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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

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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

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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

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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.

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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

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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

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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)

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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

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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

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

ITaugmentspeartechnique

Coronal CT showing healed lateral wall expansion site

ENSgrafted

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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

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EndonasalSeptal

PerforationRepair

StevenMHouser,MD,FAAOAMetroHealthMedicalCenterAssocProfOtoCWRUCoM

Outline

Septalanatomy Perforations Surgicalapproaches Endonasalflapwithacellulardermalgraft

Septalanatomy

cartilage bone:vomer,perpendicularplateofethmoid maxillarycrest anteriornasalspine

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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

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SeptalPerforation

Perforationmanagementoption?

Mostperforationrepairsinvolveslidingmucosa

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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

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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

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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!

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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