Total Nose Research Articles

Long-term outcomes of microsurgical nasal replantation: review of the literature and illustrated 10-year follow-up of a pediatric case with full sensory recovery.

We present a case of successful artery only total nose replantation in an 18-month-old child, with 10 years of follow-up and full sensory recovery despite no nerve repair. The common absence of veins for anastomosis does not prevent successful replant, as demonstrated with the use of Hirudo medicinalis use in this unique case. We comprehensively review the literature of this rare and complex injury and advocate microsurgical replantation where possible over other methods of nasal reconstruction.

Minimal Invasive Nasal Valve Repair in Treatment of Nasal Valve Obstruction

Objectives: Nasal obstruction is known to be associated with a major decrease in disease-specific quality of life, and nasal valve dysfunction can play a considerable role in nasal airflow obstruction. There are many procedures for treating this type of nasal obstruction. Aim: Evaluate the efficiency of minimally invasive valve repair for the treatment of nasal obstruction due to nasal valve stenosis in comparison with the reduction of the size of inferior turbinate by coblation and sub mucosal diathermy (SMD). Methods: This is a cross sectional study conducted atl–erbil from November 20, 2011, to September 19, 2013. The study included 43 patients suffering from nasal obstruction for more than 6 months. The patients were divided into 3 groups according to the type of surgery carried out (minimally invasive valve repair, coblation and submucosal diathermy [SMD] of inferior turbinate). Patients were followed for 3 months, and the data were statistically analyzed. Results: Patients showed highly significant differences between pre- and 1st, 30th, and 90th days postoperative total nose scale scores ( P = .0001). The difference between 1st and 30th and 90th days total score was also significant. While patients treated by coblation and SMD showed no significant difference in the mean nose score ( P = .705 and P = .2), postoperative morbidity was less in the minimal invasive valve repair group compared with coblation and SMD groups. Conclusions: Minimal invasive valve repair had more rapid improvement and less postoperative morbidity in comparison with coblation and SMD of inferior turbinate.

Seeing is believing: objectively evaluating the impact of facial reanimation surgery on social perception.

Objectively measure the ability of facial reanimation surgery to normalize the appearance of facial paralysis using eye-tracking technology. Prospective randomized controlled experiment. An eye-tracker system was used to record the eye-movement patterns, called scanpaths, of 86 naïve observers gazing at pictures of paralyzed faces (House-Brackmann IV-VI), smiling and in repose; before and after facial reanimation surgery; as well as normal, nonparalyzed faces. Observers gazed at each face for 10 seconds. Fixation durations for all predefined facial areas of interest were analyzed using mixed-effects linear regression. Observers spent the majority of time (6.6 of 10 seconds) gazing in the central triangle region (eyes, nose, and mouth) of normal faces and paralyzed faces. There were significant deviations in fixation within the central triangle of paralyzed faces as compared to normal faces. Total fixation on the eyes remained conserved. However, total nose fixation decreased and mouth fixation increased on paralyzed faces. Facial reanimation surgery normalized many of the hemifacial gaze asymmetries caused by unilateral facial paralysis, and restored a normal distribution of gaze between the functional and paralyzed sides of the face and mouth. There were objective differences in the way observers directed their attention to facial features when viewing normal and paralyzed faces. After facial reanimation surgery, the attentional distraction caused by facial feature irregularities was reduced. These findings are important additions to the emerging body of objective evidence indicating the effectiveness of reanimation surgery; they also suggest opportunities to optimize reconstruction. N/A.

Sinonasal Inverted Papilloma

Introduction: Sinonasal inverted papilloma is a rare tumour comprising about 0.5-4% of total nose and paranasal sinus tumours. Though various factors have been implicated its exact cause is unknown. This longitudinal, prospective study was carried out to nd out demographical prole, association of this tumour with smoking, occupation, variation with ethnic races and outcome of surgery. Methods: This study was carried out in the department of ENT-HNS, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu from April, 2005 to March, 2011. Result: Out of 34 patients, there were 25 male and 9 female with ratio of 2.78:1. Age of the patients ranged from 14-76 years with median age of 51.5±2.74 SE years. Disease was more common in 4th to 7th decade. It was common in farmers (20). Eighteen patients were smoker and 16 nonsmoker. The disease was more common in mongoloids than in Indo-aryans. Out of 16 patients having stage III disease, 9 were smoker and 7 nonsmoker. Eighteen patients underwent endoscopic medial maxillectomy and 15 patients underwent medial maxillectomy via lateral rhinotomy approach. One patient who had bilateral disease underwent medial maxillectomy via lateral rhinotomy on the left side and endoscopically on the right side. There was recurrence of tumour in 2 patients who underwent surgery via lateral rhinotomy approach whereas in 1 patient who underwent surgery endoscopically. Conclusion: This study showed that sinonasal inverted papilloma was common in mongoloids than in Indo-aryans and farmers but no association with smoking. Endoscopic medial maxillectomy has less reccurence of tumour in comparison to lateral rhinotomy approach. DOI: http://dx.doi.org/10.3126/joim.v34i2.9044 Journal of Institute of Medicine August, 2012; 34:2 10-13

Sinonasal Inverted Papilloma

Introduction: Sinonasal inverted papilloma is a rare tumour comprising about 0.5-4% of total nose and paranasal sinus tumours. Though various factors have been implicated its exact cause is unknown. This longitudinal, prospective study was carried out to nd out demographical prole, association of this tumour with smoking, occupation, variation with ethnic races and outcome of surgery. Methods: This study was carried out in the department of ENT-HNS, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu from April, 2005 to March, 2011. Result: Out of 34 patients, there were 25 male and 9 female with ratio of 2.78:1. Age of the patients ranged from 14-76 years with median age of 51.5±2.74 SE years. Disease was more common in 4th to 7th decade. It was common in farmers (20). Eighteen patients were smoker and 16 nonsmoker. The disease was more common in mongoloids than in Indo-aryans. Out of 16 patients having stage III disease, 9 were smoker and 7 nonsmoker. Eighteen patients underwent endoscopic medial maxillectomy and 15 patients underwent medial maxillectomy via lateral rhinotomy approach. One patient who had bilateral disease underwent medial maxillectomy via lateral rhinotomy on the left side and endoscopically on the right side. There was recurrence of tumour in 2 patients who underwent surgery via lateral rhinotomy approach whereas in 1 patient who underwent surgery endoscopically. Conclusion: This study showed that sinonasal inverted papilloma was common in mongoloids than in Indo-aryans and farmers but no association with smoking. Endoscopic medial maxillectomy has less reccurence of tumour in comparison to lateral rhinotomy approach. DOI: http://dx.doi.org/10.3126/joim.v34i2.9044 Journal of Institute of Medicine August, 2012; 34:2 10-13

The Role of Nose in Sleep and Sleep Disorder

Received February 28, 2012 Accepted March 21, 2012 Address for correspondence Chan Soon Park, MD, PhD Department of OtorhinolaryngologyHead and Neck Surgery, College of Medicine, The Catholic University of Korea, 93 Jungbu-daero, Paldal-gu, Suwon 442-723, Korea Tel +82-31-249-8304 Fax +82-31-257-3752 E-mail pcs0112@catholic.ac.kr The pathophysiology and exact mechanism for sleep-disordered breathing (SDB) have not been fully understood and the role of nose obstruction in SDB has been still controversial. However, considering that the nasal resistance contributes about half of total airway resistance and nose is the largest source in total airway resistance, it is hard to say there is no relation between nose and sleep/sleep disordered breathing. The transition from wakefulness to sleep causes major changes in many aspects of the human body, and many sleep factors (body position, sleep stage, air flow, etc.) can influence nose. Although many studies have attempted to elucidate the relationships between SDB and nasal obstruction or an improvement in nasal obstruction, there is general consensus that nasal obstruction is related to SDB, but the roles of nasal surgery alone in the treatment of SDB have been still on debate. Korean J Otorhinolaryngol-Head Neck Surg 2012;55:201-5

Sublingual immunotherapy not effective in house dust mite–allergic children in primary care

Sublingual immunotherapy (SLIT) as a therapy for the treatment of allergic rhinitis in children might be acceptable as an alternative for subcutaneous immunotherapy. However, the efficacy of SLIT with house dust mite extract is not well established. To investigate whether SLIT in house dust mite-allergic children recruited in primary care is effective and safe. Children aged 6-18 years (n = 251) recruited in primary care with a house dust mite-induced allergic rhinitis received either SLIT or placebo for 2 years. Symptoms and medication use were assessed throughout the study. Primary outcome parameter was the mean total nose symptom score (scales 0-12) during the autumn of the second treatment year. Safety was assessed by recording any adverse event. Overall, the mean nose symptom score ± s.d. after 2 years of treatment showed no significant effect of SLIT (symptom score intervention group 2.26 ± 1.84 vs. placebo group, 2.02 ± 1.67; p = 0.08). There were no significant differences in secondary outcomes, nor in subgroup analyses. The number of patients reporting adverse events was comparable between both groups. Sublingual immunotherapy with house dust mite allergen was not better than placebo in reducing rhinitis symptoms in house dust mite-allergic children in primary care. SLIT as administered in this study can be considered safe.

Total nose reconstruction using superselective embolisation and a forehead flap: overlooked in recurrent massive vascular malformations of the nose

Massive vascular malformations of the nose cause serious cosmetic, functional and psychological problems. Generally, no single treatment modality to date has provided satisfactory results. Therefore, multidisciplinary treatment approaches are being standardised. In spite of standard multidisciplinary treatments, especially postoperative outcomes in massive nasal vascular malformation cases are often aesthetically and functionally unsatisfactory due to the unique characteristics of the nose. While several studies report on the management of facial vascular malformations using local and distant flaps, none is specific to the nasal region. The present article describes the treatment of four patients with recurrent massive nasal vascular malformation (which invades more than two-thirds of the nose) using a combined-procedure approach involving preoperative superselective embolisation, extensive (en bloc) malformation resection and nasal reconstruction using a paramedian forehead flap. Patients were followed up for a mean of 19 months. Preoperative assessments included MR angiography, selective angiography and physical examination, including Doppler sonography. Preoperative superselective embolisation was then performed by a radiologist. On post-embolisation day 2, patients underwent en bloc resection and total nasal reconstruction with paramedian forehead flap hitherto overlooked in the treatment of nasal vascular malformation. Satisfactory results were achieved in all four patients. Three patients suffered a high-flow malformation and one suffered a low-flow malformation. As confirmed by the radiologist, no recurrences were noted. Colour matching and nasal contouring were satisfactory in all cases. There were no major complications such as serious infection, recurrent ulceration, postoperative bleeding or flap failure. All patients responded positively. The present novel treatment of massive vascular malformations of the nose using selective embolisation, en bloc resection and a paramedian forehead flap was successful. The findings indicate that this treatment of massive nasal vascular malformations leads to successful functional and aesthetic outcomes. The patients were followed up for an average of 2 years and ongoing follow-up is scheduled.

Total Forehead Flap

Being non-hair-bearing and relatively thin and having similar color and texture of the skin of the forehead provide an excellent characteristic not only for nasal reconstruction but also in other facial areas. A 28-year-old man presented in the Department of Plastic Surgery, Argerich Hospital, Buenos Aires, Argentina, with a giant congenital melanocytic nevus extended on complete left cheek, total nose, both upper and lower lids, ocular globe, and temporoparietal region. Tumor resection and reconstructive aspect were planned in 3 stages. (1) Excision of the tumor located in the cheek, nose, and both upper and lower left lids. The reconstruction of the cheek was made with a total forehead flap. The nose was resurfaced by means of a total skin graft. (2) resection of the temporoparietal nevus. (3) Treatment of the tumor involving the ocular structures. Total forehead flap was outlined, permitting carryout of skin of the total forehead area, and the blood supply was originated from the frontal and parietal branches of the temporal superficial artery and secondarily by anastomosis with the branches arising from both homolateral auricular and occipital vessels. Postoperative control 1 year after surgery showed an excellent aesthetic and functional result not only in the recipient area but also in the donor area.

O.599 Total nose reconstruction with forehead flap in malformation

Septic arthritis (SA) in an adult native joint is a rare condition but a diagnostic emergency due to the morbidity and mortality and the functional risk related to structural damage. Current management varies and the recommendations available are dated. The French Rheumatology Society (SFR) Bone and Joint Infection Working Group, together with the French Language Infectious Diseases Society (SPILF) and the French Orthopaedic and Trauma Surgery Society (SOFCOT) have worked according to the HAS methodology to devise clinical practice recommendations to diagnose and treat SA in an adult native joint. One new focus is on the importance of microbiological documentation (blood cultures and joint aspiration) before starting antibiotic treatment, looking for differential diagnoses (microcrystal detection), the relevance of a joint ultrasound to guide aspiration, and the indication to perform a reference X-ray. A cardiac ultrasound is indicated only in cases of SA involving Staphylococcus aureus, oral streptococci, Streptococcus gallolyticus or Enterococcus faecalis, or when infective endocarditis is clinically suspected. Regarding treatment, we stress the importance of medical and surgical collaboration. Antibiotic therapies (drugs and durations) are presented in the form of didactic tables according to the main bacteria in question (staphylococci, streptococci and gram-negative rods). Probabilistic antibiotic therapy should only be used for patients with serious symptoms. Lastly, non-drug treatments such as joint drainage and early physical therapy are the subject of specific recommendations.

Human facial allotransplantation: a 2-year follow-up study

Progress in composite tissue allotransplantation could provide a new treatment for patients with severe facial disfigurements. We did a partial facial allotransplantation in 2006, and report here the 2 year follow-up of the patient. The recipient, a 30-year-old man from China, had his face severely injured by a bear in October, 2004. Allograft composite tissue transplantation was done in April, 2006, after careful systemic preparation. The surgery included anastomosis of the right mandibular artery and anterior facial vein, whole repair of total nose, upper lip, parotid gland, front wall of the maxillary sinus, part of the infraorbital wall, and zygomatic bone. Facial nerve anastomosis was done during the surgery. Quadruple immunomodulatory therapy was used, containing tacrolimus, mycophenolate mofetil, corticosteroids, and humanised IL-2 receptor monoclonal antibody. Follow-up included T lymphocyte subgroups in peripheral blood, pathological and immunohistochemical examinations, functional progress, and psychological support. Composite tissue flap survived well. There were three acute rejection episodes at 3, 5, and 17 months after transplantation, but these were controlled by adjustment of the tacrolimus dose or the application of methylprednisolone pulse therapy. Hepatic and renal functions were normal, and there was no infection. The patient developed hyperglycaemia on day 3 after transplantation, which was controlled by medication. Facial transplantation could be successful in the short term, but the procedure was not without complications. However, promising results could mean that this procedure might be an option for long-term restoration of severe facial disfigurement.

Primary and Secondary Procedures in Functional and Aesthetic Reconstruction of Noma-Associated Complex Central Facial Defects

Most defects resulting from noma involve the lateral and anterolateral aspects of the face and are often combined with severe functional deficits. A subgroup, commonly called "central noma," is composed of defects of the upper lip, maxillary soft tissues, premaxilla, nasal cartilaginous infrastructure, and soft tissues. In contrast to unilateral involvement of the face, central noma does not affect opening of the jaw; however, it results in severe mutilation, with disfiguring three-dimensional defects erasing any individual traits from a face. The common surgical approach to centrofacial noma defects has been single-stage reconstructive procedures using locoregional flaps, but this approach often leads to disappointing outcomes in complex cases. The authors' concept for complex central noma defects is a staged approach using free flaps for soft-tissue reconstruction of the upper lip and maxillary vicinity. This approach serves as a versatile base for introducing locoregional flaps for later functional and aesthetic refinements. A secondary procedure includes total nose reconstruction with a free cartilage framework and forehead flaps. In this series (n = 53), free radial forearm (n = 4), anterolateral thigh (n = 1), and parascapular (n = 7) flaps proved suitable for the central face in terms of pedicle length, tissue pliability, and bulk. All free flaps survived completely. Three total nose reconstructions by forehead flaps were performed successfully as a secondary step. Being of limited use for subtotal or total reconstruction of the outer nose, microvascular tissue transfer preserves local and regional donor sites--particularly the forehead--for secondary reconstruction.

Nasal reconstruction in children: a review of 29 patients

Acquired large nasal defects are much more common in adulthood than in childhood because of the frequency of skin tumors after a certain age. However, from their experience in treating a number of children with sequelae of noma and burns, the authors have collected a series of 17 total and 12 partial nasal reconstructions in children aged 1 to 15 years. After reviewing the various methods used for recreating the lining, the support, and the skin cover in the whole series, three cases are reported in detail. A 1-year-old patient received a tempororetroauricular flap after total amputation of the nose and was observed for 17 years. Another patient, who was burned as a baby, underwent reconstruction at age 10 with a deltopectoral flap and was observed for 7 years. The third patient underwent total nose reconstruction at age 12 with an Indian forehead flap. From their experience, the authors conclude that, for psychosocial reasons, nasal reconstruction should be started early, despite possible reoperation at a later age. The best results are certainly obtained at the end of growth or at least after the age of 12. Adjacent bone or soft tissue defects further enhance the difficult challenge of restoring a satisfactory aesthetic appearance in these children.

Two-stage reconstruction of a massive gun-shot wound of the midface with a free radial forearm flap and a parietal osteofasciocutaneous flap

Treatment of midface gunshot injuries and their reconstruction remains one of the difficult problems of reconstructive surgery. Several flaps have been described for the reconstruction of total lip and nasal defects. We present a case of a gunshot wound to the midface in which a two-stage procedure was performed. In the first stage, a free radial forearm flap was successfully transferred for the reconstruction of the total nose. In the second stage, total upper lip reconstruction was achieved using a parietal osteofasciocutaneous flap pedicled to the parieto-temporal fascia based on the superficialis temporal artery. At a mean follow-up period of 18 months, near-normal functional and cosmetic results were obtained.

The dawn of plastic surgery in Mexico: XVIth century.

An aspect of early Mexican surgery in the sixteenth century is presented. The treatment of facial wounds by Alonso Lopez de Hinojosos and Agustin Farfán is reviewed. Farfán proposed total nose reconstruction, with a cutaneous arm flap, 18 years before its description in De Curtorum Chirurgia, by Tagliacozzi, in 1597 in Venice, Italy. The chapter on facial wounds by Lopez de Hinojosos and Farfán shows their concern for the final aesthetic results and should be considered the first Mexican publication in the field of plastic surgery.

The superior auricular artery and retroauricular arterial island flaps.

This paper reports the finding of the superior auricular artery, which is a fairly large arterial branch, about 1 mm in diameter, arising from the superficial temporal artery anterior to the auricular helix. It is covered by skin, the anterior auricular muscle, and the fascia of the parotid gland. It runs together with its concomitant vein posteriorly in the groove between the cartilage of the ear and the temporal bone and anastomoses with the posterior auricular artery. This artery has been used successfully to raise large retroauricular arterial island flaps for one case of total nose reconstruction and seven cases of reconstruction of the severely constricted anophthalmic socket. These operative procedures are described in detail.

The use of the free forearm flap for total nose reconstruction in one stage

The use of the free forearm flap for total nose reconstruction in one stage

Peak flow nasal patency indices in patients operated for nasal obstruction

In 26 patients undergoing operation for nasal obstruction, nasal and oral peak expiratory and inspiratory flow rates were measured preoperatively and 1 month postoperatively. Peak expiratory and inspiratory flow nasal patency indices were calculated from the ratio between the nasal and oral peak flow rates. Postoperatively, these indices were significantly increased for the total nose and for the preoperatively worse nasal cavity. No significant change was observed for the oral peak flow rates. A significant preoperative difference in nasal patency between the two nasal cavities was eliminated by surgery, as the postoperative peak flow of each nasal cavity reached 80% of the peak flow of the total nose on expiration and close to 50% on inspiration. A good correspondence between the subjective improvement of nasal patency and the increase in peak expiratory and inspiratory flow nasal patency indices was observed for the total nose. These findings show that peak flow nasal patency indices give valuable information pre- and post-operatively in patients undergoing nasal surgery and that the method is simple and easy to perform.

Effect of beta-endorphin on sociosexual proclivity in a choice paradigm.

Intraventricularly-administered beta-endorphin (beta-END) suppresses receptive and proceptive behaviors of the ovariectomized, estrogen-progesterone-primed rat. This rat model was used in a four-way choice paradigm to investigate the behavioral specificity and motivational aspects of sexual suppression by beta-END. The experimental females showed a preference to associate with a sexually active 'stud' male over the other incentive animals as shown by significantly more approaches to and nose pokes into the stud male compartment. beta-END did not alter that choice preference. Rather, there was a decrease in overall social interaction after beta-END treatment, as shown by decreased total nose pokes. This overall decrease in social motivation, which was blocked by subcutaneous naloxone injection, was not specific to the stud male. It was not a result of akinesia, since total movement among the inner alleys was significantly higher after beta-END treatment, an effect also reversed by naloxone. These data suggest that intraventricular beta-END may act to suppress sociosexual motivation as a whole rather than sexual activity specifically.

Comparison of sequential anterior and posterior rhinomanometry

This study was conducted to test the validity in adult subjects of the commonly used technique of summing anterior nasal measurements to describe the patency of the total nose. We measured the total nasal conductance in 36 nonallergic, nonsmoking subjects by use of posterior rhinomanometry (PRM) and compared the results with sequential summed unilateral conductances in the same subjects based on anterior rhinomanometry (ARM). Linear regression of the relationship between the two measures demonstrated significant differences. Variation between these two measures is composed of two parts: (1) random time variation and (2) a component attributable to the difference between methods. Random time variation was estimated from five serial posterior nasal conductances in nine of the subjects in a second experiment. We observed significantly greater variations between ARM and PRM than between PRM measures separated by similar time intervals (F 36.36 = 2.30, p < 0.01). We conclude that PRM is significantly more accurate than summed ARM when the goal is to quantitate precisely the patency of the nose as a whole at a given instant in time, and yet summed ARM measurements may be acceptable in clinical studies wherein large changes in nasal patency occur.