Desviación septal nasal en relación con las deformidades nasales externas: un estudio observacional / Nasal septal deviation in relation to external nasal deformities: an observational study

La nariz es estructuralmente compleja, y esta complejidad da como resultado variaciones de forma nasal. El estudio tuvo como objetivo determinar las desviaciones septales nasales que ocurren en relación con las deformidades nasales externas. Se realizó un estudio transversal en el departamento de oído, nariz y garganta, en nuestro hospital. Todos los individuos que tienen desviación septal con deformidad nasal externa de noviembre de 2017 a noviembre de 2018. Esos pacientes serán evaluados mediante un examen clínico integral de la oreja, la nariz y la garganta. Los síntomas del paciente se clasifican con el cuestionario de prueba china nasal -22. Las deformidades septales se clasificaron utilizando la clasificación Mladina modificada. Las deformidades nasales externas se clasificaron empleando la clasificación de Yong Jo Jang. Aproximadamente, el 43% eran hombres y el 57% eran mujeres. Alrededor del 90% de los pacientes de 21 años a 50 años. Alrededor del 58% de los pacientes eran sintomáticos, mientras que el resto del 42% no tenía síntomas. Al correlacionar los síntomas con el tipo de desviación, se encontró significativamente asociación (P = 0.05). La mayoría de las personas se encuentran en el grupo de mediana edad. Tipo II y IV son los tipos más comunes de NSD, mientras que el tipo I es un final común. El encuentro notable de nuestro estudio es que los pacientes no tenían deformidad

The nose is structurally complex, and this complexity results in nasal shape variations. The study aimed to determine the nasal septal deviations occurrence in relation to external nasal deformities. A crosssectional study was conducted in Department of Ear, Nose and Throat, in our hospital. All the individuals having septal deviation with external nasal deformity from November 2017 to November 2018. Those patients be evaluated by comprehensive clinical examination of ear, nose and throat. Patient's symptoms are rated with Sino-Nasal Test -22 questionnaire. Septal deformities were classified using Mladina classification modified. External nasal deformities were classified employing Yong Jo Jang's classification. Approximately, 43% were males and 57% were females. About 90% of patients aged from 21 years to 50 years. About 58% of patients were symptomatic while the rest 42% were without symptoms. On correlating the symptoms with the type of deviation it was found significantly association (P=0.05). Majority of individuals are in the middle age group. Type II and IV are the most common types of NSD whereas type I is a common END. Noteworthy finding of our study is patients had no deformity.

Secondary Rhinoplasty for Unilateral Cleft Nasal Deformity.

BACKGROUND: Secondary cleft rhinoplasty presents some of the most challenging cases of both cosmetic and functional nasal deformities. Understanding the anatomy and growth abnormality seen with the cleft nasal deformity helps to tailor surgical management. This article seeks to expand on the application of current concepts in secondary rhinoplasty for unilateral cleft lip nasal deformity. METHODS: The authors review nasal analysis in the cleft rhinoplasty patient and provide the surgical management for each aspect in the secondary cleft rhinoplasty. RESULTS: The secondary rhinoplasty was divided into seven areas: piriform hypoplasia, septal reconstruction, dorsal reshaping, tip reshaping, tip projection, alar reshaping, and alar repositioning. Surgical management for each is provided. CONCLUSION: Secondary cleft rhinoplasty requires an understanding of the structural dysmorphology, and the use of cosmetic, functional, and secondary rhinoplasty techniques for its successful management.

Bilateral congenital aplasia of nasal lower lateral cartilage: a rare anomaly.

Congenital nasal anomalies are rare and occur in 1/20 000-1/40 000 newborns. An 8-year-old boy presented with developmental aplasia of bilateral nasal lower lateral cartilages, with excessive wrinkled and loose skin on the dorsum of the nose and with difficulty breathing through the nose. This is probably the first such case to be reported in the literature. The defect was reconstructed using conchal and septal cartilage grafting through an external rhinoplasty approach. At the end of the 12-month follow-up period, the patient was found to be satisfied with the functional and aesthetic results of the operation. Bilateral congenital aplasia of nasal lower lateral cartilages is extremely rare. Paediatric rhinoplasty is imperative in such cases.

Aumento da projeção da ponta nasal com "pseudo-retalhos" obtidos dos excessos cefálicos laterais das cartilagens alares / Increased nasal tip projection with "pseudo-flaps" using excess lateral cephalic alar cartilage

Introdução: O aumento da projeção da ponta nasal às vezes se torna necessário para a obtenção de uma boa proporção entre ela e o dorso. Inúmeras técnicas e táticas são descritas com essa finalidade utilizando enxertos cartilaginosos obtidos do septo nasal, concha auricular e cartilagem costal. Quando esse aumento deve ser discreto é proposto o uso dos excedentes de cartilagens alares laterais em forma de "pseudo-retalhos". Métodos: Em rinoplastias abertas primárias os excedentes das cartilagens alares, geralmente removidas, são utilizados como "pseudo-retalhos", dobrados sobre si mesmos, em forma de "suspensório de soldado francês", sobre o domus das cartilagens alares, tendo como acolchoamento de apoio os tecidos moles delas próprias, e o tecido mole interdomal, geralmente desprezado, que é liberado, e elevado para sobre os domus. Ele é mantido, descolado e deslocado para a ponta nasal, e fica contido pelos "pseudo-retalhos" das cartilagens alares ali suturados ou cobrindo o extremo do enxerto estrutural da columela. Foram operados com essa tática 36 pacientes. Resultados: 35 com bons resultados e um apresentou um abcesso de ponta nasal, provocado pela exposição endonasal de um fio de sutura não absorvível, que foi removido. Houve necessidade de uma segunda intervenção, utilizando novo enxerto auricular, ainda com resultado insatisfatório. O método é relativamente simples para quem opera narizes. Conclusão: A ponta nasal pode ser discretamente mais projetada utilizando os excessos de cartilagens alares, "pediculadas" no domus.

Introduction: An increased nasal tip projection is sometimes necessary to achieve an appropriate proportion between nasal tip and dorsum. Numerous techniques and tactics have been described for this purpose using cartilaginous grafts obtained from the nasal septum, auricular concha, and costal cartilage. When this increased projection must be discrete, the use of excess lateral alar cartilage in the form of "pseudo-flaps" is proposed. Methods: In primary open rhinoplasty, excess alar cartilage, which is generally removed, was used to produce "pseudo-flaps". The cartilages were folded over themselves in the form of a "French soldier's suspender" over the domes of the alar cartilage and supported by interdomal soft tissue padding raised over the domus. It was kept detached, and relocated to the nasal tip and was contained by "pseudoflaps" of the alar cartilages sutured there or covering the columella's structural graft. Thirty-six patients underwent surgery using this technique. Results: Thirty-five had good results and one had a nasal tip abscess, caused by endonasal exposure to a non-absorbable suture, which was removed. A second intervention was then performed using a new auricular graft, but the result was still unsatisfactory. The "pseudoflaps" method is relatively simple for those performing nasal surgery. Conclusion: The nasal tip can be projected discretely using the excess of alar cartilage "pedicled" in the domus.

Component Restoration in the Unilateral Intermediate Cleft Tip Rhinoplasty: Technique and Long-Term Outcomes.

BACKGROUND: The intermediate cleft tip rhinoplasty is performed in childhood to address residual tip asymmetries during the most critical period of psychosocial development. The authors describe and evaluate long-term outcomes of that approach for the unilateral cleft lip and palate patient based on the concept of individual restoration of each abnormal anatomical component. METHODS: Photomorphometric analyses of unilateral cleft lip and palate patients (n = 50) who underwent intermediate cleft tip rhinoplasty using the component restoration technique were evaluated preoperatively (time 0) and postoperatively at less than 1 year (time 1), 1 to 3 years (time 2), and more than 3 years (time 3) and compared to age-matched unilateral cleft lip and palate control patients. Nasal relationships (alar symmetry, nasal tip protrusion-to-alar base width ratio, and height-to-width dimensions for the cleft and noncleft nostrils) were compared over time using a linear mixed-effect model. RESULTS: At time 0, both groups demonstrated similar nasal relationships, with the exception of a wider cleft-side nostril in relationship to height in the rhinoplasty group. The component restoration technique improved all four nasal relationships at all postoperative time points compared with time 0 in a statistically significant manner, whereas control patients did not demonstrate significant changes at the corresponding ages. Long-term differences at time 3 revealed a trend toward improved alar symmetry and cleft-side and non-cleft-side nostril dimensions, and a significant improvement in the nasal tip protrusion-to-alar base width ratio in intermediate cleft tip rhinoplasty-treated versus control patients (p = 0.002). CONCLUSION: The component restoration technique for the unilateral intermediate cleft tip rhinoplasty improves nasal relationships toward normal immediately and in a sustained manner for at least 3 years. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Relation Between the Lower Lateral Cartilages and the Function of the External Nasal Valve.

INTRODUCTION: The position of the lower lateral cartilages (LLC) is closely related to the function of the external nasal valve (ENV). When there is a cephalic malposition of these cartilages, the nasal alae have inadequate support, which leads to ENV insufficiency during deep inspiration. METHODS: Retrospective study with 60 patients evaluated: the positioning of the LLC and the occurrence of ENV insufficiency; the effectiveness of structuring the medial and lateral walls of the ENV; and the frequency of the grafts used for structuring it. RESULTS: Of the 60 operated cases, 37 patients (62%) had ENV insufficiency, in 23 cases there was cephalic malposition of the LLC, and in the latter group 17 patients (74%) presented this insufficiency. A structured ENV was effective in the treatment of this insufficiency (p = 0.001). A lateral crural strut graft was performed in 24 cases (40%) of 60 patients operated. The alar contour graft was performed from 2013 to 2015 in 4 patients (22%) of 18 cases operated, and between 2016 and 2018 it was performed in 29 patients (69%) out of 42 cases. The columellar strut was routinely used from 2013 to mid-2016 in 33 cases (100%), and after that period until the present day the tongue-in-groove technique was performed in 11 cases (41%) and in the remaining 16 cases (59%) the caudal septal extension graft was performed. CONCLUSION: Cephalic malposition of the LLC is an important red flag of ENV insufficiency. This insufficiency should be treated by structuring the walls of the ENV. 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 .

Surgical Technique for Nasal Cleft Repair.

BACKGROUND: Congenital nasal cleft is a very rare yet challenging deformity to reconstruct. Atypical craniofacial clefts that involve the nasal ala are designated as number 1 and number 2 under the Tessier classification system. These clefts typically present as notches in the medial one-third of either nasal ala and may be accompanied by a malpositioned cartilaginous framework. Nasal clefts are smaller and far less common than familiar clefts of the lip and palate, but they pose equally challenging reconstructive planning. METHODS: Our described technique relies on usage of existing nasal tissue near the cleft. Local tissue rearrangement using a laterally based rotational alar flap, a medially based triangular flap, and a nasal wall advancement flap restores normal anatomy and provides an aesthetically pleasing result. RESULTS: Five children with isolated nasal cleft were treated by the senior author (A.M.) between 2010 and 2017. All patients presented with clefts of the soft tissue with no underlying cartilaginous involvement. There were no postoperative complications. Excellent aesthetic outcome was achieved in all patients. CONCLUSION: Isolated nasal cleft can be properly corrected with the described procedure in a single stage and with optimal result.

Cribriform Plate, Crista Galli, Olfactory Fossa and Septal Deviation.

OBJECTIVES: In the present study, we investigated the relationship between olfactory fossa, cribriform plate, crista galli and nasal Septal Deviation (SD). Keros classification of olfactory fossa was also performed. METHODS: This study was performed retrospectively. Computerized Tomography (CT) images of 200 adult subjects were observed. Unilateral nasal Septal Deviation (SD) cases were included into the study. On coronal CT scans, SD side and location, SD angle, cribriform plate width, olfactory fossa depth (Keros classification) and width, area of the olfactory fossa, crista galli length, width and pneumatization were evaluated. RESULTS: Anterior and anteroposterior deviations were detected mainly. In females, 64.0% and in males, 45.3% of the SDs were located anteriorly. In males, anteroposterior SDs (40.0%) were detected more than females. In anteroposterior SDs, SD angle was higher than anterior SDs. With higher SD angle, crista galli width and height decreased. Cribriform plate width, olfactory fossa height, width and area values of contralateral side were significantly higher than those of the ipsilateral side. For Keros classification, in male group, type 1 (53.3%) and in females, type 2 (57.6%) was detected at ipsilateral side. For contralateral side, type 2 Keros was detected in both genders. Complete crista galli pneumatization was observed in 4.0% and partial pneumatization was detected in 12.0%. In 84% of the patients, there is no Crista galli pneumatization. With the presence of pneumatized crista galli, contralateral Keros values decreased. Crista galli height and contralateral olfactory fossa width showed positive correlation. In older patients, cribriform plate width decreased. CONCLUSION: In our study, there was no Keros type 3 olfactory fossa. In males' contralateral side of SD; and in females both ipsilateral and contralateral side of SD, Keros type 2 olfactory fossa were detected. Therefore, during sinus surgery, surgeons should work carefully not to made intracranial penetration.

Comparison of cranial fluctuating asymmetry between normal and pathological specimens from a modern Thai skeletal group.

The purpose of this study was to compare fluctuating asymmetry (FA) levels across cranial modules of normal and pathological cranial specimens. It was examined whether pathological specimens have significantly higher FA scores than normal specimens in cranial regions affected by a developmental disorder. For this study, a modern Thai skeletal sample from Chulalongkorn University was analyzed. Ninety-two cranial landmarks were digitized on 66 adult and eight sub-adult normal specimens and on five pathological specimens including two adults with abnormal palates, two sub-adults with craniosynostosis, and one sub-adult with natal absence of nasal bones. In sub-adults, FA scores of specimens with developmental disorders were significantly higher than normal specimens in the entire cranium (p = 0.041) and vault (p = 0.025). However, comparisons excluding specimen with coronal craniosynostosis were not statistically significant. In adult specimens, comparisons of FA scores in each separate cranial module were also not statistically significant. These results suggest that elevated cranial FA may not be confined to the specific cranial region with the developmental disorder.

Low-dose warfarin maternal anticoagulation and fetal warfarin syndrome.

Fetuses exposed to warfarin during pregnancy are at an increased risk of developing an embryopathy known as fetal warfarin syndrome or warfarin embryopathy. The most consistent anomalies are nasal hypoplasia and stippling of vertebrae or bony epiphyses. Management of pregnant patients on anticoagulation is challenging. Current guidelines suggest the use of warfarin if the therapeutic dose is ≤5 mg/day. We report the case of a newborn with signs of warfarin embryopathy born from a mother anticoagulated with warfarin due to mechanical mitral and aortic heart valves. Warfarin was required at the dose of 5 mg/day and was withheld without medical advice between weeks 8 and 10 with no other anticoagulation. The newborn presented with skeletal abnormalities and a ventricular septal defect that have not required specific treatment during the first year of life. Low-dose warfarin is associated with a lower risk of warfarin-related fetopathy but the risk of embryopathy seems unchanged.

A South African first: Congenital absence of the cartilaginous nasal septum.

Congenital absence of the cartilaginous nasal septum has been reported just once in the literature. We present a case of a young child, diagnosed by exclusion, with complete agenesis of the cartilaginous septum. We believe it is only the second case worldwide, and the first in South Africa, to be reported.

Percepção da redução nasal pela rinoplastia de aumento do radix e da ponta / Perception of nasal reduction by radix and tip augmentation rhinoplasty

Introdução: O dorso reto tem sido sempre um ideal na rinoplastia estética. A simples remoção da giba tem sido o método clássico e mais utilizado, mas pode ter consequências estéticas e funcionais adversas. Ainda existe grande resistência a procedimentos de aumento, porque a maioria dos pacientes solicitam redução e porque os benefícios de melhoria do equilíbrio nasal pelo aumento não são intuitivos. Um nariz aumentado pode parecer menor, o que é um benefício em particular em pacientes com pele espessa ou com o aspecto de terço inferior grande. Por outro lado, a percepção de redução com o aumento do radix e da ponta é muito comum, embora nunca tenha sido medida. Métodos: Esse estudo cria intervenções gráficas e reais para criar um dorso reto por meio do aumento do radix e da ponta e analisa como os pacientes e observadores independentes percebem as modificações. Analisou-se uma amostra de 42 casos consecutivos de rinoplastia. Desses, foram incluídos os que tinham dorso convexo e eram cirurgias primárias, restando 9 casos. Resultados: Houve aumento médio de 6,5% no tamanho do nariz na após a modificação gráfica, enquanto houve percepção de redução do nariz (p = 0,004). Houve aumento médio de 1% após a rinoplastia, enquanto houve percepção de redução. Conclusão: A retificação do dorso nasal pelo aumento do radix e da ponta causa percepção de redução do nariz.

Introduction: A straight bridge has always been the aesthetic ideal. Simple hump removal, the classical and most commonly applied method, can have aesthetic and functional consequences. However, great resistance to augmentation procedures persists because most patients request reduction and the benefits of improving nasal balance are counterintuitive. An augmented nose can look smaller, a particular benefit in patients with thick, inelastic skin or a large lower nose. On the other hand, decreased size perception after raising of the radix and tip is very common but has not been measured to date. Methods: This study created graphic and real interventions to achieve a straight bridge through radix and tip raising and analyzed how patients and independent observers perceive these changes. A sample of 42 sequential rhinoplasty patients was analyzed, including nine cases of primary surgery and dorsal convexity. Results: There was a 6.5% mean augmentation after graphic computing intervention but a perception of size reduction (p = 0.004). There was a 1% mean augmentation after rhinoplasty and an overall size reduction perception. Conclusion: Correction of the nasal dorsum, making a straight bridge through slightly increasing radix and tip, creates the perception of a decreased nose size.

Role of Matrix Gla protein in midface development: Recent advances.

Craniofacial development is a delicate process that involves complex interactions among cells of multiple developmental origins, their migration, proliferation, and differentiation. Tissue morphogenesis of the craniofacial skeleton depends on genetic and environmental factors, and on specific signaling pathways, which are still not well understood. Developmental defects of the midface caused by the absence, delays, or premature fusion of nasal and maxillary prominences vary in severity; leading to clefts, hypoplasias, and midline expansion. In the current review, we focus on the importance of the chondrocranium in craniofacial growth and how its impaired development leads to midface hypoplasia. More importantly, we reported how Matrix Gla protein (MGP), a potent inhibitor of extracellular matrix mineralization, facilitates midface development by preventing ectopic calcification of the nasal septum. In fact, MGP may act as a common link in multiple developmental pathologies all showing midface hypoplasia caused by abnormal cartilage calcification. This brief review discusses the gap in knowledge in the field, raises pertinent questions, which remain unanswered, and sheds light on the future research directions.

Bony/Cartilaginous Mismatch: A Radiologic Investigation into the Cause of Tension Nose Deformity.

BACKGROUND: Tension nose deformity is believed to be caused by an "oversized" septal quadrangular cartilage. Prior studies have shown that quadrangular cartilage size is relatively consistent in populations. The authors hypothesize that the tension nose deformity is actually caused by an external extrusion of a normal sized septal cartilage from an undersized bony septal encasement. METHODS: A retrospective case-control study of sagittal computed tomographic scans was conducted, measuring the perimeter and surface area of the quadrangular cartilage and bony septal aperture in tension nose cases and controls. Statistical analysis was performed. RESULTS: Of 23 patients enrolled in the study, 12 patients were sorted into the tension nose group, and 11 patients were considered controls. Both groups had similar perimeter and surface area of their quadrangular cartilage, without statistical difference between the two groups. However, the tension nose group had a statistically significant reduction in bony septal aperture perimeter compared with controls (p < 0.01) and a larger externally extruded septum compared with their internal septal size. They also had a substantially higher rate of septal deviation than controls. CONCLUSIONS: The results of this study suggest that a mismatch between a small bony septal aperture and a normal sized septal quadrangular cartilage may be responsible for caudal, upper lip, and dorsal fullness seen with the tension nose deformity caused by external extrusion of cartilage. Septal deviation may co-occur as a buckling phenomenon in a limited bony space. Surgical strategies to match the entire quadrangular cartilage size to the bony framework are suggested. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Correção do dorso nasal baixo ou em sela com enxerto composto de cartilagem conchal fragmentada fixa ao pericôndrio envolvidos à fáscia da mastóide / Correction of low or saddle nasal dorsum with a composite graft of fragmented conchal cartilage fixed to the perichondrium wrapped in mastoid fascia

Introdução: A rinoplastia de aumento em muitos casos torna-se mais difícil que a rinoplastia de redução. Enxertos dorsais sólidos realizados com cartilagem costal têm sido muito utilizados para aumento dorsal, porém estão associados com altos índices de revisão, por isso, muitos autores passaram a utilizar cartilagem em cubos envoltos por fáscia. A fáscia da mastoide, conectada ao pericôndrio da cartilagem conchal auricular, pode formar um enxerto composto para o aumento do dorso nasal, sendo também uma opção de tratamento. O objetivo é demonstrar a possibilidade do uso de cartilagem da concha auricular fragmentada fixa ao seu pericôndrio, e envoltos na fáscia da mastoide, formando um enxerto composto para aumento do dorso nasal. Métodos: Tratase de um estudo retrospectivo de 9 pacientes operados entre 2012 e 2016 no Hospital de Base da Faculdade de Medicina de São José do Rio Preto, em que foi realizado aumento do dorso nasal com cartilagem conchal fragmentada fixa ao seu pericôndrio e envolto à fáscia da mastoide. Resultados: Os pacientes foram acompanhados de 6 a 48 meses. Foram questionados quanto à satisfação do procedimento nasal e sensibilidade auricular, com avaliação positiva dos pacientes e cirurgiões. Conclusão: A cartilagem conchal parece ser uma alternativa de grande valia para procedimentos de aumento de dorso nasal. Esta cartilagem envolta com fáscia da mastoide parece ser uma alternativa vantajosa em comparação ao uso de outras fáscias, com baixa morbidade e taxa de complicações, podendo ser uma grande opção para tratamento do nariz em sela.

Introduction: In many cases, augmentation rhinoplasty is more difficult than reduction rhinoplasty. Solid dorsal grafts performed with costal cartilage have been widely used for dorsal augmentation; however, they are associated with high rates of revision. Thus, many authors began to use cartilage cut into cubes wrapped in fascia. The mastoid fascia, connected to the perichondrium of the auricular conchal cartilage can form a composite graft to augment the nasal dorsum, which is also a treatment option. The objective is to demonstrate the possibility of using fragmented auricular conchal cartilage fixed to its perichondrium and wrapped in mastoid fascia to form a composite graft for augmentation of the nasal dorsum. Methods: This is a retrospective study of 9 patients who underwent operation between 2012 and 2016 at the Base Hospital of the Faculty of Medicine of São José do Rio Preto, in which the nasal dorsum was augmented with fragmented conchal cartilage fixed to its perichondrium and wrapped in the mastoid fascia. Results: The patients were followed up for up 6 to 48 months. They were questioned about their satisfaction with the nasal procedure and hearing sensitivity, and provided a positive evaluation of the surgeons. Conclusion: The conchal cartilage seems a highly valuable alternative graft for nasal dorsum augmentation procedures. The technique of using cartilage wrapped in mastoid fascia seems to be an advantageous alternative when compared with those using cartilage wrapped in other fasciae: it has low morbidity and complications rates and can be a great option for saddle nose treatment.