A clinical evaluation of bioresorbable staples for mucoperichondrial flap coaptation in septoplasty.

BACKGROUND: During septoplasty surgery, the formation of dead space between the mucosal flaps must be minimized to prevent septal hematoma and promote healing. Historically, this has been achieved by using techniques such as nasal packing or the continuous septal quilting or whip suturing. This study presents the first clinical results using a septal stapling device that uses bioresorbable staples to achieve mucoperichondrial flap coaptation during septoplasty. METHODS: The septal stapler was used in 24 subjects. The primary outcome measure was whether septal coaptation was accomplished 1 week postoperatively. The extent of tissue reaction at the site of staple placement was also evaluated. RESULTS: In all subjects, coaptation with septal staples was successfully accomplished with no septal hematoma formation. At 1 week follow-up, there was either no (79%) or minimal (21%) tissue reaction at the site of staple placement. CONCLUSION: The use of bioresorbable staples appears to be a safe, efficient, and effective alternative to other methods used for mucoperichondrial flap coaptation in septoplasty surgery.

Surgical management of lesions of the sphenoid lateral recess.

BACKGROUND: Pneumatization of the sphenoid sinus occasionally includes an extensive lateral recess creating an area beneath the temporal lobe that is relatively inaccessible to surgical intervention. Pathology in this anatomic location presents special surgical and therapeutic challenges. Recently, several authors have described the endoscopic transpterygopalatine fossa approach to this anatomic region. This approach is associated with minimal morbidity while providing direct endoscopic surgical access for managing a variety of disease processes in this region. METHODS: This study presents eight cases requiring this approach or a modification of this approach. Six patients presented with temporal lobe meningoencephaloceles with cerebrospinal fluid rhinorrhea. Each case was managed successfully through this surgical approach. RESULTS: One patient experienced transient postoperative palatal anesthesia due to injury to the greater palatine nerve and another complained of ipsilateral dry eye postoperatively. Two other patients had neoplasms (inverting papilloma and chondrosarcoma), which were successfully addressed through this technique. There were no postoperative complications in these patients. CONCLUSION: We have previously described the relationships of neural and vascular structures in this anatomic region. This article will review these relationships as they pertain to this surgical approach and will discuss the indications, techniques, and surgical outcomes in this series of patients. This approach is a valuable addition to the endoscopic armamentarium of the experienced endoscopic surgeon.

Granulomatous diseases and chronic rhinosinusitis.

Chronic rhinosinusitis often fails to respond to standard medical or surgical treatment. In some of these cases, the underlying disease may be a chronic granulomatous process that requires aggressive topical, local, and in some instances, systemic therapy. Diseases that can present in this manner include autoimmune vasculitis, sarcoidosis, indolent infections, neoplastic processes, and various other miscellaneous conditions. This article reviews the typical presentations for some of these unusual conditions and discusses the appropriate evaluations that will lead to clinical identification and effective medical management.

Sinusitis in HIV: microbiology and therapy.

Rhinosinusitis in the HIV-infected population is an increasingly common finding as HIV infection has transitioned toward becoming a chronic medical condition. In this patient population, rhinosinusitis may be challenging to diagnose and treat effectively. However, adequate diagnostic tools are available, microbial identity can be reasonably anticipated based on the CD4 count, and effective management strategies can be implemented. In this article, we discuss the diagnostic and therapeutic options for HIV-infected patients with rhinosinusitis.

Use of a powered shaver to remove multiple oral cavity papillomas.

We report a previously undescribed method of removing multiple oral papillomas, which we performed on 5 men with human immunodeficiency virus (HIV) infection. Patients were brought to the operating room and placed under general anesthesia. In addition, 1% lidocaine with 1:100,000 epinephrine was injected under and around the lesions. We then removed the lesions with a Tricut laryngeal blade attached to a handheld powered shaver Postoperatively, patients were sent home on clindamycin, a pain medication, and Peridex. At the 1-week follow-up, patients reported only minimal pain, and their wounds were well healed. We observed no adverse events associated with the shaving procedure. Our method expedites the process of removing multiple oral cavity papillomas while reducing the morbidity generally associated with other procedures.

Sinusitis in HIV: Microbiology and Therapy.

Rhinosinusitis in the HIV-infected population is an increasingly common finding as HIV infection has transitioned toward becoming a chronic medical condition. In this patient population, rhinosinusitis may be challenging to diagnose and effectively treat. However, adequate diagnostic tools are available, microbial identity can be reasonably anticipated based on the CD4 count, and effective management strategies can be implemented. This article discusses the diagnostic and therapeutic options for HIV-infected patients with rhinosinusitis.

An endoscopic study of the greater palatine nerve.

BACKGROUND: Using an endoscopic approach, lateral sphenoid air cells and terminal branches of the internal maxillary artery often can be accessed through the pterygomaxillary fossa: however, injury to the greater palatine nerve (GPN) can occur if the anatomy of this region is not understood clearly. This study was undertaken to define the pathway of the GPN and to identify landmarks useful in preventing its injury. METHODS: Six cadaveric heads were used to endoscopically dissect and examine 11 pterygomaxillary fossae. An additional latex-injected cadaveric head was sectioned coronally and dissected bilaterally. The relationships between the vascular, neurological and bony structures and foramena were noted and described. RESULTS: All specimens studied maintained consistent relationships. The sphenopalatine and posterior nasal arteries cross nearly perpendicular and just superficial to the GPN. The GPN traveled anteriorly and inferiorly to reach the greater palatine foramen. The lateral wall of the canal ranged from a thin bony covering to complete dehiscence and was thinnest as it crossed the inferior turbinate and approached the foramen. The foramen rotundum was located lateral and superior to the sphenopalatine foramen near the roof of the maxillary sinus. CONCLUSION: When surgically approaching the pterygomaxillary fossa, injury to the GPN is avoidable by thorough knowledge of anatomy and awareness of the described landmarks.

Special features topic: the effects of limited work hours on surgical training in otolaryngology-head and neck surgery.

PURPOSE OF REVIEW: This paper reviews the historic events that culminated in the development of duty hour regulations, and then discusses many of the problems being encountered as the regulations are implemented. RECENT FINDINGS: On July 3, 2003, the Accreditation Council for Graduate Medical Education (ACGME) instituted duty hour requirements for residency training programs in the United States. Although these regulations should have come as no surprise to graduate medical education programs, many were nevertheless unprepared for their implementation. In comparison to duty hour restrictions currently in place in European countries, those being implemented in this country are much more lenient. Both the fiscal and the educational impact of these requirements on graduate medical education are substantial. Recent accreditation actions taken against a training program at Johns Hopkins University clearly demonstrates that the ACGME is prepared to strictly enforce these standards. SUMMARY: The impact of the new duty-hour requirements on residency training and education will be a matter of great interest as they are implemented throughout the graduate education system in the United States.

Endoscopic management of anterior skull base encephaloceles.

Encephaloceles are relatively rare phenomena produced by the protrusion of brain and dura through an anterior skull base defect. Although they can occur as congenital defects, encephaloceles can also present after trauma. The diagnosis is usually made with nasal endoscopy and imaging studies. This report reviews our recent experience repairing 5 encephaloceles in 4 patients. The diagnostic approach and the technical aspects of surgical management are discussed. Although encephaloceles are a rarity, this diagnosis should be considered as part of the differential diagnosis in evaluating a patient with a unilateral polypoid nasal mass, particularly in the setting of recurrent meningitis or cerebrospinal fluid rhinorrhea.

Ear, nose, and throat manifestations of sarcoidosis.

Sarcoidosis rarely affects the head and neck and represents a diagnostic challenge to the otolaryngologist. The signs and symptoms of sarcoidosis in this area are not specific and can mimic much more common disorders. Biopsy is usually necessary to make the diagnosis. Appropriate evaluations and referrals should be made once there is suspicion of sarcoidosis. Steroids remain the mainstay of the therapeutic options; however, newer agents are being used more frequently. Long-term treatment and follow-up are necessary, because the disease tends to progress and to respond unpredictably to treatment.

Methicillin-resistant Staphylococcus aureus (MRSA) in the practice of otolaryngology--an emerging community acquired organism?

Soon after antibiotics were introduced to treat bacterial infections, resistance to these agents began to emerge. Staphylococcus aureus, a common organism in human infection, quickly became resistant to penicillin; however, semisynthetic penicillins seemed to have tremendous staying power. The recent emergence of methicillin-resistant S. aureus (MRSA) created a difficult problem in treating many hospital-acquired infections soon after it was discovered. However, now it appears to be spreading into the community at large. Although newer antibiotics have been developed to help manage this threat, multiple-drug resistance remains a fear among healthcare professionals. Eradication of MRSA appears to be an unachievable goal at this time, so attention has focused on decreasing the spread of this organism, often through simple hand-washing protocols. The continued spread of MRSA will have tremendous impact on the practice of medicine and otolaryngology during the next decade and beyond.

The clinical effects of hyaluronic acid ester nasal dressing (Merogel) on intranasal wound healing after functional endoscopic sinus surgery.

OBJECTIVES: We sought to determine the efficacy of MeroGel, an absorbable hyaluronic acid nasal dressing (HA) in reducing synechia after functional endoscopic sinus surgery (FESS) compared with Merocel, a nonabsorbable packing (NAP) requiring removal. METHODS: We conducted a blinded, randomized, controlled trial of 37 patients requiring bilateral FESS for chronic sinusitis. Patients were randomized to placement of HA within the right or left middle meatus and NAP on the other side. Patients were evaluated at 2, 4, 6, and 8 weeks postoperatively. RESULTS: Blinded evaluation revealed 5 patients (14%) with synechia at last follow-up: 3 sides (8%) with HA and 3 (8%) with NAP. Thirteen patients (35%) had synechia at any visit, 10 sides (27%) with HA and 9 (24%) with NAP. Seven patients (19%) required lysis of synechia, 5 sides (14%) with HA and 3 (8%) with NAP. CONCLUSION: We found no statistically significant difference between HA and NAP dressings.

Endoscopic anatomy of the sphenopalatine and posterior nasal arteries: implications for the endoscopic management of epistaxis.

BACKGROUND: Refractory posterior epistaxis is a challenge for otolaryngologists. Most algorithms for managing this condition ultimately call for interrupting the arterial blood supply to the nasal mucosa. Traditionally, this was accomplished either by transantral arterial ligation or by arteriographic-guided embolization. More recently, the endonasal endoscopic approach has also been described. Because the primary blood supply to the posterior nasal cavity is derived from the terminal branches of the sphenopalatine and the posterior nasal arteries, we conducted this anatomic study to examine and describe the anatomic relationship of these two arteries as they exit the pterygopalatine fossa and enter the nasal cavity. METHODS: We performed endoscopic dissections of this anatomic region in nine fresh and one formalin-preserved cadaver specimens. A total of 19 sides were examined. RESULTS: In 3 of 19 specimens (16%), the sphenopalatine artery branched from the sphenopalatine artery within the sphenopalatine canal, allowing the two arteries to exit together. In 8 of the 19 specimens (42%), the sphenopalatine artery exited much more posteriorly, yet from within a shared posteriorly elongated sphenopalatine foramen. In the remaining eight specimens (42%), the sphenopalatine artery exited through a distinct foramen directly posterior to the larger sphenopalatine foramen. CONCLUSION: Understanding this anatomic relationship is important in performing endoscopic arterial ligation. If the sphenopalatine artery is not specifically identified and ligated, an important component of the posterior nasal circulation will not be addressed adequately by this surgical approach.

Sinonasal sarcoidosis: diagnosis and management.

Sinonasal sarcoidosis is a fairly uncommon, yet clinically challenging, manifestation of this systemic disease. The diagnosis is often difficult to establish, treatment options are often unclear, and ultimate clinical responses can be quite variable. This article discusses the varied clinical presentations of this unusual nasal inflammatory process, as well as various treatment options, from simple local nasal hygiene measures to more aggressive systemic therapy. Although the role of surgical intervention is controversial, a simple review of some of the indications for surgery in these patients helps to clarify this somewhat cloudy clinical area. Aggressive clinical management in conjunction with long-term surveillance can often produce dramatic clinical responses for these difficult patients with sarcoidosis in the sinonasal area.