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Acoustic Neuroma Author: Andrew A. McCall, MD, University of Pittsburgh Medical Center Overview: Acoustic neuroma, otherwise known as vestibular schwannoma, is a benign intracranial tumor that develops in the space between the brainstem and inner ear (the cerebellopontine angle). Although the tumor is commonly referred to as acoustic neuroma, this term is a misnomer because these tumors usually arise from the vestibular (balance) nerve rather than the acoustic (hearing) nerve. Most often these tumors develop spontaneously, however in a small percentage of cases they develop as a result of an underlying genetic disorder (Neurofibromatosis type 2) where the tumors are present on both sides. Symptoms: Symptoms of acoustic neuroma include unilateral or asymmetric sensorineural hearing loss (hearing loss originating from the inner ear and/or hearing nerve), tinnitus (ringing or buzzing in the ear), and imbalance or dizziness. Less common symptoms include facial numbness and rarely facial weakness or paralysis. What to Expect at Your Otolaryngologist Office Visit: A complete history and physical examination of the head and neck will usually be obtained for patients who present with symptoms suggestive of an acoustic neuroma. An audiogram will often be obtained for hearing related complaints. Vestibular testing may be performed for balance related symptomatology. If an acoustic neuroma is suspected, a MRI scan will typically be obtained to evaluate for the presence of a tumor. Many other disease processes (e.g. Meniere’s disease, sudden sensorineural hearing loss, labyrinthitis, etc.) can mimic the symptoms of acoustic neuroma, but do not share the MRI findings of a tumor. Once the diagnosis of acoustic neuroma is established, consultation is typically sought with a specialized otolaryngologist known as an otologist/neurotologist. Treatment: While each patient and situation is unique, three main treatment options should be considered: observation, surgical resection, and radiosurgery. Observation of acoustic neuroma entails evaluating the tumor for growth with serial MRI scanning. Acoustic neuroma, on average, tends to be very slow growing – on the order of one or two millimeters per year. However, some tumors are dormant and do not grow and, occasionally, some tumors grow at a more rapid pace. If a tumor should grow during observation, more active intervention with surgery or radiosurgery would likely be recommended. There are three surgical approaches used to remove acoustic neuroma: translabyrinthine, retrosigmoid, and middle fossa. The decision upon which surgical approach is best for a particular patient and tumor is highly individualized and should be discussed in detail with the treating physician. Surgery for these tumors is often performed as a team approach incorporating the skills of an neurotologist and a neurosurgeon because these tumors reside at the junction between the inner ear and brainstem. Radiosurgery is used to arrest growth of acoustic neuroma. Radiosurgery involves steering beams of radiation from multiple angles to concentrate the radiation on the tumor and spare adjacent structures, such as the inner ear or brainstem. One of several different machines may be recommended for delivery of the radiation treatment (e.g. Gamma Knife and Cyber Knife).

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Voice and Throat Disorders In This Section: Airway Stenosis Chronic Cough Dysphagia (difficulty swallowing) Spasmodic Dysphonia Zenker’s Diverticulum Airway Stenosis Author: Ahmed M.S. Soliman, MD Overview: The term stenosis refers to the abnormal narrowing of a tube-shaped organ. In the human airway, the three main areas where this can occur are in the larynx (voice box), subglottis (just below the vocal folds), and trachea (windpipe). The main cause of laryngeal narrowing is having had a breathing tube in place. Other causes include certain autoimmune/rheumatological conditions (Wegener’s granulomatosis, Sarcoidosis Relapsing polychondritis, Amyloidosis), trauma to the neck or voice box, and surgery, or radiation to the larynx. Symptoms: Symptoms include noisy breathing, coughing, and shortness of breath. It is frequently misdiagnosed as asthma. The symptoms may become quite severe and life threatening. What to Expect at Your Otolaryngologist Office Visit: Evaluation will start with a complete examination of the head and neck. It will also include examination of the nose, voice box and the throat using a laryngoscope. Your doctor may order a chest X-ray, CT or other tests as appropriate. If you have had any of these already done, please bring them with you to the visit. Treatment: Treatment usually starts with evaluation of the larynx, subglottis, and trachea in the operating room. Endoscopic treatment with the laser and dilation is usually successful although sometimes, surgical reconstruction through the neck is necessary. Chronic Cough Author: Ahmed M.S. Soliman, MD Overview: A chronic cough is a cough that persists for eight or more weeks. Chronic cough can lead to exhaustion, rib fractures, vomiting, hoarseness and lightheadedness. Symptoms: Chronic cough is a symptom and not a diagnosis. It is typically the result of an underlying condition or health factor. The most common of these include tobacco use, certain blood pressure medications, asthma, chronic rhinosinusitis, and acid reflux. Other causes of chronic cough include respiratory infections, and chronic bronchitis. What to Expect at Your Otolaryngologist Office Visit: Evaluation will start with a complete examination of the head and neck. It will also include examination of the nose, voice box and the throat using a laryngoscope. You may be given some food to eat while the doctor examines your throat (called flexible evaluation of swallowing or FEES). Your doctor may order a chest X-ray, modified barium swallow, esophagram, sinus CT or other tests as appropriate. If you have had any of these already done, please bring them with you to the visit. Treatment: Treatment will depend upon what the underlying cause or causes. This may include dietary and behavioral modifications, antibiotics, antireflux medications, inhalers, etc. Dysphagia (difficulty swallowing) Authors: Nausheen Jamal, MD – Department of Otolaryngology-Head & Neck Surgery, Lewis Katz School of Medicine, Temple University Overview: Dysphagia refers to any difficulty swallowing that a person may have. This difficulty may occur in many different forms and will affect a person’s ability to eat or drink in the upper digestive tract – in other words, anywhere from the lips down to the stomach. Causes of dysphagia vary as well. These include weakness of throat muscles, “pouches” within the throat or food pipe, narrowing of the throat or food pipe, muscle spasms, trouble with coordination within the throat or food pipe, or even issues with the teeth or dentures. Sometimes other medical conditions can lead to dysphagia. These include medications, prior stroke, any tumors, and prior surgeries. Trouble with swallowing can cause drastic quality of life issues. In addition, it can lead to serious medical complications, such as pneumonia, malnutrition, and undesired weight loss. Symptoms: Coughing and choking during eating Extra time needed to eat meals Avoiding or having difficulty with certain food consistencies because of swallowing difficulty Drooling Difficulty chewing Difficulty starting a swallow Waking up at night choking or drooling Food coming back up into the throat or nose during eating Feeling food stick in the throat or chest History of pneumonia Weight loss and malnutrition What to Expect at Your Otolaryngologist Office Visit: A careful examination of your mouth and throat will provide your doctor with a lot of information. Your otolaryngologist may perform specialized tests, including a laryngoscopy (“scope” procedure through your nose and into your throat), a swallow evaluation, and possibly even a procedure to look in your food pipe. It is possible that your otolaryngologist will order specialized testing, including x-ray swallow tests (such as a barium swallow or modified barium swallow). You may be given a referral to see a speech pathologist who is also trained in swallow disorders. Treatment: Because the causes of swallow disorders vary, so do the treatments. Generally speaking, swallow disorders that are caused by issues of weakness or lack of muscle coordination are treated with swallow therapy, which is like physical therapy for the swallowing muscles of the throat. This therapy is performed by a speech pathologist. Swallow disorders that are caused by areas of narrowing, “pouches,” certain types of muscle spasms, voice box movement disorders, or tumors are typically treated with surgery. Most of these surgeries are performed endoscopically, meaning that they are performed through the mouth without a need for incisions in the neck. Sometimes, however, a surgery that requires an incision in the neck is needed. Most surgeries require staying in the hospital for at least one night following the operation. A few minimally invasive surgeries may allow discharge on the same day as the operation. Your doctor will discuss if surgery is the right option for you, and what an operation might involve. Spasmodic Dysphonia Author: Ahmed M.S. Soliman, MD Overview: Spasmodic dysphonia (SD) is a rare neurologic disorder in which the larynx experiences involuntary spasms. There are three forms of the condition, adductor SD, Abductor SD, and Mixed SD, each with distinct vocal symptoms. It is estimated that roughly 50,000 people in North America have some form of SD. The condition usually sets in gradually during middle age, and is more likely to affect woman than men. Symptoms: Adductor SD, the most common form, causes the vocal folds to involuntarily close while speaking. The speech of someone with adductor SD sounds choppy, strained or strangled. Abductor SD is much less common and causes the vocal folds to involuntarily open with speaking that they do not vibrate properly. As a result, the voice may sound soft, weak or breathy. Mixed SD has features of both types and is rare. What to Expect at Your Otolaryngologist Office Visit: Evaluation will start with a complete examination of the head and neck. It will also include examination of the larynx or voice box using a laryngoscope. The examination is often videotaped and played back. Your doctor may order an MRI of your brain, and evaluation by Neurology and Speech Pathology. Treatment: Treatment usually involves weakening of the overactive muscle group with botulinum toxin. This treatment is usually done in the office and is highly successful. Voice therapy is often used as an adjunct to treatment. Rarely surgical procedures of the larynx are performed for this. Zenker’s Diverticulum Author: Ahmed M.S. Soliman, MD Overview: Zenker's diverticulum is a pouch that forms in the throat, where the esophagus meets the uppr part of the throat called the pharynx. The pouch forms by pushing through a weakened portion of the pharynx and balloons outward. The condition tends to occur in patients over 60 years but may occur in younger patients. It does not appear to be hereditary. Symptoms: The main symptom of Zenker's diverticulum is dysphagia, or difficulty swallowing. Undigested food or liquid can rise back into the throat and mouth even hours after swallowing. Other symptoms include choking, a buildup of mucous in the throat, bad breath, hoarseness, and recurrent pneumonias. What to Expect at Your Otolaryngologist Office Visit: Evaluation will start with a complete examination of the head and neck. It will also include examination of the voice box and the pharynx using a flexible laryngoscope. You may be given some food to eat while the doctor examines your throat (called flexible evaluation of swallowing or FEES). If you have had a swallowing test, please bring it with you. Otherwise, your doctor will likely order one. Treatment: In cases of mild dysphagia, Zenker's diverticulum can be treated with lifestyle changes. These include: Avoiding fatty, spicy and acidic foods, thoroughly chewing foods before swallowing, drinking lots of water after eating. If the dysphagia is severe, there are a variety of surgical options. The exact procedure our surgeons use will depends on the size and location of the diverticulum and include: Cricopharyngeal myotomy: This procedure is ideal for removing small diverticula. It can be performed directly through the mouth with the laser or through a small incision in the neck. Endoscopic diverticulotomy: This option involves dividing the wall between the esophagus and the diverticulum using the laser or a special staper/cut device. Once the wall is divided, food particles stuck inside the pouch are free to drain into the esophagus. The vast majority of Zenker’s diverticula are treated successfully in this minimally invasive manner. Diverticulectomy and cricopharyngeal myotomy: This procedure is the complete removal of the pouch along with a cricopharyngeal myotomy and is used for a small percentage of patients where the sac is very large or cannot be accessed through the mouth. It is done through a small neck incision.

Meeting Archive Congratulations to the 2024 winners: First Place Oral Presentation: Asthma and Comorbid Obstructive Sleep Apnea: Outcomes after Hypoglossal Nerve Stimulation Surgery David Goldrich, MD Penn State Hershey Second Place Oral Presentation: A Novel Proof-Of-Concept Study of Mixed Reality Technology for Ideal Placement of Bone-Anchored Hearing Devices for Application in Complex Patient Populations Kelly Daniels, MD UPMC First Place Poster: Response-Adaptive Surgical Timing in Neoadjuvant Immunotherapy Demonstrates Enhanced Pathologic Treatment Response in Head and Neck Squamous Cell Carcinoma Pablo Llerena, BS Thomas Jefferson University Hospital Second Place Poster: Free Flap Neurotization and Radial Forearm Free Flap Reconstruction Improves Functional Outcomes in Hemiglossectomy Defects Eric Wu, MD University of Pittsburgh Medical Center Resident Jeopardy Bowl Winner: Combined team from PCOM & Jefferson Congratulations to the 2023 winners: First Place Oral Presentation: Effects of hypoglossal nerve stimulation surgery on rhinologic quality of life - A cohort study Glen D’Souza, Jefferson Second Place Oral Presentation: Cost Effectiveness of Non-echo Planar Diffusion Weighted MRI in the Surveillance of Cholesteatoma Terral Patel, UPMC First Place Poster: The Use of Actigraphy to Assess Sleep Improvement After Parathyroidectomy Christopher Tseng, PSU Second Place Poster: Efficacy of Fibrin Sealants in Reducing Postoperative Complications in Facial Plastic Surgery Hanel Eberly, PSU Resident Jeopardy Bowl Winner: Combined team from AHN, PCOM, & Jefferson Congratulations to the following winners: First Place Oral Presentation: Endoscopic Versus Microscopic Ear Surgery for Management of Cholesteatoma: A Cost Effectiveness Analysis Lauren Gardiner, MD University of Pittsburgh Medical Center Second Place Oral Presentation: The Effects of Adjuvant Radiotherapy on Survival in Elderly Patients with Advanced Head & Neck Squamous Cell Carcinoma Joann Butkus, MD Thomas Jefferson University Hospital First Place Poster: Acoustic Neuroma: A Surveillance, Epidemilogy, and End Results (SEER) Analysis Thomas Haupt, MD Howard University Second Place Poster: Viral Integration and Genomic Instability in HPV-Transformed Tonsillar Keratinocytes Emily Milarchi, MD Pennsylvania State University Resident Jeopardy Bowl Winner: Geisinger Medical Center Congratulations to the following winners: First Place Oral Presentation: Validity of the American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) in a Pediatric Population Kelly Daniels, MD UPMC Second Place Oral Presentation: Human Papilloma Virus Integration Strictly Correlates with Global Genome Instability in Head and Neck Cancer Max Hennessy, MD Penn State Health Third Place Oral Presentations: Survivorship, At What Cost? Understanding Financial Toxicity in Patients with Head and Neck Cancer: A Systematic Review Shivam Patel, MD Penn State Health Clinical and Immunological Profile of Patients with Immune-Related Adverse Effects Following Treatment with Immune Checkpoint Inhibitors Angela Alnemri, MD Thomas Jefferson University Hospital Resident Jeopardy Bowl Winner: UPMC Pittsburgh Congratulations to the following winners: First Place Poster: Implant Failure and Osteomyelitis in the Setting of Selective Serotonin Reuptake Inhibitor Usage: A Case Report & Review of the Literature Katie Melder, MD University of Pittsburgh Second Place Poster: Post treatment Surveillance in Sinonasal Malignancies Prachi Patel, MD Thomas Jefferson University Hospital First Place Oral Presentation: Multi-institutional study utilizing surgery + cesium-131 brachytherapy in recurrent head and neck cancer Adam Luginbuhl, MD Thomas Jefferson University Hospital Second Place Oral Presentation: Analysis of spatial relationships between CD8 and FoxP3 cells using digital imaging in head and neck squamous cell carcinoma Uche Nwagu, MD Thomas Jefferson University Hospital Second Place Oral Presentation: Clinical Implications of the Integration Status of HPV in Head and Neck Cancer Brandon LaBarge, MD Penn State Health Resident Quizzo winners: Will Kennedy, MD and Ravi Shah, MD from the University of Pennsylvania. Congratulations to the following winners: First Place Oral Presentation: A Computer-Learning Neural Network Algorithm for the Radiographic Assessment of Thyroid Nodules : A Pilot Study Kelly Daniels Sidney Kimmel Medical College at Thomas Jefferson University Second Place Oral Presentation: Assessment of cranial base repair techniques in a validated cadaveric CPAP model Chandala Chitguppi, MD Thomas Jefferson University Hospital First Place Poster: Innervation of the Cricothyroid Muscle by the Recurrent Laryngeal Nerve and Implications for Clinical Practice Thomas Kaffenberger, MD University of Pittsburgh Medical Center Second Place Poster: Impact of gender on upper airway stimulation outcomes Kelly Daniels Sidney Kimmel Medical College at Thomas Jefferson University Resident Jeopardy Bowl Winners: B. Swendseid, MD, M. Chaskes, MD and J. Goldfarb, MD from Thomas Jefferson University Hospital Congratulations to the following winners: First Place Oral Presentation: Defining the role of CD169 macrophages in lymph node metastasis Michael Topf, MD Lewis Katz School of Medicine at Temple University Second Place Oral Presentation: High-Level Disinfection of Otorhinolaryngology Clinical Instruments: An Evaluation of the Efficacy and Cost-effectiveness of Instrument Storage Jason Yu, MD University of Pennsylvania Second Place Oral Presentation: Identification of Causative Mutations in Two Unrelated Kindreds with Familial Nonmedullary Thyroid Cancer Using Next-Generation Sequencing Darrin Bann Penn State Health Milton S. Hershey Medical Center First Place Poster: Quality of Life Comparison of exenterated versus non-exenterated patients with sinonasal and craniofacial malignancies Alexander Graf, MD Thomas Jefferson University Hospital Second Place Poster: Perfusion Dynamics in Pedicled and Free Tissue Reconstruction: Infrared Thermography and Laser Fluorescence Video Angiography Tom Shokri, MD Penn State Health Milton S. Hershey Medical Center Resident Jeopardy Bowl Winners: UMPC & PCOM

Cosmetic and Reconstructive In This Section: Skin Cancer Reconstruction After Mohs Surgery Bleph Brow Botox Filler Facial Scarring Facial Paralysis Skin Cancer Reconstruction After Mohs Surgery Author: Michael Ondik, MD (Montgomery County ENT) Overview: Skin cancer is a very prevalent problem. The two most common forms of skin cancer are basal cell carcinoma and squamous cell carcinoma. These cancers are typically treated by excising the area containing the skin cancer. In certain areas such as the face, hands and feet, it is essential to remove the skin cancer while removing as little normal skin as possible. Mohs surgery is a technique performed by specially trained dermatologists which can help preserve normal tissue while removing the cancer. The resulting defect from the Mohs surgery may be repaired by an Ear, Nose & Throat Surgeon (ENT) using specialized Facial Plastics techniques to produce the most cosmetic scar possible. Symptoms: Skin cancer can present in a variety of manners. In general, squamous cell may appear as rough or red scaly patches and basal cell carcinomas will appear as a pearly or waxy bump or a scar-like flat, firm, pale area. Both types of cancers can appear as a non-healing ulcer or scab. Melanoma, the third most common form of skin cancer, usually appears a dark mole-like lesion that may bleed or itch. One technique to help identify melanomas versus a benign (or non-cancerous) mole is known as the ABCDE rule: A – Asymmetry: Benign moles tend to be symmetrical B – Border: Benign moles tend to have smooth, regular borders C – Color: Benign moles tend to have a uniform color D – Diameter: Benign moles tend be have a diameter of less than 6mm E – Evolving: Benign moles tend to look the same over time and not change What to Expect at Your Otolaryngologist Office Visit: If you have a lesion on your face or neck suspicious for a skin cancer, your ENT will first have to biopsy the area to determine if it is a cancer. A biopsy is a short procedure to remove either all or a portion of the lesion so it can be sent to the lab for examination. Your doctor with inject a local anesthetic into the area and either cut out or shave off the lesion. Depending on the size of the lesion a biopsy may be sufficient to remove the entire lesion, but often another procedure will be required to remove any remaining lesion (see next section below). Treatment: If the biopsy proves to be a skin cancer then the remaining lesion and surrounding area will need to be excised to ensure that no skin cancer remains. Your ENT may excise the cancer and close the defect or you may have the cancer treated by a Mohs surgeon in which case your ENT may be involved repairing the defect. There are several methods to close skin cancer defects. Small defects can usually be closed by slightly lengthening the defect into an elliptical shape and then stitching the edges together. Other defects may require additional incisions next to the defect to move adjacent skin in a technique known as a local flap. Depending the on the size, depth and location of the defect, a skin graft may be used. A graft is skin that is taken from another area (perhaps from behind the ear) and used to fill the defect. Particularly large or complex defects may require a regional flap in which skin is borrowed from another area of face (for example, cheek skin can be transferred to the nose). This is typically a two-stage procedure in which the patient will come back in a couple of weeks for a second final procedure. Finally, some cancer defects areas can be left to heal on their own without any suturing. Bleph Brow Author(s): Tom Shokri, MD (Penn State Hershey Medical Center): Jessyka G Lighthall, MD (Penn State Hershey Medical Center) Overview: Aging typically results in decreased elasticity of the skin and soft tissues of the face. This often results in the formation of lines across the forehead and between the eyes. As this soft tissue loses elasticity, the distance between the eyebrows and eyelashes also shortens, resulting in the perception of a lower brow. 1,2. This malpositioning of the brow, in addition to deepening of wrinkle may make one appear tired or angry. A brow lift can soften facial lines, raise the eyebrows and restore a softer, more pleasing appearance. A blepharoplasty is a surgical procedure that repairs droopy eyelids and may involve removal of excess soft tissues. Symptoms: You may be an appropriate candidate for a brow lift if you have: Creases across your forehead or high on the bridge of your nose, between your eyes. Vertical creases between your eyebrows. A low or sagging brow that's contributing to sagging upper eyelids. You may be an appropriate candidate for blepharoplasty if you have: Baggy or droopy upper eyelids Excess skin of the upper eyelids that interferes with your vision Excess skin on of the lower eyelids Bags under your eyes Severe sagging of skin around your eyes and eyelids may, in addition to being unsightly, have a functional impact on your vision. It may in fact reduce your peripheral vision, particularly in the upper and lower field of vision. Blepharoplasty may be helpful in reducing or eliminating vision problems that are attributable to excess skin while making you appear younger and less fatigued. What to Expect at Your Otolaryngologist Office Visit: Initially, your evaluation will begin with a review of your medical history. Be prepared to answer questions regarding your current and prior medical conditions. Your current medications will be reviewed as well as any surgical procedures you’ve had performed in the past. Tell your provider if you are allergic to any medications. To best determine your treatment options, the physician will then perform a physical exam. The provider may also take photographs for your medical record. It is important to have a frank discussion regarding your expectations during your initial visit. Explain your main concerns and your goals in terms of your appearance after your procedure. The risks, benefits, and realistic goals will be discussed. Prior to undergoing any procedures, your doctor will ask you to stop smoking. This is due to the fact that smoking decreases blood flow to areas and increases your risk of vascular disease. This results in considerable impairment to your healing process following surgery. Patients are instructed to avoid the use of anticoagulants (Warfarin, Eliquis) prior to surgery. The physician that manages your anticoagulants will need to determine how long prior to surgery you need to stop taking these medicines. Aspirin and nonsteroidal anti-inflammatory drugs should also be discontinued for at least 2 weeks before surgery. Smoking must be discontinued for at least 4 weeks before surgery. All herbal preparations, vitamins, and homeopathic treatments should also be avoided for 2 weeks before surgery because of the risk of postoperative bleeding and intraoperative anesthetic complications. Additionally, if you have chronic medical conditions, close communication will be required with your primary care physician, and any specialists involved in your care, to determine suitability for elective surgery and obtain medical clearance. Herbal supplements to avoid prior to surgery include: Ginkgo biloba , St. John’s wort, Echinacea, ginseng, valerian, glucosamine, vitamin C (>2000 mg daily) fever few, golden seal, vitamin E (>400 mg daily), Fish oils (omega-3 fatty acids), garlic, licorice, Kava, or Licorice. 3 Treatment: Both browlift and blepharoplasty are performed either in a hospital or outpatient surgical facility. During these procedures, you will be placed under general anesthesia –rendering you unconscious. These procedures vary on a case by case basis depending on desired results and an individual’s anatomy. The specific techniques used by your plastic surgeon for brow lifts may be one of the following.4, 5 Endoscopic Brow Lift: Incisions will be placed behind your hairline. An endoscope (a long telescope with a light source and camera) will be placed through the incisions to view the underlying tissue and aid in surgery. Using a different “port” or incision site, your surgeon will lift forehead tissues and anchor them in place using sutures. This technique reduces the number of incisions needed. Coronal Brow lift: Incisions are placed behind the hairline, across the top of your head, from one ear to the other. Your forehead will be lifted, with the scalp in front of the incision now overlapping the scalp which was behind it. This area of overlap is then removed and the remaining scalp is sutured in place. It should be noted that this technique is not performed in patients with high hairlines, thinning hair, or those likely to experience either, as this may lead to poor outcomes. Hairline brow lift: Your surgeon will make an incision at the border of the top of your forehead and the beginning of your hairline. Excess skin and soft tissue from your forehead will be removed. The scalp tissue is left unaltered and as a result your hairline will not be moved back. This technique in particularly is effective in addressing forehead wrinkles and is often used in patients with receding hairlines. However, due to the fact that the incision is not placed within the scalp, a scar may be visible although it will be well camouflaged along the hairline. Following blow lift surgery, your forehead may be taped and your head might be wrapped loosely to decrease swelling. A small plastic tube, a drain, may be placed along the incision line to drain any excess blood or fluid that may accumulate under the skin and soft tissue. Blepharoplasty is also performed in an outpatient setting. This procedure is often done in combination with a brow lift or may be done independently. A cut is made along the fold of the upper eyelid, and any excess soft tissue is removed. The incision is then closed and camouflaged within the eyelid crease. The lower lid incision is performed either below the eyelashes, within the natural crease, or inside the lower lid. Excess tissue is again removed and the incision closed. After your procedure you will likely spend sometime in the recovery room, where you are monitored. You then leave later the same day to recuperate at home. Your surgeon will discuss specifics regarding wound care with your following your procedure on the day of surgery. Further Reading: https://www.aafprs.org/patient/procedures/blepharoplasty.html https://www.mayoclinic.org/tests-procedures/brow-lift/basics/definition/prc-20087441 https://www.plasticsurgery.org/cosmetic-procedures/brow-lift/procedure References: Angelos P.C., Stallworth C.L., and Wang T.D.: Forehead lifting: state of the art. Facial Plast Surg 2011; 27: pp. 050-057 Knize D.M.: Anatomic concepts for brow lift procedures. Plast Reconstr Surg 2009; 124: pp. 2118-2126 Lighthall, J.G. and Wang, T.D., Complications of Forehead Lift. Facial plastic surgery clinics of North America 2013., 21(4),619-624. Chand M, Perkins SW. Comparison of surgical approaches for upper facial rejuvenation. Curr Opin Otolaryngol Head Neck Surg 2000;8(4):326–31 Shadfar S, Perkins SW. Surgical treatment of the brow and upper eyelid. Facial Plastic Surgery Clinics. 2015 May 1;23(2):167-83. Botox Filler Author(s): Tom Shokri, MD (Penn State Hershey Medical Center): Jessyka G Lighthall, MD (Penn State Hershey Medical Center) Overview Aging typically results in decreased elasticity of the skin and soft tissues of the face. This often results in the formation of lines across the glabella (wrinkles between your eyebrows) and crow’s feet. Since it’s initial approval by the Food and Drug Administration (FDA) in 2002, cosmetic use of Botulinum toxin has allowed surgeons to noninvasively treat facial aging. These treatments are widely popular due to their efficacy and noninvasive nature. Patient’s may receive in-office treatments without prolonged recovery time. Botox Cosmetic is currently FDA approved for treatment of glabellar lines, crow’s feet, and forehead lines. Off-label uses in various other areas of the face are common however. These injections use various forms of botulinum toxin to temporarily paralyze muscles activity. There are several brands of Botulinum Toxin-A used for aesthetic purposes. Botox (also known under the commercial names BOTOX Cosmetic, Vistabel, Vistabex; Allergan, Inc. Irvine, CA) is the most well-known brand. Other products include Dyport, Myobloc, and Xeomin. Botox works by blocking acetylcholine, a chemical that is responsible for transmitting electrical signals that result in muscle contraction. This results in temporary muscle paralysis, weakening overactive muscles that may be contributing to increased facial rhytids (wrinkles). When injected into these muscles, it results in a more relaxed and smoother appearance. Botulinum toxin is also used to treat other conditions including cervical dystonia (involuntary contraction of neck muscles), hyperhidrosis (excessive sweating), chronic migraines, muscle contractures, sialorrhea (excessive production of saliva), and various other conditions. Injectable fillers play a prominent role in facial rejuvenation, with more than 1.9 million treatments a year in the United States.1 Correcting facial volume loss with aging is the most common application. The immediacy, predictability, and safety of these procedures with no recovery time makes them a particularly useful therapy, much like Botox. Injectable fillers add volume, allowing for shape restoration, to the aging face and can be used in combination with various other treatments (laser therapy, Botox, brow lifts, etc.) allowing for a more complete approach to the aging face. Dermal fillers may be biocompatible or synthetic. Biocompatible fillers are typically resorbable and have a period of duration lasting approximately 6-12 months. Synthetic fillers are permanent but have previously been associated with migration, granuloma formation, and eliciting an immune response. There are few indications currently for use of synthetic fillers to correct age-related changes. Your doctor can discuss further questions regarding filler type. Symptoms: Botulinum Toxin can be used for: smoothening of crow’s feet, forehead furrows, frown lines, lip lines, and ‘bunny lines (wrinkles adjacent to the nose). It can also be used to diminish neck bands, improve dimpling of the chin, improve a gummy smile, lift the corners of the mouth for improvement in smiling, or soften a square jaw line. Dermal Fillers may be used to: plump thin lips, enhance shallow facial contours, soften facial creases and wrinkles, improve appearance of depressed scars, augment contour deformities of the face, decrease shadows due to lower eyelids. However, in certain patients, surgery such as facelift, brow lift, or blepharoplasty may be a more appropriate approach for facial rejuvenation. This may vary on your anatomy and your doctor will counsel you regarding the most appropriate approach for your specific concerns on initial consultation. What to Expect at Your Otolaryngologist Office Visit: Initially, your evaluation will begin with a review of your medical history. Be prepared to answer questions regarding your current and prior medical conditions. Your current medications will be reviewed as well as any surgical procedures you’ve had performed in the past. Tell your provider if you are allergic to any medications. To best determine your treatment options, the physician will then perform a physical exam. The provider may also take photographs for your medical record. It is important to have a frank discussion regarding your expectations during your initial visit. Explain your main concerns and your goals in terms of your appearance after your procedure. The risks, benefits, and realistic goals will be discussed. Tell your doctor if you have received any type of botulinum treatment within the past four months. Also, inform your physician if you are taking any muscle relaxants, sleeping aids, or allergy medications. In certain circumstances, if you are taking blood thinners, you may have to discontinue them for several days prior to your injection. This is in order to reduce your risk of bleeding or excessive bruising. You will be asked to discuss this with the physician that manages your blood thinning medication prior to cessation of this medication. Treatment: Most individuals tolerate injections without significant discomfort. Your doctor may use one or more of several methods to numb the area prior to injection. These include: topical anesthesia, or ice and vibration anesthesia, using massage to reduce discomfort. These injections are performed in the office and do not require general anesthesia. A thin needle will then be used to inject aliquots of botulinum toxin into your muscles. The number and dosage of injections will vary depending on many factors, including the extent of the area being treated. Following, the procedure you can expect to resume your normal daily activities. Initially, you should attempt to refrain from rubbing or massaging the injected areas as this may cause the Botox to migrate to adjacent areas. Botox will typically take effect in 24-72 hours after injection. Its maximum effect is seen in about 1-2 weeks following injection. The aesthetic effects of Botox typically last three to four months. As the treated muscles regain movement, lines and wrinkles may begin to reappear prompting patients to return for further treatments. Over time, these lines and wrinkles may appear to be less noticeable due to retraining of the muscles to relax and a decreased reliance on them for expression. Treatment with dermal fillers is similar to that of Botox. Anticipated injection sites will be cleansed with antibacterial agent. Injections are typically well tolerated with minor discomfort as above. Depending on the extent of treatment, the entire process may take 15 minutes or as long as an hour. An ice pack will be used following treatment to decrease swelling and alleviate minor discomfort. You are then able to resume your normal activities. Further Reading: https://www.aafprs.org/media/media_resources/fact_botox.html https://www.aafprs.org/media/press-release/20160822.html https://www.plasticsurgery.org/cosmetic-procedures/botulinum-toxin https://www.plasticsurgery.org/cosmetic-procedures/dermal-fillers https://www.aafprs.org/patient/procedures/wrinkles.html References: http://www.surgery.org/sites/default/files/2014-Stats.pdf . Bass, L.S., 2015. Injectable filler techniques for facial rejuvenation, volumization, and augmentation. Facial Plastic Surgery Clinics, 23(4), pp.479-488. Dayan, S.H. and Maas, C.S., 2007. Botulinum toxins for facial wrinkles: beyond glabellar lines. Facial Plastic Surgery Clinics, 15(1), pp.41-49. Facial Scarring Author(s): Tom Shokri, MD (Penn State Hershey Medical Center): Jessyka G Lighthall, MD (Penn State Hershey Medical Center) Overview: Scarring may result following injury sustained to the skin and soft tissues after surgery or trauma. The amount of overlying skin loss affects not only the appearance of scars but the degree with which surrounding areas are distorted as well. The degree of scar deformity is influenced by extent of soft tissue loss, scar orientation, position with respect to certain facial landmarks, patient age, and genetic factors which may influence the healing process and scar formation. Scar revision involves optimization of the appearance of the scar. Ideally, scars are thin, flat, and match the color of the surrounding skin with orientation along relaxed skin tension lines or wrinkles. Scar revision procedures aim to change the characteristics of scars in such a way that they become more ideal. Of course, there are limitations imposed by the extent of the scar, shape, neighboring landmarks, and variable healing. It is important to note that the goal of this procedure is to alter a poor scar into a better appearing, less noticeable, scar. Symptoms: Different types of scars include: -Discolored scars/surface irregularities -Hypertrophic scars (thick clusters of scarred tissue; often raised with changes to pigmentation) -Keloids (typically larger than hypertrophic scars, maybe painful or itchy, and extend beyond edges of the original wound) Contracture: restrict functional movement due to scarring and resultant tethering of underlying tissue. The type of scar you have, in addition to its extent and distribution, will determine the appropriate techniques your plastic surgeon will use in revising it. What to Expect at Your Otolaryngologist Office Visit: Initially, your evaluation will begin with a review of your medical history. Be prepared to answer questions regarding your current and prior medical conditions. Your current medications will be reviewed as well as any surgical procedures you’ve had performed in the past. Tell your provider if you are allergic to any medications. To best determine your treatment options, the physician will then perform a physical exam. The provider may also take photographs for your medical record. It is important to have a frank discussion regarding your expectations during your initial visit. Explain your main concerns and your goals in terms of your appearance after your procedure. The risks, benefits, and realistic goals will be discussed. Prior to undergoing any procedures, your doctor will ask you to stop smoking. This is due to the fact that smoking decreases blood flow to areas and increases your risk of vascular disease. This results in considerable impairment to your healing process following surgery. Patients are instructed to avoid the use of anticoagulants (Warfarin, Eliquis) prior to surgery. The physician that manages your anticoagulants will need to determine how long prior to surgery you need to stop taking these medicines. Aspirin and nonsteroidal anti-inflammatory drugs should also be discontinued for at least 2 weeks before surgery. Smoking must be discontinued for at least 4 weeks before surgery. All herbal preparations, vitamins, and homeopathic treatments should also be avoided for 2 weeks before surgery because of the risk of postoperative bleeding and intraoperative anesthetic complications. Additionally, if you have chronic medical conditions, close communication will be required with your primary care physician, and any specialists involved in your care, to determine suitability for elective surgery and obtain medical clearance. Herbal supplements to avoid prior to surgery include: Ginkgo Biloba, St. John’s wort, Echinacea, ginseng, valerian, glucosamine, vitamin C (>2000 mg daily) fever few, golden seal, vitamin E (>400 mg daily), Fish oils (omega-3 fatty acids), garlic, licorice, Kava, or Licorice Scar revision minimizes scars, making them less conspicuous allowing them to blend in with surrounding skin. Your physician will remind you that scars are unavoidable results of injury and their progression may be unpredictable. Although scar revision can decrease scarring in a controlled manner, the scar cannot be completely erased. Your doctor will recommend the best choice for you. Treatment: You will be kept comfortable during your procedure through the administration of medications including local or general anesthesia, or intravenous sedation. Your procedure may be performed either in the operating room or in the office depending on the extent of the surgery and your general health. The specific type of scar revision procedure you undergo will be dependent on the severity of your scarring. The type, location, and size of your scar will be taken into consideration. A combination of techniques may be recommended by your surgeon to achieve optimal results. Topical treatments including silicone gels, tapes, or external compressive dressings may help wound closure and healing. These products may be used to aid in the healing process following your procedures. Injectable treatments, such as Dermal fillers, may be used to augment depressed or concave scars. These treatments are typically repeated to maintain results. Injection of steroid-based compounds may reduce scar formation and can help alter the texture, size, and appearance of your scar. Surface treatments such as dermabrasion, laser therapy, chemical peels, or skin bleaching agents may be recommended as well. Advanced techniques in scar revision may be required including excision of your scar with complex closure patterns such as W-plasty or Z-plasty techniques aimed at better hiding the scar with irregular patterns. Local tissue rearrangements may be performed to reposition a scar so that it is less conspicuous. Further Reading: https://www.plasticsurgery.org/reconstructive-procedures/scar-revision References: Garg, S., Dahiya, N. and Gupta, S., 2014. Surgical scar revision: an overview. Journal of cutaneous and aesthetic surgery, 7(1), p.3. Shockley, W.W., 2011. Scar revision techniques: z-plasty, w-plasty, and geometric broken line closure. Facial plastic surgery clinics of North America, 19(3), pp.455-463 Facial Paralysis Author(s): Tom Shokri, MD (Penn State Hershey Medical Center): Jessyka G Lighthall, MD (Penn State Hershey Medical Center) Overview: The seventh cranial nerve (also known as the Facial Nerve) primarily serves a motor function (some fibers control a sensory component in the external auditory canal, salivation, or taste along the anterior tongue). Injury to the nerve, anywhere along its distribution from the facial nerve nucleus within the brainstem to its final innervation of the muscles of facial expression, may cause weakness or complete paralysis of the face. Symptoms: Facial paralysis can result in one side of the face being partially or completely paralyzed. This may cause: eyebrow sagging, drooping of the eye, and corner of the mouth, incomplete closure of the eye, nasal obstruction, epiphora (overflow of tears in the eye), or minor changes to hearing. What to Expect at Your Otolaryngologist Office Visit: Initially, your evaluation will begin with a review of your medical history. Be prepared to answer questions regarding your current and prior medical conditions. Your current medications will be reviewed as well as any surgical procedures you’ve had performed in the past. Tell your provider if you are allergic to any medications. To best determine your treatment options, the physician will then perform a physical exam. The provider may also take photographs for your medical record. It is important to have a frank discussion regarding your expectations during your initial visit. Explain your main concerns and your goals with respect to your appearance. The risks, benefits, and realistic goals will be discussed. If specific risk factors for a particular etiology are identified during your examination, then laboratory testing as well as imaging will be directed toward supporting or excluding a particular cause. Your doctor will order blood work to rule out any underlying infectious cause for your facial paralysis (Lyme disease, Herpes Zoster, etc.) or autoimmune condition. A CT scan with contrast of the face/neck and temporal bone or an MRI with contrast may be ordered to visualize possible sites of injury along the course of the facial nerve. Additionally, if a stroke or neural injury is suspected imaging may be recommended to rule this out. For patients with complete facial paralysis, a electrophysiological test will likely be ordered 3-5 days following injury. Electroneuronography (ENoG) involves placement of electrodes that stimulate the facial nerve and measure muscle activity. If this test demonstrates greater than 90% degeneration, surgical decompression may be considered. This involves removal of the bony surroundings of the nerve. The need for surgery is addressed on case by case basis and is not recommended universally to all patients. Treatment: Steroids are effective in the treatment of facial nerve palsy. A steroid taper will be prescribed by your surgeon and should optimally be given within 72 hours of presentation of your symptoms. There is a moderate amount of evidence suggesting that adding antiviral medications to your steroid regimen may improve outcomes. This remains controversial although there are no significant adverse side effects to the medication. You will likely be referred to a Facial Nerve Center for reassessment of your facial paralysis and monitoring of your response to therapy. If you are unable to close your eye completely, lubricating eye drops and ointment will be recommended in addition to an eye moisture chamber which will allow for adequate moisturization of the globe and prevent injury to the cornea. If there is suspicion of injury to your eye, you may be referred to an ophthalmologist for further assessment. This is important in preventing irreversible blindness from corneal exposure and injury. If it is suspected that your paralysis is due to Lyme Disease, you will be given an antibiotic, this may be in addition to steroid treatment. Your provider will reassess your response to therapy within several weeks. The late phase of treatment of facial paralysis is directed toward any residual facial movement deficits. Your surgeon will discuss any specific surgical interventions or long term therapies based on your symptoms. A number of medical and surgical options are available to treat patients who have long-term sequelae. Further Reading: References: Sajadi MM, Sajadi MR, Tabatabaie SM. The history of facial palsy and spasm: Hippocrates to Razi. Neurology 2011;77:174–8. Adour KK, Byl FM, Hilsinger RL Jr, et al. The true nature of Bell’s palsy: analysis of 1,000 consecutive patients. Laryngoscope 1978;88:787–801. Peitersen E. Bell’s palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies. Acta Otolaryngol Suppl 2002;(549):4–30. 4. De Diego JI, Prim MP, Madero R, et al. Seasonal patterns of idiopathic facial paralysis: a 16-year study. Otolaryngol Head Neck Surg 1999;120:269–71. 5. Marson AG, Salinas R. Bell’s palsy. West J Med 2000;173:266–8. 6. Peitersen E. The natural history of Bell’s palsy. Am J Otol 1982;4:107–11. 7. Greco A, Gallo A, Fusconi M, et al. Bell’s palsy and autoimmunity. Autoimmun Rev 2012;12:323–8. 8. Eviston TJ, Croxson GR, Kennedy PG, et al. Bell’s palsy: aetiology, clinical features and multidisciplinary care. J Neurol Neurosurg Psychiatry 2015. [Epub ahead of print]. 9. Murakami S, Mizobuchi M, Nakashiro Y, et al. Bell palsy and herpes simplex virus: identification of viral DNA in endoneurial fluid and muscle. Ann Intern Med 1996;124:27–30. 10. Furuta Y, Ohtani F, Sawa H, et al. Quantitation of varicella-zoster virus DNA in patients with Ramsay Hunt syndrome and zoster sine herpete. J Clin Microbiol 2001;39:2856–9. 11. Michaels L. Histopathological changes in the temporal bone in Bell’s palsy. Acta Otolaryngol Suppl 1990;470:114–7 [discussion: 118]. 12. Baugh RF, Basura GJ, Ishii LE, et al. Clinical practice guideline: Bell’s palsy. Otolaryngol Head Neck Surg 2013;149:S1–27. 13. Ross BG, Fradet G, Nedzelski JM. Development of a sensitive clinical facial grading system. Otolaryngol Head Neck Surg 1996;114:380–6. 14. House JW, Brackmann DE. Facial nerve grading system. Otolaryngol Head Neck Surg 1985;93: 146–7. 15. Nowak DA, Linder S, Topka H. Diagnostic relevance of transcranial magnetic and electric stimulation of

Member Benefits The following are the benefits you will receive as a member of PAO-HNS: Soundings Newsletter Members receive hard copies of Soundings, the PAO-HNS member newsletter. Legislative Representation Representation in the state legislature via our own lobbyist. Direct Input with Medicare Representation on the Novitas Solutions Carrier Advisory Committee (CAC), which has input into local Medicare reimbursement policy. Specialty Events Listings Members may post their specialty events at no cost. Priority Review for ENT Journals Priority review for possible publication in ENT Journal, the official journal of the PAO-HNS. National Representation Representation on the American Academy of Otolaryngology-Head Neck and Neck Surgery's Board of Governors. Discounted Registration for Annual Science Meeting Discounted registration to our annual Scientific Meeting featuring CME-approved educational seminars focused on current otolaryngology topics and family-oriented social functions.

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Nose, Sinus, and Allergy In This Section: Allergic Rhinitis Aspirin Exacerbated Respiratory Disease (AERD) Chronic Rhinosinusitis (CRS) Deviated Nasal Septum Allergic Rhinitis Authors: Heather N. Ungerer, BA (University of Pennsylvania Hospital), Nithin D. Adappa, MD (University of Pennsylvania Hospital) Overview: Allergic Rhinitis is an inflammatory condition characterized by hypersensitive and overreactive immune system responses to allergens (otherwise harmless substances that do not cause symptoms for other individuals). Common allergens include pollen, airborne mold spores, animal dander, cockroach particles and dust mites. In patients with allergic rhinitis, the immune system responds to allergens by releasing histamine, a chemical that causes a variety of symptoms in the nose, throat, eyes, ears, and skin.[1] Allergic rhinitis can be either seasonal or perennial (year-around). Patients with seasonal allergic rhinitis will notice flare-ups in symptoms around the changing of the seasons or during certain times of the year. Allergic rhinitis is a common condition that impacts over 24 million people in the United States and between 10-30% of the worldwide population[2] [3] . A common variant of allergic rhinitis is nonallergic rhinitis with eosinophilia syndrome (NARES). NARES is a condition of unknown cause but presents with symptoms similar to that of allergic rhinitis. The primary difference between allergic rhinitis and NARES is that patients with NARES will test negative to allergens in skin tests or blood tests. Additionally, a key component of NARES is the presence of eosinophils (a type of white blood cell) in nasal secretions. While the cause remains unknown, treatment for NARES generally consists of steroid nasal sprays which can be combined with antihistamines. Symptoms: Patients with Allergic rhinitis may experience a combination of any of the following symptoms: Rhinorrhea (runny nose) or nasal obstruction Itchy or watery eyes Itchy skin or mouth Sneezing Sore or irritated throat accompanied by a cough Fatigue Headaches What to expect at your office visit: Your office visit will begin with your allergist or otolaryngologist asking you detailed questions about the onset and nature of your symptoms in addition to questions about your lifestyle in order to identify the cause of your symptoms. Important considerations include your work conditions, home conditions, exposure to household pets, geographical factors, and family medical history. A clinical diagnosis can be made based on the characteristics of the symptoms, however, in most cases your physician will recommend allergy testing in order to determine specific allergies and the severity of each. If you are experiencing severe nasal symptoms, your physician may also perform a nasal endoscopy during which a nasal endoscope, a long, thin device with a camera and light at the end, is used to access and view your sinuses. Treatment: Treatment of allergic rhinitis depends on symptoms and severity. Luckily, there are a variety of options available. Lifestyle changes (replacing carpet, air filters, using humidifiers, protective bedding) Patients benefit from small lifestyle changes that reduce their exposure to certain allergens. Airborne particulate matter can be controlled by regularly replacing air filters or using a stand-alone air filter. Dusting hardwood surfaces, vacuuming carpeted floors, and using protective bedding to control exposure to dust mites has also proved beneficial to patients with specific dust mite allergies. Antihistamines Antihistamines act by limiting the amount of histamine produced by the immune system when exposed to an irritating allergen. This mediates the body’s response to the allergen. Many over the counter options are available as either oral tablets, nasal sprays, or eye drops. Some common antihistamines include Loratadine, Ceterizine, and Fexofenadine. Please consult your doctor before beginning a new medication. Decongestants Decongestants are often confused with antihistamines. While antihistamines can help with itching and sneezing, decongestants target the inflammation inside your nose that makes you feel congested or experience sinus pressure. Decongestants are readily available over the counter but can also be prescribed in more severe cases. Decongestants should only be used for a few days at a time, otherwise side effects may occur and result in a worsening of symptoms. Immunotherapy (allergy shots) Immunotherapy, or allergy shots, is an effective way to manage allergic rhinitis that has otherwise failed to respond to medication. Immunotherapy is a long-term treatment option that can last anywhere from 3-5 years. Patients undergoing immunotherapy are incrementally exposed to the allergen(s) that cause their symptomatic response, thereby actually training the immune system to become less sensitive to the allergen. Initially, shots are administered once or twice weekly until a maintenance dose is reached. Once patients are in the maintenance phase, allergy shots are administered every two to four weeks. [1] https://www.aaaai.org/conditions-and-treatments/allergies/rhinitis [2] http://www.aafa.org/allergy-facts/ [3] https://www.healthline.com/health/allergic-rhinitis Aspirin Exacerbated Respiratory Disease (AERD) Authors: Heather N. Ungerer, BA (University of Pennsylvania Hospital), Nithin D. Adappa, MD (University of Pennsylvania Hospital) Overview: Aspirin Exacerbated Respiratory Disease (AERD), formerly known as Samter’s Triad, is a chronic inflammatory condition and a difficult to treat variant of asthma, known for its triad of symptoms: nasal polyps, asthma, and hypersensitivity or allergy to non-steroid anti-inflammatory drugs (NSAIDs) including Aspirin. Patients with AERD experience acute reactions that mimic an asthma attack when exposed to NSAIDs. AERD is an acquired condition with no known cause and generally presents around age 30-40. Symptoms: Patients with AERD will find themselves suffering from all of the following symptoms: Sensitivity to non-steroid anti-inflammatory drugs (NSAIDs) including Aspirin Nasal Polyps Asthma These symptoms can present in any order and are often accompanied by chronic rhinosinusitis and anosmia (loss of the sense of smell). What to expect at your office visit: Your office visit will begin with your physician asking you questions about the onset and nature of your symptoms in order to gain an understanding of the duration and severity. In cases where a patient has a known history of NSAID sensitivity, asthma and nasal polyps, a diagnosis can be made with minimal further testing. Your doctor will use a nasal endoscope, which is a long, thin device with a camera and light at the end, to access and view your sinuses to determine the presence of nasal polyps. You may also be asked to obtain a CT of your sinuses which will allow your physician to visualize areas unable to be accessed with the endoscope. If NSAID sensitivity is unknown, your physician may also recommend an aspirin challenge during which you will be exposed to a small amount of aspirin to see if you have a respiratory response in a carefully monitored medical setting. Treatment: Treatment of AERD is a multifaceted process that almost always involves surgical intervention, aspirin desensitization and long-term aspirin therapy. Once a positive diagnosis of AERD has been made your physician will discuss sinus surgery in order to remove nasal polyps. You can expect approximately four to six weeks after surgery to undergo aspirin desensitization. Aspirin desensitization is a procedure in a closely monitored clinical setting where you are incrementally exposed to a higher dose of aspirin until you are able to tolerate the dosage with no adverse systemic reactions. After this, your physician will place you on a daily aspirin regimen. Over time, the dosage will be lowered until you are on a maintenance dose daily. AERD is one of the most difficult forms of chronic rhinosinusitis and nasal polyposis to manage. Data supports this multidisciplinary approach as patients who are not correctly treated have multiple surgeries and continue to be symptomatic. Chronic Rhinosinusitis (CRS) Authors: Heather N. Ungerer, BA (University of Pennsylvania Hospital), Nithin D. Adappa, MD (University of Pennsylvania Hospital) Overview: Sinuses are small, air filled cavities between the bones of the head and face. Healthy sinuses are lined with soft tissue called mucosa and a thin layer of mucus. This thin layer of mucus lubricates your nose and acts to drain out allergens and bacteria down the back of your throat. Chronic Rhinosinusitis is a condition in which the sinuses become inflamed for a period of twelve weeks or longer. This inflammation disrupts the normal drainage of mucus, causing it to accumulate within the sinuses. The causes of CRS are multifaceted and are most commonly a result of the body’s natural inflammatory response to allergens and other airborne particulates. Chronic rhinosinusitis can also be due in part to chronic infections which lead patients to become chronically inflamed and swollen. The physical structure of the sinuses, including a deviated nasal septum and/or nasal polyps, respiratory disorders such as cystic fibrosis, autoimmune disorders and immunosuppressant drugs are also related to chronic rhinosinusitis. Symptoms: Patients with CRS will find themselves suffering from two or more of the four following symptoms: Facial pain or pressure or headaches around and above the eyes Thick, discolored drainage running from the nose or down the throat Congestion and nasal obstruction and difficulty breathing through the nose Loss of sense of smell What to expect at your office visit: Your office visit will begin with your physician asking you questions about the onset and nature of your symptoms in order to gain an understanding of the duration, severity and potential causes of your condition. In order to make an accurate diagnosis of your condition your doctor will use a nasal endoscope, which is a long, thin device with a camera and light at the end, to access and view your sinuses. You may be asked to obtain a CT of your sinuses which will allow your physician to visualize areas unable to be accessed with the endoscope. Your physician may also take a culture of your sinuses to determine if a bacteria is present. Treatment: If you are actively infected at the time of your visit you can expect to be prescribed a course of antibiotics and/or a steroid taper. Additional therapies may include routine sinus rinses. This can be done with an OTC nasal irrigation squeeze bottle and either a plain saline solution or with steroids and/or antibiotics that can be added to the saline. In some cases, nasal sprays will also be prescribed. Patients with severe allergy induced inflammation can expect to be directed to their local allergist for evaluation and potential immunotherapy/allergy shots. For patients with a history of long-term sinus disease, lasting over 3 months, who have exhausted all medical management, surgery is an option. Sinus surgery is also commonly known as Functional Endoscopic Sinus Surgery or FESS. Patients undergoing functional endoscopic sinus surgery can expect their surgeon to open up their sinuses by removing small bony partitions and all purulent drainage. If you have a deviated nasal septum, your surgeon will also perform a septoplasty to straighten the septum. In the case of nasal polyps, your surgeon will also remove these during surgery. In general, the vast majority of patients do well with surgery but must continue long-term with nasal rinses and allergy management (if necessary). References: https://www.uptodate.com/contents/chronic-rhinosinusitis-beyond-the-basics http://www.entnorthtexas.com/Documents/Sinus%20Surgery%20Description.pdf https://www.americansinus.com/where-does-sinus-drainage-go/ Deviated Nasal Septum Authors: Heather N. Ungerer, BA (University of Pennsylvania Hospital), Nithin D. Adappa, MD (University of Pennsylvania Hospital) Overview: A nasal septum is the piece of cartilage and bone that separates the two sides of the nasal cavity. A deviated septum is a common condition that occurs when the septum is bent, or deviated, causing one side of the nasal cavity to be narrower than the other. While patients with severe deviations can present with a variety of symptoms, most patients with a deviated septum are asymptomatic and unaware that they have a deviation. A patient with a severely deviated septum often has difficulty breathing through one side of their nose and may notice an unusual amount of nasal obstruction from one or both sides of the nose. A deviated nasal septum can be present at birth or can result from trauma to the face and nose leading to misalignment of the septum. It is important to note that a deviated septum is often not visible from the outside of the nose and does not necessarily change the apparent structure of the nose itself. Symptoms: The most common symptom of a deviated nasal septum is nasal obstruction which leads to difficulty breathing and the feeling of congestion, predominately from one side of the nose. Other symptoms include: Nosebleeds Snoring or loud breathing during sleep Headaches or facial pain Frequent or seemingly constant sinus infections What to expect at your office visit: Your office visit will begin with your physician asking you questions about the onset and nature of your symptoms. In order to make an accurate diagnosis of your condition your doctor will use a nasal endoscope, which is a long, thin device with a camera and light at the end, to access and view your septum and your sinuses. You may also be asked to obtain a CT of your sinuses which will allow your physician to more clearly visualize the severity of your septal deviation. Treatment: Currently, the only treatment for a deviated nasal septum is a surgical procedure called a septoplasty. During a septoplasty, your surgeon will straighten your septum by removing parts of the septum, repositioning them and then reinserting them. The pieces are then held in place by dissolvable stiches. Patients can generally expect 1-2 follow up visits with their surgeon to make sure that the septum has healed properly and in the correct position. Rather than surgery, patients can also attempt to manage symptoms caused by their deviated septum. Initial treatment consists of nasal steroid sprays. While nasal steroid sprays will not help the deviated septum, they act to shrink the inferior turbinates which will allow more airflow through your nasal cavities decreasing the amount of nasal obstruction. If this is not successful, surgery is the next option.

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