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One hundred eighty-two patients were evaluated after functional endoscopic sinus surgery. The goal was to establish whether any anatomical finding correlated with symptoms and to find any historical predictors of symptomatic failure. Of all physical findings reviewed, only scarring of middle meatal antrostomy and scarring of the ethmoids approached significance in predicting poor outcome. Surprisingly, of the historical factors reviewed, only gastroesophageal reflux disease was statistically significant as a predictor of poor symptomatic outcome. [ABSTRACT FROM AUTHOR]

Introduction  As experience grows with in-office balloon sinus dilation (BSD) procedures, technique modifications will evolve to meet specific needs. The major disadvantage with the maxillary BSD procedure is that the intact uncinate process prevents visualization of and instrument access into the maxillary sinus both intraoperatively and postoperatively. Combining a partial or complete uncinectomy procedure with maxillary BSD could be beneficial in selected patients with certain maxillary sinus problems. Objective  The primary objective of this study was to see if, in selected patients, combining an uncinectomy and maxillary sinus BSD together allowed visualization of and access to the maxillary sinus cavity at the time of the procedure and at follow-up visits. Method  A chart review was completed for BSD cases performed from 2013 through mid-2015 identifying patients who underwent partial or complete uncinectomy with in-office maxillary sinus BSD. A total of 14 patients were identified, with 26 sinuses treated. The data collected included: difficulty or problems in performing an uncinectomy with the maxillary sinus BSD; visualization and access to the maxillary sinus cavity both intraoperatively and at follow-up visits; and occurrence of complications or late adverse sequelae. All patients completed a minimum 6-month follow-up. Results  Combined uncinectomy and maxillary sinus BSD procedures were easily completed for all patients without complications, and no late adverse sequelae were encountered. The maxillary sinuses could be visualized and accessed, if needed, intraoperatively and at all follow-up visits. Conclusions  In selected subsets of maxillary sinus conditions this procedure modification can provide significant benefits. A case is presented for illustration.

Transitioning of rhinologic procedures from the operating room to the office setting in selected patients is a rising trend. An effective pain-control, patient-preparation protocol is essential, especially with advanced in-office rhinologic procedures such as hybrid balloon sinus dilation (BSD), in which other procedures such as ethmoidectomy, turbinate reduction, and other procedures are concomitantly performed. A regimen using oral sedation, topical tetracaine gel, topical tetracaine/epinephrine-soaked cottonoid packs, and intranasal local infiltrative anesthesia can vary significantly in effectiveness and be suboptimal at times (as determined by using treated patients as historical controls). A modification of this regimen was subsequently used, incorporating the maxillary nerve block, and qualitative differences were then assessed retrospectively between the two regimens. Twenty-five consecutive patients were retrospectively studied who underwent hybrid BSD procedures in the office setting using the maxillary nerve-block regimen modification. All patients underwent BSD of the sphenoid, frontal, and maxillary sinuses with anterior and partial posterior ethmoidectomies. Five patients also underwent septoplasty, and 18 patients underwent inferior turbinate reduction procedures. Twenty-four patients received oral sedation, and all patients received topical tetracaine/epinephrine-soaked cottonoid packs. The topical tetracaine gel was dropped after 5 patients because it was not felt to be needed anymore. No intranasal local infiltrative anesthesia was used. Several qualitative differences were observed after modifying the patient-preparation regimen incorporating the maxillary nerve block. The most important observation seen with this modification was a consistently reproducible, dense anesthesia coverage over the entire nasal cavity with good paranasal sinus coverage. This modification eliminated intranasal bleeding and swelling associated with intranasal local anesthetic injections. No complications were encountered. This preliminary study provides support for use and further evaluation of the maxillary nerve block for in-office rhinologic procedures. If the trend continues to rise in performing advanced in-office rhinologic procedures in selected patients, the maxillary nerve block may find a place in the patient-preparation protocol.

There has been a recent explosion of new in vitro tests for the diagnosis of allergies. At present there is no general agreement on which type of in vitro test is best. Recently our hospital switched in vitro testing from the modified radioallergosorbent system (mRAST) to the Pharmacia CAP system (CAP). While changing in vitro testing techniques, 47 patients were tested with both the mRAST and CAP tests. Comparisons were made between the mRAST and CAP results of Alternaria tenuis and Dermatophagoides pteronyssinus allergens. These results were then compared with the results of patients who also underwent intradermal skin testing based on end point titration techniques.

Objective: To introduce and evaluate the technique of cirummandibular wires with piriform rim suspension (CMW-PRS) combined with arch bars and a fracture site bridle in the treatment of mixed-dentition pediatric mandible fractures., Design: Five male patients (mean age, 8.2 years [age range, 7-10 years]) with an isolated mixed-dentition mandible fracture were treated with the CMW-PRS technique at the University of Texas Health Science Center, San Antonio, from 1985 to 1987 and at the University of Missouri, Columbia, from 1992 to 1995. Clinical and radiographic fracture healing, somatosensory status, and complications were evaluated., Results: All patients demonstrated clinical union to their preinjury occlusion by 3 or 4 weeks. They remained without complications until they were no longer available for follow-up. Panoramic radiographs supported the findings of clinical examinations throughout the study, and no radiographic abnormalities were found. There were no somatosensory disturbances of the lingual or mental/inferior alveolar nerves. One patient required a tracheostomy unrelated to the procedure., Conclusion: The CMW-PRS technique combined with arch bars and a fracture site bridle wire achieved equivalent historical results when compared with the dental splint. The potential advantages and disadvantages of the CMW-PRS technique compared with those of monocortical bone plating, as well as the significant advantages of the CMW-PRS over the dental splint, are discussed in the text.

Objective: To evaluate the safety and effectiveness of transcalvarial suture fixation during endoscopic repair of brow ptosis., Design: Case series., Settings: A private ambulatory surgicenter and a Veterans Affairs Hospital., Participants: Fifty patients with brow ptosis with minimum follow-up of 12 months., Results: Patients had improvement in brow position in all cases. There were no adverse effects of performing cortical tunnels and suture fixation., Conclusion: Transcalvarial suture fixation can be performed safely with good to excellent results and avoids the need for screw or plate fixation.

Our technique modifications include a systematic preauricular approach to the zygomatic arch and preservation of the temporal fat pad, which is left undisturbed. The preauricular extension permits greater access along the zygomatic arch, which may additionally reduce the risk of injury to the frontal branch of the facial nerve. Leaving the temporal fat pad undisturbed may help prevent a recently described late complication of temporal region depression that may be due to temporal fat atrophy from surgical trauma. By following the aforementioned steps, this technique can be performed efficiently and safely even if it is used infrequently.

Seventy paranasal sinus computed tomography scans of patients with cystic fibrosis were compared with those of age-matched control groups of randomly selected chronic sinusitis patients without cystic fibrosis to determine whether differences in disease patterns existed. In patients older than 10 years, frontal sinus agenesis and maxilloethmoid sinus opacification were significantly more prevalent in patients with cystic fibrosis than in chronic sinusitis patients without cystic fibrosis. Medial bulging of the lateral nasal wall was significantly greater in patients with cystic fibrosis than in chronic sinusitis patients without cystic fibrosis in patients older than 5 years. On the basis of these findings, a diagnostic triad of radiologic findings for cystic fibrosis detection is presented, as well as its clinical implications.

Allergic disease is very common in the U.S. population and even more common in children seen by otolaryngologists. Allergy causes or contributes to virtually all of the diseases in the respiratory tract that otolaryngologists, particularly otolaryngic allergists, evaluate and treat. The signs and symptoms of allergic disease in the pediatric patient are reviewed to improve the appreciation of the role of allergy in pediatric otolaryngology. Recent research developments, which are reviewed in detail in this article, underscore the importance of allergic, inflammatory response in rhinosinusitis. The key to long-term therapeutic success, particularly in pediatric rhinosinusitis, is management of the underlying allergic diathesis.

The enhanced understanding of the pathophysiology of cystic fibrosis (CF) has advanced significantly the management of this disorder, resulting in both an increased longevity and an improved quality of life. Sinonasal disease is an important aspect of CF. The goal of this article is to provide a current synopsis of CF sinonasal disease with an emphasis on disease symptomatology, physical signs, characteristic radiographic features, and outcome-based management options. When indicated, functional endoscopic sinus surgery has been shown to be a safe and effective treatment option for children with CF.

A technique for removing part of the inferior turbinate with a powered instrument is presented. This new technique is safe, quick, easy to teach, predictable and enables removal of the same amount of tissue and bone as is removed with other techniques of partial inferior turbinectomy.

Twenty-nine consecutive patients with cystic fibrosis were offered functional endoscopic sinus surgery. Twenty-six of these patients underwent surgery. A symptom questionnaire was obtained from the patient or parent before surgery. At the end of the study this symptom questionnaire was again administered to the same individual, and 21 completed it. There were 14 male and 7 female patients, with a mean age of 12.3 years and a median age of 8.7 years. Mean follow-up was 34.3 months. Results for the following symptoms were significant: nasal airway obstruction was improved (p < 0.0002), olfactory function was improved (p < 0.0037), purulent nasal discharge was decreased (p < 0.001), and activity level was increased (p < 0.001). Other parameters are also reported in the text. In summary, this study prospectively studies the effects of functional endoscopic sinus surgery on symptoms in patients with cystic fibrosis. The study points out several significant areas of symptom improvement and supports the selective use of functional endoscopic sinus surgery in patients with cystic fibrosis. Indications for surgery are provided.

Twenty asthma patients who underwent functional endoscopic sinus surgery for chronic sinusitis were studied. Medical records and questionnaire data for these 20 patients were studied regarding the impact of sinus disease and functional endoscopic sinus surgery on their asthma. We found that 95% reported that their asthma was worsened by their sinus disease (95% confidence interval, 0.74 to 0.99+), and 85% reported that functional endoscopic sinus surgery improved their asthma (0.60 to 0.97). Of the 13 patients who used both inhalers and systemic medication, 53.8% were able to eliminate some of their medication (0.21 to 0.79). Furthermore, 61.5% of these patients had a concomitant reduction in their inhaler use (0.28 to 0.85). All patients (six) who used only inhalers experienced a reduction in their inhaler use (0.54 to 1.00), and two patients were able to eliminate their inhalers completely. One of two patients who were steroid dependent was able to discontinue steroids after surgery. Of patients who used steroids intermittently (13), 53.8% were able to eliminate the use of steroids after surgery (0.21 to 0.79). Patients who required preoperative hospital admissions (4) and emergency room or urgent physician office visits (18) had a 75.0% and 81.3% (p < 0.001) reduction in visits, respectively, after surgery. Because 43% of the cost of asthma is the result of hospitalizations and emergency department/urgent physician office visits, a significant impact on health care costs can be realized with functional endoscopic sinus surgery in this patient population.

Eighteen patients were operated on by functional endoscopic sinus surgery who had no ostiomeatal unit obstruction on computed tomography scan and had unremarkable paranasal sinuses. These patients also had no apparent ostiomeatal unit obstruction on diagnostic nasal endoscopy. Data were collected on these patients regarding the impact of very limited functional endoscopic sinus surgery on their principal complaint of recurrent sinusitis with facial pain/headache thought to be of sinogenic origin. Sixteen patients (88.9%) had a reduction in the number of sinus infections requiring antibiotic therapy. This reduction was significant at p < 0.0001. Twelve of 14 patients whose facial pain/headache was believed to be of sinogenic origin had a significant reduction in severity (95% confidence interval, 49.2% to 95.3%). We discuss the role of reversible nasal mucosal disease in the pathophysiology of recurrent rhinosinusitis in this patient population. This was a very small, select group of patients who had specific complaints and had had medical treatment failures. This therapy is not recommended for every patient, but only a select few with classic complaints of sinus headaches or recurrent sinusitis and negative computed tomography scans.

A total of 283 consecutive patients with chronic sinusitis underwent functional endoscopic sinus surgery. There were 72 allergic patients and 211 nonallergic patients. Data were collected on the effect of immunotherapy on middle meatotomy patency, synechiae formation, and recurrent polyps in allergic patients. Data supported the following conclusions: (1) Immunotherapy given either before or after surgery does not statistically influence middle meatotomy patency, synechiae formation, or recurrence of polyps after functional endoscopic sinus surgery. However, the data do suggest, for all three outcome parameters, that allergic patients who undergo immunotherapy do better than those who do not undergo immunotherapy and, with the exception of recurrent polyps, do as well as nonallergic patients. (2) The prevalence of preoperative polyps is the same for allergic and nonallergic patients in this study, but polyp recurrence is higher in allergic patients. (3) Approximately 40% of allergic patients who began preoperative immunotherapy stopped immunotherapy after surgery because their allergic symptoms resolved or were minimal. A comment regarding this observation is provided.

Fifteen patients who underwent an anterior mandibular horizontal osteotomy (genioplasty) were retrospectively studied by neurosensory testing to evaluate light touch (LT) and temperature (T) discrimination. Testing was conducted using the two-alternative forced choice method. Density of a neurosensory disturbance (NSD), when it occurred, was also evaluated. A questionnaire was administered to determine if patients with a NSD perceived that their quality of life was adversely affected. The incidence of NSD was 3.4% (one of 30) to LT and 0% (none of 30) to T. The one abnormal mental nerve with a NSD to LT was moderately dense, but was not perceived by the patient as adversely affecting her quality of life.

A technique for using small plates in the management of midface fractures is presented. Principles of fracture management are similar to wire osteosynthesis. Anatomic rigid reduction allows more precise control and stabilization of the midfacial bone fragments, particularly the frontal process of the maxilla and the medial canthal region. In addition, rigid fixation aids in preventing inferomedial displacement of the zygomatic complex by the masseter muscle. The vertical dimension of the midface can be reestablished and stabilized by bone plate fixation without the need for suspension wires. Immediate opening of the mouth afforded by rigid fixation facilitates safe airway management, patient comfort, better oral hygiene, and speech and may circumvent the need for tracheostomy when concomitant nasal fractures are present.

Although rigid fixation of maxillary osteotomies has several advantages, it is technically more demanding than wire osteosynthesis. Unsatisfactory postsurgical results can be traced to any of three phases of surgical treatment: preoperative, interoperative, and postoperative. The authors review these three phases of treatment and present cases in which the desired outcome was not initially achieved. The subsequent management of the patients is discussed.

In order to assess the degree of similarity of the infraorbital nerve and inferior alveolar nerve, thirty subjects with no history of sensory injury were examined by a battery of neurosensory tests including: light touch, brush stroke direction, two-point discrimination, and thermal disk temperature assessment. In a matched sample experimental design, the sensibility of the inferior alveolar nerve (lower lip) was compared to the inferior orbital nerve (upper lip). The product moment correlations revealed a significant relationship (degree of sameness) between the upper and lower lip. The comparison of the upper and lower lip appear to be acceptable for retrospective tests for detection of neurosensory injury of the inferior alveolar nerve. Of these tests, light touch appears to be the most consistent while remaining sensitive to individual variation. The thermal disk assessment was least sensitive in that no individual variation could be demonstrated. In addition, there appear to be greater variations in men than in women.

This report describes a patient with a clinically normal airway who could not, even with the aid of a fiberoptic bronchoscope, be intubated nasotracheally. Failure was due to a large bony prominence projecting anteriorly into the nasopharynx from the body of the first cervical vertebrae. This bony prominence deflected both the endotracheal tube and fiberoptic tube anterolaterally such that they could not be aligned with the glottic opening for passage into the trachea. To our knowledge, this is the first reported case of "failure" of nasotracheal intubation associated with this anatomic abnormality.

This prospective study compares the nasal and maxillary vermillion morphology in three groups of patients who underwent maxillary osteotomies and whose soft tissues were managed by different surgical techniques. Eleven of these patients had simple primary closure (SPC) of the maxillary circumvestibular incision; ten were treated with single V-Y closure (SVY) combined with nasolabial muscle reconstruction, and the remaining 11 were treated with a double V-Y closure (DVY) combined with nasolabial muscle reconstruction. All three groups showed significant increases in the alar dome width. Further inspection of the data revealed that the DVY group showed significant, strong correlations between the preoperative and postoperative vertical vermillion measurements. Although the SVY and SPC techniques showed significant correlations for the same measurements, their correlation values were less. Small significant decreases averaging from 0.5 mm to 1.0 mm were seen in all but one of the vertical vermillion measurements with the DVY technique. Larger individual decreases and increases were seen with the SVY and SPC techniques. These findings suggest a level of predictability in the postoperative vermillion height change with the DVY closure that is not obtainable with the SVY or SPC techniques.

The following case report describes a patient who suffered an anterior maxillary alveolar ridge fracture resulting from difficult laryngoscopy and intubation. An unfortunate sequelae of this injury was the loss of two maxillary central incisors due to persistent mobility despite long term dental stabilization. To the authors' knowledge, fractures involving the premaxilla have not been reported as a complication of laryngoscopy and intubation.

Hemarthrosis of extremity joints in patients with hemophilia has been well documented. However, hemarthrosis of the temporomandibular joint in patients with coagulopathies appears to be rare. Consequently, management of a temporomandibular joint hemarthrosis is difficult because of the lack of treatment guidelines. The purpose of this article is to review the pathophysiology of hemophilic arthropathy and its management. A case of temporomandibular joint hemophilic arthropathy in a patient with a factor XI deficiency will be presented. A brief review of factor XI deficiency and a hypothetical pathophysiological mechanism for internal derangement induced by myofascial pain dysfunction are included.

Biomaterials from 11 consecutive patients with persistent infections refractory to antimicrobial therapy and local wound care were surgically removed and studied by scanning electron microscopy for the presence of bacterial-laden biofilms. Unlike previously reported biomaterial infections involving other regions of the body, infections in this study were not associated with a conspicuous bacterial-laden biofilm. Instead, adherent light bacterial colonization without a biofilm layer was noted. The only specimen that was suggestive of a bacterial-laden biofilm was in a patient who suffered from a chronic infection. Consistent with previous reports, bacterial colonization was frequently polymicrobial. Observations made in this study suggest that bacterial adherence may not require an obvious biofilm layer.

Fifty patients who had undergone Le Fort I maxillary osteotomies were studied. Cephalograms were available preoperatively and at least 6 months postoperatively. Soft-tissue analysis of the nasal profile was done employing three angles commonly used in the photometric analysis performed for rhinoplasty: nasal tip projection angle, columellar angle, and supratip break angle. Maxillary movement was assessed in two ways: 1) horizontal and vertical component vectors of A-point movement were calculated, and 2) maxillary rotation, defined as the change in the angle of a line drawn from the anterior nasal spine to the posterior nasal spine relative to the anterior cranial base, was calculated. The component vectors of A-point movement and maxillary rotation were then used as predictor variables for change in the soft-tissue angles in a multiple-regression analysis. A weak correlation was found between A-point movement in both the horizontal and vertical dimensions and the nasal tip projection angle. When A-point was moved in an anterior and superior direction, the nasal tip rotated up. The converse was true with movement in the posterior and inferior direction. Only A-point movement in the horizontal dimension had a significant relationship with columellar angle. When A-point was moved in an anterior direction, columellar angle increased. This study shows that prediction of the soft-tissue profile of the nose following maxillary surgery is difficult.

While wire osteosynthesis has been the accepted modality to use with open reduction of mandibular fractures, several authors have suggested the use of more rigid techniques to achieve the same result while also eliminating adverse effects associated with prolonged maxillomandibular fixation. Few studies have directly compared the two techniques in a prospective manner. The purpose of this paper was to evaluate complications seen with wire osteosynthesis versus a small bone plating system in management of mandibular fractures. The results suggest that small bone plating systems similar to the one used in this study may serve as a suitable alternative to wire osteosynthesis for the management of mandibular parasymphysis, body, and angle fractures. The length of the procedure, the length of hospital stay, and patient comfort were comparable with the two techniques. Factors that may contribute to failure are: location of the fracture, poor patient compliance, length of time from the trauma to the repair, antibiotic choice, and most importantly, operator skill and experience.

Masticatory muscle hyperactivity appears to have an important role in temporomandibular disorders. A pathophysiological model for masticatory muscle hyperactivity is proposed that is centrally mediated, yet maintains support for present peripheral causes and therapies. In this hypothesis, masticatory muscle hyperactivity represents a mild extrapyramidal disorder distantly related to orofacial dyskinesias. Experimental evidence suggests a neurotransmitter imbalance in the basal ganglia, involving dopaminergic preponderance, or cholinergic and GABA-nergic hypofunction as the underlying cause.

A technique has been presented for transcutaneous management of angle fractures with employment of two plates: one at the tension band, the second at the compression zone of the mandible. Our preliminary experience with this procedure has been favorable. When a comparison is made of an intraoral approach to an extraoral one, there are three advantages. First, the cutaneous scar is minimal when compared with a transcutaneous one. Second, visualization of the occlusion is maintained throughout the procedure. Third, injury to branches of the facial nerve and other anatomic structures is reduced.

Open reduction of subcondylar fractures achieves precise anatomic alignment of bony fragments and may prevent the postoperative sequelae seen with some closed reductions. Using an extraoral approach, a fracture can be easily seen and manipulated. An intraoral approach avoids large facial scars, facial nerve injury, and allows visualization of the occlusion during the procedure. Cases for this technique should be carefully selected.

Unfavorable fractures of the proximal fragment during the sagittal ramus split procedure, although uncommon, occur with an incidence ranging between 3% and 6.6%. One anatomic feature that may predispose to an unfavorable fracture is a thin mandibular ramus in the region of the medial osteotomy. One particular situation that can increase the risk of an unfavorable fracture is a lingula that is situated very high on the mandibular ramus. Even in a normal-sized mandibular ramus, a high lingula places the medial cut in a thin region where there is little or no cancellous bone. The technique presented is a modification of the sagittal split osteotomy which can assist the surgeon in preventing an unfavorable fracture should an unusually high lingula or a thin ramus be encountered.

Twenty-one patients who underwent bilateral sagittal split osteotomies using rigid fixation were evaluated by neurosensory testing. Neurosensory tests included light touch (LT), brush stroke direction (BSD), two-point discrimination (2-P), and temperature (T). Tests were conducted using the two-alternate forced choice method. The density of neurosensory disturbance was examined as well as the incidence of neurosensory disturbance as it correlated with age of the patient. The incidence of neurosensory disturbance was 45.2% (19/42) to LT, 52.4% (22/42) to BSD, 33.3% (14/42) to 2-P and 7.1% (3/42) to T. The majority of demonstrable neurosensory disturbances were not dense. Increased age was associated with an increased incidence of neurosensory disturbance.

Gingival biopsy specimens from five patients with a clinical diagnosis of thrombotic thrombocytopenic purpura (TTP) were reviewed. All biopsy specimens demonstrated the characteristic histologic lesion associated with TTP. Review of the literature showed an average diagnostic yield of 37% (30/81) for this procedure. The increase in diagnostic correlation in this study may be explained in part by the marked degree of disease expression in the patients who underwent gingival biopsy. Three of the five patients who underwent gingival biopsies ultimately died of their disease. In addition, a persistent search through multiple serial sections for the characteristic lesion, beyond the usual three levels, was performed. Despite the disparity in diagnostic yield, we consider the gingival biopsy to be a safe diagnostic correlate of TTP because of easy access, rich vascularity, and low surgical morbidity. Furthermore, we recommend biopsy, as Goodman and colleagues have, only in areas of the gingiva that appear clinically normal and free of inflammation in order to reduce misinterpretation as a consequence of false-positive intraluminal fibrin thrombi that may occur with inflammation.