Cocaine-associated Eustachian tube stenosis causing chronic 'glue ear': a rare cocaine-induced destructive lesion

BACKGROUND

Cocaine is one of the most used recreational drugs. Whilst medical uses exist, chronic recreational nasal use of cocaine is associated with progressive destruction of the osseocartilaginous structures of the nose, sinuses and palate - termed cocaine-induced midline destructive lesions.

CASE REPORT

A 43-year-old male with a history of chronic cocaine use, presented with conductive hearing loss and unilateral middle-ear effusion. Examination under anaesthesia revealed a completely stenosed left Eustachian tube orifice with intra-nasal adhesions. The adhesions were divided and the hearing loss was treated conservatively with hearing aids. Whilst intra-nasal cocaine-induced midline destructive lesions are a well-described condition, this is the first known report of Eustachian tube stenosis associated with cocaine use.

CONCLUSION

This unique report highlights the importance of thorough history-taking, rhinological and otological examination, and audiometric testing when assessing patients with a history of chronic cocaine use. This paper demonstrates the complexity of managing hearing loss in such cases, with multiple conservative and surgical options available.

The effect of nasal douching by hypertonic 2.3 per cent sea water with algae extracts on the concentration of epidermal growth factor, transforming growth factor-α and interleukin-8 in nasal secretions of patients with nasal polyposis following endoscopic surgical treatment

OBJECTIVE

To investigate epidermal growth factor, transforming growth factor-α and interleukin-8 production in nasal mucosa irrigated with hypertonic 2.3 per cent solution with algae extracts, in comparison to 0.9 per cent NaCl during the first two weeks after surgery for nasal polyposis, in relation to symptoms and local findings.

METHODS

This prospective study included 20 nasal polyposis patients postoperatively irrigated with hypertonic solution and 20 nasal polyposis patients postoperatively irrigated with isotonic solution. We evaluated nasal symptom score, endoscopic score and mediator levels in nasal secretions before and after irrigation.

RESULTS

Following treatment, nasal symptom score and endoscopic score were significantly lower in the hypertonic solution group (p = 0.023; p < 0.001, respectively). The increase in the epidermal growth factor and the decrease in the transforming growth factor-α and interleukin-8 concentration were higher in the hypertonic group (p < 0.001 for all mediators).

CONCLUSION

Irrigation with a hypertonic solution was found to be more effective than an isotonic solution in nasal mucosa reparation.

Spontaneous abscess of the nasal septum in children: a 10-year series

BACKGROUND

This paper reports a 10-year series of spontaneous nasal septal abscesses in immune-competent children, with suggestions for optimal management.

METHODS

A retrospective case note review was conducted of children undergoing an operation for incision and drainage of nasal septal abscesses between 2013 and 2023.

RESULTS

Six children were identified via electronic hospital records during the 10-year review period, five with a spontaneous abscess. The children were aged 10-14 years. All were immunocompetent and none had active sinus infection. The most common presenting features were nasal swelling, facial swelling, headache, nasal congestion and fever. The most common bacterial isolate was Staphylococcus aureus. All children received prompt surgical drainage and intravenous antibiotic therapy. Complications were seen in three children, with one child developing significant intracranial complications.

CONCLUSION

To our knowledge, this is the first series of spontaneous nasal septal abscesses in immunocompetent children. The high prevalence of Staphylococcus aureus suggests spread from the nasal mucosa or vestibule. Early recognition, computed tomography scanning, surgical drainage and antibiotic therapy are the mainstays of treatment, to prevent potentially life-threatening complications.

Long-Term Clinical Outcomes in Patients with Chronic Rhinosinusitis with Nasal Polyps Associated with Expanded Types of Endoscopic Sinus Surgery

(1) Background: Surgical criteria for chronic rhinosinusitis with nasal polyps (CRSwNP) remain unresolved. This study addresses these discrepancies by comparing the clinical outcomes of expanded-functional endoscopic sinus surgeries (E-FESS) with more-limited FESS (L-FESS). (2) Methods: A database was analyzed retrospectively to compare surgical outcomes in CRSwNP patients who underwent E-FESS versus those subjected to L-FESS. Quality of life, endoscopic and radiological outcomes were compared at the baseline and two years after surgery. The clinical status of the responder was defined when a minimal clinically important difference of 12 points in SNOT-22 change was achieved. (3) Results: A total of 274 patients met the inclusion criteria and were analyzed; 111 underwent E-FESS and 163 were subjected to L-FESS. Both groups exhibited significant clinical improvements, although a greater magnitude of change in SNOT-22 (14.8 ± 4.8, p = 0.002) was shown after E-FESS. Higher significant improvements for endoscopic and radiological scores and lower surgical revision rates were also noted in the E-FESS group. (4) Conclusions: E-FESS provides better clinical outcomes and reduced revision surgery rates when compared to L-FESS in CRSwNP patients two years after surgery, irrespective of any comorbidity. Further randomized prospective studies are needed to comprehensively contrast these results.

Improved quality of life in patients with chronic rhinosinusitis with nasal polyps associated with expanded types of endoscopic sinus surgery: A 2-year retrospective study

KEY POINTS

Expanded types of functional endoscopic sinus surgery (FESS) significantly improve quality of life and reduce revision surgeries rates, supporting their early application for moderate-to-severe cases. Minimal clinically important difference may play as a crucial role in defining surgical treatment response (i.e., responder and super-responder conditions). Expanded FESS benefits patients with chronic rhinosinusitis with nasal polyps but more data are required to have a clearer understanding of its uses due to varied approaches and reported outcomes in the literature.

Angiomyolipoma Originating From the Nasal Vestibule: A Case Report

Angiomyolipoma is a benign, mesenchymal, hamartomatous lesion often described in the kidney and may be associated with tuberous sclerosis. Nasal angiomyolipoma is an extremely rare tumor with fewer than 20 cases reported in the literature. We report a case of angiomyolipoma arising in the right nasal vestibule in a 68-year-old male with mild, recurrent right-sided epistaxis, and nasal obstruction. With the exception of arterial hypertension, the patient did not have any comorbidities. Gross examination showed a well-circumscribed, lobulated mass. On the microscopic level, it was composed of mature smooth muscle cells, thick-walled blood vessels of varying sizes, and islands of mature adipose tissue. Angiomyolipoma should be considered as a differential diagnosis for unilateral nasal masses, especially those situated in the nasal vestibule.

Clinically important estimates of improvement after septoplasty

OBJECTIVE

A statistically significant improvement in nasal obstruction ratings following septoplasty is not necessarily clinically important. This study aimed to establish useful measures of septoplasty success, namely the minimal clinically important difference and the desirable clinically important difference.

METHODS

Patients rated nasal obstruction on a 0-100 visual analogue scale pre-operatively and at 5.5 months post-operatively. Global outcome rating (completely, much, or somewhat improved, unchanged or worse) served as the anchor post-operatively. Minimal clinically important difference is the visual analogue scale value between 'somewhat improved' and 'unchanged', and the desirable clinically important difference is that between 'much' and 'somewhat improved'.

RESULTS

Statistically significant improvement in visual analogue scale scores was not clinically important. The minimal clinically important difference (daytime value of 9.5) represented 15.1 per cent improvement and the desirable clinically important difference (daytime value of 28.5) represented 45.2 per cent, without gender or age differences.

CONCLUSION

Clinical success can be defined using a minimal clinically important difference of 15 per cent improvement over a patient's baseline value. Other studies' ratings of 'satisfactory' outcome coincided with a desirable clinically important difference of 45 per cent over baseline. These values are suggested as relevant indicators of septoplasty success.

Functional nasal surgery in the office-based setting

Objective

Nasal obstruction is a very common problem often addressed by functional nasal surgery. Increasingly, these procedures are being performed in the office setting secondary to decreased down time, cost, and obviation of general anesthesia. Our goal with this review is to discuss how to appropriately select patients for office-based procedures, what procedures may be considered, and current outcomes with in-office functional nasal surgery.

Data Sources

PubMed, Scopus, Google Scholar.

Methods

Research databases were searched for articles discussing techniques for performing functional nasal surgery in an office setting, and outcomes of various in-office functional nasal procedures.

Results

Studies found and included in this review discuss many aspects of office-based functional nasal surgery, including practical points on patient selection and office set-up, what procedures can safely be performed, and outcomes of different techniques to address specific problems. Broadly, procedures amenable to performance in the office address the internal and external nasal valves, the nasal septum, and the inferior turbinates.

Conclusion

A wide range of techniques to aaddress the nasal valves, septum, and inferior turbinates can be performed in a safe and effective manner without the need for an operative suite.

The Effect of Topical Tranexamic Acid in Endoscopic Sinus Surgery: A Triple Blind Randomized Clinical Trial

OBJECTIVE

Our aim is to evaluate the effect of topical tranexamic acid (TA) on bleeding and surgical quality field in the functional endoscopic sinus surgery (FESS).

METHODS

A total of 74 patients who underwent FESS due to chronic rhinosinusitis were included. The patients were randomized into 2 groups. TA group (n = 37) received a topical cotton pledget soaked with TA and placebo (PL) group (n = 37) received a pledget soaked with saline solution.

RESULTS

A significant effect was noted for the TA group versus the PL group in the grade 1 of the Boezaart scale at 35 minutes (4 for TA group and no case for PL group). This effect was absent for higher grades. We did not notice a significant effect between the 2 groups at 5 minutes. Blood loss was 359 ml in the TA group versus 441 ml in the PL group. No significant change was observed between the 2 groups concerning the blood parameters. No side effects were reported.

CONCLUSION

Despite its safety when administrated locally and its low cost, TA provides limited effect on quality of surgical field after 35 minutes of the start of FESS in the patients with chronic rhinosinusitis. This effect was absent at the start of the intervention and when analyzing the blood loss and hematologic parameters.

A Comparison of Symptom Improvement and Outcomes After Septoplasty Alone Versus Septoplasty With Turbinoplasty

Background Various causes can lead to nasal obstruction, with the most frequent anatomical cause being deviated nasal septum. It seriously affects patients' quality of life. As a result, septoplasty is performed to enhance the nasal airways. This study aimed to compare the improvement of nasal symptoms following septoplasty with or without turbinoplasty and evaluate the surgical outcomes in both different groups. Methodology A retrospective study was conducted at a tertiary hospital among patients who had undergone septoplasty with or without turbinoplasty between 2020 and 2022. Data regarding demographics, clinical features, surgical data, and complications were collected from patient files. The Nasal Obstruction Symptom Evaluation (NOSE) scale score was assessed through structured interviews. Results In our analysis of 209 patients who underwent surgery for deviated nasal septum, septoplasty was done in 110 (52.6%) patients, whereas the remaining 99 (47.4%) underwent septoplasty with turbinoplasty. The mean NOSE score was found to be 32.94 ± 35.67%. Patients who underwent septoplasty alone significantly showed higher mean scores (56.36 ± 34.62%) compared to those who underwent septoplasty with turbinoplasty (11.14 ± 18.93%) (p < 0.001). The long-term complications showed revision surgery was done in 13 patients, which was comparatively more often done in patients who underwent a septoplasty. Other long-term complications were found to be significantly higher in patients who underwent septoplasty (76.9%) compared to those who underwent septoplasty with turbinoplasty (23.1%). Conclusions Patients who underwent additional turbinoplasty experienced an improvement in nasal symptoms than those who underwent septoplasty alone. In addition, more long-term complications were noted in patients who underwent septoplasty alone.

Maxillary Sinus Lobular Capillary Hemangioma in a 15-Year-Old Boy

Lobular capillary hemangioma (LCH) is a benign capillary proliferation with a microscopically distinctive lobular architecture, composed of small to medium-sized vessels of capillary type. Rarely, it originates from the mucosa of the nasal cavity, most frequently from the anterior nasal septum, turbinates, and nasal vestibule. Etiology is unclear, but previous investigations suggest that this lesion is associated with injury, hormonal factors, some viral infections, and therapy with some drugs. We present a case of LCH arising from the medial wall of the maxillary sinus in a 15-year-old boy, which was completely excised by preoperative embolization and endoscopic sinus surgery. To our knowledge, this is the second reported case of an LCH originating from the maxillary antrum. Etiology, pathogenesis, diagnosis, and treatment modalities of LCH were also discussed.

Outcomes of Closed versus Open Rhinoplasty: A Systematic Review

Open and closed rhinoplasty are two main approaches to perform nasal modifications. According to current literature, there is no current consensus among plastic surgeons and otolaryngologists on which technique is preferred in terms of aesthetic result, complications, and patient satisfaction. This study uses published research to determine whether open or closed rhinoplasty leads to superior patient outcomes. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for systematic reviews were followed and a literature search was conducted in four databases based on our search strategy. Articles were then imported into COVIDENCE where they underwent primary screening and full-text review. Twenty articles were selected in this study after 243 articles were screened. There were 4 case series, 12 retrospective cohort studies, 1 prospective cohort study, 1 case–control, and 2 outcomes research. There were three cosmetic studies, eight functional studies, and nine studies that included both cosmetic and functional components. Sixteen studies utilized both open and closed rhinoplasty and four utilized open rhinoplasty. Both techniques demonstrated high patient and provider satisfaction and no advantage was found between techniques. Based on available studies, we cannot conclude if there is a preference between open or closed rhinoplasty in terms of which technique leads to better patient outcomes. Several studies determined that open rhinoplasty and closed rhinoplasty leads to comparative patient satisfaction. To make outcome reporting more reliable and uniform among studies, authors should look to utilize the Nasal Obstruction and Septoplasty Effectiveness scale and the Rhinoplasty Outcome Evaluation.

Applicability of Transnasal Echography for Identification of Internal Carotid Artery

OBJECTIVE

To study the applicability of transnasal echography for the internal carotid artery (ICA) imaging during endoscopic procedures, primarily nasopharyngectomy.

STUDY DESIGN

Non-randomized controlled cohort.

METHODS

The tip of a pediatric transducer for transesophageal echography was inserted into each nostril under endoscopic control and placed in the ipsilateral Rosenmuller's fossa. The ICA's internal diameter and distance between the nasopharyngeal wall and the artery's closest point were measured on each side. Two independent examiners measured the same parameters on the axial plane of the skull base computer tomography (CT). Agreement between CT and echography measurements was estimated by the Bland-Altman approach.

RESULTS

Twenty-seven ICAs (sides) were available for the echography-CT agreement analysis. Inter method agreement for both parameters was similar to the inter examiner agreement for the CT measurements.

CONCLUSIONS

Our first study on endoscopic echography demonstrated that this method is applicable, potentially allowing safer transnasal surgery in the ICA vicinity.

LEVEL OF EVIDENCE

3 Laryngoscope, 2022.

Baska Mask is non-inferior to tracheal tube in preventing airway contamination during controlled ventilation in elective nasal surgeries: A randomised controlled trial

Background and Aims:

Baska Mask, a newly designed third-generation supraglottic device, has a sump where the pharyngeal secretions can collect and be suctioned out continuously. We aimed to study the effectiveness of Baska Mask in preventing airway contamination during nasal surgeries. Our primary objective was to assess airway soiling using fibreoptic bronchoscopy. Total airway manipulation time, haemodynamic parameters during device insertion and post-operative oro-pharyngeal morbidities were the secondary objectives.

Methods:

Eighty-four participants undergoing nasal surgeries were randomised to either have their airway maintained with Baska Mask (Group-BM) or Endotracheal tube (Group-TT). Fibreoptic bronchoscopy was performed at the end of the surgery and the airway was inspected for signs of contamination. Total airway manipulation time, haemodynamic parameters during device insertion and post-operative oro-pharyngeal morbidities were also assessed. Unpaired Student's t test was used for parametric data and Chi-square test for nonparametric data. One-way analysis of variance (ANOVA) was used for the intra-group analysis of haemodynamic data.

Results:

Tracheal contamination was not observed in any patient in either group. Time taken for device insertion (Group TT: 24.24 ± 6.86 s vs. Group BM: 24.22 ± 7.3 s; P = 0.97) was similar in both the groups. The total airway manipulation time was 2 min longer in Group-TT (P = 0.000) due to additional time taken for insertion of throat pack. Haemodynamic parameters during device insertion were stable and post-operative oro-pharyngeal morbidities were fewer with Baska Mask when compared to Tracheal tube.

Conclusions:

Baska Mask is non-inferior to tracheal tube in preventing tracheal contamination in patients undergoing nasal surgeries.

Treatment of congenital nasolacrimal duct cyst: the role of endoscopic marsupialisation

Objective

Congenital nasolacrimal duct cyst (NLDC) is a rare disorder, which can present with ophthalmological and nasal signs and symptoms. The authors analyse their personal experience to identify diagnostic criteria for NLDC, which were treated by endoscopic transnasal procedure.

Methods

Clinical records of patients with a diagnosis of NLDC were retrospectively reviewed. All patients underwent rhinoscopy and ophthalmologist evaluation before surgery, whereas imaging was performed in selected cases. All neonates underwent transnasal endoscopic marsupialisation after failure of conservative medical therapy.

Results

Five patients were included in the study. One patient presented bilateral NLDC. In 3 cases, CT scan of the sinus was carried out. A total of 6 marsupialisation procedures were performed and a bi-canalicular lacrimal stent was positioned in 1 case. Complete remission of symptoms was observed in all cases.

Conclusions

Nasal endoscopy is mandatory to diagnose NLDCs, and, in some cases, it can be complemented by radiological procedures. When symptoms persist after systemic and topical therapy, nasal endoscopic marsupialisation is the treatment of choice. This surgical procedure is effective, safe and can be repeated if needed.

Opioid use after endoscopic skull base surgery: A descriptive, prospective, longitudinal cohort study

BACKGROUND

Opioid abuse is a public health crisis and the perioperative period can be a time of first opioid exposure. Little is known about postoperative pain management after endoscopic skull base surgery (ESBS).

METHODS

This investigation was a single-institution, longitudinal, prospective cohort study of adult patients undergoing ESBS between November 2019 and March 2020. Participants completed preoperative questionnaires and were contacted every 48 hours postoperatively to quantify pain and opioid consumption.

RESULTS

A total of 33 patients were enrolled and 28 of 33 patients (85%) underwent ESBS for sellar pathology. Mean total morphine milligram equivalents (MME) consumed was 381.9 ± 476.0. History of a headache disorder (p = 0.025) and previous opioid use within 60 days preoperatively (p < 0.001) were significantly associated with greater opioid use. Mean duration of opioid use was 6.7 ± 5.1 (range, 0-20) days. Headache disorder (p = 0.01), depression (p = 0.03), anxiety (p = 0.03), age ≤46 years (p = 0.029), and previous opioid use (p = 0.008) were all associated with longer mean opioid use. Patients with headache disorder also reported higher mean postoperative pain scores. Fewer than half of the participants required opioids by postoperative day 8. Prescription of nonsteroidal anti-inflammatory drugs at discharge was significantly associated with less outpatient opioid use (p = 0.032). At 2-month follow-up, 37% of patients reported keeping excess opioids.

CONCLUSION

After ESBS, greater total opioid use was significantly associated with history of headaches and previous opioid use within 60 days. Overall, opioid use declined among all patients in the postoperative period, but several factors may contribute to longer duration of use.

Feasibility of Implementing Opioid Stewardship Recommendations for Sinonasal Surgery

OBJECTIVE

The objective of our study was to review the current literature pertaining to perioperative opioids in sinus surgery and to determine the effects of implementing opioid stewardship recommendations in the setting of endoscopic sinonasal surgery.

STUDY DESIGN

Single-institution retrospective case-control study.

SETTING

Academic medical center outpatient area.

METHODS

This retrospective review comprised 163 patients who underwent routine functional endoscopic sinus surgery, septoplasty, and/or inferior turbinate reduction before and after implementation of a standardized pain control regimen based on published opioid stewardship recommendations. The regimen consisted of an oral dose of gabapentin (400 mg) and acetaminophen (1000 mg) at least 30 minutes prior to surgery, absorbable nasal packing soaked in 0.5% tetracaine intraoperatively, and a postoperative regimen of acetaminophen and nonsteroidal anti-inflammatory medications. Tramadol tablets (50 mg) were prescribed postoperatively for breakthrough pain. The primary outcome measure for the study was the average number of hydrocodone equivalents (5 mg) prescribed before and after the new protocol.

RESULTS

The average number of opioid medications prescribed, measured as hydrocodone equivalents (5 mg), decreased from 24.59 preprotocol to 18.08 after the initiation of the new perioperative regimen (P < .001). There was no significant difference between the periods (P > .05) in number of postoperative phone calls regarding pain or in patient satisfaction scores.

CONCLUSION

Opioid stewardship recommendations can be instituted for sinonasal surgery, including multimodal perioperative pain management and substitution of tramadol for breakthrough pain, as a method to decrease the volume of opioids prescribed, without increasing patient phone calls or affecting the likelihood of physician recommendation Press Ganey scores.

Allergies, asthma or hypersensitivity to NSAIDs - are they an equally important risk factor for the development of a specific CRS phenotype?

INTRODUCTION

CRS is a complex systemic disease affecting more than 10% of the population. There are two main types of CRS phenotypes: CRSwNP and CRSsNP. In the Caucasian population, the prevalence of inflammation markers typical of the Th1 profile is observed in CRSsNP, whereas Th2 and Th17 in CRSwNP. Th2 inflammation is observed in the CRSwNP phenotype with concomitant allergies, asthma or hypersensitivity to NSAIDs.

OBJECTIVES

The aim of the study was to evaluate, based on the authors' own material, whether allergies, asthma or hypersensitivity to NSAIDs were a risk factor for the development of a specific CRS phenotype. An attempt was also made to investigate the influence of comorbidities on the extent of sinus endoscopic procedures, which depended on the severity of inflammation.

METHODS

In the years 2006-2015, ESS was performed on 2217 patients with different CRS phenotypes. Patients with an allergy, bronchial asthma and hypersensitivity to NSAIDs were subjected to analysis.

RESULTS

Based on logistic regression, it was found that among the mentioned comorbidities, only asthma (P &lt; 0.0001) and hypersensitivity to NSAIDs (P = 0.0007) significantly affect the occurrence of the phenotype with polyps, whereas the impact of allergies is statistically insignificant (P = 0.1909). The relationship between the type of ESS and CRS phenotypes is statistically significant (P &lt; 0.0001).

CONCLUSIONS

Bronchial asthma and hypersensitivity to NSAIDs have a statistically significant effect on the occurrence of the CRSwNP phenotype. This effect was not observed in allergies. The impact of allergies, asthma and hypersensitivity on the phenotype was observed in the group of patients subjected to the most extensive surgery (ESS 4).

Caudal Septal Division and Batten Graft Application: A Technique to Correct Caudal Septal Deviations

Objective

The aim of the study was to evaluate the surgical outcomes in patients who underwent in one session caudal septal division, strip excision and unilateral bony batten graft procedures, a method described for the correction of caudal septal deviations.

Methods

In this retrospective study, 27 patients with C-shaped caudal septal deviation who underwent endonasal septoplasty using caudal septal division, strip excision and unilateral bony batten grafting in our hospital in the period from August 2014 through October 2018 were reviewed. Patients were included in the study if their pre-operative and post-operative questionnaires and post-operative follow-up data (average follow-up period was 13.9 months) were available in full.

Results

The average age of the 27 patients (6 women and 21 men) was 29.6±12.4 years. Postoperative observations revealed that a straight septum was achieved in 23 patients (85.1%). Average pre- and post-operative Nasal Obstruction Symptom Evaluation (NOSE) scores were 85.1±20.4 and 22.4±4.2, respectively (p<0.0001). Septal hematoma developed in one patient in the postoperative period.

Conclusion

The surgical outcomes of patients in whom we used caudal septal division, strip excision and unilateral bony batten graft to correct caudal septal deviations demonstrated the potential of this technique as an alternative to be used by surgeons.

Does the Change in the Indications of Endoscopic Sinonasal Surgery Continue? Data between 1994-2018

Objective

Endoscopic sinonasal surgery (ESS) has changing over the years in parallel with the developments in endoscopy devices, video-imaging techniques, and surgical instruments. In the present study we investigated whether the indications of patients who underwent surgery over a period of 25 years have accommodated to these changes.

Methods

We retrospectively evaluated 1173 patients who underwent surgery in our clinic from 1994 through 2007, and 954 patients who underwent surgery from 2008 through 2018. The patients were divided into three groups as follows: chronic rhinosinusitis with polyps (CRSwNP), chronic rhinosinusitis without polyps (CRSsNP), and others. The changes in the indications during the first 14 years and the following 11 years were compared, and the results were statistically evaluated.

Results

A significant decrease was observed in the number of patients who underwent surgery following the diagnosis of CRSsNP (p<0.001). In addition, a statistically significant increase was found in CRSwNP (p<0.001) and other (p<0.001) indications.

Conclusion

When ESS indications identified in our clinic were reviewed, it was observed that the increasing trend in CRSwNP rate in the first 14 years continued, there was a significant increase in non-CRS indications in the last 11 years, and there has been an increase in patients with fungal sinusitis, especially in this group.

Squamous cell carcinoma of the nasal cavity: A descriptive analysis of cases from the head and neck 5000 study

OBJECTIVES

This paper aims to provide contemporary epidemiological data on squamous cell carcinoma (SCC) of the nasal cavity, which represents a rare type of head and neck cancer.

DESIGN, SETTING & PARTICIPANTS

A descriptive analysis of people with nasal cavity SCC treated with curative intent from the Head and Neck 5000 study; a multicentre clinical cohort study of people from the UK with head and neck cancer. People with tumours of the nasopharynx, paranasal sinuses and other sub-sites of the head and neck were excluded.

MAIN OUTCOME MEASURES

Demographic data and treatment details are presented for all participants. The main outcomes were overall survival and survival according to categories of characteristics (eg, smoker vs non-smoker); these were explored using Kaplan-Meier plots.

RESULTS

Thirty people with nasal cavity SCC were included in the study, of which most were male (67%) and current or ex-smokers (70%). The majority (70%) presented with early-stage (T1/2, N0) tumours. Cervical lymph node metastases at presentation were rare, occurring in only one person. Nine people died during the follow-up period (30%). Worse survival outcomes were seen in people with moderate or severe co-morbidities.

CONCLUSIONS

This paper provides epidemiological data on nasal cavity SCC in the UK. Patterns of disease and survival outcomes are described, identifying high-risk groups. Further studies should explore whether primary treatment modality alters survival.

Lacrimal Diversion Devices (Sinopsys Lacrimal Stent): Sharing our Experience with Patients with Chronic Rhinosinusitis without Polyposis

Introduction  Chronic rhinosinusitis (CRS) is a highly prevalent pathology in our society. Due to the prevalence of this condition and to the persisting symptoms despite an appropriate medical treatment, surgical techniques are often required. Lately, minimal invasive techniques have been described, such as lacrimal diversion devices (LDDs). This technique offers a fast and convenient choice for delivery of sinus irrigation and topical medication. Objective  We aimed to describe our experience with LDDs and evaluate the safety and effectiveness of the procedure in patients with moderate to severe CRS without nasal polyposis (CRSsNP) and persistent symptomatology despite medical therapy. Methods  A total of 7 patients underwent bilateral lacrimal stents placement in the operating room. A retrospective observational study was conducted. The Sino-Nasal Outcome Test-20 (SNOT-20) survey was performed and the score obtained was compared before and 1 month after the procedure. Results  The LDDs were used for an average of 80 days. During the follow-up, only three patients had a mild complication with the device (granuloma in the punctum, obstruction, and early extrusion). The mean baseline SNOT-20 score dropped significantly ( p  = 0.015) from 25.85 to 11.57 (mean: - 14.29) 1 month after the procedure. Conclusion  According to our experience and results, the use of LDD is a novel, feasible, and less invasive technique to treat refractory CRS. It reduces the risk of mucosal stripping, provides short-term outcomes, and the surgical procedure does not require advanced training in endoscopic sinus surgery. Moreover, it can be performed in-office under local anesthesia or sedation.

Case Report: Massive epistaxis from juvenile angiofibroma in an adolescent with severe haemophilia A

Epistaxis may be profuse in individuals with normal bleeding parameters, but in an individual with haemophilia, it may be life-threatening. It is even more dangerous when epistaxis is caused by an undetected concomitant juvenile angiofibroma, and only one such case has been reported in the English literature. We report another case, of an 18-year-old Filipino adolescent with severe haemophilia A who was referred for repeated massive epistaxis. The epistaxis had been attributed to his haemophilia and managed with nasal packing, multiple blood transfusions and Factor VIII administration. After two years of unsuccessful management, nasal endoscopy was performed for the first time, revealing an intranasal mass. Imaging showed a right intranasal vascular tumour supplied mainly by the right sphenopalatine artery. He subsequently underwent preoperative embolization and endoscopic excision of the tumour with Factor VIII transfused pre-, intra-, and post-operatively, and recombinant Factor VII added post-operatively. Final histopathology was consistent with juvenile angiofibroma. There has been no nasal obstruction or recurrence of epistaxis seven years since the surgery. Clinicians should be more meticulous in assessing epistaxis in any patient with a bleeding disorder and investigate more subtle symptoms such as nasal obstruction. Verification of the source by direct visualization and ancillary diagnostic techniques (such as imaging) when indicated should be the standard of care for all patients presenting with epistaxis, whether or not a concomitant bleeding disorder exists. A high index of suspicion for juvenile angiofibroma should be maintained in adolescent males with epistaxis and nasal obstruction.

Caudal Septal Division and Interposition Batten Graft: A Novel Technique to Correct Caudal Septal Deviation in Septoplasty

BACKGROUND

Correction of caudal septal deviation is a challenging task that may require multiple surgical approaches.

OBJECTIVE

To introduce a novel technique - caudal septal division and interposition batten graft - and evaluate its surgical outcomes in patients undergoing correction of caudal septal deviation.

METHOD

The surgical procedure includes a division of the deviated caudal L-strut preserved after resection of the deviated quadrangular septal cartilage at the central portion. A batten graft made of septal cartilage or bone is interposed between the cut ends of the caudal L-strut, the upper part of which mobilized toward the more concave side of the nasal cavity, and then sutured. The medical records of 29 patients with caudal septal deviation who underwent septoplasty using caudal L-strut division and interposition batten graft technique between January 2016 and March 2018 were retrospectively reviewed. Patient satisfaction and symptom improvement were evaluated by using the Nasal Obstruction Symptoms Evaluation scores. Endoscopic assessment of deviation correction was performed and postoperative complications were analyzed.

RESULTS

Of the 29 patients, 19 (65.5%) answered the telephonic interview. Mean Nasal Obstruction Symptoms Evaluation scores were 62.1 preoperatively and 9.2 postoperatively, exhibiting significant improvement (P < .001). Satisfaction was rated as much improved in 9 (32.0%) patients, improved in 16 (57.0%), unchanged in 2 (7%), and worse in 1 (4%). Records of endoscopic examinations showed that 26 (82.9%) patients had a straight septum, 4 (11.4%) had improved but persisting caudal deviation, and 2 (5.7%) had no available data. Four patients had postoperative complications: 2 had septal abscesses, 1 had wound dehiscence, and 1 had synechia. All of these complications were managed without persistent problems.

CONCLUSIONS

Caudal septal division and interposition batten graft can serve as an alternative surgical approach with acceptable surgical outcomes for managing severely deviated caudal septum.

LEVEL OF EVIDENCE

4.

Efficacy of hypertonic (2.3%) sea water in patients with aspirin-induced chronic rhinosinusitis following endoscopic sinus surgery

BACKGROUND

Aspirin-induced chronic rhinosinusitis (CRS) is a severe progressive persistent disease, usually associated with nasal polyps (NPs).

AIM/OBJECTIVE

To compare effect of hypertonic (2.3% NaCl) sea water and isotonic 0.9% NaCl on symptoms and endoscopic findings in those patients in the period of 1 month after endoscopic sinus surgery (ESS).

MATERIAL AND METHODS

This prospective, randomized study included 30 patients with aspirin-induced CRS undergoing ESS. Patients were divided into two groups of 15 subjects and one of the two nasal irrigation solutions was administered in each group. Intensity of 5 symptoms (nasal obstruction, nasal discharge/postnasal drip, facial pain/pressure, headache and trouble sleeping) and endoscopic findings were assessed during the 1st, 7th, 14th, 21st and 28th days after the nasal packs removal.

RESULTS

We found significantly lower total symptom score (TSS) during the 7th (p = .009), 14th (p = .003), 21st (p < .001) and the 28th day (p = .001), lower total endoscopic score (TES) on the 21st (p = .002) and 28th day (p = .001), lower nasal obstruction, facial pain/pressure, headache and trouble sleeping, and lower nasal mucosal edema, nasal secretion and nasal crusting in patients treated by hypertonic sea water.

CONCLUSION AND SIGNIFICANCE

Hypertonic sea water should be recommended douching solution in the early postoperative care of patients with aspirin-induced CRS.

Effects of tramadol on emergence agitation after general anesthesia for nasal surgery: A retrospective cohort study

Emergence agitation (EA) is common after nasal surgery. Strong opioids and N-methyl-D-aspartate (NMDA) receptor antagonists prevent EA. Tramadol also acts as an opioid receptor agonist and an NMDA receptor antagonist, but few studies have evaluated the effects of tramadol on EA. This retrospective study investigated whether tramadol is effective for reducing EA in adult patients undergoing nasal surgery.Of 210 adult patients undergoing a nasal surgical procedure under general anesthesia, the medical records of 113 were analyzed retrospectively. The patients were divided into 2 groups: patients who received tramadol during the operation (tramadol group, n = 52) and patients who did not (control group, n = 61). The incidence of EA, recovery time, changes in hemodynamic parameters, postoperative pain scores, and adverse events were compared between the 2 groups.The incidence of EA was higher in the control group than in the tramadol group (50.8% [31/61] vs 26.9% [14/52]; odds ratio 2.805; 95% confidence interval, 1.3 to 6.2; P = .010). Changes in systolic blood pressure in the 2 groups were similar, whereas changes in heart rate during emergence differed depending on the group (P = .020), although pairwise comparisons did not reveal any differences between the groups. Recovery time, postoperative pain scores, and adverse events were similar in the 2 groups.In adult patients undergoing nasal surgery, tramadol infusion decreases the incidence of EA after sevoflurane anesthesia without delaying recovery or increasing the number of adverse events.

Septoplasty versus non-surgical management for nasal obstruction due to a deviated nasal septum in adults: A modelling study of cost-effectiveness

OBJECTIVE

The objective of this study was to demonstrate how decision-analytic modelling can help to determine circumstances under which surgery may become cost-effective, using septoplasty as an example.

DESIGN

We developed a decision-analytic model comparing septoplasty to non-surgical management for nasal obstruction in adults with a deviated septum. Based on the estimated cost difference between both treatments, we calculated the minimal (a) gain in quality-adjusted life-years, or (b) reduction in productivity losses needed for septoplasty to be cost-effective. Input was derived from literature and publicly available data sources. The time horizon of our model was one year, and the willingness-to-pay per quality-adjusted life-year was €20 000, in accordance with current guidelines.

RESULTS

The cost difference between septoplasty and non-surgical management for nasal obstruction due to a deviated nasal septum was €2227 per patient from a healthcare perspective (including direct healthcare costs) and €3288 per patient from an extended perspective (additionally including travel expenses and productivity losses due to poor health). In comparison with non-surgical management, septoplasty needed to gain 0.11 to 0.16 QALYs or save 13 sick days for nasal obstruction. The longer septoplasty's effect lasts, the more time it will have to compensate its extra costs.

CONCLUSION

This study shows that the known cost difference between treatments can be used as the starting point to determine beneficial effects needed for cost-effectiveness of surgical interventions. The effect required by septoplasty from a healthcare perspective seems potentially achievable, meaning that it would be useful to perform an RCT assessing the actual benefits of septoplasty.

Randomized comparison between dexmedetomidine and midazolam for prevention of emergence agitation after nasal surgeries

Background

Emergence agitation (EA) in nasal surgeries is seen in around 22% of patients, which can go to dangerous levels. Dexmedetomidine is effective in prevention of EA in such patients. Midazolam given as premedication fails to prevent EA due to its short half-life. In this study, we compared efficacy of dexmedetomidine and midazolam by intravenous infusion for prevention of EA in adult nasal surgeries.

Materials and Methods

Seventy patients belonging to American society of anesthesiologist Status I and II, between 18 and 60 years of age posted for elective nasal surgeries were randomly divided into two groups. Group D received intravenous dexmedetomidine 0.5 mcg/kg over 15 min followed by 0.1 mcg/kg/h. Group M received intravenous midazolam 0.02 mg/kg over 15 min followed by 0.02 mg/kg/h. EA scores, emergence times, and hemodynamic parameters were monitored and compared between the groups. Statistical analysis was done by independent t-test, Mann-Whitney U-test, and Chi-square test as applicable.

Results

Incidence of EA was comparable between the groups (P = 0.23). Two patients in midazolam group developed dangerous agitation while none in dexmedetomidine group. Patients in midazolam group (12.4%) were agitated even in postoperative period, which was not seen with dexmedetomidine group. Hypotension and bradycardia were seen more in dexmedetomidine group.

Conclusion

Efficacy of midazolam when given as an intravenous infusion is comparable to dexmedetomidine in prevention of EA in nasal surgeries.

Effects of nefopam on emergence agitation after general anesthesia for nasal surgery: A prospective, randomized, and controlled trial

BACKGROUND

Emergence agitation (EA) occurs frequently after nasal surgery. N-methyl-D-aspartate (NMDA) receptor antagonists and analgesics, such as fentanyl, have been shown to prevent EA. Nefopam inhibits the NMDA receptor and shows a potent analgesic effect. We investigated the effects of nefopam on EA in patients undergoing nasal surgery.

METHODS

In this prospective, double-blind study, 100 adult patients were allocated randomly to 1 of 2 groups (each n = 50). Patients received 20 mg of nefopam in 98 mL of saline for 20 minutes immediately after induction of anesthesia (nefopam group) or 100 mL of saline (control group) in the same manner. After surgery, the incidence and degree of EA, time for extubation, hemodynamic parameters, and adverse events were evaluated by an observer blinded to the group allocation.

RESULTS

The overall incidence of EA was lower in the nefopam group than in the control group (34% [17/50] vs 54% [27/50], respectively; P = .044). The incidence of severe EA was also lower in the nefopam group than in the control group (8% [4/50] vs 38% [19/50], respectively; P = .001). Heart rate (HR) was higher in the nefopam group than in the control group from the end of surgery to 3 minutes after extubation (P = .008). Time for extubation and adverse events were similar between groups.

CONCLUSIONS

Nefopam infusion is effective in preventing and reducing the severity of EA after nasal surgery without a delay in extubation. However, caution is required regarding the increase in HR.

Assessment of Pulmonary Function before and after Sinus Surgery in Lung Transplant Recipients

Introduction  The association between sinus and lung diseases is well known. However, there are scarce studies regarding the effects of sinus surgery on pulmonary function in lung transplant recipients. The present study describes our experience with sinus surgery in lung transplant recipients with chronic rhinosinusitis. Objectives  To assess the impact of sinus surgery for chronic rhinosinusitis on pulmonary function and on inpatient hospitalization days due to lower respiratory tract infection in lung transplant recipients. Methods  A retrospective study conducted between 2006 and 2012 on a sample of lung transplant recipients undergoing sinus surgery for chronic rhinosinusitis. Pulmonary function, measured by forced vital capacity (FVC) and forced expiratory volume in the first second (FEV1), as well as inpatient hospitalization days due to lower respiratory tract infection, were compared 6 months before and 6 months after sinus surgery. Results  The FEV1 values increased significantly, and the inpatient hospitalization days due to bronchopneumonia decreased significantly 6 months after sinus surgery. The preoperative and postoperative median FEV1 values were 2.35 and 2.68 respectively ( p  =  0.0056 ). The median number of inpatient hospitalization days due to bronchopneumonia 6 months before and 6 months after surgery were 32.82 and 5.41 respectively ( p  =  0.0013 ). Conclusion  In this sample of lung transplant recipients with chronic rhinosinusitis, sinus surgery led to an improvement in pulmonary function and a decrease in inpatient hospitalization days due to bronchopneumonia.

Resection of the ethmoidal crest in sphenopalatine artery surgery

BACKGROUND

In severe cases of epistaxis, in spite of several procedures described in the literature for its management, surgical treatment has been recognized by most authors as 1 of the most effective, especially when it includes ligation and/or electrocoagulation of the nasal branches of the sphenopalatine artery. The objective of this study is to determine the importance of ethmoid crest resection during sphenopalatine artery surgery, in the management of severe epistaxis.

METHODS

We report a double-blinded randomized clinical trial, in which intervention was the ethmoid crest resection during electrocoagulation of the sphenopalatine artery. The study participants consisted of 42 patients with severe epistaxis and indication for surgical treatment, treated at the Otorhinolaryngology Emergency Room (ORL ER) of Hospital Sao Paulo, the teaching hospital of the Federal University of Sao Paulo.

RESULTS

There was significant greater exposure of the arterial branch after removal of the ethmoidal crest (p = 0.009). The rate of bleeding within 48 hours of the procedure was significantly lower in the crest removal group.

CONCLUSION

Resection of the ethmoid crest during sphenopalatine surgery proved to be feasible without additional risks, including promoting decrease in the overall surgical time. It provided better exposure of arterial branches of the sphenopalatine foramen, leading to a lower rebleeding rate within 48 hours.

Radiographic evaluation of nasal septal deviation from computed tomography correlates poorly with physical exam findings

BACKGROUND

Performance of septoplasty is dependent on objective evidence of nasal septal deviation. Although physical examination including anterior rhinoscopy and endoscopic examination is the gold standard for evaluation of septal deviation, third-party payors' reviews of septoplasty claims are often made on computed tomography (CT) findings. However, the correlation between radiographic evaluation of septal deviation with physical examination findings is unknown.

METHODS

Retrospective, blinded, independent evaluation of septal deviation in 39 consecutive patients from physical examination, including anterior rhinoscopy and endoscopic examination, by an otolaryngologist and radiographic evaluation of sinus CT scan by a neuroradiologist. Four distinct septal locations (nasal valve, cartilaginous, inferior/maxillary crest and osseous septum) were evaluated on a 4-point scale representing (1) 0% to 25%, (2) >25% to 50%, (3) >50% to 75%, and (4) >75% obstruction. Correlation between physical examination and radiographic evaluations was made by Pearson's correlation and quantitative agreement assessed by Krippendorf's alpha.

RESULTS

Statistically significant correlation was detected between physical examination including nasal endoscopy and radiographic assessment of septal deviation only at the osseous septum (p = 0.007, r = 0.425) with low quantitative agreement (α = 0.290). No significant correlation was detected at the cartilaginous septum (p = 0.286, r = 0.175), inferior septum (p = 0.117, r = 0.255), or nasal valve (p = 0.174, r = 0.222). Quantitative agreement at the nasal valve suggested a bias in CT to underestimate physical exam findings (α = -0.490).

CONCLUSION

CT is a poor substitute for physical examination, the gold standard, in assessment of septal deviation. Clinical decisions about pursuit of septoplasty or third-party payors' decisions to approve septoplasty should not be made on radiographic evidence.

A case-controlled, retrospective, comparative study on the use of biodegradable synthetic polyurethane foam versus polyvinyl acetate sponge after nasal fracture reduction

One of the most frequently used packing materials in closed reduction of a nasal bone fracture is the hydroxylated polyvinyl acetate sponge (PVAS; Merocel(®)); however this may cause synechia, epistaxis, and pain. Synthetic polyurethane foam (SPF; Nasopore(®) Forte) has recently been used in septoplasty to prevent synechia or restenosis and haematoma formation. The purpose of this study was to compare the effects of PVAS and SPF on postoperative appearance and discomfort following the reduction of nasal bone fractures. We retrospectively reviewed all patient questionnaires and medical histories, and clinical photographs and computed tomography scans obtained before and after surgery. Outcomes were assessed using the Global Aesthetic Improvement Scale (GAIS) score and visual analogue scale (VAS) scores, which were used to assess discomfort during the 6-month follow-up period. Postoperatively, there was no statistically significant difference in the GAIS for the two packing materials (P > 0.05). Postoperative epistaxis was observed at a significantly lower rate in the SPF group than in the PVAS group, whereas anterior rhinorrhea and posterior nasal drip occurred at significantly higher rates following removal of packing in the SPF group (P < 0.05). The results of this study suggest that synthetic dissolvable polyurethane may be a reliable alternative material for nasal packing and postoperative management following the reduction of nasal bone fractures.