Patient-reported outcome measures in external and endonasal functional septorhinoplasty - A propensity score matching study.

PURPOSE: Patient satisfaction after functional-aesthetic SRP (faSRP) is highly influenced by the cosmetic result of the surgical procedure. Studies that directly evaluate aesthetic success after external and endonasal faSRP are scarce. The objective of this prospective propensity score matching study was to compare patient-reported satisfaction regarding aesthetic perception following faSRP using the external and endonasal approach in a single-institution single-surgeon survey. MATERIALS AND METHODS: Out of 161 patients operated by the senior author between October 2011 and March 2017, propensity score matching (PSM) computed 54 patients each following external (group 1) or endonasal faSRP (group 2). Patients reported their satisfaction with the aesthetic appearance of the nose on a visual analogue scale (VAS, 0-10) and five Likert scale questions using the Utrecht questionnaire three and twelve months after surgery. RESULTS: The mean preoperative VAS score of 3.46 ± 1.06 improved significantly in all patients after faSRP to 4.54 ± 0.38 (F(1.69;157.04) = 634.01, p < 0.001). The VAS increase did not show any correlation to the surgical approach (F(1;93) = 1.12, p = 0.293). The mean aesthetic sum score (5 = low burden up to 25 = high burden) improved significantly from 13.89 ± 3.78 to 8.46 ± 3.63 after three months (t(95) = 14.021, p < 0.001) and remained almost unchanged after 12 months (8.10 ± 3.76; t(98) = 1.450, p = 0.150) irrespective of the surgical approach (F(1,544;143,587) = 0.126, p = 0.829). CONCLUSIONS: Both the external and endonasal faSRP allowed for significant improvement in patient's aesthetic self-assessment of similar extent.

Cartilage Scales Embedded in Fibrin Gel.

Multiple techniques have been described for dorsal nasal augmentation in rhinoplasty. In this article, we review common surgical techniques for raising the dorsum or eliminating dorsal irregularities, by highlighting inherent advantages and disadvantages of each method. Within the past few years, the use of diced cartilage grafts has become the workhorse in this field of interest. To overcome drawbacks of methods based on diced cartilage, we present a new concept for autologous augmentation, using regenerative medicine protocols. A mix of cartilage scales with cartilage pâté was embedded in platelet-rich fibrin (PRF). Since December 2015, a total of 48 patients were treated with this technique. Based on our preliminary results, cartilage scales in PRF appear to be a promising and reliable alternative to existing procedures for dorsal nasal augmentation.

Options for Middle Vault and Dorsum Restoration after Hump Removal in Primary Rhinoplasty.

Prevention of unfavorable sequelae following humpectomy in reduction rhinoplasty by restoration of the middle nasal vault complex today has become imperative in the majority of patients with perhaps the exception of small humps. In general, the techniques used for preservation and reconstruction of these important anatomical structures can be divided into two main categories: spreader graft and spreader flap techniques. Oversimplified spreader graft techniques require donor cartilage, whereas spreader flap techniques use the excess height of the medial portion of the upper lateral cartilages in patients with a cartilaginous hump. In principle, both donor cartilage and preserved upper lateral cartilages usually are positioned along both sides of the dorsal septum to provide natural and harmonious contours as well as to avoid functional impairment (valve collapse). However, the considerable number of publications on this topic attests to existing downsides of both surgical principles. To overcome these shortcomings, we illustrate additional modifications in the application of spreader grafts as well as spreader flaps. However, the main goal of this article is to provide an algorithm helping to decide which technique is best suited to meet the requirements of each individual patient.

Cranial tip suture in nasal tip contouring.

The creation of both a functionally and aesthetically pleasing nasal tip contour is demanding and depends on various different parameters. Typically, procedures are performed with emphasis on narrowing the nasal tip structure. Excisional techniques alone inevitably lead to a reduction in skeletal support and are often prone to unpredictable deformities. But also long-term results of classical suture techniques have shown unfavorable outcomes. Particularly, pinching of the ala and a displacement of the caudal margin of the lateral crus below the cephalic margin belong to this category. A characteristic loss of structural continuity between the domes and the alar lobule and an undesirable shadowing occur. These effects lead to an unnatural appearance of the nasal tip and frequently to impaired nasal breathing. Stability and configuration of the alar cartilages alone do not allow for an adequate evaluation of the nasal tip contour. Rather a three-dimensional approach is required to describe all nasal tip structures. Especially, the rotational angle of the alar surface as well as the longitudinal axis of the lateral crus in relation to cranial septum should be considered in the three-dimensional analysis. Taking the various parameters into account, the authors present new aspects in nasal tip surgery which contribute to the creation of a functionally and aesthetically pleasing as well as durable nasal tip contour.

A new classification of spreader flap techniques.

The objective of this study was to introduce various spreader flap technique modifications to adjust the width of the middle nasal vault in patients who underwent rhinoplasties with humpectomy. Decisive modifications of current spreader flap techniques were performed to allow a more natural restoration of the middle nasal vault and the internal nasal valve after humpectomy. Additional steps provide tools to adjust the width and shape of the middle nasal vault according to patients' requirements. The techniques were categorized into "basic spreader flaps," "flaring spreader flaps," "support spreader flaps," and "interrupted spreader flaps." The various spreader flap techniques were used during 576 primary septorhinoplasties in patients with hump noses, hump/crooked noses, or hump/tension noses. The average follow-up was 19 months. Patients who received basic spreader flaps or a flaring spreader flaps tended to show a slightly too wide middle nasal vault, revision surgery was necessary in four of these cases. All other patients showed an appropriate width in the middle nasal vault and an aesthetically pleasing course of the dorsal aesthetic lines. No signs of inverted v deformities or collapse of the internal nasal valve were observed in any of the patients. Patients who had reported impaired nasal breathing preoperatively described clearly improved subjective symptoms. The described techniques appear to be appropriate and highly promising as a supplement to existing procedures for reconstructing the middle nasal vault and internal nasal valves. No additional cartilage grafts are needed.

Significant polyomic and functional upregulation of the PAPP-A/IGFBP-4/5/IGF-1 axis in chronic rhinosinusitis with nasal polyps.

BACKGROUND: Chronic rhinosinusitis with nasal polyps (CRSwNP) is associated with epithelial expansion and polyp survival. However, the molecular mechanism of this aberrant proliferation is unclear. The purpose of this study was to interrogate derangements of the pappalysin-A/insulin-like growth factor binding protein/insulin-like growth factor-1 (PAPP-A/IGFBP-4/5/IGF-1 axis) as a major contributing factor to polyp growth in CRSwNP. METHODS: Matched tissue and exosomal proteomic arrays including PAPP-A, IGFBP-4, IGFBP-5, and IGF-1 were quantified using aptamer-based methods/Western blots for proteomic analysis and whole-transcriptome sequencing/quantitative polymerase chain reaction (qPCR) for transcriptomic analysis in CRSwNP and control patients. Functional PAPP-A assays were then performed in both tissue and exosomes (set 1: n = 20 per group; validation set 2: n = 26 per group). RESULTS: Tissue and exosomal PAPP-A was significantly overexpressed in CRSwNP compared to controls on both a transcriptomic and proteomic level (p < 0.0001). Known inhibitors of PAPP-A (stanniocalcin-1/-2) were significantly downregulated (p < 0.0001) as were PAPP-A cleavage products (IGFBP-5 p < 0.0001). PAPP-A function was shown to be increased 5-fold to 6-fold in tissue and exosomes. CONCLUSION: Upregulated tissue and exosomal PAPP-A signaling is significantly associated with CRSwNP and may be an important factor in the promotion of epithelial proliferation and polyp growth. These data lend further support to the emerging concept of exosomal functional and polyomic analyses as a method to study sinonasal pathology.

Nasolabial symmetry following Tennison-Randall lip repair: a three-dimensional approach in 10-year-old patients with unilateral clefts of lip, alveolus and palate.

AIM: To assess the degree of facial symmetry in patients suffering from unilateral cleft lip, alveolus and palate (UCLAP) by determining differences between the cleft and the non-cleft hemifaces from 3D surface data. PATIENTS AND METHODS: In twenty-two 10-year-old UCLAP patients, who had the lip repaired using the Tennison-Randall technique and did not undergo further revisional surgery, differences were determined between landmarks, surface areas of the upper lip vermilion and nostrils and virtual volumes of midface, nose and upper lip for cleft and non-cleft sides, separately, after having established a plane of symmetry calculated from optical 3D facial surface data. RESULTS: Statistically significant differences could be found between cleft and non-cleft sides for the nasal landmarks G(lat), G(sup) and La(med), the nostril angle and the virtual volume of the nose (p(Glat)=0.011, p(Gsup)<0.0005, p(Lamed)=0.002, p(nostril angle)=0.036 and p(nose volume)<0.0005, resp.). CONCLUSION: Analysis of 3D data shows that complete nasal symmetry is difficult to achieve with Tennison-Randall's lip repair without revisional surgery. Further trials on larger populations of patients will allow a more comprehensive and consistent analysis of the consequence of different methods for cp repair in order to identify the techniques with the best outcome in terms of facial symmetry.

Sperm protein 17 expression defines 2 subsets of primary esthesioneuroblastoma.

Esthesioneuroblastomas (ENBs) are rare malignant tumors of the nasal vault, the origin, diagnosis, and management of which are still subjects of discussion. That there is no related prognostic factor or generally recognized therapeutic regimen highlights the need for further analyses of its underlying biologic features and investigations of new marker proteins that allow more reliable clinical testing. We here show that sperm protein 17 (Sp17) is expressed in the ciliated cells of the normal olfactory epithelium and in a proportion of primary ENB lesions. We found an association between Sp17 expression and metastases at relapse (P = .035), chromogranin expression (P = .014), and a female sex prevalence. A statistically nonsignificant relation was found between Sp17 and S-100, synaptophysin, and neurofilament expression. No correlation was also found between Sp17 expression and the proliferative capacity of the lesion that was evaluated by Ki-67 immunohistochemistry. The results of this study show the usefulness of Sp17 as a means of discriminating 2 subsets of primary ENB lesions and seem to suggest the existence of 2 distinct cell pathways in their origin and development.

Rhabdomyosarcomas of the nose and paranasal sinuses: treatment results in 15 cases.

OBJECTIVE: Primary rhabdomyosarcomas (RMS) of the nose and the paranasal sinuses occur very rarely. Treatment of these tumors usually is conducted according to standardized therapy protocols like the German Cooperative Soft Tissue Sarcoma Study (CWS) or the Intergroup Rhabdomyosarcoma Study (IRS). The role of surgery still remains controversial. STUDY DESIGN AND SETTING: A retrospective analysis of 15 patients with an RMS of the nose or paranasal sinuses treated between 1979 and 2000 is presented. Patients' age ranged from 2 to 60 years, with an average of 22 years. Histologic subtypes encompassed 9 embryonal (e) and 6 alveolar (a) RMS. Resection of the tumor with subsequent radiochemotherapy (RCT) was performed in 6 cases, and primary RCT, in 9 cases. The average duration of follow-up was 4 years and 10 months. RESULTS: Overall 5-year survival was 40%. In the patient group subjected to tumor resection with subsequent RCT, 5-year survival was 66%, compared with 33% after exclusive primary RCT. With respect to histologic subtype, 5-year survival was 55% for eRMS, as compared with 33% for aRMS. Moreover, infiltration of the skull base and the presence of a residual tumor after primary therapy constituted factors associated with an unfavorable clinical course. CONCLUSIONS: Surgical removal of tumor with subsequent radiochemotherapy can be recommended if a complete resection and functionally and cosmetically satisfactory results appear possible. Patients with eRMS showed an overall more favorable clinical course than patients with aRMS.

New endoscopic instruments for paranasal sinus surgery.

BACKGROUND: Minimally invasive endoscopic and microscopic procedures represent state of the art paranasal sinus surgery techniques in both diagnostic and surgical fields. To combine favorable aspects of both techniques, we evaluated the clinical applicability and effectiveness of multifunctional microendoscopes, providing multiple features to ensure highest accuracy and surveillance when performing crucial steps in paranasal sinus surgery. METHODS: The study included both anatomic experiments on cadaveric heads and clinical tests on patients undergoing routine paranasal surgery. The systems applicability was evaluated in procedures approaching the frontal and sphenoid sinus. Three different endoscopes, 2 straight and the other 1 with a 90 degrees angle, were tested. They integrate canals for flushing and suction and a working canal for either drilling or obtaining biopsies with a miniaturized forceps. For stereotactic feedback, the applicability in combination with a computer-navigation system was evaluated. RESULTS: Anatomic tests were performed to optimize illumination and to test drilling features and forceps biopsies. In all cases, the frontal sinus ostium and the sphenoid sinus anterior wall was easily identified and enlarged by drilling under visual and stereotactic control. Continuous suction and irrigation ensured a constant visual surveillance by removing drilling debris and blood. Best suited for multifunctional endoscopic surgery were drill heads with a cylinder shape, for placing bore holes along the Z axis, and spherical drill heads, for furbishing and enlarging drill holes. CONCLUSION: These new instruments have proven their applicability in paranasal sinus surgery. Multifunctional endoscopic procedures were deemed best suited for maneuvers requiring highest precision, such as the surgery of the frontal and sphenoid sinus.

Spreader flaps for middle vault contour and stabilization.

Nasal hump excision is common during septorhinoplasty. Without appropriate restoration of the middle nasal vault, cosmetic and functional problems may ensue. Recently, spreader flaps have become an established alternative to traditional spreader grafts. Typical indications include primary rhinoplasty patients with hump noses, hump/tension noses, and moderately hooked or crooked noses. When suitable patients are selected, spreader flaps and their modifications represent a reliable alternative to the standard spreader graft, and when all of the necessary prerequisites are met, this technique obviates the need for additional cartilage grafting in most cases.

Role of ultrasonography in the detection of a subperiosteal abscess secondary to mastoiditis in pediatric patients.

The aim of the study described here was to evaluate experience in the diagnosis of a subperiosteal abscess secondary to mastoiditis by means of ultrasound. Ten consecutive cases in which an ultrasound examination of the retro-auricular region was performed for suspected mastoiditis were identified. In nine cases, we found a poorly demarcated, inhomogeneous, irregular, poorly perfused lesion abutting the outer table of the cranial vault, with elevation of the outer periosteum and a clearly delineated defect of the cortical layer. In one case, there was additional invasion of the insertion of the sternocleidomastoid muscle on the mastoid process of the temporal bone, raising the suspicion of Bezold mastoiditis. Ultrasound may help in selecting patients for further imaging and might spare computer tomography, especially in sensitive patient groups such as children and pregnant women, if a defect of the outer cortex of the temporal bone can be excluded with certainty.

Surgical application of a new robotic system for paranasal sinus surgery.

The applicability of a robotic system for fully automated surgical procedures approaching the sphenoid sinus is evaluated. An integrated robotic system, A73, for computer navigation-guided, fully automated, and telemanipulation robotic performance is described. Details of the system comprising newly designed surgical instruments for robotic operations and preoperative planning protocols are provided. Experiments with an operational accuracy of less than 1 mm were followed by surgical tests, in which the results of fully automated and telemanipulation performances on 5 cadaveric heads are seen. The A73 system has been successfully used for a reproducible and accurate resection of the anterior wall of the sphenoid sinus. Therefore, we conclude that this system is suited for further testing toward approaching fully automated and more complex procedures of paranasal surgery.

Ultrasonographic evaluation of calcification patterns in costal cartilage: implications for rib graft harvesting.

IMPORTANCE: Complex augmentation rhinoplasty often requires the use of cartilaginous grafts, especially in revision surgery. When using costal cartilage, the possibility of inadequate cartilage material because of excessive calcification must always be kept in mind. Furthermore, cartilage may be harvested but found to be not ideal, causing unsatisfying results. OBJECTIVE: To report our experience with the use of preoperative ultrasonographic (US) examinations for quality analysis of costal cartilage. DESIGN, SETTING, AND PARTICIPANTS: In an academic research setting, US imaging of the anterior rib cage was performed before 83 revision rhinoplasties requiring costal cartilage grafting. MAIN OUTCOMES AND MEASURES: Cartilage volume, quality, sex-specific calcification patterns, and the location of hidden calcification islands within viable cartilage were recorded. RESULTS: Two different calcification patterns, 1 central and 1 peripheral, were identified. CONCLUSIONS AND RELEVANCE: We found this cost-effective technique to be a valuable tool for easy preoperative cartilage assessment. Furthermore, US screening guides the surgeon to areas of harvestable cartilage and to cartilage that is best suited for rhinoplasty in terms of distribution patterns of calcification areas. LEVEL OF EVIDENCE: NA.

Intra-operative image update: first experiences with new software in computer-assisted sinus surgery.

BACKGROUND: So far, conventional navigation systems do not provide the opportunity for any modification of acquired image datasets. In particular, the surgical progress in the operating field cannot be visualized unless new imaging scans are performed. METHODS: In a feasibility study, new software creating intra-operative image updates by virtual means was tested in conjunction with conventional navigation. With this new software, surgically removed tissue volumes can be traced and viewed directly within the diagnostic image data. RESULTS AND CONCLUSIONS: The new software represents an interesting and helpful amendment to conventional computer-assisted surgery in selected cases. During surgical procedures around bony structures, the surgeon gets an accurate virtual image update of the surgical progress in the operating field and the amount of tissue removed. However, in cases where mobile structures are present or soft tissue shifts are expected, this feature seems to be suitable only to a limited extent.

A new mechatronic assistance system for the neurosurgical operating theatre: implementation, assessment of accuracy and application concepts.

OBJECTIVE: To introduce a new robotic system to the field of neurosurgery and report on a preliminary assessment of accuracy as well as on envisioned application concepts. Based on experience with another system (Evolution 1, URS Inc., Schwerin, Germany), technical advancements are discussed. MATERIAL/METHODS: The basic module is an industrial 6 degrees of freedom robotic arm with a modified control element. The system combines frameless stereotaxy, robotics, and endoscopy. The robotic reproducibility error and the overall error were evaluated. For accuracy testing CT markers were placed on a cadaveric head and pinpointed with the robot's tool tip, both fully automated and telemanipulatory. Applicability in a clinical setting, user friendliness, safety and flexibility were assessed. RESULTS: The new system is suitable for use in the neurosurgical operating theatre. Hard- and software are user-friendly and flexible. The mean reproducibility error was 0.052-0.062 mm, the mean overall error was 0.816 mm. The system is less cumbersome and much easier to use than the Evolution 1. CONCLUSIONS: With its user-friendly interface and reliable safety features, its high application accuracy and flexibility, the new system is a versatile robotic platform for various neurosurgical applications. Adaptations for different applications are currently being realized.

Determination of facial symmetry in unilateral cleft lip and palate patients from three-dimensional data: technical report and assessment of measurement errors.

OBJECTIVE: To assess measurement errors of a novel technique for the three-dimensional determination of the degree of facial symmetry in patients suffering from unilateral cleft lip and palate malformations. DESIGN: Technical report, reliability study. SETTING: Cleft Lip and Palate Center of the University of Erlangen-Nuremberg, Erlangen, Germany. PATIENTS: The three-dimensional facial surface data of five 10-year-old unilateral cleft lip and palate patients were subjected to the analysis. Distances, angles, surface areas, and volumes were assessed twice. MAIN OUTCOME MEASURES: Calculations were made for method error, intraclass correlation coefficient, and repeatability of the measurements of distances, angles, surface areas, and volumes. RESULTS: The method errors were less than 1 mm for distances and less than 1.5 degrees for angles. The intraclass correlation coefficients showed values greater than .90 for all parameters. The repeatability values were comparable for cleft and noncleft sides. CONCLUSION: The small method errors, high intraclass correlation coefficients, and comparable repeatability values for cleft and noncleft sides reveal that the new technique is appropriate for clinical use.