Clinical Adaptation According to Anatomical Types of Nasal Septum / Adaptación Clínica Según Tipos Anatómicos de Tabique Nasal

SUMMARY: The purpose of this study was to inform the anatomical types of the nasal septum of which including variations by dissection and to provide guidelines for clinical adaptation. For this purpose dissections were performed on 70 nasal septums of formalin fixed Korean adult cadavers (20 males, 11 females, and 39 of unknown sex) with an age at death of 13-105 years. The septal deviation was checked before midsagittal section the nasal cavity with the aid of a laryngoscope. The mucosa on the nasal septum was then removed to observe the morphology of the nasal septum. The shape of each component of the nasal septum was identified, and photographs were taken from a midsagittal plane. This study has discovered various anatomical types of the nasal septum and its variations. The correlations between septal types according to their proportions were also analyzed. The results reported herein provide detailed anatomical knowledge that can be used as a valuable reference for rhinoplasty procedures.

El propósito de este estudio fue informar los tipos anatómicos del tabique nasal incluyendo las variaciones por disección y brindar pautas para la adaptación clínica. Para este propósito, se realizaron disecciones en 70 tabiques nasales de cadáveres adultos coreanos fijados con formalina (20 hombres, 11 mujeres y 39 de sexo desconocido) con una edad de muerte de 13 a 105 años. La desviación septal se comprobó antes de la sección medio sagital de la cavidad nasal con la ayuda de un laringoscopio. A continuación, se retiró la mucosa del tabique nasal para observar la morfología del tabique nasal. Se identificó la forma de cada componente del tabique nasal y se tomaron fotografías desde un plano mediano sagital. En el estudio se descubrieron varios tipos anatómicos del tabique nasal y sus variaciones. También se analizaron las correlaciones entre los tipos septales según sus proporciones. Los resultados informados en este documento proporcionan un conocimiento anatómico detallado que se puede utilizar como una referencia valiosa para los procedimientos de rinoplastía.

Influence of nasal septum deviation on fluctuating asymmetries of the nasomaxillary complex: A cross-sectional study.

An important parameter in diagnostic analysis and treatment planning of different biological areas is facial symmetry, and several etiological factors have been attributed to skeletal facial asymmetry. Although causality cannot be determined, previous studies have reported a relationship between the anatomical deviation of the nasal septum and facial development. Diagnosis is critical for patients in growth stages due to the association between nasal septum deviation (NSD) and abnormal growth of the nasomaxillary complex. To understand this relationship, this study aimed to investigate the influence of nasal septum deviation on fluctuating asymmetries (FA) of the nasomaxillary complex at different stages of skeletal maturation. Another goal was to determine whether an association exists between the degrees of septal deviation severity and asymmetry of the nasomaxillary complex. This was a retrospective, cross-sectional observational study comprising 60 selected cone-beam computed tomography (CBCT) scans that were divided into four groups (n = 15) according to the degree of septal deviation and skeletal maturation: mild deviation (MD; <10°), moderate to severe deviation (MSD; ≥10°), early group (EG), and late group (LG). The angle and area of deviation were measured for the greatest NSD, and a geometric morphometric approach was used to evaluate the nasal septum (NS) shape. The morphology of the nasomaxillary complex and the presence of fluctuating asymmetries were evaluated using 23 two-dimensional landmarks on the nasomaxillary complex (nasal, lateral, and palatal regions) with Procrustes ANOVA and Mann-Whitney test. Additionally, Spearman's correlation and multivariate regression were used to correlate the NSD with asymmetries in these regions. No significant differences were observed in the Procrustes FA scores of the nasomaxillary complex between the MD-EG × MSD-EG and MD-LG × MSD-LG (p > 0.05). However, the results of the multivariate regression revealed more specific aspects of asymmetry (asymmetry component), there was a positive correlation between the NSD angle and the palatal regions (p = 0.035 and p = 0.047, middle and posterior, respectively), and the nasal septum shape and anterior palatal regions (p = 0.039). The nasal and lateral regions did not correlate with the NSD angle in the multivariate regression analysis (p > 0.05). The results of this study indicate that there were no significant differences in the fluctuating asymmetry of the nasomaxillary complex between the mild and moderate to severe nasal septum deviation groups, in both early and late skeletal maturation stages. However, a positive correlation was observed in the degree of nasal septum deviation angle and asymmetry components of the middle and posterior palatal regions, likewise between the nasal septum shape and asymmetry components of the anterior palatal region. The diagnosis of nasal septum deviation by both physicians and dentists is important, as a relationship was observed with fluctuating asymmetry component of the palatal region. This information can guide the decision of the treatment planning for these individuals, and should be considered, especially in cases of severe septum deviation, due to the great anatomical proximity of these structures.

Correlation between the upper airway volume and the hyoid bone position, palatal depth, nasal septum deviation, and concha bullosa in different types of malocclusion: A retrospective cone-beam computed tomography study.

BACKGROUND: The upper airway volume is among the factors that affect orthodontic treatment plans. Cone-beam computed tomography (CBCT), as an accurate diagnostic modality, can help assess anatomical structures associated with the upper airway volume. OBJECTIVES: This study aimed to use CBCT to determine if there are differences in the upper airway volume between different sagittal and vertical skeletal patterns, considering the hyoid bone position, palatal depth, nasal septum deviation (NSD), and concha bullosa. MATERIAL AND METHODS: From among 105 initial CBCT samples retrieved from the archive of a private radiology clinic in Tehran, Iran, 90 CBCT scans of 27 males and 63 females aged 17-65 years were considered in the study according to the inclusion criteria. The upper airway volume was assessed with regard to Angle's classification (using the A point-nasion-B point angle (ANB)), the vertical skeletal dimension (using the sella-nasion plane to mandibular plane angle (SN-MP)), the hyoid bone position, palatal depth, NSD, and concha bullosa, using CBCT and the NNT ® software. The one-way analysis of variance (ANOVA), Levene's test and the t test were used to analyze the data with the SPSS Statistics for Windows software, v. 17.0. RESULTS: The upper airway volume was significantly smaller in long-face cases (p = 0.037). There was no significant correlation between the upper airway volume and Angle's classification, the hyoid bone position, palatal depth, NSD, and concha bullosa. CONCLUSIONS: The vertical skeletal dimension was the only parameter that was related to the upper airway volume. The results of this study can be considered while preparing orthodontic treatment plans.

Flexible Tongue-in-Groove Technique and Its Effectiveness Compared to Classic Tongue-in-Groove and Columellar Strut Graft Techniques: A Retrospective Analysis of 237 Open Rhinoplasty Cases.

BACKGROUND: The medial crura are almost always supported in tip surgery using columellar strut graft placement or tongue-in-groove suturing to the caudal septum. In this study, the authors present a modified tongue-in-groove (called "flexible tongue-in-groove") technique. METHODS: A total of 237 patients who underwent open rhinoplasty between January of 2016 and June of 2018 were included in this retrospective study. The patients were divided into three main groups: (1) flexible tongue-in-groove, (2) classic tongue-in-groove, and (3) columellar strut. Using standardized preoperative and postoperative (1-, 6-, and 12-month) lateral view photographs, the nasolabial angle and Goode ratio were measured for nasal tip rotation and projection, respectively. RESULTS: Flexible tongue-in-groove (n = 53) and classic tongue-in-groove (n = 107) techniques showed a significantly smaller decrease in the nasolabial angle from month 1 to month 12 than did the columellar strut technique (n = 77) (p < 0.05). These statistically significant differences were not found when the time intervals were narrowed (p > 0.05). Flexible and classic tongue-in-groove techniques showed significantly higher Goode ratios than did the columellar strut technique at 1, 6, and 12 months (p < 0.05 for all). In various analyses using the nasolabial angle and Goode ratio, no statistically significant difference was found between flexible and classic tongue-in-groove techniques (p > 0.05). CONCLUSIONS: Flexible and classic tongue-in-groove techniques provide more durable results in nasolabial angle and Goode ratio measurements than does the columellar strut technique in primary open-approach rhinoplasty. The flexible tongue-in-groove technique is as robust as the classic tongue-in-groove technique in appropriate cases. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Caucasian Hump: Radiologic Study of the Osteocartilaginous Vault versus Surface Anatomy. Clinical Implications in Structured and Preservation Rhinoplasty.

BACKGROUND: The relation between the osteocartilaginous nasal vault and nasal hump characteristics has not been fully investigated. METHODS: Measurements were collected from computed tomographic nasal scans in the midsagittal plane in adult Caucasian patients seeking rhinoplasty because of nasal hump from January of 2015 to December of 2018. Measurements were compared to those of sex- and age-matched patients not seeking rhinoplasty (control group). Patients with other significant nasal deformities were excluded. The correlations between nasal hump length, height, and osteocartilaginous nasal vault measurements were assessed. Distances from the beginning of the nasal hump to the kyphion and ethmoidal points were measured as well. The location of the nasal hump apex in relation to the keystone area structures was detailed. RESULTS: The study included 134 Caucasian patients, with 67 presenting nasal hump. The mean patient age was 32.9 years and 69.6 percent were female patients. Nasal hump measured a mean 17 ± 2.7 mm in length and 1.8 mm (range, 1.1 to 3.8 mm) in height. Nasal hump length correlated with nose length and nasal bone length. Nasal hump height correlated with nose length and the angle over the kyphion. In 97 percent of patients, the nasal hump began caudal to the ethmoidal point, and in all patients, the kyphion was underneath the nasal hump. The nasal hump is not a symmetric structure and, in all patients, its apex was situated above the septal cartilage. CONCLUSIONS: The nasal hump characteristics are mainly attributable to the septal cartilage, and this should be the cornerstone of any dorsal hump reduction strategy. The caudal aspect of the nasal bones contributes to the nasal hump, whereas the posterior ethmoidal plate rarely does.

Middle Vault Changes After Humpectomy by Spare Roof Technique Versus Component Dorsal Hump Reduction.

Objectives: To compare the effect of two different humpectomy techniques in the internal nasal valve (INV) angle in human anatomic specimens. Methods: Seven human anatomic specimens (14 heminoses) were included. A strip of subdorsal septal cartilage was removed and, in each nose, the right side of the middle roof lied intact over and was sutured to the septal cartilage (spare roof technique [SRT]), whereas in the left side the upper lateral cartilage was folded and sutured to the septal cartilage (component dorsal hump reduction [CDHR]). The INV angle was measured pre- and postoperatively. Results: Mean age of the specimens was 69.86 (60-80) years. Five were female. CDHR resulted in a mean change of +1.71 ± 3.12° (p = 0.197), +0.62 ± 6.89° (p = 0.817) and +6.97 ± 6.84° (p = 0.036) after resection of 2, 4, and 6 mm of septal cartilage, respectively. SRT resulted in a mean change of +1.27 ± 2.37° (p = 0.207), +6.89 ± 1.19° (p < 0.001), and +12.55 ± 1.79° (p < 0.001) after resection of 2, 4, and 6 mm of septal cartilage, respectively. In SRT, the amount of septal cartilage resection presented a significant correlation with change in INV angle (r = 0.813, p < 0.001). Conclusions: In this human anatomic study, SRT significantly increased INV angle.

Finite Element Analysis of the Septal Cartilage L-Strut.

Importance: Septoplasty is one of the most commonly performed operations in the head and neck. However, the reasons for septoplasty failure and the additional stress of performing a chondrotomy on the septal cartilage are not well understood. Design, Setting, and Participants: A finite element model of the nasal septum was created using a microcomputed tomography scan of the nasoseptal complex that was reconstructed into a three-dimensional model in silico. Testing included four common chondrotomy designs: traditional L-strut, double-cornered chondrotomy (DCC), curved L-strut, and the C-curve. Tip displacement was applied in a vector parallel to the caudal strut to simulate nasal tip palpation. Main Outcomes and Measures: With finite element analysis, the maximum principal stress (MPS), von Mises stress (VMS), harvested cartilage volume, and surface area were recorded. Results: The highest MPS for the L-strut, DCC, curved L-strut, and C-curve was identified at the corner of the chondrotomy. The MPS at the corner of the chondrotomy was reduced 44% when comparing the C-curve with the traditional L-strut. The VMS patterns showed compressive stress along the caudal septum in all models, but at the corner, the stresses were highest in the chondrotomies designed with sharp-angled corners. The VMS showed a 76% decrease when comparing the C-curve with the traditional L-strut. The stress across the anterior septal angle is also higher in models with sharp-angled corners. Cartilage harvest volumetric and surface area assessments did not show meaningful differences between shapes. Conclusions and Relevance: The highest area of stress is near the transition of the dorsal to caudal septum in all models. Stresses are relatively higher in chondrotomy shapes that contain sharp-angled corners. The relative reduction in MPS and VMS utilizing a C-curve instead of an L-strut may decrease the likelihood that the septum will deform or fail in this region. The volume and surface area of the C-curve are similar to that of the L-strut technique. Avoiding sharp-angled corners reduces the stresses at the corner of the chondrotomy and across the anterior septal angle. Using a C-curve may be an improved septoplasty design.

Estudo da anatomia do septo nasal e sua relação com a morfologia do complexo nasomaxilar / Study of the anatomy of the nasal septum and its relationship with the morphology of the nasomaxillary complex

O presente estudo teve como objetivo investigar a influência do desvio do septo nasal (DSN) na morfologia do complexo nasomaxilar quanto a confiabilidade e precisão na marcação de pontos craniofaciais bidimensionais (2D) e tridimensionais (3D) em imagens de tomografia computadorizada de feixe cônico (TCFC), verificação de assimetrias do complexo nasomaxilar em indivíduos com diferentes níveis de DSN em estágios de maturação esquelética distintos, e analisar a associação entre o grau de severidade do DSN e o grau de assimetria do complexo nasomaxilar. Este foi um estudo observacional retrospectivo que utilizou um total de 60 TCFC alocadas em 4 grupos (n = 15) de acordo com o grau de desvio septal e maturação esquelética (DSN <10°, desvio de septo nasal leve, e DSN >10°, desvio de septo nasal moderado a severo, ambos antes e depois do surto de crescimento). A etapa de validação do estudo compreendeu a utilização de 30 TCFC e demarcação de 25 pontos craniofaciais, a fim de avaliar a confiabilidade e precisão desses pontos nas regiões nasal, palatina e facial lateral. Dois métodos foram utilizados: 2D, em cortes multiplanares de TCFC no programa CS 3D Imaging; e 3D, com a segmentação 3D do crânio com visualização simultânea dos cortes multiplanares no programa ITK Snap. Os dados das coordenadas foram analisados por meio do Índice de Correlação Intraclasse (ICC), média das diferenças entre os tempos das medições, fórmula de Dahlberg e gráficos de Bland-Altman. A análise da relação entre a anatomia do septo nasal e morfologia do complexo nasomaxilar, compreendeu a utilização de 60 TCFC e a demarcação de 23 pontos bidimensionais e, avaliados quanto a presença de assimetria flutuante, por meio da análise de Procrustes ANOVA, comparação intergrupos com o teste de Mann- Whitney, além do teste de correlação de Spearman e regressão multivariada (a=0,05). Os resultados obtidos nas avaliações da reprodutibilidade dos pontos craniofaciais nos mostraram que o ICC variou de 0,95 a 1,0 no método 2D e foi maior ou igual a 0,99 no método 3D, indicando que ambos os métodos tiveram alta confiabilidade. A fórmula de Dahlberg, juntamente com Bland-Altman indicaram menor precisão nos pontos zigomáticomaxilar e orbitário no método 3D, e sutura zigomáticotemporal no método 2D. Os pontos ímpares (a maioria no plano sagital mediano) e os pontos frontozigomático temporal e frontozigomático orbital tiveram os melhores resultados de precisão. Com relação a influência do DSN e assimetrias no complexo nasomaxilar, nossos resultados principais mostraram que não foram observadas diferenças estatisticamente significativas entre as distâncias de Procrustes e Mahalanobis (assimetria flutuante) do complexo nasomaxilar entre os grupos avaliados (P>0.05). Entretanto, com os resultados da regressão multivariada, relacionado aos aspectos mais específicos de assimetria (componente assimétrico), houve uma correlação positiva entre o ângulo DSN e componente assimétrico das regiões palatinas (P=0.035 e P=0.047, média e posterior, respectivamente), e também com a forma do SN e componente assimétrico da região palatina anterior (P=0.039). Sendo assim, concluímos que, ambos os métodos 2D e 3D de marcação de pontos craniofaciais no complexo nasomaxilar e facial lateral apresentaram alta confiabilidade, entretanto, o método 2D apresentou maiores valores de precisão na maioria dos pontos avaliados. Além disso, todos os pontos avaliados neste estudo foram considerados aceitáveis para fins clínicos. Com relação a análise da anatomia do septo nasal e morfologia do complexo nasomaxilar, todos os grupos avaliados apresentaram níveis significativos de assimetria flutuante. Entretanto, não foram observadas diferenças significativas na assimetria flutuante do complexo nasomaxilar nos grupos com DSN leve em relação aos grupos com DSN moderado a severo, em ambos os estágios de maturação esquelética. Por fim, foi observada correlação positiva entre o ângulo DSN e o componente de assimetria nas regiões palatinas média e posterior e entre a forma do septo nasal e a região palatina anterior. Não foram observadas correlações significativas com as regiões nasal e lateral do complexo nasomaxilar. (AU)

The present study aimed to investigate the influence of nasal septum deviation (NSD) on the morphology of the nasomaxillary complex regarding reliability and accuracy in two-dimensional (2D) and three-dimensional (3D) craniofacial landmarks in cone beam computed tomography images (CBCT), verification of asymmetries of the nasomaxillary complex in individuals with different levels of NSD at different stages of skeletal maturation, and to analyze the association between the degree of severity of the NSD and the degree of asymmetry of the nasomaxillary complex. This was a retrospective, crosssectional observational study that used a total of 60 CBCT. For the validation study, 30 CTBC were used and 25 craniofacial landmarks were marked, in order to compare the reliability and precision of these landmarks in the nasal, palatal and lateral facial regions. Two methods were used: 2D, in CBCT multiplanar sections using CS 3D Imaging Software; and 3D, from the 3D segmentation of the skull in the software ITK Snap associated with multiplanar sections. Coordinates data were analyzed using the Intraclass Correlation Coefficient (ICC), Dalhberg's formula, Bland-Altman plots and mean differences between measurement trials. To study the relationship between nasal septum and nasomaxillary complex, the 60 CBCT were divided into 4 groups (n = 15) according to the degree of septal deviation and skeletal maturation (NSD <10°, mild nasal septum deviation, e NSD >10°, moderate to severe nasal septum deviation, both before and after the growth spurt). 23 two-dimensional landmarks were marked and, to assess asymmetries, we used Procrustes ANOVA, intergroups comparisons with the Mann-Whitney test, in addition to the Spearman's correlation test and multivariate regression. The results obtained in the evaluations of the reliability and precision of craniofacial landmarks showed that the ICC ranged from 0.95 to 1.0 in the 2D method and was greater than or equal to 0.99 in the 3D method, indicating that both methods had high reliability. Dahlberg's formula, together with Bland-Altman, indicated lower precision in the landmarks zygomaxillare and orbitale in the 3D method, and zygomaticotemporal suture in the 2D method. The unpaired landmarks (mainly located at the midsagittal plane) and the landmarks frontomalar temporale and frontomalar orbitale had the best results of precision. Regarding the influence of NSD and asymmetries in the nasomaxillary complex, our main results showed that no statistically significant differences were observed between the Procrustes and Mahalanobis distances (fluctuating asymmetry) of the nasomaxilar complex between the groups (P>0.05). However, with the results of the multivariate regression, related to the more specific aspects of asymmetry (asymmetry component), there was a positive correlation between the NSD angle and palatal regions (P=0.035 and P=0.047, middle and posterior, respectively), and also with the shape of the NS and the anterior palatal region (P=0.039). Therefore, we conclude that both the 2D and 3D methods of positioning craniofacial landmarks in the nasomaxillary complex and the lateral facial region showed high reliability, however, the 2D method showed higher precision values in most of the landmarks evaluated. Furthermore, all landmarks evaluated in this study are are reasonably considered acceptable for clinical purposes. Regarding the study of the nasal septum and nasomaxillary complex, all groups evaluated presented significant levels of fluctuating asymmetry. However, no significant differences were observed in the fluctuating asymmetry of the nasomaxillary complex in the groups with mild NSD compared to the groups with moderate to severe NSD, in both stages of skeletal maturation. Finally, a positive correlation was observed between the NSD angle and the asymmetry component in the middle and posterior palatine regions and between the shape of the nasal septum and the anterior palatine region asymmetry component. There were no significant correlations with the nasal and lateral regions of the nasomaxillary complex. (AU)

Anatomical variations of the maxillary sinus septa of an Iranian population using cone-beam computed tomography: a retrospective study / Variaciones anatómicas de los tabiques del seno maxilar de una población iraní mediante tomografía computarizada de haz cónico: estudio retrospectivo

This study sought to assess the internal anatomy of the maxillary sinuses and their septa using cone-beam computed tomography (CBCT) in an Iranian population. Materials and Methods: Resorption of alveolar bone decreases the height of the maxillary alveolar ridge. This height reduction may be so severe that it warrants ridge augmentation by a sinus lift. Manipulation of the maxillary sinuses, as in sinus lift surgery, requires adequate knowledge about the sinus anatomy.Results: Maxillary sinus septum, as an anatomical variation, may complicate the surgical procedures and increase the risk of complications such as sinus membrane perforation. In this retrospective study, 366 sinuses, 190 from females and 176 from males, aged between 10 and 65 years old presenting to the Oral and Maxillofacial Radiology Department of School of Dentistry at Hamadan University of Medical Sciences were evaluated by two oral radiologists. The extension of the maxillary sinuses, presence of septa, number of septa and their location were determined. Data were analyzed using the chi square test (level of significance p≤0.001). The coefficient of agreement between the two oral radiologists was calculated based on Cohen kappa. Septa were present in 40.5% of the maxillary sinuses, out of which, 31.6% had one, 7.9% had two and 1% had three or more septa; 38% of the septa were horizontal while 62% had an oblique orientation. In total, 184 septa were found in 183 patients; out of which, 91 septa were 2mm to 5mm long while 93 septa were longer than 5mm. Conclusions: Comprehensive knowledge about the three-dimensional internal anatomy of the maxillary sinuses acquired by CBCT priorto surgical procedures can greatly help to prevent postoperative complications.

Este estudio buscó evaluar la anatomía interna de los senos maxilares y sus septos mediante tomografía computarizada de haz cónico (CBCT) en una población Iraní. Materiales y Métodos: . La resorción del hueso alveolar disminuye la altura de la cresta alveolar maxilar. Esta reducción de altura puede ser tan severa que justifique el aumento de la cresta mediante una elevación de seno. La manipulación de los senos maxilares, como en la cirugía de elevación del seno, requiere un conocimiento adecuado sobre la anatomía del seno. Resultado: El tabique del seno maxilar, como una variación anatómica, puede complicar los procedimientos quirúrgicos y aumentar el riesgo de complicaciones como la perforación de la membrana sinusal. En este estudio retrospectivo, dos radiólogos orales evaluaron 366 senos, 190 de mujeres y 176 de hombres, con edades comprendidas entre 10 y 65 años que se presentaron en el Departamento de Radiología Oral y Maxilofacial de la Facultad de Odontología de Hamadan University of Medical Sciences. Se determinó la extensión de los senos maxilares, la presencia de septos, el número de septos y su ubicación. Los datos se analizaron mediante la prueba de chi cuadrado (nivel de significación p?0.001). El coeficiente de concordancia entre los dos radiólogos orales se calculó en base a Cohen kappa. Los septos estaban presentes en el 40.5% de los senos maxilares, de los cuales, el 31.6% tenía uno, el 7.9% tenía dos y el 1% tenía tres o más septos; El 38% de los septos eran horizontales, mientras que el 62% tenía una orientación oblicua. En total, se encontraron 184 septos en 183 pacientes; de los cuales, 91 septos tenían de 2mm a 5mm de largo, mientras que 93 septos tenían más de 5mm. Conclusion: El conocimiento exhaustivo sobre la anatomía interna tridimensional de los senos maxilares adquiridos por CBCT antes de los procedimientos quirúrgicos puede ayudar en gran medida a prevenir complicaciones postoperatorias.

Decision-Making in Middle Vault Reconstruction following Dorsal Hump Reduction in Primary Rhinoplasty.

BACKGROUND: Dorsal hump reduction during open rhinoplasty disrupts the continuity between the upper lateral cartilages and the dorsal septum. Options to reconstitute the midvault include primary closure of the upper lateral cartilages to the dorsal aspect of the septum, placement of spreader grafts, and creation of spreader flaps. The authors sought to clarify from highly experienced rhinoplasty surgeons their decision-making rationale for midvault reconstruction, distilling down the group consensus into algorithmic guidelines. METHODS: A panel of internationally recognized rhinoplasty surgeons participated in a two-part organized communication method. An introductory summit consisted of open discussions on various topics in midvault reconstruction. The summit transcription was analyzed by thematic content analysis to develop a survey encompassing clinical scenarios for primary rhinoplasty, which was then individually administered to each panelist. Data gathered from both parts were used to generate technical guidelines and a decision-making algorithm. RESULTS: The panelists identified the following anatomical features as pertinent to their selection of midvault reconstruction method: size of the dorsal hump reduction, width of the midvault relative to the upper vault, presence of dorsal angulation, and presence of nasal obstructive symptoms. Individual panelist preference was gathered from the 24-scenario survey divided into either cosmetic or functional rhinoplasty cases. CONCLUSIONS: Management of the midvault after dorsal hump reduction is important to establish proper aesthetic relationships and to provide functional integrity of the internal valve. Our authors present an algorithmic approach to decision-making based on the systematic analysis practiced by senior rhinoplasty surgeons.

Practical Classification of Upper Lateral Cartilage in Middle Vault Asymmetry.

BACKGROUND: Middle vault asymmetry is a common reason for retained postoperative deviations. Although minor deformities can be camouflaged with cartilage, soft-tissue materials, or injectable fillers, comprehensive observation of upper lateral cartilage and subsequent topographic classification in major anatomical anomalies will help surgeons better plan their procedures to obtain better symmetry. METHODS: Photographs of 71 randomly selected primary open rhinoplasty patients were analyzed for anatomical presentation of their upper lateral cartilage. Photographs were taken before and after separation of upper lateral cartilage from the septum. Upper lateral cartilage was classified from class I to class V according to the width of the transverse subunits and curvature of the vertical subunits. RESULTS: The authors observed 142 upper lateral cartilages of 71 rhinoplasty patients. Upper lateral cartilage was classified as follows: class I, 53 cases; class II, three cases; class III, 40 cases; class IV, 36 cases; and class V, 10 cases. CONCLUSIONS: Upper lateral cartilage asymmetry is a common occurrence in rhinoplasty, and the upper lateral cartilage itself may be the source of nasal deviation. The middle vault requires special attention, and establishment of a classification system could enable surgeons to devise an effective plan for correction and prevention of retained postoperative nasal deviation.

Nasal cavities and the nasal septum: Anatomical variants and assessment of features with computed tomography.

The nasal cavities are complex anatomical structures with high inter-individual variability that relates to different functions. Different anatomic variants may manifest at this site, mainly belonging to the nasal septum and turbinates. Precise knowledge of the anatomy and variants is fundamental for both radiologists and ENT surgeons. This article provides an overview of the main anatomic variants and their frequency, according to the existing literature, as well as ongoing research on nasal cavity segmentation in order to obtain personal 3D models and to predict post-surgical results.

Lack of impact of radiologic septal measurements upon patient symptoms and performance of septoplasty during endoscopic sinus surgery.

BACKGROUND: Recent literature suggests that concurrent septoplasty during endoscopic sinus surgery (ESS) improves patient outcomes, however, the underlying indications for performing concurrent septoplasty are unknown. The objective of this study was to investigate the relationship between objective radiologic measures of nasal septal deviation with preoperative patient symptomatology and measures of CRS disease severity. We also sought to understand the association of objective radiologic measurements with surgeon performance of concurrent septoplasty during ESS. METHODOLOGY: Seventy-four patients with CRS undergoing ESS were prospectively enrolled. Angles of septal deviation, intranasal areas and volumes were assessed on preoperative computed tomography (CT) scans and correlated with a robust battery of patient reported outcomes measures (PROMs), objective measures of CRS severity including olfaction scores, radiologic and endoscopic staging, and performance of septoplasty. RESULTS: Intranasal areas and volumes demonstrated only weak linear associations with patient-reported nasal congestion, however, angles of septal deviation alone did not correlate with congestion or any other PROM measure. Meanwhile, radiologic septal-related measurements did not correlate with objective measures of CRS disease severity or the performance of a concurrent septoplasty. CONCLUSIONS: Though prior studies demonstrate improved patient outcomes in the setting of concurrent septoplasty during ESS, this study failed to establish an association between preoperative radiologic septal-related measurements and patient symptomatology or surgeon decision to perform septoplasty. Although objective factors to identify patients most likely to benefit from concurrent septoplasty remain unidentified, the potential improvement of surgical recommendations and patient outcomes makes this an important area of continued investigation.

Management of the Mestizo Nose.

Mestizo noses have mesorrhine nasal characteristics. They have a modest osteocartilaginous framework, nasal tips that tend to be bulbous with poor projection and rotation, and skins that tend to be thick and acne prone. A structural rhinoplasty approach is performed, focusing on anatomic findings. Conservative tissue excision with preservation or reinforcement of support structures of the nose is done. Structural grafting and suturing techniques are used to remodel cartilage and create better definition and support. The skin and soft tissue envelope is managed medically and surgically. The objective is to create balanced-looking noses that bring patients closer to their own aesthetic ideal.

Correction of the Topographic Relationship between the Depressor Septi Nasi and Incisivus Labii Superioris: Application to Cosmetic Surgery on the Lip and Nose.

BACKGROUND: The depressor septi nasi is a facial muscle with many different descriptions of its anatomy. Therefore, the aim of this study was to clarify the relationship of the depressor septi nasi, incisivus labii superioris, and surrounding structures. METHODS: Twenty sides from 10 fresh-frozen cadaveric heads were used in this study. The depressor septi nasi and incisivus labii superioris were dissected intraorally and extraorally, and the relationship with surrounding structures was observed. RESULTS: Eighteen of 20 sides had a depressor septi nasi. When present, the depressor septi nasi originated from the orbicularis oris above the central incisor and the medial portion of the inferior part of the incisivus labii superioris and inserted into the base of the medial crus of the major alar cartilage and nasal septum. These three muscles were three-dimensionally fused at the insertion point of the depressor septi nasi. There was no specimen where the depressor septi nasi originated directly from the maxilla. The depressor septi nasi runs obliquely from the nasal septum and the base of the medial crus of the major alar cartilage to the orbicularis oris and inferior part of the incisivus labii superioris. CONCLUSION: A better understanding of the depressor septi nasi, incisivus labii superioris, and surrounding structures might be important during various surgical techniques, especially rhinoplasty.

Canine nasal septum deviation can be a normal variation and correlates with increasing skull indices.

Nasal septal deviation has been studied in relation to nasal pathology and mass effect in dogs. The purpose of this retrospective, cross-sectional study was to compare the prevalence of nasal septal deviation in dogs with rhinitis, neoplasia, and those without nasal pathology based on the facial index, skull index, and cranial index. Computed tomographic studies of the nasal cavities of dogs performed over a 5-year period were retrospectively reviewed. This study had 233 dogs meeting the inclusion criteria with 135 dogs with no nasal pathology, 63 dogs with nasal neoplasia, and 35 dogs with rhinitis. The prevalence of nasal septal deviation, the angle, maximum distance, and longitudinal extent of deviation were recorded, as well as measurements to calculate the facial index, cranial index, and skull index. The results showed no difference in the prevalence of nasal septal deviation between dogs with nasal pathology and those without. The mean longitudinal extent of deviation and maximum distance of deviation was statistically greater for those with neoplasia compared to those with rhinitis and without nasal pathology. The longitudinal extent of deviation was inversely proportional to the cranial index, facial index, and skull index. The angle of deviation was directly proportional to the facial index and skull index. In conclusion, nasal septal deviation is an anatomic variant in different breeds of dogs with no predilection based on nasal pathology. Nasal septal deviation should be interpreted cautiously in the assessment of canine nasal disease.

Evaluation of the Relationship of Dimensions of Maxillary Sinus Drainage System with Anatomical Variations and Sinusopathy: Cone-Beam Computed Tomography Findings.

OBJECTIVE: The aim of this study was to evaluate the correlation between the length of the infundibulum and ostium height with the anatomic variations of osteomeatal complex (OMC) and sinus pathology using cone-beam computed tomography (CBCT). METHODS: CBCT images of 204 patients (408 maxillary sinuses) were evaluated retrospectively. The height of the ostium and the length of the infundibulum were measured. The presence of maxillary sinus pathology, nasal septal deviation, Haller cells, concha bullosa, and sinus septa were analyzed. The correlation between the size of the maxillary sinus drainage system and anatomic variations was compared using the t test, Fisher's exact test, and χ2 test. The effect of tooth loss on the length of the infundibulum and ostium height was also analyzed using ANOVA. RESULTS: The height of the ostium and the maximal septal deviation angle were found to be significantly greater in males (p < 0.05). As ostium height increased, the presence of maxillary sinus septa increased (p < 0.05). No statistically significant association was detected between other variations and the length of infundibulum or ostium height. The relationship between tooth loss and both the length of the infundibulum and ostium height were found to be insignificant (p > 0.05). CONCLUSIONS: Radiographic examination, especially on CBCT images, is important for an evaluation of maxillary sinuses. here, we demonstrated a significant relationship between ostium height and the presence of maxillary sinus septa. However, it was found that nasal septal deviation, concha bullosa, Haller cells, and other sinusopathies did not have a major effect on the size of the maxillary sinus drainage system.

The Relationship Between the Pneumatization Patterns of the Frontal Sinus, Crista Galli and Nasal Septum: A Tomography Study.

AIM: To provide detailed information about anterior skull base anatomy. MATERIAL AND METHODS: In terms of gender and laterality, the drainage pathways and anatomical variations of the frontal sinus, crista galli and nasal septum in 402 patients were evaluated via computed tomography scans. RESULTS: The pneumatization patterns of the frontal sinus were as follows: absent, 3.7%; unilateral, 8%; bilateral, 75.1% and triple, 13.2%. The pneumatized crista galli was identified in 120 (29.8%) patients, and its drainage pathway was observed in 54.1% of patients. The sinus septi nasi was identified in 92 (22.8%) and its drainage pathway was observed in 16.3%. The prevalences of the position types of crista galli regarding the cribriform plate were as follows; type I, 18.3%; type II, 64.9%; type III, 16.8%. CONCLUSION: Despite meticulous knowledge of anatomy, preoperative radiologic evaluation creates the base for successful treatment of anterior skull base pathologies with safer and effective surgery.