The evidence for reducing inferior turbinates.

Nasal obstruction is commonly due to enlargement of the inferior turbinate. This review discusses the pathophysiology of turbinate enlargement, the indications for, and methods and outcome of turbinate reduction. All techniques are successful but vary in their long-term efficacy, their propensity for complications and the degree to which they may adversely affect nasal function. Newer techniques under local anaesthetic and often endoscopic control offer outpatient treatment with satisfactory outcomes. However selecting a particular technique should take account of the individual patient's features, the surgeon's experience and judgement and informed patient choice.

The role of magnetic resonance imaging in the assessment of suspected extrinsic tracheobronchial compression due to vascular anomalies.

AIMS: To evaluate the role of magnetic resonance imaging (MRI) in the assessment of children with suspected extrinsic tracheobronchial compression due to vascular anomalies. METHODS: Retrospective case note review in a tertiary referral centre. Twenty nine children who underwent dynamic laryngotracheobronchoscopy (DLTB) and were found to have a clinical suspicion of extrinsic tracheobronchial compression were evaluated. All subsequently underwent thoracic MRI within 10 days. The findings on endoscopy were compared to those of MRI, and where performed, echocardiography, aortography, and surgery. RESULTS: There were 17 males and 12 females (mean age 5 months, range 28 weeks gestation to 60 months). The most common presenting features were stridor and cyanotic episodes. MRI showed abnormalities in 21 patients. There were five vascular rings (three double aortic arches and two right aortic arches) and 11 cases of innominate artery compression. Other vascular anomalies noted included aberrant right subclavian artery and aneurysmal left pulmonary artery. Echocardiography was generally found to be unhelpful in the diagnosis of extra-cardiac vascular abnormalities. Angiography was subsequently conducted in eight children; findings agreed with those shown on MRI. Surgery was performed on all five vascular rings, one innominate artery compression, and one aneurysmal left pulmonary artery. Surgical findings were also compatible with the preoperative MRI. CONCLUSIONS: This study shows the successful use of MRI as the initial imaging modality in endoscopically suspected extrinsic vascular compression of the upper airway. It enables accurate delineation of vascular anomalies and, unlike aortography, is non-invasive and does not require the use of contrast media.

Dimensional analysis - its role in our preoperative surgical planning of rhinoplasty.

With the advent of new reconstructive rhinoplasty techniques, we have the opportunity to correct a larger number of nasal deformities. Dimensional analysis using non-nasal references assists in identifying the abnormalities in a deformed nose. Analysis of 98 patients undergoing rhinoplasty plus or minus septal surgery was performed to identify the prevalent abnormalities with the help of the dimensional approach.

Nasal septal mucosal contact points: associated symptoms and sinus CT scan scoring.

An association between nasal septal mucosal contact points and facial pain has often been quoted, but may be coincidental. CT scans of 100 consecutive rhinology patients were examined for contact points, and the sinuses were scored according to the Lund-Mackay system. The patients' nasal symptoms were recorded using validated questions. Contact of the nasal septum with the lateral nasal structures was identified in 55 patients. The presence of contact was significantly (P < 0.01) associated with nasal blockage and reduction of smell, but there was no association with facial pain. The median Lund-Mackay score for scans with contact was significantly greater than the score for scans without contact. Whereas the results of the study support the hypothesis that nasal contact may impede ventilation and drainage of the paranasal sinuses, the study finds no evidence to support the concept that contact points cause facial pain or headaches.

Nasal septum buttons: symptom scores and satisfaction.

Patients with symptomatic septal perforations require treatment, with many surgeons advocating primary treatment with an obturator if conservative measures fail. Twenty nasal Button Outcome Questionnaires were sent to patients who had undergone insertion of a septal button between 1990 and 2000 in our unit. Fourteen questinnaires were returned. This study reveals that despite a reduction in symptom score in nine patients, septal buttons are poorly tolerated by patients with only 45 per cent of obturators ultimately being in situ. In view of these findings, patients are now offered a choice between primary surgical and mechanical closure in our unit.

A randomised trial of flexible versus rigid nasendoscopy in outpatient sinonasal examination.

Nasendoscopy is used extensively in ENT clinics both as a diagnostic tool and for local postoperative care. Both flexible and rigid fibreoptic scopes are available for the purpose of sinonasal examination. A prospective study of a flexible versus rigid endoscope was carried out, randomly assigning one type of scope to each nostril of 56 patients presenting to clinic with sinonasal symptomatology. Patients awarded each type of scope a pain score on an analogue scale, according to the level of discomfort experienced, and the operator noted the number of structures seen. Significantly more structures were visualized with the rigid scope than the flexible scope (P = 0.05). The pain scores were similarly in favour of the rigid scope, showing a trend to less discomfort. The rigid nasendoscope is the scope of choice for sinonasal examinations in the outpatient clinic based on these data.

Incidental findings on magnetic resonance imaging screening for cerebellopontine angle tumours.

The otolaryngologist who requests magnetic resonance imaging (MRI) scans to exclude cerebellopontine angle (CPA) tumours may discover incidental pathologies. We retrospectively reviewed the results of 644 consecutive MRI screening scans with the aim of identifying findings other than CPA tumours. Two hundred and eighty-nine (45 per cent) scans featured one or more anomalies or abnormalities, including CPA tumour (23, four per cent), vascular loop (30, five per cent), basilar artery ectasia (13, two per cent), multiple high signal areas (135,21 per cent), brain atrophy (52, eight per cent), sinus findings (56, nine per cent), middle ear/mastoid disease (34, five per cent), and a variety of other findings (39, six per cent) including clinically serious lesions (11, two per cent). The significance and management of these incidental findings is discussed. The majority were not clinically significant but the occasional presence of a serious incidental pathology should be borne in mind. Basilar artery ectasia and multiple high signal areas may be responsible for the symptoms investigated by MRI, and screening for cerebrovascular disease risk factors in such patients may be appropriate.

Spontaneous resolution of tonsillitis in children on the waiting list for tonsillectomy.

The aim of this study was to determine whether children undergo spontaneous resolution of recurrent acute tonsillitis whilst awaiting surgery. Eighty children who had been on the waiting list for tonsillectomy for at least 9 months were requested to attend a review clinic with a second review 6 months later if appropriate. Nineteen (27%) of the 70 children who completed the study no longer warranted surgery and were removed from the waiting list. We conclude that those children who have been on the waiting list for a long period of time should be reassessed prior to the planned tonsillectomy to see if surgery is still indicated.

The use of inhalers in patients with tracheal stomas or tracheostomy tubes.

Patients with chronic obstructive airways disease (COAD) or asthma who have a tracheostomy tube or tracheal stoma have difficulty using metered dose inhalers (MDIs) because of a failure to achieve a good seal between the tracheostomy tube or stoma and the MDI or spacer device mouthpiece. Many such patients therefore utilize nebulizers. MDIs in comparison to nebulizers have the advantages of being more compact, portable, easy to use, less time-consuming, and cheaper. We present the case of a 74-year-old man who underwent a laryngectomy with tracheal stoma formation who had a poor response with nebulizers and required oral steroids. He was subsequently, with the help of a number of attached devices, able to use his MDIs to good effect. We describe a number of devices and adaptors to enable patients with laryngectomy stomas or tracheostomy tubes to utilize MDIs and undergo respiratory function tests. We recommend that all such patients should have the benefit of a consultation with a dedicated respiratory nurse who can provide the appropriate MDIs, devices and adaptors to optimize the treatment of their lower respiratory tract condition.

The role of the temperature of the nasal lining in the sensation of nasal patency.

The receptors and neural pathways involved in the common symptom of nasal blockage are of great interest. Studies to date suggest that the sensation of nasal patency may be related to the temperature of the nasal passages. Sixty-two subjects were asked to assess their own nasal patency subjectively and indicate this on a visual analogue scale. The temperature of the nasal lining was continuously recorded during quiet nasal respiration using a non-contact infrared thermometer. The cooler the nasal lining, the clearer the nose felt, and the greater the drop in temperature on inspiration again the clearer the nose felt. The study supports the previously proposed hypothesis that the sensation of nasal airflow is derived from a cooling of the nasal lining on inspiration, and this is probably detected by cold thermoreceptors in the mucosa.

Do antral washouts have a place in the current management of chronic sinusitis?

Antral washouts have been widely used in the management of chronic sinusitis. With the advent of modern antibiotics and powerful topical nasal steroids, we sought to establish if a role remains for this procedure. One hundred and fourteen patients with chronic sinusitis were randomised into two groups. Patients in Group A received antral washouts followed by antibiotics and topical nasal steroids. Patients in the Group B received antibiotics and topical nasal steroids alone. In each group 51.6 per cent and 50 per cent of patients respectively improved with treatment. The outcome of treatment is also not influenced by endoscopic abnormality. The difference was not statistically significant (p = 0.86). The study indicates that half of patients with chronic sinusitis will improve with medical treatment but the addition of antral washout confers no additional benefits.

MR imaged neurovascular relationships at the cerebellopontine angle.

Improvements in MR imaging techniques allow visualisation of the anatomy of the cerebellopontine angle (CPA) in increasingly accurate detail, revealing the complex interrelationship of the neurovascular structures in this region. We wished to assess whether vessels and vascular loops intimately associated with cranial nerves VII and VIII, corresponded to any abnormality or symptom pattern, and thus had any clinical significance. The MR scans of 108 patients were retrospectively reviewed and the imaging status of VII, VIII, the vessels, presence of vascular loops and their relationship to the nerves, coded and recorded. The patients' records were independently reviewed and the presence and "sidedness' of asymmetrical hearing loss, tinnitus, vertigo, and the results of caloric and brain stem evoked responses recorded. The vessels were closely associated with VII and VIII in over 30% of this sample with vascular loops imaged in 21% of patients, and clearly imaged entering the IAM in 7% of both right and left CPAs studied. There was no statistically significant relationship demonstrated between the proximity of the vessels, or vascular loops, to the nerves and a symptom, or symptom pattern. These findings should be considered a normal variant on MR scanning.

Laser reduction of inferior turbinates in children.

Perennial nasal obstruction in children refractory to medical treatment may be managed by turbinate reduction. Turbinectomy may involve a risk of significant postoperative bleeding and requires nasal packing. Submucosal diathermy is followed by nasal congestion and crusting; recurrent nasal obstruction is frequent at fifteen months. This study assesses the benefits of carbon dioxide laser reduction of inferior turbinates in 20 children. Intraoperative blood loss was negligible and no nasal packing was required. There was minimal postoperative discomfort which required no analgesia. No postoperative haemorrhage was recorded. The children were able to drink and eat by 4 and 6 hours respectively. Relief of nasal obstruction occurred one to seven days postoperatively and was confirmed by rhinohygrometry. Nasal patency was maintained on eighteen to twenty-four months follow up. Mucosal healing was completed by four weeks. Mucosal saccharin clearances were normal postoperatively. We conclude laser turbinectomy is an excellent means of turbinate reduction in selected children.

Cryotherapy in the treatment of nasal obstruction: indications in adults.

Cryotherapy is an established method of treating hypertrophic obstructive inferior turbinates. The long-term effectiveness of the technique is assessed in this study, using the need for alternative nasal surgery as an objective way of distinguishing success from failure. Over 50 per cent of patients with obstructive symptoms, including those with minor septal deviation or allergy derived lasting benefit from the technique. Cryotherapy is an effective means of treating nasal obstruction due to mucosal hypertrophy of the turbinates and may replace the need for more radical surgery.

Headaches associated with nasal obstruction due to deviated nasal septum.

A deviated nasal septum not only can cause a blocked nose, but may also be associated with headaches. This study evaluates the nature of these headaches, the effect of submucous resection of the nasal septum, and the factors associated with postoperative headache relief. Deviated nasal septa were corrected by submucous resection in 99 men and 17 women. Patients were studied at 4 to 48 months (mean 18 months) postoperatively. Fifty-five of the 116 patients studied (47.4%) had preoperative recurring headaches. Thirty-five of the 55 patients with headaches (63.6%) experienced relief (complete or partial) of their headaches at a mean follow-up period of 18 months. Patients were more likely to be relieved of their headaches following submucous resection if the headaches were most intense over the frontal region, pressurelike in nature, and if the submucous resection resulted in relief of nasal obstruction. It is possible that headaches recur in the long term, and it is postulated that central mechanisms play a role.

The relationship between middle ear pressure and deviated nasal septum.

The deviated nasal septum may be associated with middle ear problems, particularly on the side of nasal obstruction. This study aims to find out whether middle ear pressure (MEP) correlates with the degree of nasal obstruction secondary to a deviated nasal septum, and to examine changes in MEP following septal surgery. Patencies of the nasal passages (measured with a peak nasal inspiratory flowmeter) and MEP (measured with a tympanometer) of 55 patients were obtained prior to surgery and 7.5 (6-10) months post-operatively [median (range)]. Forty patients completed the study. Results were analysed by linear regression. In the ear on the side of nasal blockage, MEP was -25.7 +/- 28.4 mm water pre-operatively, and following surgery increased significantly to -2.9 +/- 30.4 mm water (mean +/- SD) (P < 0.001). Pre-operatively, it was inversely related to the difference in patencies between the two nasal passages (r = -0.32, P < 0.02). Post-operatively, its improvement correlated with the degree of reduction of asymmetry of airway patency (r = 0.56, P < 0.001).

Continuous infrared thermometry of the nasal mucosa.

This study aims to continuously measure nasal mucosal temperature without interruption of nasal breathing using infrared thermometry. An infrared thermometer (Medi-Therm 310; Everest Interscience, Inc.) was directed at the nasal septum from a distance of 15 cm. Infrared radiation was continuously collected, then converted to an electrical signal proportional to the mucosal temperature and output to a chart recorder. In 70 subjects the mean nasal mucosal temperature was 30.4 +/- 2.0 degrees C on inspiration and 32.0 +/- 1.8 degrees C on expiration. Using multiple regression, nasal mucosal temperature was significantly related to atmospheric temperature (p < 0.0001) and inversely related to the airway patency of the ipsilateral nasal passage (p < 0.05).

Submucous resection for deviated nasal septum: a critical appraisal.

Submucous resection (SMR) for the deviated nasal septum had been criticised to have a higher complication rate and less patient satisfaction than septoplasty. Seventy-five patients who underwent SMR were studied and followed up at 6 months to 56 months post-operatively. The rates of short and long term complications were relatively low: septal haematoma 1.3%, nasal infection 1.3%, epistaxis 2.6%, external nasal deformity 9.3% and septal perforation 2.7%. While most patients achieved short term relief of nasal obstruction (93.4%), about 30% had persistent/recurrent nasal obstruction on long term follow-up. Similar rates had been quoted for the operation of septoplasty. We postulated that this was due to unfavourable airflow patterns as a result of minor residual septal deviation. Some patients had associated pre-operative symptoms of snoring (57.3%), headache (48.0%), rhinorrhoea (38.7%), sneezing (30.7%), hyposmia (30.7%) and epistaxis (21.3%). Frequencies of cure/improvement of these symptoms after SMR were 34.9%, 33.3%, 24.1%, 30.4%, 60.9% and 43.8% respectively. The overall post-operative long term (average 23.5 months) satisfaction rate was almost 70%. SMR, being relatively easy to perform, and having similar complication and patient satisfaction rates as septoplasty, should be retained in the surgical armamentarium for the deviated nasal septum.

Nasal airflow: resistance and sensation.

For many years nasal resistance to airflow measured by rhinomanometry has been regarded as the objective measure of nasal patency. However, recently it has become apparent that this may not be the case. The present study was designed to affirm or refute this view by using large numbers of subjects and observations. Five hundred estimations of (objective) nasal resistance to airflow and (subjective) nasal sensation of airflow where carried out. No correlation could be demonstrated between these two parameters. It is concluded nasal resistance to airflow and nasal sensation of airflow are two separate modalities which are not directly related. The possible reasons for this finding are discussed with reference to previous work on nasal sensation.