Two-flap technique with interpositional dermofat graft for anterior oronasal fistula closure in patients with cleft: A case series.

BACKGROUND: Oronasal fistula at the anterior hard palate is one of the common sequelae after cleft surgery, and the leakage negatively affects the patient's quality of life. Although several surgical techniques have been proposed for reconstruction, it remains challenging because of the scarred regional tissue with a high rate of fistula recurrence. In this study, we present the anterior oronasal fistula repair using a two-flap technique with an interpositional dermofat graft (DFG). METHODS: A retrospective review of anterior oronasal fistula repair performed by the senior author between April 2018 and August 2022 at the Craniofacial Center was conducted. Patients who underwent a fistula repair using the technique were further identified and investigated. RESULTS: Thirty-four operations were performed using the technique, and 31 fistulas were completely closed, with a success rate of 91.2%. The fistula symptom improved but persisted postoperatively in 3 patients, of whom 2 patients underwent a second fistula repair using the same procedure, resulting in successful closure. Fistula recurrence was significantly correlated with fistula size (p = 0.04). The DFG was simultaneously utilized for nasal dorsum and/or vermillion reconstruction in 28 cases. CONCLUSION: The two-flap technique enabled tension-free approximation, and the interpositional DFG facilitated watertight closure of the fistula, resulting in a high success rate of anterior oronasal fistula repair. The fistula closure could be combined with other revisional procedures for cleft-related deformities, where the DFG was simultaneously utilized.

Utility of Serum Interleukine-6 Level in Empty Nose Syndrome.

Objectives: Empty nose syndrome (ENS), a complication resulting from surgical procedures on turbinate tissue, is characterized by paradoxical nasal obstruction with wide nasal airways. Patients with ENS often also experience psychiatric symptoms, and psychiatric disorder detection remains dependent on subjective evaluation. Objective biomarkers for mental status assessment in patients with ENS are unestablished. This study aimed to evaluate the role of serum interleukin-6 (IL-6) levels in the mental status of patients with ENS. Methods: Overall, 35 patients with ENS who underwent endonasal submucosal implantation surgery were prospectively included in the study. The Sino-Nasal Outcome Test-25 (SNOT-25), Empty Nose Syndrome 6-item Questionnaire (ENS6Q), Beck Anxiety Inventory (BAI), and Beck Depression Inventory-II (BDI-II) were used to assess the physical and psychiatric symptoms of these patients preoperatively, and 3, 6, and 12 months postoperatively. Serum IL-6 levels were analyzed 1 day before surgery. Results: All subjective assessments significantly improved 3 months after surgery and plateaued at 12 months. Patients with higher serum preoperative IL-6 levels tended to experience more severe depression. Regression analysis showed that a preoperative serum IL-6 level > 1.985 pg/mL was significantly correlated with severe depression status in patients with ENS (odds ratio = 9.76, p = 0.020). Conclusions: ENS patients with higher preoperative serum IL-6 levels were more likely to have severe depressive burden. Since more suicidal thoughts or attempts were noted in these patients, timely treatment plan for patients with high levels of serum IL-6 is crucial and may consider psychotherapy after surgical treatment.

Endoscope-Assisted Multilayered Repair in Oronasal Fistula.

Oronasal fistula following cleft palate repair is a considerable complication with a recurrence rate of 33% to 37% and remains a challenging problem for surgeons. Furthermore, many patients have undergone several operations and experienced scar problems and other forms of morbidity. Therefore, we report a multilayered technique for oronasal fistula closure using an endoscopic nasal inferior turbinate composite graft with a palatal advance flap. This will increase the success rate after closure of small-sized oronasal fistula surgery without complications or recurrence (IRB: 2020-1671-0001).

Sternohyoideus-sternothyroideus muscle flap to reconstruct oronasal fistulas due to maxillary cancer in four dogs.

OBJECTIVE: To describe the repair of oronasal fistulas in dogs treated for maxillary cancer, with a novel sternohyoideus-sternothyroideus muscle flap, and to report the outcome. ANIMALS: Client-owned dogs (n = 4) with oronasal fistulas related to cancer. STUDY DESIGN: Short case series. METHODS: Maxillary defects were caused by tissue destruction by the tumor and tumor response to radiation therapy in two cases and a complication of caudal maxillectomy in two cases, one of which had neoadjuvant radiation therapy. All tumors were >4 cm at the level of the maxilla. Flaps were harvested by transecting the ipsilateral sternothyroideus and sternohyoideus muscles from their origin at the manubrium and costal cartilage. The muscles were rotated around the base of the cranial thyroid artery and tunneled subcutaneously in the neck and through an incision in the caudodorsal aspect of the oral cavity. The muscle flap was sutured to the edges of the oronasal fistula. RESULTS: The flap reached as far rostral as the level of the first premolar without tension. All dogs had clinical signs that improved postoperatively. All dogs had partial dehiscence of the flap. CONCLUSION: This flap was associated with a high rate of complications; however, all flaps were used in challenging cases. Clinical signs related to oronasal fistula were improved in all dogs in this case series.

Prospective Study of Sinonasal Outcome Following Endoscopic Skull Base Surgery.

Background: Endoscopic endonasal surgery (EES) requires wide sinonasal dissection to achieve adequate visualisation of anatomical landmarks. This can also result in nasal sequelae like crusting, nasal discharge, and anosmia. Aim: To use the sinonasal outcome test (SNOT) 22 questionnaire to study the postoperative sinonasal morbidity and its recovery in patients who have undergone EES. Materials and Method: Prospective study conducted from November 2017 to May 2018. SNOT-22 questionnaire was administered on patients operated between before EES and then re-administered during outpatient visits at 1 month, 3 months, and 6-12 months following surgery. Results: Results of 46 patients were analyzed. The mean duration of follow-up was 11.8 months. The mean preoperative SNOT-22 score was 2.69 ± 4.95. SNOT-22 score at 1 month was 5.52 ± 6.77, at 3 months follow-up was 0.39 ± 1.02, and after 6 months was 0.30 ± 1.00. In 32 patients with a nasoseptal flap, mean preoperative score was 3.34 ± 5.68 (P = 0.18), one month following surgery it was 6.68 ± 6.88 and at 3 and 6 months following surgery it was 0.56 ± 1.19 and 0.38 ± 1.15. The mean preoperative nasal domain score was 1.022 (±2.13), the postoperative 1 month score was 2.3 ± 3.7, at 3 months following surgery was 0.22 ± 0.82 and after 6 months of surgery was 0.28 ± 0.96. Conclusion: Patients undergoing EES experienced transient worsening of SNOT 22 scores in the first month following surgery and recovered within 3 months of surgery. The improvement was sustained in follow-up visits beyond 6 months of surgery.

Eosinophilic Angiocentric Fibrosis of the Nasal Cavities: A Report of an Uncommon Lesion with Emphasis on the Etiology and Differential Diagnosis.

Background and Objectives: Eosinophilic angiocentric fibrosis (EAF) is an indolent but sometimes locally destructive lesion with a predilection for the sinonasal tract. Although it was first described in 1983, its etiology remains unknown. Some authors initially attributed EAF to trauma, hypersensitivity, and/or surgical manipulation, while it has been recently suggested to include EAF within the spectrum of IgG4-related systemic diseases. Materials and Methods: We report an uncommon case of idiopathic EAF in a 76-year-old male who developed two bilateral tumefactive masses in the nasal cavities. Results: As the histological examination showed a subepithelial proliferation of fibroblasts along with sclero-hyaline fibrosis around small-sized vessels (an "onion skin-like" pattern) and an eosinophils-rich inflammatory infiltrate, a diagnosis of EAF was rendered. The differential diagnosis included granuloma faciale, Wegener's granulomatosis, and Churg-Strauss syndrome. Conclusions: Pathologists should be aware of the possibility that this lesion can be part of the wide spectrum of IgG4-related systemic diseases by performing IgG4 investigations to assess adherence to IgG4-related systemic disease criteria.

Surgical Repair of Acquired Oronasal Fistulas Secondary to Periodontal Disease in Dogs Using a Flexible Bone Membrane: A Case Series.

Oronasal fistulas are sequelae to periodontal disease in dogs. Previous case series have described the use of auricular cartilage as a type of membrane to help with surgical repair of oronasal fistulas. This case series explores the use of a commercially available flexible bone membrane in the surgical repair of ten acquired oronasal fistulas in dogs. The use of the flexible bone membrane did not necessarily improve the surgical outcomes in these cases; however, larger controlled trials are necessary to further evaluate its use.

Sinonasal Issues After Maxillectomy With Free Flap Reconstruction: Incidence and Clinical Approach.

OBJECTIVE: To characterize the clinical features associated with sinonasal complaints after maxillectomy with free flap reconstruction as well as propose a screening and treatment algorithm. METHODS: Retrospective review of patients who underwent maxillectomy and free flap reconstruction at a tertiary care center. RESULTS: Fifty-eight patients were included, 25 (43.1%) of them had documented sinonasal complaints postoperatively. Eleven patients subsequently underwent revision surgery for sinonasal complaints. Among the 25 patients with sinonasal complaints, 22 patients (88.0%) had nasal crusting, 17 (68.0%) had nasal obstruction, 12 (48.0%) had rhinorrhea, 9 (36.0%) had facial pain or pressure, and 7 (28.0%) had foul odor. Twenty-two patients (88.0%) had multiple sinonasal complaints. There was a higher incidence of both sinonasal complaints and surgical intervention in patients who underwent adjuvant radiation, but this was not statistically significant (47.7% vs 28.6%, P = .235; 29.4% vs 7.1%, P = .265). CONCLUSIONS: Sinonasal complaints are common following free flap reconstruction for a maxillectomy defect and should be screened for at postoperative visits, with early referral to a rhinologist for consideration of endoscopic sinus surgery. Nonsurgical treatment strategies include large-volume nasal saline irrigations, xylitol irrigations for persistent inflammatory symptoms, and culture-directed antibiotic irrigations for persistent infectious symptoms. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:67-72, 2022.

Double-opposing Z-Plasty Extended with a Pedicled Buccal Fat Pad Flap for Correcting Velopharyngeal Insufficiency after Primary Palatoplasty.

INTRODUCTION: Furlow double-opposing Z-plasty (DOZ) lengthens the soft palate; however, this lengthening is achieved at the expense of increased mucosal flap tension. Thus, its use is limited in patients with severe tension applied on mucosal flap after DOZ. In this study, DOZ was combined with a buccal fat pad (BFP) flap to maximize palatal lengthening and muscle repositioning. METHODS: This study included patients who underwent surgical correction for velopharyngeal insufficiency between December 2016 and February 2019. Patients with more than moderate degree hypernasality following primary palatoplasty were included in the study. Patients younger than 4 years of age, those with a submucous cleft palate, or syndromic patients were excluded. Speech outcomes were investigated for those who underwent DOZ only (DOZ group, n = 17) and those in whom a BFP was used (BFP group, n = 15) pre- and postoperatively. The velopharyngeal gaps between the uvula and pharyngeal wall were measured before and immediately after surgery to estimate the palatal length. RESULTS: Most patients who received a BFP showed improvement in hypernasality. However, the hypernasality of the DOZ group was more severe than that of the BFP group (p = 0.023). The extent of palatal lengthening was 4.4 ± 1.7 mm and 7.5 ± 2.1 mm in the DOZ and BFP groups, respectively (p = 0.001). CONCLUSIONS: BFPs reduced the tension of the DOZ mucosal flap and maximized palatal lengthening and muscle repositioning. They promoted velopharyngeal closure in patients with moderate and moderate-to-severe velopharyngeal insufficiency. Hence, our method improves the surgical outcomes of patients with velopharyngeal insufficiency after primary palatoplasty.

Sinonasal quality of life in patients after an endoscopic endonasal surgery of a sellar tumour.

Endoscopic endonasal approach uses the nasal cavity and paranasal sinuses to access the cranial base and may be a source of post-surgical morbidity in many patients with a sellar tumour. The objective of the presented study was to evaluate sinonasal quality of life and assess the effect of chosen reconstruction of the cranial base on the final condition. 65 patients, 33 male and 32 female who underwent an endoscopic endonasal surgery due to sellar expansion, were included into this prospective study. Sinonasal quality of life was evaluated using the Sinonasal Outcome Test-22 (SNOT-22) questionnaire before the surgery and six months after the surgery. Sinonasal quality of life was evaluated for the total cohort of patients and for patients after reconstruction (fascia lata, muscle) and without reconstruction. The minimum follow-up period was one year. There was no significant difference between the score (SNOT-22) before the surgery (average 14.4 points) and after the surgery (average 17.5 points), p = 0.067 in the whole cohort. Statistically significant differences were found in the following items-the need to blow nose, nasal congestion, loss of smell and taste, and thick discharge from the nose. The comparison of subgroups with and without the reconstruction yielded statistically significant differences in favour of patients with reconstruction in the following items-lack of high-quality sleep and feeling exhaustion. The endoscopic endonasal approach in patients with a sellar tumour is a gentle method with minimal effects on sinonasal quality of life over a period longer than six months. The most common complaints are the need to blow nose, nasal congestion, loss of smell and taste, and thick discharge from the nose. Cranial base reconstruction using the muscle and fascia lata seems to be a potential factor positively influencing sinonasal quality of life.

Prevention and management of oronasal fistulas.

PURPOSE OF REVIEW: The aim of this article is to present the current opinion on the prevention and management of oronasal fistulas in cleft palate patients. RECENT FINDINGS: Though cleft palate repair has seen numerous modifications and improvements, oronasal fistulas remain one of the most common complications of palatoplasty. There are various techniques available for preventing and managing this complication. SUMMARY: Oronasal fistulas can be minimized by employing proper principles for palatoplasty. Once a fistula occurs, the repair technique should be appropriate for the fistula type. Oronasal fistula classifications, various repair techniques, tissue adjuncts, and biomaterials used in both the primary palate repair and oronasal fistula repair are discussed in this review.

Analysis of nasal air conditioning in subjects with unilateral cleft lip nasal deformity.

This study evaluated the impact of unilateral cleft lip nasal deformity (uCLND) on the ability of the nasal passages to warm and humidify inspired environmental air using computational fluid dynamics (CFD) modeling. Nasal air conditioning was simulated at resting inspiration in ten individuals with uCLND and seven individuals with normal anatomy. The overall heat and water transfer through nasal mucosa was significantly greater (p = 0.02 for both heat and moisture fluxes) on the non-cleft side than on the cleft side. Unilateral median and interquartile range (IQR) for heat flux (W/m2) was 190.3 (IQR 59.9) on the non-cleft side, 160.9 (IQR 105.0) on the cleft side, and 170.7 (IQR 87.8) for normal subjects. For moisture flux (mg/(s·m2), they were 357.4 (IQR 112.9), 298.7 (IQR 200.3) and 320.8 (IQR 173.0), respectively. Significant differences of SAHF50 between cleft side of uCLND and normal existed except for anterior region. Nevertheless, air conditioning ability in subjects with uCLND was generally comparable to that of normal subjects.

Comfort rules for face masks among healthcare workers during COVID-19 spread.

BACKGROUND: The outbreak of Coronavirus disease 2019 (COVID-19) made imperative the use of protective devices as a source control tool. As there is no definite antiviral treatment and effective vaccine, the only efficient means of protecting and mitigating infectious contagion has been the use of personal protective equipment, especially by healthcare workers. However, masks affect the humidification process of inhaled air, possibly leading to a basal inflammatory state of the upper airways. STUDY DESIGN: This is a single-center observational study conducted at the University Hospital of Catania from April 1, 2020, to June 31, 2020. METHODS: We analyzed the role of protective masks on the elimination of upper airways complaints in healthcare workers of the University Hospital of Catania. We evaluated 277 subjects through a self-administered 17 item questionnaire based on respiratory, work performance and health-related quality of life domains. RESULTS: A higher prevalence of nasal and ocular symptoms, perceived reduced work performance, difficulty in concentrating, and sleep disorders were found. After two weeks adhering to a list of good practices that we recommended, significant reversibility of the symptoms investigated and work performance enhancement were observed. CONCLUSIONS: Despite clinical complaints related to personal protective equipment, effective amelioration through usage rules is easily obtained. Given the essential use of protective masks, healthcare workers have to adhere to appropriate work and safety prevention rules.

Self-reported work activities, eye, nose, and throat symptoms, and respiratory health outcomes among an industrial hog operation worker cohort, North Carolina, USA.

INTRODUCTION: Respiratory disease among industrial hog operation (IHO) workers is well documented; however, it remains unclear whether specific work activities are more harmful and if personal protective equipment (PPE), as used by workers, can reduce adverse health outcomes. METHODS: IHO workers (n = 103) completed baseline and up to eight bi-weekly study visits. Workers reported typical (baseline) and transient (bi-weekly) work activities, PPE use, and physical health symptoms. Baseline and longitudinal associations were assessed using generalized logistic and fixed-effects logistic regression models, respectively. RESULTS: At baseline, reports of ever versus never drawing pig blood, applying pesticides, and increasing years worked at any IHO were positively associated with reports of eye, nose, and/or throat irritation. Over time, transient exposures, associated with dustiness in barns, cleaning of barns, and pig contact were associated with increased odds of sneezing, headache, and eye or nose irritation, particularly in the highest categories of exposure. When PPE was used, workers had lower odds of symptoms interfering with sleep (odds ratio [OR]: 0.1; 95% confidence interval [CI]: 0.01-0.8), and eye or nose irritation (OR: 0.1; 95% CI: 0.02-0.9). Similarly, when they washed their hands eight times or more per shift (median frequency) versus less frequently, the odds of any respiratory symptom were reduced (OR: 0.3; 95% CI: 0.1-0.8). CONCLUSIONS: In this healthy volunteer worker population, increasingly unfavorable IHO activities were associated with self-reported eye, nose, throat, and respiratory health symptoms. Strong protective associations were seen between PPE use and handwashing and the odds of symptoms, warranting further investigation.

Does the radioactive iodine dose affect smell, taste sensation and nose function?

OBJECTIVE: To detect whether the adverse effects of post-operative radioactive iodine therapy following differentiated thyroid cancer on smell, taste and nasal functions were associated with radioactive iodine dose. METHODS: Fifty-one patients who had undergone total thyroidectomy because of differentiated thyroid cancer were divided into two groups depending on the post-operative radioactive iodine therapy dose: low dose group (50 mCi; 21 patients) and high dose group (100-150 mCi; 30 patients). The Sniffin' Sticks smell test, the Taste Strips test and the 22-item Sino-Nasal Outcome Test were performed on all patients one week before therapy, and at two months and one year following therapy. RESULTS: Statistically significant differences were detected in the Sniffin' Sticks test results, total odour scores, total taste scores and Sino-Nasal Outcome Test results between the assessment time points. There was no statistically significant difference between the low and high dose groups in terms of odour, taste or Sino-Nasal Outcome Test scores either before or after therapy. CONCLUSION: Radioactive iodine therapy has some short- and long-term adverse effects on nasal functions and taste and odour sensations, which affect quality of life. These effects are not dose-dependent.

Unique case of a post-traumatic nasoseptal arteriovenous malformation.

Extracranial manifestation of arteriovenous malformations (AVMs) is uncommon. Nasoseptal AVMs are an even rarer entity. In this case report, we present an interesting and first-of-its-kind case of the development of a left nasoseptal AVM in a 60-year-old man after a fall. This was likely post-traumatic, unlike the usual congenital AVMs described in the literature. The patient was managed conservatively with regular follow-up for the AVM as he was asymptomatic.

Nasal symptoms increase the risk of snoring and snoring increases the risk of nasal symptoms. A longitudinal population study.

PURPOSE: Humans have a preference for nasal breathing during sleep. This 10-year prospective study aimed to determine if nasal symptoms can predict snoring and also if snoring can predict development of nasal symptoms. The hypothesis proposed is that nasal symptoms affect the risk of snoring 10 years later, whereas snoring does not increase the risk of developing nasal symptoms. METHODS: In the cohort study, Respiratory Health in Northern Europe (RHINE), a random population from Denmark, Estonia, Iceland, Norway, and Sweden, born between 1945 and 1973, was investigated by postal questionnaires in 1999-2001 (RHINE II, baseline) and in 2010-2012 (RHINE III, follow-up). The study population consisted of the participants who had answered questions on nasal symptoms such as nasal obstruction, discharge, and sneezing, and also snoring both at baseline and at follow-up (n = 10,112). RESULTS: Nasal symptoms were frequent, reported by 48% of the entire population at baseline, with snoring reported by 24%. Nasal symptoms at baseline increased the risk of snoring at follow-up (adj. OR 1.38; 95% CI 1.22-1.58) after adjusting for age, sex, BMI change between baseline and follow-up, and smoking status. Snoring at baseline was associated with an increased risk of developing nasal symptoms at follow-up (adj. OR 1.22; 95% CI 1.02-1.47). CONCLUSION: Nasal symptoms are independent risk factors for development of snoring 10 years later, and surprisingly, snoring is a risk factor for the development of nasal symptoms.

Rhinoliths: Analysis of 24 Interesting Forgotten Foreign Body Cases.

Rhinoliths are petrified masses formed by accumulation of endogenous or exogenous salts around a nidus. Although rarely formed by the body, the most common cause is foreign bodies forgotten in the nose at childhood. Rhinoliths are rare and have been reported as a single case report in the literature. In this study, 24 different and different cases will be analyzed. Twenty-four interesting patients who were operated for rhinolith in the otorhinolaryngology clinic between 2014 and 2019 and were not seen in the literature before were analyzed retrospectively. The characteristics of these patients such as age, sex, additional pathology, foreign body coexistence, type of anesthesia used, and previous surgical status were analyzed. Fourteen patients were male and 10 were female (58.3% male, 41.7% female). The mean age was 30.4 (minimum 2, maximum 62). Twelve of the foreign bodies were on the right and 12 on the left (50%). Foreign body localization was 13 (54.1%) between the inferior turbinate (IT) and septum and 11 (45.9%) between the middle turbinate and septum. Tissue destruction was seen in 12 (50%; 7 septum, 5 IT) patients. Fifteen patients had additional pathology (mostly septum deviation). General anesthesia was used in 14 patients and local anesthesia was used in 10 (58.3%-41.7%) patients. Two patients (n = 2) had rhinoliths due to forgotten nasal packing after surgery and forgotten silicone nasolacrimal tube after dacryocystorhinostomy surgery. Rhinoliths should be considered with unilateral malodorous runny nose and resistant sinusitis attacks. The diagnosis is rigid endoscope and computed tomography imaging. It usually occurs as a result of forgotten foreign bodies. Rhinoliths may also form as a result of forgotten tampon after previous nose or eye surgery.

Effects of intranasal steroids on continuous positive airway pressure compliance among patients with obstructive sleep apnea.

BACKGROUND: Continuous positive airway pressure (CPAP) in the treatment of obstructive sleep apnea can produce troublesome nasal symptoms, especially congestion, which may affect the continuity of using CPAP. Intranasal steroids are often prescribed to reduce these side effects, although few recent studies exist supporting the benefits of this treatment for CPAP-induced nasal side effects. METHODS: Eighty-three patients with OSA were enrolled in a prospective, randomized controlled study. All patients received CPAP treatment and were divided in two groups. The study group was prescribed fluticasone furoate nasal spray 55 µg, and the compliance to CPAP for patients in both groups was recorded by device memory card. Total nasal symptom score was assessed using a questionnaire by direct interview, with follow-up performed at 30 and 90 days after treatment. RESULT: Compliance to CPAP increased in both groups with significantly greater compliance in the intranasal steroid group compared to the control group without intranasal steroid (P value = 0.002, 0.001, and 0.020, respectively) after 90 days of treatment. No difference in nasal symptoms was found between the groups after 30 days of treatment. However, adding an intranasal steroid resulted in decreased rhinorrhea and congestion symptoms (P value < 0.001 and < 0.001) after 90 days of treatment. CONCLUSION: The addition of an intranasal steroid decreased the frequency of nasal symptoms, especially rhinorrhea and congestion, among patients with OSA initiating CPAP therapy and increased compliance to CPAP after 90 days of treatment. TRIAL REGISTRATION: IRB approval ID: R179h Clinical trial ID: TCTR20200715001.