Eustachian Tube Function in Flight Attendants.

Eustachian tube (ET) function is of utmost importance in people who are under constant barometric pressure changes in their daily lives. Proper functioning is essential in avoiding pressure related injuries. We aimed to investigate how well the ET functions in flying personnel and how it compares to the non-flying population.Prospective study. Acibadem University Atakent Hospital. 115 participants were included in the study. Each underwent a thorough otorhinolarynglogic examination then undertook a tympanogram followed by eustachian tube function (EtFT) test. A statistically significant difference in ear volume was observed in flight personnel. EtFT results showed the ability to equalize pressure after Valsalva manouvre was also significantly higher in flight personnel. Flight attendants that are subject to pressure changes throughout their careers do seem to be more capable of equalizing pressure through manoeuvres such as the Valsalva. This may be due to the fact that continuous pressure changes creates a more pliable tympanic membrane.

An Update on Subciliary Lower Eyelid Blepharoplasty.

The subciliary lower eyelid blepharoplasty has evolved considerably to create a more harmonious natural appearance with a fuller and unoperated look and also to minimize the complications. While lower eyelid malposition was very common in the past, now this complication is significantly reduced by attention to preoperative evaluation, meticulous surgical planning, precise surgical technique, and postoperative care. Various prophylactic maneuvers maintaining/strengthening lower lid support can be utilized to prevent lower lid malposition including preservation of the pretarsal orbicularis oculi muscle, conservative resection of skin and muscle, and suspension of the orbicularis oculi muscle and/or tarsus to the periosteum of the lateral orbital rim. The release of the orbicularis retaining ligament and surgical transposition of orbital fat over the rim rather than excision allows for smoothing of the lid-cheek junction, filling the tear trough deformity, and reducing the appearance of bulging fat in the lower eyelid. In this article the reader will find a comprehensive approach for achieving a smooth contour with gradual blending at the lower eyelid-cheek junction while maintaining/restoring normal lower lid support. A descriptive outline of postoperative care is also provided to help in optimal healing for the patient.

Surgical Anatomy for Extended Facelift Techniques.

Preservation of the facial nerve is crucial in any type of facial procedure. This is even more important when performing plastic surgery on the face. An intricate knowledge of the course of the facial nerve is a requisite prior to performing facelifts, regardless of the technique used. The complex relationship of the ligaments and the facial nerve may put the nerve at an increased risk of damage, especially if its anatomy is not fully understood. There are several danger zones during dissection where the nerve is more likely to be injured. These include the areas where the nerve branches become more superficial in the dissection plane, and where they traverse between the retaining ligaments of the face. Addressing these ligaments is crucial, as they prevent the transmission of traction during facelifts. Without sufficient release, a satisfying pull on the soft tissues may be limited. Traditional superficial musculoaponeurotic system techniques such as plication or imbrication do not include surgical release of these attachments. Extended facelift techniques include additional dissection to release the retaining ligaments to obtain a more balanced and healthier look. However, these techniques are often the subject of much debate due to the extended dissection that carries a higher risk of nerve complications. In this article we aim to present the relationship of both the nerve and ligaments with an emphasis on the exact location of these structures, both in regard to one another and to their locations within the facial soft tissues, to perform extended techniques safely.

Endoscopic ear surgery.

OBJECTIVES: This article reviews the advantages and disadvantages of endoscopic ear surgery (EES). METHOD: Pubmed, Google and the Proquest Central Database at Kirikkale University were queried using the keywords "endoscopic ear surgery", "ear surgery" and "endoscopy" to identify the literature needed for the review. RESULTS: Endoscopes allow for enhanced surgical visualisation. The distal part of the apparatus is illuminated and contains lenses angled to allow a wider view of the operative area. Transcanal endoscopic techniques have transformed the external ear canal (EAC) into an operative gateway. The benefits EES can offer include wider views, enhanced imaging capabilities and increased magnification, and ways to see otherwise poorly visualisable portions of the middle ear. EES permits surgeons to operate using minimally invasive otological techniques. When compared with microscope-assisted surgery, endoscopic tympanoplasty has been shown to require a shorter operating time in some instances. There are a number of drawbacks to EES, however, which include the fact that it is a single-handed technique, that the light source may produce thermal injury and that visualisation using the endoscope is severely curtailed if bleeding is profuse. CONCLUSION: EES is a safe and effective technique. The current literature supports the idea that the results achieved by endoscopic methods are usually comparably beneficial to results obtained using conventional microscopic methods.

Effect of Electronic Cigarettes on the Inner Mucosa of the Craniofacial Region.

OBJECTIVES: The aim of this paper is to investigate electronic cigarettes (e-cigarettes) from the otorhinolaryngologic point of view. METHODS: The authors searched Central Database of Kirikkale University Library, Google, PubMed, and Proquest and Google Scholar. RESULTS: An electronic cigarette or e-cigarette is a battery-powered device that vaporizes a liquid, generally including nicotine. Nowadays, e-cigarettes are used for smoking cessation or to reduce the consumption of conventional tobacco cigarettes. First generation e-cigarette devices were similar to conventional tobacco cigarettes in terms of shape and size and expressed as "cigalikes." Differently from traditional cigarettes in which tobacco is burned to generate smoke, electronic cigarettes contain a tank filled with liquid. It was found that e-cigarette liquids contained different types of chemical compounds which were either previously known carcinogens or probably prove to be carcinogenic to humans in the near future. It seems that the use of electronic cigarette does not harm the oral cells. However, the use of e-cigarette for 4 weeks led to metaplasia and hyperplasia of the laryngeal mucosa in rats. Furthermore, e-ciagarettes produce some adverse effects on the nasal mucosa, supressing the immune system. CONCLUSION: It should not be considered that e-cigarettes are safer unless their effects on the mucosa of the ear, nose, and throat are more precisely clarified.

Jetlag related sleep problems and their management: A review.

OBJECTIVES: We reviewed Jetlag, particularly in view of its effects on sleep and how it can be managed. METHODS: The Proquest Central database of Kirikkale University, PubMed and Google scholar were used while searching for the following key words: "Jetlag", "symptoms", "sleep", "melatonin" and "treatment". RESULTS: Flight dysrhythmia, otherwise known as jetlag, is caused by flying globally over various time zones. Most passengers who fly over six or more different time zones generally require 4-6 days after travelling to resume their usual sleep patterns and to feel less lethargic during the day. Signs of jet lag can vary between debilitated awareness, insomnia, feeling tired during the day and frequent waking during the night. During the night our pineal glands excrete a hormone called melatonin; dim lights cause the continuation of excretion of these hormones whereas any exposure to bright lights stems the flow of release. Common precautionary measures are specific diets, bright lights and melatonin agonists (Ramelteon, Agomelatine). CONCLUSION: Sleep issues derived from jetlag were found to be most common in passengers who flew through various time belts. Melatonin assumes a critical part in adjusting the body's circadian rhythms and has been utilized restoratively to re-establish irritated circadian rhythms.

Modified Composite-Flap Facelift Combined With Finger-Assisted Malar Elevation (FAME): A Cadaver Study.

BACKGROUND: Inadequate release of retaining ligaments during facelift surgery may lead to an unnatural appearance. However, most facelift surgeons are hesitant in transecting these ligaments to avoid possible injury to facial subbranches. OBJECTIVES: In the authors' surgical practice for modified composite flap rhytidectomy, the authors employed the finger-assisted malar elevation (FAME) technique in order to enable safe release of the zygomatic cutaneous ligaments through the prezygomatic space under direct vision. The aim was to evaluate the anatomical basis and safety measures of this technique through a cadaveric dissection study. METHODS: Modified composite-flap facelift with the FAME technique was carried out in 22 fresh cadaver hemi-faces. All facial nerve subbranches were dissected thoroughly to assess for any evidence of injury during facelift, and to evaluate the safety of the operation. The relations among the facial nerve, zygomatic cutaneous and masseteric ligaments, orbicularis oculi muscle, and malar fat pad were investigated. RESULTS: Finger dissection of the prezygomatic space allows safe release of the zygomatic cutaneous ligaments as well as adequate entry to a proper surgical plane above the zygomatici muscles under direct vision, while leaving the malar fat pad and overlying structures attached to the skin without the need of a transblepharoplasty approach. CONCLUSIONS: This study by the authors shows that a modified composite-flap facelift with FAME technique is a safe procedure that allows adequate and effective repositioning of an en-bloc composite flap that produces balanced and harmonious rejuvenation of the midface and lower face without the need of a separate midface lift.

Surgical Approach to the Thick Nasolabial Folds, Jowls and Heavy Neck-How to Approach and Suspend the Facial Ligaments.

Patients with thick skin typically present with a redundant, baggy, lax skin envelope together with prominent nasolabial folds, jowls, and a heavy neck. Durable and natural-appearing rejuvenation is not possible unless the deformities are addressed adequately and harmoniously in these patients. Traditional superficial musculoaponeurotic system techniques do not include surgical release of the zygomatic cutaneous ligaments and repositioning of descendent malar fat pad, and may lead to an unbalanced, unnatural appearance and the lateral sweep phenomenon. Additional attempts to improve unopposed nasolabial folds such as fat grafting to malar region are more likely to result with a "stuffed" look, far from a natural and rejuvenated appearance, and must therefore be avoided. The facelift techniques including true release of the anchoring ligaments of the midface and allowing adequate repositioning of saggy tissues are ideal for these patients to obtain harmonious, natural result. Despite the extensive dissections, maximal release, and maximal lateral pull, additional maneuvers, e.g., platysmaplasty, subplatysmal fat removal, or partial resection of submandibular glands may be required for satisfying result in patients with heavy neck. In this article, the authors outline the relevant anatomy of the facial retaining ligaments and their implications to surgical management of patients with heavy skin are discussed.

The radiologic evaluation of osteitis type and formation in chronic rhinosinusitis with and without nasal polyposis.

OBJECTIVE: To evaluate the amount and type of osteitis observed in chronic rhinosinusitis with nasal polyposis (CRSwNP) and compare it with that of chronic rhinosinusitis without nasal polyposis (CRSnNP). SETTING: Sisli Etfal Research and Education Hospital, Istanbul, Turkey. STUDY DESIGN: Prospective, single-blind, cohort study. METHODS: Three different patient groups, designated as the CRSwNP, CRSnNP, and control groups, were included in the study. Forty patients who had CRSnNP and/or CRSwNP confirmed with a paranasal sinus computerized tomography (CT) study were included for the study group, and 20 individuals were included in the control group. Paranasal sinus CTs were evaluated and compared for osteitis. RESULTS: Hounsfield units obtained from the right and left agger nasi walls and the medial maxillary sinus wall in the control group were significantly different from the entire group. Similarly, values for the anterior ethmoid wall were statistically significant for the CRSwNP group compared with all the subjects. When the groups were compared to one another, there were significant differences in both the right and left agger nasi walls and the frontal sinus wall. CONCLUSION: Differentiating and acknowledging osteitis induced by CRSwNP rather than CRSnNP may aid in preoperative planning and indicate where to be more aggressive when excising bony structures. This may help in reducing recurrence and in increasing quality of life.

Audiovestibular Manifestations in Patients with Ankylosing Spondylitis--A Case Report and Review of the Literature.

Ankylosing spondylitis is a chronic systemic inflammatory disease of unknown origin affecting up to 1% of the population. Audiovestibular impairment has been observed in ankylosing spondylitis and sensorineural hearing loss (SNHL) is the most common form. The cause of SNHL is still unknown but the possible causes are as follows: vascular inflammation (obliterative vasculitis) of small vessels, ossification of the articular tissue of the middle ear, and use of non-steroid anti-inflammatory drugs. This is a case report of a patient with ankylosing spondylitis and SNHL along with a discussion of the literature regarding cochleovestibular impairment in ankylosing spondylitis.

Identifying Septal Support Reconstructions for Saddle Nose Deformity: The Cakmak Algorithm.

IMPORTANCE: The saddle nose deformity is one of the most challenging problems in nasal surgery with a less predictable and reproducible result than other nasal procedures. The main feature of this deformity is loss of septal support with both functional and aesthetic implications. Most reports on saddle nose have focused on aesthetic improvement and neglected the reestablishment of septal support to improve airway. OBJECTIVES: To explain how the Cakmak algorithm, an algorithm that describes various fixation techniques and grafts in different types of saddle nose deformities, aids in identifying saddle nose reconstructions that restore supportive nasal framework and provide the aesthetic improvements typically associated with procedures to correct saddle nose deformities. DESIGN, SETTING, AND PARTICIPANTS: This algorithm presents septal support reconstruction of patients with saddle nose deformity based on the experience of the senior author in 206 patients with saddle nose deformity. Preoperative examination, intraoperative assessment, reconstruction techniques, graft materials, and patient evaluation of aesthetic success were documented, and 4 different types of saddle nose deformities were defined. MAIN OUTCOMES AND MEASURES: The Cakmak algorithm classifies varying degrees of saddle nose deformity from type 0 to type 4 and helps identify the most appropriate surgical procedure to restore the supportive nasal framework and aesthetic dorsum. RESULTS: Among the 206 patients, 110 women and 96 men, mean (range) age was 39.7 years (15-68 years), and mean (range) of follow-up was 32 months (6-148 months). All but 12 patients had a history of previous nasal surgeries. Application of the Cakmak algorithm resulted in 36 patients categorized with type 0 saddle nose deformities; 79, type 1; 50, type 2; 20, type 3a; 7, type 3b; and 14, type 4. Postoperative photographs showed improvement of deformities, and patient surveys revealed aesthetic improvement in 201 patients and improvement in nasal breathing in 195 patients. Three patients developed postoperative infection and 21 patients underwent revision septal surgery. CONCLUSIONS AND RELEVANCE: The goal of saddle nose reconstruction should be not only to restore an aesthetic dorsum but also to restore the supportive nasal framework. The surgeon should provide more projected and strengthened septal support before augmentation of saddle nose deformity to improve breathing and achieve a stable long-term result. The Cakmak algorithm is a mechanism that helps surgeons identify the most effective way to maximize septal support and aesthetic appeal. LEVEL OF EVIDENCE: 4.

Comparison of conventional continuous positive airway pressure to continuous positive airway pressure titration performed with sleep endoscopy.

OBJECTIVES/HYPOTHESIS: To evaluate the effect and obtain a pressure value of continuous positive airway pressure (CPAP) under direct visualization using drug-induced sleep endoscopy (DISE) and compare the pressure values with values obtained using conventional CPAP. STUDY DESIGN: Prospective, double-blinded, cohort study. METHODS: Sixteen patients with obstructive sleep apnea syndrome (OSAS) were included in the study. Each patient underwent polysomnographic evaluation. After diagnosis of OSAS, patients underwent conventional CPAP titration. Patients were then taken to the operating theatre and put under sedation, where CPAP titration with nasendoscopy was performed (DISE CPAP). RESULTS: There were no statistically significant differences between the two techniques regarding pressure levels that decreased apneas in conventional CPAP and provided sufficient opening during DISE CPAP. CONCLUSIONS: Results with conventional CPAP titration and endoscopy-assisted CPAP titration showed no statistically significant difference. Endoscopy-assisted CPAP is a cheaper and less time consuming alternative to conventional CPAP and has similar results.

Comparison of radiofrequency applied to the total inferior choncha with application to its anterior third.

OBJECTIVE: To compare radiofrequency application to the anterior 1/3 of the inferior choncha with application to the whole of the inferior choncha. MATERIAL AND METHOD: 40 patients with nasal obstruction due to isolated inferior choncha hypertrophy were evaluated. RF was applied in the first group only to the anterior 1/3 of the choncha, whereas in the second group the whole choncha was ablated. Anterior rhinomanometry measurements were obtained both before and 6 weeks after surgery along with visual analog scales. Complete data was used to compare the efficacy of both techniques. RESULTS: The combined nasal resistance showed a significant decrease in both groups. VAS scores were also substantial for both groups. Both groups showed similar data proving the two techniques to have similar efficacy. CONCLUSION: Application to the anterior 1/3 compared with application to the whole of the choncha show no significant differences. Simple RF application here not only provides adequate control but also is safer as there is less risk of interruption of continuity of the nasal mucosa.