Septal Perforation Repair Using a Temporoparietal Fascia and Polydioxanone Plate Construct: A Multi-Institutional Analysis.

Background: Nasal septal perforations (NSPs) are notoriously difficult to fix and closure can paradoxically lead to worsening of symptoms, prompting numerous techniques for repair including temporoparietal fascia (TPF)-polydioxanone (PDS) plate interposition grafting. Objectives: To compare rates of NSP closure with TPF-PDS interposition grafting among a variety of institutions with diverse environmental influences and patient-specific factors. Methods: Retrospective review of patients undergoing TPF-PDS interposition grafting at seven different U.S. institutions over 5 years. Outcomes include closure rate, self-reported symptom improvement, change in Nasal Obstruction Symptomatic Evaluation (NOSE) score, and postoperative complications. Results: Sixty-two patients (39 female) with a mean age of 41.5 years were included. Most common perforation location was anterior (53%), and average size was 1.70 cm2. NSP closure with symptomatic improvement was achieved in 95% of participants. Postoperative NOSE scores decreased on average by 42 points. Residual crusting occurred in 29% of patients, independent of external factors. Conclusions: TPF-PDS interposition grafting is highly effective for NSP repair in a wide variety of settings, and NOSE scores correspond well with patient-reported outcomes.

Optimizing Flap Harvest in Auricular Reconstruction.

INTRODUCTION: The temporoparietal fascial (TPF) and occipital cranial fascial (OCP) flaps are the mainstay of implant coverage in alloplastic auricular reconstruction. Their optimal design is critical for elevating a robust flap that ultimately leads to favorable outcomes. MATERIALS AND METHODS: Sixteen TPF and OCP dissections were performed on 8 cadaveric specimens. Vascular anatomy and key landmarks were documented. The minimum flap size that incorporated ideal vasculature and would appropriately cover a porous polyethylene implant was measured. RESULTS: The minimum flap dimensions (length × width × base width) to cover a standard PPE auricular implants were on average 11×8.3×6.4 cm for TPF and 13.1×8.6×6.5 cm for OCP. The average axial length of the superficial temporal artery and occipital artery were 12.51 and 13.2 cm, respectively. An "occipital elbow" was located on average 8.2 cm posterior to the external acoustic canal. The postauricular fascia contained additional contributions from the occipital artery and mastoid emissary vein, which was located on average 5.9 cm posterior to the superficial temporal artery. CONCLUSIONS: This study highlights the anatomic features behind optimal TPF and OCP flap design for auricular reconstruction. Contributions to axial length and anatomic relationships of their primary arterial supply, significance of the occipital elbow as a reliable landmark for fascial dissection, and importance of the postauricular fascia and its vascular supply for flap viability are emphasized. Ultimately, the authors provide minimal dimensions for both TPF and OCP flaps to obtain adequate alloplastic implant coverage.

Complications Associated with Use of Porous High-Density Polyethylene in Rhinoplasty.

Background: Porous high-density polyethylene (pHDPE) has successfully been used as an alternative to cartilage for grafting in rhinoplasty; however, concerns exist surrounding its potential for infection and/or extrusion. Objectives: To analyze the relationship between complication rates associated with pHDPE in rhinoplasty and graft location relative to shear force applied by external manipulation. Methods: Retrospective review of 116 patients undergoing pHDPE rhinoplasty for 10 years. Results: Minor postoperative complications occurred in 3.4% of patients, each resolving with conservative management. Major complications including infection or extrusion occurred in 5.2% of all patients, at an average of 36.9 months postoperatively. All major complications occurred in patients with grafts extending into the caudal nose, and two-thirds ultimately necessitated surgical intervention. Conclusions: Cephalically contained pHDPE grafts are less prone to failure than those extending into the caudal nose. Long-term follow-up is recommended for all patients based on the risk for delayed complications.

Management of Acute Facial Nerve and Parotid Injuries.

Acute soft tissue trauma to the head and neck is a common reason for emergency department presentation and should be appropriately evaluated by a facial plastic surgeon. The evaluation of a patient who has suffered facial trauma should always include a comprehensive facial nerve exam and carry a low threshold of suspicion for parotid duct injury when involving the cheek. Injuries to the facial nerve and parotid duct can result in significant long-term functional, cosmetic, and emotional morbidity, particularly when diagnosis is delayed. In the repair of facial nerve transection, neurorrhaphy technique is primarily based on the ability to obtain tension-free anastomosis and outcomes are in large part related to timing of repair. Parotid duct injuries are generally repaired based on the site of ductal injury. In this article, we present a guide to the relevant anatomy of the facial nerve branches and the parotid duct, the important factors guiding treatment decisions alongside their related risks and benefits, as well as the management of complications of facial nerve neurorrhaphy and parotid duct injuries and repair.

Peri-Incisional Botulinum Toxin Therapy for Treatment of Intractable Head Pain After Lateral Skull Base Surgery: A Case Series.

OBJECTIVE: The objective of this case series was to describe botulinum toxin therapy as a novel treatment of intractable head pain following lateral skull base surgery. BACKGROUND: Intractable headaches following lateral skull base surgery are described in 23%-75% of patients and can significantly impact quality of life. Currently, the etiology of the headaches is unclear and treatment options are limited. Botulinum toxin is indicated for a multitude of functional and cosmetic reasons, including chronic migraine, and has been further described in treatment of various postsurgical pain syndromes. METHODS: In this case series, 4 patients underwent subcutaneous peri-incisional injections of botulinum toxin for intractable headache and head pain syndromes. Three patients had undergone lateral skull base surgery and the fourth patient had undergone a temporoparietal fascial flap harvest. Average injection dose ranged from 20 to 60 units with an average duration of effect ranging from 2 weeks to 4 months. RESULTS: All patients experienced significant relief of chronic head pain and returned for additional peri-incisional botulinum toxin injections, suggesting meaningful patient-perceived value. CONCLUSIONS: Botulinum toxin therapy may represent a novel treatment for intractable head pain following lateral skull base surgery and temporoparietal fascial flap harvest. This study represents a small case series and, although 100% of the patients who were treated significantly improved, future inquiry is necessary to confirm these findings.

Outcomes of Nasal Septal Perforation Repair Using Combined Temporoparietal Fascia Graft and Polydioxanone Plate Construct.

IMPORTANCE: Numerous techniques are used for septal perforation repair, yet success rates remain variable. Few studies have evaluated the effectiveness of interposition grafts of polydioxanone plates combined with a temporoparietal fascia graft for septal perforation repair. OBJECTIVE: To investigate and describe the use of interposition grafts of polydioxanone plates combined with a temporoparietal fascia graft for septal perforation repair and the expansion of this technique to patients with more challenging comorbidities, including granulomatosis with polyangiitis. DESIGN, SETTING, AND PARTICIPANTS: A retrospective medical record review was performed of patients who underwent septal perforation repair using interposition grafts of polydioxanone plates combined with a temporoparietal fascia graft from January 1, 2015, to July 1, 2018, at Vanderbilt University Medical Center and from January 1, 2017, to July 1, 2018, at the University of Iowa. INTERVENTION: All patients underwent septal perforation repair with interposition grafts of polydioxanone plates and a temporoparietal fascia graft. MAIN OUTCOMES AND MEASURES: Assessing closure of septal perforation was the primary outcome. Secondary outcomes were resolution of presenting symptoms of septal perforation, area of perforation, length of postoperative stent and silastic sheeting placement, postoperative complications and resolution, and duration of follow-up. Preoperative and postoperative Nasal Obstruction Symptom Evaluation (NOSE) scores were assessed. RESULTS: A total of 17 patients (12 women and 5 men; mean [SD] age, 45 [15] years) were included. The causes of perforations were iatrogenic (9 [53%]), rheumatologic (2 [12%]), and unknown or idiopathic (6 [35%]). Patients most commonly presented with nasal crusting (12 [71%]), whistling (9 [53%]), nasal obstruction (9 [53%]), and epistaxis (5 [29%]). Mean (SD) perforation size was 0.99 (1.04) cm2. Mean (SD) postoperative follow-up was 6.1 (4.1) months. A total of 15 patients (88%) had complete resolution of presenting symptoms at last follow-up. All perforations were closed with overlying mucosa at the most recent follow-up examination. Nine of 17 patients completed both preoperative and postoperative NOSE. There was a significant difference between the mean (SD) preoperative and postoperative NOSE scores (62.78 [27.74] vs 17.78 [15.83]; P = .004). CONCLUSIONS AND RELEVANCE: Repair of symptomatic nasal septal perforations using a temporoparietal fascia graft combined with a polydioxanone plate was associated with positive outcomes. Repair of septal perforations caused by rheumatologic disease, including granulomatosis with polyangiitis, can be considered for repair using this technique. Resolution of symptoms appeared to be clinically more meaningful in evaluation of septal perforation repair than rate of perforation closure, and the NOSE scale has the potential to serve as an objective corroboration to patient-reported postoperative outcomes. LEVEL OF EVIDENCE: 4.

Effect of Heliox on Respiratory Outcomes during Rigid Bronchoscopy in Term Lambs.

Objective To (1) compare physiologic changes during rigid bronchoscopy during spontaneous and mechanical ventilation and (2) evaluate the efficacy of a helium-oxygen (heliox) gas mixture as compared with room air during rigid bronchoscopy. Study Design Crossover animal study evaluating physiologic parameters during rigid bronchoscopy. Outcomes were compared with predicted computational fluid analysis. Setting Simulated ventilation via computational fluid dynamics analysis and term lambs undergoing rigid bronchoscopy. Methods Respiratory and physiologic outcomes were analyzed in a lamb model simulating bronchoscopy during foreign body aspiration to compare heliox with room air. The main outcome measures were blood oxygen saturation, heart rate, blood pressure, partial pressure of oxygen, and partial pressure of carbon dioxide. Computational fluid dynamics analysis was performed with SOLIDWORKS within a rigid pediatric bronchoscope during simulated ventilation comparing heliox with room air. Results For room air, lambs desaturated within 3 minutes during mechanical ventilation versus normal oxygen saturation during spontaneous ventilation ( P = .01). No improvement in respiratory outcomes was seen between heliox and room air during mechanical ventilation. Computational fluid dynamics analysis demonstrates increased turbulence within size 3.5 bronchoscopes when comparing heliox and room air. Meaningful comparisons could not be made due to the intolerance of the lambs to heliox in vivo. Conclusion During mechanical ventilation on room air, lambs desaturate more quickly during rigid bronchoscopy on settings that should be adequate. Heliox does not improve ventilation during rigid bronchoscopy.

Essential Anatomy and Evaluation for Functional Rhinoplasty.

The nose, a prominent facial feature in defining facial beauty, is responsible for the fundamental physiologic functions of heating, humidifying, and filtering inspired air. When the normal balance of laminar and turbulent airflow become disturbed due to anatomic abnormalities, nasal obstruction may result. To successfully restore these basic physiologic functions, the surgeon must have a detailed understanding of the nasal anatomy and be able to successfully identify the specific cause of the nasal obstruction. This article discusses the fundamental surgical anatomy and the various diagnostic techniques and instruments at the surgeon's disposal.

Use of Spreader Flaps Without Dorsal Hump Reduction and the Effect on Nasal Function.

IMPORTANCE: Internal nasal valve (INV) collapse is a common cause of nasal obstruction, and spreader grafts are the established standard of treatment. Recently, spreader flaps have gained attention in the treatment of nasal valve stenosis when performed in conjunction with dorsal hump reduction. To date, the efficacy of the spreader flap technique without dorsal hump reduction has not been previously described. OBJECTIVE: To determine whether spreader flaps are equivalent to spreader grafts in correcting INV collapse in the absence of simultaneous dorsal hump reduction. DESIGN, SETTING, AND PARTICIPANTS: This retrospective medical record review included 26 patients with nasal obstruction and INV collapse who underwent correction with spreader flaps or spreader grafts concurrently with septoplasty and inferior turbinate reduction but without dorsal hump reduction. The type of graft placed was based on surgeon preference and patient anatomy. Patients were treated at a tertiary academic medical center from September 1, 2012, through August 31, 2014, and had follow-up of at least 6 months. Follow-up was completed for this study on August 12, 2016. MAIN OUTCOMES AND MEASURES: All patients completed the Nasal Obstruction Symptom Evaluation (NOSE) questionnaire preoperatively and at 1, 3, and 6 months postoperatively. The latest postoperative NOSE score was compared with the preoperative score. RESULTS: Among the 26 patients included (12 men and 14 women; mean age, 38.4 years [range, 18-64 years]), 13 underwent spreader flap placement and 13 underwent spreader graft placement. No difference was found between patient demographic characteristics or mean (SD) preoperative NOSE score (spreader flap group, 81.9 [15.8]; range, 72.4-91.4; spreader graft group, 75.4 [19.3]; range, 63.7-87.1) between groups. In addition, no difference was found in mean (SD) postoperative NOSE score (spreader flap group, 18.5 [21.6]; range, 5.4-31.5; spreader graft group, 16.9 [16.4]; range, 7.0-26.8), total NOSE score improvement (spreader flap group, 63.5 [23.5]; range, 49.3-77.7; spreader graft group, 58.5 [27.8]; range, 41.7-75.3), or percentage of improvement in NOSE score (spreader flap group, 78.0% [23.8%]; range, 63.6%-92.4%; spreader graft group, 76.02% [26.31%]; range, 60.1%-91.9%) between groups. CONCLUSIONS AND RELEVANCE: In appropriately selected patients, spreader flaps are equivalent to spreader grafts in correcting nasal obstruction secondary to INV collapse. LEVEL OF EVIDENCE: 3.

Treatment-related determinants of survival in early-stage (T1-2N0M0) oral cavity cancer: A population-based study.

BACKGROUND: National guidelines support both surgical and radiotherapy (RT) as initial treatment options for early-stage oral cavity squamous cell carcinoma (SCC). There remains limited data evaluating the survival outcomes of RT and the current practice patterns for these lesions. METHODS: We conducted a retrospective review of 8274 patients in the Surveillance, Epidemiology, and End Results (SEER) database from 1988 to 2008 with T1 to T2N0M0 oral cavity SCC. Primary outcomes were 5-year overall survival (OS) and disease-specific survival (DSS). RESULTS: Surgical therapy had significantly improved OS (140 months; p < .001) and DSS (217 months; p < .001) compared to surgery with adjuvant RT (104 and 163 months, respectively) and definitive RT (68 and 136 months, respectively). The use of radiation alone was associated with an increased T classification, hard palate, retromolar trigone primary site lesions, and advanced patient age. CONCLUSION: Primary radiation without surgery continues to be used in a subset of early-stage oral cavity SCCs, in which it is associated with decreased OS and DSS. © 2017 Wiley Periodicals, Inc. Head Neck 39: 876-880, 2017.

Increasing use of nonsurgical therapy in advanced-stage oral cavity cancer: A population-based study.

BACKGROUND: National guidelines support surgical-based treatment and offer nonsurgical therapy as an alternative for advanced-stage oral cavity squamous cell carcinoma (SCC). There are limited data evaluating current utilization of these therapies and their survival outcomes. METHODS: A total of 5856 patients were found in the Surveillance, Epidemiology, and End Results (SEER) database from 1988 to 2008 with resectable advanced-stage oral cavity SCC tumors. Outcomes were disease-specific survival (DSS) and overall survival (OS). RESULTS: Surgical therapy had significantly improved mean DSS and OS (115 and 71 months, respectively) compared to nonsurgical therapy (63 and 35 months, respectively; p < .001). The use of nonsurgical therapy was significantly associated with the hard palate, and patients who were single, divorced, and black, with T3, T4, and N3 tumors, and the percent utilization has significantly increased from 12% to 20% (p < .05). CONCLUSION: Utilization of nonsurgical therapy for advanced-stage oral cavity SCC is increasing and is independently associated with a reduction in survival, as well as patient factors traditionally associated with reduced access to medical care and advanced T and N classifications. © 2016 Wiley Periodicals, Inc. Head Neck 39: 82-91, 2017.

Primary Caregiver Perception of Pain Control following Pediatric Adenotonsillectomy: A Cross-Sectional Survey.

OBJECTIVES: To (1) review pain medications prescribed following pediatric adenotonsillectomy (T&A), (2) identify pain medications reported to be helpful, and (3) compare parent-reported outcomes among various combinations of pain medications. STUDY DESIGN: Case series with planned data collection. SETTING: Multihospital network. SUBJECTS AND METHODS: The primary caregivers of children aged 1 to 18 years who underwent isolated T&A from June to December 2014 were contacted 14 to 21 days after surgery. Data collected included pain medications prescribed, medications most helpful in controlling pain, and duration that pain medication was required. Parents rated their children's pain on postoperative days 2, 3, 7, and 14 and reported the time to resumption of normal diet/activity, as well as any hospital return visits. RESULTS: The study cohort included 672 subjects of 1444 potential participants (46% response rate). The mean age of the patients was 7.9 ± 3.6 years. Narcotics were prescribed in 71.9%, and 70.4% were told to use ibuprofen. Children who took ibuprofen alone were significantly younger (P < .001). Pain was significantly less on postoperative days 2 and 3 in the ibuprofen-only group as compared with the groups taking narcotics only (P < .001) and ibuprofen with narcotics (P = .002). Those taking ibuprofen alone returned to normal activity (P < .001) and diet (P = .026) sooner than those taking ibuprofen with narcotics. No difference was seen in pain control on subgroup analysis comparing oxycodone and hydrocodone. CONCLUSIONS: For pediatric T&A, significant variation exists in the management of postoperative pain. Parents of children given ibuprofen reported less pain than those given narcotics with and without ibuprofen. Further studies are needed to identify the optimal pain regimen for children after T&A.