Endonasal placement of spreader grafts: experience in 41 consecutive patients.

OBJECTIVES To evaluate the efficacy of placing spreader grafts via an endonasal approach and to examine the immediate and long-term functional results. METHODS A retrospective review was performed of 41 consecutive cases involving adult patients who underwent nasal valve reconstruction. Medical history and clinical examination established the cause of nasal obstruction, with internal valve dysfunction confirmed through endoscopic evaluation and the modified Cottle maneuver. Surgical correction involved a spreader graft harvested from autologous cartilage and placed endonasally. Comparison and evaluation of preoperative vs postoperative symptom severity, photographs, and patient self-assessment were used to quantify the results of the operation. RESULTS Our study included 22 women and 19 men with a mean age (range) of 32 (19-56) years. Twenty-seven patients (66%) were Asian, 12 (29%) were white, and 2 (5%) were Hispanic. Thirty of 41 patients (73%) expressed strong concern regarding the presence of a transcolumellar scar. Among our patients with confirmed internal nasal valve dysfunction, 25 (61%) reported significant improvement, 15 (37%) noted some improvement, and 1 (2%) described no change; none reported a worsening of symptoms. CONCLUSIONS The endonasal approach to placement of spreader grafts for nasal valve reconstruction is effective at relieving nasal obstruction due to internal nasal valve dysfunction. Paramount to the success of the procedure is appropriate patient selection and careful attention to surgical technique.

Estimation of skin removal in aging Asian blepharoplasty.

OBJECTIVES/HYPOTHESIS: To describe a novel method for estimating the amount of skin to resect in upper blepharoplasty in the aging Asian eyelid and to report our experience with this technique. STUDY DESIGN: Retrospective review of patients in a single private practice. METHODS: Resection of skin in upper blepharoplasty in an Asian eyelid can often be less forgiving than in other ethnicities due to the unique anatomy of the supratarsal fold. Excising a maximal amount of excess skin will result in an unfavorable appearance of the upper eyelid in an Asian patient. We applied a technique of pinching the skin while the patient is awake until the patient is satisfied with the appearance. The skin is then measured and the precise amount resected during blepharoplasty. The supratarsal crease is always recreated even in patients who have a preexisting crease. We conducted a retrospective review of 99 consecutive patients who underwent upper blepharoplasty using this technique. All patients were Asian and aged 40 years or older. RESULTS: The study group included 99 patients with a mean age of 55.7 years (range, 42-78 years). The mean follow-up time was 24 months (range, 12-30 months). The amount of desired skin overhang superior to the supratarsal crease varied considerably among patients. Complications included asymmetry in nine patients (9.1%), scarring in three patients (3.0%), and unfavorable cosmetic result in two patients (2.0%). No patients experienced infection, bleeding, or visual changes. CONCLUSIONS: In upper blepharoplasty in the aging Asian eyelid, it is necessary to resect less skin than in the Caucasian patient to achieve the desired appearance of the upper eyelid complex. Using a patient-assisted approach to estimate the amount of skin to remove, a favorable cosmetic result with a low incidence of complications was achieved in a consecutive series of patients.

Fluconazole nasal spray in the treatment of allergic fungal sinusitis: a pilot study.

The authors describe a prospective pilot study designed to investigate the use of topical nasal antifungal spray in addition to systemic steroids and itraconazole in the treatment of allergic fungal sinusitis. Sixteen patients with a history of allergic fungal sinusitis were given fluconazole nasal spray and followed for 3 months. Stabilization or improvement of disease without significant side effects was observed in 12 of the 16 patients who were treated with this protocol. These results indicate that topical fluconazole application may help patients with allergic fungal sinusitis; however, a larger multicenter study with longer patient follow-up is required to validate these initial findings.

Management options for cerebrospinal fluid leak after vestibular schwannoma surgery and introduction of an innovative treatment.

OBJECTIVE: To review the management of cerebrospinal fluid leak after vestibular schwannoma removal reported in the literature and to present a novel approach to management of recalcitrant cases. DATA SOURCES: MEDLINE and PubMed literature search using the terms "cerebrospinal fluid leak" or "cerebrospinal fluid fistula" and "acoustic neuroma" or "vestibular schwannoma" covering the period from 1985 to present in English. A review of bibliographies of these studies was also performed. STUDY SELECTION: Criteria for inclusion in this meta-analysis consisted of the availability of extractable data from studies presenting a defined group of patients who had undergone primary vestibular schwannoma removal and for whom the presence and absence of cerebrospinal fluid leakage was reported. Studies reporting combined approaches were excluded. No duplications of patient populations were included. Twenty-five studies met the inclusion criteria. DATA EXTRACTION: Quality of the studies was determined by the design of each study and the ability to combine the data with the results of other studies. All of the studies were biased by their retrospective, nonrandomized nature. DATA SYNTHESIS: Significance (p < 0.05) was determined using the chi test. CONCLUSIONS: Incisional cerebrospinal fluid leakage responded well to local management and lumbar drainage. Rhinorrhea often necessitated surgical intervention. No specific reoperation techniques correlated exclusively with better reoperation outcomes. The transaural/transnasal approach presents an alternative for surgical management of cerebrospinal fluid rhinorrhea.

Nasal valve reconstruction: experience in 53 consecutive patients.

OBJECTIVES: To determine the cause of nasal valve obstruction in a series of patients requiring surgical correction, to evaluate the efficacy of our surgical techniques, and to assess the cosmetic effect of nasal valve repair. METHODS: Retrospective review of 53 consecutive cases involving adult patients who underwent nasal valve reconstruction over an 8-year period. The preoperative symptom severity, cause of nasal valve obstruction, preoperative photographs, anatomical findings at the time of surgery, and reconstructive techniques were reviewed. Postoperative photographs and resolution of symptoms were analyzed. RESULTS: The most common cause of nasal valve obstruction was previous rhinoplasty (79%), followed by nasal trauma (15%) and congenital anomaly (6%). Spreader grafts were used in 42 patients (79%), and alar batten grafts were used in 19 patients (36%). The patients received a minimum of 1 year of follow-up. All 12 patients with external valve dysfunction showed improvement after surgery. Thirteen (93%) of the 14 patients with concomitant external and internal valve dysfunction had improvement in nasal obstruction after treatment. Twenty-four (89%) of 27 patients with internal nasal valve dysfunction reported improvement in nasal obstruction. Spreader grafts caused a widening of the middle third of the nose. Alar batten grafts resulted in effacement of deep alar creases and a widening of the nasal tip. CONCLUSIONS: We have found that surgical correction of nasal valve obstruction is extremely effective in improving subjective nasal obstruction. Success of this procedure is predicated by correct diagnosis and appropriate surgical technique.

The incidence of cerebrospinal fluid leak after vestibular schwannoma surgery.

OBJECTIVE: To review the incidence of cerebrospinal fluid leak after vestibular schwannoma removal reported in the literature. DATA SOURCES: MEDLINE and PubMed literature search using the terms "acoustic neuroma" or "vestibular schwannoma," and "cerebrospinal fluid leak" or "cerebrospinal fluid fistula" covering the period from 1985 to the present in the English language literature. A review of bibliographies of these studies was also performed. STUDY SELECTION: Criteria for inclusion in this meta-analysis consisted of the availability of extractable data from studies presenting a defined group of patients who had undergone primary vestibular schwannoma removal and for whom the presence and absence of cerebrospinal fluid leakage was reported. Studies reporting combined approaches were excluded. No duplications of patient populations were included. Twenty-five studies met the inclusion criteria. DATA EXTRACTION: Quality of the studies was determined by the design of each study and the ability to combine the data with the results of other studies. All of the studies were biased by their retrospective, nonrandomized nature. DATA SYNTHESIS: Significance (p < 0.05) was determined using the chi2 test. CONCLUSIONS: Cerebrospinal fluid leak occurred in 10.6% of 2,273 retrosigmoid surgeries, 9.5% of 3,118 translabyrinthine surgeries, and 10.6% of 573 middle fossa surgeries. The type of cerebrospinal fluid leak was not associated with surgical approach. Meningitis was significantly associated with cerebrospinal fluid leak (p < 0.05). Age and tumor size were not associated with cerebrospinal fluid leak.

Relationship of petrous temporal bone pneumatization to the eustachian tube lumen.

OBJECTIVES/HYPOTHESIS: Objectives were to determine the incidence of petrous apex pneumatization and to define the relationship between a pneumatized petrous temporal bone and the eustachian tube lumen. STUDY DESIGN: Retrospective study with institutional review board approval including only adult patients. METHODS: One hundred head computed tomography (ct) scans and 204 petrous temporal bone CT scans performed at a tertiary teaching hospital were reviewed. The two senior authors (s.h.s., p.c.s.) independently reviewed the petrous temporal bone CT scans for grade of pneumatization. Pneumatized CT scans were then reviewed for the presence of a direct communication with the eustachian tube lumen. Significance was determined using the chi test and Pearson correlation of ranks. RESULTS: The incidence of peritubal cells opening into the eustachian tube anterior to the tympanic orifice was 92%. CONCLUSION: The direct communication of peritubal cells with the bony eustachian tube may play a role in the development of persistent cerebrospinal fluid rhinorrhea after cerebellopontine angle surgery.

Sporadic Burkitt's lymphoma of the head and neck in the pediatric population.

Burkitt's lymphoma (BL) is one of the fastest growing malignancies in the pediatric population in the United States. BL is a high-grade B-cell Non-Hodgkin's lymphoma (NHL) which exists in endemic, sporadic, and human immunodeficiency-associated subtypes. The African, or endemic, variant usually involves the maxilla and other facial bones while head and neck manifestations in non-endemic BL are rare. We present three unusual present ations of sporadic BL stemming from Waldeyer's ring and the orbit. The clinical and pathologic features of BL are reviewed.

Subcutaneous emphysema and pneumomediastinum as presenting manifestations of neonatal tracheal injury.

Neonatal tracheal injury/perforation is an uncommon complication of traumatic deliveries or endotracheal intubation. We present a case of neonatal tracheal injury following delivery at term that presented with subcutaneous emphysema and pneumomediastinum before any attempt at intubation. The clinical course, treatment, and outcome are described.