Rhinoliths: Analysis of 24 Interesting Forgotten Foreign Body Cases.

Rhinoliths are petrified masses formed by accumulation of endogenous or exogenous salts around a nidus. Although rarely formed by the body, the most common cause is foreign bodies forgotten in the nose at childhood. Rhinoliths are rare and have been reported as a single case report in the literature. In this study, 24 different and different cases will be analyzed. Twenty-four interesting patients who were operated for rhinolith in the otorhinolaryngology clinic between 2014 and 2019 and were not seen in the literature before were analyzed retrospectively. The characteristics of these patients such as age, sex, additional pathology, foreign body coexistence, type of anesthesia used, and previous surgical status were analyzed. Fourteen patients were male and 10 were female (58.3% male, 41.7% female). The mean age was 30.4 (minimum 2, maximum 62). Twelve of the foreign bodies were on the right and 12 on the left (50%). Foreign body localization was 13 (54.1%) between the inferior turbinate (IT) and septum and 11 (45.9%) between the middle turbinate and septum. Tissue destruction was seen in 12 (50%; 7 septum, 5 IT) patients. Fifteen patients had additional pathology (mostly septum deviation). General anesthesia was used in 14 patients and local anesthesia was used in 10 (58.3%-41.7%) patients. Two patients (n = 2) had rhinoliths due to forgotten nasal packing after surgery and forgotten silicone nasolacrimal tube after dacryocystorhinostomy surgery. Rhinoliths should be considered with unilateral malodorous runny nose and resistant sinusitis attacks. The diagnosis is rigid endoscope and computed tomography imaging. It usually occurs as a result of forgotten foreign bodies. Rhinoliths may also form as a result of forgotten tampon after previous nose or eye surgery.

Systematic Surgical Approach to Alar Base Surgery in Rhinoplasty.

In an era with smartphone photography and social media (specifically, "selfies"), basal view aesthetics is becoming increasingly important. Achieving balance between the nasal base and the remainder of the nose and face while preserving or restoring external valve function are essential to a successful rhinoplasty. Without a systematic approach to the nasal base, it is more difficult to achieve an ideal outcome from both aesthetic and functional standpoints. This article outlines an organized and systematic approach to the nasal base, beginning with comprehensive nasofacial analysis. The authors continue by describing idealized basal view aesthetics and provide a treatment algorithm for common deformities that include alar flaring and a wide nasal base. The authors attempt to provide a comprehensive approach to the treatment of the nasal base by discussing the implications of treating columellar deformities, tip positioning, or alar-columellar discrepancies on the overall aesthetics of the lower third of the nose. Furthermore, technical considerations are given for common surgical maneuvers addressing the alar base to help guide treatment and prevent complications such as poor scarring, notching, nostril asymmetry or stenosis (external valve obstruction), and alar deformities ("parenthesis" or "bowling pin"), to name a few.

The Simplified Nasal Septal Deviation Evaluation System and Nasal Obstruction Symptom Evaluation Scale Correlation.

Nasal septal deviation (NSD) is a common condition in otorhinolaryngology practice. The aim of this study was to investigate the possible relationship between localization and severity of NSD, and related complaints as well as to suggest a simplified assessment method for NSD. Seventy-five patients who complaint nasal obstruction were enrolled this study. The affected nasal cavity was divided into 4 separate sections as follows: antero-superior (AS), antero-inferior (AI), postero-superior (PS), and postero-inferior (PI). Each section was determined according to its relationship to the both superior edge and head of the inferior turbinate. The NSD score was calculated separately for each section according to its relationship with lateral nasal wall. The NSD-related complaints were assessed via the Nasal Obstruction Symptom Evaluation (NOSE) scale. There were 42 male and 33 female patients, with an age range of 18 to 44 years. The mean NSD score was 2.18 ±â€Š0.63 for AS section, 1.92 ±â€Š0.67 for AI section, 1.54 ±â€Š0.70 for PS section, and 1.18 ±â€Š0.60 for PI section. The mean total NSD score was 6.84 ±â€Š1.97 while the mean NOSE score was 12.5 ±â€Š5.11. There was a strong positive correlation between total NSD and NOSE scores when the NSD score was 6 or more (r = 0.9556). This correlation was also present when each section was evaluated separately. The strongest correlation was detected for AS section deviations. Our septal classification system provides a simple and effective evaluation of NSDs. The NSDs which affect internal valve are more related with nasal obstruction and patients' discomfort.

Comparison of Quality of Life Before and After Septoplasty With Short Form-36.

The authors aimed to evaluate quality of life after septal surgery with Short Form-36 survey, and the effectiveness of the survey. Nasal symptoms (nasal obstruction, facial pain, catarrh), and general quality of life (using the Turkish version of the Short Form-36 questionnaire) were assessed preoperatively and at 1st and 6th postoperative months. Acoustic rhinometry and rhinomanometry were assessed preoperatively and at 6th postoperative month. Data from 78 patients were analyzed. This prospective clinical study was conducted on patients complaining of nasal obstruction with nasal septal deviation. Seventy-eight patients were included in the study. Fourty-two patients (53.8%) were male and 36 patients (46.2%) were female. At 1st postoperative month, nasal obstruction, facial pain and catarrh scores significantly improved in all, 46, 18 patients, respectively (P < 0.0001). At 6th postoperative month, scores nonsignificantly worsened by 1 point in 12, 6, 12 patients, respectively. Nasal volume significantly increased and total resistance significantly decreased at 6th month (P < 0.0001). Compared to preoperative values, all items except social function and bodily pain significantly increased at 1st postoperative month. Compared to values at 1st postoperative month, only bodily pain score decreased at 6th postoperative month. One patient presented with septal perforation. Septoplasty is a well-established technique to reduce nasal obstruction and improve quality of life. SF-36 may be used as a reliable measure of changes in quality of life after septal surgery.

Maxillary Sinus Pneumocele Presenting as Aesthetic Deformity: A Case Report With Literature Review.

We report an interesting case of maxillary sinus pneumocele that presented with aesthetic deformity and completely treated with Caldwell-Luc approach and thoroughly review all of the past literature focusing on clinical symptoms and surgical approach. Based on our comprehensive review of maxillary sinus pneumocele, we found 2 important characteristics. First, maxillary sinus pneumocele may be asymptomatic but cause various symptoms owing to the displacement of neighboring structures, such as facial symptoms, eye symptoms, and nasal obstruction. Second, there is no standard operation technique for maxillary sinus pneumocele, but surgical approach should be individualized depending on patient's symptoms and needs. Therefore, more case studies are needed to confirm this.

Centering a Deviated Nose by Caudal Septal Extension Graft and Unilaterally Extended Spreader Grafts.

OBJECTIVE: The deviated nose presents a tremendous challenge for rhinoplasty surgeons, especially the correction of the cartilaginous dorsum deviation. In this study, we introduce the surgical techniques of correcting a deviated cartilaginous vault by creating a new center of the lower third using a caudal septal extension graft combined with unilaterally extended spreader grafts. METHODS: This retrospective observational study was conducted in a university-based tertiary medical center from December 2014 to January 2018. Thirty-two patients who underwent primary open rhinoplasty for correction of a deviated nose using this method participated in the study. Patient characteristics and surgical records were collected. Anthropometric measurements and analyses were performed based on preoperative and postoperative photographs. The aesthetic outcome consensus of three rhinoplasty surgeons was evaluated specifically for nasal dorsum deviation correction. Postoperative complications were reviewed from the medical records. RESULTS: Among the 32 patients, there were 18 males and 14 females. The mean (SD) age of the patients was 26.7 (8.76) years. Anthropometric measurements showed significant improvements in dorsal deviation angle (a 3.7° change towards midline, P < .001), nasal tip projection (increase of 6.96% measured by Goode's method, P < .001), and nostril shape (nostril axis inclination decrease of 11.7°, P < .001) after surgery. The nasolabial angle showed no significant change. Aesthetic outcomes were excellent in seven patients (21.9%), good in fourteen patients (43.7%), fair in eight patients (25.0%), and no change in three patients (9.4%). Minor postoperative complications (four patients) were observed during follow-up. CONCLUSION: Centering the cartilaginous vault using a caudal septal extension graft combined with unilaterally extended spreader grafts is a useful technical option in the correction of a deviated nose, and provides improvement in nasal tip projection and nostril shape.

Management of Postsurgical Empty Nose Syndrome.

Empty nose syndrome (ENS) is a controversial condition associated with disruption of nasal airflow caused by excessive loss of turbinate tissue. ENS arises after total or near-total inferior turbinate resection. Patients present with intense fixation on the perception of nasal obstruction. Diagnostic tools to assess for empty nose syndrome include a validated patient questionnaire and the office cotton test. Treatment involves topical moisturization, behavioral/psychiatric assessment/treatment, and surgical reconstruction. Current data show promising long-term efficacy after surgical intervention. Postprocedural ENS is best prevented by minimizing inferior and middle turbinate tissue loss.

Orientation of the premaxilla in the origin of septal deviation.

INTRODUCTION: While most people believe the nasal septum to have intrinsic deviation and overgrowth in patients seeking rhinoplasty, an alternative concept is that a mal-oriented premaxilla causes extrinsic septal buckling and external extrusion of the septal cartilage. In this sense, the premaxillary bone plays a significant role in the pathogenesis of septal deviation. This study was performed to determine if non-traumatically acquired septal/nasal functional and aesthetic pathology or septal deviation may be related to the orientation of the premaxilla relative to the skullbase. METHODS: A retrospective, single-center study of patients in the general population who underwent maxillofacial CT scans and presented for the evaluation of nasal obstruction. CT scans were used to measure features of both pathologic and non-pathologic nasal septums. RESULTS: A total of 68 subjects were evaluated. When comparing patients with a premaxillary-skullbase angle of greater than 81° (the mean of the study group) to those of less than 81°, and a more obtuse nasolabial angle was observed (p = 0.0269). When comparing the extremes of premaxillary rotation, specifically, greater than 87° (mean 91.7°, SD 5.1) and less than 77° (mean 70.7°, SD 3.6), the differences were more pronounced with regard to caudal septal excess (p = 0.0451) and septal deviation in the axial plane (p = 0.0150). CONCLUSION: Septal developmental changes may involve an overly rotated or more vertically oriented premaxillary bone relative to the skull base. An understanding of the cause of septal deformity may provide insight into the design of improved treatments.

A Modified Dorsal Split Preservation Technique for Nasal Humps with Minor Bony Component: A Preliminary Report.

BACKGROUND: In scenarios of a dorsal hump with minor bony cap, ideal esthetic dorsal lines can be preserved and refined by component separation of the upper lateral cartilages from the septal T, resection of a septal strip and ethmoid bone wedge, adjustment of width and symmetry and final re-suture of the cartilaginous dorsum after pushdown, improving width and symmetry. The associated bony cap is managed by osteoplasty only with or without narrowing osteotomies, and septal deviations can be concomitantly corrected. OBJECTIVES: A novel technique of modified dorsal cartilaginous pushdown after component separation is described in detail. This method illustrates the importance of preserving the integrity of the septal T anatomy and the elastic keystone junction. METHODS: A preliminary series of 41 consecutive patients with follow-up up to 1 year, with a mean of 6 months, is reviewed. RESULTS: All patients presented favorable outcomes with a natural looking dorsum. A learning curve led to progressive improvements by suture fixation of the septal T, finesse adjustment of dorsal width and symmetry, fine-tuning of deviation and gradual extension of the technique to include cases that required osteotomies without transverse element and those with any degree of septal manipulation. CONCLUSION: Disrupting the keystone area is fraught with potential complications which often lead to secondary revision. A modified dorsal preservation technique with pushdown limited to the septal T component of the cartilaginous dorsum combines the popular component separation concept with the preservation of the delicate anatomy of the mid-vault. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Risk factors for intraoperative saddle nose deformity in septoplasty patients.

INTRODUCTION: Septoplasty is one of the most common otolaryngologic procedures. Previous studies have reported that the overall rate of significant change in cosmetic appearance of the nose after septoplasty ranged from 0.4 to 3.4%, and saddle nose was the most commonly cited deformity. In this study, we evaluated the risk factors for intraoperative saddle nose in a group of septoplasty patients. METHODS: This case-control study (1:2 case:control) was conducted based on retrospective chart review. Intraoperative saddle nose was observed in 108 (5.1%) of 2106 patients who underwent septoplasty in our center between January 2008 and December 2017. The control group consisted of 216 randomly selected, hospital-matched septoplasty patients who had no intraoperative saddle nose deformity in the same period. The demographic data, preoperative endoscopic findings, and surgical procedures of the two groups were analyzed to identify possible risk factors of intraoperative saddle nose deformity. RESULTS: The mean ages of the two groups were 34.8 years (saddle group) and 33.2 years (control group). In multivariate logistic regression analysis, clinical risk factors associated with intraoperative saddle nose were female gender (OR 3.39; 95% CI 1.76-6.54; p < 0.01), severe caudal septal deviation (OR 2.22; 95% CI 1.30-3.79; p = 0.003), and intraoperative finding of septal cartilage fracture (OR 3.96; 95% CI 1.92-8.19; p < 0.01). CONCLUSIONS: Severe caudal septal deviation, intraoperative fracture of septal cartilage, and female gender were risk factors for intraoperative saddle nose deformity in our study population.

Beware the Alar Base Optical Illusion in Assessment of Unilateral Cleft Lip Nasal Deformity.

BACKGROUND: After repair of unilateral cleft lip, lateral drift of the alar base is expected and may require revision. Although the alar base appears wider than on the noncleft side, by measurement it could be symmetric or narrow. Is this an optical illusion? METHODS: This is a retrospective photographic evaluation of children who underwent repair of unilateral complete cleft lip and palate. On submental standardized photographs, raters judged whether the alar base position was wider, equal to, or narrower than on the noncleft side. The true alar base position was measured by photogrammetry and the frequency of alar base misjudgment was assessed. On control photographs, the cleft side alar base was wider than the noncleft side. On test photographs, the cleft side alar base was narrower than the noncleft side. Possible association between misjudgment and nasal features was also evaluated. Data were analyzed using the Fisher's exact test. RESULTS: Three raters assessed 61 patients aged 6 to 9 years and treated between 1995 and 2015. In 77 percent of control photographs, raters correctly judged the cleft side alar base as wider. In 65 percent of test photographs, raters incorrectly judged the alar base position as wider on the cleft side. Asymmetry of nostril outline and a transverse nostril axis were associated with misjudged photographs (p < 0.05). CONCLUSIONS: Alar base assessment can be altered by an optical illusion. Simple anthropometry counters this misperception. Measurement should be repeated after correction of the deviated anterocaudal septum and elevation of the lower lateral cartilage. Thereafter, a decision is made on altering the alar base position. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.

Role of Spreader Flaps in Rhinoplasty: Analysis of Patients Undergoing Correction for Severe Septal Deviation with Long-Term Follow-Up.

INTRODUCTION: The aim of this randomized controlled study was to analyze the long-term results of patients undergoing rhinoplasty because of severe septal deviation and to evaluate the stability of results. MATERIALS AND METHODS: The study was performed with a randomized design. Patients were randomly divided into four groups: group 1, spreader flaps were used in combination with spreader grafts; group 2, spreader flaps were used alone; group 3, spreader grafts were used alone; and group 4, neither spreader flaps nor grafts flaps were used. Patients answered the Italian version of the FACE-Q rhinoplasty module. Anthropometric measurements were performed by AutoCAD for MAC. We determined the angle of deviation, and we compared the pre- and postoperative angles and compared patient satisfaction in the four groups using the Chi-squared test for unpaired data. Two plastic surgeons reviewed all the postoperative photographs of the study patients and rated the photographs on a scale of 1 to 5. RESULTS: A total of 264 patients who underwent primary rhinoplasty between January 2010 and September 2016 satisfied the inclusion criteria and were finally enrolled in this study. Anthropometric measurements revealed statistically significant differences (P < 0.01) between the preoperative and postoperative values for the angle of septal deviation in group 1 versus the other groups. Over the long-term follow-up, group 1 maintained an angle close to 180 degrees (P < 0.01). Group 1 and group 3 were more satisfied compared with groups 2 and 4 (P < 0.01). According to evaluations by the 2 reviewers, group 1 and group 3 were the most satisfactory outcomes (P < 0.01). CONCLUSIONS: This was the first randomized study to show that the combined use of the spreader flap and spreader graft is the best choice for a good long-term outcome and durable correction of septal deviation. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Strategies to Evaluate Bilateral Cleft Lip Treatment.

OBJECTIVE: Evaluate treatment of patients with bilateral cleft lip operated during the last 10 years, using the methodology of Mortier and Anastassov. METHODS: A total of 84 patients were evaluated using a preoperative score assessing fissure severity and a postsurgical score assessing of uncorrected or secondary deformities. A pre- and postcorrelation analysis was performed to evaluate the gain and identify the main postoperative alterations, using Spearman's statistical test (P < 0.001). RESULTS: About 89.3% underwent surgery between 4 and 7 months. Surgical techniques used Millard 65.5% and Mulliken 34.5%. Presurgical evaluation classified fissures as mild (0%), moderate (2.4%), severe (19.1%), or very severe (78.6%). Postoperative evaluation classified results as poor (24%), satisfactory (12%), good (15, 6%), very good (34.6%), or excellent (14.3%). The postoperative changes on the lip were the notch in the vermilion and the defect in the edge of the vermilion, and in the bow of the wide cupid; in the nose, the most frequent were deficiency in the upper nasal nostril, insufficient rotation of the alar base, broad tip, and short columella; in the scar and alveolar portion, the most frequent were alveolar cleft, premaxilla protrusion, and poor scar. Spearman correlation of preoperative and postoperative was positive of 0.43. CONCLUSION: The proposed measurement method is technically simple and can be performed without equipment allowing pre- and postoperative evaluation to identify the main alterations to be corrected.

Saddle nose with sarcoidosis: "A great imitator" of relapsing polychondritis.

Sarcoidosis is a systemic granulomatous disease that can affect any organ including the nose. Nasal crusting and congestion are common nasal symptoms of sarcoidosis, whereas cases of saddle-nose deformity are rarely reported. We describe here a case of sarcoidosis that presented with saddle nose resembling relapsing polychondritis. Since sarcoidosis shares clinical features with relapsing polychondritis, the differential diagnosis of saddle nose can be challenging without a clear pathology.

Saddle nose deformity and septal perforation in granulomatosis with polyangiitis.

BACKGROUND: Patients who have granulomatosis with polyangiitis (GPA, syn. M. Wegener) often develop an external nose deformity which may have devastating psychological effects. Therefore, reconstruction of nasal deformities by rhinoplasty may become necessary to achieve a normal appearance. OBJECTIVE OF REVIEW: The aim of this systematic review was to investigate the efficacy and safety of surgical reconstruction in external nasal deformities and septal perforation in GPA patients. SEARCH STRATEGY: A systematic literature search with defined search terms was performed for scientific articles archived in the MEDLINE-Database up to 10 June 2016 (PubMed Advanced MEDLINE Search), describing management of cases or case series in GPA patients with saddle nose deformity and/or septal perforation. RESULTS: Eleven of 614 publications met the criteria for this analysis including 41 GPA patients undergoing external nasal reconstruction and/or septal reconstruction with a median follow-up of 2.6 years. Overall, saddle nose reconstruction in GPA patients is safe even if an increased rate of revision surgery has to be expected compared with individuals without GPA undergoing septorhinoplasty. Most implanted grafts were autografts of calvarial bone or costal cartilage. For septal perforation reconstruction, few studies were available. Therefore, based on the available data for surgical outcomes, it is impossible to make evidence-based recommendations. All included GPA patients had minimal or no local disease at the time of reconstructive surgery. Therefore, the relationship between disease activity and its impact on surgical outcomes remains unanswered. The potential impact of immune-modulating medications on increased complication rates and the impact of prophylactic antibiotics are unknown. CONCLUSIONS: This study systematically reviews the efficacy and safety of surgical reconstruction of external nasal deformities in GPA patients for the first time. Saddle nose reconstruction in GPA patients with minimal or no local disease is a safe procedure despite an increased rate of revision surgery. Further research is required regarding the impact of antibiotic prophylaxis, immune-modulating therapy, long-term outcomes and functional outcomes measured with subjective and objective parameters.

Impact of Septoplasty on Eustachian Tube Functions.

OBJECTIVE: To evaluate the impact of nasal septum deviation (NSD) and septoplasty on eustachian tube (ET) functions. MATERIAL AND METHODS: The study was designed as a prospective controlled study and conducted in a tertiary referral center. A study group of 25 patients who were scheduled for septoplasty for NSD; and a control group of 25 healthy individuals having no ear or nose symptoms were formed. Tympanometric analysis of ET function, subjective and objective analysis of nasal functions with acoustic rhinometry and rhinomanometry were performed. Patients in study group underwent nasal surgery and tests were repeated at postoperative 1st and 3rd months. RESULTS: Eustachian tube functions of study group were significantly worse than the control group (P = 0.032). ET functions were found to be poorer as the nasal airway resistances increase which was found to be close to significance (P = 0.056). One and 3 months after corrective surgery, both nasal airway functions and ET functions improved significantly reaching to the level of control group. CONCLUSIONS: Nasal septum deviation was associated with higher rates of ET dysfunction, which could be improved by the nasal surgery. However, in some patients, nasal surgery itself caused ET dysfunction in the early postoperative period.