Nasal septal perforations are anatomical defects of the nasal septum, causing dynamic alterations in nasal physiology which may lead to variable symptoms and otolaryngological referral.Repair of nasal septal perforations continues to remain a difficult surgical problem, and nowadays there is no definitive solution for their successful surgical closure.Thirty patients with small- or medium-sized anterior nasal septal perforations were treated with a simple technique of backwards extraction-reposition of the quadrangular cartilage. Prior nasal septal surgery and repeated cautery were the most common cause of perforation. After a minimum follow-up of two years the success rate for relief of symptoms and closure of the perforation was 87 per cent.This technique showed very good results in small-sized and selected cases with medium-sized perforations, but the mucosal dissection employed is not suitable for medium to large perforations.
The nose acts as a physiologic airway resistor, accounting for around 50% of total airway resistance. Adequate nasal resistance is essential not only for correct functioning of the nose but to ensure normal pulmonary physiology. Pathological nasal resistance is determined by alterations in the shape and volume of the nasal cavities that singly or in association disrupt nasal aerodynamics, a condition that will present mainly in the form of obstructive disorders. The authors advise against considering nasal cavity surgery simply as surgery of the nasal septum. Nasal surgery should be addressed to normalizing the geometry of the nasal cavities in order to restore physiologic nasal resistance. Surgical procedures may be classified as follows: (1) surgery of the medial wall; (2) surgery of the lateral wall; and (3) surgery of the valve area. Septal surgery is systematically performed by the authors using the maxilla-premaxilla approach (MPA). Functional correction of the septum combines mobilization and/or removal of any deranged portion of the bony and/or cartilaginous septum, followed by reconstruction of the septum support, preferably using autogenous septal grafts. When reconstructing the medial wall, great care must be taken with the most important portion of the septum, i.e., the dorso-caudal margin and the cartilaginous elements. We have called this procedure Functional Osteocartilaginous Reconstruction of the Nasal Septum (FORNS). Obstructive swelling of the turbinates is one of the most common causes of nasal obstruction as it alters the shape and reduces the volume of the nasal cavities causing an exponential increase in nasal resistance. With regard to surgery of the lateral wall, the authors firmly believe that mutilating procedures like total inferior turbinectomy can in no way be considered functional surgery of the turbinates. On the contrary, aim of lateral wall functional surgery is not simply to widen the airway, but rather to restore normal aerodynamic contours to the lateral wall in order to prevent turbulence, a phenomenon which will cause increased nasal resistance. To do this, the authors make systematic use of Conservative Submucosal Turbinoplasty (CST). The procedure is designed especially to treat the submucosa since this is the main focus of anatomo-pathological alterations. Nasal valve surgery is one of the most high-risk surgical procedures since scarring, stiffening, or loss of structural support may cause severe and even irreversible damage. Any surgery of the valve area should therefore carry minimum risk of respiratory complications and aesthetic defects. In the light of these principles, the authors propose a valve area correction technique carried out exclusively through the hemitransfixion incision. This approach affords wide access to the whole valve area, allowing the rhino-surgeon to perform a range of corrections on the anatomic sub-units constituting the nasal valve complex. This same approach can be used to place various grafts. The authors propose a "tailored surgery to norm...
Infections with endocardial vegetation or the exuberant growth of neoendothelialization tissue (cloth –tissue overgrowth) in heart valve prostheses lead, among other complications, to the malfunction of the prostheses themselves due to obstruction. Among the diagnostic methods available to us, to achieve the diagnosis of prosthetic dysfunction, in recent years three–dimensional transesophageal echocardiography (3D TTE) has become increasingly imposed. We present two clinical cases of patients admitted to our Cardiology department Case 1: Patient of 62 years old, hospitalized for established congestive heart failure. In 2006 he underwent ascending aorta replacement with Dacron 28 prosthesis and aortic valve replacement with mechanical prosthesis (Sorin 25) for aortic bicuspid and ascending aortic aneurysm. During the last follow–up was observed a slight increase in the value of intraprosthetic gradients, as well as a variability in INR values. Physical examination showed signs of heart failure (NT–ProBNP >1000 pg/ml); normal inflammation indices (PCR <2.9 mg/l); ECG: sinus rhythm at 85 bpm with left ventricular overload; trans–thoracic echocardiography showed severe intraprosthetic aortic gradient (Gmax 132mmHg–Gmed 72mmHg), doubtful for cloth adhered to prosthetic discs; 3D TTE shoved hyperechoreflective image adhered to the posterior mobile element (5x9mm) which was fixed in semi–closure. Subsequently, the patient underwent prosthetic replacement surgery with biological prosthesis. Case 2: Patient of 67 years old, heavy smoker, hypertensive, with aortic mechanical prosthesis, a few weeks before hospitalized for Corynebacterium Jeikeium infection. Hospitalized again for fever with increased inflammation indices (CRP 202mg/l). A first TTE concluded for suspected endocarditis of the prosthesis; this doubt was also dissolved by 3D TTE which showed a soft protruding image of the posterior mobile element, preventing the opening and determining severe stenosis (Gmax 160mmHg–Gmed of 80 mmHg), so this patients was transferred to the cardiac surgery department. Conclusions 3D TTE is a method of rapid and safe execution that can be exploited not only pre– or intraoperatively but also to settle diagnostic suspicions not clarified by traditional 2d methods, even managing to distinguish cloth deposits from vegetation / abscesses.
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