Classification and Management of Anomalies of the Nose

Intranasal glial heterotopia in an infant boy

INTRODUCTION

Nasal glial heterotopia is a rare congenital developmental disorder characterized by meningeal epithelium and/or glial components.

CASE PRESENTATION

A 2-month-old boy presented for treatment of a congenital mass in the right nasal cavity near the pharynx. The preoperative diagnosis was congenital intranasal neoplasm. Nasal endoscopic resection of the nasopharyngeal mass was performed under general anesthesia. Histological findings in the resected tissue supported a diagnosis of intranasal glial heterotopia. The surgical outcome was good and no surgical site infection occurred. During 1 year of follow-up, the patient did not exhibit recurrence of heterotopia or related symptoms.

CONCLUSION

Transnasal endoscopic surgery is recommended for patients with intranasal glial heterotopia. Thorough preoperative imaging should be performed before glioma resection. The mass should be differentiated from encephalocele to prevent cerebrospinal fluid leakage and meningitis.

Intranasal glial heterotopia in a male infant: A case report

RATIONALE

Nasal glial heterotopia is a rare type of neoplasm consisting of meningothelial and/or neuroglial elements.

PATIENT CONCERNS

A 2-month-old male was evaluated for treatment of a congenital mass in the right nasal cavity near the pharynx.

DIAGNOSES

The patient was preoperatively diagnosed with a congenital intranasal neoplasm.

INTERVENTIONS

Nasal endoscopic resection of the nasopharyngeal mass was performed under general anesthesia. Histological examination of the resected tissue provided a diagnosis of intranasal glial heterotopia.

OUTCOMES

The surgical outcome was good, with no surgical site infection. After 1 year of follow-up, the boy was asymptomatic with no recurrence.

LESSONS

Excision of a nasopharyngeal mass via nasal endoscopy resulted in no recurrence during 1 year of follow-up. Before any surgical treatment for suspected glial heterotopia, the mass should be differentiated clinically and radiologically from an encephalocele to prevent the risk of cerebrospinal fluid leakage and meningitis.

A CARE-compliant article: Extranasal glial heterotopia in a female infant: A case report

RATIONALE

Nasal glial heterotopia is a rare type of neoplasm consisting of meningothelial and/or neuroglial elements.

PATIENT CONCERNS

A 17-month-old female infant was evaluated for treatment for a congenital mass present since birth on the right side of the nasal dorsum.

DIAGNOSES

The patient was preoperatively diagnosed with a congenital extranasal neoplasm.

INTERVENTIONS

Surgery was performed under general anesthesia, and the mass was completely resected. The tissue was sent for histological examination, and the diagnosis was of extranasal glial heterotopia.

OUTCOMES

The surgical outcome was good, and no surgical site infection was recorded. After 6 months of follow-up, the girl was asymptomatic with no recurrence.

LESSONS

Surgical excision, a curative method used to address extranasal glial heterotopia, resulted in no recurrence during the clinical follow-up period. The potential for an intracranial connection must always be kept in mind when considering how to surgically treat a congenital midline mass to prevent the risk of cerebrospinal fluid leakage.

Nasal Glioma: A Rare Cause of Congenital Inner Canthal Swelling

Nasal glioma, encephalocele, and ectopic brain are rare congenital anomalies. The terminology applied to these entities has been historically confusing. In many cases, the terms overlap and may be employed synonymously although some authors emphasize their differences. The authors describe herein a child with an inner canthal mass of brain-like tissue that they interpret as nasal glioma, a variety of encephalocele that has lost its connection to the intracranial contents. This research was conducted in conformity with the Helsinki Declaration and Health Insurance Portability and Accountability Act regulations.

Allergic and Nonallergic Rhinitis. Classification and Pathogenesis: Part II. Nonallergic Rhinitis

Part I of this review classified and defined the causes of chronic rhinitis, describing in detail the etiology and pathophysiology of allergic rhinitis. Part II focuses on the nonallergic (non-IgE) causes of chronic rhinitis, concentrating on their clinical presentations, differential characteristics, and known or speculative pathophysiology. A comprehensive understanding of the allergic and nonallergic conditions associated with symptomatic rhinitis should aid the clinician in the appropriate diagnosis and treatment of patients with chronic rhinitis.

Congenital nasal neuroglial heterotopia and encephaloceles: An update on current evaluation and management

OBJECTIVES/HYPOTHESIS

To describe our experience and current management approach for congenital nasal neuroglial heterotopia (NGH) and encephaloceles.

STUDY DESIGN

Retrospective chart review at a tertiary pediatric hospital from 1970 to 2013.

METHODS

Thirty patients met inclusion criteria: 21 NGH and nine encephaloceles. Data including demographics, pathology, imaging modality, surgical approach, resection extent, outcomes, and complications were analyzed.

RESULTS

Fourteen NGH patients (67%) presented with an internal nasal mass and nasal obstruction. Three patients (14%) presented with an external nasal mass and four (19%) had a mixed lesion. Median age at surgery was 0.51 years (interquartile range 1.32 years). Thirteen (62%) had an intranasal endoscopic approach. Median operative time was 1.6 hours (interquartile range 1.2 hours), and there were no major complications. Nine patients with encephalocele were identified: six (67%) presented with transethmoidal encephaloceles, two (22%) presented with nasoethmoidal encephaloceles, and one (11%) presented with a nasofrontal lesion. The median age at surgery was 1.25 years (interquartile range 1.4 years). All patients required a craniotomy for intracranial extension. Median operative time was 5 hours (interquartile range 1.9 hours), and eight patients (88%) had a total resection. Length of stay ranged from 3 to 14 days.

CONCLUSION

Nasal neuroglial heterotopia and encephaloceles are very rare lesions that require multidisciplinary evaluation and management. At our institution, there has been a shift to magnetic resonance imaging alone for the evaluation of NGH to avoid radiation exposure. Endoscopic extracranial resection is feasible for most intranasal and mixed NGH without an increase in operative time, residual disease, or complications.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:2161-2167, 2016.

Nasal Septal Deviations: A Systematic Review of Classification Systems

Objective. To systematically review the international literature for internal nasal septal deviation classification systems and summarize them for clinical and research purposes. Data Sources. Four databases (including PubMed/MEDLINE) were systematically searched through December 16, 2015. Methods. Systematic review, adhering to PRISMA. Results. After removal of duplicates, this study screened 952 articles for relevance. A final comprehensive review of 50 articles identified that 15 of these articles met the eligibility criteria. The classification systems defined in these articles included C-shaped, S-shaped, reverse C-shaped, and reverse S-shaped descriptions of the septal deviation in both the cephalocaudal and anteroposterior dimensions. Additional studies reported use of computed tomography and categorized deviation based on predefined locations. Three studies graded the severity of septal deviations based on the amount of deflection. The systems defined in the literature also included an evaluation of nasal septal spurs and perforations. Conclusion. This systematic review ascertained that the majority of the currently published classification systems for internal nasal septal deviations can be summarized by C-shaped or reverse C-shaped, as well as S-shaped or reverse S-shaped deviations in the anteroposterior and cephalocaudal dimensions. For imaging studies, predefined points have been defined along the septum. Common terminology can facilitate future research.

Nasal obstruction in newborns

Nasal obstruction is a serious clinical scenario in the newborn infant with a large differential diagnosis. This article reviews the etiologies of nasal obstruction to aid the pediatrician in prompt evaluation, diagnosis, and treatment.

Nasal dermoids - our experience

Dermoid Cysts and fistulas of the nose represent an uncommon embryological error. The frequency of misdiagnosis and recurrences of this lesion indicates the lack of awareness of its occult ramifications which lead to a compromised incomplete excision and are classified as "misadventures", We would like to present our experience with nasal dermoids - their clinical presentation and management.

Neonatal respiratory distress secondary to bilateral intranasal dacryocystocoeles

Obstruction of the nasolacrimal duct is a common congenital abnormality reported in up to 84% of neonatal patients [J. Yohendran, A.C. Wignall, E.J. Beckenham, Bilateral congenital dacryocystocoeles with concurrent intranasal mucocoeles causing respiratory distress in a neonate, Asian J. Surg. 29 (2) (2006) 109-111; M.J. Cunningham, J.J. Woog, Endonasal endoscopic dacryocystorhinostomy in children, Arch. Otolaryngol. Head Neck Surg. 124 (1998) 328-333; D. Guery, E.L. Kendig, Congenital impotency of the nasolacrimal duct, Arch. Ophthalmol. 97 (1979) 1656-1658]. Rarely, obstruction results in the development of an intranasal lacrimal duct cyst, or dacryocystocoele, which arises inferolateral to the inferior turbinate [H.R. Jin, S.O. Shin, Endoscopic marsupialisation of bilateral lacrimal sac mucoceles with nasolacrimal duct cysts, Auris Nasus Larynx 26 (1999) 441-445]. These lesions can cause nasal obstruction and, when bilateral, significant respiratory compromise. We present the case of a 3-day-old infant with bilateral intranasal lacrimal duct cysts causing nasal obstruction and intermittent respiratory compromise. The diagnosis was suspected on clinical examination and confirmed on MRI. The patient was successfully managed by bilateral endoscopic marsupialisation and probing of the nasolacrimal ducts. We also present a review of the literature surrounding investigation and management of intranasal lacrimal duct cysts.

Nasal ganglioglioma--difficulties in radiological imaging

Ganglioglioma is a tumour containing both astrocytic and neuronal components. Most gangliogliomas are observed in the brain, but may also manifest as a nasal glioma. Approximately 250 cases of nasal gliomas have been described in the literature. Gliomas are classified as heterotopias of glia tissue. In the paper we describe the case of nasal ganglioglioma and the diagnostic difficulties. The differences between ganglioglioma, nasal glioma and other congenital midline nasal masses are discussed.

Nasopharyngeal glioma: A unique presentation in infants

Despite the complex embryological development of the nose and surrounding structures, significant developmental nasal anomalies are rare. Of the various anomalies like-nasopharyngeal cysts, hairy polyps, dermoids, haemangiomata, fibromas, mucocoeles, lipoma, aplasias. We are presenting a rare case of Heterotopic Brain Tissue in the nasopharynx. This 1.5-month-old patient was operated through transpalatal route and mass excised. Histopathologicaly it consisted of various central nervous tissue elements. Seven months post surgery patient is thriving well.

Congenital frontonasal masses: developmental anatomy, malformations, and MR imaging

The newborn, infant, or young child who presents with a midline frontonasal mass often poses a diagnostic challenge to the clinician. The most pressing issue is whether the mass extends intracranially. The development of the frontonasal region or anterior neuropore is complex. Aberrant embryogenesis leads to three main types of anomalies: nasal dermal sinus, anterior cephalocele, and nasal glioma. Understanding the developmental anatomy of the anterior neuropore and postnatal maturation will serve the radiologist well when it comes to imaging frontonasal masses. Pitfalls particularly common to CT imaging interpretation include the evolving ossification of the frontal, nasal and ethmoid bones in the first year of life, morphology and size of the foramen cecum, and the natural intumescence of the anterior nasal septum. Determination of the presence of a connection between the frontonasal mass and the anterior cranial fossae is crucial in the imaging assessment and clinical management. In the case of the nasal dermal sinus, failure to appreciate the intracranial components of the malformation can lead to fatal meningitis. MR imaging is the modality of choice for assessing the pediatric frontonasal region. Its advantages include multiplanar imaging, distinguishing the interface among cartilage, bone, brain and fluid, diffusion imaging to detect epidermoid tumors, and the capacity to evaluate the brain for associated cerebral anomalies.

Nasal glioma and encephalocele: diagnosis and management

OBJECTIVE

To review the biology of nasal glioma and encephalocele and to present an algorithm for preoperative evaluation and surgical management.

DESIGN

Retrospective review and analysis.

SETTING

Tertiary care medical center: 1970 to 2002.

PATIENT

Sixteen patients with glioma (n = 10) and encephalocele (n = 6).

OUTCOME

Age at the time of presentation, sex, signs and symptoms, imaging findings, surgical approach, pathology, complications, rate of recurrence, and follow-up were recorded.

RESULTS

Ten patients presented with nasal glioma with a mean age of 9 months. All patients underwent surgical excision. No complication was encountered with a mean follow-up of 3.5 years. Six patients presented with encephaloceles with a mean age of 15.5 months. All patients underwent surgical excision. Complications included cerebrospinal fluid leak (n = 1) and epiphora (n = 1). Follow-up was 1 to 14 years (mean, 4 years).

CONCLUSION

Nasal glioma and encephalocele are rare, benign, congenital lesions with a potential for intracranial extension. Evaluation should include a complete rhinologic and neurologic examination. Preoperative imaging with a thin-cut axial and coronal computed tomography scan and/or multiplanar magnetic resonance imaging is essential. Surgical intervention should be performed soon after diagnosis to alleviate the increased risk of meningitis. A frontal craniotomy approach is recommended if intracranial extension is identified based on preoperative evaluation, followed by an extracranial resection. If there is no evidence of intracranial extension, a conservative extracranial approach is recommended.

Congenital salivary gland anlage tumor of the nasopharynx

OBJECTIVE

Nasal and upper respiratory tract obstruction in the neonatal period can result from a variety of conditions, and may present with variable symptoms. In the absence of dysmorphic features or other abnormalities, causes of nasal obstruction may be difficult to differentiate on initial examination. We report an unexpected and potentially life-threatening condition arising during the work-up of this common neonatal complaint.

DESIGN

Case report with literature review.

RESULTS

A male neonate presented with complaints of nasal obstruction and feeding difficulties. A common diagnostic approach to neonatal nasal obstruction was performed, resulting in an unexpected and potentially life-threatening, albeit curative, result. Cannulation of the nasal cavity to rule out choanal atresia resulted in a burst of bleeding from the nose and mouth. A finger sweep of the oropharynx produced a dislodged mass lesion. Pathology revealed a salivary gland anlage tumor of the nasopharynx.

CONCLUSIONS

The diagnosis of a nasopharyngeal mass lesion should be considered in neonates with nasal obstructive symptoms. It is wise to place an index finger in the oropharynx when passing catheters to rule out choanal atresia to feel a dislodged mass lesion before it can become an airway foreign body. Should passage of nasal catheters result in bleeding and/or respiratory distress, the possibility of a displaced mass lesion must be considered immediately to institute prompt intervention.

Nasal deformity in neonates and young children

Pediatric nasal deformities comprise a broad range of congenital and acquired pathologies. The congenital deformities are rare and often require specific surgical interventions. The acquired deformities are more common, and in the majority of cases surgical intervention is not necessary. The decision to operate is based primarily on the extent of the functional impairment and the severity of the aesthetic deformity.

Endoscopic marsupialization of congenital nasolacrimal duct cyst with dacryocoele

A congenital nasolacrimal duct cyst is an uncommon condition in the newborn usually treated by ophthalmologists. Prolapse or expansion of the cyst into the nose may lead to respiratory distress and difficulty in feeding as newborns are obligate nose breathers, which needs the involvement of the Otolaryngologist in diagnosis and management. The authors report a series of 8 children presenting with a congenital nasolacrimal duct cyst and dacryocoele and highlight the importance of endoscopic nasal examination of newborns presenting with respiratory problems. Diagnostic studies included intranasal endoscopy and CT scanning of the nasolacrimal system and nose. All the patients were treated by endoscopic marsupialization of the cyst. Nasolacrimal duct abnormality should be considered in the differential diagnosis of neonatal respiratory distress and nasal obstruction. Nasal endoscopy is essential in the work-up of all children with nasal obstruction and respiratory distress. CT scanning is the investigative method of choice. Endoscopic marsupialization followed by lacrimal duct irrigation is effective in the treatment of congenital nasolacrimal duct cyst and results in complete resolution of symptoms.

Choanal and ileal atresia: a new syndrome or association?

Choanal atresia is a relatively common congenital malformation which is often associated with other anomalies. On the other hand, ileal atresia is very rare, mostly nonsyndromic and occasionally associated with other anomalies. The association of choanal and ileal atresia is unknown. Here we report the first instance of bilateral choanal atresia and ileal atresia in a full term male infant and describe the subsequent surgical treatment of both conditions. The association is unique and may represent a syndrome.

Intranasal Meningoencephalocele and the Use of Fibrin Glue

Meningoencephaloceles are rarely seen in adults. This case report illustrates the management of a large intranasal meningoencephalocele in an adult man. Excision of this lesion resulted in a defect in the cribriform plate which was closed using tissue and fibrin glue.

Airway compromise from nasal obstruction in neonates and infants

Nasal obstruction in neonates can cause significant airway compromise and even be life-threatening. In general, otolaryngologists are familiar with management of the neonate born with choanal atresia but there have been few reports and there are no guidelines for management of the neonate or young infant who presents with nasal obstruction and airway compromise but who does not have choanal atresia (NOWCA). This study demonstrates the difficulty in diagnosis, variability in severity of airway compromise, and delineates the problematic aspects of management.

Developmental nasal anomalies

Despite the complex embryological development of the nose and surrounding structures, significant developmental nasal anomalies are rare. We therefore present our experience in the management of such anomalies (excluding choanal atresia) over the past 10 years. Fifty cases were surgically treated; two nasopharyngeal cysts, four hairy polyps, two meningoencephalocoeles, seven gliomata, 20 dermoids, two capillary haemangiomata, four fibromas, one fibromyxyoma, one mucocoele, one granuloma, one lipoma, two nasal aplasias, two nasal clefts and one nasal web. All cases presented with nasal obstruction and/or as a nasal mass. Computerized tomography and magnetic resonance imaging aided diagnosis determining the extent of intracranial involvement. Various surgical techniques were used ranging from simple excision to the lateral rhinotomy and Goodman's external rhinoplasty approach. Only five patients (10 per cent) suffered complications; two CSF leaks and three recurrences, all treated successfully.

The complex nasal dermoid

In a series of 74 nasal dermoids, 45 (61%) were of the simple variety involving skin only. Twenty nine (39%) were of the complex variety with deeper tissue involvement requiring more extensive surgery. Of the 29 complex dermoids, 9 (31%) extended to the cribriform plate region but only 3 (10%) of these had an extradural extension. All of the complex nasal dermoids were adequately managed by a transnasal approach. On these findings a preliminary craniotomy should only be considered in exceptional circumstances.