nostril apex angles preoperatively (31.3° [8.9°]) and postoperatively (24.5° [6.8°]) indicated a net decrease of 6.8° (P < .001). Excluding patients who had other rim-lowering grafts (alar rim and/or composite grafts), we saw a similar result comparing preoperative (31.1° [8.2°]) and postoperative (24.5° [6.7°]) angles, with a net decrease of 6.6° degrees (P < .001). When examining patients who underwent lateral crural repositioning alone compared with those who also had lateral crural strut grafts, we saw a decrease of 6.9° (P < .001) and 6.7° degrees (P < .001), respectively. CONCLUSIONS AND RELEVANCE: Repositioning of the lower lateral cartilages results in a statistically significant lowering of the alar rim. Our data suggest that when combined with lateral crural repositioning, the addition of adjunctive grafts does not add significantly to the rim-lowering effect. LEVEL OF EVIDENCE: 3.

Near-complete supraglottic transection of the larynx after a motorbike accident.

Severe laryngeal trauma is rare in the civilian environment and requires appropriate and timely surgical intervention. We report a case from Sydney, Australia, which was managed with open reduction and internal fixation of the larynx with resorbable plates. The use of resorbable plates for operative fixation of the larynx has rarely been reported in literature but may be a viable alternative.

Delayed Mental Nerve Neuralgia following Chin Augmentation.

This paper describes a case of mental nerve neuralgia following a traumatic dislodgement of a chin implant ten months after surgery. Our case is unusual, both in the specific complication and the patients' atypical representation-delayed and initially without mention of trauma. To the authors' knowledge, this case has not been reported previously in the literature. We review the complications of chin augmentation and the techniques for fixation and discuss implications for the preoperative disclosure with patients.

Giant de novo pleomorphic adenoma arising from the parapharyngeal space.

Introduction. De novo pleomorphic adenomas in the parapharyngeal space are rare and cause difficulties in its surgical management. We report the largest de novo pleomorphic adenoma arising from the parapharyngeal space and discuss its surgical management. Presentation of Case. A 34-year-old male presented with a giant de novo pleomorphic adenoma arising from the parapharyngeal space, which was initially misdiagnosed as an impacted wisdom tooth. Measuring 8.4 × 6.5 × 3.9 cm in size and weighing 87.3 g, this is the largest primary salivary gland tumour arising de novo from the parapharyngeal space reported in the literature, presenting challenges in its surgical management. Discussion. Parapharyngeal space tumours cause nonspecific symptoms and may be difficult to diagnose, which can allow the tumours to become very large and cause obstructive and compressive symptoms in an anatomically difficult area. A combined trans-cervical and trans-oral approach can be used to safely perform an en bloc resection. Conclusion. We report the diagnosis and surgical management of the largest pleomorphic adenoma arising de novo from the parapharyngeal space reported in the literature.

A novel technique of otic barotrauma management using modified intravenous cannulae.

This article provides the first detailed description and systematic evaluation of the management of otic barotrauma using modified intravenous cannulae. A 24-gauge IC cannula was modified as a tool for tympanostomy tube placement and middle ear ventilation. The medical records of 271 ears of 156 adult patients (median age 49 years) who underwent this procedure were reviewed retrospectively. Hundred and ninty-one tubes were placed for otalgia because of hyperbaric oxygen therapy, 58 tubes were inserted for air travel prophylaxis and 22 tubes were placed for management of otic barotrauma post-flight. All the patients who had this procedure for prophylaxis experienced regular otic barotrauma symptoms during air travel prior to tube placement. All patients were reviewed 6 weeks (range 2-9 weeks) post-procedure. This technique of otic barotrauma management worked effectively in 99 % of treated patients. On follow-up, 88 % of tubes were found to be extruded and non-extruded tubes were removed in clinic without any anaesthesia. 99.6 % of tympanic membrane had healed completely and spontaneously without sequelae. Given the safety, effectiveness, low risk of complications associated with this novel tympanostomy technique, it provided a simple yet effective therapeutic option for the management of otic barotrauma. Finally, this technique can be easily applied in all health settings as it only requires medical supplies readily available in hospitals, therefore there is no additional cost.