Increased recognition of Q fever aortitis as a chronic manifestation of Q fever in tropical North Queensland, Australia.

Aortitis is a life-threatening, manifestation of chronic Q fever. We report a series of 5 patients with Q fever aortitis who have presented to our hospital in tropical Australia since 2019. All diagnoses were confirmed with polymerase chain reaction (PCR) testing of aortic tissue. Only one had a previous diagnosis of acute Q fever, and none had classical high-risk exposures that might increase clinical suspicion for the infection. All patients underwent surgery: one died and 3 had significant complications. Q fever aortitis may be underdiagnosed; clinicians should consider testing for Coxiella burnetii in people with aortic pathology in endemic areas.

Iatrogenic injury to the subclavian artery during central venous access.

Subclavian artery injury during central venous line placement is a potentially life-threatening complication. Due to historically high mortality rates with attempted manual pressure for haemostasis, the current favoured method of repair is by open or endovascular means. This case describes the management of a central venous catheter placed through the internal jugular vein into the subclavian artery via a supraclavicular puncture. CT angiography revealed the arterial injury located 1 cm distal to the vertebral artery origin. Under fluoroscopic guidance in an endovascular hybrid theatre, a covered stent was deployed across the affected segment of the subclavian artery which resulted in occlusion of the vertebral artery origin to attain safe proximal seal. This was done during simultaneous removal of the catheter and manual pressure over the internal jugular vein. There were no complications and the patient recovered well post-procedure. This case highlights the importance of appropriate ultrasound techniques for central catheter insertion for precise visualisation to prevent inadvertent injury to distal structures. CT angiography is useful in planning endovascular management. Occlusion of the vertebral artery in this case did not result in any neurological complications.

Association Between Mental Health Status and Patient Satisfaction With the Functional Outcomes of Rhinoplasty.

IMPORTANCE: Mental health can have an impact on patient satisfaction with rhinoplasty. However, the association between mental health and patient satisfaction with functional outcomes of rhinoplasty is poorly understood. OBJECTIVE: To determine whether preoperative mental health is associated with satisfaction with functional outcomes of rhinoplasty. DESIGN, SETTING, AND PARTICIPANTS: This case-control study assessed baseline nasal function and postsurgical functional outcomes for 88 consecutive patients undergoing rhinoplasty with both cosmetic and functional goals at 2 tertiary rhinologic centers in Sydney, Australia. EXPOSURES: Poor mental well-being was defined preoperatively by the Optum SF-36v2 Health Survey mental component summary. MAIN OUTCOMES AND MEASURES: Nasal function was assessed with patient-reported outcome measures, including visual analog scales, the Nasal Obstruction Symptom Evaluation Scale (NOSE), the 22-item Sinonasal Outcome Test (SNOT-22), and Likert scales. Objective outcomes included nasal peak inspiratory flow, nasal airway resistance, and minimum cross-sectional area. All outcomes were assessed preoperatively and 6 months postoperatively. The 36-item Optum SF-36v2 Health Survey mental component summary was used to assess mental well-being, with a score of less than 40 indicating poor mental well-being and a score 40 or higher indicating normal well-being. RESULTS: Mean (SD) patient age was 37.6 (12.9) years and 53 of 88 (60.2%) were women. The mental component summary defined impaired well-being in n = 24 (cases) and normal well-being in n = 64 (controls). There were improvements in the total study population across most nasal function outcomes and in both groups. After rhinoplasty, benefit was seen for both groups in visual analog scale (left side mean [SD] change, 18 [30]; P < .001 and right side mean [SD] change, 24 [30]; P < .001); NOSE (mean [SD] change, 1.35 [1.21]; P < .001); and SNOT-22 (mean [SD] change, 0.81 [0.88]; P < .001) scores. Nasal peak inspiratory flow improved for both groups (mean [SD] change, 32 [45] L/min; P < .001), while nasal airway resistance and minimum cross-sectional area remained similar (change in nasal airway resistance, 0.086 Pa/cm3/s; 95% CI, -0.007 Pa/cm3/s to 0.179 Pa/cm3/s and change in minimum cross-sectional area, -0.04 cm2; 95% CI, -0.21 cm2 to 0.13 cm2). Patients with poor mental health had similar improvements in nasal function compared with controls. CONCLUSIONS AND RELEVANCE: Rhinoplasty imparts similar benefits to nasal function assessed by patient-reported outcome measures and objective airflow measures regardless of preoperative mental health status. LEVEL OF EVIDENCE: 3.

Association of Mental Health Status With Perception of Nasal Function.

IMPORTANCE: Mental health issues are thought to be overrepresented among patients undergoing rhinoplasty and may be associated with patient presentation prior to surgery. OBJECTIVE: To assess the association of poor mental health with perception of nasal function. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional study of patients presenting for airway assessment was performed from December 1, 2011, to October 31, 2015, at 2 tertiary rhinoplasty centers in Sydney, Australia. Mental health was independently defined preoperatively by the Mental Component Summary of the 36-item Short Form Health Survey version 2 (a score of <40 indicated poor mental well-being), the Rosenberg Self-Esteem Scale (a score of <15 indicated low self-esteem), and the Dysmorphic Concerns Questionnaire (a score of >11 indicated above-average dysmorphic concerns). MAIN OUTCOMES AND MEASURES: Nasal function was assessed with patient-reported outcome measures, including the Nasal Obstruction Symptom Evaluation Scale, the 22-item Sinonasal Outcome Test, a visual analog scale to rate ease of breathing on the left and right sides, and Likert scales to assess overall function and nasal obstruction. Nasal airflow was assessed by nasal peak inspiratory flow, nasal airway resistance, and minimum cross-sectional area. RESULTS: Among 495 patients in the study (302 women and 193 men; mean [SD] age, 36.5 [13.6] years), compared with patients with good mental health, those with poor mental health had poorer scores in all patient-reported outcome measures, including the visual analog scale for the left side (mean [SD], 51 [25] vs 42 [25]; P = .001), visual analog scale for the right side (mean [SD], 54 [24] vs 45 [26]; P < .001), Nasal Obstruction Symptom Evaluation Scale (mean [SD], 2.64 [0.95] vs 1.96 [1.04]; P < .001), 22-item Sinonasal Outcome Test (mean [SD], 2.14 [0.84] vs 1.33 [0.83]; P < .001), nasal obstruction (58 of 145 [40.2%] vs 83 of 350 [23.7%] with severe or worse obstruction; P < .001), and nasal function (72 of 145 [49.7%] vs 111 of 350 [31.8%] with poor or worse function; P < .001). Subclinical differences in nasal peak inspiratory flow could be demonstrated, but all other nasal airflow measures were similar. Low self-esteem produced a similar pattern, but dysmorphia did not. CONCLUSIONS AND RELEVANCE: Poor mental health status is associated with a poorer self-perception of nasal function compared with those who are mentally healthy with clinically similar nasal airflow. Clinicians should be aware that patients with poor mental health reporting obstructed airflow may in part be representing an extension of their negative emotions rather than true obstruction and may require further assessment prior to surgery. LEVEL OF EVIDENCE: NA.

Two-dimensional assessment of the nasal valve area cannot predict minimum cross-sectional area or airflow resistance.

BACKGROUND: Clinicians who manage nasal obstruction often comment on the shape and size of the nasal valve (NV) area. However, correlation of the symptoms of obstruction, nasal airflow dynamics, and the endoscopic appearance of the anatomic cross-sectional area of the NV is poorly understood. Endoscopic imaging and calculation of the NV area is investigated as a tool for either clinical or research use. OBJECTIVE: To describe and evaluate a two-dimensional measurement of the minimum cross-sectional area (MCA) of the NV by using endoscopic imaging. METHODS: A cross-sectional study of patients with symptoms of nasal obstruction who were undergoing nasal assessment was performed. The NV was measured with digital imaging taken from the endoscopy. Adobe Photoshop was used to calculate the digital MCA of the NV based on pixel count and a reference marker placed in the image field. Airway parameters were assessed by using a nasal obstruction visual analog scale, nasal airway resistance via rhinomanometry, and acoustic rhinometry derived MCA (acoustic MCA). Correlation of the digital MCA and airway parameters was made and interobserver correlation of the MCA measures was calculated. RESULTS: Thirty-three nasal airways were assessed: mean (standard deviation) digital MCA (0.28 ± 0.13 cm(2)) and mean (standard deviation) acoustic MCA (0.51 ± 0.15 cm(2)). Correlation of the digital MCA with visual analog scale was poor (Pearson r = 0.10, p = 0.56). Similar finding between digital and acoustic MCA was poor (Pearson r = 0.50, p = 0.56, respectively) despite a moderately strong interobserver correlation for the digital MCA (Pearson r = 0.79, p < 0.001). CONCLUSION: Qualitative endoscopic assessment of the NV may help clinicians predict NV dysfunction but simple two-dimensional measures seemed to be of limited value in accurately assessing the three-dimensional NV quantitatively.

Airflow and patient-perceived improvement following rhinoplastic correction of external nasal valve dysfunction.

IMPORTANCE: External nasal valve dysfunction (ENVD) is a common cause of nasal obstruction. Although many techniques are described to help correct ENVD, evidence of the objective changes in the airway achieved by these interventions is mainly unknown. OBJECTIVE: To document the airway changes in patients with ENVD by comparing subjective and objective measures obtained before and after rhinoplasty. DESIGN, SETTING, AND PARTICIPANTS: Prospective case series with validated subjective and objective outcomes at a tertiary rhinologic center in Sydney, Australia. We included 19 patients with nasal obstruction and clinically diagnosed ENVD from January 2012 to May 2013. INTERVENTIONS: Functional reconstructive rhinoplasty involving lateral crural underlay strut grafts using costal cartilage or lateral crural cephalic turn-in maneuvers performed to correct ENVD. MAIN OUTCOMES AND MEASURES: Objective assessment included nasal peak inspiratory flow, nasal airway resistance, and minimum cross-sectional area. Subjective assessment included a visual analog scale for nasal obstruction, the 22-item Sinonasal Outcome Test, the Nasal Obstruction Symptom Evaluation Scale, and the 36-Item Short Form Health Survey, version 2. A 13-point Likert scale was also used to assess overall function and cosmesis. Objective data and visual analog scale scores were obtained before and after decongestion at baseline and 6 months after surgery. RESULTS: Mean (SD) age of the patients undergoing assessment was 33.3 (12.4) years; 13 patients (68%) were female. Significant improvement was observed in scores for the Sinonasal Outcome Test (mean [SD] change, 0.85 [0.96]), Nasal Obstruction Symptom Evaluation Scale (mean [SD] change, 30.53 [26.14]), and overall function (median [25th-75th percentiles] change, -6.5 [-7.0 to 1.0]) and cosmesis (median [25th-75th percentiles] change, -4.0 [-8.0 to -1.0]) (P < .01). The mean (SD) nasal peak inspiratory flow increased from 102.6 (45.6) to 124.0 (52.9) L/min (P < .01). Median (25th-75th percentiles) nasal airway resistance showed no significant change (from 0.296 [0.237-0.414] to 0.292 [0.267-0.371] Pa/cm3/s; P = .92). The minimum cross-sectional area also showed no significant change (mean [SD], from 1.188 [0.407] to 1.229 [0.336] cm2; P = .69). CONCLUSIONS AND RELEVANCE: Contrary to common belief, successful rhinoplasty had little effect on structural shape or resistance in ENVD, but symptoms improved with changes in collapsibility as defined by the nasal peak inspiratory flow. The need to reconstruct lateral wall support is reinforced by the data presented. LEVEL OF EVIDENCE: 4.