Closure of a perforated nasal septum through an endonasal technique can be achieved with a unilateral mucosal flap based on the anterior ethmoidal artery.
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...
Obesity induces multiple physiologic changes at the respiratory and circulatory systems level. A study was developed to identify symptoms and signs able to discriminate subjects at high risk of obstructive sleep apnea (OSA) and to evaluate the presence of OSA in a population of obese patients referred to the Clinical Nutrition Service of the Luigi Sacco Hospital for weight loss therapy. Twenty-seven obese patients (14 males, 13 females) without neurologic, cardiac, and lung diseases were measured for height, weight, neck, waist, and hip circumference; a sample of venous blood was taken for hematological data; and were given a pulmonary function test, hemogasanalysis, and full-night polysomnography. Statistical analysis were performed using paired and unpaired StudentOs t test, PearsonOs chi square, and Spearmann Rank correlation; the significance level was set at p<0.05. The results showed hemotological values in the normal range and pulmonary function findings were not different from predicted, but expiratory reserve volume (ERV), as expected in obese subjects, was significantly reduced (p<0.001). Waist, hip, and neck circumference, and waist/hip ratio were 114 +/-14, 118 +/-12, 44 +/-4, and 0.96 +/-0.4 cm respectively. An apnea-hypopnea index (AHI) cutoff value of <15 was used to classify the patients as suffering from OSA: 15 patients (12 males, 3 females, age in years 55 +/-12, body mass index (BMI) kg/m(2) 37 +/-6, AHI 30 +/-12) were OSA and 12 patients were non OSA (2 males, 10 females, age in years 49 +/-20, BMI kg/m(2) 35 +/-2, AHI 3 +/-2). PaO2 and pH were lower and PaCO2 higher in OSA (p<0.05, p<0.01, p<0.05, respectively). Red blood cells (RBC), Hb, and neck circumference were increased in OSA (p<0.05). In OSA patients, S3%, S4% of total sleep time, SaO2% mean of nadir were reduced (p<0.001), and DEF increased (p<0.0001). In obese patients, AHI was correlated with neck circumference (r = 0.74, p<0.0001) and waist/hip ratio (r = 0.48. p<0.01). DEF was correlated with RBC, Hb, Htc% (r = 0.82, 0.71, 0.66, p<0.001). SaO2;% mean of nadir was significantly related to RBC, Hb, and Htc% (r = 0.44, 0.40, p<0.05, respectively). Our data showed a prevalence of OSA in 55% of the obese patients. A significant correlation exists between RBC, Hb, Htc%, with desaturation events frequency (DEF) and SaO2% of nadir indicating that transient, episodic desaturation during sleep is linked to a moderate increase of RBC and Hb found in obese patients with OSA, in contrast to obese, nonOSA patients. The most important result of the present study was the determination that classical symptoms and signs of OSA, such as male gender, neck circumference, waist/hip ratio, RBC, and Hb at the upper limit of normal, are simple inexpensive screening tools, and useful predictors of sleep-disordered breathing and discriminate the individuals with higher risk of OSA.
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