Understanding the Use of Polycaprolactone in East Asian Structural Rhinoplasty: Questions and Answers

Surgery as an art in rhinoplasty involves grafting techniques wherein materials (usually autologous) are taken from the septum and supplemented by conchal cartilage. However, not all noses have adequate cartilage material. The quest for materials as possible replacement for human tissue have led to invention of synthetic (e.g. silicone, e-PTFE, porous polyethelene) and non-synthetic products (e.g. processed homograft and xenograft). In this era of advanced medical science, tissue engineering has started the use polycaprolactone (PCL) as a template and scaffold for tissue growth. Because of this characteristic feature, PCL as a mesh has a significant role in structural rhinoplasty. What is structural rhinoplasty? The surgical goal of rhinoplasty is to achieve functional improvement in breathing and aesthetic overall look, most notably the tip. The tip is determined by the final shape of the lower cartilage in its proper location - - but since the lower cartilage is a floating structure supported only by fibrous tissue and ligaments, there is a high incidence of tip drooping post op. So, the idea of structured rhinoplasty was conceptualized in 1997 by Dr. Byrd and popularized by Dr. Toriumi.1,2 A piece of central septum is harvested and fashioned as an extension of the caudal margin of the septum. This is called a septal extension graft (SEG) and the lower cartilage is sutured to the caudal margin of the SEG for better control of the tip. Since then, the technique has been the main workhorse support graft for the tip.3 (Figure 1) Why is structural rhinoplasty needed in East Asian noses? East Asian noses, particularly Southeast Asian noses are usually short and small, with low dorsum and upturned bulbous nose. Tremendous strength in the design of the structural support with its foundation base at the caudal septum should be achieved in order to elongate the nose, counter rotate and project the tip. (Figure 2) This is made possible by using the central harvested cartilage as a SEG attached to the residual strong dorsal and caudal strut.4 (Figure 3)

Oliverio O. Segura, MD (1933-2021) Through A Son’s Eyes – A Tribute to Dad

I was born and raised in the old mining town of Barrio DAS (Don Andres Soriano), Lutopan, Toledo City where Atlas Consolidated Mining and Development Corp. (ACMDC) is situated. Dad started his practice in the company’s hospital as an EENT specialist in the early 60’s and was the ‘go to’ EENT Doc not only of nearby towns or cities (including Cebu City) but also the surrounding provinces in the early 70’s. In my elementary years, he was Assistant Director of ACMDC Hospital (we lived just behind in company housing, only a 3-minute walk). I grew interested in what my dad did, sometimes staying in his clinic an hour or so after school, amazed at how efficiently he handled his patients who always felt so satisfied seeing him. At the end of the day, there was always ‘buyot’ (basket) of vegetables, live chickens, freshwater crabs, crayfish, catfish or tilapia. I wondered if he went marketing earlier, but knew he was too busy for that (and mom did that) until I noticed endless lines of patients outside and remembered when he would say: “Being a doctor here - you’ll never go hungry!” I later realized they were PFs (professional fees) of his patients. As a company doctor, Dad received a fixed salary, free housing, utilities, gasoline, schooling for kids and a company car. It was the perfect life! The company even sponsored his further training in Johns-Hopkins, Baltimore, USA. A family man, he loved us so much and was a bit of a joker too, especially at mealtimes. Dad’s daily routine was from 8 am – 5 pm and changed into his tennis, pelota, or badminton outfit. He was the athlete, winning trophies and medals in local sports matches. Dad wanted me to go to the University of the Philippines (UP) High School in the city. I thought a change of environment would be interesting, but I would miss my friends. Anyway, I complied and there I started to understand that my dad was not just an EENT practicing in the Mines but was teaching in Cebu Institute of Medicine and Cebu Doctors College of Medicine (CDCM) and was a consultant in most of the hospitals in Cebu City. And still he went back up to the mountains, back to Lutopan, our mining town where our home was. The old ACMDC hospital was replaced with a new state-of-the-art hospital now named ACMDC Medical Center, complete with Burn Unit, Trauma center and an observation deck in the OR for teaching interns from CDCM. Dad enjoyed teaching them. Most of them are consultants today who are so fond of my dad that they always send their regards when they see me. My dad loved making model airplanes, vehicles, etc. and I realized I had that skill when I was 8 years old and I made my first airplane model. He used to build them out of Balsa wood which is so skillful. I can’t be half the man he was but I realized this hobby enhanced his surgical skills. My dad was so diplomatic and just said to get an engineering course before you become a pilot (most of dads brothers are engineers). I actually gave engineering a go, but after 1 ½ years I realized I was not cut out for it. I actually loved Biology and anything dealing with life and with all the exposure to my dad’s clinic and hospital activities … med school it was! At this point, my dad was already President of the ORL Central Visayas Chapter and was head of ENT Products and Hearing Center. As a graduate of the UP College of Medicine who finished Otorhinolaryngology residency with an additional year in Ophthalmology as one of the last EENTs to finish in UP PGH in the late 50’s, he hinted that if I finished my medical schooling in CDCM that I consider Otorhinolaryngology as a residency program and that UP-PGH would be a good training center. I ended up inheriting the ORL practice of my dad mostly, who taught me some of Ophthalmology outpatient procedures. Dad showed me clinical and surgical techniques in ENT management especially how to deal with patients beyond being a doctor! You don’t learn this in books but from experience. I learned a lot from my dad. Just so lucky I guess! He actually designed and made his own ENT Treatment Unit, which I’m still using to this day (with some modifications of my own). And he created a certain electrically powered ‘eye magnet’ with the help of my cousin (who’s an engineer now in Chicago) which can attract metallic foreign bodies from within the eyeball to the surface so they can easily be picked out – it really works! Dad loved to travel in his younger years especially abroad for conventions or just simply leisure or vacations, most of the time with my mom. But as he was getting older, travels became uncomfortable. His last travel with me was in 2012 for the AAO-HNS Convention in Washington DC. It was a great time as we then proceeded to a US Navy Airshow in nearby Virginia after the convention, meeting up with my brother who is retired from the USN. Then we took the train to New York and stayed with my sister who is a PICU nurse in NY Presbyterian. Then off to Missouri and Ohio visiting the National Museum of the US Air Force, the largest military aircraft museum in the world. For years, Dad had been battling with heredofamilial-hypercholesterolemia problem which took its toll on his liver and made him weak and tired but still he practiced and continued teaching and sharing his knowledge until he retired at the age of 80. By then, my wife and I would take him and my mom out on weekends, he loved to be driven around and eat in different places. I really witnessed and have seen how he suffered from his illness in his final years. But he never showed it or complained, never even wanted to use a cane! He didn’t want to be a burden to anyone. What most affected me was that my dad passed and I wasn’t even there. I had helped call for a physician to rush to the house and had oxygen cylinders to be brought for him as his end stage liver cirrhosis was causing cardio-pulmonary complications (non-COVID). Amidst all this I was the one admitted for 14 days because of COVID-19 pneumonia. My dad passed away peacefully at home as I was being discharged from the hospital. He was 88. I never reached him just to say good bye and cried when I reached home still dyspneic recovering from the viral pneumonia. I realized from my loved ones who told me that dad didn’t want me to stress out taking care of him, as I’ve been doing ever since, but instead to rest and recuperate myself. I cried again with that thought. In my view, he was not only a great Physician and Surgeon but also the greatest Dad. He lived a full life and touched so many lives with his treatments, charity services and teaching new physicians. It’s seeing, remembering and carrying on what he showed and taught us that really makes us miss him. I really love and miss my dad and with a smile on my face, I see he’s also happy to be with his brothers and sisters who passed on ahead. And that he’s rested. He is a man content, I remember he always said this, ‘ As long as I have a roof over my head and a bed to rest my back, I’m okay!”

Death and Dying During the COVID-19 Pandemic: Tahan Na, Humimlay

Nagwakas ang araw Lupa’t dagat, langit, pumanaw Tahan na, Humimlay Siyanawa — JF Lapeña, Tahan Na, Humimlay The continuing COVID-19 pandemic has directly or indirectly claimed the lives of countless colleagues, friends, and family. I personally thought my tears had run dry as people I knew and loved died throughout the past year, but the wells of grief run deep, even as the plague continues its scourge as of this writing. Especially when fellow front-liners fall, the haunting bugle call echoes the finality of death: “day is done, gone the sun, from the lake, from the hills, from the sky.”1 Of my original fellow office-bearers in the Philippine Association of Medical Journal Editors (PAMJE), two have passed on: Dr. Gerard “Raldy” Goco and Jose Ma. “Joey” Avila.2 Even in our Philippine Society of Otolaryngology - Head and Neck Surgery, I do not recall us dedicating so many passages in issues past as we do now, with tributes to Dr. Elvira Colmenar, Dr. Ruben Henson Jr., Dr. Marlon del Rosario, and Dr. Oliverio Segura. Our Philippine Medical Association Central Tagalog Region (PMA-CTR) has lost more than its share of physicians: Dr. Joseph Aniciete, Dr. Patrocinio Dayrit, and Dr. Rhoderick Presas of the Caloocan City Medical Society; Dr. Mar Cruz, Dr. Mayumi Bismarck, and Dr. Edith Zulueta of the Marikina Valley Medical Society; Dr. Kharen AbatSenen of the Valenzuela City Medical Society; Dr. Romy Encanto and Dr. Cosme Naval of the San Juan Medical Society; Dr. Roberto Anastacio and Dr. Encarnacion Cabral of the Makati Medical Society; and Dr. Amy Tenedero and Dr. Neil Orteza of the Pasay Parañaque Medical Society. The rest of the PMA has lost over 145 physicians due to, or during, the pandemic. As healthcare workers, how do we deal with their deaths, the inevitability of more deaths, and the very real prospect of our own deaths during these trying times? How do we continue our work of saving lives in our overcrowded hospitals and community-based clinics while dealing with grief and facing our own fears for ourselves and our families? Over 50 years ago, Elisabeth Kübler-Ross formulated a model of dying with five stages of coping with impending loss of life (denial, anger, bargaining, depression and acceptance) based on her work with dying patients at the University of Chicago, and these have become widely considered as phases of grief that people go through when faced with the prospect of their own death (or as a response to any major life change).3 By focusing “on dying, rather than death,” her work “shifted attention of religious thinkers, pastors, and authors of personal testimonies onto the themes and framework she offered” and “her legacy was to offer a fresh way to think and speak about dying, death and grieving.”4 Whether, and how we might appropriate her framework in order to cope with our personal and collective experiences during this pandemic, a pandemic that is arguably worse than any worst case scenario ever imagined, is another matter altogether. Does the framework even apply? The very nature of the COVID-19 pandemic is changing how people die -- in ambulances, makeshift tents and long queues outside overflowing hospitals, or en route to distant hospitals with vacancies (with patients from the National Capitol Region travelling to as far away as Central and Northern Luzon or Southern Tagalog and Bicol), or in their own homes (as people with “mild” symptoms are encouraged to monitor themselves at home, often rushing in vain to be admitted in hospitals with no vacancies when it is already too late) -- and “we have to make difficult decisions regarding resuscitation, treatment escalation, and place of care,”5 or of death. The new normal has been for COVID-19 patients to die alone, and rapidly so, within days or even hours, with little time to go through any process of preparation. Friends and family, including spouses, parents, and children, are separated from the afflicted, and even after death, the departed are quickly cremated, depriving their loved ones of the usual rites and rituals of passage. In most cases, wakes and novenas for the dead can only be held virtually, depriving the grieving loved ones of the support and comfort that face-to-face condolences bring. Indeed, the social support systems that helped people cope with death have been “dismantled, and the cultural and religious rituals that help us process grief also stripped away.”5 Amidst all this, “we must ensure that humanity, community, and compassion at the end of life are sustained,” and that “new expressions of humanity help dispel fear and protect the mental health of bereaved families.”6 What these expressions might be, and whether they can inspire hope in the way that community pantries7 have done remains to be seen. But develop these expressions we must, for our sakes as for the sake of our patients. The “hand of God” -- two disposable latex gloves filled with warm water and tied around the hand of a woman with COVID-19 to alleviate her suffering by nurse technician Araújo Cunha at the Vila Prado Emergency Care Unit in São Paulo is one such poignant expression.8 Ultimately, we must develop such expressions for and among ourselves as well. As healthcare workers, our fears for ourselves, our colleagues, and our own loved ones “are often in conflict with professional commitments” and “given the risks of complicated grief,” we “must put every effort into (our) own preparation for these deaths as well as into (our) own healthy grieving.”9 We cannot give up; our profession has never been as needed as it is now. True, we can only do so much, and so much more is beyond our control. But to this end, let us imagine the soothing, shushing “tahan na” (don’t cry) we whisper to hush crying infants, coupled with the calming invitation “humimlay” (lay down; rest; sleep). Yes, the final bugle call may echo the finality of death, but it can simultaneously reassure us that “all is well, safety rest, God is nigh!”1

The Use of Commercially Available Non-Medical Grade USB Cameras for Physician Guided ENT Out-Patient Self-Examination During the COVID-19 Pandemic

ABSTRACT Objective: To describe the use of commercially available, non-medical grade USB cameras in a non-contact examination of simple cases involving the ears, nose and oral cavity of patients during the COVID-19 pandemic Methods: Design: Instrument innovation Setting: Tertiary Government Training Hospital Participants: Patients who consulted at the ENT-HNS outpatient department during the COVID-19 pandemic. Results: Commercially available USB cameras were able to provide basic visualization of the ears, nose and oral cavity. The non-medical grade USB cameras captured lower quality images when compared to the medical grade endoscopes but provided enough visualization to aid in the examination and diagnosis of simple cases. There was a learning curve in using the set-up but patients were able to adjust well, taking an average time of 2.7 minutes to complete the examination. Conclusion: Non-medical grade USB cameras may play a role in aiding otolaryngologists in examining simple cases during the COVID-19 pandemic. Integration of this system into current examination practices may offer an extra layer of protection for otolaryngologists and patients alike. However, the use of these instruments as part of regular ENT practice may be controversial and will need further study.

Self-Inflicted Craniofacial Impalement Injury with a Screwdriver During the COVID-19 Pandemic: A Case Report

ABSTRACT Objective: To present a case of a 37-year-old man presenting with craniofacial impalement injury from a screwdriver that happened during the early stages of the COVID-19 pandemic. Methods: Design: Case Report Setting: Tertiary Government Training Hospital Patient: One Results: During the early stages of COVID-19 pandemic a 37-year-old man was brought to the emergency room with a screwdriver embedded in his right eye. A multidisciplinary team observing available recommendations (level IV PPE, carefully planned operative directives) successfully performed endoscopic endonasal transsphenoidal surgery with application of a nasoseptal Hadad flap and abdominal fat obliteration. Aside from medial gaze limitations of the right eye, there was no CSF leak or rhinorrhea and no neurologic sequelae on follow up. Conclusion: Endoscopic skull base surgery for such an impalement injury as this is a formidable multidisciplinary challenge, even in normal times. The early stages of the COVID-19 pandemic presented additional challenges. Observing evolving guidelines minimized the high risk of exposure for health care workers while maximizing care for the patient.

Smell Training in Prolonged COVID-19 PostInfectious Olfactory Dysfunction: A Case Report

ABSTRACT Objective: To report the case of a woman who underwent smell training for post-infectious olfactory dysfunction presumably from COVID-19. Methods: Design: Case Report Setting: Tertiary Private Training Hospital Patient: One Result: A 41-year-old woman who developed olfactory dysfunction attributed to COVID-19 underwent smell training. At baseline, her responses were mostly “no smell,” and those reported as “can smell a bit” were rated as distorted. After three months, she could now smell items that she previously could not smell, but these smells were still distorted. At the time of this writing, she was on her 4th month of smell training. Conclusion: Although we cannot rule out spontaneous resolution of anosmia in our patient, we would like to think that smell training contributed to her recovery of smell.

To the Lip and Beyond: A Case Report of a Midline Tessier 30 Cleft

ABSTRACTObjective: To present the case of a midline Tessier 30 cleft in a baby boy who initially underwent a glossoplasty, cheiloplasty and mentoplasty. Methods:Design: Case ReportSetting: Tertiary Government Training HospitalPatient: One Result: A 4-month-old boy with a complete midline cleft of the lower lip, alveolus and mandible, and bifid distal tongue that was fused with the floor of the mouth, underwent glossoplasty, cheiloplasty and mentoplasty with subsequent excellent aesthetic outcome and normal oral competency. Conclusion: Tessier 30 is a rare congenital midline mandibular cleft. Prompt glossoplasty, cheiloplasty and mentoplasty can correct the gross deformity, restore oral competency, and address functional needs such as feeding, swallowing and early speech development. Future bony repair will hopefully complete the reconstruction.

Fenestral Otosclerosis: A Subtle Lesion Easily Missed

A 29-year-old Filipina of Chinese descent presented with progressive bilateral conductive hearing loss of several years’ duration. While working overseas, she consulted with an otolaryngologist and underwent computerized tomographic (CT) imaging of the temporal bone as part of her evaluation. She was informed that no abnormalities were identified in the imaging exam, and she was offered exploratory middle ear surgery with possible stapes surgery. She then sought a second opinion, with the intention of obtaining a more definitive diagnosis prior to any invasive medical intervention. A review of the CT imaging study, with particular emphasis on looking for radiologic evidence of otosclerosis, revealed the presence of a focal region of bone demineralization in the region of the fissula ante fenestram. (Figure 1) This finding is consistent with a diagnosis of fenestral otosclerosis. Otosclerosis is one of the main differential diagnoses for a patient presenting with bilateral conductive hearing loss and no other visible evidence of otologic disease. Although it is more common in the Caucasian population,1 it must remain as one of the considerations in the Asiatic population, including Filipinos. High-resolution CT is the imaging technique of choice in the evaluation of conductive hearing loss.2 When evaluating a scan for evidence of otosclerosis, it must be remembered that the most common location of involvement is the bone just anterior to the oval window, in a small cleft known as the fissula ante fenestram. It is this relationship that gives rise to the term fenestral otosclerosis. The fissula is a thin fold of connective tissue extending through the endochondral layer, located in the region between the oval window and the cochleariform process, where the tensor tympani tendon turns laterally toward the malleus.3 (Figure 2) Since the average length of the stapes footplate along its short axis is around 1.5 mm, it is highly recommended that submillimeter image slice thickness be routinely ordered for the CT imaging study, in order to maximize the opportunity to identify the oftentimes small and subtle areas of focal demineralization. At a slice thickness of 0.5 mm, such a lesion might only be identified by an astute clinician in 2-3 sequential axial imaging slices.

Inverted Ductal Papilloma of the Salivary Gland

This is a case consult of slides stated to be from an excision of a buccal mucosa mass in a 58-year-old-man. The specimen was described as a 3 cm diameter roughly oval tan-gray tissue with a 2 x 1.5 cm mucosal ellipse on the surface that has a central ulcerated punctum. Cut section showed an underlying 1.7 cm diameter roughly oval well-circumscribed mass with a granular tan surface. Histological sections show a papillary lesion with an orifice on the mucosal surface and with epithelial nests invaginating into the underlying lamina propria in a non-infiltrative pattern. (Figure 1) The lesion is composed of papillary epithelial fronds with cleft-like spaces between the fronds. (Figure 2) The papillary fronds are lined by non-keratinizing basaloid stratified squamous cells with a superficial layer of columnar glandular cells along with mucous goblet cells interspersed among the squamous cells. (Figure 3) All the cellular components are devoid of cytologic atypia and mitoses. Based on these microscopic features we signed the case out as inverted ductal papilloma (IDP). Ductal papillomas are uncommon benign epithelial tumors with a papillary configuration that originate from the excretory ductal system of salivary gland acini.1-3 The World Health Organization recognizes two sub-types depending on the growth pattern: an intraductal papilloma (IP) and an IDP.1 An IDP usually presents as an asymptomatic submucosal nodule, measuring about 1.5 centimeters in diameter, and most commonly involving the buccal mucosa, followed by the lips, palate, and floor of the mouth.2,3 Histological sections typically show an unencapsulated though well-circumscribed epithelial proliferation with a papillary configuration on the luminal surface, and a nodular, endophytic or invaginating (“inverted”) configuration at its interface with the underlying lamina propria.2 Both the papillary and the invaginating areas are composed of basaloid, non-keratinizing stratified squamous epithelium that are often covered with a cuboidal or columnar ductal cell layer.2 Scattered among these are mucous goblet cells which can form microcysts.1,2 There is an overall morphological similarity to the sinonasal inverted papilloma.3 A relationship to trauma has been proposed.1,4 Association with Human Papilloma Virus (HPV) has also been reported.1 Others, however, have not been able to demonstrate this association.4 Differential diagnoses primarily include IP - which is differentiated from IDP architecturally by being a unicystic intraluminal papillary proliferation within a dilated excretory duct 2 – and sialadenoma papilliferum – which is predominantly polypoid and pedunculated with a verrucoid surface rather than a submucosal nodule, and an over-all morphologic similarity to the cutaneous tumor syringocystadenoma papilliferum.1,4 An important differential diagnosis that has to be ruled out is mucoepidermoid carcinoma (MECA) because of the presence of both squamous and mucin-secreting cells. MECA is distinguished by poor circumscription, and an infiltrative solid-cystic growth pattern.2,4 IDP is benign and non-recurrent. Unlike the nasal tumor, there has been no report of malignant transformation.2,3 Complete surgical excision is considered curative.1,2 Reporting these cases is encouraged to further our knowledge of the entity and elucidate a potential association with HPV.