Computed tomography-based training model for otoplasty.

Otoplasty for the correction of protruding ears is characterized by various techniques and a common and popular cosmetic procedure. For the surgeon, whether beginner or advanced, it is essential to understand the principles and master techniques for standard auricular deformities before applying further sophisticated methods, because a lot of complications and failures are caused by wrong indication and incorrect surgical techniques. The different surgical steps are best learned from teaching models. Therefore, we developed two different silicone models of protruding ears with moderate auricular deformities: one with conchal hyperplasia for the training of conchal resection, and one without antihelix for creating an antihelical fold by suturing technique, based on computed tomography scans of patients. The silicone ear models were evaluated during four standardized surgery courses for residents in otorhinolaryngology by 91 participants using specially designed questionnaires. Nearly all participants rated the training on the auricular models as very helpful (n = 51) or good (n = 31); the scores for the different techniques and properties of the models ranged from 2.0 to 2.6 in a range from 1 (very good) to 4 (inadequate). The good results demonstrate the possibility for learning different surgical otoplasty techniques with this newly designed teaching tool.

The intranasal Schirmer test: a preliminary study to quantify nasal secretion.

Adequate secretion of the nasal mucosa is essential for normal nasal physiology. A "dry" nose is a frequent complaint of ENT patients. Measurement of secretion is currently impossible because of the absence of a recognized test. The aim of the present study was to investigate the feasibility of an intranasal Schirmer test in a large number of patients and to define standard values for nasal secretion. The test population comprised 159 healthy, non-smoking volunteers and 30 healthy smoking volunteers. All subjects were examined by nasal endoscopy for anatomic or mucosal disease. A Schirmer test strip was placed on both sides of the mucosa of the anterior nasal septum by anterior rhinoscopy. After 10 min in standardized conditions, the strip was removed and the wetted distance was measured. Active anterior rhinomanometry (ARR) and acoustic rhinometry (AR) were later performed. In the non-smoking group (n = 159), the median wetting distance of the test strip was 10.3 mm (range 3.6-35.0 mm). Age, gender, nasal geometry, and flow (according to ARR and AR) had no significant influence on nasal secretion. The test for normal distribution was negative. In the smoking group (n = 30), the median wetting distance was 8.4 mm (range 2.5-28.0 mm), significantly shorter than the wetting distance in the non-smoking group (p < 0.05). The Schirmer test offers a practical method to quantify mucosal humidification. The test is inexpensive and well tolerated by patients. In healthy people, wetting distances from 6 to 18 mm are considered normal.

Numerical simulation of airflow patterns in nose models with differently localized septal perforations.

OBJECTIVES/HYPOTHESIS: The most typical complaints of patients with nasal septal perforation (SP) are nasal obstruction, crusting, and recurrent epistaxis depending on the size and site of the SP mainly due to disturbed airflow patterns. The objective of the study was to determine the influence of differently localized SPs on intranasal airflow patterns during inspiration by means of numerical simulation. STUDY DESIGN: An experimental setup using three dimensional computer models of a human nose was created. Four different models with three differently localized septal perforation allowed an examination of intranasal airflow changes. METHODS: Four high-resolution, realistic, bilateral computer models of the human nose with three differently localized SPs were reconstructed based on computed tomography. A numerical simulation was performed. The intranasal airflow patterns (path lines, velocity, turbulent kinetic energy) during inspiration were displayed, analyzed, and compared. RESULTS: SPs cause a highly disturbed airflow in the area of the SP and behind. A spacious vortex within the perforation, including various localized vortices, was detected. The airflow in the nose was disturbed to varying degrees depending on the location of the perforation. SPs within the anterior caudal septum in area II led to increased negative turbulences and crossflow. CONCLUSIONS: The numerical simulations demonstrate significantly disturbed intranasal airflow patterns due to SPs. This fact may contribute to crusting and nosebleed due to dehydration of the nasal mucosa. The location and size of the SP are crucial for the impact on disturbed airflow pattern and therefore the patients' complaints. Anterior caudal SPs seem to be the worst. Surgical closure of SPs or simply changes in the site and size of the SP if a complete closure is surgically impossible makes sense.

The auricle's cavum conchae composite graft in nasal reconstruction.

BACKGROUND: Autologous transplants consisting of skin and cartilage, so-called composite grafts (CGs), are useful in nasal reconstruction of multilayered defects. A CG from the auricle's cavum conchae serves both functional and esthetic demands. This article outlines the indications and the requirements of the CG, making special considerations to improve wound healing, and discusses our results in consideration with recent publications. METHODS: A retrospective case-control study assessing the functional and esthetic long-term results in the donor and recipient site is presented. RESULTS: Between 2005 and 2011, 91 patients received differently sized CGs of the auricle for nasal reconstruction. In 85/91 cases the donor site defect was closed using a retroauricular pedicled island flap. Six of 91 defects were closed primarily. Indications were multilayered defects of the nasal vestibule, the nasal floor, the inner nasal valve, and the lateral sidewall. The main indication for surgery was skin malignancies. One of 91 major and 14/91 minor complications were observed. Seventy-seven of 91 patients received a custom-made prosthesis to prevent stenotic scarring. The 2.5-year follow-up showed excellent results of stability and shape at the donor and recipient site. CONCLUSION: The auricular inner lining CG is a versatile and reliable autologous transplant, which is ideal for multilayered nasal reconstruction because of easy harvesting, little donor site morbidity, and its convex shape. Septal splints and custom-made prosthesis secure healing and prevent stenotic scarring.

Detection of paranasal ectopic adrenocorticotropic hormone-secreting pituitary adenoma by Ga-68-DOTANOC positron-emission tomography-computed tomography.

Ectopic adrenocorticotropic hormone (ACTH)-secreting tumors account for approximately 10% of Cushing's syndrome (CS). We present an extremely rare case of a patient with CS caused by an ectopic ACTH-secreting pituitary adenoma (EAPA) of the ethmoid sinus. The tumor was identified by positron-emission tomography-computed tomography (PET/CT) using the somatostatin receptor analogue Ga-68-DOTANOC. Transnasal endoscopic resection was performed and the patient showed significant clinical improvement with normalization of the endocrine pituitary axis. Immunostaining showed a somatostatin receptor 2 and 5-positive ACTH-producing adenoma. In patients with ectopic ACTH secretion, Ga-68-DOTANOC-PET/CT may play an important role in the localization of EAPA. Transnasal endoscopic resection is the therapy of choice.

Telomere shortening impairs regeneration of the olfactory epithelium in response to injury but not under homeostatic conditions.

Atrophy of the olfactory epithelium (OE) associated with impaired olfaction and dry nose represents one of the most common phenotypes of human aging. Impairment in regeneration of a functional olfactory epithelium can also occur in response to injury due to infection or nasal surgery. These complications occur more frequently in aged patients. Although age is the most unifying risk factor for atrophic changes and functional decline of the olfactory epithelium, little is known about molecular mechanisms that could influence maintenance and repair of the olfactory epithelium. Here, we analyzed the influence of telomere shortening (a basic mechanism of cellular aging) on homeostasis and regenerative reserve in response to chemical induced injury of the OE in late generation telomere knockout mice (G3 mTerc(-/-)) with short telomeres compared to wild type mice (mTerc(+/+)) with long telomeres. The study revealed no significant influence of telomere shortening on homeostatic maintenance of the OE during mouse aging. In contrast, the regenerative response to chemical induced injury of the OE was significantly impaired in G3 mTerc(-/-) mice compared to mTerc(+/+) mice. Seven days after chemical induced damage, G3 mTerc(-/-) mice exhibited significantly enlarged areas of persisting atrophy compared to mTerc(+/+) mice (p = 0.031). Telomere dysfunction was associated with impairments in cell proliferation in the regenerating epithelium. Deletion of the cell cycle inhibitor, Cdkn1a (p21) rescued defects in OE regeneration in telomere dysfunctional mice. Together, these data indicate that telomere shortening impairs the regenerative capacity of the OE by impairing cell cycle progression in a p21-dependent manner. These findings could be relevant for the impairment in OE function in elderly people.

Ear, nose, and throat effects of high altitude.

High altitude changes human physiology and can result in illnesses such as acute mountain sickness, high-altitude cerebral edema, and high-altitude pulmonary edema. The physiological impacts of high-altitude illnesses occur secondary to extravasation of fluid from the intravascular space into the extravascular space during a rapid ascent. Headache, hearing disturbances, vestibular disturbances, epistaxis, sleep apnea, coughing, respiratory tract infections, and nasal obstruction are main ear, nose, and throat complaints of individuals travelling to high altitude. These complaints can cause delays or cancelations in a person's climbing plans. In this article, we review the ear, nose, and throat effects of high altitude based on the relevant literature.

Auricular keloids: treatment and results.

The aim of this study was to present long-term results in patients with auricular keloids after surgical excision and/or medical therapy by corticoid injection. A retrospective study at an academic tertiary referral centre is presented. Seventeen patients after excision, injection of corticoid, full skin grafting (single therapy or combination of interventions) for auricular keloids were followed up. The validated questionnaires SF-36 and patient outcomes of surgery-head/neck were applied to evaluate the quality of life and the patients' satisfaction after therapy. Photographs of the former keloid site were rated by an experienced facial plastic surgeon being unaware of treatment method and the patient's own estimation. The best results for retroauricular keloids were reached by excision, skin grafting and triamcinolone injection, and for earlobe keloids by excision, primary wound closure and triamcinolone injection. Both in rating by the patients and in grading by an investigator, the highest scores for aesthetics and satisfaction were found after triamcinolone injection together with or without excision or skin grafting. A size-related resection of keloids with defect reconstruction by full thickness skin grafting for retroauricular keloids and primary wound closure of ear lobe keloids with an additional steroid injection lead to good cosmetic results and high level of satisfaction among patients.

The impact of nasal surgery on air-conditioning of the nasal airways.

Air-conditioning in the nasal passageways is one of the most important functions of the upper airways. By means of in-vivo-measurements and numerical simulation, the air-conditioning function of the nose has been extensively investigated. Less well known is the effect of nasal surgery on the nasal climate. The following study presents a summary of the effect of various rhino-surgical operations, i.e. turbinoplasty, septoplasty, septorhinoplasty, repair of septal perforations, functional and radical sinus surgery, on the air-conditioning function of the nose. Nasal and sinonasal interventions have been demonstrated to be associated with increased nasal heating and humidification when the mucosal lining is preserved. Radical interventions with reduction of turbinate tissue cause reduced nasal warming and moistening within the nasal airway, with increased risk of nasal dryness and crusting. Although the impact of the nasal cycle and the airflow distribution within the nasal cavity on nasal temperature and humidity distribution is not fully understood yet, too much widening of the nasal cavity by sinunasal interventions has carefully to be avoided.

Effects of nasal mask leak and heated humidification on nasal mucosa in the therapy with nasal continuous positive airway pressure (nCPAP).

The purpose of this study was to determine the objective short-term influence of nasal continuous positive airway pressure (nCPAP) therapy, nasal mask leak (NML) and heated humidifiers (HH) to nasal conditioning of spontaneously breathing subjects. This was a prospective, non-randomized, non-blinded day-time study. Eighteen healthy subjects were enrolled in the study. All subjects received nCPAP therapy for 60 min in three different conditions successively: (1) nCPAP without humidification, (2) nCPAP with a defined leakage of nasal mask (slashed circle 28.3 mm2) and (3) nCPAP with HH. Nasal humidity and temperature were measured in the anterior turbinate area using a miniaturized thermocouple and a relative humidity sensor. The measurements were accomplished at the beginning of therapy, after 60, 120 and 180 min. Absolute humidity (aH) in the anterior turbinate area decreased significantly (p = 0.0075) from 17.41 +/- 3.81 mg/l (baseline) to 15.27 +/- 2.21 mg/l (nCPAP alone). With attachment of a NML, aH decreased from 15.27 mg/l not significantly (p = 0.058) to 13.77 +/- 2.28 mg/l (nCPAP and NML) compared to nCPAP alone. After addition of heated humidification to nCPAP, aH increased again from 13.77 mg/l significantly (p = 0.042) to 15.29 +/- 3.51 mg/l (nCPAP and HH) compared to aH (nCPAP+NML). No difference was found between aH (nCPAP and HH) and aH (nCPAP alone). Airway temperature did not change significantly after application of nCPAP alone, nCPAP and NML, and nCPAP and HH. These data indicate that nCPAP therapy with NML tends to have more remarkable reduction of the nasal humidity than nCPAP therapy without NML. nCPAP with heated humidifier is able to compensate the dehydration effects induced by nCPAP therapy with NML by increasing the aH at the anterior turbinate area to the levels observed during breathing with nCPAP alone.

Nasal conditioning after endonasal surgery in chronic rhinosinusitis with nasal polyps.

BACKGROUND: Endoscopic sinus surgery (ESS) is a frequently performed operation for chronic rhinosinusitis (CRS). The aim of this study was to investigate nasal conditioning after ESS with/without septoplasty and turbinoplasty in patients with CRS with nasal polyps and to determine its relation to nasal patency and geometry. METHODS: Twenty-one patients were enrolled into this study. Nasal conditioning, AAR, and acoustic rhinometry were measured before and 4-8 months after endonasal surgery. RESULTS: The temperature and humidity gradient across the nose increased significantly after operation. High nasal volumes and patency were positively correlated with elevated nasal conditioning. No correlation between preoperative and postoperative changes in nasal geometry and nasal airflow with changes in conditioning values was found. CONCLUSION: Patients with CRS with nasal polyps seem to profit from ESS with/without septoplasty and turbinoplasty because nasal conditioning is improved postoperatively. Properly performed ESS has its importance within the variety of nasal surgical procedures ensuring improved nasal function.

Diagnostic accuracy of peak nasal inspiratory flow and rhinomanometry in functional rhinosurgery.

OBJECTIVES: Sensitivity and specificity of active anterior rhinomanometry (RMM) and peak nasal inspiratory flow (PNIF) in the diagnosis of functionally relevant structural nasal deformities should be assessed. The reference standard was clinical judgment based on all clinical data available. STUDY DESIGN: Prospective study of diagnostic accuracy at a tertiary rhinologic referral center. METHODS: RMM and PNIF were performed on 53 patients with symptomatic nasal stenosis and 40 healthy volunteers. Cut-offs for RMM and PNIF were defined by receiver operating characteristic analysis. RESULTS: A cut-off between normal and pathological of 700 mL/second for RMM at a transnasal pressure difference of 150 Pa, and of 2,000 mL/second (120 l per minute) for PNIF was calculated. No significant differences in terms of sensitivity of RMM and PNIF (0.77 vs. 0.66), specificity (0.8 vs. 0.8) and diagnostic accuracy (0,79 vs. 0.72) were found. CONCLUSION: RMM and PNIF provide valuable information to support clinical decision making. However, with both methods, approximately 25% of symptomatic patients with functionally relevant nasal structural deformity were not detected. A negative test outcome of RMM or PNIF does not exclude a functionally relevant nasal stenosis.

The impact of septorhinoplasty and anterior turbinoplasty on nasal conditioning.

BACKGROUND: Septorhinoplasty and turbinoplasty is a frequently performed operation in facial plastic surgery. The aim of this study was to investigate nasal conditioning after septorhinoplasty and inferior turbinoplasty in patients with internal and external nasal deformities and hypertrophy of the inferior turbinates and to determine its relation to nasal patency. METHODS: Ten patients and 10 volunteers as controls were enrolled into this study. Measurement of nasal conditioning and active anterior rhinomanometry were performed before and 4-6 months after functional-esthetic septorhinoplasty and inferior turbinoplasty. RESULTS: Nasal airflow was significantly higher postoperatively than preoperatively. The preoperative nasal temperature (TEMP) and heat increase (HI) was lower in the patients compared with the controls. The postoperative TEMP, HI, total water content, and water gradient were significantly higher than the preoperative values. CONCLUSION: Based on this relatively small series, functional-esthetic septorhinoplasty in combination with inferior turbinoplasty may be associated with improved nasal conditioning.

Influence of nasal sponges on patients' complaints after nasal and sinus surgery.

BACKGROUND: The goal of this study was to investigate the effect of nasal sponges on the subjective nasal well-being after nasal and sinus surgery. METHODS: The study was designed as a randomized prospective clinical trial comparing four different types of sponges used as nasal passive humidifiers (NPHs). The 40 participants were blinded to the size and pore structure of the NPHs. The NPHs were applied in both nostrils for 1 hour on the 2nd postoperative day. Subjective nasal sensations were evaluated on a visual analog scale. RESULTS: Wearing comfort was rated as satisfactory. Intranasal humidity and feeling of a dry nose were rated as improved after wearing the NPHs. CONCLUSION: The use of NPHs may have a positive effect on the patients' perception of nasal obstruction and intranasal humidity. Additional investigations in patients with intranasal dryness are planned to improve patients' complaints.

Risks and complications in rhinoplasty.

Rhinoplasty is regarded to be associated with many risks as the expectations of patient and physician are not always corresponding. Besides of postoperative deformities many other risks and complications have to be considered. Reduction-rhinoplasty e.g. can cause breathing disturbances which are reported in 70% of all revision-rhinoplasty-patients. One has to be aware however that scars and loss of mucosal-sensation can also give the feeling of a "blocked nose". The main risks of autogenous transplants are dislocation and resorption, while alloplasts can cause infection and extrusion. In this respect silicone implants can have a complication rate between 5-20%. Less complications are reported with other materials like Gore-Tex. Complications of skin and soft tissues can be atrophy, fibrosis, numbness, cysts originating from displaced mucosa or subcutaneous granulomas caused by ointment material. Postoperative swelling depends mainly on the osteotomy technique. Percutaneous osteotomies cause less trauma, but may result in visible scars. Infections are rare but sometimes life-threatening (toxic-shock-syndrome). The risk is higher, when sinus surgery and rhinoplasty are combined. Osteotomies can also cause injuries of the orbital region. Necrosis of eye-lids by infections and blindness by central artery occlusion are known. There are reports on various other risks like rhinoliquorrhea, brain damage, fistulas between sinus-cavernosus and carotid artery, aneurysms and thrombosis of the cavernous sinus. Discoloration of incisors are possible by damage of vessels and nerves. Rhinoplasty can also become a court-case in dissatisfied patients, a situation that may be called a "typical complication of rhinoplasty". It can be avoided by proper patient selection and consideration of psychological disturbances. Postoperative deformities are considered as main risks of rhinoplasty, causing revision surgery in 5% to 15% of the cases. The analysis of postoperative deformities allowes the identification of specific risks. The most frequent postoperative deformity is the "pollybeak" when a deep naso-frontal angle, cartilaginous hump and reduced tip projection are present preoperatively. The pollybeak is the indication in about 50% of all revision rhinoplasties. Other frequent postoperative deformities are a pendant and wide nasal tip, retractions of the columella base or irregularities of the nasal dorsum. These deformities are very often combined and caused by a loss of septal support. This is why the stability of the caudal septum in septorhinoplasty is the key for a predictable result. Maintaining the position of the tip and the columella is one of the main issues to avoid typical postoperative deformities. The risks for rhinoplasty-complications can be reduced with increasing experience. A prerequisite is continuing education and an earnest distinction between complication and mistake.

Complications in septoplasty.

The most frequent complications of septoplasty are deformities, infections, and perforations. The effects of each of these complications, however, can be very different. Dislocations and deformities of the septum may result not only in an impaired airway but also in visible deformities of the entire nasal base and dorsum. A patient who underwent septoplasty can be "stigmatized." Infections may lead not only to septal abscess but also to endocranial complications such as meningitis or septicemia with endocarditis. Permanent perforations of the nasal septum can result in significant symptoms if they are located in the anterior part of the nose. Surgical closure is the treatment of choice, with a high success rate if the patients are selected properly. Besides these three major types of complications there are many others, from smell disturbances to blindness. Causes, prevention, and correction of selected complications are presented and data of the recent literature reported.

Influence of passive humidification on nasal conditioning.

BACKGROUND: Passive humidifiers (PH) have been beneficial to upper and lower airway humidity, especially in patients who are in a long-time ventilated intensive care unit. The goal of this pilot study was to provide nasal conditioning data and measure the benefit of a nasal PH to spontaneously breathing, conscious subjects. METHODS: Eleven healthy volunteers had to wear a PH for 1 hour, which was introduced into both nasal vestibules. The PH had a heat and moisture restoring body of polyurethane foam with an open-pore structure. Before and after application of the nasal PH, nasal conditioning was measured and nasal symptoms were assessed by the participants. RESULTS: Ten minutes after removal of the PH a significant increase was observed for the scores for nasal patency and nasal humidity. CONCLUSION: We hypothesize that the nasal PH could provide a valuable contribution to the supportive therapy of diseases that accompany nasal mucosal dryness.

Radiofrequency-induced thermotherapy on nasal polyps: preliminary results.

BACKGROUND: The aim of this study was to determine the effects of radiofrequency-induced thermotherapy (RFITT) in patients with nasal polyps. METHODS: A retrospective analysis was performed of prospectively collected data from 17 consecutive patients (11 men and 6 women; mean age, 51.7 +/- 16.9 years) treated with RFITT from 2002 to 2003. The postoperative outcome was assessed using active anterior rhinomanometry, "sniffin' stick" test, and endoscopic nasal examination preoperatively and 4 weeks postoperatively. Subjective complaints were assessed with Likert scales. RESULTS: Transnasal airflow increased by 40.3% 4 weeks postoperatively (p = 0.029). Endoscopic appearance of nasal polyps indicated a nonsignificant reduction of 37.1%. Subjective complaints such as impaired nasal ventilation (p = 0.014), nasal discharge (p = 0.0007), postnasal drip (p = 0.0002), and hyposmia (p = 0.048) improved significantly 4 weeks after surgery. CONCLUSION: RFITT is well tolerated as a day case procedure under local anesthesia and might be a procedure for treating recurrence of NP after sinus surgery. It remains unclear at this point whether RFITT for nasal polyps results in a permanent reduction.