Nasal dermoplasty for Japanese hereditary hemorrhagic telangiectasia

OBJECTIVE: While generally considered an effective treatment for moderate to severe epistaxis in hereditary hemorrhagic telangiectasia (HHT), nasal dermoplasty (ND) has not been well established in Japan. This prompted the present Japanese assessment of clinical efficacy and patient satisfaction following this procedure. METHODS: Retrospective analysis of clinical records of 15 patients with HHT undergoing ND between August 1991 and May 2004 and survey of these patients as to postsurgical conditions. Main outcome measures were skin graft "take" frequency after surgery (all patients), reported patient satisfaction (eight recent patients), and reported volume and frequency of epistaxis after versus before surgery (eight recent patients). RESULTS: Graft take rate was 100%. Most patients experienced reduced frequency and volume of bleeding. One patient required an additional operation, total closure of the external nares, 2 years later. Overall patients felt satisfied with ND, experiencing less nasal obstruction than expected. CONCLUSIONS: ND is effective in Japanese patients with moderate and severe nasal bleeding from HHT, reducing their risk of bleeding.     

Can snoring relief after nasal septal surgery be predicted?

Patients with nasal obstruction often have associated snoring. This study aims to find out if there are reliable predictors for the success or failure of septal surgery in relieving snoring in patients with symptomatic nasal obstruction secondary to a deviated nasal septum and who have associated snoring. Thirty patients were studied pre-operatively and at 4–12 months (mean 6 months) post-operatively. The intensity of snoring was measured on a visual analogue scale. Nasal patency was measured with a peak nasal inspiratory flow meter. The collapsibility of the soft palate was gauged by the degree of velopharyngeal closure on the Muller manoeuvre. Fifteen patients (50%) achieved snoring relief after septal surgery. The severity of nasal obstruction and intensity of snoring pre-operatively, the magnitude of nasal obstruction relief post-operatively and the degree of collapsibility of the soft palate were found not to influence the outcome of septal surgery on snoring. The relationship between nasal obstruction and snoring is complex and the alteration of airflow patterns after septal surgery is postulated to be important in influencing snoring relief.     

A randomised clinical trial of turbinectomy for compensatory turbinate hypertrophy in patients with anterior septal deviations

Turbinectomy is performed at the time of nasal septal surgery by many otolaryngologists. One reason given for this procedure is the presence of a hypertrophied contralateral inferior turbinate. A randomised trial was undertaken to evaluate the relief of nasal obstruction following contralateral turbinectomy with septal surgery. Patients presenting with nasal obstruction who had a unilateral septal deviation and contralateral inferior turbinate enlargement were prospectively randomized to contralateral turbinectomy or no turbinate surgery at the time of septal surgery. Questionnaires and active anterior rhinomanometry were used for evaluation. Twenty-six patients (mean age 31 years) demonstrated a reduction in subjective and objective measures of nasal obstruction (P < 0.05) 8 weeks after operation. There was no intergroup difference, the median total decongested nasal resistance postoperatively in the non-turbinectomized patients was 0.17 kPal-1 s and 0.21 kPal-1 s in the turbinectomized patients. Contralateral inferior turbinectomy does not add to the relief of nasal obstruction beyond that attained by septal surgery in these patients.     

Endoscopic adenoidectomy in children with submucosal cleft palate

OBJECTIVE: To determine the safety and effectiveness of endoscopic partial adenoidectomy for the treatment of nasal obstruction in children with submucosal cleft palate. METHODS: The medical files of children with symptoms of nasal obstruction and submucosal cleft palate who underwent partial transnasal endoscopic adenoidectomy from January 1993 to December 2003 were reviewed. Operative complications, relief of nasal obstruction, presence of postoperative velopharyngeal insufficiency were recorded. RESULTS: There were no operative complications. All the children had relief of nasal obstruction. Velopharyngeal insufficiency was not observed during the postoperative follow-up. CONCLUSIONS: Endoscopic partial adenoidectomy is a safe and effective procedure for the treatment of nasal obstruction in children with submucosal cleft palate.     

Nasal obstruction and its impact on sleep-related breathing disorders

Upper airway patency is essential during sleep in order to avoid sleep-related breathing disorders (SRBD). Nasal obstruction may have a negative impact on sleep quality and must be considered to be a co-factor in the pathophysiology of SRBD. In this paper we will discuss the relation between nasal physiology at night and sleep quality and the possible mechanisms between nasal obstruction and obstructive sleep apnea-hypopnea syndrome (OSAS). We will review the effect of the relief of nasal obstruction (with nasal dilators, medication and/or surgery) on SRBD. Also an algorithm on the management of OSAS patients when nasal surgery is indicated will be proposed.     

The medical and surgical treatment of nasal polyps

The work of Kern and Schenck introduced the concept that the nasal polyp was allergic in origin. The ethmoid sinus mucosa is the most common target organ for this allergic reaction leading to the formation of polyps with subsequent nasal obstruction. Patients with nasal polyposis complain of nasal obstruction and may have hyperplastic sinusitis associated with this. This purulent infection compounds the problem of management in these cases. A thorough history and physical examination is necessary to make this diagnosis. X-ray examinations of the nose and paranasal sinuses are essential to formulate a rational plan of management. Therapy should include an allergic evaluation and a plan of allergic management. Surgical management in the past has included nasal polypectomy as the chief mode of therapy in providing temporary relief of the nasal obstruction. Radical, destructive intranasal and paranasal sinus surgery has led to unnecessary and quite severe complications and mortality, and is to be condemned. Ethmoidectomy, and when indicated, a Caldwell-Luc procedure will provide drainage of infection, removal of necrotic tissue and necrotic bone when hyperplastic sinusitis complicates the picture. Intrapolyp injection of corticosteroids has proven of great benefit for less severe cases of nasal polyposis without infection. This treatment may need to be repeated in order to achieve the desired relief from nasal obstruction but is only active locally and does not produce systemic side effects. This mode of therapy may be supplemented by oral corticosteroids and by the use of systemic antibiotics. Intranasal mechanical obstruction other than nasal polyps should be corrected by rational surgery to the nasal septum and turbinates. A thorough workup and evaluation is necessary for a plan of management and any therapy, whether medical or surgical, must be based on this type of thorough evaluation of the patient's problem.     

The relief of snoring by nasal surgery

Patients with nasal obstruction may also complain of snoring. It is uncertain whether surgery which relieves the nasal obstruction will also relieve the snoring. We have reviewed 126 patients who complained of both nasal obstruction and snoring and who underwent nasal surgery. Snoring was completely relieved in 39 patients (31%), was less loud in a further 72 patients (57%), unchanged in 11 and louder in 4. It occurred on fewer nights post-operatively in 61, on the same number in 24 and more frequently in 2. Patients who had nasal polypectomy as part of their nasal surgery obtained the greatest snoring relief. This study suggests that when snoring and nasal obstruction coexist nasal surgery should be considered as the first line of surgical treatment.     

The relief of snoring by nasal surgery.

Patients with nasal obstruction may also complain of snoring. It is uncertain whether surgery which relieves the nasal obstruction will also relieve the snoring. We have reviewed 126 patients who complained of both nasal obstruction and snoring and who underwent nasal surgery. Snoring was completely relieved in 39 patients (31%), was less loud in a further 72 patients (57%), unchanged in 11 and louder in 4. It occurred on fewer nights post-operatively in 61, on the same number in 24 and more frequently in 2. Patients who had nasal polypectomy as part of their nasal surgery obtained the greatest snoring relief. This study suggests that when snoring and nasal obstruction coexist nasal surgery should be considered as the first line of surgical treatment.     

New classification of nasal vasculature patterns in hereditary hemorrhagic telangiectasia

BACKGROUND: Hereditary hemorrhagic telangiectasia (HHT) is a disorder characterized by the triad of recurrent epistaxis, telangiectasia, and a family history of the disease. Management of recalcitrant epistaxis in HHT remains a challenging problem for otolaryngologists. The precise coagulation of telangiectasias with the Nd-YAG laser has shown efficacy in the treatment:of HHT-associated epistaxis, but results can be variable and patient selection is critical in ensuring a successful outcome. We propose a new classification of nasal vasculature patterns in HHT as a means for selecting the Nd-YAG laser for photocoagulation treatment. METHODS: The records of 40 patients who underwent Nd-YAG laser photocoagulation for HHT were reviewed retrospectively. Outcomes after Nd-YAG laser treatment were correlated with three observed nasal vasculature patterns: (I) isolated punctate telangiectasias or individual small arteriovenous malformation; (II) diffuse interconnecting vasculature with "feeder" vessels; and (III) large solitary arteriovenous malformation, which may be associated with scattered telangiectasia. RESULTS: Types I and II were the most common vasculature patterns seen in this patient population. Patients with patterns I and III showed greater improvement in epistaxis after Nd-YAG laser photocoagulation. Patients with pattern II fared better with septodermoplasty. CONCLUSION: These findings suggest that analysis of nasal vasculature patterns can improve therapeutic stratification of.patients with HHT. Proper patient selection using this new classification scheme may improve the management of epistaxis in patients with HHT.     

Patients with positive allergen test have less favorable outcome after endoscopic microdebrider-assisted inferior turbinoplasty

BACKGROUND: Endoscopic microdebrider-assisted inferior turbinoplasty is a newly developed surgical technique to treat patients with nasal obstruction. Although the procedure has been reported to be safe and effective, we tested the hypothesis that the prognosis might deteriorate with time in allergic rhinitis patients as identified by a positive allergen test in patients who have a persistent regional inflammation of the nose. We assessed the degree of nasal obstruction in a prospective cohort to investigate whether positive allergen test predicts outcome. METHODS: In 70 consecutive patients, the symptom of nasal obstruction was evaluated subjectively by a visual analog scale (VAS) and objectively by acoustic rhinometry using cross-sectional area of the second notch (CSA-2) and nasal cavity volume before operation, and 3 months, 12 months after operation, respectively. Then, patients were classified and compared according to the multiple-antigen simultaneous test (MAST). RESULTS: Both MAST(+) and MAST(-) groups showed statistically significant improvement in VAS score, CSA-2, and nasal cavity volume at 12 months after operation (p < 0.01). Of note, MAST(+) patients showed less favorable results than MAST(-) patients at 12 months after operation (p < 0.05). CONCLUSION: Microdebrider-assisted inferior turbinoplasty provides effective relief for patients with nasal obstruction. However, such turbinate surgery may be successful only for a short period of time in patients with allergic rhinitis. Our finding suggests that, in selecting appropriate candidates, surgeons should consider criteria other than symptomatology, especially in patients with allergic rhinitis who may have manifestations other than at the level of the inferior turbinate contributing to nasal blockage.     

Is oestrogen therapy justified in the treatment of hereditary haemorrhagic telangiectasia: a biochemical evaluation

Systemic and topical oestrogen can provoke squamous metaplasia of epithelium. In Hereditary Haemorrhagic Telangiectasia (HHT) the underlying telangiectasia may be protected from trauma and epistaxis reduced. Oestrogens have been advocated but their efficacy is unclear. Recent advances have now identified two oestrogen and one progesterone receptors. The aim of this study is to analyse the sex receptor status of HHT nasal mucosa to determine if oestrogen therapy is biochemically justified. Five HHT patients (three men, two women) and eight controls (four men, four women) underwent nasal mucosa biopsy. Samples were fixed in formalin and paraffin embedded. Alpha oestrogen (ERalpha) and beta oestrogen (ERss) and progesterone (PgR) receptors were identified using mouse monoclonal antibodies by the Streptavidin-biotin peroxidase method. ERss was detected in two HHT subjects (1 M: 1F) and two control subjects. ERalpha and PgR was absent in HHT subjects. This pilot study demonstrated that a subgroup of HHT patients were ERss positive. Oestrogen therapy therefore has a potential therapeutic role on a biochemical basis in these patients. ERss status should be determined before considering oestrogen therapy.     

Use of a sprayed fibrin hemostatic sealant after laser therapy for hereditary hemorrhagic telangiectasia epistaxis

BACKGROUND: Hereditary hemorrhagic telangiectasia (HHT) is a relatively common autosomal dominant condition. Epistaxis is a frequent manifestation, often occurring daily and requiring iron and blood transfusions. Surgery often is bloody and difficult. The aim of this study was to evaluate the effectiveness of a sprayed fibrin, hemostatic sealant in preventing postoperative epistaxis after laser treatment of nasal mucosa in HHT. Fibrin sealant was compared with nasal packing for likelihood of postoperative epistaxis and financial impact including material costs and hospitalization fees. METHODS: Retrospective review was performed of 64 individual laser treatments for epistaxis in HHT patients at the University of California, San Diego, Medical Center between 2002 and 2005. Nasal packing was used in 30 procedures and fibrin sealant was used in 34 procedures. RESULTS: Six of 30 (20%) procedures using postoperative nasal packing required admission with an average hospital expense of $5914. One of 34 patients (3%) in the fibrin sealant group required hospitalization (p = 0.04). CONCLUSION: Aerosolized fibrin sealant prevents postoperative epistaxis after nasal laser treatment in HHT patients. Compared with traditional nasal packing we found improved patient comfort and recovery with substantial cost savings.     

Complications following total inferior turbinectomy: facts or myths?

Various surgical procedures have been described for the relief of chronic nasal obstruction due to inferior turbinate hypertrophy, but none has been consistently satisfactory. We have performed total inferior turbinectomy for this condition for 5 years. Of the 39 patients followed for at least 2 years, 90% were relieved permanently of nasal obstruction. However, only 36% and 61% of patients with rhinorrhoea and anosmia respectively were relieved of these symptoms. Complications were minimal. It is concluded that even in a dry, dusty tropical climate, inferior turbinectomy does not appear to disturb the function of the nasal cavity appreciably.     

A new cryoprobe with advantages in turbinate freezing

Freezing of the turbinates has an established role in the relief of nasal obstruction in the conditions of vasomotor and allergic rhinitis. However, present designs are limited in being bulky to use. By application of cryosurgical principles a probe has been designed which is only 2 mm. wide compared with 6 mm. of a standard probe (5N13) and which freezes as well as the standard probe in-vitro and in-vivo.     

Endoscopic Inferior Turbinate Reduction: An Outcomes Analysis

Objectives/Hypothesis In a previous publication, we introduced an endoscopic technique for the treatment of nasal obstruction caused by inferior turbinate hypertrophy. The technique, a modification of the procedure popularized by Mabry, involves resecting the inferior and lateral aspects of the inferior turbinate with a microdebrider under endoscopic guidance. Our preliminary postoperative results were favorable. All 20 patients experienced improvement by postoperative day 5 and the incidence of complications over the first 6 months after surgery was low. The objective of this study is to perform a long‐term outcomes analysis of patients undergoing the procedure. Study Design Follow‐up survey questionnaire and analysis. Methods We sent questionnaires to 60 patients, ranging from 6 to 40 months after surgery, inquiring about continued use of nasal medications, need for further surgery, presence of adverse effects, and improvement in symptoms. Nasal airway obstruction was assessed on a subjective scoring scale from 1 (no obstruction) to 6 (complete obstruction). Results Of the 28 (47%) patients who returned questionnaires, the severity of daytime nasal obstruction was rated as 2.3 and nighttime nasal obstruction as 2.7. The use of nasal steroids and oral decongestants was 25% and 21%, respectively. Adverse effects were minimal and all but one patient (96%) experienced improvement in their nasal airway. Conclusion These results confirm the long‐term effectiveness of this procedure for the relief of nasal obstruction.     

Clinical strategy in hereditary hemorrhagic telangiectasia

BACKGROUND: Hereditary hemorrhagic telangiectasia (HHT) is a recurrent bleeding tendency caused by vascular malformations and preferentially involving the mucous membrane of the nose. The rhinological management of epistaxis is a challenge in which the frequency of bleeding has to be reduced without damage to the nasal mucosa, despite the fact that therapy necessarily has to be repeated. METHODS: The clinical course in 30 patients with HHT was monitored prospectively. Nasal mucosal efflorescences underwent Nd:YAG laser therapy at individually defined intervals, and the effect on the frequency and duration of bleeding was documented, as were adverse effects. RESULTS: No serious adverse effects (e.g., septal defects or synechiae) were observed as a consequence of therapy. During the course of laser therapy and ongoing compliance with nasal mucosal care instructions, the frequency of bleeding fell from "several times daily" to "every 2 weeks." CONCLUSION: In conjunction with Nd:YAG laser therapy, ongoing and consistent care of the nasal mucosa is a proven and effective treatment regimen in HHT. As an integral element in an interdisciplinary strategy for diagnosis and therapy, this regimen yields satisfactory quality of life while avoiding local complications.     

鼻内镜下108例鼻腔扩容术疗效分析

目的 探讨鼻内镜下鼻腔扩容术的疗效.方法 选择108例鼻中隔偏曲和慢性肥厚性鼻炎患者,根据具体病情分别行个性化手术,如鼻中隔偏曲行鼻内镜下鼻中隔成形术或三线减张鼻中隔矫正术;慢性肥厚性鼻炎行鼻内镜下下鼻甲外移术酌情联合下鼻甲等离子消融术或下鼻甲黏膜下切除术及下鼻甲部分切除术等.结果 术后随访3～12个月,有效率为97.2%,患者无头痛,鼻干等并发症发生.结论 鼻内镜下鼻腔扩容术处理鼻中隔偏曲和慢性鼻炎疗效确实.

Abstract：

Objective To investigate the efficacy of endoscopic nasal cavity enlarging surgery for the alleviation of nasal obstruction.Methods One hundred and eight patients with deviation of the nasal septum ( DNS) and chronic hypertrophic rhinitis ( CHR) were included in this study.Individualized operations were performed.DNS patients were treated by three line tension relaxing correction or nasal septum plasty.CHR patients were treated by inferior turbinate outfracture in combination with plasma radiofrequency ablation for reducing the volume of nasal soft tissue,sub-mucoperiosteal partial resection of the inferior turbinate or partial inferior turbinectomy.Results All patients were followed for 3-12 months after surgry with an effective improvement in 97.2%.Symptoms of headache or complications of rhinitis sicca were not found.Conclusions Being careful to keep the physiological function of nasal mucosa,the integrity of the nasal septum,appropriate expansion of the nasal cavity volume,and restore ventilation with bilateral symmetry of the nasal cavity,satisfactory relief of nasal obstruction can be achieved.     

Trimming of the inferior turbinates: a prospective long-term study

The aim of this study was to determine whether the initial benefits of radical trimming and anterior trimming of the inferior turbinates on nasal airflow persisted in the long term. Radical trimming significantly reduced nasal resistance at 2 months following operation (n = 12) (P less than 0.005). There was no significant change in nasal resistance over the next 20 months. Symptom scores for nasal obstruction also showed a significant reduction (n = 16) (P less than 0.005), at 2 months, and did not change significantly over the next 20 months. Radical trimming of the inferior turbinates is a highly effective operation in patients with hypertrophy of the inferior turbinates with few initial complications. However, further analysis of the data revealed that up to 20% of patients lose the initial subjective benefit of relief of nasal obstruction within 2 years of follow-up. Late onset crusting occurs in some patients though this is not directly attributable to an increase in nasal airflow. This study also concludes that anterior trimming of the inferior turbinates cannot be recommended as a form of treatment.     

Treatment of home oxygen induced rhinitis: an unusual use for a nasal obturator

Patients requiring home oxygen can experience drying and crusting of nasal mucosa. On occasion it can be severe causing significant discomfort. In this report we present such a case. To prevent nasal airflow and hence reduce symptoms the patient was fitted with a nasal obturator. The use of the nasal obturator resulted in a rapid resolution of her symptoms. In this case the use of the nasal obturator was reversible and a simple solution for the treatment of a difficult condition.     

Choanal adenoid in adults with persistent nasal symptoms: endoscopic management to avoid misdiagnosis and unsuccessful surgeries

Our objective was to confirm the necessity of nasal endoscopy in the diagnosis and treatment of choanal adenoid in adult patients with persistent bilateral nasal obstruction and recurrent nasal infections that may lead to repeated unsuccessful medical and surgical procedures. We present a series of 64 adult patients (18–37 years: 40 males, 24 females). All patients had persistent bilateral nasal obstruction and recurrent nasal infections. There was history of repeated medical and surgical unsuccessful procedures. Choanal adenoid was confirmed by nasal endoscopy and CT scanning. Absence of adenoid tissues in the nasopharynx was confirmed in all cases. Surgical removal of choanal adenoids was undertaken in all cases endoscopically. Some other surgical procedures like straightening of a deviated septum or reduction of a hypertrophied turbinate were undertaken in some indicated cases. Most of the cases experienced complete relief from obstruction and return of a patent nasal airway, and improvement of associated complaints such as dry mouth and persistent cough. A thorough review of this phenomenon and its clinical relevance, and methods of diagnosis and management are presented. We recommend a thorough nasal endoscopy as a routine in cases of persistent nasal obstruction even in the presence of an apparent cause of obstruction.