A prospective study of 113 deep neck infections managed using a clinical practice guideline.

OBJECTIVES/HYPOTHESIS: Retropharyngeal abscesses are a difficult to diagnose condition in children. Though some children with such abscesses can be managed with intravenous (IV) antibiotics alone, our group has argued that surgical drainage is the gold standard for safe management and likely leads to shorter hospital stays. We present prospective data on children with retropharyngeal infections who were managed according to a clinical practice guideline that emphasizes reliance on computed tomography and prompt surgical drainage when pus is felt to be present. STUDY DESIGN: Prospective observational study at a tertiary care children's hospital. METHODS: Children were included in the study if a retropharyngeal infection was suspected and they were treated according to the clinical guideline between July 2001 and March 2004. RESULTS: Of 111 children in the study, 73 were ultimately treated with incision and drainage. There was no long-term morbidity or mortality. Surgical patients were more likely to require an intensive care unit (ICU) admission than patients managed with IV antibiotics alone (26.0% vs. 5.3%, P < .01) and on average cost nearly $8,000 more ($22,071 and $14,950; P < .01). However, these results may be biased, as patients requiring surgery were younger, which likely influenced the decision for ICU admission. CONCLUSIONS: It is possible to treat pediatric retropharyngeal infections according to our clinical guideline with nearly zero long-term morbidity and mortality. Our data showed good outcomes for both groups, and substantially higher costs for patients treated surgically. These results cannot be regarded as definitive, because surgery was consistently advised for all patients with suspected pus, and because the surgical group was younger than the nonsurgical group.

Metrics of nasal tip rotation: a comparative analysis.

OBJECTIVE: We introduce a new metric for measuring nasal tip rotation, the "columellar facial angle." The present study aimed to determine the degree of correlation of the nasolabial angle, the nostril axis, and the columellar-facial angle as metrics of nasal tip rotation in healthy volunteers. The study also aimed to identify any nasal or facial features unrelated to tip position, which consistently altered these values. METHODS: Lateral photographs in the Frankfort horizontal plane were taken of 100 volunteers. Measurements of tip rotation were then calculated for each model using three different methods: nasolabial angle, nostril axis, and columellar-facial angle. Data were analyzed for degree of correlation of the three values for all models. Facial features in those subjects with low correlation between measurement methods were analyzed. RESULTS: For all grouped data, both the nasolabial angle and the nostril axis showed moderate correlations with columellar facial angle but no correlation with each other. Individual subjects whose measurements did not correlate tended to display certain anatomic features: premaxillary deficiency, premaxillary excess, sloped upper lips, or vertical malposition of the nostrils. CONCLUSIONS: No one method of measurement of nasal tip rotation is reliable for all patients. Certain nasal and facial features are likely to alter these values. Of the three measurement methods presented, the columellar-facial angle is most likely to yield consistent measurements of nasal tip rotation.

Biomechanical strength of human nasal septal lining: comparison of the constituent layers.

OBJECTIVE/HYPOTHESIS: Nasal septal perforation is a common complication following surgery involving the nasal septum. Septoplasty, septorhinoplasty, and submucosal resection may result in the inadvertent resection of perichondrium, which may predispose the patient to septal perforations. STUDY DESIGN: Controlled human cadaver study testing the biomechanical strength of the constituent layers of nasal septal lining. METHODS: Uniform samples of nasal septal mucosa, perichondrium, and a composite of both layers were obtained from five fresh human cadavers. The mechanical tensile strength of these layers was evaluated and compared with the Instron 4301 Mechanical Testing System (Canton, MA). RESULTS: Mixed-effects regression analysis demonstrated a significant difference in the tensile strength of the three groups (mean values +/- SD: mucosa, 662 +/- 308 g; perichondrium, 1370 +/- 798 g; composite, 2340 +/- 1252 g). All three pairwise comparisons among the three groups showed a significant difference in tensile strength. CONCLUSION: The perichondrial layer imparts the majority of the biomechanical strength to septal lining. Lining flaps containing both perichondrium and mucosa are stronger than flaps with either perichondrium or mucosa alone. Dissection in the subperichondrial plane during septal surgery provides a stronger septal flap and may prevent the development of nasal septal perforation during nasal surgery.

A novel intranasal stent for functional rhinoplasty and nostril stenosis.

OBJECTIVES/HYPOTHESIS: The surgical correction of nostril stenosis and external nasal valve collapse typically involves the addition of tissue to widen and strengthen these areas. However, over the ensuing months, postoperative scar contracture may act to reverse the surgical modifications. This study aimed to determine the safety and efficacy of the use of nasal stents fashioned from a nasopharyngeal airway tube to prevent postoperative contracture at these sites. STUDY DESIGN: Retrospective review of six patients who underwent functional rhinoplasty with alar batten graft placement for nasal valve collapse and one patient who underwent composite graft repair of unilateral nostril stenosis. METHODS: Patients completed a survey inquiring about the ease of use, discomfort, presence of infection, and ability to breathe with these nasal stents. Patients also completed the NOSE (nasal obstruction symptom evaluation) instrument to compare their overall level of preoperative and postoperative nasal breathing. The functional rhinoplasty patients were examined for degree of dynamic airway nasal wall collapse and position of the lateral nasal wall on intranasal examination. RESULTS: Six of seven patients overall reported no to minimal discomfort, easy application, and no to minimal obstruction of nasal breathing with the use of the stents. One patient reported difficulty with application. Preoperative NOSE scores averaged 67.1 (SD 10.4), 18.6 (SD 14.6) at the time of splint removal, and 21.4 (SD 15.2) at 3 months after stent removal. Paired t test analysis showed significant differences between the NOSE scores preoperatively as compared with the time of splint removal (P = .0002) or 3 months after splint removal (P = .0003). All patients demonstrated a significant reduction of lateral nasal wall collapse with inspiration on physical examination. CONCLUSIONS: The use of nasal stents made from nasopharyngeal airway tubes is a safe, convenient, and economic treatment for the prevention of contracture after surgical correction of nostril stenosis or nasal valve insufficiency.