Nasolacrimal duct stenosis-Surgery with a novel robotic endoscope positioning system.

BACKGROUND: Distal nasolacrimal duct stenosis is usually treated by head and neck surgeons with transnasal endoscopic dacryocystorhinostomy (DCR). The presented clinical study discusses advantages and drawbacks of a robot-assisted endoscope positioning system, which allows for hands-free visualization of the surgical field. MATERIAL AND METHODS: Two patients were treated by surgical DCR. The endoscopic positioning system (Medineering® ) features a mechatronic holding arm with four segments and seven degrees of freedom. It is driven by using a foot pedal. RESULTS: Visualization and instrumentation of the surgical field including the relevant anatomical landmarks were feasible. The endoscope position could be controlled with sufficient precision. The surgeon was able to maintain bimanual instrumentation. CONCLUSION: The endoscope positioning system allows for two-handed surgery, which facilitates the essential steps of the surgical procedure. If the benefit of the system is sufficient for the use in clinical routine, it has to be evaluated in repeated applications.

[Analysis of facial asymmetry in patients with crooked noses]. / Analyse von Gesichtsasymmetrien bei Patienten mit Schiefnasen.

BACKGROUND: Surgical management of crooked nose is challenging even for experienced rhino surgeons, although numerous techniques for correction have been described. Not infrequently, there is a facial asymmetry in addition to the crooked nose influencing the aesthetic results of the operation. Therefore, the purpose of this study was to determine how often there is an asymmetry of the face in addition to a crooked nose. MATERIAL AND METHODS: Retrospectively the data of 607 patients with a crooked nose (304 women, 303 men, mean age 30 years) were evaluated. The preoperative photos of the face were anthrometrically assessed based on angle measurements. RESULTS: 382 of the 607 patients had a c-shaped (63 %) and 225 an i-shaped (37 %) crooked nose. More than three-quarters of the patients had facial asymmetry in respect to the connecting line of the pupils and nasal base line. 49 % of patients reported a history of nasal trauma, but this had no relevant influence on the frequency of facial asymmetry. CONCLUSIONS: Pre-existing facial asymmetry is very common in patients with crooked nose and can significantly affect the aesthetic outcome of nasal surgery. This should be addressed as part of the informed consent. In particular, it should be mentioned that the surgical outcome can remain below the patient's aesthetic expectations. Not rarely, a revision surgery may be necessary.

Surgery of Anterior Skull Base Lesions in Children.

INTRODUCTION: Lesions affecting the anterior skull base represent a rare group of craniofacial pathologies. A tumor of the facial midline, meningitis, or rhinoliquorrhea may be indicative of malformations like dermoid cysts, gliomas, encephaloceles, or nasal fistulas. METHODS: We present a case series of 13 children (4 months to 12 years; 8 males, 5 females) with lesions involving the anterior skull base, which were treated surgically in an interdisciplinary setting. This case series includes cases of nasal fistulae (n = 5), nasal cysts (n = 5), aneurysmal bone cyst, nasal glioma, and meningoencephalocele (n = 1). RESULTS: All lesions were resected with a transnasal, transcutaneous, and/or transcranial approach with reconstruction of the anterior skull base if intracranial/intradural extension was detected. In 5 cases, a dura leakage was visible, which was sealed via Onlay-technique in 3 cases, whereas in 2 cases involving a greater dural defect, the GAP-CAS technique was performed. No complications occurred, and no recurrence was visible in a long-term follow-up. An algorithm for a systematic approach to these various pathologies is provided. CONCLUSION: Congenital pathologies of the anterior skull base are rare, challenging to diagnose, and present as clinical emergencies. An interdisciplinary surgical approach is needed for best functional and aesthetic results.

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.

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.

Surgery of the turbinates and "empty nose" syndrome.

Surgical therapy of the inferior and/or middle turbinate is indicated when conservative treatment options have failed. The desired goal is a reduction of the soft tissue volume of the turbinates regarding the individual anatomic findings, whilst simultaneously conserving as much mucosa as possible. As the turbinates serve as a functional entity within the nose, they ensure climatisation, humidification and cleaning of the inhaled air. Thus free nasal breathing means a decent quality of life, as well.Regarding the multitude of different surgical techniques, we confirm that no ideal standard technique for turbinate reduction has been developed so far. Moreover, there is a lack of prospective and comparable long-term studies, which makes it difficult to recommend evidence-based surgical techniques. However, the anterior turbinoplasty seems to fulfil the preconditions of limited tissue reduction and mucosa-preservation, and therefore it is the method of choice today.Radical resection of the turbinates may lead to severe functional disturbances developing a secondary atrophic rhinitis. The "empty nose" syndrome is a specific entity within the secondary atrophic rhinitis where intranasal changes in airflow result in disturbed climatisation and also interfere with pulmonary function. Results deriving from an actual in vivo study of climatisation and airflow in "empty nose" patients are presented.

Lower airway humidification in spontaneously breathing tracheostomized patients: comparative study of trachea spray versus heated humidifier.

BACKGROUND: Our aim was to compare inhalation with molecular water (vaporizing humidifier) and particulate water (trachea spray) in spontaneously breathing tracheostomized patients. METHODS: We performed a randomized, 2-way crossover study and a prospective, comparative, nonblinded study. Tracheal humidity and temperature were measured before and after use of a humidifier and spray for 1 week. RESULTS: After both inhalation and spray, the tracheal temperature and total water content increased significantly (study 1). The temperature gradient between ambient and tracheal air was significantly higher after spray, but not after inhalation (study 2). The water gradient increased nonsignificantly after spray and inhalation. The water gradient after inhalation or spray did not differ significantly. CONCLUSIONS: Molecular water is not superior to particulate water because of temperature and humidity increase after both forms of water delivery. Because of its easy use, portability, and moisturizing effect, a trachea spray may offer additional options in postoperative tracheostomy care.

Nasal mucosal temperature in relation to nasal airflow as measured by rhinomanometry.

BACKGROUND: The aim of this study was to measure in vivo nasal mucosal temperature and assess its relationship to nasal patency. METHODS: Nasal mucosal temperature of 30 nasal cavities was measured by means of a miniaturized thermocouple within the anterior turbinate area during respiration. Temperature values were compared with corresponding rhinomanometrical data. RESULTS: The median mucosal temperature ranged from 30.2 degrees C (range, 28.9-31.7 degrees C) after inspiration to 32.2 degrees C (range, 31.0-33.9 degrees C) after expiration. The end-inspiratory (r = -0.85) and end-expiratory mucosal temperature values (r = -0.88) negatively correlated with the rhinomanometrical data. CONCLUSION: This study supports the fact that there is a negative correlation between nasal mucosal temperature and nasal resistance. Changes in nasal patency seem to influence nasal mucosal temperature. Within this context, nasal thermoreceptors might play an important role concerning the perception of nasal patency.

Operative treatment of functional facial skin disorders.

The skin is the principal interface between the body and the surrounding world and thus serves as a protective barrier against trauma, temperature extremes and radiation. With receptors for pressure, movement, heat and cold, it also acts as sensory organ and through sweat secretion plays a role in thermoregulation and electrolyte metabolism. Not all of these functions are relevant to facial skin, however, cosmetic aspects are of vital importance.Disorders primarily affect the protective skin function in defect and scar areas. For operative correction, the following principles should be applied: Minimization of scar development by adherence to indicated incision lines in the face, preferred use of local skin flaps for defect coverage in order to obtain optimal results regarding texture, complexion and sensitivity of skin, as well as consideration of aesthetic units. Recent developments in this field are tissue culture, occlusive dressings, and the use of growth factors. Age-related skin changes with impairment of cosmetic function are characterized by the development of creases and looseness of skin. Rejuvenation has become an important segment of skin surgery. For surface treatment, especially of creases and acne scars, various types of laser treatment are employed. Deeper lines can be filled with filler materials. The integration of the superficial musculoaponeurotic system (SMAS) into face lift procedures has lead to more viable and natural results. Due to protruding tissue, blepharoplasty of the upper lid is often carried out in combination with forehead lift and eyebrow lift procedures.The optimized use of growth factors and synthetic materials, which serve as a matrix, are aimed at skin replacement which mimics the quality and functions of skin as closely as possible. On the whole, however, the reconstruction of defect through local tissue transfer is still considered as the treatment of choice.