Incidental findings on cone beam computed tomography scans in cleft lip and palate patients

Evaluation of maxillary sinus volumes and pathologies in children with and without cleft lip and palate using cone beam computed tomography

OBJECTIVE

The aim of this study is to evaluate the maxillary sinus (MS) volume and pathologies, nasal septum (NS) deviation, and MS septa formation in children with and without cleft lip and palate (CLP); also to investigate the possible causes of MS pathologies.

MATERIALS AND METHODS

Cone Beam Computed Tomography (CBCT) images of 200 (100 CLP, 100 control) children (5-18 years old) were evaluated from the computer database of Marmara University Faculty of Dentistry. Children with a history of maxillofacial trauma, diseases that affect bone metabolism, orthognathic surgery, extrinsic pathologies of the MS, and accompanying syndromes were excluded. NS deviation, MS septa formation, volume, and pathologies evaluated using Mimics® software. In statistical evaluations; Student t test, paired sample t test, Chi-Square test, Fisher's Exact Chi-Square test, Continuity Correction, Chi-square analysis in one-eyed layout, McNemar test, and logistic regression analysis were used.

RESULTS

Total MS volume was smaller in the CLP group (21 232 mm3) than in control children (23 763 mm3) (P:0.026). NS deviation and MS pathology were more frequent in the CLP. In logistic regression analysis, there was no significant relation between the presence of NS deviation and pathology in MS. The presence of CLP increased the risk of MS pathology by 2.6 times.

CONCLUSION

We found that children with CLP have less MS volume and an increased rate of NS deviation and MS pathology compared to the control group. Further radiological and clinical studies are needed to explain the predisposing factors of MS pathology in children with CLP.

Nasal Airway Volumes are More Asymmetric in Skeletally Mature Patients With Cleft lip and Palate Than Controls on 3-Dimensional Analysis

BACKGROUND

This study assesses nasal airway volumes in skeletally mature patients with CLP and healthy controls and examines the relationship among nasal volumes, cleft laterality, and facial asymmetry.

METHODS

Computed tomography images from patients with CLP and controls were analyzed using Mimics Version 23.0 (Materialise, Leuven, Belgium). Relationships among nasal airway volume, cleft laterality, and facial asymmetry were compared.

RESULTS

The 89 patients in this study included 66 (74%) CLP and 23 (17%) controls. Nasal airway volumes in CLP were more asymmetric than controls (26.8±17.5% vs. 17.2±14.4%; P=0.015). In UCLP, the smaller nasal airway was on the cleft side 81% of the time (P<0.001). Maximum airway stenosis was on the cleft side 79% of the time (P<0.001), and maximum stenosis was on the same side as the smaller airway 89% of the time (P<0.001). There was a mild linear relationship between nasal airway asymmetry and maximum stenosis (r=0.247, P=0.023). On 3-dimensional image reconstruction, the septum often bowed convexly into the cleft-sided nasal airway with a caudal deviation towards the noncleft side. Nasal airway asymmetry was not associated with facial midline asymmetry (P>0.05).

CONCLUSION

The nasal airway is more asymmetric in patients with cleft lip and palate compared with the general population, with the area of maximum stenosis usually occurring on the cleft-sided airway. In patients with unilateral cleft lip and palate, the septum often bows into the cleft side, reducing the size of that nasal airway. Nasal airway asymmetry did not correlate with facial asymmetry.

Frequency and Clinical Significance of Incidental Findings on CBCT Imaging: a Retrospective Analysis of Full-Volume Scans

Objectives

This retrospective study aims to identify incidental findings in cone-beam computed tomography scans of patients irradiated for preoperative evaluation for implant placement and obtained using the same imaging unit as well as the same field of view. The incidence of each incidental finding, as well as the overall incidence, were calculated and the findings were ranked according to their clinical significance.

Material and Methods

A total of 741 cone-beam computed tomography (CBCT) examinations with extended field of view (15 x 15 cm) were retrospectively evaluated for incidental findings (IFs). These were identified, recorded, classified as to their location, and ranked according to their clinical significance.

Results

The vast majority of CBCT examinations presented at least one IF, resulting in a surprisingly high prevalence in total. If extreme anatomical variants are considered (nasal septum deviation, sinus septations etc.), the cumulative prevalence exceeds 99%. IFs of major significance, that may require immediate attention, are beyond 10% in frequency.

Conclusions

We found high prevalence of incidental findings on cone-beam computed tomography examinations performed for preoperative evaluation for implant placement (99.5% if anatomical variants included). Most incidental findings were of minor significance. Although the number of incidental findings that require immediate attention is relatively low, there is a considerable number of cases that need periodic evaluation and/or referral.

Prevalence and Features of Maxillary Sinus Septa in Patients with Cleft Lip and Palate: Cone Beam Computed Tomography Imaging Technique

OBJECTIVE

The development of the maxillary sinus is different in patients with cleft lip and palate (CLP) compared to non-CLP individuals. To investigate the prevalence and features of maxillary sinus septa (MSS) in patients with CLP in comparison with the non-CLP population.

DESIGN

Retrospective study.

INTERVENTION

Cone beam computed tomography (CBCT) evaluation.

SETTING

CLP center in Shiraz faculty of dentistry, Iran.

PATIENTS

A total 306 sinuses (88 cleft and 218 noncleft) on 153 images (CLP group: n  =  66; control group: n  =  87) were examined to determine the prevalence of septa and characterize them.

MAIN OUTCOME MEASURES

Sinus septa were characterized according to height, orientation, angle, origin, and location. The chi-square test, Mann-Whitney U test, and Fisher's exact test were used for statistical analysis.

RESULTS

The prevalence of septa was 28.9% and 32.1% in the CLP and control groups, respectively. No significant difference was found between the study groups in terms of prevalence, location, and orientation of MSS. The average height and angle of septa were significantly higher in the control group compared to the CLP group. Inferior origin was significantly more prevalent in the control group than in the CLP group (P = .004).

CONCLUSION

There was no difference in the prevalence of MSS between patients with CLP and non-CLP individuals. However, certain features of the septa were different in patients with CLP.

Airway changes in patients with unilateral cleft lip/palate (UCL/P) after maxillary advancement

OBJECTIVES

To assess the effect on the retropalatal airway (RPA), retroglossal airway (RGA), and total airway (TA) volumes and cephalometrics (SNA, SNB, ANB, PP-SN, Occl-SN, N-A, A-TVL, B-TVL) after maxillary advancement orthognathic surgery in patients with unilateral cleft lip/palate (UCL/P) using cone-beam computed tomography (CBCT).

MATERIALS AND METHODS

The CBCT scans of 30 patients (13 males and 17 females, 17-20 years old) with UCL/P were evaluated at two time points: preoperative (T1) and postoperative (T2). The interval between T1 and T2 ranged from 9-14 weeks, except for two patients in whom the interval was 24 weeks. Intraexaminer reliability was measured with an intraclass correlation coefficient test. A paired t-test was used to compare the airway and cephalometric measurements between T1 and T2, with a P value of .05 being considered significant.

RESULTS

From T1 to T2, significant increases were found in the volumes of RPA (from 9574 ± 4573 to 10,472 ± 4767, P = .019), RGA (from 9736 ± 5314 to 11,358 ± 6588, P = .019), and TA (from 19,121 ± 8480 to 21,750 ± 10,078, P = .002). In addition, the RGA (from 385 ± 134 to 427 ± 165, P = .020) and TA (from 730 ± 213 to 772 ± 238, P = .016) sagittal area increased significantly. For minimal cross-sectional area (MCA), only the RPA increased significantly (from 173 ± 115 to 272 ± 129, P = .002). All cephalometric changes were statistically significant between T1 and T2 except for SNB.

CONCLUSIONS

Maxillary advancement in patients with UCL/P produces statistically significant increases in the retropalatal (volumetric and MCA), retroglossal (volumetric and sagittal), and total (volumetric and sagittal) airways based on data from CBCT imaging.

Prevalence and Clinical Significance of Incidental Findings in the Maxillofacial Complex of Adolescent Orthodontic Patients: A Retrospective Cone Beam Computed Tomography Analysis

OBJECTIVES

The aim of this study was to determine the prevalence and severity of incidental findings in the maxillofacial complex of orthodontic patients imaged with cone beam computed tomography (CBCT) and assign those findings an appropriate clinical significance.

METHODOLOGY

Incidental findings (IF) were identified in 250 CBCT scans of adolescent orthodontic patients (aged 13-18 years) with a large field-of-view and categorized based on their anatomic location and placed into one of six subgroups based on anatomic region: i) sino-nasal, ii) dentoalveolar, iii) nasooropharyngeal airway, iv) temporomandibular joint, v) neck, vi) calcifications, and vi) miscellaneous findings. Additionally, findings were assigned a clinical significance score based on severity on a scale of mild, moderate and severe. Mild IF was defined as an IF that does not require any further investigation or referral. Moderate IF was defined as an IF that has the tendency to become clinically significant and should be observed periodically. IFs that warrant further investigation and/or intervention were designated as severe.

RESULTS

The percentage of IFs in sino-nasal and dento-alveolar regions were 44.7% and 19.1% respectively. The percentage of IFs with mild, moderate, and severe clinical significance were 27%, 72%, and 1%, respectively. Out of the IFs involving calcifications, 80.8% were stylohyoid calcifications and <1% were cranial cavity IFs such as petroclinoid calcifications and falx cerebri calcifications. Among the sino-nasal findings, 1.2% were identified as severe.

CONCLUSION

The sino-nasal region had the highest frequency of IFs. Understanding the prevalence of incidental findings and its clinical relevance is important for clinicians to allow for appropriate monitoring and timely treatment of patients.

Nasopharynx evaluation in children of unilateral cleft palate patients and normal with cone beam computed tomography

OBJECTIVE

This study aimed to examine the morphological characteristics of the nasopharynx in unilateral Cleft lip/palate (CL/P) children and non-cleft children using cone beam computed tomography (CBCT).

METHODS

A retrospective study consisted of 54 patients, of which 27 patients were unilateral CL/P, remaining 27 patients have no CL/P. Eustachian tubes orifice (ET), Rosenmuller fossa (RF) depth, presence of pharyngeal bursa (PB), the distance of posterior nasal spine (PNS)-pharynx posterior wall were quantitatively evaluated.

RESULTS

The main effect of the CL/P groups was found to be effective on RF depth-right (p < 0.001) and RF depth-left (p < 0.001). The interaction effect of gender and CL/P groups was not influential on measurements. The cleft-side main effect was found to be effective on RF depth-left (p < 0.001) and RF depth-right (p  =  0002). There was no statistically significant relationship between CL/P groups and the presence of bursa pharyngea.

CONCLUSIONS

Because it is the most common site of nasopharyngeal carcinoma (NPC), the anatomy of the nasopharynx should be well known in the early diagnosis of NPC.

Cone-Beam Computed Tomographic Assessment of Maxillary Sinus Characteristics in Patients With Cleft Lip and Palate: A Systematic Review and Meta-Analysis

The aim of this systematic review and meta-analysis was to evaluate the maxillary sinus characteristics of patients with cleft lip and palate (CLP).

The study included manuscripts which met the following criteria: (1) study of individuals with CLP in any age group or gender and (2) study of individuals in whom assessment of maxillary sinus characteristics had been done by cone-beam computed tomography. Studies with (1) individuals having special health-care needs and (2) individuals with any syndrome affecting the development of the head and neck were excluded.

In total, 11 articles were included in the review, based on the inclusion and exclusion criteria. Pooled maxillary sinus volume (MSV) on the cleft sides of patients with unilateral cleft lip and palate (UCLP) was found to be 9433.14 mm³ (95% CI, 7453.99-11 412.30), which was significantly smaller than that of controls. The meta-analyses also revealed significantly reduced MSV on the cleft sides of patients with UCLP. The differences between cleft and noncleft sides of the patients with UCLP were not found to be statistically significant. Strength-of-evidence was found to be moderate in 4 characteristics, along with 10 out of 11 articles showing low risk-of-bias.

It was concluded that MSV was reduced and mucosal thickening was increased/present in patients with CLP as compared with controls. The differences between MSV of cleft and noncleft sides of the patients with UCLP could not be established. However, heterogeneity was found in terms of sample size, stratification of samples by age, and evaluation of some confounding factors.

A Novel Classification of Relationship Between Nasal Septum and Inferior Turbinate Associated With Nasal Airway Obstruction in Patients With Unilateral Alveolar Cleft

OBJECTIVE

This study aims to investigate nasal morphologies associated with nasal airway obstruction in unilateral alveolar cleft patients.

METHODS

A total of 234 unilateral alveolar cleft cases were performed cone beam computed tomography scans. The digital imaging and communication in medicine data were imported into Simplant Pro software. The radiographic features including nasal septum deviation and inferior turbinate hypertrophy as well as nasal airway volume and sinusitis were analyzed.

RESULTS

A new radiographic classification of relationship between nasal septum and inferior turbinate (NS-IT) on the cleft side was proposed and three types of NS-IT relationship (type I, II and III) were identified in 234 cases. The statistical analysis revealed that the nasal airway volume on non-cleft side was significantly higher than that on cleft side in each of three types (P  < 0.0001), while no difference of nasal airway volume on non-cleft side was found among three types. In addition, the nasal airway volume on non-cleft side in type I and II was significantly higher than that in type III (P < 0.0001). Also, type III presented higher rate of maxillary sinusitis (P = 0.0154) and ethmoid sinusitis on cleft side (P = 0.0490) than type I and II. The other indexes including clinical variances were not significant among three types.

CONCLUSIONS

Unilateral alveolar cleft patients with type III NS-IT relationship could have nasal airway obstruction and higher rate of maxillary and ethmoid sinusitis on cleft side, which may be taken into account at primary cleft repair and alveolar bone grafting treatment.

Evaluation of Maxillary Sinus Characteristics in Patients With Cleft Lip and Palate Using Cone Beam Computed Tomography

OBJECTIVES

The detection of anatomical variation impairments in patients with cleft lip and palate (CLP) is crucial in combined orthodontic and maxillofacial surgical treatments. Therefore, this study aimed at evaluating the anatomical maxillary sinus characteristics, nasal septum deviation (NSD), and mucosal thickening of the maxillary sinus in patients with CLP using cone beam computed tomography (CBCT).

DESIGN

The CBCT images were classified into 3 groups of unilateral cleft lip and palate (UCLP; n = 40), bilateral cleft lip and palate (BCLP; n=14), and noncleft (control; n = 54). Subsequently, the maxillary sinus linear dimensions were assessed. Height, width, depth, infundibulum height, and ostium width were assessed as quantitative measures, whereas nasal septum deviation and mucosal thickening were assessed as qualitative measures. One-way analysis of variance and χ² tests were utilized to identify any significant differences among the groups regarding the aforementioned variables.

RESULTS

Significant differences were observed among the groups regarding maxillary sinus height and depth, NSD, and mucosal thickening. Moreover, UCLP and BCLP groups showed higher incidence of NSD and mucosal thickening. However, the size of maxillary sinus height and depth was lower in the UCLP and BCLP groups.

CONCLUSION

The results showed that BCLP and UCLP groups obtained lower maxillary sinus height and depth compared to the control group. On the other hand, incidence of the NSD and mucosal thickening was significantly higher in UCLP and BCLP groups than those in the control group.

Comparison of Anatomical Features of Alveolar Cleft in Unilateral Cleft Lip and Palate Patients of Different Ages

OBJECTIVES

This study aimed to compare the anatomical features of alveolar cleft in patients with complete unilateral cleft lip and palate (UCLP) of different ages.

METHODS

Sixty UCLP patients were divided into 3 groups as follows: group 1 (7-12 years old), group 2 (13-18 years old) and group 3 (more than 18 years old). The radiographic images were analyzed based on cone beam computed tomography (CBCT) images.

RESULTS

The mean age in 3 groups was 10.45 ± 1.15, 15.05 ± 1.90, and 22.55 ± 3.00 years (P < 0.0001). The lip-palatal width in Group 2 and 3 was 15.14 ± 3.67 mm and 15.50 ± 3.92 mm, which was significantly larger than 12.97 ± 1.82 mm in Group 1 (P = 0.037). The volume of alveolar defect was 1.09 ± 0.23 cm, 1.28 ± 0.38 cm and 1.40 ± 0.58 cm in 3 groups, and the difference between any 2 of them was significant (P = 0.0004). The prevalence of ipsilateral but contralateral maxillary sinusitis was significant among 3 groups (P = 0.0015) while the other nasal deformities including nasal septum deviation and inferior turbinate hypertrophy was not found significant.

CONCLUSIONS

Alveolar cleft volume increased with age, which is properly due to enlarged width of lip-palatal defect. The significant higher frequencies of ipsilateral maxillary sinusitis in patients under 18 could increase the risk of bone infection.

Temporomandibular joint dislocation in patients with cleft lip and palate after maxillary distraction osteogenesis: Three case reports

INTRODUCTION

Distraction osteogenesis (DO) is a widely used for cleft and palate related maxillary hypoplasia. There has been little research on temporomandibular joint (TMJ) dislocation after maxillary DO. We present these 3 cases and analyze the possible causes for reference by other clinicians.

PATIENT CONCERNS

In the late stages of maxillary DO, the patients gradually felt a decrease in mandibular mobility and suffered from limited mouth opening. Case 2 and 3 could open their mouth up to 1 and 2 fingers and Case 1 barely able to open her mouth at the completion of distraction.

DIAGNOSIS

Case 1 and Case 3 were diagnosed as right TMJ dislocation and Case 2 had a TMJ dislocation on her left side.

INTERVENTIONS

Patients with TMJ dislocation were repositioned with manipulation as soon as detected.

OUTCOMES

There was no recurrence in all three cases during the postoperative follow-up period.

CONCLUSIONS

Maxillary DO can sufficiently advance the maxilla in cleft lip and palate patients. Clinicians should be mindful of the TMJ dislocations that maxillary DO can exert on patients.

Cone-Beam Computed Tomography Incidental Findings in Individuals With Cleft Lip and Palate

OBJECTIVES

The use of cone-beam computed tomography (CBCT) is well-established in clinical practice. This study seeks to categorize and quantify the incidental finding (IF) rate on CBCT in patients with cleft lip and palate (CLP) prior to orthodontic or surgical treatment.

METHODS

This is systematic retrospective review of head and neck CBCTs in patients with nonsyndromic CLP taken between 2012 and 2019 at a single tertiary referral center. All assessments were performed independently by 4 observers (a head and neck radiologist and 3 orthodontists, including 2 fellowship-trained cleft-craniofacial orthodontists ). The images were divided into 9 anatomical areas and screened using serial axial slices and 3D reconstructions. The absolute number of IFs was reported for each area and statistical analysis was performed.

RESULTS

Incidental findings were found in 106 (95.5%) of the 111 patients. The most common sites were the maxilla (87.4%, principally dental anomalies), paranasal sinuses (46.8%, principally inflammatory opacification), and inner ear cavities (18.9%, principally inflammatory opacification). Eleven patients had skull malformations. Thirty-three patients had IFs in 1 anatomical area, 49 patients in 2 anatomical areas, 19 patients in 3 areas, and 5 patients presented with IFs in 4 of the 9 anatomical areas.

DISCUSSION

In patients with CLP, IFs on CBCT exam were present in the majority of cases. Most patients with IFs had them in multiple anatomical areas of the head and neck. The maxillary dental-alveolar complex was the most common area. Inflammatory changes in the inner ear cavities and paranasal sinuses were also common; however, cervical spine and skull abnormalities were also identified. Clinicians caring for patients with CLP should be aware of IFs, which may warrant further investigation and treatment.

Schneiderian Membrane Thickness Is Increased in Patients With Cleft Lip and Palate

OBJECTIVE

Patients with cleft lip and palate (CLP) are more likely to have sinusitis. The purpose of this study is to determine whether patients with CLP have thickening of the Schneiderian membrane. Specific aims were to (1) compare Schneiderian membrane thickness in patients with CLP to noncleft controls, (2) evaluate whether membrane thickening is associated with cleft side in patients with unilateral cleft lip and palate (UCLP), and (3) evaluate if age and sex are predictors of mucosal thickening.

DESIGN

Case-control study.

SETTING

Tertiary care center.

PATIENTS

Patients with CLP and controls.

MAIN OUTCOME MEASURE

The primary outcome variable was maximum Schneiderian membrane thickness measured on cone beam computed tomography. The primary predictor variable was the presence of a cleft. Additional variables were cleft phenotype, age, and sex.

RESULTS

There were 225 patients with CLP and 93 controls. Median mucosal thickness was 2.4 mm in cleft group and 0.0 mm in controls (P = .006). In cleft group, 56.7% of sinuses had mucosal thickness >2.0 mm compared to 38.2% in controls (P = < .004). Pathologic membrane thickening (>4.0 mm) was significantly higher in cleft group (P = .005). No statistically significant difference in mucosal thickness between cleft and noncleft sides in patients with UCLP. Linear regression showed no association between age or sex and Schneiderian membrane thickness.

CONCLUSION

Schneiderian membrane thickening is more common in patients with CLP and is not associated with the side of the cleft in patients with UCLP.

The effect of ectodermal dysplasia on volume and surface area of maxillary sinus

PURPOSE

Ectodermal dysplasia (ED) is a congenital syndrome characterized by abnormal development of ectodermal structures, such as skin, hair, nails, teeth, or salivary glands. Patients with ED demonstrate craniofacial dysmorphology, midfacial hypoplasia and hypodontia. The aim of this study is to evaluate volume and surface area of maxillary sinus and craniofacial structures in patients with ectodermal dysplasia (ED) using cone-beam computed tomography (CBCT) images.

METHODS

The CBCT images of 20 patients with ED (study group) and 20 healthy individuals (control) which are equal in terms of age and gender were evaluated. After a three-dimensional analysis and segmentation of each maxillary sinus, the volume and surface area were calculated. Craniofacial dimensions were measured on the sagittal planes of the CBCT images. The results of the ED and control groups were statistically compared.

RESULTS

The right and left sinus volumes and surface areas were significantly lower in the ED group than in the control group (p < 0.05) while the SNA was significantly higher (p < 0.05). ANB and SN-GoMe were also lower in patients with ED than in controls (p < 0.05). The difference in SNB values between the two groups was not significant (p > 0.05).

CONCLUSIONS

The volumes and surface areas of both maxillary sinuses were found to be smaller in patients with ED compared to healthy individuals. Class III malocclusion with maxillary retrusion is a characteristic craniofacial feature of these patients.

Cone-beam CT in paediatric dentistry: DIMITRA project position statement

DIMITRA (dentomaxillofacial paediatric imaging: an investigation towards low-dose radiation induced risks) is a European multicenter and multidisciplinary project focused on optimizing cone-beam CT exposures for children and adolescents. With increasing use of cone-beam CT for dentomaxillofacial diagnostics, concern arises regarding radiation risks associated with this imaging modality, especially for children. Research evidence concerning cone-beam CT indications in children remains limited, while reports mention inconsistent recommendations for dose reduction. Furthermore, there is no paper using the combined and integrated information on the required indication-oriented image quality and the related patient dose levels. In this paper, therefore, the authors initiate an integrated approach based on current evidence regarding image quality and dose, together with the expertise of DIMITRA's members searching for a state of the art. The aim of this DIMITRA position statement is to provide indication-oriented and patient-specific recommendations regarding the main cone-beam CT applications in the pediatric field. The authors will review this position statement document when results regarding multidisciplinary approaches evolve, in a period of 5 years or earlier.

Cleft lip and palate subjects prevalence of abnormal stylohyoid complex and tonsilloliths on cone beam computed tomography

INTRODUCTION AND OBJECTIVES

Tonsilloliths and abnormal stylohyoid complex may have similar symptoms to others of different aetiology. Individuals with cleft lip and palate describe similar symptoms because of the anatomical implications that are peculiar to this anomaly. The aim of this study was to determine the prevalence of abnormal stylohyoid complex and tonsilloliths on cone beam computed tomography in individuals with cleft lip and palate.

METHODS

According to the inclusion and exclusion criteria, 66 CT scans out of of 2,794 were analysed, on i- Cat ® vision software with 0.8 index Kappa intra-examiner.

RESULTS

The total prevalence of ossification of the incomplete stylohyoid complex in individuals with cleft lip and palate was 66.6%; the prevalence of these findings in females was 75% and 61.9% in males. The total prevalence of tonsilloliths was 7.5%.

CONCLUSION

It is important to ascertain calcification of the stylohyoid complex and tonsilloliths in the radiological report, due to the anatomical proximity and similarsymptomatology to other orofacial impairments inindividuals with cleft lip and palate, focusing on females with oral cleft formation, patients with incisive trans foramen cleft and incisive post foramen cleft because they are more prevalent. Greater knowledge of the anatomical morphometry of individuals with cleft lip and palate greatly contributes towards the selection of clinical behaviours and the quality of life of these patients, since cleft lip and palateis one of the most common anomalies.

Panel 2: Anatomy (Eustachian Tube, Middle Ear, and Mastoid-Anatomy, Physiology, Pathophysiology, and Pathogenesis)

Objective In this report, we review the recent literature (ie, past 4 years) to identify advances in our understanding of the middle ear-mastoid-eustachian tube system. We use this review to determine whether the short-term goals elaborated in the last report were achieved, and we propose updated goals to guide future otitis media research. Data Sources PubMed, Web of Science, Medline. Review Methods The panel topic was subdivided, and each contributor performed a literature search within the given time frame. The keywords searched included middle ear, eustachian tube, and mastoid for their intersection with anatomy, physiology, pathophysiology, and pathology. Preliminary reports from each panel member were consolidated and discussed when the panel met on June 11, 2015. At that meeting, the progress was evaluated and new short-term goals proposed. Conclusions Progress was made on 13 of the 20 short-term goals proposed in 2011. Significant advances were made in the characterization of middle ear gas exchange pathways, modeling eustachian tube function, and preliminary testing of treatments for eustachian tube dysfunction. Implications for Practice In the future, imaging technologies should be developed to noninvasively assess middle ear/eustachian tube structure and physiology with respect to their role in otitis media pathogenesis. The new data derived from these structure/function experiments should be integrated into computational models that can then be used to develop specific hypotheses concerning otitis media pathogenesis and persistence. Finally, rigorous studies on medical or surgical treatments for eustachian tube dysfunction should be undertaken.

Nasal Septal Anatomy in Skeletally Mature Patients With Cleft Lip and Palate

IMPORTANCE

Septal deviation commonly occurs in patients with cleft lip and palate (CLP); however, the contribution of the cartilaginous and bony septum to airway obstruction in skeletally mature patients is poorly understood.

OBJECTIVES

To describe the internal nasal airway anatomy of skeletally mature patients with CLP and to determine the contributors to airway obstruction.

DESIGN, SETTING, AND PARTICIPANTS

This single-center retrospective review included patients undergoing cone-beam computed tomography (CBCT) from November 1, 2011, to July 6, 2015, at the cleft lip and palate division of a major academic tertiary referral center. Patients met inclusion criteria for the study if they were at least 15 years old at the time of CBCT, and images were used only if they were obtained before Le Fort I osteotomy and/or formal septorhinoplasty. Twenty-four skeletally mature patients with CLP and 16 age-matched control individuals were identified for the study.

MAIN OUTCOMES AND MEASURES

Septal deviation and airway stenosis were measured in the following 3 coronal sections: at the cartilaginous septum (anterior nasal spine), bony septum (posterior nasal spine), and midpoint between the anterior and posterior nasal spine. The perpendicular plate of the ethmoid bone and vomer displacement were measured as angles from the vertical plane at the coronal section of maximal septal deviation. The site of maximal septal deviation was identified.

RESULTS

Among the 40 study participants, 26 were male. The mean (SD) age was 21 (5) and 23 (6) years for patients with CLP and controls, respectively. Septal deviation in patients with CLP was significantly worse than that of controls at the anterior nasal spine (2.1 [0.5] vs 0.8 [0.2] mm; P < .05) and posterior nasal spine (2.9 [0.5] vs 1.0 [0.3] mm; P < .01) and most severe at the midpoint (mean [SD], 4.4 [0.6] vs 2.1 [0.3] mm; P < .01). The point of maximal septal deviation occurred in the bony posterior half of the nasal airway in 27 of 40 patients (68%). The CLP bony angular deviation from the vertical plane was significant in the CLP group compared with the control group (perpendicular plate of the ethmoid bone, 14° [2°] vs 8° [1°]; vomer, 34° [5°] vs 13° [2°]; P < .05 for both), and vomer deviation was significantly associated with anterior nasal airway stenosis (r = -0.61; P < .01).

CONCLUSIONS AND RELEVANCE

Skeletally mature patients with CLP have significant septal deviation involving bone and cartilage. Resection of the bony and cartilaginous septum should be considered at the time of definitive cleft rhinoplasty.

LEVEL OF EVIDENCE

NA.

A Multivariate Analysis of Unilateral Cleft Lip and Palate Facial Skeletal Morphology

Unilateral cleft lip and palate (UCLP) occurs when the maxillary and nasal facial prominences fail to fuse correctly during development, resulting in a palatal cleft and clefted soft and hard tissues of the dentoalveolus. The UCLP deformity may compromise an individual's ability to eat, chew, and speak. In this retrospective cross-sectional study, cone beam computed tomography (CBCT) images of 7-17-year-old individuals born with UCLP (n = 24) and age- and sex-matched controls (n = 24) were assessed. Coordinate values of three-dimensional anatomical landmarks (n = 32) were recorded from each CBCT image. Data were evaluated using principal coordinates analysis (PCOORD) and Euclidean distance matrix analysis (EDMA). Approximately 40% of morphometric variation is captured by PCOORD axes 1-3, and the negative and positive ends of each axis are associated with specific patterns of morphological differences. Approximately 36% of facial skeletal measures significantly differ by confidence interval testing (α = 0.10) between samples. Although significant form differences occur across the facial skeleton, strong patterns of morphological differences were localized to the lateral and superioinferior aspects of the nasal aperture, particularly on the clefted side of the face. The UCLP deformity strongly influences facial skeletal morphology of the midface and oronasal facial regions, and to a lesser extent the upper and lower facial skeletons. The pattern of strong morphological differences in the oronasal region combined with differences across the facial complex suggests that craniofacial bones are integrated and covary, despite influences from the congenital cleft.

Evaluation of the anterior mandibular donor site one year after secondary reconstruction of an alveolar cleft: 3-dimensional analysis using cone-beam computed tomography

The aim of this study was to analyse changes in the volume of the chin after harvest of a bone graft for secondary reconstruction of an alveolar cleft. Cone-beam computed tomographic (CT) scans of 27 patients taken preoperatively, and immediately and one year postoperatively, were analysed, and 3-dimensional hard-tissue reconstructions made. The hard-tissue segmentation of the scan taken one year postoperatively was subtracted from the segmentation of the preoperative scan to calculate the alteration in the volume of bone at the donor site (chin). A centrally-orientated persistent concavity at the buccal side of the chin was found (mean (range) 160 (0-500) mm(3)). At the lingual side of the chin, a central concavity remained (mean (range) volume 20 (0-80) mm(3)). Remarkably, at the periphery of this concavity there was overgrowth of new bone (mean (range) volume 350 (0-1600) mm(3)). Re-attachment of the muscles of the tongue resulted in a significantly larger central lingual defect one year postoperatively (p=0.01). We also measured minor alterations in volume of the chin at one year. Whether these alterations influence facial appearance and long term bony quality is to be the subject of further research.

[The state of the nasal cavity and paranasal sinuses in the children presenting with congenital cleft of upper lip and palate]

The objective of the present study was to evaluate the state of the nasal cavity and paranasal sinuses in the children presenting with congenital cleft of upper lip and palate (CLP). A total of 23 children at the age from 9 to 16 years who had undergone the surgical treatment of the above malformations during the first year of life were examined. The comprehensive study including routine ENT examination, endoscopic examination of the nasal cavity and nasopharynx, and computed tomography has demonstrated that 50% of the patients with congenital cleft of upper lift and palate suffered the deflection of the nasal septum associated with hyperplasia of inferior turbinal bones. The children with congenital cleft of upper lip and palate were characterized by enhanced pneumatization of the anterior end of the middle turbinate despite the absence of well apparent differences between their paranasal sinuses and those of the healthy children, with the degree of pneumatization being consistent with the patient's age in both groups.

Difference in maxillary sinus volumes of patients with cleft lip and palate

BACKGROUND AND OBJECTIVE

Sinus disease is noted to be common in patients with cleft lip and palate. Many have wondered if anatomic differences are a cause or at least a contributor of this. In this sense, comparisons of sinus volumes of patients with different craniofacial clefts may be helpful to determine possible differences from normal. Thus, the present study aimed to evaluate and compare the maxillary sinus volume of patients with unilateral (UCLP) and bilateral (BCLP) cleft lip and palate to control, i.e. non-cleft patients, using cone beam computed tomography (CBCT) images.

METHODS

The sample consisted of 30 subjects with UCLP, 15 with BCLP and 15 control individuals (non-cleft). Each maxillary sinus was assessed three-dimensionally, segmented and its volume was calculated. The comparison between right and left sinus was performed by Student t-test, and the differences between the control and cleft groups were calculated using ANOVA.

RESULTS

No statistical differences were found when the sides were compared (p>0.05). In relation to the assessment among groups, all comparisons had statistically significant differences (p<0.05), with the UCLP group presenting the lowest sinus volume.

CONCLUSION

UCLP individuals present maxillary sinuses with smaller volumes, without differences found between the cleft and non-cleft side. BCLP subjects also present a reduction in the volume when compared to a control sample, but the average sinus volume is larger than in UCLP patients.