The Physiologic Treatment of Nasal Obstruction

Safety of Steroid Injections in the Treatment of Nasofrontal Recess Obstruction

A retrospective review was undertaken to determine if steroid injection is a safe and effective intervention in the management of chronic nasofrontal recess obstruction. Seventy-four patients were identified who had undergone prior endoscopic sinus surgery and subsequently developed nasofrontal recess obstruction that was treated with injection of Kenalog 20 mg/mL (Bristol-Myers Squibb Co., Princeton, NJ) directly into the polyps or fibrosis. The study included 38 men and 36 women with a mean age of 45.4 years. These patients collectively underwent 687 injections, an average of 9.3 injections per patient. The indication was polyposis in 70 patients and fibrosis in 17 patients, with 13 sharing both indications. These patients also required 112 office procedures to maintain nasofrontal recess patency, an average of 1.5 procedures per patient. Three patients eventually required frontal sinus obliteration. The mean follow-up period from the initial injection was 50.1 months, and no complications were reported. Therefore, nasofrontal steroid injection appears to be safe and effective in the treatment of nasofrontal recess obstruction.

The effects of systemic, topical, and intralesional steroid treatments on apoptosis level of nasal polyps

OBJECTIVE

The purpose of this study was to compare the apoptotic responses to systemic, topical, and intrapolyp injection of glucocorticoid with no treatment in nasal polyps.

STUDY DESIGN

Prospective, randomized controlled study.

SETTING

Tertiary training hospital.

SUBJECTS AND METHODS

The study was performed on 48 patients with nasal polyposis in the Department of Otorhinolaryngology between 2008 and 2009. Patients were assigned to 1 of 4 groups of 12 patients. Group A was treated with oral methylprednisolone 1 mg/kg/d, and the dose was tapered gradually. Group B received 0.3 mL triamcinolone acetonide (40 mg/mL), which was injected into polyp tissue. Group C was treated with topical 55 µg triamcinolone acetonide 2 times daily for 1 month. Group D received no medication. Samples were collected endoscopically after the seventh day for groups A and B, the first month for group C, and the first visit for group D. Apoptotic indexes were determined using the terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling method.

RESULTS

Statistically significant differences in apoptotic index were found between each steroid-medicated group and the control group (P (D-A) = .0001; P (D-B) = .003; P (D-C) = .026) and between groups A and C (P (A-C) = .012). Group B did not differ significantly from either group A or C (P (A-B) = .11; P (B-C) = .75).

CONCLUSIONS

The apoptotic index in nasal polyps treated with systemic, topical, and intrapolyp injection forms of glucocorticoids was higher than that in the control group. Systemic steroid treatment induced the most apoptosis.

Endoscopic neural blockade for rhinogenic headache and facial pain: 2011 update

BACKGROUND

Over 45 million Americans suffer from recurrent headaches, and an estimated $11.9 million was spent on doctor's visits for rhinogenic pain last year. Sphenopalatine blocks have been described for various facial pain syndromes, but their use and the type of blockade agents remain controversial. The objective of this study was to demonstrate that endoscopic nerve blocks, using a mixture of bupivicaine and triamcinolone-40, injected into the anterior ethmoid or sphenopalatine regions, can be a relative safe and effective option for refractory pain.

METHODS

The charts of all patients undergoing endoscopic neural blockade, in a private practice setting from 1998 to 2008 were retrospectively reviewed. A 1:1 mixture of 0.5% bupivicaine and triamcinolone acetonide injectable suspension was injected into the patients' anterior ethmoid or sphenopalatine neural distribution, or both, depending on the pain distribution. Charts were reviewed to assess outcomes and any adverse events from nerve blocks.

RESULTS

A total of 882 nerve blocks were administered to 147 patients, over the course of 431 office visits. Four mild complications, 2 moderate complications, and no severe or permanent complications were noted. No permanent visual complications were observed. Of all the charts, 85% had documented effects of the nerve block at follow-up. Of those, 81.3% claimed improvement, 17.9% reported feeling the same, and 0.79% stated they had worse pain.

CONCLUSION

Endoscopic neural blockade appears to be a relatively safe and viable option in the treatment of refractory headache and facial pain with a rhinogenic component.

The role of local steroid injection for nasal polyposis

Sinonasal polyps affect a small but significant percentage of patients with chronic sinusitis. Treatments vary and range from oral and topical medical treatments to surgical removal. Corticosteroids typically have been regarded as the gold standard medical treatment for sinonasal polyps. Delivery of steroids is traditionally via oral or topical means. Over the years, otolaryngologists have also found that intrapolyp injection of corticosteroids is an effective means to treat some patients with sinonasal polyps. This article reviews the prevalence, pathophysiology, and medical treatment options for sinonasal polyps. Focused attention is paid to treatment with steroid injections, including a review of its associated risks and benefits.

Steroid injection for sinonasal polyps: the University of Virginia experience

BACKGROUND

Sinonasal polyps are treated with topical steroids, systemic oral steroids, surgical excision, and intrapolyp steroid injection. Use of steroid injection is not widespread because of reported complications. The objective of this study was to evaluate the complications of intrapolyp steroid injections and compare it to the complications of surgical removal of polyps.

METHODS

All patients seen between 1994 and 2003 with a diagnosis of nasal polyps were reviewed retrospectively. Demographics, complications, follow-up, and comorbidities were collected. Frequency of each treatment modality used and complications of each treatment were compared.

RESULTS

Three hundred fifty-eight patients were in the study with a mean follow-up of 30 months. Respiratory comorbidities were asthma alone (35%), aspirin triad (16%), and cystic fibrosis (15%). Other comorbidities were smokers (21%). Treatment modalities were medical treatment alone (14%); medical treatment and steroid injections (19%); medical treatment and surgery (33%); and medical treatment, injections, and surgery (34%). Patients who underwent injection had fewer surgeries (p < 0.001). There was 1 minor complication associated with 1495 injections and 11 major and 16 minor complications associated with the 310 surgeries. The differences in complication rates were statistically significant (p < 0.001). There was no significant difference in demographics, follow-up, or comorbidities between patients who received injections and patients who underwent surgery.

CONCLUSION

Intrapolyp steroid injection is associated with a significantly lower rate of complication than is surgical excision of sinonasal polyps. Steroid injection also may decrease the need for further surgical intervention of polyps.

Rhinoplasty with advancing age

Rhinoplasty in the aging patient poses a unique set of challenges to the plastic surgeon. Aging patients usually have different expectations and motivations than their younger counterparts; therefore, open communication and frank discussions are paramount to define realistic goals. Anatomically, changes in skin quality, cartilage characteristics, underlying bony framework, and the nasal airways mandate special considerations to optimize the functional and aesthetic results. This review will present a practical approach to the management of the nose in the aging patient.

Augmentation rhinoplasty with a combination of triple cartilage grafts for secondary rhinoplasty in a middle-aged population

Because of physiologic changes with advancing age as well as previously traumatized and then healed tissues, secondary rhinoplasty for a middle-aged patient is a challenging procedure. Depending on both factors, changes in the midvault can cause a functional airway disorder, and the nose also may need a complete correction for cosmetic purposes. To achieve aesthetic and functional outcomes, augmentation rhinoplasty using a combination of triple cartilage grafts, namely, spreader, columellar, and dorsal onlays, was performed for 12 patients. Sufficient nasal airways with satisfactory appearance were achieved for 11 of 12 patients. Only one patient had improved but still insufficient nasal function with a good aesthetic result. Augmentation rhinoplasty using a combination of triple cartilage grafts for middle-aged patients could be considered an effective procedure for improving the patient's nasal airway and appearance.

Rationale for submucous resection of hypertrophied inferior turbinates in rhinoplasty: an evolution

To achieve success in rhinoplasty, the plastic surgeon takes advantage of numerous intraoperative techniques designed to manipulate nasal soft tissue and the osseocartilaginous framework. Although the postoperative result may meet preoperative aesthetic goals, an element of nasal airway obstruction can persist from failure to acknowledge the role of inferior turbinates. Surgically responsive inferior turbinate hypertrophy is frequently not addressed secondary to inadequate history taking, incomplete physical examination, and/or surgeon reluctance to handle these sensitive structures. The goal of this article is to discuss the anatomy and physiology of the inferior turbinates, to present the role for inferior turbinate surgery during rhinoplasty, and to delineate the evolution of the current technique of submucosal resection of the inferior turbinates. Over the past 14 years, the senior author (R.J.R.) has performed inferior turbinates surgery on 648 patients as part of a rhinoplasty.

[Treatment of the hypertrophic inferior turbinate. 1]

Chronic nasal obstruction is a common disorder, mostly caused by hypertrophied inferior turbinates. If there is inadequate response to conservative medical management, the inferior turbinates should be reduced. The choice of treatment is mainly influenced by whether the nasal airway obstruction is due to hypertrophic mucosa or to an enlarged turbinate bone. The first part of this review describes the various surgical modalities for treatment of swelling of the turbinal mucosa. The indications, advantages, disadvantages, complications, and controversies of each modality (submucous diathermy, cryosurgery, infra-red coagulation, argon-plasma coagulation, radiofrequency, laser surgical techniques) are reviewed and discussed.

Rhinoplasty with advancing age: characteristics and management

Rhinoplasty in the aging nose is a distinctly different entity whose unique characteristics must be appreciated by the rhinoplasty surgeon to optimize the functional and aesthetic results. Although the aesthetic and functional goals are similar to those in younger patients, the operative techniques necessary to achieve these goals in older patients differ. This article reviews the changes that occur in progressive aging of the nose and discusses the unique aspects in the management of the aging nose.

Management of blindness in the practice of cosmetic surgery

Blindness (amaurosis) as a complication of cosmetic surgery is not common, but has been reported in cases of blepharoplasty, as well as in connection with facial injection of various substances, including collagen. The anatomic and pathophysiologic basis for embolization of the retinal artery is presented, and the literature regarding thromboembolic, spasmodic, and vaso-obliterative etiologic factors in amaurosis is reviewed. It is recommended that ocular examination be carried out prior to both injection of materials into the face and blepharoplasty. The treatment of this most serious complication is reviewed in detail. Finally, it is suggested that the surgeons who practice cosmetic surgery be aware of this complication and the current treatment modalities.

CO2 laser turbinectomies for chronic, obstructive rhinitis

A CO2 laser approach to partial inferior nasal turbinectomies for patients with severe, obstructive, chronic, perennial rhinitis that is refractory to nonsurgical therapeutic regimens is presented. CO2 laser vaporization of the anterior one fourth to one half of the inferior turbinate was done under topical and local anesthesia, as an office outpatient procedure. It does not require nasal packing. It allows the patient to return to his daily routine upon completion of the procedure. Along with these advantages, bleeding risks are decreased compared to conventional nasal turbinectomy techniques.

Nasal obstruction after rhinoplasty

Nasal obstruction is a frustrating sequel of rhinoplasty to both the patient and the surgeon. Physiologic problems are caused by altered vasomotor mechanisms of the lining. Mechanical obstruction results from (1) over-correction of the nasal supporting structures, (2) infracture of long nasal bones, (3) septal irregularities, and (4) surgical adhesions.Simple and effective techniques for correcting each of these problems are described.

Nasal surgery and airway resistance

This study investigates the effects of surgery and bronchodilation on nasal and pulmonary resistance. The plethysmograph is evaluated as a clinical tool for nasal flow studies. The method of adapting the plethysmograph to measure nasal resistance is presented. Discriminant Function Analysis considers the effects of surgery and bronchodilatation on 15 variables. The statistical analysis of 38 cases demonstrates the benefits of improved nasal airway for pulmonary airway resistance. A review of the literature points out many of the difficulties in measuring nasal airflow. The plethysmograph emerges as an available easily adapted clinical tool that overcomes many of the short-comings in earlier techniques and in rhinomanometry. The rhinologist is offered further insight into the nasopulmonary relationship and the use of the plethysmograph to document the effects of nasal surgery.