Endoscopic Repair of Nasal Septal Perforations With Fascia Lata.

PURPOSE: Nasal septal perforation (NSP) consists of defects of mucosa, cartilage, and bone. Nasal septal surgery is by far the most common cause of NSP. Many surgical approaches have been described for NSP repair. In this study, the authors describe a novel technique for repairing all sizes of NSP using an only fascia lata graft. METHODS: The authors implemented a retrospective study design. Seventeen patients who underwent NSP repair between January 2016 and January 2019 were included to the study. Entire nasal surgical steps were performed under endoscopic view, harvested fascia lata graft is placed in tympanoplasty fashion after all edges of perforation is elevated and implantation bed is prepared. RESULTS: The mean size of the septal peforations were 18.52 ±â€Š4.17 mm horizontally, 11.52 ±â€Š3.42 mm vertically. The mean follow up period was 14.47 ±â€Š9.5 months (range: 2-36). In 15 of the 17 patients, total NSP closure was achieved (88,23%). CONCLUSIONS: Endoscopic close technique using fascia lata for nasal septal perforation closure is a safe and reliable technique with high success rate and it should be considered in patients with nasal septal perforation.

Unilateral Blindness After Septoplasty.

Septoplasty is a frequently performed procedure with mostly minor complications. Nevertheless, it may lead to serious complications.The authors present a 29-year-old patient admitted to their hospital 10 days after septoplasty in another institution. He suffered a total loss of vision immediately after the surgery.High-resolution computed tomography and magnetic resonance imaging revealed a direct trauma of the optic canal and an inflamed and edematous optic nerve. Even though a successful endoscopic optic nerve was performed, the patient's loss of vision did not improve after the surgery.Blindness after septoplasty is an extremely rare but a devastating complication. There are only few patients that indicates the optic nerve injury caused by a direct trauma.

Puzzle-Formed Modified Turkish Delight for Nasal Dorsum Augmentation.

Structural deficiencies of the nasal dorsum are most commonly of congenital, traumatic, or iatrogenic etiology. Various grafts, including autografts, homografts, and synthetic materials, have been used to this end and are described in the literature.Autologous septal cartilage is the most commonly used graft material when limited augmentation rhinoplasty is planned. However, it is difficult to retain sufficient cartilage to allow of such augmentation in instances where most of the septal cartilage has been used. The authors place moderately crushed cartilage beneath a monolayer of surgicel when performing limited nasal dorsum augmentation. The aim of the present study is to describe authors' approach and its utility by reviewing other methods reported in the literature.

The Importance of Soft Triangle in Rhinoplasty.

The soft triangle is a basic, yet delicate and vulnerable, subunit of the nose that is under-rated both academically and surgically. The soft triangle is located at the apex of the nostril, at the point where the dermis is in direct contact with dermis that contains no intervening subcutaneous tissue and it may be unintentionally harmed during rhinoplasty.The authors suggest using a modified incision and closure and filling with significantly or severely crushed cartilage to prevent notching and to provide support for the soft triangle. The more the authors understand the nature of the soft triangle, the more they will be able to obtain superior surgical results in the nasal tip area.

The Benefit of a Complete Cephalic Trim and the Importance of the Scroll Area.

Cephalic trimming of the lower lateral cartilage (LLC) of the nose is often performed to refine a broad nasal tip in the horizontal dimension. The focus of cephalic trimming remains the preservation of the width of the lateral crura and the cartilage remnant at the cephalic end of the LLC is usually left intact, which leads to inadequate cephalic trimming.The authors suggest that cephalic trimming should continue all the way to the cephalic end of the LLC and no remnant cartilage should be left in the scroll area. This would make it possible to reduce the bulk of the nasal tip in an acceptable manner. Trimming of the whole cephalic side of the LLC would disrupt the scroll area, allowing authors to assess rhinoplasty as a 2-stage surgical procedure: that is, nasal tip and middle vault.In conclusion, complete cephalic trimming without leaving any remnant cartilage in the scroll area is necessary for adequate nasal tip refinement, and disruption of the scroll area allows the rhinoplasty to be compartmentalized to achieve more desirable results in the middle vault and the nasal tip.

Comparison of postoperative bleeding between submucosal uvulopalatopharyngoplasty and tonsillectomy.

BACKGROUND: The aim of this study was to compare the incidence of postoperative secondary hemorrhage for tonsillectomy and submucosal uvulopalatopharyngoplasty (smUPPP). MATERIALS AND METHODS: In this retrospective case series, the medical records of 404 patients who underwent tonsillectomy with unipolar electrocautery and smUPPP at our institution between January 2001 and December 2010 were reviewed. The patients were divided into two groups: Group 1 (198 patients) underwent tonsillectomy; Group 2 (206 patients) underwent smUPPP. Main outcome measures were incidence of bleeding or complications after tonsillectomy and smUPPP and the need for revision surgery. RESULTS: The mean age of Group 1 patients was 38.1 (±2.58) years and that of Group 2 was 37.7 (±2.25) years. Males were 51.3% of Group 1 and 46.7% of Group 2. No statistically significant difference in age or gender distribution was found between Groups 1 and 2. The incidence of secondary, delayed hemorrhage was 5.05% (10 patients) in Group 1 and 1.45% (three patients) in Group 2 (P = 0.05). The incidence of delayed hemorrhage requiring surgical treatment was 4.54% (nine patients) in Group 1 and 0.97% (two patients) in Group 2. CONCLUSION: In adults, smUPPP, which includes tonsillectomy, has a lower incidence of postoperative delayed hemorrhage than does tonsillectomy with unipolar cautery.

The morphology of the nasopharyngeal inlet in obstructive sleep apnea.

Routine flexible optic laryngoscopy (FOL) can visualize the airway from the nasopharynx to the hypopharynx in obstructive sleep apnea (OSA). With the tip of a flexible endoscope at the nasopharyngeal inlet (NPI), we can visualize the morphology of this area. We evaluated the effect of NPI morphology on OSA severity. Videos were obtained during FOL examinations of the NPI in 83 patients (11 females, 72 males; mean age 42.1 ± 9.5 years) and NPI morphology was examined. Two main morphologies were seen: wide and narrow. The narrow NPI group (n = 45) was further subdivided into kidney-shaped (n = 34), elliptical (n = 6), and circumferential (n = 5) groups. The wide NPI group (n = 38) was subdivided into circumferential (n = 20) and kidney-shaped (n = 18) groups. Mean Respiratory Disturbance Index (RDI) values were 30.38 ± 22.36 and 14.51 ± 13.9 in the narrow and wide groups, respectively. Mean RDI values were 45.32 ± 30.6, 23.74 ± 10.8, and 28.72 ± 21.5 in the narrow circumferential, elliptical, and kidney-shaped groups, respectively. Mean RDI values were 11.58 ± 12.91 and 17.8 ± 14.6 in the wide circumferential and kidney-shaped groups, respectively. RDI values were significantly lower in the wide morphology group (p < 0.0005). NPI morphology might predict OSA during routine FOL examination. Further analysis of the subgroups supported evidence of narrowing, reflected as higher RDI values.

Bilateral internal laryngoceles mimicking asthma.

Laryngocele is an air-filled, abnormal dilation of the laryngeal saccule that extends upward within the false vocal fold, in communication with the laryngeal lumen. A case of 43-year-old male with bilateral internal laryngoceles, who has been treated as asthma for 4 years, is presented. The patient had dyspnea, cough, and excessive phlegm for a month and a late onset stridor. Flexible nasopharyngolaryngoscopy showed bilateral cystic enlargements of the false vocal folds and true vocal folds could not be visualized. Laryngeal CT without contrast enhancement showed bilateral internal laryngoceles. Submucosal total excision of bilateral cystic masses including parts of false vocal folds was performed. The symptoms resolved immediately after surgery. Although the incidence of internal laryngocele is rare, it should be remembered in the differential diagnosis of upper airway problems and diagnostic flexible nasopharnygolaryngoscopy is routinely indicated for airway evaluation in at-risk patients.

Evaluation of tissue response to Gore-Tex (expanded polytetrafluoroethylene) implantation.

OBJECTIVE/HYPOTHESIS: The aim of this study was to assess the tissue response to Gore-Tex (expanded polytetrafluoroethylene) in rats and compare the results of surgical placement modalities. STUDY DESIGN: Prospective animal study. MATERIALS AND METHODS: Experiments were performed in 18 young Sprague-Dawley rats that were divided into 3 groups. Gore-Tex patches were implanted subcutaneously over the periosteum in the first group and under the periosteum in the other groups. Gore-Tex was immersed in an antibiotic-containing solution in the third group. All animals were killed 4 weeks after the procedure. The tissue samples were stained with hematoxylin and eosin stain and evaluated using a light microscope. RESULTS: The Gore-Tex patches were displaced and not observed at the originally implanted sites in the first group. The Gore-Tex patches were observed at the originally implanted sites in the other groups. In group 1, edema and inflammation were prominent. In the second group, ossification was detected in 5 rats and foreign-body reaction and edema were identified in 1 rat. In the third group, all of the rats were found to have developed ossification, but no inflammatory reactions were observed. CONCLUSIONS: The results suggest that implanting synthetic graft materials immersed in an antibiotic solution at the subperiosteal plane provides better stabilization and low complication rates.

Effect of uvulopalatopharyngoplasty on retropalatal region.

Flexible optic laryngoscopy (FOL) allows us to visualize the obstructive sleep apnea (OSA)-related airway passages. Retropalatal region is a part of upper airway contributing to the OSA. We aimed to demonstrate the changes in the retropalatal surface area (RPSA) after submucosal uvulopalatopharyngoplasty (smUPPP) in an attempt to exhibit enlargement as a predictor of surgical treatment. It is a prospective, case-control study and conducted at the Otolaryngology department in a university hospital. Twenty patients with OSA who underwent smUPPP were prospectively evaluated. Pre and postoperative respiratory disturbance index (RDI) and RPSA measurements were studied. Retropalatal region videos were obtained at the base of uvula during FOL. Photographic images were captured at the same level of a virtual horizontal line passing through the base of uvula posteriorly to measure RPSAs using AutoCad2004. RDI levels, RPSA measurements were compared using paired t test. Twenty patients underwent smUPPP. There were 17 (85 %) male and 3 (15 %) female. The mean age was 37 years. The RPSA measurements were between 18.41 and 144.102 (mean 63.39) preoperatively. The RPSA measurements were between 83.784 and 255.463 (mean 143.87) postoperatively. The RPSA measurements were significantly enlarged postoperatively (p < 0.0005). The mean RPSA increased from 63.39 ± 29.3 to 143.82 ± 57.8. The mean RDI decreased from 22.95 ± 19.2 to 9.0 ± 8.2 (p = 0.011). RPSA increases in smUPPP patients postoperatively, evidencing enlarged retropalatal region. Decreased RDI levels indicate amelioration in OSA. RPSA measurements can be used to predict UPPP surgical treatment success.

Quantification of retropalatal region in obstructive sleep apnea.

OBJECTIVE: Flexible optic laryngoscopy (FOL) allows us to visualize the obstructive sleep apnea (OSA)-related airway passages. However, objective data presenting evidence of OSA through this perspective are lacking. The aim of this study was to quantify the surface area of the retropalatal region in control subjects and OSA patients utilizing FOL images. This was a prospective, case-control study. The study was performed at the otolaryngology department of a university hospital. SUBJECTS AND METHODS: Sixty-seven OSA patients in group 1 and 87 patients with no complaints of OSA in group 2 were evaluated. Retropalatal region photographs were captured at the base of uvula through endoscopic images. The retropalatal surface area (RPSA) was measured using AutoCAD. Groups 1 and 2 RPSA measurements were analyzed. The RPSA measurements of subgroups in group 1 were analyzed to document severity of OSA. RESULTS: Mean RPSA measurements in group 1 was 73.21 (SD, 31.99), and that in group 2 was 129.31 (SD, 26.54), respectively. Retropalatal surface area is significantly larger in group 2 when compared with group 1 (P = 0.0001). Twenty-four patients had mild (mean respiratory disturbance index [RDI], 10.83 [SD, 3.63], 26 had moderate (mean RDI, 20.9 [SD, 4.14]), and 17 had severe OSA (mean RDI, 52.13 [SD, 17.24]) in group 1. The mean RPSA measurements are 72.48 (SD, 28.9) in mild subgroup, 73.88 (SD, 30.5) in moderate subgroup, and 73.22 (SD, 39.59) in severe subgroup, showing no evidence of correlation between the severity OSA and RPSA measurements. CONCLUSIONS: The RPSA measurements are significantly larger in control subjects (group 2) when compared with OSA patients (group 1). This might implicate that RPSA measurements through FOL examination can be a predictor of OSA when screening patients.

Importance of placing Gore-Tex in the subperiosteal plane for augmentation rhinoplasty.

OBJECTIVE: The purpose of this study was to present the placement technique of Gore-Tex implants for nasal augmentation. METHODS: The study group comprised 32 patients of various nasal deformities who underwent consecutive rhinoplasty via open approach with Gore-Tex implant material for dorsal augmentation. A pocket is made subperiostally at the nasal dorsum. The implant is rinsed in antibiotic solution and placed in position. Complications due to Gore-Tex were observed during the follow-up period. RESULTS: There were 12 men and 20 women. The mean age was 28.4 years. There were 9 primary rhinoplasty and 23 revision rhinoplasty. Patients were followed up postoperatively for 12 to 24 months. During the postoperative follow-up period, no complications were encountered in this series of patients. The implants were stable and immobile under the skin. CONCLUSIONS: In the cases of nasal dorsum augmentation, Gore-Tex can be a suitable graft material. We recommend implanting graft materials at subperiosteal plane to provide better stabilization and low complication rates.

Will a crushed concha bullosa form again?

OBJECTIVES/HYPOTHESIS: This study endoscopically and radiologically evaluated whether a surgically crushed concha bullosa (CB) can form again. STUDY DESIGN: Prospective study. METHODS: This study included 14 adults who underwent CB surgery between March 2010 and February 2011. The middle turbinate was examined endoscopically and classified pre- and postoperatively into four groups according to size. The CB volume of all patients was measured using pre- and postoperative paranasal sinus computed tomography (CT). The pre- and postoperative measurements were compared using the paired t test. RESULTS: This study included 22 CB in 11 men and 3 women with a mean age of 35.85 (range, 20-47) years. The mean follow-up period was 4.42 (range, 2-10) months. The middle turbinates were significantly smaller postoperatively (P < .0005), as was the CB volume measured using paranasal sinus CT (P < .0005). CONCLUSIONS: The CB crushing technique is an easy, conservative treatment modality. As the CB does not appear to reform after crushing, this technique can be considered a definitive treatment. Nevertheless, these patients should be followed for the long term.

Long-term efficacy of submucosal uvulopalatopharyngoplasty for obstructive sleep apnea syndrome.

The objective of the study was the assessment of the long-term efficacy of submucosal uvulopalatopharyngoplasty in patients with obstructive sleep apnea syndrome. Thirty-two of 156 patients who underwent UPPP between January 2001 and March 2007 with a follow-up period of 36-96 months (mean, 56 months) were included in the study conducted at the university affiliated center. Preoperative and postoperative snoring evaluation forms and Epworth Sleepiness Scale (ESC) scores were used for subjective analysis. Preoperative and postoperative respiratory distress index (RDI) levels were evaluated objectively. Patients who had 50% or more reduction in RDI levels postoperatively were named as responders to the procedure. The other patients were named as non-responders. Body mass index (BMI) was also analyzed preoperatively and postoperatively. Snoring disappeared in 83% of the patients, did not change in 13% and deteriorated in 4% of the patients (p < 0.001). Excessive daytime sleepiness decreased in 22 patients (68%) and ESC values decreased from 14.6 ± 3.7 to 6.5 ± 3.9 (p = 0.0001). RDI decreased by more than 50% of the preoperative values in 15 (46.9%) of 32 patients forming the responders and the mean RDI decreased from 33.3 ± 22.9 to 23.7 ± 22.8 (p = 0.027). BMI increased over years (p = 0.0001) evidencing a preponderance in non-responder patients. Submucosal uvulopalatopharyngoplasty is an effective tool in treating patient's subjective symptoms of OSAS. Objective findings suggest that smUPPP is inadequate in treating OSAS. It cannot abolish OSAS, though it can decrease the intensity of the condition in nearly half of the patients. Weight gain decreases the success of the procedure over the years.

Evaluation of pediatric subglottic cysts.

INTRODUCTION: Subglottic cysts (SGCs) are increasingly recognized as a cause of upper airway obstruction in previously intubated infants. Endoscopic marsupialization with cold steel instruments or CO(2) laser has been reported to be the standardised treatment method for SGCs. SGC case series of 9 patients who were treated with endoscopic marsupialization with cold steel instruments or CO(2) laser and mechanical decompression with balloon dilatation are presented. PATIENTS AND METHODS: Retrospective study of 9 cases of subglottic cysts treated between 2003 and 2010 was done. Diagnoses were made by performing flexible nasopharyngolaryngoscopy and surgical treatment was done through endoscopic marsupialization with cold steel instruments or CO(2) laser. RESULTS: The age range of SGC patients were between 3 months and 36 months (average 12, 11 months). Two of the patients were female (2/9), 7 of them were male (7/9). SGC diagnoses were made by flexible nasopharyngolaryngoscopy. History of intubation was noted in 3 of the patients (3/9). Duration of intubation was 28 days, 6 days, and 8 days respectively. Cysts were multiple in all cases, and located posteriorly and laterally at the subglottic area and upper trachea. The patients presented with were stridor, fail to thrive, and recurrent croup attacks. Treatment methods preferred for these patients were endoscopic marsupialization with cold steel instruments or CO(2) laser and mechanical decompression with balloon dilatation. The follow-up period after treatment ranged between 8 months and 3 years. Recurrence of the SGCs did not happen and re-evaluation under general anesthesia was reserved for the symptomatic patients. CONCLUSION: Diagnostic laryngoscopy and bronchoscopy are important in diagnosing SGC. History of premature birth and intubation are not 'sine qua non' of SGC as SGC may be congenital as well. Symptoms of SGCs may mimic the characteristic features of chronic obstructive lung disease, so evaluation of the airway should be considered in such infants if they have stridor or hoarseness not responding to routine treatment. Laryngoscopy and bronchoscopy are routinely indicated for airway evaluation in at-risk infants.

Placement technique of extended spreader grafts.

OBJECTIVES: This study aims to show the placement of extended spreader grafts in reductive septorhinoplasty operations to support the nasal bony vault as well as the middle cartilaginous structures. PATIENTS AND METHODS: Thirty-eight patients (16 males, 22 females; mean age 26.4 years; range 18 to 55 years) who underwent septorhinoplasty under general anesthesia via open approach between January 2008 and December 2010 were included in this study. Two separate cartilage grafts were placed end-to-end and secured to the septum on both sides after removing the cartilage and bony hump. These grafts not only transverse the full length of the middle one-third of the nose, also run approximately 1 cm under the nasal bones cephalically and the anterior septal angle caudally on both sides. The obtained data were evaluated retrospectively. Patients were followed up postoperatively for 7 to 24 months with a mean follow-up of 14 months. RESULTS: There was no significant bony vault collapse or irregularity, inverted-V deformity or middle-vault narrowing observed during the postoperative period. All of the patients were satisfied with the cosmetic and functional results. CONCLUSION: We think that extended spreader grafts are more beneficial not only in reconstructing the middle one-third of the nose but also in supporting the collapsed and/or distrupted nasal bony vault in reductive septorhinoplasty.

[Endonasal phototherapy in the treatment of allergic rhinitis]. / Alerjik rinit tedavisinde endonazal fototerapi.

OBJECTIVES: In this study, we assessed the effect of endonasal phototherapy on quality of life, nasal obstruction and the other symptoms in allergic rhinitis with visual analog scale (VAS), sinonasal outcome test-20 (SNOT-20), and acoustic rhinometry. PATIENTS AND METHODS: Twenty-four patients (6 males, 18 females; mean age 41.3±13.0 years; range 20 to 60 years) suffering allergic rhinitis refractory to anti allergic drugs for at least two years were enrolled in the study. Each patient underwent a total of six sessions of endonasal phototherapy with Rhinolight (Rhinolight Ltd, Szeged, Hungary) performed three times a week for two weeks. During course of the investigation, additional therapy was not applied to any of the patients. Before and one month after treatment, patients completed visual analog scale and SNOT-20 forms and nasal obstruction was evaluated with acoustic rhinometry. RESULTS: After the treatment, the mean VAS score and the mean total SNOT-20 score were found lower than the results before the therapy (p=0.0001, p=0.0001). A significant decrease was found in the scores of sneezing, nasal discharge, postnasal drainage, coughing after treatment (p=0.0001). During objective evaluation of nasal obstruction with acoustic rhinometry, no statistically significant difference was found between pre- and post-treatment findings. CONCLUSION: Endonasal phototherapy is an effective modality in the treatment of symptomatology in allergic rhinitis patients refractory to antiallergic drugs. It is detected that endonasal phototherapy has positive effects on the quality of life. However, no effect on nasal obstruction was found with acoustic rhinometry which is an objective method.

Removing intranasal splints after septal surgery.

BACKGROUND: The aim of this retrospective chart review of the patients who had septal surgery with or without turbinate surgery was to compare the postoperative complication rates according to the time of intranasal-splint (INS) removal. METHODS: The data of 137 patients who underwent septal surgery with or without turbinate surgery at 2 different hospitals of Acibadem Health Care Group between January 2007 and March 2009 were retrospectively evaluated. The patients who had these risk factors were eliminated, and 96 patients were included in this study. The patients were divided into 2 groups according to splint-removal time. The first group comprises patients whose nasal splints were removed in 24 hours after surgery, and the second group comprises patients whose splints were removed 5 days after the surgery. Any bleeding, septal hematoma, and synechia after pack removal were recorded. Analysis of the rate of complications was done with the χ test. RESULTS: Sixty-five male and 31 female patients with a mean age of 32.4 years (range, 18-57 years) were included in the study groups. Septal surgeries were performed in association with turbinate surgery in all 96 patients. These patients were divided into 2 groups. In the first group (n = 50), INSs were removed in 24 hours after surgery. In the second group (n = 46), INSs were removed 5 days after surgery. Bleeding within the first postoperative week was not recorded in both groups. Late bleeding was recorded in 2% (n = 1) of group 1 and in 2.17% (n = 1) in group 2. Septal hematoma and synechia were not recorded in none of the groups. The results were not statistically significant (P = 1). CONCLUSIONS: The routine use of INSs after septoplasty and removing them 24 hours after septoplasty are sufficient to avoid postoperative complications, and it minimizes postoperative discomfort.

Pleomorphic adenomas recurrences within the parapharyngeal space.

This study was undertaken to evaluate and concentrate on the recurrent pleomorphic adenomas (PAs) of the parapharyngeal space. The records of 9 patients treated for recurrent PAs occupying parapharyngeal space were retrospectively reviewed. The study population comprised 6 women and 3 men with a mean age of 51 (range, 35-79 years). Before the first revision surgery, imaging studies and clinical examinations showed 1 solitary mass in 4 patients, 2 solitary masses in 3 patients, and 3 or more masses in 2 patients. After first revision surgery, 4 patients had rerecurrences with multinodular disease. Two of 4 patients underwent radiation therapy (RT), and the other 2 patients underwent second revision surgery, among whom 1 patient underwent third revision surgery, and the other one was also submitted to RT. Overall, 12 reoperations were performed, and at the end of all operations, 4 patients had rerecurrences and residual disease. In conclusion, we recommend RT to patients with multinodular disease, known tumor spillage, and residual tumor in addition to revision surgery. Histopathologic features, surgical resection, relationship to surrounding vital tissues, and postoperative adjuvant radiotherapy are the most important determinants for recurrent PAs.