Nasal tip bossae in rhinoplasty. Etiology, predisposing factors, and management techniques.

OBJECTIVES: To identify preoperative risk factors and surgical techniques that influence the risk of developing postoperative nasal tip bossae in rhinoplasty. A secondary objective was to review the characteristics, management techniques, and outcomes of those study patients with postoperative bossae. DESIGN: Univariate and multivariate analysis carried out in a case series. SETTING: Private facial plastic surgery practice. PATIENTS: All patients who underwent aesthetic nasal surgery that included surgical modification of the nasal tip, and in whom documentation was complete and photographic follow-up was available, were considered eligible. The study group consisted of 875 patients of whom 37 (4.2%) developed bossae postoperatively. MAIN OUTCOME MEASURES: Potential risk factors for postoperative bossae included age, sex, previous nasal surgery, preoperative tip asymmetry, preoperative lobular bifidity, preoperative bossae, skin thickness, surgical tip technique, use of columellar struts, columellar battens, lobular crushed cartilage grafts, and tip shield grafts. RESULTS: In the univariate analysis, females, patients undergoing primary rhinoplasty, younger age groups (12- to 22-year-olds), thin skin, and widened interdomal distance (bifidity) were all noted to have moderate or strong associations with nasal tip bossae. In the multivariate analysis, the younger age group, thin skin, and bifidity were statistically significant and independently associated with nasal tip bossae, independent of the type of tip surgery. In addition, clinically relevant associations were noted in females and patients undergoing primary rhinoplasty. Recognition of risk factors, preventive measures, and treatment methods is recommended.

Asymptomatic enophthalmos: the silent sinus syndrome.

Although uncommon, enophthalmos may be a presenting symptom of chronic maxillary sinusitis with secondary attentuation of the orbital floor. As such, as awareness of this entity, known as the "silent sinus syndrome," is important to all practising otolaryngologists. Two such cases are presented herein, together with a discussion of the pathophysiology, management, and current literature.

Analysis of nasal air flow following repair of vestibular stenosis.

OBJECTIVE: Vestibular stenosis is an uncommon but debilitating cause of nasal obstruction. The etiology of the stenosis is variable, but iatrogenic causes are by far the most common. A number of techniques have been described for repair of the stenotic segment. We present a surgical technique that employs the concepts of: excision of the stenotic segment, enlargement of the bony pyriform aperture, and placement of a full-thickness skin graft. RESULTS: Our results have been very favourable, and we have documented improvement in nasal obstruction by performing preoperative and postoperative nasal airflow studies on all our patients. CONCLUSIONS: These results suggest that significant improvement in nasal airflow can be obtained in most patients with the use of this technique.

Issues in the surgical management of parathyroid disorders.

At St. Joseph's Health Centre in London, Ontario, the Departments of Otolaryngology and Endocrinology of the University of Western Ontario work closely together in the medical and surgical management of patients with parathyroid disease. Recently, a multidisciplinary Grand Rounds was held during which current issues in the management of these patients were discussed, with particular emphasis on the role of localization studies as well as the potential difficulty inherent in distinguishing parathyroid adenomas from parathyroid hyperplasia. The following is an edited transcript from the Grand Rounds.

Acoustic neuroma management: a six-year review.

The purpose of this investigation is to review the outcome of 83 consecutive acoustic neuroma patients, managed solely or in part by the Department of Otolaryngology at University Hospital, London, Ontario, over a 6-year period (1987 to 1993). The majority of patients underwent operative intervention, utilizing the middle cranial fossa, suboccipital, or most commonly, the translabyrinthine approach depending on the tumour size and level of residual hearing. Demographic, preoperative, intraoperative, and postoperative data are analyzed including complications of surgery. As well, we report on our experience with the use of fibrin glue in the dural closure following translabyrinthine resections and the resultant impact on the postoperative CSF leak rate. Overall, our results and complications are comparable to other large acoustic neuroma series in the literature. In addition, we feel that further study is merited in the use of fibrin glue in dural repair and its relationship to postoperative cerebrospinal fluid fistula.