Prior Nasal Surgery Research Articles

Depth of the subcutaneous tissue in the nose: Application to filler injection.

The nasal region plays a pivotal role in both facial esthetics and functionality. The use of volumizing fillers has emerged as a potential means to enhance nasal appearance. Preliminary findings from cadaveric studies have highlighted potential risks associated with deeper needle injection, leading to cartilage damage and lateral migration of filler material. Understanding the subcutaneous tissue depth is crucial to prevent such complications and ensure safe filler placement guided by anatomical knowledge. This study aimed to employ ultrasonographic assessment to precisely measure the depth of soft tissue in the nasal area. Fifty-two participants without prior nasal surgery or filler injections underwent detailed ultrasonographic evaluation, focusing on seven key anatomical points: Glabellar, Sellion, Rhinion, between Rhinion and Pronasal, Pronasal, between Pronasal and Subnasal, and Subnasal. The ultrasonographic observation revealed varying depths of subcutaneous tissue across these points: Glabellar (4.11 ± 0.79), Sellion (5.21 ± 0.97), Rhinion (2.02 ± 0.74), Rhinion to Pronasal midpoint (6.45 ± 3.1), Pronasal (9.5 ± 2.2), between Pronasal and Subnasal (8.8 ± 0.8), and Subnasal (8.5 ± 0.5). The discussion underscores the significance of understanding subcutaneous tissue depth in guiding needle length and approach angles during filler injections. This knowledge aids in achieving effective filling while ensuring safe placement within the subcutaneous tissue.

Crowdsourced Assessment of Aesthetic Outcomes of Dorsal Preservation Rhinoplasty

Abstract Goals/Purpose The inherent subjectivity in evaluating aesthetic outcomes presents a unique challenge in assessing rhinoplasty. Crowdsourcing has provided a new metric for objective analysis. The authors designed a study to compare the aesthetic outcomes of dorsal preservation rhinoplasty versus structural rhinoplasty using a reliable and valid crowdsourcing platform. We aim to objectively quantify the relative aesthetic advantages of performing a dorsal preservation technique. Additionally, we aim to demonstrate the efficacy of using crowdsourcing as an efficient and reliable method for evaluating any plastic surgery aesthetic outcome. Methods/Technique This retrospective observational study was approved by the IRB at UCLA. A total of 64 patients who had previously undergone rhinoplasty performed by the senior author were included. All surgeries were performed at the UCLA Ronald Reagan Medical Center. Patients with prior nasal surgery or trauma were excluded. All subjects were photographed using standard rhinoplasty views during the pre-and postoperative visits. Frontal and right profile photographs were then cropped in a standardized fashion (Photos, Version 8.0, Apple Inc.) and used for evaluation. All evaluations and ratings were collected using the HIPPA compliant and encrypted software via a secure online platform (LoveMyDelta, Inc., Philadelphia, PA). All crowd workers were recruited and vetted through this platform, with internal fidelity checks performed. Each crowd worker was shown a profile and frontal view of a patient and asked to score the overall appearance of the nose, the nasal dorsum profile, the symmetry of the dorsal aesthetic lines, and the dorsal contour using a visual analog scale. Scoring was performed using a provided validated visual assessment guide. They were asked whether they believed the subject had undergone rhinoplasty and asked to provide a level of confidence in their guess. Crowdworkers’ responses were aggregated to allow for high-powered intra-rater analysis. Intra-rater reliability and confidence intervals were calculated. Aggregate data from all raters were used to generate an absolute value of aesthetic state for each cohort. A "delta" was then obtained for each value by comparing the preoperative to the postoperative state to obtain a representative value of the improvement after undergoing surgery. Raters were asked if the patient appeared to have had surgery, and each correct and incorrect response was proportionally weighted based on the raters' confidence in their answer. The delta (difference in preoperative to postoperative aesthetic state) for each parameter for the dorsal and non-dorsal preservation cohorts was calculated using non-paired T-tests to determine significance. Results/Complications A total of 64 patients were included for evaluation. The structural rhinoplasty cohort consisted of 34 patients. The dorsal preservation cohort included 30 patients. Both dorsal preservation and non-dorsal preservation rhinoplasty cohorts were associated with improved overall crowdsourced aesthetic outcomes and improved outcomes across all subparameters. Overall, delta (d) improved in both dorsal preservation (0.300, 95% CI +/- 0.047) and structural (0.377, 95% CI +/- 0.055) cohorts. When raters were asked to predict whether a patient had surgery, the correlation coefficient between the confidence in the prediction and that prediction being correct was 0.74 (95% CI +/- 0.47 in the structural group, suggesting that a crowd worker was likely to be correct in identifying whether a patient had structural rhinoplasty. However, the correlation coefficient was -0.0554 (95% CI +/- 0.058) in the dorsal preservation group. This suggests the raters were unable to consistently identify which patients had dorsal preservation rhinoplasty with any confidence. Conclusion In the ongoing challenge to achieve better aesthetic outcomes in plastic surgery, crowdsourcing is a valuable tool for helping to measure these outcomes. We compared the aesthetic outcomes of dorsal preservation rhinoplasty versus structural rhinoplasty using a reliable and valid crowdsourcing platform. We found that significant improvements in overall aesthetic outcomes were achieved with both techniques, while a more natural “unoperated” outcome was achieved when performing a dorsal preservation technique. With this type of study and assessment tool, we helped to demonstrate the efficacy of using crowdsourcing as an efficient and reliable method for evaluating any plastic surgery aesthetic outcome.

Bystander-application of a novel nasal swab optimized for drug delivery is safe and non-traumatic for the general population

ObjectiveThe PN Naloxone Nasal Swab (Pocket Naloxone Corp., Bethesda, MD) is a swab optimized for drug delivery and intended for use by non-medical personnel for the emergency treatment of opioid overdose. The aim of this study (PNC-20–003) is to determine the safety of this nasal swab in a real-world environment. MethodsThis was a single-institution, quantitative-qualitative prospective trial performed at an outpatient clinic. Patients with normal or abnormal nasal structure were recruited. A non-medically trained individual placed the nasal (soaked in fluorescein dye) on each side of the patient’s nose. Endoscopy with recording was performed before and after swab placement. An independent reviewer rated degree of staining, mucosal bleeding, and trauma at nasal subsites. ResultsVideos from 32 nasal cavities (16 participants) were reviewed. All cavities had high intensity staining at the septum and the inferior turbinate. No patients had staining within the middle meatus, agger nasi, or olfactory regions. In patients with normal anatomy, obstructive nasal anatomy or prior nasal surgery, all cavities had staining near the nasal septum. Only 7 cavities (22 %) had minor bleeding defined as ooze that stopped in 1–2min, and 3 (9 %) had minor trauma defined as mucosal disruption less than 5mm. There were no significant differences in comparing pre- and post-swab nasal cavity, trauma, or bleeding exams. ConclusionsThese study results showed that this swab is atraumatic to the nasal mucosal membranes when administered by non-medical personnel. Analysis suggests contact with targeted sites for drug absorption regardless of anatomy.

Effect of Nasal Tip Reshaping on Tip Projection in Primary Rhinoplasty without Cartilage Grafting from a Second Donor Site in an Asian Population

Objectives: Many Asian patients with nasal aesthetic surgery desire a sharper, more defined nasal tip. In many cases, their nasal cartilage is not abundant enough, necessitating cartilage transplantation from an extranasal location. We investigated which patients would qualify for a method of reshaping the nasal tip without needing donor cartilage by reshaping the lower cartilage using the transdomal suture technique and local cartilage grafting.Methods: We performed a single-center retrospective cohort study of patients undergoing nasal tip surgery. We divided patients into two groups. Group 1 comprised 13 patients with nasal tips with thin skin and soft tissue and relatively abundant cartilage. Group 2 included 31 patients with nasal tips with thicker, firmer skin and soft tissue and a smaller amount of cartilage. No patients had prior nasal surgery, and all patients were followed up for at least 3 months. Patients in both groups underwent the transdomal suture technique and local cartilage grafting. Five patients in Group 2 underwent alar reduction. Preoperative and postoperative lateral view photographs were superimposed and analyzed to measure changes in tip projection.Results: Patients in Group 1 showed a mean increase in tip projection of 3.9%. Patients in Group 2 demonstrated a mean decrease in tip projection of −1.5% without alar reduction and −5.6% with alar reduction.Conclusions: If the nasal tip is predominantly cartilaginous, patients may undergo surgery that does not involve donor cartilage from another site with good results. However, most patients, who have a relatively small amount of nasal tip cartilage, are not good candidates for this procedure.

Two-year outcomes of temperature-controlled radiofrequency device treatment of the nasal valve for patients with nasal airway obstruction.

The objective of this study was to evaluate long-term symptom improvements in patients with nasal airway obstruction (NAO) secondary to nasal valve collapse (NVC) following minimally invasive temperature-controlled radiofrequency (TCRF) treatment. A prospective, single-arm, multicenter study in patients >18 years with NAO due to NVC. Inclusion criteria were response to nasal valve dilation (e.g., modified Cottle maneuver) and baseline Nasal Obstruction Symptom Evaluation (NOSE) Scale score ≥60. Patients were treated in the nasal valve region with a TCRF device and followed through 2 years. A responder was ≥20% reduction NOSE Scale score or ≥1 reduction in severity class. A total of 122 patients were treated and 91 reached 2 years. The mean baseline NOSE Scale score was 80.3 (95% CI, 78.1-82.6). The adjusted mean change in score at 2 years was -45.8 (95% CI, -53.5 to -38.1), p < 0.001; a 57.0% improvement. The 2-year responder rate was 90.1% (95% CI, 82.3%-94.7%). Significant and sustained symptom improvement was achieved in subpopulations based on sex, age, body mass index, baseline NAO severity, nasal surgery history, NVC mechanism, septal deviation, and other anatomic contributors of NAO. No serious adverse events with a relationship to the study device and/or procedure were reported. Minimally invasive TCRF device treatment of the internal nasal valve for NAO is well tolerated and leads to significant and sustained improvement in NAO symptom severity through 2 years, including in patients with both static and dynamic NVC, septal deviation, turbinate enlargement, or prior nasal surgery. 2b.

The Role of Nasal Endoscopy in the Preoperative Evaluation of Nasal Airway Obstruction.

To examine the prevalence and nature of nasal endoscopic findings in patients referred for structural nasal obstruction, and analyze how such findings influence the preoperative evaluation or operative plan. Cross-sectional study. University-based academic otolaryngology practice. Nasal endoscopy was performed by a single surgeon and the exam findings were documented. Patient demographics, variables in the patient history, Nasal Obstruction Symptom Evaluation scores, and an Ease-of-Breathing Likert Scale were tested for associations with findings on endoscopy. A total of 82 of 346 patients (23.7%) had findings on rigid nasal endoscopy not appreciable on anterior rhinoscopy. Prior nasal surgery (p = .001) and positive allergy testing (p = .013) were significantly associated with findings on nasal endoscopy. Endoscopic findings prompted additional preoperative studies in 50 (14.5%) patients, and a change in the operative plan in 26 (7.5%) patients. In patients referred for surgical management of nasal obstruction, findings on nasal endoscopy otherwise undetected with anterior rhinoscopy are most common in but certainly not limited to those with prior nasal surgery or allergic rhinitis. Routine nasal endoscopy should be considered for all patients being evaluated for nasal airway surgery. These results may benefit future updates of the clinical consensus statements regarding the role of nasal endoscopy in the evaluation of nasal valve compromise and septoplasty.

0749 Does Prior Nasal Surgery Impact Outcomes of Upper Airway Stimulation Therapy for OSA?

Abstract Introduction Nasal airway obstruction can play an important role in pathogenesis and treatment of obstructive sleep apnea (OSA). Surgery for nasal obstruction can improve patient-reported OSA outcomes, including snoring and daytime sleepiness, as well as adherence and pressure requirements with continuous positive airway pressure (CPAP) therapy. The aim of this study was to examine whether previous nasal surgery was associated with UAS treatment efficacy. Methods From the ADHERE Registry, propensity score matching generated a cohort of UAS patients with prior nasal surgery including septoplasty, turbinate reduction, polyp removal (NS) and a comparable cohort of UAS patients without prior nasal surgery (WNS). Patients were matched based on demographic variables including pre-operative oral appliance use, prior CPAP use, gender, age, baseline apnea hypopnea index (AHI) and baseline Epworth Sleepiness Score (ESS). Data included demographic variables, therapy outcome measures including AHI, ESS, therapy use, and responder rate. Student’s t-test was used to compare normally distributed numeric data and Fisher’s exact test to compare categorical data. One sided t-tests with non-inferiority margin of 7.5 events/hr for AHI, 2 points for ESS, and 0.5 hr/night for Therapy Use were performed to determine non-inferiority. Results The ADHERE dataset from October 2021 included 169 patients from each cohort were matched for comparison. Reduction in AHI was 21.01 ±17.94 in WNS cohort and 18.39 ± 16.4 after UAS (p=0.162) in NS cohort. Reduction in ESS in WNS cohort was 4.85 ± 4.98 and 4.48 ±5.83 (p=0.528) in NS cohort. Therapy use was similar, 5.67 ± 1.95 in WNS and 5.97 ± 2.06 in NS (p=0.181). Responder rate was also similar in WNS (64.5%) and NS (62.1%) (p=0.735). Conclusion Retrospective analysis of UAS patients with vs without prior nasal surgery did not identify differences in UAS therapy outcomes or adherence. Furthermore, outcomes for patients with nasal surgery were non-inferior to those without. Future prospective studies of UAS candidates with nasal airway obstruction may better determine the role of adjunctive nasal surgery in this population. Support (If Any) Inspire Medical Systems

Changes in Nasal Staphylococcus Colonization and Infection Rates After Nasal Surgery.

Background: The relationship between nasal flora and infection rates in patients undergoing nasal surgery is of interest. This relationship has been studied though changes that may take place due to surgery have never been elucidated. Objective: To assess colonization rates and changes in colonization patterns of methicillin-resistant or methicillin-sensitive Staphylococcus aureus (MRSA/MSSA) in nasal flora in patients undergoing nasal surgery and to determine whether colonization is a risk factor for postoperative infection. Methods: Patients undergoing nasal surgery including septoplasty, rhinoplasty, or nasal valve repair were recruited prospectively. Patients completed a survey preoperatively concerning risk factors of postoperative infection. Nasal swabs and cultures were done preoperatively and at 1 week postoperatively. Patients were assessed for surgical site infections postoperatively. Results: Fifty-five patients completed both preoperative and postoperative nasal swabs. Preoperative to postoperative colonization rates increased for MRSA (2-5%) and MSSA (22-36%). Of the 55 patients, 11 had a change in nasal flora postoperatively, 9 of whom were colonized with a Staphylococcus aureus strain. However, MSSA/MRSA colonization either preoperatively or postoperatively was not associated with surgical site infections. Gender was the only variable found to be associated with postoperative infection (p = 0.007) with all four infections occurring in females. Conclusions: MSSA and MRSA do not appear to be major risk factors for surgical site infection in nasal surgery, whereas prior nasal surgery is a risk factor. This is the first report of a change in nasal colonization after nasal surgery. This could have implications for antibiotic prophylaxis in select nasal surgery cases.

Preoperative characteristics of over 1,300 functional septorhinoplasty patients.

To identify characteristics of patients presenting preoperatively for functional septorhinoplasty associated with increased Nasal Obstruction Symptom Evaluation (NOSE) scores. Retrospective analysis of a prospective cohort at a tertiary medical center. Only baseline assessments were analyzed in this cross-sectional study. 1,338 patients completed baseline nasal evaluation, resulting in 1,034 NOSE scores. Demographics, medical history, surgical history, and physical exam findings were recorded. The average preoperative NOSE score was 59.8 out of 100 (standard deviation: 24.9). Fifty-four percent (578 per 1,074) of respondents were female, although sex did not affect baseline NOSE score (P = 0.7). Forty-five percent (404 per 896) reported prior nasal surgery. History of rhinoplasty was not associated with a difference in baseline NOSE score (P = 0.1924); however, history of septoplasty (P = 0.0390) was associated with an increased baseline NOSE score. Snoring was also both associated with higher baseline NOSE score (P = 0.0003). All 12 septal/nasal valve measurements were associated with higher preoperative NOSE score, whereas the internal nasal valve narrowing variables retained significance in multivariate analysis (left: P = .0490; right: P = .0077). Patients presenting for nasal airway obstruction were evaluated. Sex was not associated with difference in NOSE score. History of septoplasty was associated with higher baseline NOSE score, as were snoring and internal nasal valve narrowing at rest. 2C Laryngoscope, 130:25-31, 2020.

In-office treatment of nasal valve obstruction using a novel, bipolar radiofrequency device.

ObjectivesTo assess the safety and effectiveness of in‐office bipolar radiofrequency treatment of nasal valve obstructionStudy DesignProspective, nonrandomized, multicenter case seriesMethodsAdult patients with a Nasal Obstruction Symptom Evaluation scale (NOSE) score ≥60 were selected. Patients were clinically diagnosed with dynamic or static internal nasal valve obstruction as primary or significant contributor to obstruction and were required to have a positive response to nasal mechanical dilators or lateralization maneuvers. Bilateral radio‐frequency treatment was applied intranasally using a novel device, under local anesthesia in a single session. Safety and tolerance were assessed by event reporting, inspection, and Visual Analogue Scale (VAS) for pain. Efficacy was determined using the NOSE score and patient‐reported satisfaction survey at 26 weeks.ResultsFifty patients were treated. No device or procedure‐related serious adverse events occurred. Soreness, edema, and crusting resolved by 1 month. The mean baseline NOSE score was 79.9 (SD 10.8, range 60–100), and all had severe or extreme obstruction. At 26 weeks, mean NOSE score was 69% lower at 24.7 (P < .0001) with 95% two‐sided confidence intervals 48.5 to 61.1 for decrease. The decrease in NOSE score did not differ significantly between patients who did or did not have prior nasal surgery. Patient satisfaction mean by survey was 8.2 of 10.ConclusionIn office treatment of internal nasal valve obstruction using a bipolar radiofrequency device is safe and well‐tolerated. Nasal obstruction, as assessed using the NOSE questionnaire at 26 weeks, was markedly improved with high patient satisfaction.Level of Evidence2b, prospective cohort

Pediatric septoplasty and functional septorhinoplasty: A quality of life outcome study

ObjectiveThis study assessed disease-specific quality-of-life outcomes among pediatric patients undergoing septoplasty or functional septorhinoplasty. The Nasal Obstruction Symptom Evaluation (NOSE) score was obtained pre- and post-operatively. Additional analyses determined whether demographics, nasal trauma, prior nasal surgery, or allergic rhinitis history affected NOSE scores. MethodsPatients undergoing septoplasty or functional septorhinoplasty were evaluated prospectively at a tertiary children's hospital. NOSE scores were assessed pre- and post-operatively. Change in NOSE score was analyzed using the Wilcoxon Signed Rank test, while multiple regression analysis evaluated factors associated with NOSE score change. Results136 patients (mean age 15.7 ± 2.1 years) were evaluated; 52 (38.2%) underwent septoplasty while 84 (61.8%) underwent functional septorhinoplasty. Mean follow-up was 3.6 ± 5.1 months. There was a statistically significant decrease in NOSE score from pre-operative septoplasty and functional septorhinoplasty: median = 75 to post-operative septoplasty: median = 20 (z = −5.9, p < 0.001) and functional septorhinoplasty: median = 15 (z = −7.9, p < 0.001). Gender, age, nasal trauma, prior nasal surgery, and allergic rhinitis did not have a significant effect on NOSE score change for either group. Additional surgery at the time of procedure was not a confounding variable in the relationship between surgery type and NOSE score. A NOSE Scale reliability analysis demonstrated high internal consistency with Cronbach's α of 0.83 across septoplasty and functional septorhinoplasty patients. ConclusionThere was significant improvement in disease-specific quality-of-life in pediatric patients undergoing septoplasty or functional septorhinoplasty. Gender, nasal trauma, prior nasal surgery, and allergic rhinitis did not significantly affect NOSE scores in either group.

Nasal Valve Reconstruction Using a Titanium Implant: An Outcomes Study.

Septoplasty alone is not always sufficient to correct nasal obstruction. Various techniques have been employed to repair nasal valve collapse and improve airflow. This article aimed to evaluate outcomes and quality of life following nasal valve reconstruction using a titanium implant in patients with nasal valve collapse. This is a single-center retrospective study that consisted of a telephone questionnaire of 37 quality-of-life measures and questions related to the surgical procedure and recovery process to evaluate postsurgical outcomes. Fifteen patients completed the survey. There was a significant improvement in nasal blockage/obstruction, breathing through the nose, sleeping, breathing through nose during exercise, the need to blow nose, sneezing, facial pain/pressure, fatigue, productivity, and restlessness/irritability after surgery. Overall, 100% of patients were satisfied with the results and would recommend this procedure. The most common postoperative complaints were pain (33%) and difficulty breathing (33%). Patients noticed no increase (20%) or a slight increase (73%) in the size of their nose. Sixty percent of patients cannot see the implant and 13% report the implant is barely noticeable. Nasal valve repair with a titanium implant was successful at improving symptoms of nasal obstruction and other quality-of-life issues. Satisfaction was high among all patients. The implants are palpable, thought to be visible by some patients, yet accepted by the majority of patients. This approach may be especially important in patients with prior nasal surgery but continue to experience refractory symptoms.

Early and Late Recurrent Epistaxis Admissions: Patterns of Incidence and Risk Factors.

Objective Epistaxis is a common complaint, yet few studies have focused on the incidence and risk factors of recurrent epistaxis. Our objective was to determine the patterns of incidence and risk factors for recurrent epistaxis admission (REA). Study Design Case series with chart review. Settings Single academic center. Subjects and Methods The medical records of patients admitted for epistaxis between 1999 and 2015 were reviewed. The follow-up period was defined as 3 years following initial admission. REAs were categorized as early (30 days) and late (31 days to 3 years) following initial admission. Logistic regression was used to identify potential predictors of REAs. Results A total of 653 patients were included. Eighty-six patients (14%) had REAs: 48 (7.5%) early and 38 (6.5%) late. Nonlinear incidence curve was demonstrated for both early and late REAs. Based on logistic regression, prior nasal surgery and anemia were independent risk factors for early REAs. According to multivariate analysis, thrombocytopenia was significantly associated with late REAs. Conclusion Early and late REAs demonstrate different risk predictors. Knowledge of such risk factors may help in risk stratification for this selected group of patients. All patients at risk should be advised on possible preventive measures. Patients at risk for early REA may benefit from a more proactive approach.

Pyriform Widening with Concurrent Z-Plasty for Nasal Valve Surgery: Revisiting a Time-Tested Technique

Introduction: Nasal obstruction may originate from the nasal valve. Many surgical techniques to improve the nasal valve are available but may fail to correct obstruction originating from a narrow pyriform aperture. We present a technique to widen the narrow pyriform aperture and review the literature. Materials and Methods: The article highlights a retrospective case series of patients who underwent pyriform widening with concurrent Z-plasty (PWZ) for nasal obstruction. Subjective measures of nasal obstruction were analyzed using the Nasal Obstruction Symptom Evaluation (NOSE) scale. The procedure consists of an incision made anterior to the inferior turbinate along the inferior aspect of the lateral bony pyriform. The periosteum is elevated, and a rongeur is used to widen the exposed bone. After oblique incisions are made, soft tissue flaps are elevated and transposed. The literature is reviewed. Results: Six adults underwent PWZ for nasal obstruction from 2011 through 2014. Three patients had prior nasal surgery. All patients reported subjective improvement, with mean NOSE scale scores of 15.7 preoperatively and 9.7 postoperatively. In the literature, all prior articles on pyriform aperture widening report positive outcomes. Conclusions: The surgical correction of nasal obstruction is challenging, given the complexity of the nasal valve. Upon review of the literature and analysis of our experience, we advocate consideration of PWZ in patients with anatomic obstruction at the level of the pyriform rim who have failed previous procedures or as an adjunct to primary nasal valve surgery. Further research is needed to examine the effects of pyriform widening on nasal obstruction.

Safety of cyanoacrylate-based adhesives in creating layered septal cartilage grafts during open structure septorhinoplasty

PurposePatients having suffered severe nasal trauma or having undergone prior septal surgery present particular problems during open structure septorhinoplasty. Septal cartilage deficient noses often require costal or conchal cartilage grafting or the use of allograft material, resulting in secondary donor site morbidity, longer operative times and variable results. The present study evaluated the utility of cyanoacrylate-based adhesives (CBA) in creating layered septal cartilage grafts from remnant septal cartilage for L-strut reconstruction during open septorhinoplasty. Study designA retrospective clinical review was performed at a university-based facial plastic and reconstructive surgical practice, identifying patients undergoing open structure septorhinoplasty performed by the senior authors. Procedures involved construction of a layered caudal or dorsal L-strut graft from at least two smaller autologous septal cartilage grafts. The grafts were adhered together with CBA with 5-0 polydioxanone suture (Ethicon, Somerville, NJ) used for reinforcement. Stability of the final construct was assessed postoperatively. ResultsFifteen patients were included with mean age of thirty-nine years (range: 15–65). Fifty-three percent of the patients had undergone prior nasal surgery: Seven had undergone at least one prior external septorhinoplasty and one had undergone prior endonasal septoplasty. Median follow-up was 144 days (range: 45–405). Postoperatively, one local infection was noted and two patients complained of post-operative columellar deviation. No other complications were encountered. ConclusionCBAs provide a safe technique in the crafting of layered grafts to provide reliable tip/dorsal support when performing open structure septorhinoplasty among patients with cartilage deficient or severely traumatized septa.

Nasal Valve Reconstruction: A Quality of Life Assessment

Objective: 1) Evaluate patient reported outcomes of nasal valve repair using a survey. 2) Understand quality of life measures following nasal valve reconstruction. Method: This retrospective study evaluated patients who underwent nasal valve reconstruction between December 2005 and December 2011. The study involved a 39-question survey that measured quality of life, overall satisfaction with the surgical outcomes, and patient-reported surgical outcomes in multiple symptoms including nasal obstruction, exercise tolerance, sleep, etc. Results: Forty-four patients completed the survey, and 25 had prior nasal surgery. The most common postoperative complaint was breathing difficulties (36%). Seventeen patients (39%) reported no change in the size of the nose despite augmentation of the nasal valve. Of those patients who did notice a change, 52% stated they notice the increase in size occasionally and never hear comments from others (70%). Overall, patients were satisfied with the results (81%), and 98% would recommend the procedure to others. There was a statistically significant improvement in nasal blockage/obstruction, breathing through the nose, sleeping, and breathing through the nose during exercise. Conclusion: Our data suggest that nasal valve reconstruction is a reasonable approach to patients with nasal obstruction and trouble breathing through the nose. This approach may be especially important in patients who have already had prior nasal surgery but refractory symptoms.

Paecilomyces lilacinus causing debilitating sinusitis in an immunocompetent patient: a case report

IntroductionSince the discovery of the first documented case of Paecilomyces in 1963, only five cases of Paecilomyces sinusitis have been described to date and all of them have predisposing factors such as immunocompromised status or prior nasal surgery. We present the first case of Paecilomyces lilacinus sinusitis in a fit young woman with no identified predisposing factors. To the best of our knowledge, this is the first known case in the UK and in Europe.Case presentationA 20-year-old Iraqi woman who has lived in the UK for the past five years presented with rhinorrhea, hyposmia, and nasal obstruction. She was previously fit and well and had no significant medical history. Imaging revealed a fungal infection that was eventually revealed on cytological examination to be P. lilacinus.ConclusionsP. lilacinus is both a difficult and important organism to identify because it has intrinsic anti-fungal resistance. In our case, the infection was severe and recurrent, and the organism demonstrated resistance to common oral anti-fungal agents. There was a delay in its diagnosis, owing to its similarity in appearance to Penicillium and a difficulty in distinguishing between the two without specialized knowledge of fungal taxonomy. In the field of otolaryngology, Paecilomyces is relatively unknown. Our intention is to raise awareness of this organism as well as to describe the challenges in its management.

Treating Internal Nasal Valve Collapse: The Intranasal Valvuloplasty

Introduction: Nasal obstruction requires a careful and thorough examination of the nose and nasal cavity. Particular interest should be placed on the internal and external nasal valves and their collapse. We discuss a simple yet effective technique to resolve obstruction of the internal nasal valve, called the intranasal valvuloplasty/valvulopexy. These procedures can be of benefit for valvular obstruction, especially postrhinoplasty. Objective: Nasal obstruction as sequela to aesthetic surgery may occur more often than recognized. The purpose of this paper is to explain a relatively simple yet expedient technique to address nasal valvular collapse. Method: Retrospective review of patients treated with the intranasal valvuloplasty/valvulopexy technique in the outpatient setting. Results: We reviewed our last 6 patients with the technique our senior author has been performing for 20 years. The patients noted 80–100% subjective improvement and we noted comparable objective improvement. Of the 6 patients, 50% were done bilaterally and 33% were combined with either a septoplasty or with a septorhinoplasty. Of these, 66.7% had a history of prior nasal surgery, usually rhinoplasty. Discussion: The valvuloplasty is an effective and straightforward approach to nasal valve collapse either alone or in conjunction with other rhinological procedures.

Categorization of patients with allergic rhinitis: a comparative profile of “sneezers and runners” and “blockers”

The recent Allergic Rhinitis and Its Impact on Asthma (ARIA) workshop report classified patients into "sneezers and runners" and "blockers" and described a new disease severity categorization. To sketch the profile of these 2 groups and to evaluate the relevance of categorization. Patients were categorized as "sneezers and runners" (group 1) or "blockers" (group 2). The patients responded to a questionnaire that sought information on symptoms and associated factors. They were then categorized into seasonal allergic rhinitis (SAR) and perennial allergic rhinitis (PAR) groups and "intermittent" and "persistent" disease groups and compared. A total of 114 patients (72 in group 1 and 42 in group 2) participated in the study. The significant features in group 1 were age at onset younger than 20 years (90%); birth date between June and September (61%); family history of atopy (88%); itching of skin (26%), eye (43%), ears (43%), and throat and palate (67%); and aggravation with dust (93%). History of breathlessness (90%), mouth breathing (81%), loss of smell (36%), and prior nasal surgery (31%) were significant in group 2. Significantly more patients in group 1 had SAR (54%) and moderate-severe intermittent disease (60%), whereas group 2 had PAR (81%) and mild persistent (69%) disease (P = .03). Patients classified as having SAR had intermittent disease (40, 83%) (P = .005), and those with PAR had persistent disease (51, 76%) (P < .001). Sixteen patients (24%) classified as having PAR were in the intermittent category, whereas 7 (17%) classified as having SAR were in the persistent category. This study demonstrated that the 2 groups had distinct clinical profiles and that it is important to categorize patients, according to the ARIA report, into intermittent and persistent allergic rhinitis groups.

The evaluation and management of olfactory disorder following upper respiratory tract infection.

Of the 5 senses, the sense of smell is the most neglected. The perception of smell is an integral and critical component of a person’s life. This is true, of course, unless it is altered or absent. The loss of the olfactory sense leads to an impaired quality of life as well as certain safety issues involving smoke and gas odor perception. Hyposmia and anosmia may be caused by a variety of factors. Prior nasal surgery, nonobstructive or obstructive nasal and sinus disease (ie, inhalant allergy, chronic sinusitis, nasal polyposis), dementia, Alzheimer disease, and normal aging may affect olfaction. Nasal septal deviation has not proven to be associated with anosmia. Clinically significant diminutions in olfactory sensitivity are present in more than 23% of patients who have allergic rhinitis. Histologically, the olfactory mucosa has proven essentially normal in those patients with nasal and sinus disease. Prior URTI is implicated in 14% to 26% of all presenting cases of hyposmia or anosmia. Other medical conditions as well as many drugs may cause a disordered sense of smell and are described elsewhere. Environmental pollutants can also have an effect on the olfactory system. Tumors such as olfactory groove meningiomas, frontal lobe gliomas, suprasellar pituitary tumors, and esthesioneuroblastomas are very rare causes of anosmia. The list of causes of sudden anosmia is quite short. Traumatic anosmia probably results from a shearing injury to the olfactory nerves. Postviral anosmia is the second most common type. Of 1834 patients who presented to 3 major centers of taste and smell disorders (the Connecticut Chemosensory Clinical Research Center, Farmington, Conn; the State University of New York Clinical Olfactory Research Center, Syracuse, NY; and the University of Pennsylvania Smell and Taste Center, Philadelphia), 349 (19%) had smell dysfunction related to a URTI. Only 36% of these patients had anosmia on testing. Standardized smell testing is used to demonstrate anosmia. The University of Pennsylvania Smell Identification Test is a 40-item, 4-alternative, forced-choice identification test using microencapsulated odors and is commercially available. Other forms of testing are also available. Neuroradiographic imaging serves to rule out abnormalities of the central nervous system. When indicated, magnetic resonance imaging (MRI) is the radiologic study of choice in the workup of anosmia. Subfrontal petechial hemorrhage can be detected on T1weighted imaging in the subacute and chronic periods following trauma. An MRI can also detect tumors of the olfactory system, nose, and paranasal sinuses. Congenital From the Division of Otolaryngology–Head and Neck Surgery, University of Kentucky Chandler Medical Center, Lexington. Sanford M. Archer, MD CLINICAL CHALLENGES IN OTOLARYNGOLOGY