Congenital Arhinia: A Rare Case Report and Review of Literature

Two Forehead Flaps for Nasal Reconstruction of a Patient with Arhinia

Complete or total arhinia, in which nasal soft tissue is absent, is an extremely rare disease. The embryological origin of the defect is thought to be the maldevelopment of paired nasal placodes. In this article, we introduce nasal reconstruction with two forehead flaps. The reconstruction was done with two forehead flaps in a 20-year-old male patient with arhinia. Using one frontal flap of the forehead as the inner layer and the other one as the outer layer. The postoperative care was uneventful. He was able to breathe through the nose. No chest pain or any difficulty was mentioned in daily activities. The principal advantage of this technique over previous techniques is that the operation is performed in two stages and at the end of the procedure the patient has the final shape of the nose and is able to breathe normally. Furthermore, this technique could be performed for all age groups.

Prenatal Diagnosis of Arhinia

Arhinia is a rare congenital anomaly that is not typically associated with known genetic mutations and is usually discovered after an affected infant is born. Prenatal diagnosis is important because neonates with arhinia often require specialized respiratory support with creation of an artificial airway. We present a case of isolated arhinia diagnosed on second-trimester ultrasound. A patient presented for routine ultrasound at 18 weeks gestation, and nasal tissues were absent in an otherwise morphologically normal appearing fetus. Cell free fetal DNA was unremarkable. The patient elected to undergo termination of pregnancy by dilation and evacuation. Subsequent genetic analysis confirmed a normal fetal karyotype and microarray, and no examination of fetal structural anatomy was possible. Antenatal diagnosis of arhinia is important to guide maternal-fetal care decisions and requires methodical sonographic evaluation to identify this malformation prior to delivery.

Concurrent arhinia and choanal atresia in a day old male kid

Arhinia is a congenital nasal developmental anomaly that is seldom reported in literature, and especially not reported in domestic animals. This report describes a case of concurrent occurrence of congenital arhinia and choanal atresia in a day-old male kid which had no external nares with the nasal bones fused together with the nasal processes of the premaxillae presententing as a conical shaped rhinal structure with a tapering rostral apex and an occluded nasal vestibule. A bilateral osseous choanal atresia was also seen at the pharynx. Additionally, craniofacial and brain anomalies presented in this condition with right lateral deviation of the face and the absence of olfactory apparatus including olfactory bulbs, tracts and nerves and a vestigial trigonum olfactorium were noted. This, to the best of our knowledge is the first report in the literature indexed in the Medline of concurrent occurrence of congenital arhinia and choanal atresia in a goat.

Reconstruction of Congenital Arhinia With Stereolithographic Modeling: Case Correlate and Literature Review

Complete congenital arhinia is a rare defect of embryogenesis leading to the absence of the external nose and airway. We report our novel multistaged reconstructive approach and literature review. Nasal methyl methacrylate prosthesis was created from a stereolithographic model for use as a temporary prosthesis and tissue expander. Lefort 1 with cannulization was utilized for midface advancement and airway formation. External framework was reconstructed with bilateral conchal bowl cartilage and rib osteocartilagenous grafts. Patient was pleased with the aesthetics and had safe decannulation with the ability to breathe through the nose and airway.

Congenital bony nasal cavity stenosis: A review of current trends in diagnosis and treatment

Congenital bony nasal cavity stenosis is caused by alterations of the normal embryological development of the nasal cavity. Depending on the site of the obstruction, the most important types of stenosis are: choanal atresia and stenosis, congenital nasal pyriform aperture stenosis, congenital midnasal stenosis, arhinia and nasal septum deviation. Although they are uncommon, they could be potentially life-threatening conditions that require early diagnosis and proper treatment. In case of neonatal nasal obstruction, appropriate differential diagnosis with other causes, such as rhinitis and sinonasal masses, are performed by nasal endoscopy and radiological exams. Treatment strategy consisting of medical nasal therapies and endoscopic or open nasal surgery should be tailored according to the types and the degree of the stenosis. When indicated, endoscopic endonasal approach is considered the most effective technique in neonates warranting minimal surgical invasiveness and maximum effect. In order to promote the management of these rare yet clinically relevant neonatal nasal breath disorders, we review the current trends in diagnosis and treatment of congenital bony nasal cavity stenosis.

Congenital arrhinia: A case report and literature review

INTRODUCTION

Underdevelopment of the nose is a wide spectrum entity ranges from partial absence of the nose to congenital arrhinia (CA). CA is the congenital absence of the external nose, nasal cavities, and/or nasal nostrils±olfactory apparatus, and is an extremely rare entity as less than 50 cases reported in the literature. CA can be isolated and idiopathic in origin or be a part of genetic-linked certain syndromes. Of note, the isolated CA can be inherited as an autosomal dominant condition with incomplete penetrance.

PRESENTATION OF CASE

We report a 13-month-old Palestinian female patient with isolated CA complicated with recurrent lower and upper respiratory tract infections (URTI). The family history is significant for the mother with incomplete and uncomplicated underdevelopment of the external nose and nasal nostrils. The patient uses a tracheostomy to breathe and is waiting for the optimal age for surgical correction. In addition, we reviewed the available literature using PubMed and summarized all CA cases reported from 2016 to 2019 since two studies had presented the literature before 2016, and presented them in a very comprehensive table.

DISCUSSION

CA is largely idiopathic and not well understood. Although CA can be inherited and runs in families with incomplete penetrance, no causative genetic abnormalities had been found in most of the reported cases. CA frequently presents with upper airway obstruction and respiratory distress, recurrent lower and URTI, and feeding difficulties. CA is managed initially with tracheostomy and should be followed by a surgical correction at the appropriate age.

CONCLUSION

CA may be sporadic, familial, or a part of a syndrome. CA carries a significant rate of morbidity and mortality and a tracheostomy should be inserted initially to alleviate the early CA complications and followed by surgical reconstruction when the patient reaches the age of preschool/school age. More studies are required to determine CA inheritance.

Insight Into the Ontogeny of GnRH Neurons From Patients Born Without a Nose

CONTEXT

The reproductive axis is controlled by a network of gonadotropin-releasing hormone (GnRH) neurons born in the primitive nose that migrate to the hypothalamus alongside axons of the olfactory system. The observation that congenital anosmia (inability to smell) is often associated with GnRH deficiency in humans led to the prevailing view that GnRH neurons depend on olfactory structures to reach the brain, but this hypothesis has not been confirmed.

OBJECTIVE

The objective of this work is to determine the potential for normal reproductive function in the setting of completely absent internal and external olfactory structures.

METHODS

We conducted comprehensive phenotyping studies in 11 patients with congenital arhinia. These studies were augmented by review of medical records and study questionnaires in another 40 international patients.

RESULTS

All male patients demonstrated clinical and/or biochemical signs of GnRH deficiency, and the 5 men studied in person had no luteinizing hormone (LH) pulses, suggesting absent GnRH activity. The 6 women studied in person also had apulsatile LH profiles, yet 3 had spontaneous breast development and 2 women (studied from afar) had normal breast development and menstrual cycles, suggesting a fully intact reproductive axis. Administration of pulsatile GnRH to 2 GnRH-deficient patients revealed normal pituitary responsiveness but gonadal failure in the male patient.

CONCLUSIONS

Patients with arhinia teach us that the GnRH neuron, a key gatekeeper of the reproductive axis, is associated with but may not depend on olfactory structures for normal migration and function, and more broadly, illustrate the power of extreme human phenotypes in answering fundamental questions about human embryology.