Jason D. Bloom

Current management of juvenile nasopharyngeal angiofibroma: a tertiary center experience 1999-2007.

Background Over the past 10 years, the management of juvenile nasopharyngeal angiofibroma (JNA) has been redefined because of the improvement of transnasal skull base techniques. However, the limits of endoscopic resection still have to be fully defined. The purpose of this study was to report on a series of patients presenting with JNA in an effort to further define an optimal treatment algorithm and improve outcomes. Methods A retrospective review was performed of 18 patients presenting to a tertiary care institution with JNA from 1999 to 2007. Patients were categorized by Andrews stage and data were collected on presentation, operative technique, and postoperative course. Results All patients underwent preoperative embolization. Stages 1, 2, and one 3a lesions were approached endoscopically while the remainder underwent open resection. In the endoscopic group the intraoperative blood loss was almost half that of the open group (506 versus 934 mL) and the average hospital stay was 1 day less (3 vs. 4 days). Conclusion Endoscopic resection is reasonable for Andrews stage 1, 2, and select 3a lesions and may allow for less bleeding and a shorter hospital stay. This study supports the current trend of expansion of indications for endoscopic JNA resection.

Domal Stabilization Suture in Tip Rhinoplasty

OBJECTIVE To investigate use of the domal stabilization suture as a complementary suture modification technique for refining and securing the nasal tip. METHODS A single permanent or absorbable suture is placed via an open or cartilage delivery approach. The suture is placed along the cephalic borders of the domes at the medial third of the lateral crura bilaterally just posterior to the junction of the intermediate and lateral crura as a final step in tip rhinoplasty. RESULTS The domal stabilization suture provided a means to help maintain dome symmetry in the setting of variable healing and scarring forces with no complications and no effect on tip rotation or projection. CONCLUSION Use of the domal stabilization suture enables correction of subtle changes in mild tip asymmetry and irregularities in domal height and provides subtle narrowing of the interdomal distance.

Surgical treatment of nasal obstruction in rhinoplasty.

Often, rhinoplasty patients present not just for aesthetic correction, but for improvement of their nasal breathing due to functional abnormalities or problems. Because the aesthetic and functional problems must be addressed together, an understanding of both the internal and external anatomy is essential. In this article, the authors review the differential diagnosis of nasal obstruction and the important components of a thorough examination. In this article, medical treatment options are not discussed, but just as an exacting aesthetic analysis leads to an appropriate cosmetic rhinoplasty plan, a thorough functional analysis will dictate the appropriate medical or surgical treatment.

Laser Facial Nerve Welding in a Rabbit Model

OBJECTIVE To assess the feasibility of laser tissue welding for repair of facial nerve injury. METHODS In a prospective in vivo animal survival surgery model, rabbit facial nerve injury was followed by either standard suture neurorrhaphy or laser tissue welding using a diode laser (808 ± 1 nm) to weld biological solder. Rabbits were evaluated at 4, 8, 12, and 16 weeks by facial videography and electromyography. Histopathological analysis of the repair was performed at 4 and 16 weeks. RESULTS Videographic analysis demonstrated the laser tissue welding repair trended toward superior outcomes compared with suture neurorrhaphy at all 4 time points. Electrophysiological analysis demonstrated similar or better results, with statistically significant improvement at week 16 (P < .05). Histologic analysis demonstrated no difference in axon organization or extravasation between groups; however, the laser nerve repair created a greater initial inflammatory reaction. An analysis of operative time demonstrated significantly decreased time and ease of use for laser tissue welding. CONCLUSIONS This pilot study demonstrates that laser nerve welding may be an expedient, feasible, and safe method for facial nerve repair in a rabbit model. Further experiments with larger numbers are needed to provide additional evidence that laser tissue welding produces a neurorrhaphy that has functional, electrophysiological, and histological results that could rival traditional suture neurorrhaphy.

Biofilm accumulation on endotracheal tubes following prolonged intubation.

OBJECTIVE To demonstrate that patients who have been intubated for prolonged periods of time will have an increased likelihood of developing bacterial biofilm on their endotracheal tubes. METHODS We collected endotracheal tubes from patients at the time of extubation, and analysed representative sections with scanning electron microscopy for morphologic evidence of biofilms. RESULTS From September 2007 to September 2008, 32 endotracheal tubes were analysed with electron microscopy. Patients who had been intubated for 6 days or longer had a significantly higher percentage of endotracheal tubes that exhibited bacterial biofilms, compared with patients intubated for less than 6 days (88.9 versus 57.1 per cent, p = 0.0439). CONCLUSIONS Longer duration of intubation is associated with a higher incidence of bacterial biofilm. Further research is needed to link the presence of bacterial biofilms to acquired laryngotracheal damage.

Reformatted Computed Tomography to Assess the Internal Nasal Valve and Association With Physical Examination

OBJECTIVES To assess the cross-sectional area and angle of the internal nasal valve more accurately by reformatting computed tomography (CT) scans of the nasal airway according to a more appropriate orientation than scans traditionally sectioned in the coronal plane and then to compare the results with clinical data on the nasal valve obtained from physical examination. METHODS We performed a retrospective review of the medical records of 24 rhinoplasty patients treated at a private practice facial plastic surgery office affiliated with a tertiary care university hospital. The patients had fine-cut (0.75-mm section) CT scans ordered for nasal airway obstruction or nasal valve compromise at the same institution. These patients were evaluated from January 1, 2000, through December 31, 2010. The previously acquired CT scans were reformatted to obtain sections through the internal nasal valve at a more appropriate orientation. The internal nasal valve cross-sectional area and valve angle were measured through a standardized section (1 cut immediately anterior to the head of the inferior turbinate) from the reformatted scans. The cross-sectional area was also measured through the same point on the traditionally oriented CT scan, and the values were compared. The results from each patients scan were compared with data from the patients medical record and analyzed against the patients preoperative modified Cottle examination findings. RESULTS The CT scans oriented in the reformatted plane through the internal nasal valve provided a narrower valve angle than the traditionally oriented CT scans and more closely approximated the hypothesized true value of the internal nasal valve of 10° to 15° (P < .001). In a comparison of the same-side internal nasal valve angle and cross-sectional nasal valve area between the 2 different CT scan orientations, a statistically significant difference in the internal nasal valve angles between the 2 scan orientations was discovered, but this finding did not reach significance when distinguishing the nasal valve cross-sectional area. Finally, no correlation was found with regard to the preoperative modified Cottle maneuver scores for the internal nasal valve angle and cross-sectional valve area values in either scan orientation. CONCLUSIONS Precise preoperative evaluation of the internal nasal valve is critical to the workup for reconstruction or repair of problems that involve this area. Although tools such as acoustic rhinometry exist to evaluate the cross-sectional area of the nasal valve, many rhinoplasty surgeons do not have access to this expensive equipment. A CT scan with reformatting in the proper plane of the internal nasal valve can provide the surgeon with improved anatomical information to assess that region. With this in mind, however, the surgeon should always perform a thorough preoperative physical examination and treat the patient and his or her symptoms, not the imaging studies, when considering a candidate for a surgical intervention.

Face-lift complications.

Avoiding complications of rhytidectomy requires meticulous technique, anatomic knowledge, and insight into perioperative risks. The surgeon must provide a swift diagnosis to resolve any potential complications. The surgeons goal is to deliver the best results while minimizing procedural risks.

Osteotomies in the Crooked Nose

The crooked nasal pyramid and upper third of the nose can be straightened with various osteotomes. Appropriate solutions to maximize successful nasal straightening require a thorough knowledge of the anatomy, a comprehensive preoperative plan, and the appropriate osteotomy choice.

Laser Tissue Welding in Lung and Tracheobronchial Repair: An Animal Model

BACKGROUND Violation of the integrity of the airway (pulmonary parenchymal air leak or tracheobronchial injury) remains a challenging problem in chest medicine and thoracic surgery. Tissue sealants such as fibrin glue have been suggested to improve outcomes but they are still associated with significant failure rates. Laser tissue welding (LTW) is an alternative method that produces wound repairs that are significantly stronger than those of fibrin glue and may be used to repair air leaks. METHODS We used an Institutional Animal Care and Use Committees-approved New Zealand white rabbit model of lung parenchymal and tracheal injury. Lung wounds (n = 8 per condition) were created and either left open or repaired using fibrin glue or LTW. Tracheal wounds (n = 5 per condition) were created using incisions in the membranous and cartilaginous portions or by removing a tracheal ring, and were repaired using LTW. Within each tissue type, the burst strength of the wounds was measured using a digital manometer and were compared with one another using a two-tailed, paired Student t test. RESULTS Among the lung injuries, the burst strength of the LTW repair (19.95 +/- 4.98 mm Hg) was significantly stronger than that of the fibrin glue repair or open wound (10.53 +/- 5.01 mm Hg, P = .001, and 7.61 +/- 2.64 mm Hg, P < .001, respectively). Among the tracheal injuries, the burst strength of the membranous incision (101.00 +/- 20.25 mm Hg) was significantly higher than that of the cartilaginous incision (75.08 +/- 10.50 mm Hg, P = .03) but not that of the cartilaginous defect (77.34 +/- 12.35 mm Hg). CONCLUSIONS LTW is capable of sealing wounds in the tracheobronchial tree and can produce bonds that are twice as strong as fibrin glue in lung parenchyma. LTW may be a better alternative than fibrin glue in the repair of injuries to the airway.

A Patient Seeking Aesthetic Revision Rhinoplasty and Correction of Nasal Obstruction

Thorough evaluation of a patient presenting with nasal obstruction, including nasal endoscopy and a CT scan when indicated, is recommended to guide proper diagnosis and treatment. The rhinoplasty surgeon should be aware of the differential diagnosis of nasal obstruction and should proceed with thorough evaluation or refer the patient for appropriate complete evaluation.