Samuel S. Becker

Revision septoplasty: review of sources of persistent nasal obstruction.

Background Patients with nasal obstruction from septal deviation commonly undergo septoplasty to improve nasal airflow. Some patients suffer from persistent obstruction after their primary septoplasty and may undergo a revision septoplasty to improve their nasal passageway. Our objective was to identify patients who underwent revision septoplasty and to identify their sources of persistent nasal obstruction. Methods Patients who underwent septoplasty at our institution between 1995 and 2005 were reviewed. Data is collected on demographics, comorbidities, age at septoplasty, associated and concomitant procedures, surgical approach, and anatomic site of obstruction. Results Five hundred forty-seven patients met inclusion criteria including 477 who underwent primary septoplasty and 70 who underwent revision surgery. Nineteen percent of nonrevision patients underwent nasal valve surgery along with their primary septoplasty versus 4% of patients in the revision group. Fifty-one percent of revision patients had nasal valve surgery at revision surgery. Patients who underwent sinus surgery along with primary septoplasty were less likely to undergo revision septoplasty. History of facial trauma, obstructive sleep apnea, site of deviation, and performance of inferior turbinate surgery did not affect the likelihood of revision septoplasty. Conclusion A significant number of patients who undergo revision septoplasty also have nasal valve collapse. We recommend that in addition to septal deviation and inferior turbinate hypertrophy, nasal valve function be fully evaluated before performing septoplasty. This will help to ensure a complete understanding of a patients nasal airway obstruction and, consequently, appropriate and effective surgical intervention.

Endoscopic Localization of the Anterior and Posterior Ethmoid Arteries

Objectives: Understanding the endoscopic locations of the anterior and posterior ethmoid arteries is important during endoscopic sinus or endoscopic skull base procedures so that these arteries can be avoided. Therefore, the objective of this study was to define the endoscopic locations of the ethmoid arteries. Methods: Twenty-four cadaver heads were used to identify the endoscopic location of the ethmoid arteries via an external incision. An image guidance system was used to record the locations of these arteries. The anterior ethmoid artery was referenced to the axilla of the middle turbinate, and the posterior ethmoid artery to the anterior wall of the sphenoid sinus. The closest lamella to these arteries was identified. Results: Forty-eight nasal cavities were dissected. The mean distance from the axilla to the anterior ethmoid artery was 17.5 mm. The anterior ethmoid artery was located immediately anterior to (31%), at (36%), or immediately posterior to (33%) the superior attachment of the basal lamella. The mean distance from the posterior ethmoid artery to the anterior ethmoid artery was 14.9 mm. The mean distance from the posterior ethmoid artery to the anterior wall of the sphenoid sinus was 8.1 mm. The posterior ethmoid artery was either anterior to (98%) or at (2%) the anterior face of the sphenoid sinus. Conclusions: Specific endoscopic anatomic relationships and measurements have been presented for the anterior and posterior ethmoid arteries.

Nasal reconstruction: the state of the art

Purpose of reviewCutaneous malignancies of the nose are common problems and create the need for nasal reconstruction within many otolaryngology practices. In spite of the fact that such reconstruction is an ancient art, there continue to be innovations and advances that allow for more predictable and functional long-term results. Recent findingsAnalyzing the nasal defect through an organized algorithm can be useful in many circumstances, especially when one needs to consider vectors of tension, minimizing alar base asymmetry, resultant scars, and preservation of the intranasal airway. Application of the principle of aesthetic subunits has greatly improved the cosmetic results for many large nasal defects, and there have been some proposals to modify the original definitions and concept. Structural reconstruction is paramount with complex defects that involve the nasal framework or with those that are located in functionally critical areas. Autogenous cartilage grafting remains the gold standard, but the use of alloplastic and homograft materials for grafting continues to be reported as an alternative. Internal lining repair is essential with larger defects and the versatility of intranasal flaps is understood, but at times not available. Other flaps have been described and may be useful on such occasions. SummaryThere are many considerations during nasal reconstruction, and the surgeon must be facile with a variety of options within his/her armamentarium.

Steroid injection for sinonasal polyps: the University of Virginia experience.

Background Sinonasal polyps are treated with topical steroids, systemic oral steroids, surgical excision, and intrapolyp steroid injection. Use of steroid injection is not widespread because of reported complications. The objective of this study was to evaluate the complications of intrapolyp steroid injections and compare it to the complications of surgical removal of polyps. Methods All patients seen between 1994 and 2003 with a diagnosis of nasal polyps were reviewed retrospectively. Demographics, complications, follow-up, and comorbidities were collected. Frequency of each treatment modality used and complications of each treatment were compared. Results Three hundred fifty-eight patients were in the study with a mean follow-up of 30 months. Respiratory comorbidities were asthma alone (35%), aspirin triad (16%), and cystic fibrosis (15%). Other comorbidities were smokers (21%). Treatment modalities were medical treatment alone (14%); medical treatment and steroid injections (19%); medical treatment and surgery (33%); and medical treatment, injections, and surgery (34%). Patients who underwent injection had fewer surgeries (p < 0.001). There was 1 minor complication associated with 1495 injections and 11 major and 16 minor complications associated with the 310 surgeries. The differences in complication rates were statistically significant (p < 0.001). There was no significant difference in demographics, follow-up, or comorbidities between patients who received injections and patients who underwent surgery. Conclusion Intrapolyp steroid injection is associated with a significantly lower rate of complication than is surgical excision of sinonasal polyps. Steroid injection also may decrease the need for further surgical intervention of polyps.

Limits of endoscopic visualization and instrumentation in the frontal sinus

BACKGROUND: Endoscopic limitations in the frontal sinus are poorly defined. We set out to define these limits. METHODS: Fifteen cadaveric heads underwent endoscopic frontal sinusotomies (Draf IIA, IIB, III). Areas of frontal sinus openings were calculated. Coordinates of the most distant points for instrumentation, visualization, and instrumentation with visualization in the frontal sinus were identified with the use of image guidance. RESULTS: Twenty-eight frontal sinuses were evaluated. The mean sinus opening areas were 47.5 mm2, 105.1 mm2, and 246.4 mm2 for Draf IIA, IIB, and III. Visualization exceeds instrumentation and visualized reach (P < 0.05) regardless of different frontal sinusotomies. Anterior and lateral instrumentation and visualized reach increase as the frontal sinus opening increases (P < 0.05). For lateral visualization, Draf III > IIB > IIA (P < 0.04). There is no statistical difference for superior visualization, instrumentation, and visualized reach among various sinusotomies (P > 0.05). CONCLUSIONS: Endoscopic visualization exceeds instrumentation and instrumentation exceeds visualized reach. Enlarging frontal sinus opening area increases instrumentation and visualization.

Risk factors for recurrent sinus surgery in cystic fibrosis: review of a decade of experience.

Background Patients with cystic fibrosis (CF) who undergo endoscopic sinus surgery often require multiple revision procedures. Our objective was to identify risk factors for revision sinus surgery in patients with CF, to better identify this subset of patients who might be better suited for alternative interventions at their initial procedure. Methods Patients with CF who presented to our academic tertiary care sinus clinic between 1994 and 2003 were reviewed. Data were collected from CT scans using the Lund-Mackay scale. Data are collected on demographics, comorbidities, CF genotype, number and type of sinus surgeries, and pulmonary function tests. Results Eighty-one patients met inclusion criteria. Fifty patients were <18 years old at presentation. Forty-one patients were Δ508 homozygotes, 32 patients were Δ508 heterozygotes, and 5 patients were non-Δ508 heterozygotes. Respiratory comorbidities were asthma alone (28%) and aspirin triad (5%). Eighteen (22%) patients either smoked or lived with smokers. The mean Lund-Mackay score before the initial surgery was 16. Twenty patients were treated with medication only; 35 patients underwent 1 surgery; 14 patients underwent 2 surgeries; 8 patients underwent 3 surgeries; 2 patients underwent 4 surgeries; and 2 patients underwent 5 surgeries. Patients with higher Lund-Mackay scores at their initial CT were more likely to undergo repeat surgeries (p < 0.05). Conclusion CF patients with high Lund-Mackay scores at their initial surgery are more likely to undergo several revision surgeries. These patients should be considered for more alternative initial management of their sinuses.

Malpractice in Head and Neck Surgery A Review of Cases

Objective To examine the sources of litigation related to the practice of head and neck surgery. Study Design Analysis of malpractice claims directly related to the diagnosis and treatment of head and neck disease provided by 16 medical liability insurance companies. Setting Not applicable. Subjects and Methods Data were obtained from 16 members of the Physician Insurers Association of America. All claims were either filed or closed between 1978 and 2007. Claims were evaluated for patient age, the cause for the claim, any surgical complications, and indemnity paid. Results Three hundred fifteen claims were identified between 1978 and 2007. The mean patient age was 48 years (median, 47 years). The greatest number of claims came from the 36- to 45-years age group (n = 68, 24.6%). Perioperative complications represented the largest cause of claims (n = 169, 53.7%), followed by delay of or missed diagnosis (n = 109, 34.6%) and persistence or recurrence of disease (n = 21, 6.7%). Among perioperative complications, nerve injuries were the largest group (n = 64, 20.3%), followed by airway-related claims (n = 27, 8.6%), esophageal injuries (n = 14, 4.4%), poor cosmetic results (n = 14, 4.4%), vessel injuries (n = 11, 3.5%), and postoperative infections (n = 2, 0.6%). Overall, mortalities resulted in 62 (19.7%) claims. Conclusions Four important risks for malpractice litigation in head and neck surgery were identified: young patient age, perioperative complications, delay of or missed diagnosis, and persistence or recurrence of disease.

Initial Surgical Treatment for Chronic Frontal Sinusitis: A Pilot Study

Objectives: The initial surgical treatment for chronic frontal sinusitis is not well defined. Our objective was to determine the effectiveness of anterior ethmoidectomy for chronic frontal sinusitis. Methods: Patients with chronic frontal sinusitis who underwent anterior ethmoidectomy as initial surgical treatment were reviewed. Data were collected from computed tomography scans with use of the Lund-Mackay scale. Data on demographics, comorbidities, management, postoperative recovery, and follow-up were collected. Results: Seventy-seven patients representing 121 diseased frontal sinuses met the inclusion criteria. The respiratory comorbidities were asthma alone (8.3%), asthma and polyps (6.6%), aspirin triad (5.8%), and cystic fibrosis (0.8%). Nineteen of 121 frontal sinuses (15.7%) belonged to smokers. Fourteen of 121 frontal sinuses (11.5%) exhibited postoperative evidence of disease. Of these 14 frontal sinuses, 10 (8.3%) underwent revision surgery. Frontal sinuses of patients with aspirin triad, with both nasal polyposis and asthma, or with inter-frontal sinus septal cells were more likely to fail Draf I surgery (p < .05). Conclusions: Anterior ethmoidectomy for drainage of frontal sinuses appears to be effective initial surgical treatment for chronic frontal sinusitis. Patients with aspirin triad, both asthma and polyposis, or inter-frontal sinus septal cells are more likely to fail this procedure.

An algorithmic approach to the evaluation and treatment of olfactory disorders.

Purpose of review To review the current evidence in diagnosing olfactory disorders and suggest an algorithmic approach to patients with relevant complaints. Recent findings New literature suggests that the incidence of olfactory loss increases with age. Age-associated olfactory loss is often multifactorial and requires careful history and physical exam. Psychophysical tests have a role in screening patients at risk for Parkinsons and Alzheimers disease, but there is lack of evidence regarding timing and patient selection. Prediction of olfactory improvement in patients with chronic rhinosinusitis (CRS) is difficult with variable results from different studies. Olfactory training is suggested to be an emerging modality in patients with postinfectious olfactory loss. Summary There is no standard treatment for olfactory loss. Each patient must be approached individually based on the suspected cause. Patients with CRS may require medical management and surgical treatment for alleviation of their olfactory dysfunction.

Malpractice Claims in Nasal and Sinus Surgery: A Review of 15 Cases

Otolaryngologists may encounter claims of medical malpractice during the course of their careers. A sample of 15 cases involving patient claims of medical malpractice relating to care delivered for problems of the nose and paranasal sinus is presented. A short summary of each case is provided, which may be useful to practicing otolaryngologists.