Congenital nasal malformations

Special Considerations in Pediatric Endoscopic Skull Base Surgery

Originally pioneered in adults, endoscopic endonasal approaches for skull base pathology are being increasingly applied as a minimally invasive alternative for young children. Intrinsic anatomic differences between these patient populations have sparked discussions on the feasibility, safety, and efficacy of these techniques in pediatric patients. This work aims to serve as a primer for clinicians engaged in the rapidly evolving field of pediatric endoscopic skull base surgery. A succinct overview of relevant embryology, sinonasal anatomy, and diagnostic workup is presented to emphasize key differences and unique technical considerations. Additional discussions regarding select skull base lesions, reconstructive paradigms, potential surgical complications, and postoperative care are also highlighted in the setting of multidisciplinary teams.

Bilateral congenital choanal atresia in a preterm neonate - a rare neonatal emergency: A case report and review of literature

Congenital choanal atresia results from the developmental failure of the nasal cavity to connect posteriorly with the nasopharynx. Although congenital choanal atresia is a well-recognized developmental disorder, it is an uncommon condition with an overall incidence of approximately 1 per 10,000 live births. The authors aim to highlight that in very preterm neonates, early diagnosis of bilateral congenital choanal atresia needs a high index of suspicion to avoid life-threatening events. It is considered as one of the neonatal emergencies, and repair is recommended in the first few weeks of life. The authors report an uncommon presentation of a very preterm neonate born at 31 weeks of gestation, diagnosed to have bilateral congenital choanal atresia with repeated failure of a trial of extubation. A transnasal endoscopic repair was performed in the eighth week of life to relieve the life-threatening nasal obstruction.

Bilateral Choanal Atresia in an Adolescent Female: A Rare Case Report

Choanal atresia is a rare congenital anomaly of the nasal cavities characterized by lack of patency of the posterior ends of one or both nasal cavities (choanae). It is the most common congenital anomaly of the nasal cavity. Bilateral choanal atresia accounts for a third of the cases and is almost invariably detected in the neonatal age due to respiratory distress. Detection of bilateral choanal atresia in adulthood is extremely rare and has been reported only a few times. We report a case of a teenage girl who was diagnosed with bilateral choanal atresia after presenting with longstanding snoring and intermittent nasal discharge. She was managed with bilateral transnasal endoscopic choanoplasty to restore the choanal patency.

Post dermoid excision nasal tip deformity correction using gelatin sponge

Reconstruction of the nasal tip after the excision of the dermoid cyst is difficult, especially if the size of the dermoid is large. Tip reconstruction using Interdomal sutures of alar cartilages and auricular cartilage graft has been used in such cases. We share a new method to manage the nasal tip defect following excision of nasal dermoid, using an absorbable gelatin sponge. A 13 years old female presented with a swelling tip of the nose for the past 2 years. The CT scan revealed a dermoid cyst at the tip of the nose over the alar cartilage with prominent buckling of the cartilages. The Dermoid cyst was excised through an open rhinoplasty incision. There was a defect of 2.2 cm diameter at the tip of the nose with deformed alar cartilages. A piece of absorbable gelatin sponge was folded, cut according to the shape of the cavity, and used to fill the cavity. The skin was draped over the cartilage and gelatin sponge. The post-operative period was uneventful. After 2 years of follow-up, the patient remained asymptomatic and satisfied with a nice contour of the nasal tip.

A review of genetics of nasal development and morphological variation

The nose is central in the determination of facial esthetics. The variations in its structural characteristics greatly influence the ultimate dentoskeletal positioning at the end of an orthodontic therapy. A careful insight into its developmental etiology will greatly aid the health care professional in identifying patient's real concern about the facial appearance. This in turn will aid in the fabrication of a better treatment plan regarding the end placement goals for the teeth and jaws in all the three dimensions of space. However, this important structure is often missed as a part of the diagnostic and treatment planning regime owing to the lack of meticulous understanding of its developmental etiology by the orthodontists. The development of the nose in the embryo occurs in pre skeletal and skeletal phases by a well-coordinated and regulated interaction of multiple signaling cascades with the crucial importance of each factor in the entire mechanism. The five key factors, which control frontonasal development are sonic hedgehog (SHH), fibroblast growth factors (FGF), transforming growth factor β (TGFβ), wingless (WNT) proteins, and bone morphogenetic protein (BMP). The recent evidence suggests the association of various nasal dimensions and their related syndromes with multiple genes. The revelation of nasal genetic makeup in totality will aid in ascertaining the direction of growth, which will govern our orthodontic treatment results and will also act as a harbinger for potential genetic editing and tissue engineering. This article describes at length the morphological and genetic aspect of nasal growth and development in light of the gender and racial variability along with the emphasis on the importance of knowing these nasal features with regard to diagnosis and treatment planning in orthodontics.

Pediatric sinonasal and skull base lesions

Pediatric skull base lesions are complex and challenging disorders. Safe and comprehensive management of this diverse group of disorders requires the expertise of an experienced multidisciplinary skull base team. Adult endoscopic skull base surgery has evolved due to technologic and surgical advancements, multidisciplinary team approaches, and continued innovation. Similar principles continue to advance the care delivered to the pediatric population. The approach and management of these lesions varies considerably based on tumor anatomy, pathology, and surgical goals. An understanding of the nuances of skull base reconstruction unique to the pediatric population is critical for successful outcomes.

Management of congenital midline nasofrontal masses: case report and review of literature

Epidermoid cysts, dermoids, gliomas, and meningo-/encephaloceles are the most important differential diagnoses in congenital nasofrontal masses. Since they arise from an abnormal fusion during fetal development, intracranial extension of the lesion has to be ruled out radiologically before therapy. Dermoids are the most common entity. We report about a congenital epidermoid cyst of the glabella and nasion that had been growing over the last two years before presentation in a 24-year-old patient. We discuss radiological imaging and the different surgical approaches described in literature.

Rare nasal cleft in a patient with holoprosencephaly due to a mutation in the ZIC2 gene

BACKGROUND

Holoprosencephaly (HPE) is a spectrum of midline malformations of the prosencephalon generally reflected in a continuum of midline facial anomalies. Patients with mutation in the ZIC2 gene usually present a normal or mildly dysmorphic face associated with a severe brain malformation. Here we present a rare unilateral nasal cleft (Tessier cleft n. 1) with holoprosencephaly in a patient with a ZIC2 mutation.

CASE

The male newborn presented with alobar HPE, microcephaly, ocular hypertelorism, upslanting palpebral fissures, a bulky nose with a left paramedian alar cleft. Mutational screening for HPE genes revealed the occurrence of a frameshift mutation in the ZIC2 gene. The mutation was inherited from the father who presented only mild ocular hypotelorism but had an affected child with HPE from his first marriage.

CONCLUSION

The occurrence of oral clefts is common in patients with HPE, but unusual in patients with mutation in the ZIC2 gene. To our knowledge, clefts of the nasal alae have been reported only once or twice in patients with ZIC2 mutations. In documented patients from the literature, only 2% of individuals with described pathogenic mutations in the ZIC2 gene (3/171) presented facial clefts, one of them a nasal cleft, while common oral clefts were observed in 27% of individuals (7/26) described with nonpathogenic ZIC2 mutations or presenting a concomitant mutation in another HPE gene. When compared with the general population, nasal clefts are common in ZIC2 mutations and these mutations must be searched for in undiagnosed cases.

Endoscopic endonasal surgery for nasal dermoids

Midline congenital lesions are rare and commonly comprise nasal dermoids (NDs), encephaloceles, and gliomas. This article discusses the epidemiology of NDs. Management is also discussed, as well as prognosis.

Impact and risk factors of craniofacial malformations in a Colombian population

OBJECTIVE

Craniofacial malformations comprise diverse diagnoses, implying a wide range of morbidity and disability among populations. Our aim was to study them as a group and describe their epidemiological factors inside a population as well as finding common risk factors for their presentation in Colombia.

METHODS

We conducted a case-control study in several Colombian hospitals participating in the ECLAMC (Spanish acronym for Latin-American Collaborative Study of Congenital Malformations) program. For the analysis we included 374 cases of isolated malformations and 728 controls, out of 44,701 births.

RESULTS

A rate of 83.67 cases per 10,000 births was found for craniofacial malformations as a group, with an overall sex ratio of 1. We found predominance for their presentation on the right side. As main associations we obtained a positive family history of another craniofacial malformation (OR: 3.10 CI 95% [2.24-4.30]), particularly preauricular tags (OR 52.36 CI 95% [12.62-217.16]), preauricular pits (OR: 36.35 CI 95% [4.82-274.27]) and cleft lip with or without palate (OR: 2.50 CI 95% [1.07-5.84]). Medication use during pregnancy was also linked to malformations (OR: 2.00 CI 95% [1.38-2.89]). Specific agents such as ferrous sulfate (OR: 1.46 CI 95% [1.13-1.89]), folic acid (OR: 1.35 CI 95% [1.02-1.79]) and nifedipine (OR: 2.88 CI 95% [1.22-6.79]) also showed a significant correlation. Maternal alcohol use was also identified as a possible risk factor (OR: 2.45 CI 95% [1.39-4.29]).

CONCLUSIONS

Craniofacial malformations are frequently encountered among the group of congenital defects. When they present in an isolated fashion, familial history is an important risk factor, although some prenatal factors such as alcohol and some medications may have influence over their prevalence.