Margherita Tofanelli

External osteotomy in rhinoplasty: Piezosurgery vs osteotome ☆

PURPOSE To achieve the desired outcome in rhinoplasty depends on many factors. Osteotomy and surgical reshaping of nasal bones are important steps that require careful planning and execution. The availability of different tools raises the question of which one provides significant advantages for both technique and surgical outcome. Our prospective randomized pilot study compared the outcome of post-traumatic rhinoplasty performed with two different external techniques: ultrasound osteotomic cut using the Piezosurgery Medical Device (Mectron, Carasco, Italy) and traditional external osteotomy. MATERIAL AND METHODS Forty-four lateral osteotomies of the nasal wall were performed in twenty-two patients. In twelve patients the osteotomies were conducted with a 2-mm traditional osteotome (control group), while in the remaining ten patients these were done with the Piezosurgery Medical Device (experimental group). RESULTS At the postoperative evaluation, significantly lower pain, edema and ecchymosis were noticed in the experimental group (p<0.05). Moreover, the endoscopic evaluation showed fewer mucosal injuries in the experimental group (p<0.05), whereas bleeding, symmetry of the pyramid and presence of external scars, were similar in the two groups. CONCLUSIONS In the present study, Piezosurgery Medical Device allowed for safe lateral osteotomies in rhinoplasty preliminarily demonstrating the potential to reduce some of the most frequent complications of rhinoplasty.

How we fix free flaps to the bone in oral and oropharyngeal reconstructions.

PURPOSE The use of suture anchors has been described in orthopedic, hand, oculoplastic, temporomandibular joint and in aesthetic surgery, but no study reports the use of the Mitek® anchors (Depuy Mitek Surgical Products, Inc. Raynham, Massachusetts) for fixing the free flaps used in oncologic oral and oropharyngeal reconstruction. MATERIALS AND METHODS In this prospective non-randomized study, 9 patients underwent surgical resection of oral or oropharyngeal cancer followed by a free flap reconstruction; mini anchors were used to fix the flap directly to the bone. We collected data regarding the patients, the tumor stage, the surgical procedure, the radiotherapy and the number of anchors used. RESULTS The average follow-up was 28months (range 24-38).We observed no complications with trans-oral, sub-mandibular and trans-mandibular approach in both oral and oropharyngeal reconstructions. All anchors became osteo-integrated and no complications occurred after radiotherapy. CONCLUSIONS In our opinion this device favors free flap adhesion to the bone. We registered no postoperative complications related to the use of the device which looks suitable for use in irradiated tissues. The radiotherapy did not cause any long-term complications related to the use of Mitek® mini bone anchors.

Hyaluronate effect on bacterial biofilm in ENT district infections: a review

Bacterial resistance is a growing phenomenon which led the scientific community to search for new therapeutic targets, such as biofilm. A bacterial biofilm is a surface‐associated agglomerate of microorganisms embedded in a self‐produced extracellular polymeric matrix made of polysaccharides, nucleic acids, and proteins. Scientific literature offers several reports on a biofilms role in infections regarding various body districts. The presence of a bacterial biofilm is responsible for poor efficacy of antibiotic therapies along with bacterial infections in ear, nose, and throat (ENT) districts such as the oral cavity, ear, nasal cavities, and nasal sinuses. In particular, bacterial biofilms are associated with recalcitrant and symptomatically more severe forms of chronic rhinosinusitis. As of today, there are no therapeutic options for the eradication of bacterial biofilm in ENT districts. Hyaluronic acid is a glycosaminoglycan composed of glucuronic acid and N‐acetylglucosamine disaccharide units. Its efficacy in treating rhinosinusitis, whether or not associated with polyposis, is well documented, as well as results from its effects on mucociliary clearance, free radical production and mucosal repair. This reviews aim is to evaluate the role of bacterial biofilms and the action exerted on it by hyaluronic acid in ENT pathology, with particular attention to the rhinosinusal district. In conclusion, this paper underlines how the efficacy of hyaluronate as an anti‐bacterial biofilm agent is well demonstrated by in vitro studies; it is, however, only preliminarily demonstrated by clinical studies.

Surgical treatment of nasal polyposis: a comparison between cutting forceps and microdebrider.

Background Nasal polyposis (NP) is defined as a specific form of chronic rhinosinusitis (CRS), characterized by bilateral and multifocal polyps. Functional endoscopic sinus surgery represents the gold standard therapy when medical treatment fails. The availability of different tools raises the question of which one provides significant advances in technique and surgical outcome. This study considered the outcome of the surgical treatment of NP in relation to several comorbidities and the surgical device used: the microdebrider versus the Blakesley traditional forceps. Other studies compared the two instruments but did not evaluate the clinical relevance of history of comorbidities such as asthma, allergy, and eosinophilia. Methods A prospective randomized single-blind study was designed to analyze 311 cases of bilateral CRS with NP. Each patient served as his/her own control, meaning that one side was operated on using the Blakesley forceps and the opposite side using the microdebrider. The follow-up period was 13.3 ± 1.2 months. Results The Blakesley forceps caused a significantly lower NP recurrence rate than the microdebrider (p < 0.001), which was more effective in preventing synechia formation (p < 0.05). Only asthma was significantly associated with a higher recurrence rate, without being influenced by the instrument used (p < 0.001). Conclusion The manual instrument allowed for a significantly lower recurrence incidence but yielded a higher rate of synechia formation compared with the microdebrider. Only asthma was significantly associated with a poorer clinical outcome, and gender, age, allergy, and eosinophilia did not affect the surgical prognosis.

Repeated canalith repositioning procedure in BPPV: Effects on recurrence and dizziness prevention

PURPOSE To evaluate whether a repeated canalith repositioning procedure (CRP) influences the residual symptoms and the rate of recurrence of benign paroxysmal positional vertigo (BPPV) in patients with post-CRP dizziness. MATERIALS AND METHODS In this retrospective study, we analyzed 292 patients at the referral center for ENT diseases with a first episode of BPPV treated with a single CRP following clinical practice guidelines. In 178 patients (67.9%) who presented dizziness after BPPV recovery at the follow-up visit, 94 patients underwent CRP (treated group) and 84 did not (non-treated group). A subjective evaluation of vertigo was made by way of a questionnaire. The rates of recurrence of BPPV and residual dizziness were statistically compared between the treated and the non-treated groups; survival analysis was carried out as well. RESULTS In an observational period ranging from 1 to 6years, BPPV recurred in 122 subjects (46.6%) of the investigated population. Among the patients with residual dizziness, the difference in rate of recurrence of BPPV between the treated group and the non-treated group was not statistically significant (p=0.84). The treated group presented a significantly higher rate of recovery from dizziness compared to the non-treated group (p<0.001). CONCLUSIONS A repeated CRP in patients with post-CRP dizziness increased the rate of recovery from dizziness but had no influence on BBPV recurrence.

Suture anchors to fix free flaps in oral and oropharyngeal reconstruction

F he use of suture anchors has been widely described in rthopaedic, oculoplastic, temporomandibular, and aesthetic urgery,1,2 and they have also been used to fix pedicle flaps in ases of ulcers or post-traumatic deficiency.3 Other authors ave described their use in oncological head and neck surgery, ut only when a free flap was not needed.4 We have recently ested the use of the anchors for fixing free flaps to reconstruct oth the oral cavity and the oropharynx after resections for ancer.5 The Mitek® suture anchors (Depuy Mitek Surgical Prodcts, Inc. Raynham, Massachusetts) are produced in a number f different sizes (micro, mini, GII, and Super) but we use the ini. It is composed of a body and two wings, the body being ade of titanium alloy, and the wings of nickel-titanium alloy, hich benefits from superelasticity and its memory of shape. he packaging includes both the anchor and the insertion evice, in which the anchor is already preloaded. The bottom f the anchor has a loop that contains the suture, which is harged on to the insertion device (Fig. 1). The first step is the exposure of the bone. A calibrated ole is then drilled with the drill bit supplied in the package hat corresponds to the size of the anchor. The drilling is one slowly, perpendicular to the bone, and under abundant rrigation (Fig. 2). It is important to realise that the drill is not equired to pierce the entire thickness of the bone, because he anchor has to be positioned within the cortical bone to inimise the risk of overpenetration. Once the pilot hole has

Liberatory vertigo: a new prognostic factor for repositioning maneuvers.

OBJECTIVE This study suggests the new concept of liberatory vertigo to facilitate emergency department treatment of benign paroxysmal positional vertigo. METHODS The present prospective nonrandomized study enrolled 535 patients with typical forms of positional vertigo, who were treated following clinical practice guidelines. We observed the onset of liberatory vertigo during the maneuver as a prognostic factor, and we tested the correlation between that symptom and therapeutic effectiveness. A subjective evaluation of vertigo was made by way of a questionnaire. Data analysis was performed that made use of statistical software. RESULTS Complete recovery occurred in 287 patients (76.5%) with posterior semicircular canal positional vertigo and in 67 patients (80%) with horizontal semicircular canal positional vertigo; liberatory vertigo occurred in 195 (67.9%) and 59 (88%) of those cases, respectively. Differences in terms of recovery probability resulted regardless of the canal involved. Positive predictive value ranged from 93% to 97%. CONCLUSIONS In our sample, liberatory vertigo could predict the effectiveness of the maneuver regardless of the canal involved.

New autostatic surgical retractor in head and neck surgery

Fig. 1. A ReeTrakt device. dequate exposure of the operative field is important in ll operations, and head and neck surgery encompasses everal techniques including microscopic, endoscopic, and pen operations. Conventional self-retaining stainless steel etractors can both hinder a complete view and obstruct the lacement of other instruments. These devices often require djustment, their prongs are sharp, and they keep tissues in raction by increasing the stretch and injury to the wound.1 he ReeTrakt (Insightra Inc. – Irvine, CA, USA) is a new isposable retractor that was first used in the treatment of an rteriovenous fistula. The retractor used had an ergonomic ook made of polycarbonate, the tip of which was too large o be used in head and neck surgery.2 The ReeTrakt device that we tested consisted of a flexible ticky pad bonded to a thin retraction strap that passed through he bottom of an ergonomic hook, which came in a number f different designs. The stainless steel hook is engaged at he edge of the wound parallel to the subcutaneous layer. The dhesive base can easily be applied to the skin or to the surical drapes once the protective backing has been removed. he strap is tightened until the desired tension is achieved; t this point the strap and the base are fixed together with elcro® (Fig. 1). We generally place the hooks symmetrially on the opposite sides of the wound; once applied, the ssistant adjusts the retractor to obtain the desired tension sing only one hand. This work was approved by our hospital’s ethics comittee on clinical investigation (No. 53/2013) and written nformed consent was obtained from all patients.