Intraoperative use of a tablet computer to aid rhinoplasty.

Open septorhinoplasty enables excellent exposure to the structural components of the nasal tip. Nevertheless, it runs the risk of weakening its support mechanisms, which can lead to notable changes to tip projection and rotation as well as to the nasolabial angle. It is therefore paramount that the surgeon reconstructs the nose to the desired endpoint at the end of the operation. Currently, the gold standard of care in rhinoplasty uses preoperative photographs with the patient sitting or standing. However, this is not a true representation of the face in the operative position as the patient is placed supine and so gravity affects the appearance of the nose in a different way. Other factors such as head drapes and traction on the endotracheal tube can also cause subtle changes. We therefore advocate additional intraoperative profile view photographs to improve the accuracy of nasal tip positioning. In our department, in addition to standard preoperative photographs, immediate preoperative profile photos are taken with the patient supine, intubated and draped. Images are captured using a tablet computer at a distance of 1 meter from the patient. We ensure that the Frankfort plane is perpendicular to the floor. The picture is enlarged so that the image is full scale and the tablet is subsequently placed immediately behind the patient for direct comparison. This is then used during the procedure to check tip projection and rotation as well as at the end of the procedure following closure of the columellar incision to ensure correct placement of the nasal tip.

Rapid treatment of rhinophyma with powered microdebrider.

We describe here our experience in using sinus microdebrider to rapidly debulk and sculpt the tissues in cases of rhinophyma correction. We utilized the use of the 4 mm M4 Rotatable Cutting Straight Sinus Blade on a straight Straightshot M4 Microdebrider by Medtronic at 800 rpm oscillation which is normally utilised in our sinus surgery practice. The microdebrider is straightforward to use and is already stocked in most ENT departments. It requires no additional training or cost outlay for departments that perform endoscopic sinus surgery with microdebrider. In our experience it affords the surgeon the ability to rapidly and accurately sculpt the nose to an excellent aesthetic result. We feel it is a more precise tool than cold steel or Bovie cautery, quicker than CO2 laser techniques, and avoids the aerosol of dermabrasion. No complications occurred in our series, and all patients rated their cosmetic outcome as good to excellent.

Estimation of tracheostomy tube cuff pressure by pilot balloon palpation.

Two methods can be used to assess the intra-cuff pressure of tracheostomy tubes: digital palpation of the pilot balloon and use of a hand-held manometer. We conducted a telephone survey to determine the prevalence of both methods in intensive care units within 21 teaching hospitals across the United Kingdom. Forty-two per cent of the intensive care units surveyed used a protocol for monitoring cuff pressure with a manometer.A study to compare these two methods, using the manometer as the reference standard, was then carried out. The cuff pressure was correctly estimated in pre-inflated tracheostomy tubes, in a tracheal model, by 61 per cent of a cross-section of intensive care unit and otolaryngology staff.Using pilot balloon palpation is inaccurate and leaves a significant proportion of patients at risk of tracheal injury. We advocate the wider availability of hand-held pressure manometers in intensive care units and the institution of protocols for monitoring cuff pressure for any patient with a tracheostomy tube with an inflated cuff in situ.

Functional rhinoplasty with batten and spreader grafts for correction of internal nasal valve incompetence.

OBJECTIVE: We a describe technique for correction of internal nasal valve incompetence (INVI) using functional rhinoplasty (FRP) with combined cartilaginous batten and spreader grafts and report the functional and cosmetic outcomes. DESIGN: Prospective series using subjective improvement in nasal airway and quality of life. SETTING: Subregional ENT centre, one operating rhinologist. PARTICIPANTS: Twenty-three consecutive adults presenting to ENT department at North Hertfordshire NHS Trust with symptomatic INVI. MAIN OUTCOMES MEASURES: Pre and post-operative symptom scores for nasal obstruction and its impact on overall quality of life using visual analogue scales (1-100mm). Cosmetic outcome graded using subjective scores. Statistical analysis performed using the Wilcoxon signed rank test. RESULTS: We found a median subjective improvement on the visual analogue scale of 55 mm for nasal patency (p<0.001) and of 49 mm for quality of life (p<0.001). Twenty-two patients felt that the appearance of their nose had not changed or had significantly improved post operatively. CONCLUSION: Combined use of batten and spreader grafts for the correction of INVI in normal or narrow nasal vaults is effective without compromising cosmesis.

How we do it: free conchal cartilage revisited for primary reconstruction of attic defects in combined approach tympanoplasty.

Keypoints * There are concerns over the efficacy of free cartilage autografts in attic reconstruction (scutumplasty) for combined approach tympanoplasty (CAT). * Our operative technique uses free conchal cartilage autografts and an additional piece of conchal cartilage to buttress the reconstruction. * Of the 16 cases where this technique was used, there were two cases (13%) of failure of the attic reconstruction and a keratin pearl (residual disease) in one case (6%). This compares favourably with comparable series using a variety of reconstruction techniques.

Short-term persistence of carcinoma of the uterine cervix after radiation. An indicator of long-term prognosis.

Between 1959 and 1980, 590 evaluable patients received a full course of radiation therapy as primary treatment of invasive epidermoid carcinoma of the cervix. At follow-up visits conducted between 1 and 3 months after the completion of radiation, 72 patients had physical or biopsy findings indicative of persistent disease (PER), whereas an additional 36 had findings suggestive of tumor (SUS). The remaining 482 demonstrated a complete response (CR) by 1 month after the administration of treatment. The lower the stage, the more likely was a CR by 3 months (Stage I, 94.4%; Stage II, 86.2%; Stage III, 62.7%). A higher proportion of CR was obtained in patients with tumor of less than 5 cm in diameter than in those with tumors greater than 5 cm in diameter (82.4% versus 76.3%, respectively; 0.1 greater than P greater than 0.05). CR patients enjoyed a marked survival advantage over those with PER, whereas women with SUS demonstrated intermediate 5-year survival (76.0%, 41.5%, and 7.4%, respectively; P less than 0.0001). The same survival gradient of CR greater than SUS greater than PER was demonstrated when tumors of each stage were analyzed separately. There was no difference in survival between patients with PER or SUS at 1 month and those with PER or SUS at 3 months. The proportion of recurrent tumors diagnosed as exclusively distant metastases decreased from CR to SUS to PER. Analysis of dosimetry data suggests that the likelihood of CR was not a function of treatment variability. It was concluded that tumors that do not regress promptly are likely to recur, most with distant metastases. Such poor-prognosis patients should be targeted for early adjuvant or salvage therapy.