UW ENT Grand Rounds November 19th, 2008

6:30 am – John S. Rhee, MD, MPH, Associate Professor, Division of Facial Plastic Surgery, Dept of Otolaryngology, Medical College of Wisconsin “Anatomic Nasal Airway Obstruction:  A Model of Integrative Outcomes Research”7:30 am – Matthew Old, MD, Head and Neck Fellow, Otolaryngology-Head and Neck Surgery, Vanderbilt University “Head and Neck Surgery: The Nigerian Experience” 

Dr. John Rhee presented his research with an emphasis on standardizing surgical outcomes. He admits a few interesting things. First, there are few clinically practical objective measures of airflow. Second, most airway flow is measured clinically using subjective NOSE (Nasal Obstruction Symptom Evaluation) scores. He went on to describe how latex and computer modeling is being used to evaluate the effect of various surgical interventions on airflow.

Next Dr. Matthew Old presented an amazing look into his surgical travels to Nigeria. What was most impressive was his willingness to work in conditions most of us would never dream of. For example, Dr. Old (who is really quite young) had us all gasping at what the Nigerian clinic called “sterile.” It involved dumping bloodied lap sponges and gloves on the floor and moving them to a sink where they would be water-rinsed for reuse. He mentioned that sadly, if a patient was found to be HIV antibody positive (by 2010 incidence in Nigeria will exceed 10 million – the world’s third largest HIV infected population), they were disqualified from much needed head and neck surgeries. The reason? Less than 10% of those infected are receiving anti-retroviral treatment and the likelihood that they will succumb to HIV related illness is almost assured. As a physician who treats cases of mild to moderate sinus trouble, I was shocked and severely humbled by Dr. Old’s experience. It was inspiring to be in the company of a humanitarian who offered us this “armchair” tour of such sadness. 

I’ve got a few observations. Upon viewing a computer model of peri-turbinate airflow, I was impressed by the “absolute zero” nature of flow at the distal recesses of the meatuses (nasal passageways). Given the spiral nature of the turbinates, I wondered how well even normal meatuses discharge dust, pollens, and pollutants – not to mention bacteria, spores, and viruses.

Next, the computer modeling and statement of difficulty measuring airflow in everyday life got me thinking: What is optimal airflow? Who defines it? Well, it should be the patient. Right? Is there a meaningful objective measure for “perfect” airflow? And if there were, should it matter to a person with chronic nasal congestion? I think the answer is, of course, treat the cause and symptoms to the patient’s satisfaction. REST does this quite well 9 times out of 10.

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