Charles R. Woodard

Trends in common rhinologic illnesses: Analysis of U.S. healthcare surveys 1995–2007†

Up to date information on the epidemiology of, and recent changes in, allergic rhinitis (AR), acute sinusitis (AS), and chronic sinusitis (CS) office and emergency department (ED) visits and prevalence is sparse. Current studies may quote data that is outdated or based solely on patient self‐report. The purpose of this work was to describe basic epidemiologic measures of office and ED visits for AR, AS, and CS between 1995 and 2007, and to analyze trends over time for each of these diseases.

Dual Action of TGF‐β1 on Nasal‐Polyp Derived Fibroblasts

Objectives: Transforming growth factor β‐1 (TGF‐β1) is a known fibrogenic factor with immunosuppressive properties. We wanted to determine the effect of stimulation with TGF‐β1 on nasal polyp‐derived fibroblasts and assess the role this molecule would have in polyp formation and growth.

Role of hypoxia in inflammatory upper airway disease

Purpose of reviewHypoxia is a potent stimulus for inflammation and remodeling. Hypoxia develops in chronic sinusitis as shown via tissue oxygen concentrations and colonization with obligate anaerobes. This hypoxia reflects occlusion of the sinus ostia and thereby failure of transepithelial oxygenation, nonvascularized exudates, and the tendency of inflammatory hyperplasia to exceed neovascularization. Recent findingsHypoxia-induced transcription factors are responsible for transcription of numerous inflammatory cytokines and growth factors, including vascular endothelial growth factor, CXCL8, CCL11, transforming growth factor-ß, inducible nitric oxide synthase, as well as matrix remodeling proteins such as procollagen and matrix metalloproteinases. SummaryMany diseases, such as asthma, share the tendency to afflict respiratory epithelium of the lower (bronchi) and upper (sinus) airway. Although the histopathology and inflammation of asthma and its associated sinusitis share many features, aggressive fibrosis, polyp formation and intense hyperplasia are not features of asthma, a disease seldom associated with significant chronic hypoxia. In contrast, fibrosis is a cardinal feature of hypoxic diseases of the lungs such as interstitial lung diseases and primary pulmonary hypertension. Arguably, chronic sinusitis can be viewed as reflecting both ‘asthma’ and ‘primary pulmonary hypertension’ of the upper airway.

Reconstruction of Nasal Defects 1.5 cm or Smaller

OBJECTIVES To review the repair of smaller nasal defects (≤1.5 cm) and their associated complications, elaborating on nasal obstruction and techniques to avoid it, and to determine outcomes with functional cartilage grafting. METHODS The medical records of patients requiring nasal reconstruction for Mohs defects 1.5 cm or smaller were reviewed. Variables analyzed included defect location, defect size, use of cartilage, flap design, smoking status, and postoperative complications (nasal obstruction and flap/graft necrosis). RESULTS A total of 208 patients with 213 nasal defects 1.5 cm or smaller were identified. The most common location was the alar subunit, followed by the tip, dorsum, and sidewall. Ninety-eight of the defects (46.0%) used cartilage grafts for reconstruction. Seventy-three of 84 alar defects (86.9%) were reconstructed with cartilage as a composite or batten graft. The sidewall and dorsum were the least likely to require cartilage grafting: 1 of 15 (6.7%) and 0 of 21, respectively. Ten patients (4.8%) had a postoperative complication: 6 of 19 smokers (31.6%) and 4 of 189 nonsmokers (2.1%). Overall, nasal obstruction was an infrequent complication (1.4%). CONCLUSIONS Regardless of defect size, defect location, and flap design, smokers were at higher risk for postoperative complications. Subtle modifications in the classic flap design and liberal use of cartilage grafting reduce the risk of postoperative nasal obstruction.

Nasal and Facial Analysis

Rhinoplasty remains one of the most challenging aesthetic procedures to master. Astute surgeons must consider a continually evolving societal perception of beauty with their own sense of aesthetic proportion when planning surgical intervention. Optimal results are achieved when the outcome is anticipated and satisfying to patient and surgeon. This requires a careful, thoughtful, systematic approach to preoperative analysis. Patients should leave with a clear understanding of the surgeons perspective of their nose, aesthetically and anatomically. Understanding the interplay of surface deformities and their underlying anatomic counterpart is critical, involving a systematic analysis to create a surgical plan that avoids landmines leading to a suboptimal result.

Preservation of the nasal valve area with a lateral crural hinged flap: a cadaveric study.

BackgroundOverresection of the lateral crura of the lower lateral cartilages is referred to as the most common cause of nasal valve collapse after rhinoplasty. The modern approach to functional rhinoplasty recognizes the importance of the tip framework’s structural integrity and preserves tip support.MethodsTraditional cephalic resections of lateral crura were performed on one side of five adult cadaver noses. On the opposite sides, hinged flaps of lateral crura were created. The noses were cross-sectioned at or near the internal nasal valve level, and the difference between the two sides was described.ResultsThe study findings demonstrated improvement in the postoperation nasal valve area of the hinged flap side compared with the cephalic trim side.ConclusionsThis preliminary study showed that the hinged flap is an option in nasal tip reduction surgery that may provide improved long-term aesthetic and functional outcomes through preservation of the nasal valve area.

Surgical Training and Education in Promoting Professionalism: a comparative assessment of virtue-based leadership development in otolaryngology-head and neck surgery residents

Introduction Surgical Training and Education in Promoting Professionalism (STEPP) was developed in 2011 to train tomorrows leaders during residency. It is based on virtue ethics and takes an approach similar to West Point military academy. The purpose of this research was: (i) to compare the virtue profiles of our residents with that of the military cohort using a standardized virtue assessment tool; and (ii) to assess the value of virtue education on residents. Methods As part of STEPP, otolaryngology residents participated in a virtue-based validated assessment tool called Virtue in Action (VIA) Inventory. This was completed at the initiation of STEPP in July 2011 as well as 1 year later in June 2012. Comparison of the VIA to a military cohort was performed. Leadership ‘Basic Training’ is a series of forums focused on virtues of initiative, integrity, responsibility, self-discipline, and accountability. A pre- and post-test was administered assessing resident perceptions of the value of this ‘Basic Training’. Results Virtues are shared between otolaryngology residents (n=9) and military personnel (n=2,433) as there were no significant differences in strength scores between two military comparison groups and otolaryngology-head and neck surgery (OHNS) residents. There was a significant improvement (p<0.001) in the understanding of components of the leadership vision and a significant improvement in the understanding of key leadership concepts based on ‘Basic Training’. All residents responded in the post-test that the STEPP program was valuable, up from 56%. Conclusions A virtue-based approach is valued by residents as a part of leadership training during residency.

Complications in Facial Flap Surgery

Local flaps are a common reconstructive technique of the head and neck. Consequently, knowledge of fundamental concepts and pitfalls to avoid will reduce surgical complications. These complications result from tension-related, ischemic, hematologic, and infectious causes. This paper seeks to address each of these causes with pearls to accomplish a successful outcome.

Opportunity Cost of Surgical Management of Craniomaxillofacial Trauma.

The provision of trauma care is a financial burden, continually associated with low reimbursement, and shifts the economic burden to major trauma centers and providers. Meanwhile, the volume of craniomaxillofacial (CMF) trauma and the number of surgically managed facial fractures are unchanged. Past financial analyses of cost and reimbursement for facial trauma are limited to mandibular and midface injuries, consistently revealing low reimbursement. The incurred financial burden also coincides with the changing landscape of health insurance. The goal of this study is to determine the opportunity cost of operative management of facial trauma at our institution. From our CMF database of greater than 3,000 facial fractures, the physician charges, collections, and relative value units (RVUs) for CMF trauma per year from 2007 to 2013 were compared with a general plastic surgery and otolaryngology population undergoing operative management during this same period. Collection rates were analyzed to assess if a significant difference exists between reimbursement for CMF and non-CMF cases. Results revealed a significant difference between the professional collection rate for operative CMF trauma and that for other operative procedures (17.25 vs. 29.61%, respectively; p < 0.0001). The average number of RVUs billed per provider for CMF trauma declines significantly, from greater than 700 RVUs to 300 over the study period, despite a stable volume. Surgical management of CMF trauma generates an unfavorable financial environment. The large opportunity cost associated with offering this service is a potential threat to the sustainability of providing care for this population.

Dysphagia, hoarseness, and globus in a postoperative patient☆

Sore throat, hoarseness, and dysphagia are known and recognized postoperative complications of laryngeal mask airway use during operative procedures. The patients symptoms, present immediately after surgery, are thought related to airway manipulation. Airway foreign bodies, although low on the differential, can cause similar symptoms. We present a case of a single patient who presented to a tertiary care center after an elective outpatient procedure with postoperative sore throat, hoarseness, and dysphagia. A foreign body was found lodged in the patients hypopharynx. The differential diagnosis of sore throat, hoarseness, and dysphagia in the postoperative patient is explored in further detail.