Paul Sabini

Use of Porous High-Density Polyethylene in Revision Rhinoplasty and in the Platyrrhine Nose

Abstract: Nasal reconstruction presents a significant challenge to the facial plastic surgeon. Reestablishment of the desired aesthetic nasal contour and restoration of respiratory function are the dual goals of this endeavor. While autologous cartilage or bone is considered optimal grafting material, the supply is often limited and harvesting entails additional morbidity. Many synthetic materials have been introduced for use in nasal reconstruction, but high infection and extrusion rates have left most surgeons dissatisfied with conventional implants. Porous polyethylene (Medpor) implants were used for nasal reconstruction in 187 patients; 66 (35.3%) patients underwent primary rhinoplasty, while revision surgery was performed in 121 (64.7%) patients. Most patients required multiple implants, including columella struts, plumper grafts, dorsal tip implants, and nasal valve battens. Postoperative follow-up ranged from 6 months to 3.5 years. Complications occurred in five (2.6%) patients. Three early and two delayed infections necessitated implant removal in five patients, all of whom had compromised skin–soft tissue envelopes secondary to heavy smoking, cocaine abuse, or prior surgery. One case of an overly augmented nasal dorsum and tip required implant removal, reduction, and reinsertion. All implants were easily removed. No other complications including implant extrusion or skin erosion have been noted. Porous polyethylene (Medpor) implants allow for fibrovascular ingrowth, which lends stability to the implant. Porous polyethylene implants are well tolerated and provide an ideal material for nasal reconstruction.

Teleconsultation in otolaryngology: live versus store and forward consultations.

OBJECTIVE : To evaluate the relative strengths and weaknesses of interactive and delayed teleconsultations in otolaryngology. SETTING : Ambulatory clinic at an urban tertiary care facility. SUBJECTS : Forty-five adult patients with known or suspected upper aerodigestive tract pathology. INTERVENTION : Patients were interviewed by an otolaryngology chief resident (CR) using a standardized protocol; the results were presented to a board-certified otolaryngologist present locally (LBCO) and a remote physician viewing the encounter by video-conferencing elsewhere in the hospital (RBCO). The CR performed a complete otolaryngologic examination, including fiberoptic nasopharyngolaryngoscopy. The CR and LBCO viewed the examination on a video monitor; the RBCO viewed the same image on the video-conferencing monitor. Each physician independently recorded findings and rendered a diagnosis. A third board-certified otolaryngologist, who reviewed the stored data file (text and stored images) in a delayed fashion (DBCO), documented his findings and made a diagnosis. RESULTS : The CR and LBCO agreed on diagnosis in 92% (36 of 39) of cases. The LBCO and RBCO arrived at the same diagnosis in 29 of 34 (85%) cases. The DBCO agreed with the LBCO for 18 of 28 (64%) diagnoses. Agreement on management recommendations between the LBCO/DBCO pair were also lower than for the LBCO/RBCO pair. CONCLUSIONS : Both interactive and delayed techniques can be used to provide relatively accurate clinical consultations in otolaryngology. Telemedicine can be applied for subspecialty consultations, screening programs, remote emergency triage, second opinions, and resident education.

Telemedicine applications in otolaryngology.

A prospective study of the use of realtime and store-and-forward teleconsulting was carried out in patients who presented to the New York Eye and Ear Infirmary for otolaryngology care. Forty-five patients were seen in the study. There were no significant differences between local and remote otolaryngologists when interpreting the examinations, indicating that transmission did not affect the ability of a qualified physician to make an accurate diagnosis. In the store-and-forward examinations only 62% of the electronic records provided sufficient information for a confident diagnosis. Records were judged inadequate primarily due to poor selection, or an insufficient number of stored images. The study demonstrates that both interactive and store-and-forward techniques can be used to provide accurate clinical consultations in nasopharyngolaryngoscopic examinations. However, since store-and-forward consultations include less information and do not provide immediate feedback, a well defined clinical protocol for assembling the electronic consultation is needed.

Efficacy of serologic testing in asymmetric sensorineural hearing loss

PURPOSE The goal of this study was to determine the efficacy of a detailed questionnaire, auditory brain stem response testing (ABR), MRI, and an extensive battery of serologic tests in diagnosing asymmetric sensorineural hearing loss (ASNHL). METHODS AND MATERIAL Patients with audiograms demonstrating ASNHL of 10 dB or greater in 2 consecutive frequencies or 15 dB in any 1 frequency between 250 and 6000 Hz were asked to participate. Patients underwent MRI scanning of the cerebellopontine angle, internal auditory canals, and posterior fossa with gadolinium contrast, ABR, and an extensive battery of tests. The causative diagnosis was made by the individual clinician based on each patients history, physical examination, and test results. RESULTS Forty-five patients completed the study. A review of the data confirmed the utility of a detailed history and physical examination, MRI, and fluorescent treponemal antibody test in all cases. Erythrocyte sedimentation rate, glycosylated hemoglobin, Lyme antibody titers, and total hemolytic component (CH50) were helpful in selected cases. Thyroid function testing, complete blood count, Sequential Multiple Analysis-7, prothrombin time/partial thromboplastin time, lipid profile, and ABR were of no value in these patients. CONCLUSION A careful history and physical examination, MRI, and fluorescent treponemal antibody test should be performed for the evaluation of all patients with ASNHL; however, more extensive serologic testing, including sedimentation rate, glycosylated hemoglobin, Lyme antibody titers, and CH50, should be selectively performed, based on a suggestive history or suspicious physical findings.

Focal myositis of the sternocleidomastoid muscle: A case report and review of the literature

The otolaryngologist is often confronted with the challenge to diagnose and treat neck masses in the adult population. The differential diagnosis includes both inflammatory and neoplastic diseases. History, physical examination, fine needle aspiration, and computed axial tomography (CAT) scanning are among the tests frequently performed to assist the clinician in making the diagnosis. Despite performing these tests, uncommon diseases often masquerade as common diseases and may make correct clinical diagnosis difficult. The clinician must be aware of unusual diseases that may present in this fashion. We present an unusual case of focal myositis (of Heffner) in the sternocleidomastoid muscle. This inflammatory pseudotumor of skeletal muscle most commonly affects the calf and thigh musculature. We believe we add to the medical literature a fourth case of focal myositis affecting the sternocleidomastoid muscle. This is only the second report of this diagnosis in an adult patient. We present clinical and pathological features of this benign pseudotumor of the head and neck. This will better familiarize the otolaryngologist when confronted with this rare inflammatory mass.

The role of endoscopic sinus surgery in Patients with acquired immune deficiency syndrome

PURPOSE Increasingly, otolaryngologists are treating patients with acquired immunodeficiency syndrome (AIDS) who suffer from associated sinusitis refractory to medical therapy. Despite this trend, few reports in the literature detail the mode of surgical therapy, pathogens, and outcome in this patient population. Our aim in this study was to describe our experience in treating these patients, with particular attention to surgical outcome and pathogens. PATIENTS AND METHODS We reviewed our experience with performing sinus surgery in 33 AIDS patients. Endoscopic sinus procedures were performed in 24 patients, while the remaining nine patients underwent nasal antral windows and/or Caldwell-Luc operations. Follow-up information was obtained in 16 of the 24 patients who underwent endoscopic sinus surgery. RESULTS At an average follow-up time of 16 months, 14 of the endoscopic sinus surgery patients reported improvement from their preoperative condition. Thirty-seven pathogens were identified in 23 patients. A larger percentage of nontraditional pathogens was found in these patients, which suggests a larger role for microbiologic diagnosis and treatment versus empiric therapy. CONCLUSION Patients with AIDS and chronic sinusitis may benefit from endoscopic sinus procedures.

Multistaged reconstructive efforts via medical missions: keys to optimizing outcome.

S ERVING IN MEDICAL MISsions has become commonplace for internists, infectious disease specialists, and surgeons alike, but it has become especially popular among general and facial plastic and reconstructive surgeons. The mission service fulfills the surgeons’ desire to perform humanitarianworkandsimultaneouslypermits themtoperformmanyofasingle type of case ina longitudinal series.While overall, recipient countries tend to express gratitude for such services, resentment from the local medical communitycanalsobean issue.This resentment stems from the contrast between locally available resources and those provided by global missions.Therecanbetheperceptionthat these missions are used as training grounds for inexperienced surgeons and that many of the patient groups receive inadequate follow-up in the early postoperative period. Our team has traveled for 8 years to a specific site in South America (Quito, Ecuador) to provide facial reconstructive services with support from both Medical Missions for Children and the Help Us Give Smiles Foundation. Our focus has been on microtia over the past 5 years. In our experience, several mission features have emerged as critical to achieving positive outcomes in the Third World setting: (1) developing close relationships between the visiting surgeons and the local reconstructive surgeons; (2) having a strong native language speaker among the traveling surgeons; (3) maintaining detailed electronic medical records; (4) documenting the work with meticulous photography; (5) committing to annual trips to the same location; and (6) keeping team turnover low. Over the past 50 years, humanitarian health care delivery efforts outside the United States have grown increasingly popular among American physicians, and opportunities to engage in these activities have grown. This is especially true for general and facial plastic and reconstructive surgeons visiting areas in the Third World setting where a higher incidence of certain birth defects occurs and where fewer resources are available to attend to non–life-threatening medical issues. Medical missions range from large, internationally sponsored organizations to small grass roots organizations, somewhat like our own. For widely varying reasons, approximately 25% of reconstructive surgeons participate at some point in their careers in mission service. Among the compelling reasons to get involved in mission work are the desire to fulfill a humanitarian need, interest in traveling abroad, and interest in further developing a particular surgical skill. The last of these goals has been heavily criticized as a weakness of international missions. A number of organizations have received negative press for achieving poor overall surgical results, poor follow-up, lack of geographic continuity to the same location year after year, and inadequate relationships with the local medical communities. Recognizing the obstacles to the delivery of thorough, continuous care in a Third World setting, our group has made it a priority over the past 5 years to overcome the lack of continuity using several strategies. First, we chose a location with a high prevalence of microtia, our reconstructive problem of interest. We spent several years developing relationships with both community leaders and local plastic surgeons to ensure that our efforts would be well received. We believe that fluency in the indigenous language and a commitment to annual visits to a single site for at least a decade are both important. We also established a portable, electronic medical recording system that we can use to treat the same population of patients on an annual basis. Over the past 5 years, we have strived to improve our photographic documentation, made efforts to prevent loss to follow-up, and continued to grow our relationships with the local medical community. We have found that over time, these efforts have resulted in decreased complication rates and improved mission efficiency. Several elements critical to the success of our reconstructive efforts have emerged, including excellent physicianpatient communication, the keeping of detailed records, and low team turnover. Between 1999 and 2007, a total of 271 patients were treated for auricular deformities. Approximately 91% of these had microtia, and of these approximately 85% had unilateral microtia. The remaining patients had either auricular trauma (burns or avulsion injuries) or minor congenital auricular anomalies (lop or cup ear deformities). The same 4 attending surgeons, the 4 of us, were present over a period from 2002 to 2007, though different surgical fellows and residents served every year. In 2002, we treated a total of 22 patients with microtia and auricular reconstruction using surgical intervention; by 2007, this number had increased nearly 4-fold to 70 patients. Our team included support staff and nursing staff from our home institutions as well as several staff members from affiliated insti-

New Horizons in Facial Plastic Surgery

As physicians, we strive to provide our patients with the most efficacious and least disruptive treatments available. However, we are at times targeted by manufacturers touting their products as the ‘‘latest and greatest.’’ Unfortunately, many seemingly invaluable tools and techniques are proven through clinical experience to have only limited clinical utility or fall short of the promised results. As such, we have approached this ‘‘New Horizons’’ issue of Clinics with some trepidation. We have selected authors with extensive clinical experience with the techniques and technologies they describe, areas which appear to have great potential for future development and expansion. We have asked these authors to look ‘‘beyond the horizon’’ and describe developments that they believe will be in the forefront of facial plastic surgery of the future. We thank these authors and encourage the reader to use these articles as a ‘‘springboard’’ for further advancement of the art and science of facial plastic surgery. Anthony P. Sclafani, MD, FACS Guest Editor Director of Facial Plastic Surgery The New York Eye and Ear Infirmary New York, New York, USA Associate Professor of Otolaryngology— Head and Neck Surgery New York Medical College Valhalla, New York, USA