Kent Lam

Comparison of nasal sprays and irrigations in the delivery of topical agents to the olfactory mucosa.

Sinonasal diseases are often treated with topical agents administered through various application techniques, but few prior studies have examined their distribution to the olfactory mucosa. The purpose of this study was to compare the distribution of nasal irrigations to sprays within the olfactory cleft.

Is there a future for biologics in the management of chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a heterogeneous inflammatory condition of the sinonasal mucosa consisting of poorly defined subtypes and characterized by variable clinical manifestations, responses to therapy, and underlying pathophysiologies. In the related disorder of asthma, progress has been made in defining disease subtypes on both clinical and pathophysiologic levels, facilitating the development of targeted biologic pharmacotherapy. The potential role of these drugs for the management of CRS will be reviewed. The objective of this work is to highlight the emerging therapeutic targets in CRS in light of evolving treatment options for asthma and enhanced understandings of the clinical manifestations and pathophysiology of CRS.

The association of premorbid diseases with chronic rhinosinusitis with and without polyps

Purpose of reviewTo review the recent insights regarding the epidemiology of adult chronic rhinosinusitis (CRS), with particular attention to its association with other premorbid conditions. Identifying premorbid disease associations establishes potential risk factors for developing CRS and helps corroborate current postulates of the various pathophysiologic mechanisms involved with the development and persistence of paranasal sinus inflammation. Recent findingsRecent findings demonstrate that the diagnosis of CRS is associated with a higher premorbid prevalence of upper airway diseases, lower airway diseases, gastroesophageal reflux disease, diseases of epithelial tissues, autoimmune disorders, and psychiatric conditions. Although some of these conditions have long been associated with CRS, improvements in study design and future studies in the general population will more accurately estimate the relative strengths of associations, clinical relevance, and temporal relationship of these various conditions in relation to the development of CRS. SummaryThe predisposing patterns of premorbid illnesses may provide valuable information regarding the underlying causes of CRS and allow for both therapeutic and preventive interventions. There remains conflicting evidence within the literature regarding the association of CRS with some medical conditions, signifying the need for continued research on the subject. Limitations of the current studies include small sample sizes, lack of prospective longitudinal or interventional studies that help establish causality, and variable criteria for diagnosis of CRS in the outpatient setting.

Superior turbinate eosinophilia correlates with olfactory deficit in chronic rhinosinusitis patients

To evaluate if molecular markers of eosinophilia in olfactory‐enriched mucosa are associated with olfactory dysfunction.

The Nasal Keystone Region: An Anatomical Study

T he nasal keystone region is an aptly named confluence of bone and cartilage at the junction of the upper and middle thirds of the nose. Its importance to the stability and structure of the nose is exemplified by the number of complications that may arise from poor surgical handling of this area. The keystone region consists of contributions from the paired nasal bones cephalically, paired upper lateral cartilages (ULCs) caudally, quadrangular cartilage anterior-inferiorly, and perpendicular plate of the ethmoid (PPE) posteriorinferiorly. We sought to review the anatomy of fresh-frozen cadavers in regard to the keystone region, in concert with previous anatomical descriptions, to expand on the significance of this region for rhinoplasty.

Analgesic Effects of Intravenous Acetaminophen vs Placebo for Endoscopic Sinus Surgery and Postoperative Pain: A Randomized Clinical Trial

Importance Intravenous acetaminophen is a commonly prescribed analgesic for the prevention and treatment of postsurgical pain. Its efficacy in the context of endoscopic sinus surgery (ESS) has yielded mixed results. Objective To compare the efficacy of perioperative intravenous acetaminophen (IVAPAP) with that of placebo in improving early postoperative pain after endoscopic sinus surgery (ESS). Design, Setting, and Participants A prospective, randomized clinical trial including 62 patients undergoing ESS for chronic rhinosinusitis in a single tertiary referral hospital. Interventions Participants were randomized to receive 1 g of IVAPAP or 100 mL of placebo consisting of saline infusions immediately before the start of surgery and 4 hours after the initial dose. Main Outcomes and Measures The primary outcome was postoperative pain measured by visual analog scale (VAS) scores up to 24 hours after surgery by blinded observers. Secondary endpoints included postoperative opioid (intravenous and oral) use and adverse events in the 24-hour postoperative period. Results Of the 62 enrolled adult participants, 60 were randomized (31 to IVAPAP intervention and 29 to placebo). The mean (SD) age of participants was 53.7 (14.7) years and 35 (58%) of the participants were men and 25 (42%) were women. Within the first hour, mean pain scores were reduced in the IVAPAP group compared with the control group, reaching a maximum difference of 7.7 mm on a VAS scale favoring the treatment group with a true difference possibly as high as 22 mm, and the data are compatible with a clinically meaningful difference. At 12- and 24-hours, average pain scores were less in the placebo group and the data are compatible with a clinically meaningful difference of 5.8 (−5.2 to 16.8) and 8.2 (−1.9 to 18.4), respectively, favoring the placebo group. However, at all time points the CIs included the null value and were wide, thus preventing definitive conclusions. Inspection of the secondary outcomes favored IVAPAP, but the wide range of the CIs and inclusion of the null value prevent definitive conclusions. Conclusions and Relevance The results of this study are inconclusive. The data suggest that perioperative intravenous acetaminophen may reduce immediate postoperative pain and opioid requirements compared with placebo and these differences could be clinically meaningful. Unfortunately, the imprecision of the estimates prevents definitive conclusion. Use of IVAPAP does not seem to increase adverse events. Trial Registration clinicaltrials.gov Identifier: NCT01608308

Use of Autologous Fat Grafts for the Endoscopic Reconstruction of Skull Base Defects: Indications, Outcomes, and Complications

Background The use of abdominal free fat is a traditional surgical method for the repair and reconstruction of the anterior skull base. Our objective is to assess the outcomes associated with the autologous fat graft to endoscopically repair anterior skull base defects at a single tertiary care center. Methods All patients, who underwent endoscopic skull base repair utilizing abdominal free fat from September 2009 to June 2016, were included for retrospective chart review. Evaluated outcome measurements included (1) the successful closure of preoperative and intraoperative cerebrospinal fluid (CSF) leaks and (2) complications at both donor and recipient graft sites during the postoperative periods. Four representative clinical cases have additionally been selected to highlight the common indications for which the fat graft may be effective in skull base reconstruction. Results Of the 27 patients who were identified for inclusion in this review, 25 (92.6%) demonstrated successful repair of preoperative or intraoperative CSF leaks following primary skull base repair. Two patients developed recurrent CSF leaks occurring about 1 week after their primary closures, and a secondary closure rate of 96.3% was achieved with use of fat grafts. Other complications included seroma and hematoma formation at the abdominal donor sites, each occurring in 1 patient. Conclusions The use of autologous fat remains a viable option for grafting material during endoscopic skull base reconstruction. Despite the wide variety of closure techniques in skull base surgery, autologous fat provides safe and easily accessible material to repair CSF leaks.

Sinocutaneous Fistula Formation After Forehead Recontouring Surgery for Transgender Patients

Forehead recontouring is a common part of facial feminization surgery. The procedure, which alters the shape and structure of the frontal bone, is regarded as safe and well tolerated by patients. The occurrence of delayed complications, however, is much less understood. The authors describe a patient involving the development of a sinocutaneous fistula as a delayed complication of forehead recontouring surgery. The clinical presentation and management of this patient are discussed. As facial feminization surgery expands as a cosmetic option for patients who desire more feminine facial features, practitioners should recognize the potential risk of sinonasal complications associated with forehead recontouring surgery.

Defect Closure After Lesion Excision of the Face

The options to close facial defects range from closure by secondary intent, which is the simplest of techniques in the reconstructive ladder, to a microvascular free flap, which sits at the highest rung of complexity in the reconstructive ladder. Consideration of reconstructive options for cutaneous facial defects generally start with the simplest options, but move up the reconstructive ladder as needed in order to achieve a functionally and cosmetically adequate outcome for patients. Along this gradient of options, the use of linear primary closures on the face is oftentimes a sufficient and reliable technique for most soft tissue defects encountered by surgeons.

Effect of ionic compositions in nasal irrigations on human olfactory thresholds

Nasal irrigations are commonly employed to promote nasal hygiene in the treatment of various sinonasal conditions. Few studies have evaluated how the ionic composition of irrigation solutions affects olfactory performance. The purpose of this study was to determine the dose responsiveness of human olfactory thresholds for each of the following ions: potassium, sodium, and calcium.