[Clinical characteristics, diagnosis and treatment of nasal cartilage mesenchymal hamartoma in infants].

Objective: To explore the clinical characteristics, pathological features, and diagnosis and treatment strategies of nasal chondromesenchymal hamartoma (NCMH) in infants and young children. Methods: A retrospective analysis was conducted on seven cases of NCMH infants and young children admitted to Beijing Children's Hospital, Capital Medical University from April 2015 to January 2022. The cohort included 5 males and 2 females, aged from 6 days to 2 years and 3 months. General information, clinical symptoms, imaging findings, treatment plans, postoperative complications, recurrence and follow-up time were collected, summarized and analyzed. Additionally, immunohistochemical characteristics of the lesion were examined. Results: The clinical symptoms of 7 children included nasal congestion, runny nose, open mouth breathing, snoring during sleep, difficulty feeding, and strabismus. All patients underwent electronic nasopharyngoscopy examination, with 5 cases of tumors located in the right nasal cavity and 2 cases in the left nasal cavity. No case of bilateral nasal cavity disease was found. All 7 patients underwent complete imaging examinations, with 5 patients underwent MRI and CT examinations, 1 patient underwent CT examination only, and 1 patient underwent MRI examination only. The CT results showed that all tumors were broad-based, with uneven density, multiple calcifications and bone remodeling, and some exhibited multiple cystic components. The MRI results showed that the tumor showed low signal on T1 weighted imaging and high or slightly high signal on T2 weighted imaging. All patients were diagnosed through histopathological examination and immunohistochemistry, including 7 cases of Ki-67 and SMA (+), 5 cases of S-100 and Vimentin (+), and all EMA and GFAP were negative. All patients underwent endoscopic resection surgery through the nasal approach, with 3 cases using navigation technology. Five cases of tumors were completely removed, and two cases of tumors were mostly removed. No nasal packing was performed after surgery, and no postoperative nasal, ocular, or intracranial complication occurred in all patients. Follow up assessments conducted 6 to 84 months post-surgery revealed no instances of tumor recurrence in any of the patients. Conclusions: The clinical symptoms of children with NCHM mainly depend on the size and location of the tumor. Nasal endoscopic surgery is the main treatment method. In cases where critical structures like the skull base or orbit are implicated, staged surgical interventions may be warranted. Long-term follow-up is strongly advised to monitor for any potential recurrence or complications.

[Deforming endonasal mass during pregnancy]. / Deformierende endonasale Raumforderung während der Schwangerschaft.

This article presents the case of a 33-year-old woman who consulted the authors' ENT clinic in the 39th week of pregnancy with recurrent epistaxis. A livid endonasal mass was found on the left side, subtotally displacing the nose and leading to deformation of the external nose. External biopsy provided no indications of malignancy. Postpartum CT of the paranasal sinuses revealed a mass destroying the cartilaginous nasal septum. Endoscopic resection of the finding was performed with preservation of the clinically sound nasal septal cartilage. Histopathological examination revealed a capillary hemangioma, which was classified as granuloma gravidarum due to its occurrence during pregnancy.

Nasal cartilage destruction associated to cutaneous histoplasmosis in AIDS.

BACKGROUND: Systemic histoplasmosis is a disease of high morbidity and mortality in immunocompromised patients. Patients with AIDS get the infection through inhalation of spores, triggering a primary lung infection with a subsequent hematogenous spread to multiple organs, including the skin. Tissue necrosis have been documented in cutaneous histoplasmosis with multiple clinical manifestations that mimic other diseases. CASE PRESENTATION: We report the case of nasal cartilage destruction associated to cutaneous histoplasmosis in AIDS. A 24-year-old man, resident in Ecuadorian coast, with a history of HIV for 7 years without any treatment. In the last 3 months, he has been presenting a molluscum-like lesions on his nasal bridge with subsequent dissemination to the trunk and extremities. He was admitted to the emergency department for dyspnoea, cough, and malaise. Due to his respiratory failure, he was admitted to the intensive care unit (ICU) with mechanical ventilation. Physical examination reveals a crusted surface ulcer that involves the nose and cheeks, associated with erythematous papules, some with a crusted surface which are spread to the face, trunk, and upper limbs. The patient has a specific skin involvement with a butterfly-like ulcer appearance and destruction of the upper and lower lateral cartilage of the nose. At admission CD4 cell count was 11/mm3 with a HIV viral load of 322,908 copies. Mycological cultures identified Histoplasma capsulatum. A treatment with highly active antiretroviral therapy (HAART) was stablished, associated with liposomal amphotericin B at a dose of 3 mg/kg/day and itraconazole 200 mg twice a day for 12 months. CONCLUSIONS: Cutaneous histoplasmosis is a rare manifestation of pulmonary histoplasmosis in patients with AIDS. The cutaneous manifestations included papules, nodules, plaques, and ulcers. A histology examination is required to rule out other fungal or parasitic infections. Treatment includes highly active antiretroviral therapy (HAART), amphotericin B liposomal and itraconazole, the latest for at least 12 months.

Chondrodermatitis nodularis nasi.

Chondrodermatitis nodularis helicis is a relatively common ulcerative, inflammatory condition affecting the skin, and cartilage of the ear. We present a case of chondrodermatitis affecting the skin and cartilage of the nose, designated chondrodermatitis nodularis nasi. Clinically, chondrodermatitis presents as a singular, painful, ulcerated papule or nodule that results from prolonged pressure, trauma, sun exposure, or vascular compromise. The clinical features resemble those seen in skin cancer, and a biopsy is often required to secure the diagnosis. Histopathologic analysis of chondrodermatitis demonstrates a central ulcer, beneath which there is fibrinoid necrosis of the dermis and inflammatory infiltrates. The ulcer is bordered by pseudoepitheliomatous hyperplasia with underlying granulation tissue. In addition to a clinical and morphologic description of chondrodermatitis nodularis nasi, a discussion of etiological factors and differential diagnoses is included. Increased recognition and reporting of the condition will allow for the exploration of optimal treatment strategies.

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.

Preservation of Autogenous Septal Cartilage for Revision Surgery.

The aim of this study is to find the ideal solution and the optimum temperature to protect the viability of the cartilage graft. This randomized prospective study consists of 30 patients with septal deviation. All patients had septoplasty operation for chronic nasal obstruction. Ten strips of cartilages were prepared from each excised septum and then immersed in formalin, alcohol (96%), saline (0,9%), gentamicin (80 mg), and cefazolin sodium (Cezol 1gr) solutions in a total of 300 vials. Those vials were stored for 6 months at both +4°C and -18°C temperatures. Two groups were compared with each other. 22 cases were male (73%) and 8 patients were female (7%). The age range was between 20 and 48 (average 25.34 ±â€Š4.09 years). Parameters at +4°C; the cartilage volume was not significantly different among the solutions (P >0.05). Necrosis was significantly lower in the alcohol (46.7%) compared to other solutions (P = 0.001). Calcification was lower in the gentamicin group (56.7%). The loss of metachromasia was lower in the alcohol solutions (P = 0.000). Parameters at -18°C; the loss of metachromasia was higher in the gentamicin group (56.7%) than the other solutions (P = 0.003). The authors observed no significance in the rates of necrosis, calcification, metaplasia, inflammation, vascularity, or fibrosis among the solutions (P >0.05). Less necrosis and metachromosis loss in the alcohol solution indicated that alcohol was more suitable for preservation of the cartilage. In addition, temperature degree for the preservation of the cartilage did not show any significant differences.

Toward tissue-engineering of nasal cartilages.

Nasal cartilage pathologies are common; for example, up to 80% of people are afflicted by deviated nasal septum conditions. Because cartilage provides the supportive framework of the nose, afflicted patients suffer low quality of life. To correct pathologies, graft cartilage is often required. Grafts are currently sourced from the patient's septum, ear, or rib. However, their use yields donor site morbidity and is limited by tissue quantity and quality. Additionally, rhinoplasty revision rates exceed 15%, exacerbating the shortage of graft cartilage. Alternative grafts, such as irradiated allogeneic rib cartilage, are associated with complications. Tissue-engineered neocartilage holds promise to address the limitations of current grafts. The engineering design process may be used to create suitable graft tissues. This process begins by identifying the surgeon's needs. Second, nasal cartilages' properties must be understood to define engineering design criteria. Limited investigations have examined nasal cartilage properties; numerous additional studies need to be performed to examine topographical variations, for example. Third, tissue-engineering processes must be applied to achieve the engineering design criteria. Within the recent past, strategies have frequently utilized human septal chondrocytes. As autologous and allogeneic rib graft cartilage is used, its suitability as a cell source should also be examined. Fourth, quantitative verification of engineered neocartilage is critical to check for successful achievement of the engineering design criteria. Finally, following the FDA paradigm, engineered neocartilage must be orthotopically validated in animals. Together, these steps delineate a path to engineer functional nasal neocartilages that may, ultimately, be used to treat human patients. STATEMENT OF SIGNIFICANCE: Nasal cartilage pathologies are common and lead to greatly diminished quality of life. The ability to correct pathologies is limited by cartilage graft quality and quantity, as well as donor site morbidity and surgical complications, such as infection and resorption. Despite the significance of nasal cartilage pathologies and high rhinoplasty revision rates (15%), little characterization and tissue-engineering work has been performed compared to other cartilages, such as articular cartilage. Furthermore, most work is published in clinical journals, with little in biomedical engineering. Therefore, this review discusses what nasal cartilage properties are known, summarizes the current state of nasal cartilage tissue-engineering, and makes recommendations via the engineering design process toward engineering functional nasal neocartilage to address current limitations.

Comparison of Micro-Computed Tomography and Clinical Computed Tomography Protocols for Visualization of Nasal Cartilage Before Surgical Planning for Rhinoplasty.

IMPORTANCE: There is no imaging standard to model nasal cartilage for the planning of rhinoplasty procedures. Preoperative visualization of cartilage may improve objective evaluation of nasal deformities, surgical planning, and surgical reconstruction. OBJECTIVES: To evaluate the feasibility of visualizing nasal cartilage using high resolution micro-computed tomography (CT) compared with the criterion standard of pathologic findings in a cadaveric specimen and to evaluate its accuracy compared with various clinical CT protocols. DESIGN, SETTING, AND PARTICIPANTS: Anatomic study at the University of Washington using single human cadaveric nasal specimens performed from July 10, 2017, to March 30, 2018. INTERVENTIONS: A micro-CT acquisition with 60-micron resolution was obtained of a nasal specimen. The specimen was then scanned with 5 different clinical CT protocols to span both clinical care and machine limits. The specimen was then sectioned in 5-mm axial slices for pathologic analysis. MAIN OUTCOMES AND MEASURES: Micro-CT images were registered to pathologic specimen cross-sections using a graphite fiducial system. Cartilage substructures were manually segmented and analyzed. A library of matched images across the micro-CT and various clinical CT protocols was then developed. Region of interest analysis was performed for each of the cartilage structures and their boundaries on clinical CT protocols and micro-CT, with the outcome of mean (SD) density using Hounsfield units. RESULTS: A single human cadaveric nasal specimen was used to obtain the following results. Lower lateral cartilage, upper lateral cartilage, and septal cartilage were accurately delineated on the micro-CT images compared with pathologic findings. The mean absolute deviation from pathologic findings was 0.30 mm for septal cartilage thickness, 0.98 mm for maximal upper lateral cartilage length, and 1.40 mm for maximal lower lateral cartilage length. On clinical CT protocols, only septal cartilage was well discriminated from boundary. Higher radiation dose resulted in more accurate density measurements of cartilage, but it did not ultimately improve ability to discriminate cartilage. CONCLUSIONS AND RELEVANCE: The results of this anatomic study may represent a notable step toward advancing knowledge of the capabilities and pitfalls of nasal cartilage visualization on CT. Nasal cartilage visualization was feasible on the micro-CT compared with pathologic findings. Future research may further examine the barriers to accurately visualizing upper lateral cartilage and lower lateral cartilage, a prerequisite for clinical application. LEVEL OF EVIDENCE: NA.

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.

Large Nasal Defects with Exposed Cartilage: The Folded Transposition Flap as an Innovative Alternative to the Paramedian Forehead Flap.

BACKGROUND: Skin cancer removal surgery involving the tip or dorsum of the nose often results in large-sized defects with exposure of cartilage. In such cases, the paramedian forehead flap is a frequently used reconstruction technique; however, this method is complex and can result in a cosmetically unsatisfying outcome. OBJECTIVE: To describe the folded transposition flap as an aesthetically pleasing alternative to the paramedian forehead flap for large nasal defects with exposed cartilage. METHODS: The folded transposition flap is a 2-stage surgical modification of the transposition flap. In the first stage, an overlong axial cheek pedicle is used to cover the defect. In the second stage, the flap is thinned and the nasal scars are revised. RESULTS: All 4 patients experienced aesthetically pleasing results. CONCLUSION: The folded transposition flap is an alternative for reconstructing large surgical defects of the nasal tip or distal dorsum of the nose.

Relapsing polychondritis in a liver transplant recipient: A case report.

RATIONALE: Relapsing polychondritis (RP) is a multisystemic, progressive disease of unknown etiology characterized by recurrent inflammation and progressive cartilage destruction. It can involve all types of cartilage including ears and nose, tracheobronchial tree, joints, and any other tissue rich in proteoglycans such as heart, eyes, and blood vessels. Recurrent chondritis can be life-threatening if the respiratory tract, heart valves, or blood vessels are affected. To date there is no data in the literature on the post solid organ transplantation RP. PATIENT CONCERNS: We present a 59-year-old male liver transplant recipient with primary sclerosing cholangitis who developed RP of the earlobes and nose despite post-transplant immunosuppression. DIAGNOSES: Based on the clinical criteria, scintigraphy and biopsy from the left auricle his condition was diagnosed as RP. INTERVENTIONS: Pulses of methylprednisolone followed by high-dose oral steroids along with azathioprine were administered. OUTCOMES: Such therapy diminished local cartilage inflammation, improved patient's general condition and the laboratory results. Significant loss of ear cartilage and characteristic "saddlenose" were observed after remission of acute symptoms. The control scintigraphy proved very good treatment response. LESSONS: To the best of our knowledge this is the first report on the RP in liver transplant recipient. Based on our patient presentation, we suggest that RP should be suspected in any transplant recipient with cartilage inflammation, and that the Michet's clinical criteria and scintigraphy seem to be the best diagnostic tools for solid organ transplant recipients suspected of RP.

Age-related histologic and biochemical changes in auricular and septal cartilage.

OBJECTIVES/HYPOTHESIS: To characterize the histologic and biochemical properties of auricular and septal cartilage and analyze age-related changes in middle-aged to older adults. STUDY DESIGN: Cross-sectional study of auricular and septal cartilage from 33 fresh cadavers. METHODS: Auricular and septal cartilage specimens were stained using Safranin O for glycosaminoglycans, Verhoeff's stain for elastin, and Masson's trichrome for collagen. Percentage of tissue stained, cell density and size were quantified. Relationships between donor characteristics and histologic properties were evaluated using mixed model analyses. RESULTS: The average donor age was 75 years (standard deviation = 11 years; range, 55-93 years). In auricular cartilage, each 1-year increase in age was associated with a 0.97% decrease in glycosaminoglycans (P < .001) and a 0.98% decrease in elastin (P < .001). In septal cartilage, glycosaminoglycans decreased 2.4% per year (P < .001). Age did not affect collagen content significantly in auricular (P = .417) or septal cartilage (P = .284). Cell density and cell size declined with age in auricular (both P < .001) and septal cartilage (P = .044, P = .032, respectively). Compared to septal cartilage in patients of all ages, auricular cartilage had more glycosaminoglycans, less collagen, higher cell density, and smaller cells. CONCLUSIONS: In auricular and septal cartilage, glycosaminoglycans, elastin, cell density, and cell size decrease significantly with age in patients over 55 years of age. Glycosaminoglycan content declines faster with age in septal cartilage than auricular cartilage. These age-related changes may affect biomechanical properties and tissue viability, and thereby have implications for graft choice in functional, aesthetic, and reconstructive nasal surgery. LEVEL OF EVIDENCE: NA. Laryngoscope, 127:E399-E407, 2017.

A modified nasolabial flap for reconstruction of transfixing alar wing defects.

Reconstruction of an entire alar wing is a frequently encountered reconstructive challenge in onco-dermatologic surgery. The aim of this technical note was to describe a surgical technique total for reconstruction of the alar wing, with a modified nasolabial flap with an inferior pedicle associated with a cartilaginous graft. This rapid procedure seems to be a well alternative for elderly people and patients who do not want a forehead flap. The aesthetic and functional outcomes of the donor and recipient sites were satisfactory.

The presence of aberrant p53 pattern is a negative prognostic predictor in squamous cell carcinoma of the nasal vestibule.

The aim of this study was to analyze the role of Ki-67, p53, and the "aberrant p53 pattern" in squamous cell carcinomas of the nasal vestibule. Patients between 1995 and 2014 were included. Baseline characteristics and outcome were analyzed with respect to immunohistochemical staining of Ki-67 and p53. "Aberrant p53 pattern" was represented by a moderate or strong staining of at least 60% of the tumor cells or a complete absence of immunoreactivity. Forty-six patients were included of whom 31 (67.4%) were available for Ki-67 and 32 (69.9%) for p53 immunohistochemistry. The "aberrant pattern" of p53 was present in 50% of the patients. While immunoreactivity for both Ki-67 and p53 was not related to each other or outcome, the "aberrant p53 pattern" was associated with a worse disease-free survival (p = 0.014). The "aberrant p53 pattern" is a negative prognostic factor in squamous cell carcinoma of the nasal vestibule and might enable a patient-tailored treatment.

A systematic review of the surgical techniques for the treatment of internal nasal valve collapse: where do we stand?

BACKGROUND: A myriad of interventions have been described to address the restoration or preservation of the internal nasal valve, the narrowest portion of nasal airway. OBJECTIVE OF REVIEW: To review systematically available knowledge and evidence about management options of the collapse of the internal nasal valve area. TYPE OF REVIEW: Systematic review. SEARCH STRATEGY: A MEDLINE, EMBASE, Cochrane Library and CENTRAL database search, followed by extensive hand searching for the identification of relevant studies. EVALUATION METHOD: Review of all English-language studies addressing the treatment of the internal nasal valve collapse. RESULTS: Fifty-three studies were eventually identified and systematically reviewed. The majority (50 of 53) of the included articles are graded as level IV evidence and only one randomised trial was identified. The included randomised study reported no significant difference in improvement between the intervention group (autospreader flap) and placebo arms. The majority of the included studies presented in this systematic review provide level IV evidence concerning the optimal approach for cases of nasal valve collapse. Current research is driven more by reports of techniques than patient outcomes. CONCLUSIONS: Proper evaluation and identification of the cause of the internal nasal valve collapse is paramount prior to selection of the preferred surgical solution. The three-dimensional construction of the nasal valve implies that many pathologies cannot be restored by a single solution. Treatment approaches should be directed at specific involved sites. Present systematic review of the literature revealed that the available evidence is based on low-level studies and focuses more on the description of various surgical techniques rather than on patient-reported outcome measures. Future studies are needed, including homogenous patient groups, comparing different surgical techniques and incorporating patient-reported outcome measures.

Eficácia das técnicas estruturada e convencional na abordagem estética e reparadora do nariz / Efficacy of structured and conventional techniques on aesthetic and corrective rhinoplasty

Introdução: A rinoplastia, como outras subespecialidades da Cirurgia Plástica, apresentou evolução muito grande nas últimas décadas, tanto em termos de técnica operatória quanto em diagnóstico das alterações a serem tratadas. O objetivo deste trabalho é avaliar a eficácia das técnicas Estruturada e Convencional na abordagem estética e reparadora do nariz. Métodos: Foram estudados de forma retrospectiva 49 pacientes operados pelo autor do trabalho, que foram submetidos a uma das duas técnicas operatórias. A eficácia das técnicas foi avaliada a partir da crítica dos pacientes e do cirurgião com relação aos resultados e à capacidade de se chegar ao objetivo do pré-operatório. Resultados: Ambas as técnicas se mostraram eficazes para alcançar o objetivo final da cirurgia. A satisfação dos pacientes e do cirurgião foram semelhantes nos dois casos, e não houve complicações maiores em nenhum dos grupos. Conclusão: O trabalho mostrou que tanto a técnica Estruturada quanto a Convencional são eficazes para o tratamento das alterações nasais, sendo o mais importante o correto diagnóstico pré-operatório das alterações para a escolha da melhor abordagem em cada caso.

Introduction: Rhinoplasty, like other plastic surgery subspecialties, has greatly evolved in recent decades, as both a surgical technique and a diagnosis of the alterations that need to be performed. The objective of the current study was to evaluate the efficacy of the structured and conventional surgical techniques on nasal aesthetic and corrective approaches. Methods: A total of 49 patients, who underwent surgical operation by the author of this work, were retrospectively studied. The patient generally underwent one of the two surgical techniques. The efficacy of each technique was evaluated by means of the critique provided by the patients and the surgeon regarding the results, and the ability to reach the pre-operative goals. Results: Both techniques were efficient in attaining the final objective of the surgery. Patient and surgeon satisfaction were similar in both cases, and there were no major complications in any of the groups. Conclusion: The present work showed that both the structured and the conventional techniques were efficient in the treatment of nasal alterations. The most important factor for selecting the best approach in each case was the correct pre-operative diagnosis of the required alterations.

Presurgical Nasoalveolar Molding Therapy Using Figueroa's NAM Technique in Unilateral Cleft Lip and Palate Patients: A Preliminary Study.

OBJECTIVE: The objective of the study was to evaluate the results of nasoalveolar molding (NAM) in the treatment of patients with unilateral cleft lip and palate using a modified technique in a South Indian population. STUDY DESIGN: The design was a prospective study with blinded measurements. The sample constituted 10 complete unilateral cleft lip and palate (UCLP) patients who underwent NAM therapy by the same operator. Direct extra and intra oral anthropometric measurements were done using a digital vernier caliper before and after NAM therapy. A photographic evaluation was also done to rate the nasal deformity post NAM therapy. The differences between measurements were statistically analyzed using paired t tests. RESULTS: The extra oral measurements revealed a statistically significant increase in bi-alar width, columellar length and width. The intraoral measurements demonstrated a statistically significant reduction in anterior alveolar cleft width. There was also a significant increase in arch width and greater and lesser segments length. All cases were rated as improved by the surgeons in photographic analysis. CONCLUSION: The study has quantitatively shown that the modified NAM therapy improved nasal asymmetry by columellar lengthening and effectively molded the maxillary alveolar arch.