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1.  Preventing and treating discitis: cephazolin penetration in ovine lumbar intervertebral disc 
European Spine Journal  2006;15(9):1397-1403.
Infection can occur after any spinal procedure that violates the disc and although it is not common, the potential consequences are serious. Treatment of discitis is not always successful and the key to management is prevention. Intradiscal prophylaxis with antibiotic is routinely used in spinal surgery, but there is a limited understanding of how well antibiotics can enter the avascular disc after intravenous injection. An in vivo ovine study to optimise prophylactic and parenteral treatment of discitis is described to assess the effectiveness of cephazolin in preventing and treating infection. The concentration of cephazolin was measured in disc tissue from normal and degenerate sheep discs to determine if cephazolin can enter the disc and if disc degeneration affects antibiotic uptake. Fourteen sheep were deliberately inoculated with bacteria to induce discitis. Eight sheep (“prophylaxis” group) were given either a 0, 1, 2 or 3 g dose of prophylactic cephazolin before inoculation while the remaining sheep (“treatment” group) were treated with cephazolin commencing 7 days after inoculation for 21 days at a dose of 50 mg/kg/day. Histopathology and radiography were used to assess the effect of the different treatments. Cephazolin was given 30 min prior to sacrifice and the intradiscal concentration was measured by biochemistry. In the “prophylaxis” group all doses of antibiotic provided some protection against infection, although it was not dose dependent. In the “treatment” group discitis was confirmed radiologically and histologically in all animals from 2 weeks onwards. Biochemical assay confirmed that antibiotic is distributed throughout the disc but was present in higher concentration in the anulus fibrosus than the nucleus pulposus. This study demonstrated that whilst the incidence of iatrogenic discitis can be reduced by antibiotic prophylaxis, it could not be abolished in all incidences with a broad-spectrum antibiotic such as cephazolin. Furthermore, antibiotics were ineffective at preventing endplate destruction once an intradiscal inoculum was established.
PMCID: PMC2438566  PMID: 16830132
Cephazolin; Discitis; Prophylaxis; Treatment; Intervertebral disc
2.  Does Cosmetic Rhinoplasty Affect Nose Function? 
ISRN Otolaryngology  2011;2011:615047.
Objective. To evaluate the changes in nasal dimensions of healthy Iranian volunteered for cosmetic rhinoplasty after surgery using acoustic rhinometry. Methods. Pre- and postoperative nasal dimension of 36 cases undergoing cosmetic rhinoplasty were compared using acoustic rhinometry (AR), and the measured variables were distance to first and second constriction (d1, d2), first and second minimal cross-sectional area (MCA1, 2), and volume. Results. Mean age (SD) of cases were 24.63 (4.4) years. Septoplasty was performed in 12 cases (33.3%). After surgery, bilateral d1 and both MCA2 decreased significantly, while significant increase was observed in MCA1 postoperatively using decongestant. Cases with septoplasty experienced more increase in MCA1 and less constriction in MCA2 postoperatively. In cases with rhinoplasty alone, they received benefit from double osteotomy in MCA1. In either group of rhinoplasty with and without septoplasty, placing a strut was beneficial for patients. Discussion. The cross-sectional area of the nose is a major factor in the determination of airflow. Cosmetic rhinoplasty may generate a mix effect on nose function. Performing osteotomy may better help patients to save nasal patency, septoplasty is beneficial even in mildly deviated septums, and placing a strut may be beneficial in most of the cases.
PMCID: PMC3658547  PMID: 23724256
3.  Are Cross-hatching Incisions Mandatory for Correction of Cartilaginous Septal Deviation? 
Cross-hatching incisions have been considered mandatory for correcting cartilaginous septal deviation. We evaluated the clinical outcome of septoplasty without cross-hatching incisions to determine the necessity for making septal cartilage incisions.
The reconstructed septal components during septoplasty were categorized into four anatomical areas: vomer, maxillary crest, perpendicular plate of ethmoid (PPE) and septal cartilage (the area for cross-hatching incisions). During septoplasty, we attempted to complete the surgery only by removing or fracturing the bony part of the septum without cross-hatching incisions on the cartilage. Only in the cases that the deviation was not immediately corrected, the cross-hatching incisions were made onto the cartilage at the end of the procedure. We analyzed the frequency of manipulating the septal components. The changes of symptoms were evaluated using a modified nasal obstruction symptom evaluation (NOSE) scale and a visual analog scale (VAS) preoperatively, 1 and 3 months after the surgery.
Seventy five percents of the deviated septums were immediately corrected only by removing or fracturing of the bony septal components. In decreasing order of frequency, the sepal components for correcting septal deviation were the vomer (59%), maxillary crest (49%), septal cartilage (cross-hatching only: 25%) and PPE (15%). The modified NOSE scale and the VAS demonstrated significant improvement of the nasal symptoms postoperatively (P<0.05).
Most of septal deviations could be corrected by manipulating only the bony septum. The results of this procedure were not different from conventional septoplasty with cross-hatching incisions. Our data suggest cross-hatching incisions during septoplasty might have been overemphasized and that the main cause for cartilaginous deviation may be the extrinsic forces that are generated by the neighboring bony structures.
PMCID: PMC2671754  PMID: 19434257
Nasal septum; Cartilage; Surgery
4.  Retrospective analysis of 697 septoplasty surgery cases: packing versus trans-septal suturing method 
The trans-septal suturing method has been developed in septoplasty as an alternative to packing. This study was carried out to compare the postoperative results of trans-septal suturing with the anterior Merocel packing technique. The study involved 697 patients who underwent septoplasty. Following surgery, patients were randomly divided into two groups, one with trans-septal suturing and the other with Merocel packing. Patients were asked to record pain levels using a visual analogue scale. Postoperative symptoms and complications were compared. A total of 697 nasal operations were evaluated in the postoperative period considering pain, bleeding, haematoma, septal perforation synechiae and septal perforation. The results for haemorrhage, haematoma, synechiae and perforation were not statistically different (p > 0.05) between groups. In contrast, the level of postoperative pain in patients undergoing trans-septal suturing was significantly less than in the group who received Merocel packing (p < 0.05). Patients with Merocel packing had significantly more pain and nasal discomfort when assessed 1 week after intervention. Therefore, the trans-septal suturing technique may be the preferred option to provide higher patient satisfaction.
PMCID: PMC3383079  PMID: 22767972
Septoplasty; Trans-septal suturing; Nasal packing
5.  Reproductive outcome after hysteroscopic septoplasty in patients with septate uterus - a retrospective cohort study and systematic review of the literature 
Septate uterus, one of the most common forms of congenital uterine malformations, negatively affects female reproductive health.
In a retrospective cohort study, we evaluated the reproductive outcome after hysteroscopic septoplasty in 64 women with septate uterus and primary or secondary infertility. We performed a systematic review of studies evaluating the reproductive outcome after hysteroscopic septoplasty.
Sixty-four women underwent hysteroscopic septoplasty. In 2/64 (3%) women, intraoperative uterine perforation occurred. Complete follow-up was available for 49/64 (76%) patients. Mean follow-up time was 68.6 +/- 5.2 months. The overall pregnancy rate after hysteroscopic septoplasty was 69% (34/49). The overall life birth rate (LBR) was 49% (24/49). The mean time interval between surgery and the first life birth was 35.8 +/- 22.5 months. Including our own data, we identified 18 studies investigating the effect of septoplasty on reproductive outcome in 1501 women. A pooled analysis demonstrated that hysteroscopic septoplasty resulted in an overall pregnancy rate of 60% (892/1501) and a LBR of 45% (686/1501). The overall rate of intra- and postoperative complications was 1.7% (23/1324) and the overall rate of re-hysteroscopy was 6% (79/1324).
In women with septate uterus and a history of infertility, hysteroscopic septoplasty is a safe and effective procedure resulting in a pregnancy rate of 60% and a LBR of 45%.
PMCID: PMC2885403  PMID: 20492650
6.  The Efficacy of Bioabsorbable Mesh as an Internal Splint in Primary Septoplasty 
Archives of Plastic Surgery  2012;39(5):561-564.
Nasal bone fractures are often accompanied by septal fractures or deformity. Posttraumatic nasal deformity is usually caused by septal fractures. Submucosal resection and septoplasty are commonly used surgical techniques for the correction of septal deviation. However, septal perforation or saddle nose deformity is a known complication of submucosal resection. Hence, we chose to perform septoplasty, which is a less invasive procedure, as the primary treatment for nasal bone fractures accompanied by septal fractures. During septoplasty, we used a bioabsorbable mesh as an internal splint. We used the endonasal approach and inserted the mesh bilaterally between the mucoperichondrial flap and the septal cartilage. The treatment outcomes were evaluated by computed tomography (CT) and the nasal obstruction symptom evaluation (NOSE) scale. The CT scans demonstrated a significant improvement in the septal deviation postoperatively. The symptomatic improvement rated by the NOSE scale was greater at 1 month and 6 months after surgery compared to the preoperative status. There were no cases of extrusion or infection of the implant. In cases of moderate or severe septal deviation without dislocation from the vomerine groove on the CT scan, our technique should be considered one of the treatments of choice.
PMCID: PMC3474417  PMID: 23094256
Nasal septum; Nasal bone; Bioabsorbable implants
7.  Lateralized olfactory difference in patients with a nasal septal deviation before and after septoplasty* 
Hippokratia  2012;16(2):166-169.
Background: Patients with a smell disorder and less often, healthy people, exhibit an olfactory difference between the two sides of the nose. Higher olfactory thresholds are correlated with the obstructed side of a nasal septal deviation (NSD). With this prospective study we sought to investigate if a NSD compromises the olfactory identification.
Materials and methods: Thirty patients with nasal obstruction due to a NSD were recruited. The patients were listed for primary septoplasty with or without radiofrequency reduction of the inferior turbinates. Pre- and postoperatively, patients were assessed by visual analogue scales for symptoms and by the bilateral nasal spirometry (nasal partitioning ratio-NPR) for the side/degree of obstruction. Olfactory identification was tested separately for each nasal cavity by means of the 12 item Sniffin Sticks test (12-SS test) and a 3-point difference between the nasal sides was considered significant.
Results: The mean age of patients (25 males/5 females) was 33 years (range 17-52). No complications or anosmia were reported postoperatively. Subjective hyposmia, nasal obstruction and the NPR were reduced (p<0.001). Significant lateralized differences were present in 20% and 13% of patients before and after septoplasty respectively; the change was not significant (p=0.754). Patients with a significant lateralized olfactory difference had a greater NPR pre- (p=0.031) but not postoperatively (p=0.783). The sides of obstruction and worst olfactory performance did not differ in these patients before surgery.
Conclusions: Olfactory identification may be compromised on the convex side of a large NSD. Post-operatively, patients exhibit a lateralised smell identification difference as often as healthy people. The effect of a clinically significant NSD on the different aspects of olfactory performance warrants further study.
PMCID: PMC3738420  PMID: 23935274
septoplasty; nasal septal deviation; olfaction; sniffin sticks test; olfactory identification test
8.  Emergency department management of home intravenous antibiotic therapy for cellulitis 
Emergency Medicine Journal : EMJ  2005;22(10):715-717.
Objectives: To evaluate the safety and efficacy of using intravenous cephazolin as a first line antibiotic for the treatment of cellulitis in a supervised outpatient programme.
Methods: This study was a retrospective analysis and included all patients who attended the emergency department (ED) of a university affiliated hospital in Sydney over the period of 1 year and who satisfied the following inclusion criteria: (a) age >16 years, (b) presented with acute cellulitis, and (c) were suitable for home intravenous antibiotic therapy according to APAC guidelines.
Results: In total, 124 patients were included, of whom 53 (42.7%) presented directly to the ED and 71 (57.3%) were referred by their general practitioner. Of these 124 patients, 75 (60.5%) were men and 49 (39.5%) were women. Age range was 16–97 years. There were 82 (66.2%) presentations of cellulitis of the lower limb, 30 (24.2%) of the upper limb, 9 (7.2%) of the face and 3 (2.4%) of the torso. Cephazolin 2 g twice daily was given to 123 (99.2%) of the patients, and one patient (0.8%) received ceftriaxone 2 g once daily. In total, 105 patients (84.7%) were treated successfully and 19 (15.3%) were re-admitted. Four of the unsuccessful treatment group required incision and drainage of abscesses. The mean duration of intravenous therapy was 6.24 days. One patient developed diarrhoea. There were no other complications attributable to therapy.
Conclusion: Low re-admission rates verify the efficacy of cephazolin 2 g twice daily in treating cellulitis in the home environment. Benefits are multiple and include economic savings and reduced risk of nosocomial infection.
PMCID: PMC1726556  PMID: 16189034
9.  Day-Case Septoplasty and Unexpected Re-Admissions at a Dedicated Day-Case Unit: A 4-Year Audit 
Septal surgery has been identified as suitable for day-surgery, but is not widely performed as such. Guidelines for day-surgery state that the unexpected admission rate should be 2–3%. Previous audits have not achieved this figure and septoplasty is not universally considered suitable for day-surgery. We have reviewed practice over 4 years in our institution to identify surgical and patient factors associated with unexpected admission following septoplasty.
A retrospective case note based audit of day-case septoplasty procedures reviewed at the end of each year between October 1998 and October 2002.
A total of 432 septal surgery procedures were performed, comprising 378 septoplasties and 54 submucous resections. Thirty-eight patients were admitted, overwhelmingly because of haemorrhage in the immediate postoperative period, giving an overall admission rate of 8.8% within the first 24 h. Factors associated strongly with re-admission were the use of intranasal splints, the performance of revision surgery, submucous resection (as opposed to septoplasty) and, less so, the performance of additional procedures and the peri-operative administration of diclofenac. There was no correlation between unexpected admission and grade of surgeon, surgical technique or any of the patient factors analysed.
The unexpected admission rate of septal surgery performed at our unit is above that recommended for day-case procedures, but is within the range previously published. Patient satisfaction with day-case septoplasty has been shown to be high. We believe that septoplasty should be performed in this setting but there is a significant chance that patients may need admission, and a pathway should be in place for this to occur with minimal disruption to the patient.
PMCID: PMC1964047  PMID: 16551420
Septal surgery; Audit; Day-case
10.  Unexpected overnight admissions following day-case surgery: an analysis of a dedicated ENT day care unit. 
Day-case surgery is an integral part of otolaryngology, and many procedures can be performed as day-cases provided strict criteria are applied in the selection of patients. We reviewed patients who required unexpected admission from the day-case unit at the Royal National Throat, Nose and Ear Hospital, London between April 1997 and March 1998. The total number of patients undergoing surgery was 1642. Of the total, 29 (1.8%) had to be admitted unexpectedly for overnight stay: 24 of these patients had undergone nasal surgery, representing 5.4% of all the nasal procedures performed--and the cause of all these admissions was haemorrhage. Further analysis revealed 22 of these 24 nasal operations had included a septoplasty. The total number of septoplasties performed was 163; thus, septoplasty had an unexpected admission rate of 13.4%. This information has been used to formulate stricter guidelines for day-case septoplasty admissions in our unit.
PMCID: PMC2503604  PMID: 11041031
11.  Assessment of Septoplasty Effectiveness using Acoustic Rhinometry and Rhinomanometry 
Septal deviation is the chief cause of chronic nasal obstruction. In order to treat such cases, nasal septoplasty surgery is usually performed based on patient complaints and a surgeon's examination, both of which are subjective. This study aims at using the objective parameters of acoustic rhinometry and rhinomanometry to evaluate the effectiveness of septoplasty surgery.
Materials and Methods:
A prospective study was performed in 30 candidate patients for septoplasty surgery. Acoustic rhinometry and rhinomanometry tests were performed on all patients both before and 3 months after the operation. The symptom recovery rate was recorded according to the patient's statements and anterior rhinoscopic examinations 3 months after surgery. Data were analyzed using a t-test and chi-square tests in a SPSS package.
A total of 26 of 30 patients returned for a post–procedure follow-up examination after 3 months. Patients were aged from 18 to 32 years (average, 25 years). In total 69.2% (18 patients) were satisfied with the results of the procedure. In addition, rhinomanometry resulted in a decrease in general nasal resistance if patients used decongestants (P=0.03). However, the decrease was not significant before the use of decongestants (P=0.12). Furthermore, according to the results from acoustic rhinomanometry, there was an increase in the nasal cross-sectional area on both the narrow and wide sides after the operation (P<0.05), although this increase was not so notable in the narrower side after using decongestants. There was, however, no significant relationship between the results from the objective tests and the patient's symptoms or clinical examinations (P>0.05).
The findings of this study show that although the objective tests confirm an improvement in general nasal resistance and an increase in the nasal cross-sectional area after surgery, no unambiguous relationship between the patient's symptoms and the clinical examinations is observed. Therefore, such objective tests do not prove to be sufficient diagnostic criteria for the effectiveness of septoplasty.
PMCID: PMC3846266  PMID: 24303423
Acoustic rhinometry; Nasal airway obstruction; Nasal septum; Rhinomanometry
12.  Selected surgical managements in snoring and obstructive sleep apnea patients 
The diagnostic process and the surgical procedures in patients with snoring and obstructive sleep apnea syndrome (OSAS) are crucial. The aim of this study was to assess the efficacy of surgical treatment in snoring and OSAS patients.
A precise laryngological examination and screening polysomnography (Poly-Mesam) were performed in all patients with mild, moderate and severe OSAS before and 6 months after surgery. The patients completed questionnaires concerning their complaints. We included patients qualified to septoplasty, laser-assisted uvulopalatoplasty (LAUP), uvulopalatopharyngoplasty (UPPP) and radiofrequency-induced thermotherapy of the tongue base (RITT). Outcome evaluation of surgery was performed on the basis of data received from follow-up laryngological examinations, selected parameters obtained from the Poly-Mesam test and follow-up questionnaires.
In most cases we observed improvement, defined as decreasing some sleep parameters, such as a respiratory disturbance index (RDI), by more than 50%, decreasing the loudness of snoring, decreasing the number of hypopneas, and obtaining better blood saturation values. After UPPP we noticed changes in retropalatal space, soft palate dimensions and uvula-posterior pharyngeal wall distance. In the postoperative period we did not observe severe complications. In some cases we found short-lived palatal deficiency after UPPP. Patients after RITT experienced discomfort and throat pain lasting from 2 to 4 days. In 2 patients we observed swelling of the tongue base, which decreased after few days.
Surgery in OSAS contributes to normalization of some sleep parameters. The majority of patients experienced improvement after surgery.
PMCID: PMC3560687  PMID: 22207114
snoring; sleep apnea syndrome; septoplasty; uvulopalatoplasty; uvulopalatopharyngoplasty; radiofrequency-induced thermotherapy
13.  Phenylephrine as an alternative to cocaine for nasal vasoconstriction before nasal surgery: A randomised trial 
Indian Journal of Anaesthesia  2013;57(2):163-169.
Cocaine is often used topically to provide the profound vasoconstriction required for nasal surgery; however, it has been associated with intraoperative cardiac adverse effects. We compared cocaine with phenylephrine as an alternative to ascertain their relative efficacy as vasoconstrictors in nasal septoplasty.
Adult patients, presenting for elective nasal septoplasty, of American Society of Anaesthesiologists physical status I-III, were randomised to either 0.5% phenylephrine or 4% cocaine. The primary outcome was quality of vasoconstriction on a 5-point scale (1=unacceptable, 5=excellent), rated by the surgeon at the end of the procedure.
Twenty-nine patients received phenylephrine and 26 received cocaine. The median rating for quality of the vasoconstriction was 4.0 (good) in both the phenylephrine and cocaine groups (P=0.84). Median blood loss was 50 ml in the phenylephrine group and 62.5 ml in the cocaine group (P=0.49). In secondary analyses, phenylephrine was shown to be non-inferior to cocaine on both quality of vasoconstriction (non-inferiority delta of 1 point, P=0.009) and estimated blood loss (non-inferiority delta of 25 ml, P=0.028). The frequency of ventricular ectopy, ST segment changes or blood pressure changes after nasal packing was not significantly different between the two groups.
Phenylephrine in a concentration of 0.5% is not different from 4% cocaine on the quality of vasoconstriction in septoplasty. Given the abuse potential of cocaine and the added administrative burden associated with its handling, phenylephrine might serve as an alternative.
PMCID: PMC3696264  PMID: 23825816
Cocaine; hypertension; local anaesthetics; nasal surgery; neo-synephrine; phenylephrine
14.  Comparative evaluation of endoscopic with conventional septoplasty 
A study was conducted to assess the merits and demerits of endoscopic septoplasty. Fifty patients having symptomatic DNS were randomly divided into two groups of 25 patients each. One group underwent endoscopic septoplasty and other group underwent conventional septoplasty. The groups were compared regarding the complaints with pack in postoperative period, relief of symptoms after surgery and complications. The symptoms complained by the patients with pack in postoperative period and complications after surgery were significantly less in endoscopic septoplasty group.
PMCID: PMC3450123  PMID: 23120599
Endoscopic septoplasty; Conventional septoplasty
15.  Quality of life comparison in common rhinologic surgeries 
Allergy & Rhinology  2012;3(1):e1-e7.
Various questionnaires are used in patients who undergo rhinologic surgeries but a unique comprehensive questionnaire is needed to evaluate quality of life (QOL) in rhinologic surgeries. The purpose of this study was to prepare a comprehensive questionnaire and compare QOL among four common rhinologic surgeries including functional endoscopic sinus surgery, septoplasty, septorhinoplasty, and septoplasty with turbinoplasty preoperatively and 6 months postoperatively. This was a prospective interventional before-and-after study. Preoperative and 6 months postoperative evaluations were performed with a Modified Health-Related Quality of Life (HRQL) questionnaire designed to cover all needed QOL aspects and the 22-item Sino-nasal Outcome Test questionnaire to cover all needed QOL aspects. The Modified HRQL included 33 items in six subgroups (nasal symptoms, sleep problems, headache, nonnasal symptoms, and practical and emotional problems) and general feeling. From 202 patients who completed the questionnaire before the procedures, 146 (72% of all patients) who were interviewed 6 months postoperatively were included in this study. Comparing preoperative data between followed up patients and missed patients showed no statistical difference among surgeries (p = 0.90). Comparison of patient's pre- and postoperative QOL showed a significant improvement in global QOL and in all questionnaire items (p < 0.0001 in all comparisons). Comparison of QOL changes before and after surgery among different surgeries revealed no statistical difference (p = 0.282). Our data showed a significant improvement in each surgery but the amount of improvement in different surgeries was almost constant.
PMCID: PMC3404471  PMID: 22852123
Functional endoscopic sinus surgery; Modified Health-Related Quality of Life questionnaire; quality of life; rhinologic surgeries; septoplasty; septorhinoplasty; turbinoplasty
16.  The Efficacy of Preemptive Analgesia With Pregabalin in Septoplasty 
Pregabalin is used to treat neuropathic pain and has shown analgesic properties in postoperative pain. The aim of this study was to investigate the effectiveness and safety of pregabalin in reducing postoperative pain in patients after septoplasty.
Forty-seven patients scheduled for elective septoplasty were randomly assigned to groups that received either pregabalin (150 mg) or placebo, both one hour before surgery and 12 hours after the initial dose. Pain (verbal numerical rating scale, VNRS) and side effect assessments were performed at 6, 12, 12 to 24, and 24 to 48 hours postoperatively.
From 1 to 12 hours postoperatively, VNRS scores for pain were lower in the pregabalin group (n=24) than in the placebo group (n=23; P<0.05). The number of patients who needed rescue analgesics was lower in the pregabalin group (P=0.042). The incidence of nausea and vomiting did not differ between groups (P=0.666), and the incidence of sedation was higher in the placebo groups (P=0.022).
The perioperative administration of oral pregabalin (150 mg twice) is an effective and safe way to reduce early postoperative pain in patients undergoing septoplasty.
PMCID: PMC4050080  PMID: 24917905
Postoperative pain; Pregabalin; Septoplasty; Preemptive analgesia
17.  Comparison of dexmedetomidine and midazolam for monitored anesthesia care combined with tramadol via patient-controlled analgesia in endoscopic nasal surgery: A prospective, randomized, double-blind, clinical study 
Monitored anesthesia care (MAC) may be applied for septoplasty or endoscopic sinus surgery in which an adequate sedation and analgesia without respiratory depression are desired for comfort of both the patient and the surgeon. Several combinations with different agents have been used for this purpose in these patients. However, analgesic properties for these agents have not been reported.
The aim of this study was to investigate the analgesic and sedative effects of dexmedetomidine or midazolam infusion combined with tramadol that was used via patient-controlled analgesia (PCA), and to document the effects of these drugs on early cognitive functions.
This prospective, randomized, double-blind, clinical study enrolled patients undergoing septoplasty or endoscopic sinus surgery at the Abant Izzet Baysal University Hospital, Bolu, Turkey, between February and September 2006. Patients were randomly allocated in a 1:1 ratio into 1 of 2 groups: the dexmedetomidine group (group D) patients received IV dexmedetomidine 1 μg/kg for 10 minutes followed by continuous infusion of 0.5 μg/kg · h−1; and the midazolam group (group M) patients were administered a loading dose of IV midazolam 40 μg/kg for 10 minutes followed by infusion at the rate of 50 μg/kg · h−1. A 1-minute bolus dose of IV tramadol (1.5 mg/kg) was administered in both groups 10 minutes after the administration of the primary drug, and continued via infusion using a PCA device. After baseline measurements, systolic arterial pressure (SAP), diastolic arterial pressure (DAP), mean arterial pressure (MAP), heart rate (HR), oxygen saturation, and rate of respiration were recorded after the loading dose of study drug, after the bolus tramadol dose, at 10-minute intervals during the operation, and twice in the recovery rooms; 5 minutes after arrival and 5 minutes before discharge. Verbal rating score (VRS) and Ramsay sedation score were determined at baseline (after surgery was started), every 10 minutes thereafter until the end of the operation, and 2 times during recovery. All patients were assessed with the Wechsler Memory Scale-Revised at baseline (preoperatively) and 4 hours after the operation.
Seventy patients were enrolled in the study and randomly assigned to 1 of 2 groups: group D (sex, male/female, 23/12; mean [SEM] age, 32.53 [2.07] years; mean [SEM] weight, 73.03 [2.41] kg) or group M (sex, male/female, 21/14; mean [SEM] age, 34.43 [1.83] years; mean [SEM] weight, 67.90 [2.32] kg). All hemodynamic parameters (SAP, DAP, MAP, HR) were significantly higher in group M compared with group D from the onset of the surgery to discharge time (P < 0.05). Pain and sedation scores were similar in both groups, but the amount of PCA-administered rescue tramadol was significantly higher in group M (P = 0.001). A higher, though not statistically significant, prevalence of adverse events (ie, hypotension, bradycardia, and perioperative nausea and vomiting) were observed in group D. Postoperative logical verbal memory and digit span values were significantly higher in group D when compared with group M (P < 0.05). Postoperative digit span and visual reproduction scores were significantly higher than preoperative values in group D (P < 0.05). Postoperative personality functioning scores were significantly higher than preoperative values in group M (P < 0.05).
Based on VRS, Ramsay sedation scores, and surgeon and anesthesiologist satisfaction scores, dexmedetomidine or midazolam combined with tramadol PCA provided adequate analgesia and sedation in these adult patients undergoing septoplasty or endoscopic sinus surgery with MAC. A significantly larger amount of rescue tramadol was used by group M, suggesting that a better analgesic effect was achieved with dexmedetomidine.
PMCID: PMC3965987  PMID: 24678121
dexmedetomidine; midazolam; sedoanalgesia; cognitive function
18.  Postoperative Histological Changes in Polypose Rhinosinusitis 
The aim of this study was to evaluate the effect of surgery on the histology of nasal mucosa in patients with nasal polyposis and the comparison/also to compare it with normal population. This case-control study was conducted on 20 patients at the Otorhinolaryngology-Head and Neck Surgery Department, Qaem Hospital, Mashhad University of Medical Sciences during October 2007 to June 2008. Patients with polyposis and patients with septal deviation who were candidate for septoplasty were considered as case and control groups, respectively, including 10 subjects in each. Specimens of polyp tissue and the inferior conchae (mucosa) were taken during sinus endoscopy from the case group. One month later, another specimen was taken from the inferior conchae (mucosa). Moreover, specimens of the inferior conchae (mucosa) were taken of the control group. Percentage of goblet cells among the epithelial cells was determined for each group. Goblet cell percentage found to be 15.7% in polyps, consistent with significant difference with that of in postoperative (13.3%) and in preoperative nasal mucosa specimens (39.86%), (P = 0.043 and P = 0.03, respectively). Goblet cell percentage was 39.86% and 4.9% in the case and control groups, in that order, which were significantly high (P < 0.001). Percentage of goblet cells showed to be lower in polyps than mucosa. Also percentage of goblet cells in postoperative nasal mucosa specimens was significantly lower than preoperative specimens. Therefore, surgery has additional benefit of histological improvement rather than opening nasal airway.
PMCID: PMC3477442  PMID: 24294588
Nasal polyposis; Goblet cell; Surgery; Endoscopy
19.  The Efficacy of Submucosal Tramadol in the Postoperative Treatment of Pain Following Septoplasty Operations 
Tramadol is a centrally acting opioid which is effective for moderate-severe pain and is being used for various acute and chronic pain scenarios. The primary endpoint of this controlled, randomized double blind study was to evaluate the effect of submucosal tramadol on VAS scores after septoplasty operations and secondary endpoint was to investigate the effects on total opioid and additional analgesic consumption and patient satisfaction. 60 patients scheduled for septoplasty under general anaesthesia were enrolled. In Group T, at the end of surgery following hemostasis, 2 mg/kg tramadol was applied as submucosal infiltration to both surgical sites, 2 ml (total 4 ml), by the surgeon. In Group P, at the end of surgery following hemostasis, 2 ml isotonic solution (total 4 ml) was applied as submucosal infiltration to both surgical sites by the surgeon. Total opioid consumption, VAS scores, patient satisfaction was evaluated at the end of 24 h VAS values were higher in Group P on the first and second postoperative hours. Patient controlled analgesia demand and delivery values were higher in Group P on the postoperative 1, 2, 4, 6, 12 and 24th hours. Patient satisfaction was higher and opioid consumption was lower in Group T compared to Group P. There was no difference in additional analgesic consumption between two groups. The results show that patients receiving tramadol had lower VAS scores compared with the placebo groups postoperatively.
PMCID: PMC3585556  PMID: 24381911
Septoplasty; Submucosal tramadol; Postoperative pain; Opioids
20.  Effect of Pregabalin and Dexamethasone on Postoperative Analgesia after Septoplasty 
Pain Research and Treatment  2014;2014:850794.
Objectives. The aim of this study was to explore effect of a combination of pregabalin and dexamethasone on pain control after septoplasty operations. Methods. In this study, 90 patients who were scheduled for septoplasty under general anesthesia were randomly assigned into groups that received either placebo (Group C), pregabalin (Group P), or pregabalin and dexamethasone (Group PD). Preoperatively, patients received either pregabalin 300 mg one hour before surgery, dexamethasone 8 mg intravenously during induction, or placebo according to their allocation. Postoperative pain treatment included tramadol and diclofenac sodium 30 minutes before the end of the operation. Numeric rating scale (NRS) for pain assessment, side effects, and consumption of tramadol, pethidine, and ondansetron were recorded. Results. The median NRS score at the postoperative 0 and the 2nd h was significantly higher in Group C than in Group P and Group PD (P ≤ 0.004 for both). The 24 h tramadol and pethidine, consumptions were significantly reduced in Groups P and PD compared to Group C (P < 0.001 and P < 0.001). The incidence of blurred vision was significantly higher in Group PD compared to Group C within both 0–2 h and 0–24 h periods (P = 0.002 and P < 0.001, resp.). Conclusions. We conclude that administration of 300 mg pregabalin preoperatively may be an adequate choice for pain control after septoplasty. Addition of dexamethasone does not significantly reduce pain in these patients.
PMCID: PMC4020296  PMID: 24876957
21.  Malpractice claims and unintentional outcome of tonsil surgery and other standard procedures in otorhinolaryngology 
Background: Septoplasty, tonsillectomy (with and without adenoidectomy) and cervical lymph node excision are amongst the most common 50 inpatient operations in Germany. Intracapsular tonsillectomies (i.e. tonsillotomies) are increasingly performed. The aim of this study was to evaluate technical traps and pitfalls as well as alleged medical malpractice associated with tonsillectomy (TE), adenoidectomy (AE), tonsillotomy (TT), septoplasty (SP) and cervical lymph node excision (LN).
Methods: A questionnaire was sent to the Regional Medical Conciliation Boards, Medical Services of the Health Insurance Companies (MDK) and Regional Institutes of Forensic Medicine in Germany to collect anonymized cases of complications following TE, TT, AE, LN and SP. The results were discussed in the light of the contemporary medical literature and published trials and verdicts in Germany.
Results: The response rate of our survey was 55.9%. The Institutes of Forensic Medicine contributed nine cases, 49 cases were submitted by the Regional Conciliation Boards and none by MDK. All forensic cases were associated with exsanguinations following tonsillectomy including two children (5 and 8 years of age) and seven adults (aged 20 to 69 years). The fatal post-tonsillectomy hemorrhage (PTH) had occurred 8.7 days on average; four patients experienced the bleeding episode at home (day 5, 8, 9 and 17, respectively). Repeated episodes of bleeding requiring surgical intervention had occurred in 6 patients. Three Conciliation Boards submitted decicions associated with TT (1), AE (4), LN (3), SP (16) and TE (25). Cases with lethal outcome were not registered. Only three of the 49 cases were assessed as surgical malpractice (6.1%) including lesion of the spinal accessory nerve, wrong indication for TE and dental lesion after insertion of the mouth gag. The review of the medico legal literature yielded 71 published verdicts after AE and TE (29), LN (28) and SP (14) of which 37 resulted in compensation of malpractice after LN (16; 57%), TE (10; 37%), SP (8; 57%) and AE (2; 100%). There were 16 cases of PTH amongst 27 trials after TE resulting either in death (5) or apallic syndrome (5). Bleeding complications had occurred on the day of surgery in only 2 patients. 16 trials were based on malpractice claims following SP encompassing lack of informed consent (6), anosmia (4), septal perforation (2), frontobasal injury (2) and dry nose (2). Trials after LN procedures were associated exclusively with a lesion of the spinal accessory nerve (28), including lack of informed consent in 19 cases. 49 cases (69%) were decided for the defendant, 22 (31%) were decided for the plaintiff with monetary compensation in 7 of 29 AE/TE-trials, 9 of 28 LN-trials and 6 of 14 SP-trials. Lack of informed consent was not registered for AE/TE but LN (11) and SP (2).
Conclusion: Complicated cases following TE, TT, ATE, SP and LN are not systematically collected in Germany. It can be assumed, that not every complicated case is published in the medical literature or law journals and therefore not obtainable for scientific research. Alleged medical malpracice is proven for less than 6% before trial stage. Approximately half of all cases result in a plaintiff verdict or settlement at court. Proper documentation of a thourough counselling, examination, indication, informed consent and follow-up assists the surgeon in litigation. An adequate complication management of PTH is essential, including instructions for the patients/parents, instructions for the medical staff and readily available surgical instruments. Successful outcome of life-threatening PTH is widely based on a proper airway management in an interdisciplinary approach. Electrosurgical tonsillectomy techniques were repeatedly labeled as a risk factor for bleeding complications following TE. Institutions should analyse the individual PTH rate on a yearly basis. Contradictory expert opinions and verdicts of the courts concerning spinal accesory nerve lesions following LN are due to a lack of a surgical standard.
PMCID: PMC3884543  PMID: 24403976
tonsillectomy; tonsillotomy; adenoidectomy; septoplasty; cervical lymph node; malpractice; litigation; complication; negligence; death; fatality
22.  Computed nasal resistance compared with patient-reported symptoms in surgically treated nasal airway passages: A preliminary report 
Nasal airway obstruction (NAO) is a common health condition impacting mood, energy, recreation, sleep, and overall quality of life. Nasal surgery often addresses NAO but the results are sometimes unsatisfactory. Evaluating surgical treatment efficacy could be improved if objective tests were available that correlated with patient-reported measures of symptoms. The goal of this study was to develop methods for comparing nasal resistance computed by computational fluid dynamics (CFD) models with patient-reported symptoms of NAO using early data from a 4-year prospective study.
Computed tomography (CT) scans and patient-reported scores from the Nasal Obstruction Symptom Evaluation (NOSE) scale and a visual analog scale (VAS) measuring unilateral airflow sensation were obtained pre- and postoperatively in two NAO patients showing no significant mucosal asymmetry who were successfully treated with functional nasal surgery, including septoplasty. Pre- and postsurgery CFD models were created from the CT scans. Numerical simulation of steady-state inspiratory airflow was used to calculate bilateral and unilateral CFD-derived nasal resistance (CFD-NR).
In both subjects, NOSE and VAS scores improved after surgery, bilateral CFD-NR decreased, and unilateral CFD-NR decreased on the affected side. In addition, NOSE and VAS scores tracked with unilateral CFD-NR on the affected side.
These preliminary results suggest a possible correlation between unilateral NR and patient-reported symptoms and imply that analysis of unilateral obstruction should focus on the affected side. A formal investigation of unilateral CFD-NR and patient-reported symptoms in a series of NAO patients is needed to determine if these variables are correlated.
PMCID: PMC3490502  PMID: 22643935
Computational fluid dynamics; nasal resistance; nasal surgery; NOSE scale; numerical simulation; patient-reported measures; patient-reported symptoms; septoplasty; unilateral nasal resistance; VAS scale
23.  The role of septal surgery in cosmetic rhinoplasty 
Septoplasty is performed to resolve breathing problems, but it often becomes pivotal to correct external nasal deviation, representing a central step in rhinoplasty surgery. Even in patients with no functional problems, septal surgery may represent the best solution for obtaining a proper realignment of the external nasal pyramid. One-stage septorhinoplasty has become the standard of treatment for a deviated nose, hence septoplasty cannot be considered as a separate procedure to perform before or after rhinoplasty or as a partial operation subject to later revision. The aim of this article is to discuss the close relationship between the nasal septum and the aesthetics of the nose, and how a graduated surgical approach for the correction of septal deviations could affect the external deviated nose.
PMCID: PMC3709526  PMID: 23853409
Septorhinoplasty; Deviated septum; Septoplasty; Cosmetic rhinoplasty
24.  Evaluation of the nasal mucociliary transport rate by rhinoscintigraphy before and after surgery in patients with deviated nasal septum 
In this study, we have investigated the effect of nasal septal deviation (NSD) on nasal mucociliary activity and how does a septoplasty operation affecs the nasal mucociliary transport rate in the first and third months during the post-operative period. Twenty-two patients who were diagnosed with NSD and 22 healthy controls were studied using rhinoscintigraphy with Tc-99m-macroaggregated albumin (Tc-99m-MAA). On each case, the nasal mucociliary transport rate (NMTR) was measured pre-operatively only on five cases, on the first and third months of post-operative period. The NMTRs of patients with a deviated septum were significantly lower than the NMTRs of the healthy controls on both the convex and concave sides. Significant improvement was observed in the first post-operative month. On the concave and convex sides, the average postop third month post-operative NMTR value was higher than the first month post-operative NMTR values. It was concluded that the septoplasty operation improves reduced NMTRs after surgery. The effect of nasal surgery on nasal mucociliary activity may be more accurately evaluated in the third month than the first month of post-operative period.
PMCID: PMC2824839  PMID: 19816701
Nasal septum; Septal deviation; Septoplasty; Mucociliary clearance; Rhinoscintigraphy
25.  Quality of life before and after septoplasty and rhinoplasty 
Subjective assessment of quality of life (QOL) as an important aspect of outcomes research has received increasing importance during the past decades. QOL is measured with standardized questionnaires which had been tested with regard to reliability, validity, and sensitivity.
Surgical procedures of the nasal septum (septoplasty) and the external nose (rhinoplasty) are frequently performed. Since many years subjectively assessed results of these operations have been reported in the literature. However, validated QOL instruments were applied only for one decade. Beforehand, measurements were performed using retrospective assessment of satisfaction or visual analogue scales. Prospective application of validated disease-specific and general measuring instruments has to be demanded for future studies.
Most of the septoplasty patients as well as most of the rhinoplasty patients evaluate the operation being successful. However, a relevant number of patients is not satisfied with the result of surgery. In this context, QOL instruments have the potential to identify further factors influencing the outcome. Especially in rhinoplasty patients, special attention has to be drawn on potential psychosocial effects of the operation.
PMCID: PMC3199828  PMID: 22073110
validation; quality of life; nasal obstruction; nasal function

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