Hematoma de tabique: informe de dos casos pediátricos / Septal hematoma: Report of two pediatric cases

Los hematomas y abscesos septales constituyen una urgencia en rinología y requieren tratamiento quirúrgico temprano debido al riesgo de complicaciones infecciosas, funcionales y estéticas. Suelen aparecer como consecuencia de un traumatismo nasal, aunque también se han descrito en relación con otros desencadenantes. La acumulación de sangre o pus entre el mucopericondrio y el cartílago septal causa lesión por necrosis avascular en el cartílago y la destrucción de este.Desde el punto de vista clínico, se presenta como insuficiencia ventilatoria nasal y dolor facial. Con menor frecuencia, el motivo de consulta es deformidad del dorso nasal, epistaxis, rinorrea purulenta y fiebre.Se presentan en este trabajo dos casos clínicos con diagnóstico de hematoma septal que requirieron cirugía.

Hematomas and septal abscesses are an emergency in rhinology and require early surgical treatment due to the risk of infectious, functional, and aesthetic complications. They generally occur as a consequence of nasal trauma, although they have also been described in relation to other triggers. Accumulation of blood or pus between the mucoperichondrium and septal cartilage, causes avascular necrosis injury to the cartilage with cartilage destruction.Clinically it presents as nasal ventilatory insufficiency and facial pain. In a lower percentage, the reason for consultation was nasal dorsal deformity, epistaxis, purulent rhinorrhea and fever.We present two clinical cases with septal hematoma. Both required surgery.

A potential post-removal pH neutralization strategy to mitigate nasal button battery injuries.

OBJECTIVE: Button batteries (BBs) impacted in the nose of children can cause septal perforation, synechia, atrophy, necrosis and deformities such as saddle nose. Developing mitigation strategies that can reduce tissue damage after BB removal can decrease these complications. METHODS: 3 V lithium BBs were placed on the cadaveric sheep nasal septum model segments. After 3, 6, 12 and 24 h, BB on each segment was removed and intermittent irrigation was performed with 0.25% acetic acid solution. Irrigation with saline was performed as the control. Visual tissue damage that occurred just before and after irrigation was photographed. BB voltage, temperature and pH changes in the tissue were recorded. Each segment was examined after irrigation for the depth of necrosis and presence of cartilage necrosis. RESULTS: The voltage of 3 V lithium BB was observed to drop to about half at the end of the 3rd hour. It was observed that full-thickness mucoperichondrial necrosis occurred in the nasal septum segments at all time points. Although 0.25% acetic acid irrigation significantly decreased tissue pH compared to saline without increasing temperature, it did not show a significant superiority compared to saline in reducing neither visually nor histologically damage. While cartilage necrosis was not observed for the first 12 h, it was measured 105 µm in the segment irrigated with 0.25% acetic acid at the end of 24 h, and 518 µm in the segment irrigated with saline. CONCLUSIONS: The pH neutralization strategy with post-removal 0.25% acetic acid irrigation to mitigate nasal BB injury appears to be ineffective in reducing the full-thickness mucoperichondrial necrosis starting within 3 h. Although this strategy seems to decrease the progression of cartilage necrosis starting after 12 h, the development of pre-removal strategies for the first 3 h may be more effective and superior in reducing mucoperichondrial damage.

Postoperative epistaxis and sphenoid sinus ostial stenosis after posterior septal branch injury during sphenoidotomy.

BACKGROUND: Postoperative arterial epistaxis and sphenoid sinus stenosis after sphenoidotomies for endoscopic sinus surgery (ESS) and transsphenoidal approaches (TSAs) are uncommon. One potential source of epistaxis after sphenoidotomy is the sphenopalatine artery's posterior septal branch (PSB). PSB injury, in addition to other factors, could increase the risk of sphenoid stenosis. The purpose of this study was to determine incidence of, and risks factors for, the following outcomes after sphenoidotomy: PSB injury; postoperative epistaxis from the injured PSB; and sphenoid stenosis after PSB injury. METHODS: A single-institution, prospective case series was conducted based on 233 sphenoidotomies performed during ESS (n = 163) and TSAs (n = 70). Outcome measures included intraoperative PSB injury, postoperative epistaxis from the PSB, and sphenoid stenosis. RESULTS: The incidence of PSB injury was 17.2% during ESS-related sphenoidotomies, and 5.7% during TSA-related sphenoidotomies (p = 0.010). After PSB injury during ESS- and TSA-related sphenoidotomies (n = 32), there was 1 instance of epistaxis from the PSB (3.1%). Of the 161 ESS-related sphenoidotomies, 6 developed complete or near-complete stenosis (3.7%), which was more likely to occur with smaller anterior sphenoid face dimensions (p = 0.001). PSB injury, revision sphenoidotomy, and other factors did not increase the risk of stenosis. None of the TSA-related sphenoidotomies stenosed completely. Median follow-up was 7 months. CONCLUSION: PSB injury occurred in 17.2% of ESS-related sphenoidotomies and 5.8% of TSA-related sphenoidotomies. After PSB injury, postoperative epistaxis from the PSB was rare (3.1%). After ESS-related sphenoidotomies, sphenoid stenosis was rare (3.7%), and was more likely to occur with smaller sphenoid dimensions, but not with PSB injury or other factors.

Primary Nasal Reconstruction in Self-Inflicted Nasal Injury.

Self-inflicted injury of the nose is extremely rare. It may be associated with severe psychopathology and suicidal ideation. The authors report a case of a 24-year-old man, who presented with soft-tissue loss over both the alae of his nose. He had cut off the alar rims with an ordinary razor blade. He was overtly concerned about his nose being excessively broad and fat. A diagnosis of body dysmorphic disorder with nonsuicidal self-injury was made. Patient was observed during 72 hours in hospital with psychiatric support and local dressings. The authors undertook primary nasal reconstruction with nasolabial flaps on both sides for coverage. In conclusion, self-inflicted nasal injury mandates a judicious balancing of psychiatric support and surgical reconstruction. This can prevent untoward sequelae including further self-harm and suicide.

Complications of balloon packing in epistaxis.

Although balloon packing appears to be efficient to control epistaxis, severe local complications can occur. We describe four patients with local lesions after balloon packing. Prolonged balloon packing can cause damage to nasal mucosa, septum and alar skin (nasal mucosa, the cartilaginous skeleton and the overlying soft-tissue envelope) and should, therefore, be avoided. We suggest early nasendoscopy in general anesthesia to identify and treat the bleeding focus, if bleeding cannot be controlled with regular packing.

Hydrocolloid to prevent breakdown of nares in preterm infants.

PURPOSE: To determine if a double-barrier hydrocolloid dressing prevents trauma to the nares and columella in very low birthweight (VLBW) infants (<1,500 grams) receiving heated humidified high-flow nasal cannula (HHHFNC) oxygen. STUDY DESIGN AND METHODS: Retrospective two-group comparative study design. SAMPLE: Medical records (N = 53) of VLBW infants receiving HHHFNC were reviewed. Control infants (n = 27) did not have a double-barrier hydrocolloid dressing. Intervention infants (n = 26) had a double-barrier hydrocolloid dressing. Groups were similar on sex, race, birthweight, and gestational age. Control infants were significantly older than intervention infants at study entry (4.3 weeks and 1.5 weeks, respectively, p = .001). Skin condition of nares was scored daily ranging from 3 (no breakdown) to 9 (extensive breakdown). Skin scores were abstracted from medical records at baseline then weekly for comparison over time. RESULTS: There were no significant differences in skin scores between groups or over time. Week 1 mean skin score was 3.4 (±0.1) in both groups. Mean skin score at week 4 was 3.4 (±0.1) in Control infants and 3.1 (±0.08) in Intervention infants. CLINICAL IMPLICATIONS: HHHFNC is more frequently being used in infants of extreme prematurity. The dressing may have protected the more immature skin of the intervention infants; however, vigilant nursing observation of the infants' nares during HHHFNC cannot be ruled out. Nurses need adequate education on the consistent application of the hydrocolloid barrier and on documenting skin assessment scores each shift to promote skin protection in this vulnerable population.

The primary closure approach of dog bite injuries of the nose.

The nose holds an outstanding position on the face, acquiring great importance within the context of facial aesthetics. Because of the functional, psychological, and social aspects of trauma in a society increasingly demanding about aesthetics, treatment institution must reduce, as accurate as possible, the sequelae that hinder social integration. This clinical report relates an immediate nasal reconstruction of a complex animal bite wound. A 7-year-old patient was victim of a dog bite with avulsion of the left nasal ala and part of the ipsilateral nasal tip. The treatment was immediate nasal reconstruction with auricular composite graft. After 1 year of follow-up, the shape of nasal ala was stable, and the color was consistent with the surrounding tissue. The 2 nasal sides exhibited satisfactory symmetry when evaluated. It can be concluded that the composite graft derived from the auricular helix is a safe option for reconstruction of nasal ala defects with compromised margins in pediatric patients when conditions of reimplantation do not exist.

Management of perforations of the nasal septum: can extracorporeal septoplasty be an effective option?

PURPOSE: Perforation of the nasal septum is a frustrating problem frequently reported in the literature. Surprisingly, in most reports, iatrogenic perforation during septoplasty and electrocautery are the leading causes of this complication. This article presents the management of septal perforations and the indications for an extracorporeal approach. MATERIALS AND METHODS: Fourteen patients with septal perforations were referred for treatment. Treatment was chosen based on defect size. Flaps, extracorporeal repair, or no treatment was used as indicated. RESULTS: Two of 14 perforations were small and were repaired by local flaps, 5 cases were treated by extracorporeal repair, and the 7 remaining cases required no surgical procedure. CONCLUSIONS: The extracorporeal technique, when indicated, can be used effectively for the repair of nasal septum perforations in selected cases.

Revision of severe nasal trauma.

Facial trauma commonly includes injury to the nose and perinasal area. In this review, we will focus on the sequelae of severe nasal trauma and provide examples of correction of the severely deviated nose, the severely collapsed nose, and revision of a traumatic deformity after prior rhinoplasty. We will then discuss coexistent deformities of perinasal regions in addition to functional and posttraumatic nasal correction, including posttraumatic periorbital deformities.

Pediatric nasal fractures: evaluation and management.

Nasal fractures have been reported as 1 of the 3 most commonly encountered pediatric facial bone fractures. The most common causes of nasal fractures in this age group are auto accidents (40%), sports injuries (25%), intended injuries (15%), and home injuries (10%). Nasal fractures are usually treated with closed reduction (Higuera S, Lee EI, Stal S. Nasal trauma and the deviated nose. Plast Reconstr Surg 2007;120:64S-75S). This results in a significant incidence of posttraumatic deformities, often requiring secondary surgical treatment. For this reason, it is paramount to pay careful attention to the underlying structural nasal anatomy during the initial diagnosis and management.

Evolução das lesões nasais em pacientes com hanseniase / Evolution of nasal lesions in leprosy patients

Doença causada pelo bacilo Mycobacterium leprae, a hanseníase ataca a pele e os nervos periféricos, em especial dos olhos, do nariz, das mãos e dos pés. Sua maior morbidade associa-se aos estados reacionais e ao acometimento neural que podem causar deficiências físicas, comprometendo a qualidade de vida dos pacientes. Este estudo teve como finalidade descrever as alterações e avaliar a evolução das lesões nasais encontradas durante o tratamento de hanseníase com poliquimioterapia, mediante avaliações realizadas pelo profissional no serviço de prevenção e de reabilitação das incapacidades físicas. Os resultados demonstraram que a lesão nasal é freqüente (69,8%). A lesão mais encontrada foi o ressecamento (38,2%), seguido de crostas (23,6%) e de obstrução nasal (8%). Considerando reavaliações e orientações quanto aos cuidados com o nariz no sentido de prevenir lesões e de cuidar das já instaladas, o acompanhamento do paciente ao longo do tratamento resultou em melhora das lesões em 47,2% dos casos, em manutenção da lesão em 39,5% dos casos, em ausência de lesão em 6,3% e em piora das lesões em 7% dos casos. O nariz deve ser elencado como local de avaliação e de cuidados na rotina de atendimento em prevenção de incapacidades na hanseníase.

Leprosy, an infectious disease caused by Mycobacterium leprae, affects skin and peripheral nerves, especially in eyes, nose, hands and feet. Its highest morbidity is associated with reactional episodes and neural involvement which cause physical deformities, compromising the quality of life of the patients. This study aimed to describe the alterations in nose and to evaluate the evolution of the nasal injuries appearing during leprosy treatment with multidrug therapy. It was based on evaluations done by professional from the service of prevention of incapacities and rehabilitation. The results demonstrated that nasal injury is frequent (69.8%). The most common lesion finding is the dryness (38.2%), followed by crusts (23.6%) and nasal clogging (8%). The follow-up and orientation of patients in respect to care of the nose to prevent appearance of lesions and to promote healing resulted in improvement in 47.2% of the cases, maintenance of lesions in 39,5%, absence in 6,3% and worsening in 7% of the cases. The nose should be selected amongst the sites for evaluation and routine care during assistance in prevention of incapacities of leprosy patients.

Complications and solutions in presurgical nasoalveolar molding therapy.

OBJECTIVE: To outline three main categories of nasoalveolar molding complications, describe their etiologies and manifestations, and prescribe preventive and palliative therapy for their proper management. Estimates of the incidence of each complication also are provided. MATERIALS AND METHODS: Data were collected retrospectively from the charts of 27 patients with complete unilateral cleft lip and palate treated by the first author (D.L.-B.) at the University of Puerto Rico (n = 12) and the Medical College of Georgia (n = 15). Confidence intervals for the true incidence of each complication were calculated using exact methods based on the binomial distribution. A significance level of .05 was used for all statistical tests. RESULTS: Of the soft and hard tissue complications considered, only one (tissue irritation) had an estimated incidence greater than 10%. Compliance issues were of greater concern, with an estimated incidence of 30% for broken appointments and an estimated incidence of 26% for removal of the nasoalveolar molding appliance by the tongue. CONCLUSIONS: Although benefits outnumber the complications, it is important to address all complications in order to prevent any deleterious outcomes.

Titanium mini-plate for securing septal cartilage--a case of high-impact nasal trauma.

A technique is presented of securing the cartilaginous nasal septum using titanium mini-plates in the repair of a complex open comminuted type I nasoethmoid fracture, with internal impaction of the external cartilaginous nose. This technique allows primary skin closure and obviates the need for external metal-work and the attendant potential complications.

Classification and treatment of the saddle nose deformity.

The saddle nose deformity results from a disruption in the nose's integral support mechanisms. Reconstructive surgeons must not only reestablish facial aesthetic contours but also rebuild the nose's structural framework while preserving or restoring nasal function. The causes and the classification of saddle nose deformities are reviewed, and the preferred techniques of correction and reconstruction are illustrated.

Cosmetic and functional effects of cephalic malposition of the lower lateral cartilages: a facial plastic surgical case study.

Certain anatomic variations of the lower lateral cartilages can predispose patients to nasal obstruction. One particular orientation is the cephalic malposition of the lower lateral cartilages which often results in both cosmetic and functional nasal effects. This article will discuss the pertinent surgical anatomy, diagnosis, the process to identify patients at risk with cephalic malposition of the lower lateral cartilages, pitfalls, and poor surgical changes that result in external nasal valve collapse. Appropriate diagnosis, prevention, and surgical maneuvers to address this will be discussed.

Preventing pressure sores of the nasal ala after nasotracheal tube intubation: from animal model to clinical application.

PURPOSE: Nasal-ala pressure sores induced by nasotracheal intubation are common complications of oral and maxillofacial surgery, but are easily ignored. To determine whether such sores could be prevented, we studied the effects of a combination of cushioning material in an animal model, and then analyzed the efficacy of this combination clinically. MATERIALS AND METHODS: Four pigs received nasotracheal intubation. Each pig received intubation for 4, 8, 12, or 16 hours. Outcomes from pigs undergoing 500-gram-weight compression on each nostril were compared: one nostril received an application of cushioning materials, and the contralateral nostril did not. After the required study period, clinical assessment and further evaluation were performed by measuring pressure-sore dimensions and performing incisional biopsies. Clinical applications of this protective technique were then undertaken. Eight patients who underwent intubation without Soft Liner (GC Co, Tokyo, Japan) and DuoDERM CGF (ConvaTec, Inc, Princeton, NJ) protection, and 10 patients with Soft Liner and DuoDERM protection, were evaluated. RESULTS: The protective efficacy of the cushioning materials was significant in the animal model as well as in clinical practice. Pressure sores were avoided on the protected side, with severe tissue necrosis documented on the control side. CONCLUSION: We found that the combined use of Soft Liner and DuoDERM reduced the size and severity of nasal-ala pressure sores attributable to nasotracheal intubation during oral and maxillofacial surgery.

The crooked nose: the use of medial iliac crest bone graft as a supporting framework.

The crooked nose is one that the vertical axis of the nose inclines from the midline. As a rule, a major septal deformity almost always accompanies to impairing breathing and aesthetic appearance. To achieve total straightening of the crooked nose, the septum must become the target of the treatment. To prevent redeviation, we used rigid bone grafts instead of flexible and relatively weak cartilage to maintain the support of the corrected deformity. Between February 2005 and July 2007, 9 patients (all male) with crooked noses underwent corrective surgery. The mean age of the patients was 21 years (range, 19-23 years). The source of the bone graft was medial side of iliac crest in all patients. The mean follow-up was 18 months, ranging from 10 to 26 months. All patients had both functional and cosmetic problems. Mean operation time was 4 hours. Airway patency was improved in all cases. The grafts did not shift in any case and did not develop unsightly irregularities over time. Absorption of the grafts was not seen in the follow-up. There were no cases of extrusion or infection. No donor site complication occurred. None of the patient required secondary surgery. A residual deviation can be obvious despite all attempts, which has no deleterious effect on patient satisfaction. This article introduces a novel technique for the correction of the crooked nose.