Revision Sinus Surgery

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Failure of ESS

Failure of ESS in children is reported to be in the range of 12–13%. Failure should be defined as those children who 30 require another surgical procedure or those who continue to have signs and symptoms of CRS despite continued medical therapy. Causes of failure in children can be divided into two groups if we exclude those with cystic fibrosis, immune deficiency, or ciliary abnormalities [4–6]: (1) children who have a surgical cause of failure, and (2) children who failed because of their age, presence of asthma/ allergy, or severity of their disease. These two groups differ in the cause of the failure; however, in some children it may be a combination of those factors. Knowledge of the surgical causes of failure, however, may help us reduce the

failure rate for some of these children.

Surgical Causes of Failure of ESS

Reports on the surgical causes of failure of ESS in children are very rare. In 1992, Lazar et al. reported that the most common causes of failure in children were recurrence of disease, adhesions, and narrowing of the maxillary sinus ostium [11]. In adults, numerous articles are available concerning causes of failure after ESS, which include extent of disease, nasal polyposis, previous traditional sinus surgery, presence of allergy, and anatomical abnormalities such as a deviated septum [9].

Analysis of the author’s experience between 1993 and 2005 showed that 243 children had ESS. Children with cystic fibrosis, immune deficiency/suppression, and ciliary abnormalities were excluded because the reasons of

Hassan H. Ramadan

failure in those children are very well known. Data were available on 176 children with at least 1 year of follow up; 23 (13%) children required revision ESS.

Analysis of the data showed that in the 23 patients, 47 findings were present causing the failure. Patients may have had more than one finding. The most common finding in our revision cases was adhesions in 57% of the cases, followed by maxillary sinus ostium stenosis or missed maxillary sinus ostium in 52% of the cases (Figs. 30.1 and 30.2). In 39% of the cases there was recurrent disease requiring revision surgery in the sinuses that were operated on initially. Interestingly however, we found that in 26% of the revision cases surgery was needed because of disease that was present in nonoperated sinuses during the primary ESS (Fig. 30). Four (17%) of the patients required a limited septoplasty at the time of revision that was thought to be the cause of failure on the side of deviation. In 13% of the children revision was needed because of a mucocele, which was causing symptoms of sinusitis due to obstruction of the sinuses (Fig. 30.4).

Follow up was available on 19 patients with a range of 1–5 years and a mean of 3 years. Fifteen (79%) patients at last follow up were doing well and only 4 (21%) continue to have sinusitis requiring medical management. Three patients required 3 revisions, 14 required 2 revisions, and 6 required 1 revision.

Medical Causes of Failure in ESS

The success of primary ESS ranges between 88 and 92% [12]. Conversely, those who continue to exhibit problems can either be manifesting a surgical failure as discussed

Fig. 30.3  a Coronal computed tomography (CT) scan of sinuses prior to primary sinus surgery showing maxillary sinus disease but clear sinuses. b Coronal CT sinuses before revision shows

surgical changes at the maxillary sinus ostium, but now disease involving the ethmoid sinuses

above, or they can be exhibiting certain medical morbidities. The most common cause of failure of ESS is asthma, followed by severity of sinus disease as evidenced by CT score. Age at time of surgery also plays a significant role in the outcome of surgery [6].

Asthma seems to impact outcome of ESS significantly. Children with asthma had a 62% success rate compared to 80% for those without asthma. Severity of disease as measured by CT score (Lund-McKay system) also seems to impact the outcome of ESS. Children with a higher CT score had a higher failure rate than those with a lower CT score. It was also noted that younger children (less than 6 years of age) had a higher failure rate with ESS than older children. Children who were older had an 84% success rate compared to 60% for the younger children. Allergy, smoke exposure, and day-care attendance have also been shown to influence the outcome of ESS, although to a lesser extent than asthma, age, and severity of disease. Children with cystic fibrosis, immune deficiency/suppression, and those with ciliary abnormalities can be included in this section.

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Indications

Indications for revision ESS are similar to those of primary ESS. However, in children the primary procedure 30 is usually very conservative. In revision cases the surgeon can be more aggressive in addressing the diseased sinuses,

as done in adults.

Indications of revision sinus surgery in children include:

1.Complicated rhinosinusitis.

2.CRS symptoms not responsive to continued medical management for at least 3 months with antibiotics and ancillary medications.

3.Recurrent acute rhinosinusitis with periods of remission of at least 3 weeks between episodes. Children with four or more episodes of rhinosinusitis in a 6- month period should be considered for revision.

4.Presence of sinus disease on CT scans of the sinuses.

5.Allergic fungal sinusitis.

6.Antrochoanal polyp or presence of polyps not responding to medical management.

7.Mucocele present in the sinuses.

Contraindications

Contraindications can be relative and each surgeon should individualize depending on the status of his patient. Absolute contraindications can be children who are medically unfit for general anesthesia or those who have a terminal illness where the sinus disease is the least of their worries.

Relative contraindications for revision sinus surgery in children include:

1.Children with cystic fibrosis who did not respond to prior sinus surgery.

2.Children with developmental/mental delay whose symptoms do not cause any change in their quality of life.

3.Children with ciliary abnormalities who did not respond to prior sinus surgery.

4.Significant anatomical abnormalities with a high risk of complications; in these cases an open approach may be more desirable.

5.Disease that is present in the lateral aspect of the frontal sinus.

Preoperative Workup

The most important preoperative test in preparation for revision ESS in children is obtaining CT scan to identify disease and so that it can be used during the surgical proce-

Hassan H. Ramadan

dure [6]. Image-guided surgery for revision ESS has been shown to be advantageous for obtaining a better outcome and to decrease complications [13]. If not already done, these children should have an immunology evaluation and allergy testing as part of their workup prior to revision ESS, and ciliary biopsy at the time of surgery. For those children with nasal polyposis, a course of oral steroids 1 week prior to surgery will help intraoperatively. Using preoperative antibiotics is controversial and is left to the discretion of the surgeon. If the child develops an infection a few days before surgery, it is advisable to treat the infection and defer the surgical procedure until the child is better.

Surgical Technique

The surgical technique is similar to that done during the primary procedure, as described elsewhere, especially for those sinuses that have not been operated on before [14].

Useful recommendations for revision sinus surgery in children:

1.Use of image-guided technology for a more complete procedure and decreased likelihood of complications.

2.Use of power tools, especially for cases of nasal polyposis and severe adhesions.

3.Care should be taken to identify the middle turbinate and to separate it from the lateral nasal wall intact if possible.

4.Identification of the natural maxillary ostium, especially in cases where a missed ostium is the cause of failure. Once identified it should be widened and joined to the accessory ostium.

5.If a deviated septum is thought to be the cause of failure then a limited endoscopic septoplasty should be performed.

6.Mucoceles and antrochoanal polyps can be easily identified and their excision is facilitated with power instruments.

Tips and Pearls to Avoid Complications

1.Obtain adequate accuracy with the image-guided system used.

2.Use a 4-mm scope for better visualization whenever possible. In most children a 4-mm scope can be used instead of a 2.7-mm scope.

3.Use the 0 and 30 scopes interchangeably during the procedure.

4.Identify and spare the middle turbinate; it is an important anatomical landmark for completing the revision procedure.

5.Extreme caution is needed while revising the maxillary antrostomy to avoid orbital fat herniation.

Revision Endoscopic Sinus Surgery in Children

Complications

Complications are uncommon in children even in revision cases. They can be intraoperative or postoperative.

Intraoperative complications of revision sinus surgery in children include:

1.Cerebrospinal fluid (CSF) leak. This needs to be recognized during the procedure and repaired immediately.

2.Orbital entry with fat herniation. In most instances the procedure can be completed and no intervention is needed.

3.Orbital hemorrhage with increased pressure. An immediate lateral canthotomy should be performed with removal of all the packing on that side. An ophthalmology consult should be obtained.

4.Stripping of the maxillary sinus mucosa. This needs to be recognized otherwise, even though the bony ostium is open, the mucosa inside the sinus will be collapsed with no ventilation of the inside of the sinus.

5.Inadvertent injury to the middle turbinate. All attempts should be made to preserve it in place.

6.Bleeding. If bleeding is considerably impairing the surgeon’s vision the procedure should be aborted. There is no need to put the patient at risk for blood transfusion. If the bleeding is excessive with respect to the blood volume of the child, the procedure should also be aborted.

Postoperative complications of revision sinus surgery in children:

1.Bleeding. In most instances it is self-contained. Rarely packing or exam in the operating room is needed.

2.Adhesions. Those can be very common depending on the age of the child. If they are not causing any symptoms, then they can be left alone. If symptomatic and severe, a reexamination to deal with them would be appropriate.

3.Orbital swelling and ecchymosis. If eye pressure is high, then proceed as in intraoperative increased pressure. If pressure is normal and the child is cooperative enough, remove the packing and observe.

4.CSF leak. Put the patient on complete bed rest, head elevation, and give stool softeners for 1 week. There is no support in the literature for a lumbar drain. If the CSF persists, then consider endoscopic repair.

Postoperative Care

1.All patients are given oral antibiotics for 10–14 days.

2.We recommend sleeping with the head elevated for 7 days.

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3.We discourage blowing of the nose or use of nasal sprays for 1 week.

4.Absorbable packing is used. It will be absorbed by around 2–3 weeks, thus debridement in children is not necessary.

Outcomes

1.Success rate of revision ESS in children ranges between 77 and 82%.

2.Children may require more than one revision before achieving success.

3.Major complications in children are extremely rare.

References

1.Bhattacharyya N (2006) Surgical treatment of chronic recurrent rhinosinusitis: a preliminary report. Laryngoscope 116:1805–1808

2.Smith TL, Batra PS, Seiden AM, Hannley M (2005) Evidence supporting endoscopic sinus surgery in the management of adult chronic rhinosinusitis: a systematic review. Am J Rhinol 19:537–543

3.Dursun E, Korkmaz H, Eryilmaz A, Bayiz U, Sertkaya D, Samim E (2003) Clinical predictors of long-term success after endoscopic sinus surgery. Otolaryngol Head Neck Surg 129:526–531

4.Lusk RP, Muntz HR (1990) Endoscopic sinus surgery in children with chronic sinusitis. Laryngoscope 100:654–658

5.Parsons DS, Phillips SE (1993) Functional endoscopic surgery in children: a retrospective analysis of results. Laryngoscope 103: 899–903

6.Ramadan HH (2004) Surgical management of chronic sinusitis in children. Laryngoscope 114:2103–2109

7.Buchman CA, Yellon RF, Bluestone CD (1999) Alternative to endoscopic sinus surgery in the management of pediatric chronic rhinosinusitis refractory to oral antimicrobial therapy. Otolaryngol Head Neck Surg 120:219–224

8.Friedman EM, Stewart M (2006) An assessment of sinus quality of life and pulmonary function in children with cystic fibrosis. Am J Rhinol 20:568–572

9.McMains KC, Kountakis SE (2005) Revision functional endoscopic sinus surgery: objective and subjective surgical outcomes. Am J Rhinol 19:344–347

10.Ramadan HH (1999) Adenoidectomy vs endoscopic sinus surgery for the treatment of pediatric sinusitis. Arch Otolaryngol Head Neck Surg 125:1208–1211

11.Lazar RH, Younis RT, Long TE, Gross CW (1992) Revision functional endonasal sinus surgery. Ear Nose Throat J 71:131–133

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12.Hebert RL 2nd, Bent JP 3rd (1998) Meta-analysis of outcomes of pediatric functional endoscopic sinus surgery. Laryngoscope 108:796–799

13.Dubin MG, Kuhn FA (2005) Stereotactic computer assisted

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14.Ramadan HH (2007) Pediatric sinus surgery. In: Kountakis SE, Önerci M (eds) Rhinologic and Sleep Apnea; Surgical Techniques. Springer, Heidelberg, pp 211–218

 Core Messages

■Consider carefully the cause of failure before embarking on further open surgery.

■Osteoplastic frontal sinus surgery is the most common open sinus procedure to be required after failed primary surgery.

■External ethmoidectomy for failed primary endoscopic sinus surgery is rarely, if ever, indicated.

Introduction

Theconceptof“failedprimarysinussurgery”itselfrequires some discussion. Obviously, surgery may fail because the infection one sought to cure was not cured. In the most obvious example, a patient with an intracranial abscess related to sinus infection may not be adequately drained and may go on to death; the patient with invasive mucormycosis of the sinonasal tract may not be adequately debrided and may die. In both examples, intensive medical therapy is equally as important as surgical drainage/debridement. Fortunately, however, such obvious examples of failure rarely occur. More commonly, when we speak of failed primary sinus surgery we are speaking about a patient who remains symptomatic after primary sinus surgery, or in whom continued objective evidence of ongoing inflammation persists after primary sinus surgery.

Several groups of failed patients can be identified:

1.The persistently symptomatic patient without objective evidence of sinonasal inflammation with or without anatomical derangement.

2.The persistently symptomatic patient with objective evidence of sinonasal inflammation with or without anatomical derangement.

3.The patient with a wholly new set of symptoms after primary sinus surgery that are felt to be iatrogenic in nature.

4.The patient for whom endoscopic surgery proved inadequate to achieve the necessary exposure and anatomical results.

The first question to be asked is whether or not the disease process in question is truly a surgical problem. Were the symptoms for which the patient initially underwent sinus surgery really related to sinonasal disease? Headache, for example, may have been the initial complaint and may have been due to some other factor such as migraine rather than sinonasal disease, or perhaps the migraine was exacerbated by sinonasal disease, but other factors are now causing persistent symptoms. Persistent mucosal inflammatory disease may or may not be amenable to surgical correction. It may instead be secondary to allergic rhinitis or other immune or inflammatory conditions related to environmental factors. Allergic fungal sinusitis is the most obvious of these conditions. Surgery may be necessary, but is not generally sufficient for control of the disease process. My subjective impression over the years is that often misguided initial surgery that is not successful in relieving a patient’s symptoms may be followed by ever more aggressive surgical therapy that is equally misguided and ultimately results in iatrogenically created dysfunctional sinonasal cavities.

Ultimately, surgical intervention in diseases of the paranasal sinuses can change anatomy and drain infection.

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It cannot intrinsically affect allergy, primary disease of the respiratory mucosa, the causes of nasal polyps, or alter mucosal sensitivity to the environment. If one must operate on the paranasal sinuses, one should set specific anatomic objectives and then aim to accomplish those objectives in as safe a manner as possible. The underly-

31 ing mucosal disease must then be addressed medically. In the best of circumstances, recurrent or persistent localized sinus disease can be clearly related to an identifiable anatomic problem.

Particularly after failed primary sinus surgery, it behooves the surgeon to consider carefully and optimally treat underlying allergic and inflammatory conditions before embarking on further surgical treatment.

Indications

■Open approaches for failed endoscopic primary surgery are indicated primarily to correct specific anatomic abnormalities that are not accessible endoscopically.

The number of such abnormalities is increasingly limited. If primary surgery failed because of underlying mucosal disease rather than because of some anatomical aberration that prevented adequate aeration and drainage endoscopically, then there is no particular reason to believe that open surgery, aimed simply at creating drainage, would be any more likely to succeed.

Although it is anathema to some, another indication for open surgery might be to completely remove irreversibly condemned mucosa, with the intention of replacing it with nonrespiratory cuboidal epithelium and scar. The concept of “functional” endoscopic surgery was first predicated on the theory that no such irreversibly condemned mucosa existed, but rather that through aeration and drainage this mucosa could return to normal. Nonetheless, for practical purposes, it is debatable whether or not some patients might be better served in specific pathologic situations by removal of mucosa and obliteration of a sinus. True obliteration can only be adequately accomplished in the frontal and sphenoid sinuses. Attempts at obliteration of the maxillary sinuses with fat failed, but the end result after a Caldwell-Luc operation is essentially an obliteration of the maxillary sinuses that fill in with scar and cuboidal, nonrespiratory epithelium. In a recent review, Barzalai and Greenberg felt that the only remaining indications for the Caldwell-Luc operation were for fungal disease and in conjunction with endoscopic surgery for the treatment of inverting papilloma [1].

The most frequent indication for open surgery after failed primary endoscopic sinus surgery is for persistent or iatrogenically induced frontal sinus obstruction. This

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is probably because the frontal sinus is the most likely to present anatomical features that preclude adequate long-term drainage via an endoscopic approach. Overly aggressive removal of mucosa in the frontal recess may result in scarring and stenosis of the frontal sinus outflow tract, which is difficult to repair. Although an endoscopic Lothrop procedure may be possible in some cases, a narrow anteroposterior diameter of the frontal sinus outflow tract may preclude this approach. Failure to adequately remove an osteoma, inverted papilloma, or other neoplasm from this area endoscopically may also lead to the necessity of open surgery.

External ethmoid surgery is unlikely to have any real advantage in this day and age over revision endoscopic surgery for ethmoidal sinus disease. In addition, the Lynch procedure with attempted reconstruction of a functional nasofrontal outflow tract seems increasingly to be of historical interest only.

Procedures

Osteoplastic Frontal Sinus Obliteration

■Indications for osteoplastic frontal sinus obliteration:

1.Failed primary endoscopic frontal sinus drainage procedures or failed Lynch or Lothrop procedures.

2.Inability to adequately remove neoplasm such as inverted papilloma from the frontal sinus endoscopically.

■Contraindications: acute frontal sinusitis, as this may lead to infection of the bone flap.

The osteoplastic frontal sinus obliteration procedure remains an important part of the sinus surgeon’s armamentarium. Although it can be carried out unilaterally, it is generally performed bilaterally (Fig. 31.1).

■The keys to success of frontal sinus obliteration are:

1.Complete removal of all frontal sinus mucosa.

2.Burring of the inner table of bone of the sinus cavity.

The sinus is generally obliterated with abdominal fat harvested from the left lower quadrant of the abdomen so as not to be confused in the future with an appendectomy incision. Montgomery has shown in cats, and personal experience corroborates, that fat can survive long term within the sinus cavity [2].

Preoperatively, the patient has a Caldwell view X-ray taken from 6 feet (approximately 2 m) away and the frontal sinus is cut out of the film to be used as a template during surgery. Alternatively, one can use intraoperative

Fig. 31.1  Osteoplastic frontal sinus operation

computed tomography guidance or transillumination to delineate the borders of the frontal sinus. A coronal flap is elevated in a plane superficial to the periosteum, down to the supraorbital rim. The supratrochlear and supraorbital nerves are spared and may be released from the foramina as needed. Utilizing the template, or other method, the sinus is outlined and an oscillating or sagittal saw used to cut the frontal bone slightly inside the limits shown by the template. There is no need to follow the exact lateral contours of the sinus. The saw blade should be greatly beveled in toward the central sinus. At the supraorbital rims, the very thick bone must be completely transected; a horizontal bony incision is made at the nasal root. A fine osteotome is inserted through the superior bony kerf and used to divide the interfrontal sinus septum. The osteoplastic flap with vascularized periosteum adherent to its anterior wall is then fractured inferiorly through the roofs of the orbits. Next, all mucosa is painstakingly removed from the frontal sinus, and the lining cortical bone drilled with a cutting burr. Small, 1–2-mm burrs can be helpful in removing mucosa from small extensions of the sinus. The intersinus septum is completely drilled away. This dissection extends down into the nasofrontal drainage system. The sinus is copiously irrigated with saline or bacitracin solution. Small pieces of fat or separately harvested temporalis muscle are used to obliterate the nasofrontal drainage system and the frontal sinus filled with atraumatically harvested abdominal fat. The flap is then returned to anatomic position and fixed in position with small wires or miniplates. The periosteum is closed with absorbable suture and the coronal skin flap closed in layers over closed suction drains that exit separate stab-wound incisions laterally. In recent years, the necessity of keeping the bone flap vascularized by leaving the periosteum intact and pedicled inferiorly has been called into question. When performing craniofacial resection, the bone flap is routinely harvested without the perios-

teum, which is then used to reline the floor of the anterior cranial fossa as a periosteal flap. Bone necrosis is rarely a problem in these situations.

The Caldwell-Luc Procedure

■Indications of the Caldwell-Luc procedure:

1.Chronic polypoid maxillary sinusitis unresponsive to conservative intranasal endoscopic procedures.

2.Acute complicated maxillary sinusitis unresponsive to intranasal endoscopic procedures.

3.As a route to biopsy of lesions not accessible transnasally:

a.maxillary sinus mass

b.infraorbital nerve.

4.As an approach to the orbital floor when additional exposure is needed:

a.to treat fracture

b.for orbital decompression of Grave’s ophthalmopathy.

The Caldwell-Luc procedure is a sublabial approach to the maxillary sinus through the anterior wall under the upper lip. Traditionally it was used to treat chronic maxillary sinusitis with irreversible changes of the maxillary sinus respiratory epithelium. During the procedure all the lining mucosa of the maxillary sinus is removed and will be replaced by a rind of scar tissue covered by cuboidal nonciliated epithelium as the sinus heals. Because there is no longer any active transport of mucous within the sinus, drainage must be created inferiorly through the inferior meatus. Since the floor of the maxillary sinus is lower than the floor of the nose, gravity does not serve entirely to drain the sinus. After a Caldwell-Luc procedure, plain films (Caldwell views) of the maxillary sinus will forever be abnormal with some degree of opacification. In recent times, it has been felt that creating aeration of the maxillary sinus via the natural ostium will allow for healing of the damaged mucosa of chronic sinusitis and reestablishment of the natural mucociliary transport system. Theoretically, respiratory epithelium within the sinus will regenerate. There may still, however, be a role for this operation in cases in which maximal medical and “functional” surgery of the sinus has failed to restore healthy mucosa to a sinus. Attempts have been made to obliterate the maxillary sinus with fat and other substances, but these have never been successful. After a well-performed Caldwell-Luc operation, the sinus is to some extent “obliterated” by the natural course of healing.

Other indications for a Caldwell-Luc approach include:

1.The treatment of oroantral fistulae.

2.The treatment of malignant exophthalmos.

Fig. 31.3  Incisions for external ethmoidectomy (blue) and extension for Lynch procedure (red)

ply attempted to reconstruct the drainage system. A lateral nasal wall mucosal flap is fashioned with a superior base, and turned up at the conclusion of the operation to reline the nasofrontal drainage system medially. The reconstructed duct is stented for about 3 months with an endless variety of materials. The most popular is rolled silastic sheeting and cut portions of endotracheal tubes that are sewn to the nasal septum. The major complication of this procedure is restenosis of the nasofrontal drainage system and subsequent mucocele formation or recurrent frontal sinus obstruction and infection.

The Lynch procedure, like other “functional” operations is predicated on the belief that creating an adequate drainage system for the frontal sinus, in conjunction with medical therapy, can result in the return to normal of chronically diseased mucosa within the frontal sinus.

The Lothrop Procedure

■Indications for the Lothrop procedure: failed primary surgery where hope still exists of reconstructing the frontal sinus outflow tract.

The Lothrop procedure is performed via a unilateral or bilateral external anterior ethmoidectomy and middle turbinectomy. The frontal intersinus septum is resected along with the most anterosuperior portion of the nasal septum, creating a large drainage pathway. In cases of unilateral disease, the opposite nasofrontal drainage system could theoretically serve as a pathway for egress of frontal sinus secretions. Like its endoscopic counterpart, it works best in frontal sinuses with wide anteroposterior dimensions. Like the Lynch procedure, it assumes that “irreversibly damaged” mucosa does not exist within the frontal sinus.

Other Procedures

■Sometimes after failed attempts at endoscopic resection of cranial-base tumors or repair of extensive cerebrospinal fluid (CSF) leaks, it may be necessary to resort to an external approach.

Although unusual, it might at times prove necessary to resort to an external craniofacial approach to close a CSF leak or to resect tumors of the anterior skull base after failed attempts at endoscopic resection. This would most likely occur as a result of an error in judgment regarding the true extent of a tumor or the extent of a defect of the skull base. More commonly, these extensive lesions would be approached via an open approach initially, although this is beginning to change. It is important to remember that at times, endoscopic and open approaches are complementary and can be used in consort to achieve complete extirpation of particularly extensive lesions.

References

1.Barzilai G, Greenberg E, Uri N (2005) Indications for the Caldwell-Luc approach in the endoscopic era. Otolaryngol Head Neck Surg 132:219–220

2.Montgomery WW (1964) The fate of adipose implants in a bony cavity. Laryngoscope 74:816–827