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Transcript of 35 - Empty Nose Syndrome - Steven - entpa.org - Empty Nose Syndrome - H · PDF...

  • 3/19/2014

    1

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    Creativeusesforacellular dermis

    StevenM.Houser,MD,FAAOAMetroHealth MedicalCenter

    CWRUCoM

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    Disclosure

    none

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    LearningObjectives

    Explainwhatis,andwhatisnot,ENS DescribemanagementofENS Discussseptalperforationwithrepair

  • 3/19/2014

    2

    EmptyNoseSyndrome:Diagnosisandtreatment

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    Postnasalsurgeryissues

    Rhinitissicca Drynessdirectlycorrelatestovolumeoftissueabsent,andmeds,andotherdiseases

    Chronicpainsyndrome Implantsofnohelp

    Persistentsensationofmucus Implantsofnohelp

    Emptynosesyndrome Breathingdysfunctionafternasal(turbinate)surgery

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    Etiology

    Nasalsurgerytypicallyinvolvingresectionofturbinates orsometurbinatesurgerythatdamagesthemucosalsurface,e.g.,laserreduction

    Inferiorturbinatesmostcommonlyinvolved BothIT&MTofteninvolved Middleturbinatesaloneoccasionallyinvolved

  • 3/19/2014

    3

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    SensationtoAirflow

    Airflowsensationpoorlyunderstood Nasalvestibulemostsensitivearea ITnextmostsensitive,andsensationdecreasesasmovehigherinthenose

    ClarkeClinOtolaryngol1992;17:3837 WrobelAmJOtol2006;20:3648

    Receptionlocalizedtothemucosalsurface ENSisalossofsensationtoairflow

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    ENSphysiology

    Mucosaatsurgicalsitemaylosesensitivitytoairflow Poorsensorynerveregrowthaftersurgery Zb:persistentnumbnessatinguinalherniorrhaphysite:26.4%

    MikkelsenAnesthAnalg.2004;99(1):146151.

    Airfloweasilydivertstowardemptyspace Normalmucosahasbeenrobbedofairflow

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    Definition

    Paradoxicalnasalobstruction Widelypatentnasalairway Patientcomplainsofapoornasalairway

    blocked,empty,hollow

    Drymucosa/crustingwiththickmucus Poorsmell Poorvoice Respiratorydysfunction

  • 3/19/2014

    4

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    Definition

    WhatisnotENS PainisvariablebutoftenspeaksagainstENS Iatrogenicatrophicrhinitisorsecondaryatrophicrhinitis

    Tissueismissing,notatrophic;noodiferouscrusts DelayedENSoccurs suggestsatrophyorsomedelayednerveinjurypossible

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    WhatENSis

    Airfloweasilydivertstowardemptyspace Mucosasurroundingtheemptyspaceappearstohavelostsomesensitivitytoairflow

    Normalmucosahasbeenrobbedofairflow Conflictingmessagestobrain

    NosesaysImsuffocating Lungs/diaphragmsaysbreathingfine

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    HowcommonisENS?

    22.2%incidenceofatrophy(likelyENS)followingtotalinferiorturbinectomy PassliD,LaurielloM,AnselmiM,BellussiL.Treatmentoftheinferior

    turbinate:longtermresultsin382patientsrandomlyassignedtotherapy.AnnOtolRhinolLaryngol.1999;108(6):569575.

    8%ofpartialturbinectomypatientsdevelopedadrynose CourtissEH,GoldwynRM.Resectionofobstructinginferiornasal

    turbinates:a10yearfollowup.PlastReconstrSurg.1990;86(1):152154.

  • 3/19/2014

    5

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    Definition ENSIT

    Inferiorturbinatesignificantlyresected ENSMT

    Middleturbinatesignificantlyresected ENSboth

    BothIT&MTsignificantlyresected ENStypesymptoms

    Appeartohaveadequatetissue,butsymptomsandcottontestsuggestENSispresent

    ENSIT

    right

    left

  • 3/19/2014

    6

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    ENSMT

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    ENSboth

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    ENStype

  • 3/19/2014

    7

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    Diagnosis

    Historyofsurgicalinterventionwithturbinateresection/surgery

    Appropriatesymptoms Suffocation,possiblecrusts

    ImprovementwithCottontest Cottonplacedintoareaofdeficittoobstructairflowleadstoasubjectiveimprovement innasalpatency

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    CottonTest

    RequiresthatNOanestheticagentbeapplied

    Takestimeforpatienttoassessbenefit

    Movecottonintodifferentlocations

    Altersizeofcotton Recordfindingsassurgical

    plan

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    Planning

    ReviewCT&nasalendoscopytoidentifydefect Cottonplacedatselectedarea(s)tosimulategraft

    Airshiftedawayfromemptyarea,towardunoperatedarea Assesspatientssubjectivesensationofnasalbreathing Alternatively,siteinfiltratedwithsalinetoswellthesite(e.g.,ITinjection)

  • 3/19/2014

    8

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    SurgicalRepairTechnique

    ImplantsolidAllodermintolocationidentifiedpercottontest

    Septum Craftallodermintoappropriateshapewithchromicsuture

    Lateralwall Injectablestoexistingturbinate

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    ENSsurgicaltechniques

    Septalimplantation Originaltechniqueusedd/tfearofnasolacrimalobstructionatside

    StillusedforENSMT(12x4cmthick) Likely100%postseptoplastyrevision Cancraftacellulardermisintodesiredshapewithchromicsutures

    Anchorgrafttomucosaforpositioning Onesideatatimeifcartilagepresent

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    SeptalImplantation

  • 3/19/2014

    9

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    LateralWallImplant

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    Rightlateralwallelevation

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    Rightlateralwallfilled

  • 3/19/2014

    10

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    ITaugmentspeartechnique

    Coronal CT showing healed lateral wall expansion site

    ENSgrafted

  • 3/19/2014

    11

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    ENSimplantation:myvolume

    81casesperformedon57differentpatients Rangingfrom1to5caseperpatient Performedfrom2003to2013 ENSIT33,both12,type9,MT3

    Locations(maybe>1location/case) Septum:40 Lateralwall:44 Inferiorturbinate(spear):18

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    Shouldturbinatesbereduced?

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    Conclusion

    ENSisoftenaseverlydebilitatingprocess Poorlyunderstood Notaccepted/believedbyallENTs Thesepatientscanbemademorecomfortableandtheytendtobeverygrateful

  • 3/19/2014

    12

    EndonasalSeptal

    PerforationRepair

    StevenMHouser,MD,FAAOAMetroHealthMedicalCenterAssocProfOtoCWRUCoM

    Outline

    Septalanatomy Perforations Surgicalapproaches Endonasalflapwithacellulardermalgraft

    Septalanatomy

    cartilage bone:vomer,perpendicularplateofethmoid maxillarycrest anteriornasalspine

  • 3/19/2014

    13

    Septalbloodsupply

    convergenceofbloodsupplyonant.Septum 90%epistaxis KisselbachsplexusatLittlesarea contributors:

    ant.ethmoidal post.septal(terminalbranchofsphenopalatine) greaterpalatine superiorlabial

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    Septalperforationorigin Digitaltrauma(picking) Nasalsprays Cocaine Surgery(septoplasty) Septalcauteryforepistaxis Autoimmunedisease

  • 3/19/2014

    14

    SeptalPerforation

    Perforationmanagementoption?

    Mostperforationrepairsinvolveslidingmucosa

  • 3/19/2014

    15

    Septal rotation flap possible from either side

    Cut back of perf 1800

    Raise septal flap and encouter anterior edge of perf inside

    Routine septoplasty flap on left

    Rotation flap on right septum

  • 3/19/2014

    16

    Inside septum after flap suturing

    Donor site on right

    Acellular dermis visible per hole in left septum

    Splints in place for 3 weeks

    Tissue grows into acellular

    dermis

    3 weeks post

    2 months post

    What is the largest perf that can be repaired?

    Likely 2.5cm if donor tissue present

  • 3/19/2014

    17

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    Septalperforationrepairresults

    20patientstreated 17successfulclosures(85%overall)

    89%small2cm(1patient)

    Int Forum Allergy Rhinol. 2012 Sep-Oct;2(5):392-6.

    Acellular dermis removed 6 months after implantation

    Thanks for listening!

  • 3/19/2014

    18

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    InternationalForumofAllergy&Rhinology LaunchedbyARSandAAOA

    ImpactFactorof1.00 IndexedinMEDLINE NowMonthly!

    Free colorforauthors

    Fast publicationonlineaheadofprint

    Rapid EditorialdecisionsonsubmissionsIn4th YearofPublication

    Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

    EditorinChief:DavidW.Kennedy,MD

    AssociateEditors:BerrylinFerguson(U