Importance

Palpation of the nasal tip is an essential component of the preoperative rhinoplasty examination. Measuring tip support is challenging, and the forces that correspond to ideal tip support are unknown.

Objective

To identify the integrated reaction force and the minimum and ideal mechanical properties associated with nasal tip support.

Design, setting, and participants

Three-dimensional (3-D) printed anatomic silicone nasal models were created using a computed tomographic scan and computer-aided design software. From this model, 3-D printing and casting methods were used to create 5 anatomically correct nasal models of varying constitutive Young moduli (0.042, 0.086, 0.098, 0.252, and 0.302 MPa) from silicone. Thirty rhinoplasty surgeons who attended a regional rhinoplasty course evaluated the reaction force (nasal tip recoil) of each model by palpation and selected the model that satisfied their requirements for minimum and ideal tip support. Data were collected from May 3 to 4, 2014.

Results

Of the 30 respondents, 4 surgeons had been in practice for 1 to 5 years; 9 surgeons, 6 to 15 years; 7 surgeons, 16 to 25 years; and 10 surgeons, 26 or more years. Seventeen surgeons considered themselves in the advanced to expert skill competency levels. Logistic regression estimated the minimum threshold for the Young moduli for adequate and ideal tip support to be 0.096 and 0.154 MPa, respectively. Logistic regression estimated the thresholds for the reaction force associated with the absolute minimum and ideal requirements for good tip recoil to be 0.26 to 4.74 N and 0.37 to 7.19 N during 1- to 8-mm displacement, respectively.

Conclusions and relevance

This study presents a method to estimate clinically relevant nasal tip reaction forces, which serve as a proxy for nasal tip support. This information will become increasingly important in computational modeling of nasal tip mechanics and ultimately will enhance surgical planning for rhinoplasty.

Level of evidence

NA.

Objective

To critically analyze each reported case of malignant transformation of vestibular schwannoma (VS) after either stereotactic radiosurgery (SRS) or microsurgery (MS).

Data sources

We searched the Pubmed/Medline database using the relevant key words vestibular schwannoma, acoustic neuroma, malignant, transformation, radiation, induced, stereotactic, radiosurgery, malignancy, GammaKnife, and CyberKnife and combinations thereof.

Study selection

Inclusion criteria for malignant transformation of VS after SRS included histopathology of initially benign VS, subsequent histopathology confirming malignant VS, reasonable latency period between malignancy and benign diagnoses.

Data extraction

A neurotologist and a skull base neurosurgeon independently assessed each case report for quality, entry, exclusion criteria, and comparability of extracted data.

Data synthesis

We calculated median age, latency times, and survival times for each case report.

Results

Malignant transformation has been documented to occur after either SRS or MS. Eight cases were included that showed histopathologic evidence of malignant transformation after SRS and MS. Four cases of malignant transformation were included that demonstrated malignant transformation after MS only. Malignant transformation of VS can also occur de novo, and de novo malignant VSs are also encountered, which can confound a causal inference from either SRS or MS. Eighteen cases of primary malignant VS were included. Studies that were identified but not included in the review are summarized and tabulated. We found 12 studies of malignant transformation associated with NF2.

Conclusion

The potential mechanism leading to malignant transformation of VS seems more obvious for SRS and is less understood for MS. Given a low incidence of de novo malignant schwannoma, the possibility that these are spontaneous events in either setting cannot be ruled out. Risk of malignant transformation of VS after either SRS or MS is not zero; however, the magnitude of this risk is probably minimal based on the evidence from eight histopathologically confirmed cases.

Objective

To determine whether endoscopic cholesteatoma removal can be performed efficiently and safely using a curved fiberoptic-based laser.

Background

Angled instruments are required in endoscopic ear surgery to access recesses of the middle ear without extra drilling. Lasers are effective at ablating visible and microscopic cholesteatoma matrix and removing granulation tissue.

Study design

Retrospective case review from 2006 to 2013.

Setting

Single tertiary care center.

Patients

Patients who underwent cholesteatoma surgery with otoendoscopy.

Intervention

Residual cholesteatoma that could not be reached by conventional microinstruments was identified using an endoscope. This residual cholesteatoma was ablated in a contactless manner using a fiberoptic-based curved laser carrier with an argon laser. The laser tip through the carrier probe has a 45-degree curve, and the length of the tip is adjustable, allowing it to be used in recesses or around corners, such as in the sinus tympani, around the stapes suprastructure, in the oval window, or in the Eustachian tube orifice.

Main outcome measures

Presence or absence of residual cholesteatoma after laser ablation and complications.

Results

In 7 cases, the fiberoptic curved laser was used to ablate cholesteatoma completely with no injury to surrounding structures and with no evidence of recidivism with a mean follow-up period of 19 months. There were no cases of sensorineural hearing loss or perilymphatic fistula.

Conclusion

The curved laser probe allows for precise removal of cholesteatoma endoscopically.

BACKGROUND AND OBJECTIVES: Hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu disease, causes recurrent mucous membrane hemorrhage, especially epistaxis. In this systematic review, we discuss the efficacies of the three most common laser photocoagulation treatments for HHT-related epistaxis. STUDY DESIGN/MATERIALS AND METHODS: A systematic literature search was conducted in PubMed and MEDLINE from database inception to March 2019. Studies reporting epistaxis outcomes following argon, neodymium-doped yttrium aluminum garnet (Nd:YAG), and diode laser photocoagulation for HHT were included. χ2 and Barnards exact tests were utilized to detect differences in reduced epistaxis frequency and intensity rates. RESULTS: Fifteen out of 157 published studies met our eligibility criteria, spanning a collective 362 patients. Argon, Nd:YAG, and diode laser therapy reduced epistaxis frequency in 90.4%, 88.9%, and 71.1% of patients, respectively, and reduced epistaxis intensity in 87.8%, 87.2%, and 71.1% of patients, respectively. Diode laser photocoagulation significantly underperformed in both outcome measurements when compared with argon (frequency: P = 0.005; intensity: P = 0.034) and Nd:YAG (frequency: P = 0.012; intensity: P = 0.041). There was no significant difference between argon and Nd:YAG in reducing HHT epistaxis frequency (P = 0.434) or intensity (P = 0.969). Categorizing HHT patients by clinical severity demonstrated a higher rate of improvement in the mild-moderate group compared with the severe group in both argon (P < 0.001) and Nd:YAG (P < 0.001) therapeutic methods. While no significant differences were found in rates of improved epistaxis outcomes between argon and Nd:YAG in mild-moderate HHT patients (frequency: P = 0.061; intensity: P = 0.061), Nd:YAG demonstrated greater rates of reduction in epistaxis frequency (P = 0.040) and intensity (P = 0.028) than argon among severe HHT patients. CONCLUSIONS: HHT is a lifelong disease, plaguing patients with debilitating epistaxis. Intranasal laser photocoagulation of telangiectasias using argon or Nd:YAG laser therapy can yield improved epistaxis outcomes compared with diode laser photocoagulation. In severe cases of HHT, Nd:YAG laser therapy provides greater improvements in epistaxis outcomes than argon photocoagulation. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Objectives/hypothesis

To better understand the features of migraine in Meniere's disease (MD).

Study design

Retrospective review of prospectively obtained surveys in an outpatient clinic of a tertiary medical center.

Methods

Detailed questionnaires on headaches and dizziness were given to consecutive patients presenting with dizziness. The responses were verified by the clinician with the patient. The data, in addition to the clinical history and audiogram, were used to diagnose patients with migraine headaches and MD using criteria set by the International Headache Society (IHS) and the American Academy of Otolaryngology-Head and Neck Surgery, respectively. The prevalence of migraine-like symptoms in those patients with MD, who did not fit the diagnostic criteria for migraine, was evaluated.

Results

Thirty-seven patients with definite MD were included. There was a predominance of females (female/male:26/11). Mean age of patients was 52 ± 14 years. Nineteen patients (51%) had migraine headaches. Fifteen patients fulfilled the criteria for definite vestibular migraine. Of those who did not fulfill the IHS migraine criteria, a majority had characteristics such as a family history of migraine, visual motion sensitivity, or lifelong motion sickness that were highly suggestive of a migraine disorder.

Conclusions

A majority of patients with MD have migraine headaches as defined by the IHS. Sensitivity to visual motion, light and sound, head motion, smells, weather changes, or medication was present in 95% of all patients with definite MD and 82% of non-IHS migraine MD patients. This may suggest that MD may be an atypical variant of migraine.

Copyright © 2014 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company OBJECTIVE: To determine whether endoscopic cholesteatoma removal can be performed efficiently and safely using a curved fiberoptic-based laser. BACKGROUND: Angled instruments are required in endoscopic ear surgery to access recesses of the middle ear without extra drilling. Lasers are effective at ablating visible and microscopic cholesteatoma matrix and removing granulation tissue. STUDY DESIGN: Retrospective case review from 2006 to 2013. SETTING: Single tertiary care center. PATIENTS: Patients who underwent cholesteatoma surgery with otoendoscopy. INTERVENTION: Residual cholesteatoma that could not be reached by conventional microinstruments was identified using an endoscope. This residual cholesteatoma was ablated in a contactless manner using a fiberoptic-based curved laser carrier with an argon laser. The laser tip through the carrier probe has a 45-degree curve, and the length of the tip is adjustable, allowing it to be used in recesses or around corners, such as in the sinus tympani, around the stapes suprastructure, in the oval window, or in the Eustachian tube orifice. MAIN OUTCOME MEASURES: Presence or absence of residual cholesteatoma after laser ablation and complications. RESULTS: In 7 cases, the fiberoptic curved laser was used to ablate cholesteatoma completely with no injury to surrounding structures and with no evidence of recidivism with a mean follow-up period of 19 months. There were no cases of sensorineural hearing loss or perilymphatic fistula. CONCLUSION: The curved laser probe allows for precise removal of cholesteatoma endoscopically.

Objectives

To evaluate the outcomes and complications of transcanal excision of exostoses using micro-osteotomes, without a postauricular incision or the use of the drill.

Study design

A retrospective chart review of patients undergoing exostoses excision.

Setting

Tertiary Care Medical Center.

Subjects and methods

All of the patients underwent surgical removal of the exostoses using only a 1 or 2 mm micro-osteotomes. Patients were followed postoperatively and associated complications were evaluated.

Results

One-hundred thirty-eight ears in 106 patients were treated for obstructive exostosis. The average age of patients was 43 ± 16 years. Of these, 99 were man (93%) and 7 were woman (7%). A majority of the patients (84%, n = 89) had 90 to 100% obstruction of the ear canal. Complete ear canal healing was observed in 80% of patients by 3 weeks. All but one patient had healed by 6 weeks postoperatively. There were 9 (6.5%) slit tympanic membrane perforations that healed with intraoperative gelfoam or fascia myringoplasty. One patient had an anterior canal mobilization which required Xeroform packing for 3 weeks for stabilization. There were no postoperative vertigo, facial paresis, conductive/sensorineural hearing loss, soft tissue stenoses, and no skin grafting required.

Conclusions

This is the first study to report a series of patients performing solely a transcanal approach using micro-osteotomes for removing exostoses. Results indicate that it is a safe procedure with low complication rate and expeditious healing. Patients with 100% obstruction can have this procedure performed with no significant increase in morbidity.

Background

With the increasing prevalence of electronic readers (e-readers) for vocational and professional uses, it is important to discover if there are visual consequences in the use of these products. There are no studies in the literature quantifying the incidence or severity of eyestrain, nor are there clinical characteristics that may predispose to these symptoms with e-reader use.

Purpose

The primary objective of this pilot study was to assess the degree of eyestrain associated with e-reader use compared to traditional paper format. The secondary outcomes of this study were to assess the rate of eyestrain associated with e-reader use and identify any clinical characteristics that may be associated with the development of eyestrain.

Methods

Forty-four students were randomly assigned to study (e-reader iPAD) and control (print) groups. Participant posture, luminosity of the room, and reading distance from reading device were measured during a 1-h session for both groups. At the end of the session, questionnaires were administered to determine symptoms.

Results

Significantly higher rates of eyestrain (p = 0.008) and irritation (p = 0.011) were found among the iPAD study group as compared to the print 'control' group. The study group was also 4.9 times more likely to report severe eyestrain (95 % CI [1.4, 16.9]). No clinical characteristics predisposing to eyestrain could be identified.

Conclusions

These findings conclude that reading on e-readers may induce increased levels of irritation and eyestrain. Predisposing factors, etiology, and potential remedial interventions remain to be determined.

Background and objectives

Hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu disease, causes recurrent mucous membrane hemorrhage, especially epistaxis. In this systematic review, we discuss the efficacies of the three most common laser photocoagulation treatments for HHT-related epistaxis.

Study design/materials and methods

A systematic literature search was conducted in PubMed and MEDLINE from database inception to March 2019. Studies reporting epistaxis outcomes following argon, neodymium-doped yttrium aluminum garnet (Nd:YAG), and diode laser photocoagulation for HHT were included. χ² and Barnard's exact tests were utilized to detect differences in reduced epistaxis frequency and intensity rates.

Results

Fifteen out of 157 published studies met our eligibility criteria, spanning a collective 362 patients. Argon, Nd:YAG, and diode laser therapy reduced epistaxis frequency in 90.4%, 88.9%, and 71.1% of patients, respectively, and reduced epistaxis intensity in 87.8%, 87.2%, and 71.1% of patients, respectively. Diode laser photocoagulation significantly underperformed in both outcome measurements when compared with argon (frequency: P = 0.005; intensity: P = 0.034) and Nd:YAG (frequency: P = 0.012; intensity: P = 0.041). There was no significant difference between argon and Nd:YAG in reducing HHT epistaxis frequency (P = 0.434) or intensity (P = 0.969). Categorizing HHT patients by clinical severity demonstrated a higher rate of improvement in the mild-moderate group compared with the severe group in both argon (P < 0.001) and Nd:YAG (P < 0.001) therapeutic methods. While no significant differences were found in rates of improved epistaxis outcomes between argon and Nd:YAG in mild-moderate HHT patients (frequency: P = 0.061; intensity: P = 0.061), Nd:YAG demonstrated greater rates of reduction in epistaxis frequency (P = 0.040) and intensity (P = 0.028) than argon among severe HHT patients.

Conclusions

HHT is a lifelong disease, plaguing patients with debilitating epistaxis. Intranasal laser photocoagulation of telangiectasias using argon or Nd:YAG laser therapy can yield improved epistaxis outcomes compared with diode laser photocoagulation. In severe cases of HHT, Nd:YAG laser therapy provides greater improvements in epistaxis outcomes than argon photocoagulation. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

A modified lateral temporal bone resection (mLTBR) is a unique technique that spares the tympanic membrane (TM) and ossicles in select patients with squamous cell carcinoma (SCCa). The records of 5 patients with SCCa of the temporal bone with negative frozen-section biopsy at the tympanic annulus were reviewed. The mean follow-up time for the patients was 29.2 months. One patient received postoperative radiation due to cervical nodal extracapsular spread. All patients were recurrence free as of the most recent follow-up (range, 8-50 months). Postoperative audiometry demonstrated an average conductive hearing loss of 9 dB (range, 0-17 dB). The mLTBR with sparing of the TM can be an effective alternative to the traditional lateral temporal bone resection (LTBR) with better hearing results for patients with SCCa involving the bony external auditory canal. In the short term, oncologic results of mLTBR appear equivalent to the LTBR. However, long-term follow-up is needed for >5-year outcomes.