Algorithm for the treatment of external nasal valve insufficiency

IntroductionNasal obstruction is one of the most prevalent complaints in the population. The main causes of nasal obstruction are inflammatory, infectious or anatomical alterations. Anatomical alterations include nasal septum deviation, turbinate hypertrophy, and nasal valve insufficiency (external and/or internal). The diagnosis of nasal valve insufficiency remains a clinical one and is based on inspection and palpation of the nose, evaluating both its static and dynamic functions. The literature presents several options for the correction of external nasal valve insufficiency. These are chosen according to the choice and experience of each surgeon.ObjectiveTo create a practical algorithm for the treatment of external nasal valve insufficiency that can guide nasal surgeons in their choice of treatment for the different anatomical alterations found in patients with these disorders.MethodsWe used the treatment options found in the literature and correlated them with our surgical options for each type of anatomical alteration found. Therefore, we used basically three parameters related to physical examination findings (degree of insufficiency and characteristics of the lower lateral cartilage) and the patient's complaint (present or absent aesthetic complaint regarding the nasal tip).ResultA practical algorithm was developed for the treatment of external nasal valve insufficiency according to the degree of insufficiency (mild-to-moderate or severe), aesthetic complaint of the nasal tip (present or absent) and characteristics of the lower lateral cartilage (size and orientation).ConclusionThrough this simple algorithm, one can use each type of graft and/or maneuver according to the patients’ complaints and the anatomical alterations found.     

Efficacy of nasal irrigation with hypertonic saline on chronic rhinosinusitis: systematic review and meta-analysis

IntroductionCurrently, several different concentrations of saline are recommended for use in nasal irrigation. Increasing studies show that nasal irrigation with hypertonic saline is more effective than traditional saline in the treatment of rhinosinusitis, but there have been few systematic analyses of the effect of nasal irrigation with hypertonic saline on chronic rhinosinusitis.ObjectiveWe sought to compare the effects of hypertonic saline and isotonic saline in the treatment of rhinosinusitis in order to provide a reference for clinical nasal irrigation for chronic rhinosinusitis treatment.MethodsMedline, cochrane library, EMBASE, PubMed, Chinese biomedical journal database, China national knowledge infrastructure, Wanfang database, and other databases were searched, and the searching was supplemented by manual searches for relevant references to treatment of rhinosinusitis by saline nasal irrigation. The last retrieval date was March 2018. The included studies were evaluated for quality, and data were extracted for meta-analysis using RevMan 5.3.ResultsSeven studies were included. Effects favoring hypertonic saline on nasal symptoms were greater in 4 subgroups. These were (1) patients with nasal secretion (SMD = 1.52; 95% CI: 1.04, 2.00; p < 0.01), (2) patients with congestion (SMD = 1.52; 95% CI: 1.04, 2.00; p < 0.01), (3) patients with headache (SMD = 0.82; 95% CI: 0.38, 1.26; p < 0.01), (4) patients with overall symptomatic relief (SMD = 1.63; 95% CI: 0.83, 2.44; p < 0.01). However, no difference was shown in smell improvement (SMD = 0.47; 95% CI: −0.65, 1.59; p = 0.41) and radiologic scores improvement (SMD = 2.44; 95% CI: -3.14, 8.02; p < 0.01). Besides, hypertonic saline showed greater improvement in mucociliary clearance time scores than did the isotonic saline group (SMD = 1.19; 95% CI: 0.78, 1.60; p < 0.01). Hypertonic saline brought greater minor adverse effects.ConclusionCompared with isotonic saline, hypertonic saline nasal irrigation for the treatment of chronic rhinosinusitis is significantly more effective and has mild side effects in improving nasal symptoms and ciliary movement, but there is no significant difference in imaging findings and smell improvement. Although hypertonic saline is worthy of widespread use in clinical practice, it is still necessary to further study the exact manner and concentration of nasal irrigation.     

Evaluation of the nasal shape after orthognathic surgery

IntroductionPatients with dentofacial deformities may benefit from orthognathic surgery in the maxilla. Maxillary osteotomy may include procedures in the bone, cartilaginous, and soft tissues of the nose, leading to shape alterations.ObjectiveTo evaluate the anatomic alterations of the nasal region in patients undergoing a Le Fort I osteotomy for advancement or superior impaction.MethodsThis is a clinical prospective study. Twenty-one patients were evaluated during the pre- and postoperative periods. The positioning of the nasal tip and the modification of the nasal base were evaluated.ResultsThe results showed that the nasal tip was superiorly positioned in 85% of the cases, advanced in 80%, rotated in 80%, and there was a wide nasal base in 95%, resulting in esthetic improvement.ConclusionsSurgeries of maxillary advancement and superior reposition tend to cause elevation and advancement of the nasal tip, as well as enlargement of the nasal base.     

Effects of buffered 2.3%, buffered 0.9%, and non-buffered 0.9% irrigation solutions on nasal mucosa after septoplasty

A prospective randomized study was designed to compare the effect of different irrigation solutions on mucociliary clearance and nasal patency and to compare the limitations of the used solutions, such as nasal burning by a visual analog scale. Forty-five patients who underwent septoplasty were divided into three groups postoperatively. Each group was administered with 2.3% buffered hypertonic seawater, buffered isotonic saline solution and non-buffered isotonic saline, respectively, as irrigation fluid. Saccharine test and acoustic rhinometer were used to determine mucociliary activity and nasal patency. Patients were asked about the burning sensation using a 10-cm visual analog scale. There was no significant difference in saccharine clearance time (SCT) on the 5th postoperative day between the three groups (P = 0.07). On the 20th day, there was a significant difference in SCT between the hypertonic buffered seawater group and non-buffered isotonic saline (P = 0.003). Buffered hypertonic seawater improved nasal airway patency more than the buffered isotonic saline (P = 0.004). Buffered hypertonic solutions used after endonasal surgery have been advantageous for both mucociliary clearance and postoperative decongestion.     

Disease-specific quality of life after septoplasty and bilateral inferior turbinate outfracture in patients with nasal obstruction

Introduction

Septal deviations might cause nasal obstruction and negative impact on the quality of life of individuals. The efficacy of septoplasty for treatment of septal deviation and the predictors of satisfactory surgical outcomes remain controversial. Technical variability, heterogeneity of research samples and absence of a solid tool for clinical evaluation are the main hindrances to the establishment of reliable statistical data regarding the procedure.

Evaluation of pre- and post-pyriform plasty nasal airflow

Introduction

Nasal obstruction is a frequent complaint in otorhinolaryngology outpatient clinics, and nasal valve incompetence is the cause in most cases. Scientific publications describing surgical techniques on the upper and lower lateral cartilages to improve the nasal valve are also quite frequent. Relatively few authors currently describe surgical procedures in the piriform aperture for nasal valve augmentation. We describe the surgical technique called pyriform plasty and evaluate its effectiveness subjectively through the NOSE questionnaire and objectively through the rhinomanometry evaluation.

The influence of standardized dry ivy leaf extract on the proportion of nasal secretion after post-septoplasty nasal packing removal

IntroductionAfter post-septoplasty nasal packing removal, a certain proportion of nasal secretion occurs, leading to local and sometimes systemic infections.ObjectiveThe aim was to determine if standardized dry ivy leaf extract application after nasal packing removal influences the reduction of nasal secretion and diminish the occurrence of local infections.MethodsThe study included 70 post-septoplasty patients (divided into two equal groups) whose nasal packing was removed on the third day after the procedure. Group I was treated with standardized dry ivy leaf extract syrup along with regular nasal irrigation for the five days after the nasal packing removal whereas the Group II had only nasal lavage. On the sixth day after nasal packing removal, the quantity of nasal secretion was determined using a visual analog scale and nasal endoscopic examination.ResultsThe group treated with standardized dry ivy leaf extract syrup had significantly lesser nasal secretion both by subjective patients’ assessment (p < 0.001) and by nasal endoscopic examination (p = 0.003). The post-surgical follow up examination on the sixth day after nasal packing removal showed no development of local infection in the Group I, while in the Group II a local infection was evident in five patients (14.29%) and antibiotic therapy was required.ConclusionThe use of the standardized dry ivy leaf extract after nasal packing removal significantly lowers the proportion of nasal secretion.     

Nasal patency and otorhinolaryngologic-orofacial features in children

Introduction

Nasal obstruction is a common symptom in childhood, related to rhinitis and pharyngeal tonsil hypertrophy. In the presence of nasal obstruction, nasal patency may be reduced, and nasal breathing is replaced by mouth breathing. Orofacial and otorhinolaryngologic changes are related to this breathing mode. Objective evaluation of upper airways may be obtained through nasal patency measurement.

Assessment of mucosal changes associated with nasal splint in a rabbit model

IntroductionThere is no consensus on duration of the nasal splint after nasal septum surgeries. The pressure of nasal splint on the mucosa may cause tissue necrosis and nasal septum perforation.ObjectivesTo investigate the histopathological changes of the nasal mucosa caused by nasal splints in a rabbit model.MethodsNo splint was used in group A. Bilateral silicone nasal splints were placed for five, ten, and 15 days in groups B, C, and D, respectively. Biopsy of the nasal mucosa was performed after removal of splint. Histopathologic evaluations were performed. The severity and depth of the inflammation were scored.ResultsGroup A had a normal histological appearance. Comparison of the results of groups B, C, and D with group A demonstrated statistically significant differences with regards to the severity of histopathological findings. There was no statistically significant difference between groups B and C. There were statistically significant differences between the groups B and D, and also between groups C and D.ConclusionsLonger duration of nasal splint had a higher risk for septal perforation. Therefore, removal of the splint as soon as possible may be helpful for preventing potential perforations.     

Septum pyramidal adjustment and repositioning – a conservative and effective rhinoplasty technique

Introduction

In rhinoplasty, the nasal dorsum has important relevance regarding the esthetic and functional aspects of the surgery. Its reduction should be performed with maximum accuracy and controlled resection to prevent or minimize potential complications. The septum pyramidal adjustment and repositioning consists of a conservative surgical technique of the nasal dorsum, which does not require the detachment of the upper lateral cartilages of the nasal septum, allowing the remodeling of the nasal dorsum while maintaining esthetic lines and nasal function, potentially reducing frequent complications in more traditional surgeries.

Clinical study and literature review of nasal irrigation

OBJECTIVES/HYPOTHESIS: Nasal disease, including chronic rhinosinusitis and allergic rhinitis, is a significant source of morbidity. Nasal irrigation has been used as an adjunctive treatment of sinonasal disease. However, despite an abundance of anecdotal reports, there has been little statistical evidence to support its efficacy. The objective of this study was to determine the efficacy of the use of pulsatile hypertonic saline nasal irrigation in the treatment of sinonasal disease. Study DESIGN: A prospective controlled clinical study. METHODS: Two hundred eleven patients from the University of California, San Diego (San Diego, CA) Nasal Dysfunction Clinic with sinonasal disease (including allergic rhinitis, aging rhinitis, atrophic rhinitis, and postnasal drip) and 20 disease-free control subjects were enrolled. Patients irrigated their nasal cavities using hypertonic saline delivered by a Water Pik device using a commercially available nasal adapter twice daily for 3 to 6 weeks. Patients rated nasal disease-specific symptoms and completed a self-administered quality of well-being questionnaire before intervention and at follow-up. RESULTS: Patients who used nasal irrigation for the treatment of sinonasal disease experienced statistically significant improvements in 23 of the 30 nasal symptoms queried. Improvement was also measured in the global assessment of health status using the Quality of Well-Being scale. CONCLUSIONS: Nasal irrigation is effective in improving symptoms and the health status of patients with sinonasal disease.     

Steroid vs. antibiotic impregnated absorbable nasal packing for wound healing after endoscopic sinus surgery: a randomized,double blind,placebo-controlled study

IntroductionEndoscopic sinus surgery can lead to crusting or synechiae formation, which can affect the healing process.ObjectiveThe aim of our study was to compare the influence of steroid versus antibiotic versus saline solution impregnated absorbable nasal spacers on postoperative wound healing and patient satisfaction.MethodsEighty patients, 33 women and 47 men, were enrolled in this study. At the end of the surgery, two pieces of 4 cm biodegradable material were applied in each ethmoid cavity. One of them was impregnated with saline solution, while the second one with steroid, or with antibiotic.ResultsWe observed statistically significant differences in the Lund–Kennedy score between the control and both treatment groups: for the Antibiotic-group on days 10 and 30 (p = 0.009; p = 0.009) and for the Steroid-group on day 90 (p = 0.008). The extended endoscopic appearance of nasal mucosa indicated statistically significant differences in crust formation on day 10 comparing the steroid and control dressing (p = 0.025), in secretion type on days 10 and 30 comparing the antibiotic and control dressing (p = 0.003; p = 0.016) and additionally for steroid and control on day 90 (p = 0.046). On Day 90 we observed statistically significant differences in the absence of mucosal edema in the S-group compared to controls (p = 0.007).ConclusionsThe results of this study reveal the significant positive influence of steroid- and antibiotic-impregnated biodegradable nasal packing on the postoperative healing process and patient satisfaction compared to the saline soaked dressing.     

Rapid maxillary expansion in mouth breathers: a short-term skeletal and soft-tissue effect on the nose

Introduction

Rapid maxillary expansion can change the form and function of the nose. The skeletal and soft tissue changes can influence the esthetics and the stability of the results obtained by the procedure.

Acoustic rhinometry in mouth breathing patients: a systematic review

IntroductionWhen there is a change in the physiological pattern of nasal breathing, mouth breathing may already be present. The diagnosis of mouth breathing is related to nasal patency. One way to access nasal patency is by acoustic rhinometry.ObjectiveTo systematically review the effectiveness of acoustic rhinometry for the diagnosis of patients with mouth breathing.MethodsElectronic databases LILACS, MEDLINE via PubMed and Bireme, SciELO, Web of Science, Scopus, PsycInfo, CINAHL, and Science Direct, from August to December 2013, were consulted. 11,439 articles were found: 30 from LILACS, 54 from MEDLINE via Bireme, 5558 from MEDLINE via PubMed, 11 from SciELO, 2056 from Web of Science, 1734 from Scopus, 13 from PsycInfo, 1108 from CINAHL, and 875 from Science Direct. Of these, two articles were selected.ResultsThe heterogeneity in the use of equipment and materials for the assessment of respiratory mode in these studies reveals that there is not yet consensus in the assessment and diagnosis of patients with mouth breathing.ConclusionAccording to the articles, acoustic rhinometry has been used for almost twenty years, but controlled studies attesting to the efficacy of measuring the geometry of nasal cavities for complementary diagnosis of respiratory mode are warranted.     

Endoscopic outcomes of resorbable nasal packing after functional endoscopic sinus surgery: a multicenter prospective randomized controlled study

Nasal packings can aid in control of postoperative bleeding and healing following functional endoscopic sinus surgery (FESS), but traditional non-resorbable stents have several inherent drawbacks. We performed a randomized, controlled, multicenter clinical trial to assess efficacy of resorbable nasal packing in patients undergoing FESS for chronic rhinosinusitis. A total of 66 patients for 88 nasal cavities were randomized to receive either hyaluronan resorbable packing (MeroGel^®) or standard non-resorbable nasal dressing after FESS. All underwent preoperative rhinoscopy, CT of sinuses, and, after surgery, were reassessed by rhinoscopy at 2, 4, and 12 weeks in blinded fashion. A total of 44 nasal cavities (MeroGel^®-group) received resorbable packing, whereas the remaining 44 were packed with non-resorbable nasal dressing. At follow-up endoscopic visit, the presence of nasal synechia was evaluated as primary outcome. Moreover, the tolerability and surgical handling properties of MeroGel^® and its comfort were assessed by surgeons and patients. Preoperative severity of rhinosinusitis was similar in both groups. No significant adverse events were observed in all patients. Follow-up endoscopy showed a lower proportion of nasal adhesions in MeroGel^®-group at both 4 (P = 0.041) and 12 weeks (P < 0.001). Moreover, an improvement of other endoscopic nasal findings such as re-epithelialization, presence of granulation tissue, and appearance of nasal mucosa of nasal cavities after FESS was observed in the MeroGel^®-group. Tolerability and surgical handling properties of MeroGel^® were positively rated by clinicians and the overall patient judged comfort of MeroGel^® was favorable. In conclusion, MeroGel^® can be considered a valid alternative to standard non-resorbable nasal dressings. It is safe, well-accepted, well-tolerated, and has significant advantage of being resorbable. Moreover, it may favor improved healing in patients undergoing FESS and reduce formation of adhesions.     

Free tissue flaps in head and neck reconstruction: clinical application and analysis of 93 patients of a single institution

Introduction

Reconstruction with a free flap is routine in head and neck surgery because of better functional outcomes, improved esthetics, and generally higher success rates.

Comparison of subjective and objective assessment of glucocorticoid response in nasal polyps: a preliminary study

Background: Glucocorticoids (GC) therapeutic response in patients with chronic rhinosinusitis with nasal polyps (CRSwNP) varies markedly.

Aims/Objectives: To compare the utility between subjective and objective assessment of GC sensitivity in reflecting the impact of GC on systemic and local eosinophilia in CRSwNP patients.

Material and methods: Twenty-six patients with CRSwNP were enrolled. All patients were given 30?mg of prednisone once daily for 7 days and subsequently classified into subjectively GC-sensitive and -insensitive subgroup or objectively GC-sensitive and -insensitive subgroup. The numbers of eosinophils and neutrophils in blood and polyp tissues were compared between GC-sensitive and GC-insensitive subgroup.

Results: 17/26 (65.4%) patients were subjectively and 8/26 (30.8%) patients objectively sensitive to GC treatment. The absolute number and percentage of eosinophils in blood were decreased both in GC-sensitive and -insensitive subjects after GC treatment. In addition, a significant reduction in tissue eosinophil percentage was only observed in objectively GC-sensitive subjects after GC treatment. Furthermore, the change of tissue eosinophil percentage in objectively GC-sensitive subjects was significantly higher than that in objectively GC-insensitive subjects.

Conclusions and significance: Objective assessment may better reflect oral GC response in tissue eosinophilic inflammation than subjective assessment in patients with CRSwNP.     

The efficacy and safety of once-daily mometasone furoate nasal spray in nasal polyposis: a randomized,double-blind,placebo-controlled study

Conclusion. In subjects with mild-to-moderate nasal polyposis, treatment with mometasone furoate nasal spray (MFNS) 200?µg once daily (QD) significantly decreases nasal congestion, reduces polyp size, and improves quality of life. Objectives. To evaluate the efficacy and safety of MFNS, administered QD in the morning, in subjects with mild-to-moderate nasal polyposis. Subjects and methods. This randomized, double-blind, double-dummy, placebo-controlled clinical trial enrolled subjects with mild-to-moderate nasal polyposis at 12 centers in Denmark, Finland, Norway, and Sweden. Inclusion criteria were: age?≥?18?years, a diagnosis of bilateral nasal polyps, and clinically significant nasal congestion. Following a 2–4-week run-in period, subjects were randomized to receive MFNS 200?µg QD or matching placebo for 16?weeks. Results. A total of 298 subjects were randomized to treatment. Of those subjects included in the intent-to-treat efficacy analysis (n?=?291), a statistically greater proportion of the MFNS group than the placebo group had improvements in investigator-assessed nasal congestion score between baseline and end point (the primary outcome) (74.3% vs 46.8%; p?<?0.001). Significant benefits of MFNS were also seen for secondary end points, including polyp size, sense of smell, peak nasal inspiratory flow, therapeutic improvement, and quality-of-life measures. MFNS was well tolerated, with no unusual or unexpected adverse events.