A comprehensive approach to rhinoplasty for thick-skinned patients.

OBJECTIVE: This study aimed to propose a systematic approach for managing thick-skinned rhinoplasty patients. METHODS: A retrospective review of the treatment of 26 thick-skinned patients with aesthetic and/or functional problems over a period of three years from January 2018 to January 2021 with a follow up for one year. A presurgical evaluation of skin was carried out initially. Skin thickness due to sebaceous overactivity was treated with retinoic acid derivatives, and skin thickness due to increased adipose tissue or hypertrophic fibrofatty layers was treated surgically. Open rhinoplasty was performed in all patients and a strong osseocartilaginous framework was created with the skin stretched as much as the aesthetic tolerance allowed. RESULTS: Post-operative outcomes were based on subjective assessment, photographic evaluation and the Rhinoplasty Outcome Evaluation questionnaire, which indicated significant patient satisfaction. CONCLUSION: Using this systemic approach for treating thick-skinned rhinoplasty patients, predictable results with improved aesthetic satisfaction in patients were achieved.

Septal Extension Graft in Increasing Nasal Tip Projection.

To study the use of septal extension graft for increasing nasal tip projection in cases of an under-projected nasal tip and to evaluate post-operative aesthetic and functional outcomes associated with it. 28 patients of underprojected tip underwent rhinoplasty with use of Direct caudal type of Septal extension graft with a minimum follow up of 12 months, operated between January 2018 to January 2020. ROE questionnaire and photographic evaluation were used for the assessment of post-operative functional and aesthetic outcomes. Significant improvement was seen in both aesthetic and functional outcomes with a mean ROE questionnaire score of 30.5 pre-operatively to 79.5 post-operatively. Pre-operative and post-operative photographic evaluation showed significant improvement in aesthetic outcome. None of the patients reported any postoperative complication. Septal extension graft can be used in patients with nasal tip deformity, Binder's syndrome, caudal septal dislocation, drooping tip,/ retracted columella and short nose with good post-operative aesthetic and functional outcomes and hence is an important technique for grafting. Owing to its rigid fixation with nasal septum, anterior nasal spine and lower alar cartilage, long term results for the control of nasal tip projection and rotation are remarkable.

Caudal Septal Deviation: New Classification and Management Strategy.

To propose a classification of anatomical variation of the caudal septal deviation and propose strategy for the management of caudal septal deviation by septo-rhinoplasty and to evaluate the efficacy of treatment of different types of caudal septal deviation in terms of aesthetic and functional outcome. The study is a retrospective review of 124 cases with significant anterior caudal deviation causing aesthetic and or functional problems, treated by septo-rhinoplasty within a 5 year period from December 2014 to December 2019, with a minimum follow up of 6 months. Visual analogue scale, photographic evaluation and subjective assessment were used for postoperative outcomes. Significant improvement in the treatment of nasal obstruction was achieved, with mean visual analogue scale score of 7.83 preoperatively to 3.56 postoperatively, Subjective assessment showed marked satisfaction in 96 patients, moderate satisfaction in 21 and no improvement in seven patients of total 124 patients. The rate of revision was (4%). A novel classification of anterior caudal septal deviation is proposed with surgical technique directed for individual deformity and we have achieved very good results.

Endoscopic Modified Danker's Approach for Management of Sinonasal Inverted Papilloma: Our Experience.

Sinonasal inverted papilloma (SNIP), Inverting papilloma, Schneiderian papilloma etc. It is a benign tumor with incidence nearly 70% of all sinonasal papilloma and 0.5-4.0% of all sinonasal neoplasms. The most common site of origin is lateral nasal wall and common presenting symptom is nasal obstruction followed by epistaxis. On histopathology examination, it is characterized by invagination of neoplastic epithelium into underlying stroma. With the advent of technology, the endoscopic modified dankers approach became the surgical approach of choice. The present study was undertaken to study its role in management of SNIP with reference to rate of recurrence and malignancy. An observational study was conducted in a tertiary health center in which 40 biopsy proven cases of SNIP, operated by endoscopic assisted modified Danker's approach between September 2008 and January 2019 with minimum follow-up period of 6 months were analyzed. Male:Female ratio was 2.33:1. The most common symptom was nasal obstruction (97.5%) followed by rhinorrhoea (87.5%). Using various imaging and diagnostic measures, lateral nasal wall was found to be the most common site of origin. Out of total 40 cases, 9 (27.5%) patients had recurrence, of these, 6 were benign and remaining 3 had malignancy as confirmed by biopsy. Most of the cases of SNIP can be managed endoscopically, although extensive lesions or the lesions with malignant transformation, external approach may be needed so expertise in both endoscopic and conventional techniques is needed. Although most of the recurrences occurred in first 2 years, but life time follow-up is advisable.

Non-surgical Rhinoplasty and Use of Hyaluronic Acid Based Dermal Filler-User Experience in Few Subjects.

This study was intended to assess the utility of hyaluronic acid dermal fillers in patients who do not wish surgery in addition to the patients with minor post-surgery asymmetries. This was a prospective study which included post-surgery patients for minor nasal asymmetries, patients unwilling for surgery and those waiting for revision surgery. It is of great use in candidates who do not wish surgery but had the desire for different nasal appearance especially for important life events like marriage etc. This study included 20 patients with follow up period of 18 months. The results were compared on Nasal Imperfection Scale and Rhinoplasty Outcome Evaluation along with pre and post injection photographs. Nasal Imperfection Scale difference of 5 and Rhinoplasty Outcome Evaluation Scale differential of 50 is considered to be significant, which was observed in all individual cases. The growing need of medical rhinoplasty by the patient as well as surgeons has led to the introduction of fillers. Hyaluronic acid fillers are safe, easy and effective dermal fillers for patients undergoing all the expected indications of medical rhinoplasty. There is also growing number of candidates who wish for a 'nose job' for desired changes without coming under surgeon's scalpel. Our clinical experience with 20 patients has been described with satisfactory results.

A Study to Determine Various Factors Influencing Auditory Outcomes in Paediatric Cochlear Implantation.

To evaluate various factors that affects the auditory outcomes in pediatric patients with bilateral profound sensorineural hearing loss who underwent unilateral cochlear implantation. 50 prelingually deaf pediatric patients aged between 1 and 6 years with bilateral profound sensorineural hearing loss who underwent unilateral cochlear implantation between January 2016 and June 2018 at our tertiary centre were included in this study. Auditory performance was measured using revised categories of auditory performance score at 1 year post cochlear implantation. A Statistical analysis of several factors was performed to reveal any significant relation with outcomes of cochlear implantation. The results of the study showed that patients with younger age at implantation, patient who used hearing aid prior to surgery and patients with normal cochlear morphology had better auditory outcomes post cochlear implantation than their counter group and are the factors which have positive effect on the cochlear implantation outcomes, whereas factors which did not showed any significant relation with the auditory outcomes of cochlear implantation are gender, consanguinity and birth hypoxia. Age at implantation, use of hearing aid prior to surgery and cochlear morphology are the factors with direct impact on the outcomes of cochlear implant.

Ultrasonic Wave Bone Cutting Technique (Piezotome) in Cochlear Implant Surgery by Veria Technique.

To study use of ultrasonic wave bone cutting technique (piezotome) in cochlear implant surgery by veria technique. The Piezoelectric device is a bone cutting tool that transmits ultrasonic high frequency vibrations through a metallic tip to selectively cut bone while sparing the surrounding soft tissues. We have used the piezo tools instead of the perforator in over 50 cases of Cochlear Implant by the non mastoidectomy Veria technique [which uses a specially designed hand piece perforator with a guide (Kiratzidisa et al. in ORL J Otorhinolaryngol Relat Spec 64:413-416, 2002)]. These tools are helpful in: straightening the posterior bony canal wall, making the well for Implant bed, making space for excess electrodes and removing bone tissue close to dura without risk of injury to dura. Though use of Piezo tools in various otologic surgeries has been described but we feel the piezo tools will be an important tool in a CI surgeon's armament.

The Role of Extracorporeal Septoplasty in Severely Deviated Nasal Septum.

Extracorporeal septoplasty is a valuable tool in the armamentarium of the nasal surgeon for the reconstruction of the severely deviated septum. Extracorporeal septoplasty offers the surgeon the opportunity to correct the septum under direct visualization, shape the nasal vault and address the nasal dorsum with the ultimate goal of providing both form and function for the patient with a complex septal deviation. The study was conducted with the aim to measure the outcomes of extracorporeal septoplasty in severely deviated nasal septum, relief of symptoms (nasal obstruction), surgical complications, if any, revision, if any with objective to evaluate the functional outcome and aesthetic aspects of extracorporeal septoplasty. This was a prospective observational study of 35 patients with severe deviated nasal septum with or without external deformity of nose attending the ENT OPD between Jan 2015 and Jan 2016 at Sri Aurobindo Medical College and Post Graduate Institute, Indore (M.P.). In this study, 17 patients (48.57%) shows excellent improvement on VAS scale, out of which 13 patients shows excellent improvement and 4 patients shows good improvement on photographic assessment. 11 patients (31.43%) show good improvement on VAS as well as photographic assessment and 7 patients (20%) show moderate improvement on VAS scale and fair improvement on photographic assessment. Extracorporeal septal reconstruction is an important surgical option for the correction of the markedly deviated nasal septum. Fixation of the straightened and replanted septum at the nasal spine and dorsal septum border with the upper lateral cartilages is essential. Spreader grafts for stabilization of the internal nasal valve and dorsal onlay grafts to prevent dorsal irregularity are strongly encouraged.

Papillary carcinoma of thyroid with an unusual presentation.

Papillary thyroid carcinoma is well known for its low malignant potential and good prognosis. The outcome can be fatal in patients with low compliance and delayed treatment. Recent advances in ultrasonographic screening and US guided fine needle aspiration biopsy has facilitated early diagnosis of papillary thyroid carcinomas. This epithelial thyroid tumour accounts for more than 80 % of all thyroid tumours. An occult primary carcinoma of thyroid presenting as lymphangioma has been reported rarely. We present a case of a 40-year-old female patient with huge cystic midline swelling on the right side of the neck mimicking lymphangioma on USG. MRI neck showed a cystic mass causing displacement of the trachea and arising from Rt lobe of thyroid gland. Hemithyroidectomy was carried out and histopathology revealed papillary carcinoma. In patients with neck swellings presenting as huge cystic mass the differential diagnosis of Intra cystic variant of papillary carcinoma thyroid and metastatic thyroid papillary carcinoma must always be considered prior to planning surgery.

Giant odontogenic fibroma of maxilla.

Odontogenic fibroma is a benign ectomesenchymal tumor classified as central and peripheral on the basis of its location and as an epithelium rich or epithelium poor based on its histological features. Radiological findings consist of radiolucent areas with well-defined bony margins. The lesion is detected early because of its location and usually treated with surgical excision and curettage. We present a case of giant odontogenic fibroma of right maxilla presenting as gross facial deformity and posing a dual challenge of excising the tumor mass and reconstructing the ensuing defect.

Diced cartilage: an effective graft for post-traumatic and revision rhinoplasty.

Rhinoplasty has grown and developed over so many years but the choice of the graft material in revision rhinoplasty and rhinoplasty for post-traumatic cases still remains debatable. In such patients, non-availability of adequate autogenous graft, multiple septal fractures and skin fibrosis are a challenge to the rhinologist. To deal with this problem authors have used diced cartilage pieces as a grafting material. Secondary rhinoplasty for correction of the nasal dorsum was done in 32 patients and evaluated. The study, highlights the distinct advantages of using diced cartilage wrapped in fascia for dorsal augmentation. Full length grafts were used in all patients and this was supported on a L-shaped cartilage fixed between the two upper lateral cartilage. Fascial tube was prepared from fascia lata and conchal, rib or septal cartilage was the source of diced cartilage (0.5-1 mm sized pieces). The L-shaped structural support was prepared from the remnant of septal cartilage if any or from the conchal or rib cartilage. Patients were followed for a period of 6 months-3 years. In 30 patients post-op course was uneventful with good reconstruction results. Step-deformity was encountered in one patient and in another patient the tube opened with extrusion of diced cartilage pieces. Both these patients were effectively managed. In conclusion, diced cartilage wrapped in fascial tube has distinct advantages like it is simpler procedure and graft material is adequate and autogenous. Grafts can be prepared as per the desired length, shape and size to fit the specific defect. These being highly malleable can be used without any tension on the already thickened and fibrosed skin and soft tissue. Complications like step deformity and extrusion rarely occur and can be easily managed. Over correction and graft visibility were not met with.

Endoscopic Approach to Fisch Stage II to III-b Juvenile Nasopharyngeal Angiofibroma.

Juvenile nasopharyngeal angiofibroma (JNA) are locally growing highly vascular tumours treated primarily by surgical excision (open approach as wide as a mid facial degloving or endoscopic approach). All our patients underwent exclusive endoscopic tumour excision after a pre-operative embolisation. The tumours were completely resected with acceptable blood loss and no recurrences or residual masses were seen. Post-operative morbidity was minimal without external scar-marks. To conclude endoscopic excision is a very effective method to resect JNA even for extensive tumours.