The Nasal Width and Boxiness Index: Introduction and Pilot Study on Reliability and Validity of Sonographic Morphometry.

Both intended and unintended surgical modifications of nasal width and shape of the nasal tip continue to be of interest to the rhinoplasty surgeon. As validated instruments for quantifying width and boxiness are lacking, the objective of this study was to introduce a width index and a boxiness index for the nasal dorsum and the nasal tip. A width index and a boxiness index were defined within the methodological limits of noncontact sonography. The reliability of both indices was studied by comparing the measurements of two examiners on the noses of five volunteers. The validity of the indices was studied by correlating the sonographic width and boxiness with the 5-point Likert scale ratings of photographs of 5 noses by 21 lay persons. Nasal width was defined as the diameter at a distance of 5 mm from the skin surface on a sonographic cross-section perpendicular to the skin surface. Boxiness was defined as the quotient of width at a depth of 1 and 5 mm. Bland-Altmann analysis revealed negligible bias between both examiners and 95% of limits of agreement of 13, 7, and 13% for width at 1 mm, width at 5 mm, and boxiness, respectively. Corresponding Pearson's correlation coefficients were r = 0.93, r = 0.93, and r = 0.71. The correlation between the cumulative lay persons' scores and sonographic width and boxiness were r = 0.97, r = 0.66, and r = 0.81 for nasal tip width, dorsal width, and boxiness, respectively. Both the width at a depth of 5 mm as measured with sonography and the boxiness index that is defined as width at a depth of 1 mm divided by the width at a depth of 5 mm may prove to be acceptable surrogate parameters for width and boxiness of the nose in comparative morphometric studies.

Nasolacrimal duct obstruction caused by lymphoproliferative infiltration in the course of chronic lymphocytic leukemia.

BACKGROUND: Endoscopic dacryocystorhinostomy (DCR) is the standard treatment of nasolacrimal duct obstruction. Only in rare cases, blockage may be caused by malignant tumors and even more exceptionally by lymphatic neoplasms so that biopsies are not routinely taken for diagnostic purposes. METHODS: A computerized retrieval system was used for this retrospective study to identify all patients with histologically documented lymphoproliferative infiltration in the lacrimal drainage system from 2001 to 2009. RESULTS: In four of 191 patients (2.1%), infiltration of the nasolacrimal sac mucosa with a small lymphocytic lymphoma (SLL)/chronic lymphatic leukemia (CLL) was found. Patients who develop symptoms like epiphora within the course of known CLL are highly suspicious for lymphoproliferative infiltration of the lacrimal drainage associated lymphoid tissue. CONCLUSION: A proactive approach with ophthalmologic consultation and DCR should be followed in these patients to avoid dacryocystitis.

The Nose Influences Visual and Personality Perception.

Nasal deformities are known to attract attention, are felt to be stigmatizing, and are known to affect negatively the perception of personalities. These effects have not been studied on profile views. The objective of this study was the quantification of visual attention directed toward nasal deformities and its impact on the perception of personality traits. Forty observers were divided into two groups and their visual scanpaths were recorded. Both groups observed a series of photographs displaying profile views of 20 adult patients' faces with one or more nasal deformities or computer-morphed corrected noses. Photographs were chosen from a consecutive sample of patients (range: 17-68 years, median: 45) who requested a rhinoplasty at the Department of Otolaryngology, Head and Neck Surgery, Facial Plastic Surgery of the Cantonal Hospital Sankt Gallen, Switzerland. Patients' photographs showed a nasal deformity in one series and a computer-morphed nose in the other series and vice versa. Visual fixation times on the noses were compared between the photographs with and without a nasal deformity. Observers subsequently rated personality traits using visual analog scales. The nasal profile with a deformity received more visual attention in 17 of 20 patients (85%). The mean relative fixation duration of all nasal deformities was significantly larger compared with all computer-simulated noses (17.3 ± 6.9 [SD] vs. 10.6 ± 2.5%; p < 0.001). Cumulative personality questionnaire scores and the score for satisfaction were significantly lower for faces with nasal deformities compared with computer-morphed noses (27.8 ± 6.0 vs. 29.1 ± 6.0, p = 0.040, and 5.3 ± 1.59 vs. 5.7 ± 1.53, p = 0.017, respectively). For deformed noses, the mean relative fixation duration did not correlate with the cumulative personality score (R = - 0.399; p = 0.082). To the best knowledge of the authors, an attention-drawing potential of nasal deformities on a profile view has been quantified for the first time. This seems to lead to a more negative perception of personality traits.

Sound localization measured by eye-tracking.

OBJECTIVE: To introduce a new method of measuring sound localization ability based on eye-tracking and to test this method by analysing the influence of mild induced conductive hearing loss on sound localization. DESIGN: Sound signals were presented from different angles, and the participant's responses were measured using an eye-tracking device. For validation, a comparison of responses to visual stimuli was performed. To test the clinical application of this method, a mild conductive hearing loss was simulated, and the impact of this change on sound localization was measured. STUDY SAMPLE: Fifteen participants. RESULTS: The system provided repeatable measurements, and there was a good correlation of sound and visual signals. A large number of trials could be completed fairly rapidly. Following the induced conductive hearing loss, a decline of 5.5° in the accuracy of sound localization in the horizontal plane was found towards the side of the non-impaired ear for frontal presentations. CONCLUSIONS: Quantifying sound localization by eye-tracking was found to be feasible, fast and accurate. A mild conductive hearing loss caused a slight degradation of sound localization accuracy within the 30° frontal sector, which is in good agreement with results found using methods requiring more extensive instrumentation.

Frontobasal Fractures.

Frontobasal fractures occur in up to 24% of head injuries and often require a multidisciplinary approach. Besides the common bone fractures, the complex anatomy can cause damage to the sense of vision and smell. Further possibly lethal complications such as cerebrospinal fluid leak followed by meningitis or internal carotid bleeding can follow. Diagnostic and treatment options are reviewed with a focus on the endoscopic endonasal approach.

Maxillofacial Fractures: Midface and Internal Orbit-Part I: Classification and Assessment.

Fractures of the midface and internal orbit occur isolated or in combination with other injuries. Frequently, the patients are first seen in emergency rooms responsible for the coordination of initial diagnostic procedures, followed by the transfer to specialties for further treatment. It is, therefore, important for all physicians treating facial trauma patients to understand the basic principles of injuries to the midface. Thus, this article aims to describe the anatomy and the current classification systems in use, the related clinical symptoms, and the essential diagnostic measures to obtain precise information about the injury pattern.

Management of Zygomatic Fractures: Bone and Arch.

Zygomatic bone and arch fractures are among the most common facial fractures treated by facial plastic surgeons. Controversy still remains regarding the optimal management of these fractures. Computed tomographic scanning (including three-dimensional reconstruction) represent a fundamental tool for diagnosis and treatment planning of zygomatic fractures. Main indications for treatment are functional impairment, cosmetic deformity, or both. Fracture reduction can be performed through an open or closed approach depending on the amount of exposure necessary to achieve accurate reduction. The common goal among all treatment plans is the exact three-dimensional restoration of the disturbed anatomy and function while minimizing complications.

Maxillofacial Fractures: Midface and Internal Orbit-Part II: Principles and Surgical Treatment.

Current clinical assessment and imaging techniques were described in part 1, and this article presents a systematic review of the surgical treatment principles in the management of midface and internal orbit fractures from initial care to definitive treatment, including illustrative case examples. New developments enabled limited surgical approaches by standardization of osteosynthesis principles regarding three-dimensional buttress reconstruction, by newly developed individualized implants such as titanium meshes and, especially for complex fracture patterns, by critical assessment of anatomical reconstruction through intraoperative endoscopy, as well as intra- and postoperative imaging. Resorbable soft tissue anchors can be used both for ligament and soft tissue resuspension to reduce ptosis effects in the cheeks and nasolabial area and to achieve facial aesthetics similar to those prior to the injury.

Eye tracker based study: Perception of faces with a cleft lip and nose deformity.

AIM: Quantification of visual attention directed towards cleft stigmata and its impact on the perception of selected personality traits. METHODS: Forty observers were divided into two groups and their visual scan paths were recorded. Both groups observed a series of photographs displaying full frontal views of the faces of 18 adult patients with clefts, nine with residual cleft stigmata and nine with digitally-corrected stigmata (each patient only appeared once per series). Patients that appeared with residual stigmata in one series appeared digitally corrected in the other series and vice versa. Visual fixation times on the upper lip and nose were compared between the original and corrected photographs. Observers subsequently rated personality traits as perceived using visual analogue scales and the same photographs that they had observed in the series. RESULTS: In faces depicting cleft stigmata observers spent more time looking at the oronasal region of interest, followed by the eyes (39.6%; SD 5.0 and 35.1%; SD 3.6, respectively, p = 0.0198). Observers spent more time looking at the cleft lip compared with the corrected lip (21.2%; SD 4.0 and 16.7%; SD 5.0, respectively, p = 0.006). The differences between questionnaire scores for faces with cleft stigmata compared with faces with corrected stigmata for withdrawn-sociable, discontent-content, lazy-assiduous, unimaginative-creative, unlikeable-likeable, and the sum of individual personality traits were not significant. CONCLUSION: According to these findings, cleft lip and cleft nose have an attention-drawing potential with the cleft lip being the major attention drawing factor. These data do not provide supportive evidence for the notion reported in literature that patients with clefts are perceived as having negative personality traits.

Effect of protruding ears on visual fixation time and perception of personality.

IMPORTANCE: Protruding ears are often thought to be a stigma, supposedly drawing attention and negatively influencing the perception of personality. These purported negative effects that may indicate corrective aesthetic otoplasty in patients too young to provide informed consent have not been quantified. OBJECTIVE: To quantify attention directed toward protruding ears and its effect on the perception of selected personality traits. DESIGN, SETTING, AND PARTICIPANTS: In this observational study conducted from August 1, 2013, to October 31, 2013, visual scan paths were recorded of 20 lay observers looking at photographs of faces of 20 children (age range, 5-19 years) with either protruding ears or ears morphed via computer software to appear nonprotruding. Subsequently, the observers rated 10 perceived personality traits based on the same photographs. MAIN OUTCOMES AND MEASURES: Visual fixation time on protruding vs nonprotruding ears was compared and correlated with observers' scores for personality traits. RESULTS: Fixation time on protruding ears was significantly longer compared with that for morphed nonprotruding ears (mean [SD], 9.6% [5.6%] vs 5.8% [3.2%] of total fixation time, P = .04). The difference between the overall personality questionnaire scores and between individual scores for assiduousness, intelligence, and likeability was not significant for protruding and nonprotruding ears. Faces in which the protruding auricles received the highest percentage of visual attention scored higher than average for the overall personality scores (mean [SD], 66.09 [4.50] vs. 55.81 [13.36]) and for assiduousness (6.64 [0.74] vs. 5.59 [1.41]), intelligence (6.78 [0.74] vs. 5.83 [1.31]), and likeability (7.29 [0.47] vs. 6.28 [1.40]). CONCLUSIONS AND RELEVANCE: Protruding ears had the potential to draw viewers' attention but did not cause a negative perception of personality traits. This study therefore does not provide confirmatory evidence for the stigmatizing nature of protruding ears. LEVEL OF EVIDENCE: 3.

The diced cartilage glue graft for nasal augmentation. Morphometric evidence of longevity.

BACKGROUND: A grafting technique that uses diced cartilage without fascia, which improves formability while maintaining long-term stability, would be a welcome addition to the rhinoplasty armamentarium. METHODS: A diced cartilage glue graft was recently introduced as the Tasman technique. The technique has been used by one of us (A.-J.T.) in 28 patients who were monitored clinically for 4 to 26 months. Sonographic morphometry of the graft was used in 10 patients with a maximum follow-up of 15 months, and 2 biopsies were obtained for histologic examination. RESULTS: Fashioning the diced cartilage glue graft reduced operating time compared with the diced cartilage fascia graft and allowed for a wide variety of transplant shapes and sizes, depending on the mold used. All grafts were used for augmentation of the nasal dorsum or radix and healed uneventfully. Sonographic cross-section measures of the grafts changed between 6% and ­29%(median, ­5%) in the early postoperative phase and 8%and ­7% (median, ­2%) between 3 and 15 months after insertion. Histologic examination of the graft biopsies revealed viable cartilage with signs of regeneration. CONCLUSION: The diced cartilage glue graft may become an attractive alternative to accepted methods for dorsal augmentation, the diced cartilage fascia graft in particular.

[Current controversies in the treatment of frontal sinus fractures]. / Stirnhöhlenfraktur: aktuelle Kontroversen zur Therapie.

The surgical treatment of frontal sinus fractures is foreshadowed by fears of late complications. Complications such as meningitis and mucoceles should be prevented by cranialization or obliteration of the frontal sinus. These procedures are still standard treatment despite of recent developments over the last two decades in endoscopic sinus surgery, in medical imaging and surgical instrumentation. Nowadays the role of cranialization and obliteration is challenged by refined endoscopic frontal sinus surgery techniques, the widely-used image-guided systems and the multiplanar high-resolution computed tomography along with new data about postoperative complications. This overview summarizes the current literature, taking into account the existing evidence in the treatment of frontal sinus fractures.