Composite Thickness and Stiffness Analysis of the Nasal Septum.

Background: The nasal septum supports the structure of the nose and is frequently manipulated during septorhinoplasty. Objective: To compare measurements of thickness and compressive Young's modulus (YM) between different regions of nasal septa from human anatomic specimens. Study Design: Case series. Methods: Cartilaginous septa from human anatomic specimens were dissected. Septum thickness was measured at 24 points with regular intervals using a digital caliper. Compressive YM was determined at 14 regions using a force gauge. Two-tailed student's t-tests were used to compare the average thickness and YM between different regions. Results: Septa from 40 human anatomic specimens were included, with age ranging from 50 to 89. Fifty percent of specimens were female. The mean (standard deviation) thickness of the septum was 1.75 (0.76) mm. The mean YM was 2.38 (1.29) MPa. The septum was thickest near the maxillary crest (3.09 [1.17] mm) and the keystone area (2.52 [0.91] mm) and thinnest near the anterior septal angle (1.29 [0.58] mm). The septum was most stiff posteriorly (2.90 [1.32] MPa) and least stiff anteriorly (1.80 [1.15] MPa). Conclusion: The nasal septum is thickest posteriorly, inferiorly, and along its bony edges. The septum is stiffest posteriorly, ventrally, and along its bony edges.

The Creation of an Average 3D Model of the Human Cartilaginous Nasal Septum and Its Biomimetic Applications.

The cartilaginous nasal septum is integral to the overall structure of the nose. Developing our an-atomic understanding of the septum will improve the planning and techniques of septal surgeries. While the basic dimensions of the septum have previously been described, the average shape in the sagittal plane has yet to be established. Furthermore, determining the average shape allows for the creation of a mean three-dimensional (3D) septum model. To better understand the average septal shape, we dissected septums from 40 fresh human cadavers. Thickness was measured across pre-defined points on each specimen. Image processing in Photoshop was used to superimpose lateral photographs of the septums to determine the average shape. The average shape was then combined with thickness data to develop a 3D model. This model may be utilized in finite elemental analyses, creating theoretical results about septal properties that are more translatable to real-world clinical practice. Our 3D septum also has numerous applications for 3D printing. Realistic models can be created for educational or surgical planning purposes. In the future, our model could also serve as the basis for 3D-printed scaffolds to aid in tissue regeneration to reconstruct septal defects. The model can be viewed at the NIH 3D model repository (3DPX ID: 020598, Title: 3D Nasal Septum).

Antiaging Effects of Topical Defensins.

Topical defensins have recently gained attention as agents to improve skin composition. This study aimed to aggregate and synthesize studies in the literature assessing the effects of topical defensins on skin composition in the context of its ability to combat signs of aging.

Medial Sural Artery Perforator Flap: A Middle Ground Between Anterolateral Thigh and Radial Forearm Flaps.

OBJECTIVE: The medial sural artery perforator (MSAP) flap has gained popularity in head and neck reconstruction primarily as a less morbid alternative to the radial forearm free flap (RFFF). However, no direct comparison of thickness exists among the MSAP, RFFF, and anterolateral thigh (ALT) flaps, which together represent the commonly utilized nonosseus-free flaps in head and neck reconstruction. Thus, this study aimed to compare these flap sites and identify predictors of thickness that will aid in reconstructive surgical planning. STUDY DESIGN: Cross-sectional study. SETTING: Tertiary referral hospital. METHODS: The thickness of skin and subcutaneous tissue at the RFFF, MSAP, and ALT donor sites were measured in 54 adult patients using Doppler ultrasound. General linear models were generated to identify predictors of flap thickness. RESULTS: The mean thickness of the RFFF, MSAP, and ALT flaps was 3.8 ± 2.2 mm, 7.4 ± 3.8 mm, and 9.6 ± 4.7 mm. Body mass index (BMI) was the only statistically significant contributing factor (p < .0001, coefficient: 0.15) for the RFFF. MSAP was affected by age (p = .006, coefficient = 0.06), female gender (p < .0001, coefficient = 3.2), and BMI (p < .001, coefficient = 0.25), while the ALT was affected by female gender (p = .0005, coefficient = 3.3) and BMI (p < .0001, coefficient = 0.35). Thus, the ratio of increase for flap thickness with respect to BMI is 3:5:7 for the RFFF, MSAP, and ALT flaps, respectively. CONCLUSION: The MSAP is about twice the thickness of the RFFF and 2 mm thinner than the ALT; however, 22% of patients had thicker MSAP than ALT flaps. As the strongest predictors of flap thickness, female gender, and BMI may be taken into consideration during surgical planning for reconstruction.

Transoral Excision of Parapharyngeal Tumors.

OBJECTIVES: The transoral approach for parapharyngeal space tumors has been criticized due to its restrictive exposure and increased rate of vascular and nerve injuries. However, for certain tumors-namely those that are prestyloid, benign, and well-encapsulated-the transoral approach reduces overall morbidity while providing direct access. Transoral surgeons can rely on this approach for select tumors seen clearly on intraoral examination in the bulging lateral pharynx. In this article and with a supplemental operative technique video, we demonstrate our transoral approach in these select patients. METHODS: We reviewed our 26 cases using this approach and chose a representative case of a 50-year-old man who presented with a large, prestyloid, encapsulated parapharyngeal mass affecting his voice and swallowing. A transoral approach to the parapharyngeal tumor is illustrated. RESULTS: A vertical curvilinear incision is completed from the hamulus to below the inferior extent of the tumor. Blunt dissection of the tumor capsule proceeds inferiorly. Controlled violation of the tumor capsule can aid in visualization. After tumor delivery, the wound is irrigated and closed. CONCLUSIONS: In our experience, the transoral approach is an effective method to access well-encapsulated, prestyloid parapharyngeal space tumors. Patient selection is important when considering a transoral approach.

Complications and Treatment of Delayed or Inadequately Treated Nasoorbitoethmoid Fractures.

Delayed or improper repair of nasoorbitoethmoid (NOE) fractures can lead to debilitating outcomes including diplopia, epiphora, nasal obstruction, facial asymmetry, and poor cosmesis. As such, NOE fractures should be repaired promptly and properly to prevent these unwanted sequelae. Treating patients with delayed, untreated, or inadequately reduced NOE fractures is challenging due to scarring and contracture. Saddle nose deformity, telecanthus, enophthalmos, nasolacrimal duct obstruction, and soft-tissue scarring are often encountered in the secondary management of NOE fractures and should be addressed in the overall context of reestablishing facial symmetry and function.

Mandibular muscle attachments in genial advancement surgery for obstructive sleep apnea.

OBJECTIVES/HYPOTHESIS: Genioglossus advancement is performed in select patients with obstructive sleep apnea. Surgical techniques attempt to capture the genial tubercle of the mandible; however, measurements of the genioglossus, geniohyoid, and digastric muscles are poorly delineated. This investigation is the largest anatomic study exploring the muscles of genial advancement surgery and the first to quantitatively characterize muscular attachments relative to the tubercle, providing new insights from an anatomic perspective on optimizing muscular advancement. STUDY DESIGN: Cadaveric study. METHODS: Fifty-three fresh cadaveric mandibles underwent dissection of the genial tubercle and genioglossus, geniohyoid, and digastric muscles. RESULTS: Genial tubercle, geniohyoid, and genioglossus mean height was 7.78 mm, 5.15 mm, and 6.11 mm, respectively. On average, the geniohyoid began 4.88 mm and ended 10.03 mm from the inferior border of the mandible; the genioglossus 11.91 mm and 18.01 mm, similarly. Intermuscular distance, if present, was 2.67 mm; the muscles overlapped in 28% of cadavers. The combined vertical height of the muscles at their mandibular attachment was 13.94 mm, significantly differing from the height of the genial tubercle. The left and right lateral insertion of the digastric muscles was 19.34 mm and 19.31 mm, respectively, from midline. CONCLUSIONS: The variable range of muscle attachments suggests that genioglossal and geniohyoid attachments extend beyond the genial tubercle and may not originate concentrically from the tubercle, but overlap and lie in very close proximity. Mandibular anterior muscle attachments require anatomic accuracy and an effective operative evaluation of advancement before reproducible, clinically effective osteotomies can be recommended. LEVEL OF EVIDENCE: NA Laryngoscope, 129:2424-2429, 2019.

Redefining the nasal septal L-strut: A quantitative analysis of septal arcs and angles.

OBJECTIVE: To define and quantify common points and relationships within the anterior nasal septum and recognize the anatomic curvature of the dorsal and caudal septum as arcs with certain rises. STUDY DESIGN: Case series study. METHODS: Forty cadaveric quadrangular cartilages were dissected. Points along the septum were defined and relationships measured. Angles that composed the anterior septum using values that did account for the curvature of the anterior nasal septum, or classical L-strut values, were compared to C-strut values, which included rises away from the L-strut. RESULTS: The mean arc of the nasal septum dorsum was significantly longer than the caudal arc (25.9 ± 5.14 mm vs. 23.96 ± 4.07 mm, P = 0.048); the mean rise of the dorsal arc was significantly shorter than the rise of the caudal arc (3.04 ± 1.25 mm vs. 3.88 ± 1.42 mm, P = 0.006). The mean point of furthest rise of the dorsal arc was slightly anterior to the midpoint of the dorsal strut (13.43 ± 5.07 mm); the mean caudal equivalent was slightly posterior to the midpoint of the caudal strut (8.55 ± 4.33 mm). Septal angles measured using L-strut versus C-strut values were significantly different. CONCLUSION: The L-strut leading edge is not congruent with the anatomic septum and can be better described as a C-strut with arcs and rises away from classically interpreted straight L-strut lines, all of which may guide surgeons in the creation of a more natural, supportive cartilage framework while encouraging quantifiable septorhinoplasty teaching. LEVEL OF EVIDENCE: NA. Laryngoscope, 1806-1810, 2018.

Sialodochoplasty Stents: Cost Analysis and Outcomes.

PURPOSE: We reviewed a patient cohort receiving sialodochoplasty with or without salivary stent placement. We propose the Firlit-Kluge pediatric urinary catheter (Cook Medical, Bloomington, IN) as an advantageous alternative stent because of our duct patency results with stenting, considering the advantages and disadvantages of specific stents. We also provide a simple cost summary of commonly used stents. MATERIALS AND METHODS: A retrospective review of a case series of patients undergoing sialodochoplasty or salivary duct surgery from 2012 to 2015 was undertaken at a tertiary care center. The indications, duct reconstruction results, and complications were analyzed, and a comparative cost analysis was performed. RESULTS: Of 25 patients, 16 were stented with Firlit-Kluge catheters, 2 with CORFLO ULTRA feeding tubes (Corpak Medsystems, Buffalo, NY), 1 with an Introcan Safety intravenous (IV) catheter (B. Braun Medical Inc, Melsungen, Germany), and 6 were not stented. All 16 Firlit-Kluge-stented patients had successful duct reconstruction with a patent duct orifice draining saliva on the last follow-up visit, and only 1 stent dislodged early. All patients stented with feeding tubes or the IV catheter experienced discomfort or early dislodgement of the stent. Comparing the Firlit-Kluge stent to commercially available salivary stents, the cost savings in the Firlit-Kluge stent group was $2,480.16 compared with the cost of the Walvekar and Schaitkin stents (Hood Laboratories, Pembroke, MA) and $880.15 to $1,120.00 compared with Ad-Tech-Med stents (Lublin, Poland). However, the cost of the Firlit-Kluge stent exceeded the costs of the Braun IV catheter, Bard infant urinary catheter (Bard Medical Division, CR Bard, Louisville, CO), and CORFLO ULTRA stent by $60.48, $24.64, and $258.72, respectively. CONCLUSIONS: The Firlit-Kluge urinary catheter incurs considerable cost savings compared with commercial stents, and its silicone makeup and ball flange enhances comfort and prevents dislodgment by aiding in suture placement.

Mycobacterium bovis cervical lymphadenitis: A representative case and review.

Mycobacterium bovis is a tuberculosis causing bacterium that commonly presents with cervical lymphadenopathy. It is important to differentiate M. bovis from other Mycobacterial pathogens to ensure selection of correct anti-microbial therapy. This may decrease the number of treatment failures, the prevalence of anti-mycobacterial drug resistance patterns, and the need for surgical intervention. M. bovis has universal resistance to pyrazinamide and thus may not respond to typical first line mycobacterial drugs and may require surgical intervention. This case report and review of M. bovis cervical lymphadenitits demonstrates the need for accurate diagnosis as well as combined management with infectious disease and public health specialists.