Congenital Vomer Agenesis: A Case Report From Saudi Arabia.

The nasal septum consists of the quadrangular septal cartilage, the maxillary and palatine bone crests, the perpendicular plate of the ethmoid bone, and the vomer. Congenital agenesis of the vomer is a rare condition. This case involves a 29-year-old male who presented to our clinic with alternating bilateral nasal obstruction and no history of allergic symptoms. Examination revealed clear bilateral osteomeatal complexes without polyposis or discharge. A CT scan of the sinuses showed a right-sided septal spur and confirmed the absence of the vomer bone. This case was reported at King Abdulaziz Medical City, Riyadh, Saudi Arabia.

Effect of the extent of posterior septectomy on surgical access during the endoscopic endonasal approach to the sella: A technical note.

Background: Using the bi-nostril 4-hand technique during the endoscopic endonasal approach (EEA) facilitates bimanual microsurgical techniques yet requires resection of the posterior nasal septum. The surgical exposure and degree of maneuverability gained proportionate to the extent of posterior septectomy in the sagittal plane was previously quantified. Research question: We aim to describe our technique of posterior septectomy, and the effect of its extent in the axial plane on surgical access, and instrument maneuverability. Material and methods: After fracturing the posterosuperior nasal septum, we disarticulate the vomer from the sphenoid rostrum and remove its upper part. The sphenoid rostrum is excised next exposing the clival recess where a suction tip without a side channel is anchored, allowing the assisting surgeon to use an additional instrument in their dominant hand. The vomer is removed down to the level of the floor of the sphenoid sinus. Results: A wide exposure is achieved in the coronal plane bilaterally at the level of the sphenoid rostrum allowing unobstructed instrument manipulation in the craniocaudal and cross-court trajectories. Furthermore, the floor of the sella is reached through a straight rather than angled trajectory facilitating surgical access, manipulation, and instrument maneuverability. For lateral lesions requiring contralateral access, the assisting surgeon can assist in dissection from the contralateral nostril without changing the position of the endoscope. Discussion and conclusion: Removing the upper vomer improves surgical access, and instrument maneuverability. Simultaneous dissection from both nostrils might be attempted. Caudally extending the posterior septectomy during the EEA allows better exposure and improves surgical access in all planes.

Comparative Anatomy of the Vomeronasal Organ (VNO) in Sheep (Ovis aries) and Dogs (Canis familiaris) with Simple Reference to its Histological Structure and Vasculature Supply

SUMMARY: The vomeronasal organ (VNO) is located in the anteroinferior part of the nose and the accessory olfactory organ in mammals which is responsible of sense of smell. This study aims to compare the macro and microanatomical structure of the VNO between sheep and dogs. In the current study, we used ten adult slaughtered sheep and ten adult synchronized dogs with different sexes ages 1-2 years. The head of both animals were preserved in 10 % formalin for one week. This study shows in both animals, the VNO occupies the same position in the cavity of the vomer bone and the same relationship in the cranial part of the nasal cavity. Furthermore, the VNO is divided into three parts based on shape that are the rostral, central, and caudal part. The results show the VNO in sheep has a (U) shape and is opened dorsolaterally. It has a small and narrow cavity. It is long 6 cm long, and it has different diameters on its course. In comparison, the vomeronasal organ in dogs is very developed and has a (J) shape. It has a large and long cavity and ends at the fourth molar. Its length is about 10 cm, and it has one diameter on its course. The VNO receives the blood supply from the sphenopalatine and caudal palatine arteries. The present study shows main differences between sheep and dogs VNO in which the structure of vomeronasal bone between the sheep and dog is completely different. The finding will illustrate fundamental differences and provide specific structural differences between the two species.

El órgano vomeronasal (OVN) se encuentra en la parte anteroinferior de la nariz y el órgano olfativo accesorio en los mamíferos es responsable del sentido del olfato. Este estudio tuvo como objetivo comparar la estructura macro y microanatómica del OVN entre ovejas y perros. En el estudio utilizamos diez ovejas adultas y diez perros adultos de diferentes sexos con edades de 1 a 2 años. Las cabezas de ambos animales se conservaron en formol al 10 % durante una semana. Este estudio mostró que en ambos animales, el OVN ocupa la misma posición en la cavidad del hueso vómer y la misma relación en la parte craneal de la cavidad nasal. Según su forma el OVN se divide en tres partes: rostral, central y caudal. Los resultados mostraron que el OVN en las ovejas tiene forma de (U) y está abierto dorsolateralmente. Presenta una cavidad pequeña y estrecha. Además, tiene una longitud de 6 cm y tiene diferentes diámetros en su recorrido. En comparación, el órgano vomeronasal en los perros está muy desarrollado y tiene forma de (J). Presenta una cavidad grande y larga y termina en el cuarto molar. Su longitud es de unos 10 cm y tiene un diámetro distinto en su recorrido. El OVN recibe el suministro de sangre de las arterias esfenopalatina y palatina caudal. El presente estudio muestra las principales diferencias entre el OVN de ovejas y perros en el que la estructura del hueso vomeronasal entre estos dos animales es completamente diferente. Además, los hallazgos ilustran diferencias fundamentales y determinan diferencias estructurales específicas entre las dos especies.

A Systematic Review: Early Simultaneous Vomer Flap with Primary Cleft Lip Repair, Does it Bring More Benefits?

INTRODUCTION: Vomer flap is a technique to close cleft lip and palate. This technique is a simple procedure that has many benefits. However, the vomer flap's application together with primary lip closure is still questionable. OBJECTIVE: To find out whether the vomer flap's application in primary cleft lip repair can provide significant benefits. DESIGN: A systematic review was conducted using the PRISMA methodology has been licensed in PROSPERO databases (CRD42023399487). SETTING: A comprehensive search was set out, utilizing eight data sources up to March 2023. PARTICIPANTS: Both cohort studies and randomized control trials regarding the use of vomer flaps performed concurrently with cleft lip repair in children up to six months old. RESULTS: This article involved 8 studies involving 542 patients who met the inclusion criteria, consisting of 6 retrospective cohort studies, 1 RCT study, and 1 prospective cohort study. Vomer flaps provide a reduction in palatal cleft distance of 3-5 mm, a relatively small number of fistulas (0-4%), improvement of velopharyngeal function (nasal tone and nasal emission), maximal development of the maxilla although it is still controversial. CONCLUSION: The vomer flap's application in primary cleft lip repair provides many advantages, such as reduced palatal and alveolar clefts, decreased risk of oronasal fistula, increased velopharyngeal function, and increased maxillary growth. It is reliable for the management of cleft lip and palate.

A Rare Case of Glial Choristoma Arising from the Vomer in Association with Cleft Palate.

Heterotopic neuroglial tissue represents normal glial tissue in an abnormal location distant from the central nervous system. It is a rare congenital condition and the majority of these lesions are diagnosed at birth or early childhood. We report a rare case scenario of a growth arising from the vomer associated with cleft palate. The origin of a glial choristoma from the midline of the nasal cavity in association with a cleft palate has not been reported in the literature. Complete surgical excision was performed prior to palatoplasty with no postoperative complications or evidence of recurrence.

Three-dimensional Analysis of Factors Related to the Effective Alveolar Molding in Presurgical Infant Orthopedics: Findings From a Pilot Study.

OBJECTIVE: Presurgical infant orthopedics (PIO) reduces the severity of the original cleft and burden on patients and their parents, provides better esthetics and function, and enables surgeons to achieve better surgical repair. To reduce the alveolar cleft width and to predict treatment difficulty using PIO, various measures were examined in pretreatment cast models. DESIGN: Retrospective case-control pilot study. PATIENTS: The patients were 22 infants with non-syndromic unilateral cleft lip and palate (UCLP), and cast models of these infants were used. METHODS: After PIO using passive plates, infants with UCLP were divided into two groups: contact group (12 cases with close proximity of the greater and lesser segments) and non-contact group (10 cases without proximity of segments). The two groups were compared, and variables related to the proximity between alveolar clefts were examined. RESULTS: There was no significant difference in age at PIO initiation between the two groups. However, the treatment duration was significantly longer in the non-contact group than in the contact group. Among the 13 variables, the initial lateral deviation of the nasal septum was significantly larger in the contact group than in the non-contact group. A significant positive correlation was observed between the initial lateral deviation of the nasal septum and reduction of the alveolar cleft width by PIO. CONCLUSION: Initial lateral deviation of the nasal septum is a predictive factor for the proximity between alveolar segments in infants with UCLP at the PIO.

Ultrastructural focus on the oral cavity roof of the juvenile and adult white grouper (Epinephelus aeneus): Novel view of its development with carnivorous adaptation.

The present study aims to characterize the ultrastructural roof of the oral cavity roof in juvenile and adult Epinephelus aeneus using SEM. The investigation used 10 roofs of the oral cavity of juvenile and adult stages of age. The results in both age groups showed that the roof had five tooth bands, an upper valve, and a palatine region. The upper lip was divided into the anteriorly median and two lateral parts. The posterior margin of the anterior labial part is not attached to the incisive or canine teeth. The anterior surface of the canine teeth was attached to the transverse part of the upper incisive ridge that was separated from the posterior labial part by a deep groove. The semilunar upper velum showed two surfaces, two borders, and two parts. The median part of the oral surface of the velum carried the extension of the longitudinal part of the upper incisive ridge that had some variation among the two examined age stages. In addition, the median part of the oral surface of the upper velum had two rough areas located laterally on each side of the longitudinal part of the upper incisive ridge. The oral surface had several slightly elevated fungiform papillae with taste buds. The palatine region was divided into the peripheral semilunar part and the wide median part, by palatine teeth and the palatine groove laterally and by vomer teeth anteriorly. The results provided important data for the aquaculture in Egypt in relation to their diet.

Effect of vomer position following surgically assisted rapid palatal expansion.

PURPOSE: To evaluate the effect of vomer position and prevalence of periodontal dehiscence in patients who underwent surgically assisted rapid palatal expansion (SARPE). The null hypotheses were the following: (1) vomer position in the coronal plane does not influence the degree of skeletal and dental expansion; and (2) there is no association between expansion, periodontal dehiscence and vomer position. METHODS: Twenty-one patients were evaluated before treatment (T0) and immediately after SARPE expansion (T1). After SARPE, the vomer was in the right side in 11 patients and in the left in 10 patients. Skeletal and dental effects were evaluated using CBCT, landmarks and measurements. RESULTS: The maxilla and the nasal cavity expanded asymmetrically. The side containing the vomer had less skeletal expansion but more dental tipping. Dehiscence increased significantly from T0 to T1 and was associated with the amount of skeletal displacement, especially when greater than 3.20 mm. In the first premolars region, there was more than 2 mm of asymmetric expansion observed in 38.5% of the patients. CONCLUSION: The null hypotheses were rejected. The side containing the vomer had less skeletal expansion of the maxilla and nasal cavity but more dental tipping. Dehiscence increased after expansion, but there were no differences between sides.

Presurgical Alignment of Bilateral Cleft Segments With 3D Simulation Under Special Consideration of the Vomer: A Technical Note.

BACKGROUND: The main goal of presurgical orthopedics (PSO) for patients with bilateral cleft lip and palate is to correct the protruded and/or twisted premaxilla. However, PSO is associated with the risk of uncontrolled development of the vomer, which has received little attention to date. SOLUTION: We present a removable orthodontic device that can be used to keep or align the vomer and the premaxilla in the midline during preoperative molding of cleft segments independently and 3 dimensionally.

Oronasal Fistula Incidence Associated With Vomer Flap Repair of Cleft Palate: A Systematic Review and Meta-Analysis.

OBJECTIVES: To determine the incidence of oronasal fistulas (ONF) associated with primary repair of the anterior palate using a single-layered, superiorly based, vomer mucoperiosteal flap. DESIGN: A systematic review of MEDLINE, PubMed, Cochrane, and Web of Science databases using the keywords: "vomer flap" and "cleft palate repair" were carried out. A meta-analysis was performed using random effect modeling with stratified analysis by syndromic diagnosis, number of surgeons, and mean age. MAIN OUTCOME MEASURE(S): Incidence of ONFs. RESULTS: The meta-analysis included 9 studies with a total of 464 children who met inclusion criteria. The overall ONF rate was 3.0% (95% CI: 1.0-9.0). Fistula rates were not significantly different in studies that included syndromic patients compared to studies that did not, 5.0% (95% CI: 1.0-24.0) versus 3.0% (95% CI: 1.0-6.0), respectively. There was no significant difference between studies in which there was a single surgeon versus multiple surgeons, 3.0% (95% CI: 1.0-13.0) versus 4.0% (95% CI: 1.0-8.0), respectively. Age at the time of cleft repair showed no statistically significant difference in fistula rate when comparing children with a mean age less than 12 months to those greater than 12 months, 3.0% (95% CI: 1.0-5.0) versus 5.0% (95% CI: 1.0-28.0), respectively. CONCLUSIONS: The vomer flap technique in cleft palate repair appears to be associated with a low ONF rate unaffected by syndromic diagnosis, number of surgeons, or patient age at time of repair.

Review of literature of saddle nose deformity reconstruction and presentation of vomer onlay graft.

OBJECTIVE: Saddle nose deformity is a well-described condition that most commonly results from trauma or prior surgery. For larger saddle nose deformity defects, bone grafts are a reconstructive option that provide adequate structure for repair. One new technique for repair of these deformities is a vomerian bone onlay graft. We aim to provide a review of literature on autogenous repair of saddle nose deformities, as well as introduce a new technique in which the vomer bone is used as an onlay bone graft. METHODS: Literature review and case series. Five cases in which vomer onlay grafts were used for repair of saddle nose deformity were reviewed between January 2013 and December 2015. Aesthetic outcomes and postoperative complications were evaluated at subsequent follow-up visits in clinic. RESULTS: In all cases where vomer bone was harvested, the vomer onlay graft provided adequate structure to traverse the saddle nose deformity. No postoperative complications were observed in an 18 month follow-up period. CONCLUSION: Vomerian bone onlay grafts are a reconstructive option for saddle nose deformity and nasal dorsum defects. While septal cartilage is commonly used, and ethmoidal bone has been previously described as an option for composite graft reconstruction, vomer bone onlay grafting has not been well described in the literature. This method may be of use when previous nasal surgery has been performed and standard septal cartilage is not possible to harvest. The aesthetic outcomes following nasal dorsum reconstruction using onlay grafts are favorable, but long-term outcomes of these grafts require further study. LEVEL OF EVIDENCE: IV.

Secondary correction of premaxilla in bilateral cleft lip and palate with lag-screw fixation.

It is not unusual for the protruding premaxilla to attain an undesirable position after cleft lip repair. Such a premaxilla may lead to considerable problems in facial aesthetics, or oral functions, or both in early childhood. These abnormal premaxillas may produce difficulties in bone grafting and orthodontic treatment in late childhood. In such cases, surgical correction of the premaxilla in childhood is justified. From 2013 to 2018, 11 children, aged 2 to 11 years, had a secondary ostectomy of their premaxilla. A new stabilisation method (developed by us) was used to provide rigid fixation to the premaxilla. The follow up period ranged from 1 - 6 years. The results were satisfactory in all except for a few minor issues in three patients. There was significant improvement in their appearance, oral functions, and most importantly in their quality of life. The need for secondary osteotomy of the premaxilla should always be weighed against its potential complications. The fixation technique described by us, though, provides rigid fixation, but may potentially be associated with a few complications if not practised carefully.

Three-Dimensional Morphological Changes of the True Cleft under Passive Presurgical Orthopaedics in Unilateral Cleft Lip and Palate: A Retrospective Cohort Study.

The aim of this cohort study was to quantify the morphological changes in the palatal cleft and true cleft areas with passive plate therapy using a new analysis method based on three-dimensional standardized reproducible landmarks. Forty-five casts of 15 consecutive patients with complete unilateral cleft lip and palate were laser scanned and investigated retrospectively. The landmarks and the coordinate system were defined, and the interrater and intrarater measurement errors were within 1.0 mm. The morphological changes of the cleft palate area after a period of 8 months of passive plate therapy without prior lip surgery are presented graphically. The median decrease in cleft width was 38.0% for the palatal cleft, whereas it was 44.5% for the true cleft. The width of the true and palatal cleft decreased significantly over a period of 8 months. The true cleft area decreased by 34.7% from a median of 185.4 mm2 (interquartile range, IQR = 151.5-220.1) to 121.1 mm2 (IQR = 100.2-144.6). The palatal cleft area decreased by 31.5% from a median of 334 mm2 (IQR = 294.9-349.8) to 228.8 mm2. The most important clinical considerations are the reproducibility and reliability of the anatomical points, as well as the associated morphological changes. We propose using the vomer edge to establish a validated measuring method for the width, area, and height of the true cleft.

Does Primary Vomer Flap Significantly Affect Maxillary Growth?

BACKGROUND: Cleft lip and palate (CLP) is a common congenital anomaly. Efficient surgical management of CLP is challenging in severe cases with wide clefts. Use of primary vomer flap simultaneous with cleft lip repair is effective in some cases, but remains a challenging topic. METHODS: This study evaluated 81 non-syndromic CLP patients with extensive palatal cleft and no other underlying condition. Thirty-nine patients (group A) who were infants over 6 months of age underwent primary vomer flap during lip repair to decrease the size of their extensive palatal cleft. The results in this group were compared with group B (n=42) who did not receive primary vomer flap. RESULTS: Comparison of the two groups showed that although maxillary growth impairment and maxillary constriction had a higher frequency in group A, the palatal cleft was smaller among them, which enabled easier and more efficient cleft repair in the next step. The difference in maxillary growth impairment was not significant between the two groups. However, the prevalence of some complications such as velopharyngeal incompetence and maxillary growth impairment was slightly higher in group A compared with group B. CONCLUSION: Use of primary vomer flap at the time of lip repair can decrease the size of palatal cleft and enhance its later closure. However, since impairment of the maxillary growth was slightly (but insignificantly) higher in the vomer flap group, it should be performed at ages over 6 months of age, as well as in certain cases.

Lag screw fixation of the premaxilla during bilateral cleft lip repair.

In synchronous primary premaxillary setback and cleft lip repair for bilateral cases with severely protruding premaxilla, stabilization of the premaxilla is mostly achieved by gingivoperiosteoplasty. This kind of repair carries risk of impairment of blood supply to the premaxilla and/or prolabium, and at the same time it cannot ensure adequate stabilization of the premaxilla postoperatively. To overcome these problems, we have developed a unique technique of fixation of the premaxilla. In this paper, we discussing this technique, its advantages, and potential complications associated with it. From 2016, 10 patients aged 4-10 months, with bilateral cleft lip and palate with premaxillary protrusion (≥10 mm) underwent premaxillary setback and cheilorhinoplasty in the same stage. Instead of gingivoperiosteoplasty, a 'lag screw' fixation technique was used to stabilize the premaxilla. The follow-up period ranged between 5 and 32 months. In all the cases, we achieved adequate stabilization of the premaxilla. None of the patients had any issue related to the vascularity of the premaxilla or prolabium. There was no impairment in the eruption process of deciduous teeth in the premaxillary segment. Overall aesthetic outcomes of the lip and nose were acceptable. This technique of premaxillary fixation with lag screw gives us the liberty to perform primary cheilorhinoplasty along with premaxillary setback in the same stage, without risking the vascularity of premaxilla and prolabium. It ensures adequate stabilization of the premaxilla, but evaluation of regular growth of the midface and, if needed, corrective orthodontic and surgical treatment in the follow-up periods are advisable.

Influence of vomer flap on craniofacial growth in patients with cleft lip and palate: A systematic review.

The aim of this review was to evaluate the impact of the vomer flap on craniofacial growth in patients with cleft lip and palate. The review was conducted according to the PRISMA checklist and is registered in the International Prospective Register of Systematic Reviews (PROSPERO - CRD42018095714). Two investigators performed the research using the PubMed/MEDLINE, Embase, and Web of Science databases for studies published until November 2018. The focused question was 'Does the vomer flap have a lesser impact on craniofacial growth in patients with cleft lip and palate?'. A total of 13 articles was selected for this review, comparing the vomer flap technique with other flap surgery techniques. The outcomes analyzed were: facial development (primary outcome); and the growth of the maxilla and mandible, occlusion, occurrence of fistula, and speech development (secondary outcomes). It was concluded that there is no difference in impact between vomer flap and the other flap surgery techniques on craniofacial development.

Posteroinferior septal defect due to vomeral malformation.

PURPOSE: Vomeral malformation may lead to a posteroinferior septal defect (PISD). It is usually found incidentally, without any characteristic symptoms. The purpose of this study was to evaluate its clinical implications. METHODS: In this study, we included 18 patients with PISD after reviewing paranasal sinus computed tomography scans and medical records of 2655 patients. We evaluated the shape of the hard palate and measured the distances between the anterior nasal spine (A), the posterior end of the hard palate (P), the posterior point of the vomer fused with the palate (V), the lowest margin of the vomer at P (H), and the apex of the V-notch (N). RESULTS: None of the PISD patients had a normal posterior nasal spine (PNS). Six patients lacked a PNS or had a mild depression (type 1 palate), and 12 had a V-notch (type 2 palate). The mean A-P, P-H, and P-V distances were 44.5 mm, 15.3 mm, and 12.4 mm, respectively. The average P-N distance in patients with type 2 palate was 7.3 mm. There were no statistically significant differences between the types of palates in A-P, P-H, or P-V distances. In patients with type 2 palate, there was a significant correlation between P-V and P-N distances (r = 0.664, p = 0.019). CONCLUSIONS: PISD due to vomeral malformations was identified in 0.7% of the cases in this study. None of the subjects had a normal PNS, which suggests that the development of the vomer is closely related to that of the hard palate.

[Diagnostics and management of choanal atresia]. / Diagnostik und Management der Choanalatresie.

Choanal atresia is a rare malformation that represents a special challenge. While bilateral choanal atresia usually needs to be surgically treated within a few days of birth, the intervention for one-sided choanal atresia can be postponed for years. Treatment planning requires adequate imaging (CT or MRI), which also serves to exclude other skull base malformities. Surgical treatment currently focuses on transnasal endoscopic techniques. Simultaneous resection of the parts of the vomer involved in the atresia seems to be important surgical success. Postoperative stenting is still controversially discussed. Postoperative application of corticosteroid nasal sprays and saline nasal rinsing for several weeks is of great importance. Due to the rarity of the diagnosis, the absence of prospective randomized controlled trials does not allow definitive statements regarding the optimal surgical technique or stenting.

Congenital Vomer Agenesis: A Rare and Poorly Understood Condition Revealed by Cone Beam CT.

Isolated congenital vomer agenesis is a very rare and poorly understood condition. In the context of dental work-up by cone-beam computed tomography (CBCT), the explored volume of the facial bones occasionally reveals incidental abnormalities. We report the case of a 13-year old Caucasian female who underwent CBCT for the pre-treatment evaluation of primary failure of tooth eruption affecting the permanent right upper and inferior molars. CBCT depicted a large defect of the postero-inferior part of the nasal septum without associated soft tissue abnormality and without cranio-facial malformation or cleft palate. In the absence of a history of trauma, chronic inflammatory sinonasal disease, neoplasia and drug abuse, a posterior nasal septum defect warrants the diagnosis of vomer agenesis. A discussion of this condition and of salient CBCT features is provided.