Search

Background: Congenital malformations, granulomatous diseases, and trauma can all cause destruction of the nasal structural framework, resulting in functional nasal obstruction and altered facial cosmesis. Current methods of nasal reconstruction include cartilaginous and bony grafts, Silastic implants, and homograft only materials. However, these techniques have significant functional and cosmetic drawbacks and are not risk free. Native, isotonic, neutral-pH, space-filling type I collagen gels have been shown to mediate total repair of critical-size collagen grafts provide a framework for rapid intramembranous ossification and osteoconduction of bone from the perimeter of a defect, resulting in total bony coverage., Objective: To evaluate a novel approach to nasal reconstruction using a major defect of the bony nasal dorsum with a type I collagen gel matrix., Design: Sixteen retired male breeder Sprague-Dawley rats were divided into control and experimental groups. The nasal bones were exposed through a dorsal incision and completely removed with a bone-cutting drill to the level of the mucosal membranes of the nasal vestibule. Defects in the experimental animals were then implanted with 200 micrograms of type I collagen gel, with control animals receiving no inlay. After 6 weeks, the animals were examined with three-dimensional computed tomography before necropsy, at which time the defects were photographed, measured by planimetry, and sectioned for histologic analysis., Results: Experimental defects were observed to manifest 100% surface area healing with a thin layer of bone using a type I collagen gel osteoconductive implant for nasal reconstruction. Conversely, control animals showed only a 5.7% (+/- 3.7% SD) healing by area. Histologic sections of the collagen gel implant revealed restoration of the anatomy with a thin plate of immature bone spanning the defect in continuity with the cartilage of the nasal septum and with apparent preservation of maxillonasalis suture lines., Conclusions: Native, isotonic, neutral-pH, space-filling collagen gels positively influenced the repair of large nasal defects, which showed minimal bone closure in untreated animals. Their use in this role merits further investigation.

Nostril stenosis is an infrequent finding that often has an iatrogenic cause. It is a very difficult problem to resolve and usually requires several months of prosthetic support in order to counteract the recurrence of internal scarring and shrinking. We present a 4-year-old child with a monolateral iatrogenic nostril stenosis. A satisfactory and stable correction was obtained using a "piercing" flap taken from the labial vestibule. The use of a nasal stent (not placed immediately and worn only at night) was necessary for only 2 months. This technique has a number of advantages: the absence of external scars, little or no tendency to recurrence due to the absence of contraction provided by the well-vascularized flap tissue, and the ease and rapidity of the surgical procedure.

Sarcoidosis is a chronic multisystem granulomatous disease that has a predilection for pulmonary and upper respiratory tract involvement. Because the initial signs and symptoms of sarcoidosis may be identical to those of other forms of chronic sinonasal inflammatory disease, these patients will often first seek treatment from an otolaryngologist. We present a series of 28 patients whose primary symptoms was involvement of a sinonasal tract. A new staging system is proposed to categorize the severity and sites of involvement and to guide the aggressiveness of therapy. Sarcoidosis should be considered in the differential diagnosis of inflammatory sinonasal disease.

Objective: To evaluate a new technique for correction of severe caudal septal defects., Design: For all patients, preoperative photographs were graded with regard to the severity of caudal septal defects. Preoperatively, nasal airway breathing surveys were conducted and nasal tip projection (NTP) measurements were recorded. The caudal septal defects were then repaired with use of the ethmoid bone sandwich grafting technique. Photographs, NTP measurements, and an airway survey were then repeated 6 and 12 months postoperatively. Preoperative and postoperative assessments were compared and analyzed. Lateral nasal roentgenograms were obtained in five of 10 patients to assess resorption of the bone grafts. Complications were noted if present., Setting: Urban medical center., Patients: Ten volunteers with severe caudal septal defects causing both cosmetic and functional problems. All patients had undergone at least one previous submucous resection., Outcome Measures: Durability and degree of correction, maintenance of NTP, airway improvement, and morbidity., Results: After 1 year, all patients maintained satisfactory correction of their caudal septal defect based on postoperative photographic grading and physical examination findings. The NTP was maintained in eight of 10 patients. Two patients experienced loss of NTP after 1 year that was not present 6 months postoperatively. Average airway improvement was 126.7% after 1 year. Postoperative roentgenograms showed only minor (< 10%) bone graft resorption. The only complication was a granuloma., Conclusions: The ethmoid bone sandwich grafting technique corrected severe caudal septal deviations while maintaining or strengthening structural support of the caudal septal strut without loss of NTP, airway compromise, or morbidity.

Although the forked flap procedure has been widely used as a technique to lengthen the columella in the bilateral cleft lip deformity, often the results are unfavourable. We describe a technique to achieve a more natural shape, in which the unsatisfactory forked flap is excised and the columella is reconstructed by mobilization and rotation of nasal skin, combined with bilateral reverse-U flaps. Five consecutive patients who underwent this secondary correction procedure are presented.

Nasal continuous positive airway pressure (CPAP) is being used more frequently in neonatal intensive care units to avoid endotracheal intubation and its attendant complications. Nasal deformities secondary to the nares-occluding prongs employed to deliver the CPAP in former preterm infants have been recognized, and prevention and surgical treatment of these deformities are discussed. An awareness of the potential for these deformities is important to all pediatric otolaryngologists as nasal CPAP is gaining increasing favor as a primary treatment for respiratory disease of the newborn.

We describe a patient with protracted superficial Wegener's granulomatosis. On the basis of nasal mucosa and conjunctival biopsy specimens, a diagnosis of sarcoidosis was originally made. However, later biopsy specimens and the clinical condition indicated a rare variant of Wegener's granulomatosis, one with a protracted course of granulomatous ulcers localized to the skin and mucosa.

A simple photographic method of assessing a commonly encountered nasal deformity has been devised. The method described is of use in quantifying a subjective appearance and in assessing the result of surgery.

A large variety of graft materials have been used for augmentation rhinoplasty. To date there has been no graft material which can be regarded as completely satisfactory. The modern trend is to prefer autologous material to new biological material. The membranous bones of the calvarium are extremely suitable for augmenting moderate to severe saddle nose deformities. Calvarial bone grafts can be harvested easily, with minimum donor site morbidity and disfigurement. Our experience with calvarial bone grafts for augmentation rhinoplasty is presented.

Idiopathic midline destructive disease (IMDD) is a diagnosis of exclusion in patients who manifest midline nasal necrosis with no specific etiology such as infection, tumor, or Wegener's granulomatosis. Recently, a group of cocaine abusers has been identified that manifests a syndrome that mimics IMDD, but is less fulminant in its course. To better define the natural history of this syndrome, we reviewed the medical records, radiographs, and pathologic material from five such patients treated at the University of California, Los Angeles. Other causes of midline nasal destruction were excluded in each patient on the basis of histopathology, cultures, and laboratory tests. Biopsy material, available in four patients, demonstrated inflammation and necrosis without vasculitis. Treatment was conservative in four of the five patients, using antibiotics, local care, debridement, and cessation of cocaine use. During the follow-up period, progressive disease developed in one of the five patients, requiring radiation and steroid therapy. We conclude that the treatment of midline nasal destruction in cocaine abusers should initially be conservative, once other etiologies have been systematically excluded.

Surgery has often been blamed for the subsequent poor growth and deformity of the nasal complex in patients with cleft lip and palate. This study compares two groups of patients with unilateral clefts of the lip and palate for the effect that different surgical techniques have on nasal symmetry and facial attractiveness.

Fourier series has been applied in a numerical analysis of the human nostril morphology. The relationship between the nostril form and the Fourier coefficients was examined: the constant affected the size, the first term determined the roundness, and the second term determined the flatness of the morphology. The inclination of the apse line was calculated from the phase of the second term. Ninety-five standardized nostril photographs were analyzed by Fourier series: 48 of adult Japanese females and 47 of German females. The German nostril was larger in size, flatter in shape, and the apse line closer to the sagittal plane than the Japanese counterpart. As a clinical application of nostril digitization, pre- and post-operative cleft lip noses were analyzed. Fourier analysis has proved to be useful in a numerical evaluation of morphological differences of, and post-operative changes made to, the nostril.

A new approach for creating an anatomically aesthetic nasal tip is presented. It is based on extensive cadaver dissections which demonstrate that a convex domal segment plus a sharp domal segment-lateral crural drop-off are key determinants of a refined tip. This configuration can be achieved with sutures in a manner similar to creating the anthelical curl in an otoplasty. Two operative variations are presented. One achieves tip refinement with a limited increase in projection, while the other provides maximum projection. Currently, the technique is of value in bilateral cleft lip noses, posttraumatic deformities, certain secondary cases, and very selected primary aesthetic cases where tip refinement and projection are limited.

As a rule some kinds of nasal septum deformities are more frequently found in subjects whose maxilla has more or less stressed morphological irregularities than in those with a normally shaped maxilla. The subjects with asymmetry between the nasal floor levels (the right and left side) show heavier septal damages than others. It means that a regularly shaped maxilla as well as a symmetric nasal floor serve like a fuse against the more severe deformations after nasal trauma. In this paper we have made a classification of the septal pathological deformities.

The results of a septoplasty because of a nasal obstruction were studied in 261 children, their ages ranging from 4 to 14. No arrest of nasal growth after the septoplasty and osteotomies was recorded. Histological examination revealed a cartilaginous regeneration at the borders of the resected septal cartilage in 15 cases in which a second rhinoplasty was necessary because of a new nasal obstruction. Often the cartilaginous growth was undirected and excessive leading to a new septal deviation. In 80 per cent of our cases good functional long-term results were obtained by one rhinoplasty only which was performed according to the techniques of Cottle and Masing.

The addition of rhinoplasty to primary cheiloplasty for cleft lip improves not only the post-operative state but also, by re-establishing the equilibrium of all the cartilaginous and musculo-periosteal structures, favourises maxillary growth. The author describes a technique and presents some results.

Report of a case affecting a middle-age woman, 48, involving the E.N.T. area only. The AA comment on the features of the disease and report on the good results with medical treatment (prednisolone, indomethacin and dapsone).

A case of an impacted mesiodens that produced a marked nasal deformity and a deviated nasal septum is discussed.

Stenosis of the nasal vestibule is a frequent cause of nasal obstruction. An anatomical study of the region will enable one to understand the physiopathology of the stenosis of the floor of the vestibule which frequently accompanies septal deformities in the premaxilla region, or which occurs after septal surgery. The correction of this circumferential stenosis has been handled satisfactorily by the use of a "Z" plasty of the floor of the vestibule. Pertinent anatomical material, schematic drawings, and clinical cases are presented.

Numerous synonyms have been used to describe syndromes affecting structures derived from the first and second branchial arches. These conditions are most conveniently grouped into the asymmetrical anomalies of hemifacial microsomia and the symmetrical syndrome of mandibulofacial dysostosis. By examination of animal models of these conditions it can be demonstrated that the pathogenesis is distinct but different for each group. The characteristic facies of mandibulofacial dysostosis suggests a mechanism of malformation which operates early in embryogenesis, acting uniformly on parts which are derived from neural crest cells. In the serial examination of a phenocopy of mandibulofacial dysostosis, induced in the rat by the teratogen vitamin A, focal death of pre-otic neural crest cells is observed to occur, creating both a spatial rearrangement of the developing ears and a paucity of ectomesenchyme in the first and second branchial arches. The result of these deviations from normal morphogenesis is the development of a facial skeleton which is symmetrical but distinctly different in form from that in the normal animal. Microscopic study of the induced ear and jaw defects revealed that the animal model was closely comparable in all respects to human mandibulofacial dysostosis. The specific nature of the interaction between teratogen and migrating neural crest cells is not yet clear; nor is it known whether these cells are attacked before or after their specific destination is determined. The greater part of the damage is inflicted in a general fashion and leads to symmetrical abnormal development. Minor examples of dyssymmetry do occur, however, in the animal model and man, but these are compatible with the hypothesis of a pathogenetic mechanism which is initiated centrally and symmetrically but modified locally at a later stage. A description of the pathogenesis of these two conditions, scientific predictions can be made with respect to the timing and technique of reconstruction of the orofacial defects, and the effects of surgery on growth and development.

Recreational cocaine abuse via intranasal "snorting," "free-base" smoking, "body-packing," or intravenous injection can be lethal. Increasing illicit use of cocaine hydrochloride and the misuse of legal over-the-counter (OTC) nasal drugs are known causative agents of nasal septal perforation with loss of taste and smell. Although 2 to 3 mg/kg is the recommended maximum dose for topical anesthesia, cocaine snorters may use 1,000 mg or more daily on a "run." Furthermore, the newer route of smoking the extracted volatile "free-base" form of the adulterated street drug provides a plasma concentration producing the same physiological and subjective effects of intravenous cocaine. Presented are two cases exemplifying unusual complications of cocaine abuse: 1. total nasal septal bony and cartilaginous necrosis with resultant saddle-nose deformity and osteolytic sinusitis secondary to chronic intranasal "snorting" and 2. tracheobronchial rupture with pneumomediastinum secondary to smoking "free-base" cocaine.

The structural relationships of the upper lateral cartilage and the septum form an important anatomic area called the liminal valve, one of three known paired valves of the nose. A small deformity in the region of the liminal valve may cause significant airway obstruction that usually can be relieved by surgery. Eighty percent of the population has alternating congestion and decongestion of the nasal turbinates, a phenomenon know as the nasal cycle. The exact function of this cycle is unknown, although it probably allows the two nasal chambers to act in unison and function as one nose. It is important to recognize the cycle as a normal phenomenon and to differentiate it from pathologic causes of nasal obstruction.

Biopsies from the septal cartilage in children have been examined histologically to study the influence of trauma, surgery, septal abscess, and transplantation on the growing cartilage. Loss of cartilage, complete, but mostly incomplete regeneration of the defects are the main reactions. A regenerative potential mainly arising from the perichondrium plays an important factor for restoring the septal structure, often in a deforming and excessive way. Even preserved cartilage implanted immediately into the septal abscess, may be transformed into autogenous cartilage if the perichondrium is preserved.

Functional problems and deformities of the eyes have become a major concern in the surgical treatment of ortital hypertelorism and craniofacial dysostosis, as experience with skeletal relocation for these disorders has been gained. Comprehensive preoperative and postoperative study and measurements of the bony orbits, the globes, the lids, the canthi, and the nose are necessary for the evaluation of present techniques and the design of alternative procedures. Some of the deformities of the blepharo-canthal complex are part of the congenital malformation. Other distortions, seen only postoperatively, are secondary to specific surgical maneuvers. Awareness of these primary and secondary factors has led to better soft tissue reconstruction at the time of the bony orbital translocations or the craniofacial disjunction. We describe the techniques which we have found especially useful in avoiding and correcting these postoperative blepharocanthal deformities.

A systematic surgical approach to nasal valve abnormalities depends on adequate and precise exposure of the abnormality to be corrected and is facilitated by the use of magnification. Small anatomic disturbances in the region of the nasal valve can produce significant airway obstruction by narrowing the nasal valve angle. Normally, this angle between the caudal end of the upper lateral cartilage and the nasal septum is from 10 to 15 degree. In all patients with nasal airway obstruction, a meticulous clinical evaluation of the nasal valve is required. Nasal valve abnormalities can produce symptoms due to an already increased collapsibility of the nasal valve; therefore surgical intervention is directed toward reconstruction of normal anatomic relationships, usually by widening the nasal valve angle and preventing either extreme of rigidity or collapsibility. Appropriate and delicate handling of the intercartilaginous aponeurosis between the upper lateral (roof) cartilage and the lower lateral (lobular or alar) cartilage with prevention of excessive scar tissue formation usually can be achieved by dissection on the upper lateral cartilage. The surgical plane is beneath the overlying musculature and neurovascular layers. By preserving the mucocutaneous lining and by accurate suturing of incisions, primary wound healing is facilitated. Clinical experience suggest that the application of these concepts benefits patients by preventing or treating abnormalities of the nasal valve. Eventually, longterm results with preoperative and postoperative physiologic testing (rhinomanometry), coupled with critical clinical re-evaluation, should allow adoption, rejection, or, more likely, modification of the principles offered by this contribution.

The direction of air currents through the nose have been studied by many investigators. However, in injury of the nose followed by deformities, a marked change in the nasal configuration occurs. Many patients will present localized areas of crusting and attention is not drawn to this condition until the patient is seen with an epistaxis. In this study, we are interested in the character of the mucosa and their changes as affected by long-term injury from the trauma of the inspiratory and expiratory air currents, which, on sniffling or snorting, may reach hurricane speeds. In the study of the naso-respiratory mucosa from these areas by electron-microspy, it was found metaplastic respiratory epithelium where the cells have undergone mucinous transformation and areas exposed to air jets how metaplastic changes followed by erosion. We wish to thank Nikolajs Cauna, M.D. for his assistance and making available the micrographs used in this paper.

The author presents his experience with the primary correction of nasal deformity in unilateral cleft lips in twenty five cases ranging in age from five months to 30 years. Emphasis is placed upon the important anatomical characteristics of the deformity, i.e. attenuation of the alar cartilage, displacement of the medial crus, thickening of the alar base as the result of deposition of fibrofatty tissue between the two separated layers of skin, accumulation of fibrofatty tissue between the two separated alar domes, drooping of the involved nostril and the presence of a well marked alar arch web. The technique described includes an adequate exposure through a bilateral gingivolabial sulcus incision connected by an intercartilaginous incision, release of the displaced alar base and columella, freeing of the alar cartilage from the opposite side and from overlying skin, repositioning of the alar cartilage and alar dome to a normal anatiomical position, and maintenance by a through and through mattress suture and a post-operative nasal pack. The immediate results have been satisfactory.

We introduce acoustic rhinometry as a new, objective method to assess the geometry of the nasal cavity. The cross-sectional area of the nasal cavity as a function of distance from the nostrils was obtained. A group of 21 patients with septal deformities was examined with acoustic rhinometry preoperatively and postoperatively. These values were compared with those of 21 normal control subjects. The minimal cross-sectional area (MCA) is located in the anterior part of the nose, and it shifts anteriorly under the effect of decongestion. The preoperative value of MCA is related to the location and severity of the anterior septal deformity. Postoperative smaller MCA found in the opposite side of that narrowed by a severe anterior septal deformity may be explained by the impact of septoplasty without reduction of a hypertrophic turbinate. A highly significant relation between MCA and the subjective feeling of nasal patency, before and after surgery, suggests that MCA is a valuable parameter to express nasal patency. Correction of posterior septal deformities is found to increase significantly the cross-sectional area posteriorly. The effect of decongestion in the postoperative values, however, suggests that the mucosa contributes even more to the cross-sectional area of the posterior part of the nose. Acoustic rhinometry seems very suitable for evaluation of the nasal cavity in cases where septoplasty and turbinoplasty is considered, as well as for the postoperative evaluation.

Classical Wegener's granulomatosis is a relentlessly progressive and rapidly fatal disease. A pulmonary 'limited form' is associated with a much better prognosis. We report 3 cases of Wegener's granulomatosis which ran a prolonged indolent course despite major manifestations outside the lower respiratory tract and review the literature on survival.