Biomedical subjects
Publications and source records attributed to E B Kern.
A series of 1,000 consecutive intranasal ethmoidectomies performed on 565 patients was reviewed. There were 28 complications (2.8%) in 26 patients. No patient died, and none became blind. This experience suggests that, in experienced hands, intranasal ethmoidectomy for polypoid disease and chronic ethmoid sinusitis can be a safe operation.
In a series of 505 consecutive procedures, the transseptal-transsphenoidal pituitary operation has proved safe and effective. The overall mortality in this series is 1.39%. A wide variety of sphenoid and sellar lesions and nearly every pituitary adenoma have been found suitable for the exposure provided through the sublabial-transseptal approach. This statement rests on the premise that both the rhinologist's and the neurosurgeon's skills are optimally applied to each case. The role of the otorhinolaryngologist is defined in this paper, and the benefits of the team approach are explored. An interpretive history of the transsphenoidal approach is presented, and the evolution of the transseptal technique developed at the Mayo Clinic from 1972 to 1978 is reviewed. Emphasizing the rhinologic aspects, all details of the surgical technique are described and illustrated. Our experience with the special endocrine syndromes is also reviewed to spotlight clinical features that require individual consideration by the rhinologic surgeon.
If the septal component of a nasal injury is adequately managed, usually the entire nasal injury will be well managed. Major or minor nasal trauma can cause cartilage fracture, deviation, dislocation, hematoma, or abscess formation, and the various associated sequelae, some of them life-threatening. A negative x-ray report should never be used as a substitute for a complete intranasal examination in any child with nasal trauma. Any nasal abnormality should be referred for immediate evaluation and treatment.
Between June 1972 and November 1977, 108 patients had medical-grade Silastic buttons inserted transnasally into a perforation of the nasal septum. This nonsurgical technique was done as an office procedure with use of 5% cocaine applied topically in 97 of the 108 patients. The Silastic button has remained in place in 70.4% of the patients, with follow-up ranging from 9 months to 6 years. This mechanical device is inserted easily and has reduced crusting and bleeding considerably in many patients. The failures frequently were related to patient intolerance or poor mechanical fit and occurred in the first few days or first few months after insertion.
The site of cerebrospinal fluid leaks from the nose can be localized by means of radioactive substances. The technical aspects are important for success.
Apparently, the incidence of postoperative maxillary sinus mucoceles is greater in Japan than in the Western world. Between 1967 and 1976 at the Tokyo Medical and Dental University Hospital, Department of Otorhinolaryngology, 132 patients had the diagnosis of mucoceles of the maxillary sinus. Of these patients, 131 (99%) had histories of previous maxillary sinus surgery. A number of etiologic mechanisms are probably involved in producing these mucoceles.
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Transseptal, transsphenoidal pituitary surgery is safe and effective in the management of various problems associated with the region of the sella turcica. This series include 285 operations on 272 patients treated from Sept. 1, 1972, to Sept. 1, 1976. The operative mortality was 1.75%. In every patient, the anatomy should be assessed preoperatively by polytomograms of the sella and the sphenoid sinus and by bilateral carotid angiography. The operating microscope and intra-operative x-ray control with the image-intensifier are essentials. Pneumoencephalography is performed whenever the possibility of an empty sella or arachnoidal cyst exists and when angiography does not satisfactorily outline the suprasellar extension of large pituitary tumors. Computerized tomographic scanning is also of value. A new group of pathologic problems, namely microadenomas (tumors less than 1 cm in diameter), has now become amenable to transseptal surgical management. This series includes a group of 50 patients with microadenomas: 45 with functioning pituitary adenomas and 5 with nonfunctioning pituitary adenomas. The transfrontal intracranial surgical approach also has specific indications. This choice is determined by the anatomy and the extent and nature of the pathologic lesion. The rhinologic concepts of exposure and reconstruction are modifications of the "maxilla-premaxilla" (Cottle) approach to the nasal septum. This allows direct midline access to the sphenoid sinus and sella turcica while preserving both the caudal end of the nasal septum and the anterior nasal spine, thereby minimizing rhinologic airway and cosmetic complications. We believe that, by combining the talents of the neurosurgeon, endocrinologist, neuroradiologist, ophthalmologist, and rhinologist, this procedure can be offered to patients with a wide range of disorders and excellent results may be anticipated.
Seroma formation was most apparent in the A-treated groups and was probably related to the continued leakage of methyl alcohol from the graft. Warping in the pinna, fibrosis around grafts, graft resorption, and cellular infiltration were least evident in the FZ and R groups. Both produced better results than storage in BSS or A, but because radiation is far more expensive and less convenient than FZ, the latter is the better preparation and preservation technique.
The alternating congestion and decongestion of the nasal mucosa, termed the "nasal cycle", was investigated with current mask (posterior) active rhinomanometric techniques. This communication reports variations in nasal resistance in 50 human subjects, each studied for about 7 hours. Approximately 600 resistance values (cm H2O/liter per second) were obtained from each subject. The nasal cycle defined in rhinomanometric terms was that alternating congestion and decongestion of the nasal turbinates which produced a change in pressure and airflow values calculated as resistance (comparing one side with the other) of 20% or greater for two consecutive observations (at least 15 minutes). The data demonstrated that 36 of 50 subjects (12 of 18 males and 24 of 32 females) had at least one nasal cycle during the period of observation.
A systematic surgical approach to nasal valve abnormalities depends on adequate and precise exposure of the abnormality to be corrected and is facilitated by the use of magnification. Small anatomic disturbances in the region of the nasal valve can produce significant airway obstruction by narrowing the nasal valve angle. Normally, this angle between the caudal end of the upper lateral cartilage and the nasal septum is from 10 to 15 degree. In all patients with nasal airway obstruction, a meticulous clinical evaluation of the nasal valve is required. Nasal valve abnormalities can produce symptoms due to an already increased collapsibility of the nasal valve; therefore surgical intervention is directed toward reconstruction of normal anatomic relationships, usually by widening the nasal valve angle and preventing either extreme of rigidity or collapsibility. Appropriate and delicate handling of the intercartilaginous aponeurosis between the upper lateral (roof) cartilage and the lower lateral (lobular or alar) cartilage with prevention of excessive scar tissue formation usually can be achieved by dissection on the upper lateral cartilage. The surgical plane is beneath the overlying musculature and neurovascular layers. By preserving the mucocutaneous lining and by accurate suturing of incisions, primary wound healing is facilitated. Clinical experience suggest that the application of these concepts benefits patients by preventing or treating abnormalities of the nasal valve. Eventually, longterm results with preoperative and postoperative physiologic testing (rhinomanometry), coupled with critical clinical re-evaluation, should allow adoption, rejection, or, more likely, modification of the principles offered by this contribution.
A group of 51 patients was studied by a technique of active posterior rhinomanometry that assessed the influence of breath holding, hyperventilation, and exercise on nasal resistance. Breath hodling of 30 seconds or longer produced a decrease in nasal resistance in most of the subjects tested. Hyperventilation had variable effects on nasal resistance, and exercise consistently decreased nasal resistance. These observations are consistent with the proposed effect of chemoreceptor stimulation on nasal airway resistance.
Intranasal dermoplasty and estrogen therapy have been shown to be the most effective means of managing epistaxis in patients with hereditary hemorrhagic telangiectasia. In a series of 80 patients studied, the most effective treatment was by intranasal dermoplasty; of 22 patients so treated, 14 had improvement for more than six months after surgery and six had improvement for one to six months. Regrafting for recurrent epistaxis was successful in four of five patients (improvement for more than six months). Estrogen was administered for systemic effect to 16 patients and produced improvement of more than six months' duration in eight and of one to six months' duration in three. Other forms of management were less effective for the prolonged control of epistaxis.
Intranasal administration of a 4% solution of cromolyn sodium for the treatment of ragweed hay fever was tested in an 8-week double-blind matched-pair study involving 66 patients. Patients on active drug received 5.2 mg into each nostril 6 times daily; control patients received a placebo spray. The treated group showed a significant reduction in mouth breathing (p less than 0.001), stuffy nose (p less than 0.002), runny nose (p less than 0.003), and postnasal drip (p less than 0.035). Patients receiving the active drug also reported fewer sneezing episodes (p less than 0.003) and nose blowing episodes (p less than 0.015). One patient using cromolyn solution developed nasal ulceration, tongue swelling, coughing, and wheezing. Other side effects were minimal and occurred with equal frequency in both groups. In the treated group relief of symptoms was most marked in patients with high preseasonal levels of IgE ragweed antibody. Intranasal 4% cromolyn solution appears to be an effective drug for the treatment of ragweed hay fever; measurement of the preseasonal level of IgE ragweed antibody is a useful screening test to identify patients most likely to achieve a maximal beneficial response to treatment.
The physiologic phenomenon of alternating congestion and decongestion of the nasal airways was studied by rhinomanometric techniques. This study included the largest reported normal population, 50 persons (32 females, ages 14 to 72 years, mean 25, and 18 males, ages 14 to 50 years, mean 23). The "mask-flowmeter" technique of active posterior rhinomanometry was used to collect data continuously (15-minute intervals) on each subject for about 7 hours. We defined the nasal cycle (in terms of rhinomanometry) as that alternating congestion and decongestion of the nasal airways producing a resistance change (comparing one side to the other, right and left) so that after two consecutive calculations (covering a 30-minute period) the resistance between the sides was at least greater than 20%. By this criterion, we found that 72% of the subjects demonstrated a clearly defined nasal cycle. This resistance difference of 20% between the two sides (right and left) reversed or changed sides at least once for two consecutive calculations during the 7 hours of testing. Normal individuals are not usually aware of this phenomenon because the total nasal resistance usually remains fairly constant and is less than the resistance of either one of the individual nasal passages.
Current methods of rhinomanometry used by various workers from around the world were investigated. The data for this communication were based on the studies of 11 scientists who have an accumulation of approximately 81 years of experience with more than 20,000 rhinometric examinations. The results of this survey provide a consensus of methods, procedures, data collection, and presentation which should be considered so that rhinomanometric uniformity may be achieved. It is fully recognized that standardization of rhinomanometry requires further inquiry and evaluation and that this is not the final communication on the subject but merely a current consensus from a limited few working in the field.
Some patients with a fixed uninasal obstruction in whom the normal or patent side becomes temporarily obstructed because of the nasal cycle, and in whom the total nasal resistance is elevated, complain of nasal obstruction. It is when the normal side responds to the congestive phase of the nasal cycle that the patient becomes symptomatic; hence, the term "paradoxical nasal obstruction." Rhinomanometric tests, serial tomography, and direct patient observation allow confirmation of the phenomenon of paradoxical nasal obstruction.